Follow-up One Year after Parent-Child Interaction Training: Effects on Behavior of Preschool Children

Follow-up One Year after Parent-Child Interaction Training: Effects on Behavior of Preschool Children JOSEPH M. STRAYHORN, M.D .,

AN D

CARLA S. WEIDMAN , PH.D.

Abstract. A preventive mental health intervention previously reported found positive effects in a parentchild interaction training program on attention deficit and internalizing symptoms of low-income preschool children as rated by parents. Families were randomly assigned to a " minimal treatment " control group or a more extensive treatment experimental group. The present study reports follow-up results measured approximately I year after the end of the intervention. Parent ratings and child achievement test scores showed no difference between the two groups . Teachers blind to the condition of the intervention, however, rated experimental children as significantly superior to control children with respect to attention deficit and hyperactivity symptoms (preintervention ratings by teachers on the same variable were statistically controlled). Composite teacher ratings of child behavior also significantly favored the experimental group . Children' s improvements in classroom behavior were significantly correlated with improvements parents had shown during the intervention in their behavior toward the children. J. Am. Acad . Child Adolesc. Psychiatry, 1991,30,1 :138-143 . Key Words: intervention, outcome, parent training , preschool children , prevention, parent-child interaction. There have been many studies of the effects of parent training, especially with disruptive disorders. These have been reviewed by Kazdin (1987), Gard and Berry (1986), and Dumas (1989). Follow-up studies have examined the maintenance of gains in treated groups for a year or more (e.g., Webster-Stratton et aI. , 1989, Baum and Forehand 1981 ), but these studies have not compared randomly assigned treated groups with untreated or minimally treated controls at follow-up. One recent study (Kazdin et al. , 1987) has accomplished that task. These investigators found significant positive effects at l-year follow-up on both home and school functioning in 7- to 12-year-old children after a combined course in which both parents and children received training (the children were trained in problem-solving skills). The most recent study relevant to the present one is by Pisterman et a1. (1989) who found improved compliance in hyperactive preschoolers at 3-month follow-up after a parent training intervention but found no significant effect on Connors Hyperactivity ratings. A previous investigation by the authors (Strayhorn and Weidman, 1989) examined effects of a preventive mental health intervention with parents of preschool children . The present study reports the results of a follow-up 1 year after the completion of this intervention. Method Pre vious Intervention

The study recruited low-income parents who complained Accepted May 22, 1990 . The authors performed this study while at Western Psychiatric Institute and Clinic, the University of Pittsburgh. Pittsburgh. PA . The authors are now at Allegheny General Hospital. Pittsburgh. PA . Dr. Jacob Cohen was statistical consultant f or this projec t. Doug Fitzgerald performed the statistical analyses fo r this article. This work was supported by NIMH grants R01 MH41127 and R23 MH39461. Reprint requests to Dr . Strayhorn, Early Childhood Behavior Disorders Clinic, 1 Allegheny Square. Ste. 414, Pittsburgh, PA 15212 . 0890-8567/9113001-0138$02.00/0© 1991 by the American Academy of Child and Adolescent Psychiatry .

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of at least one behavioral or emotional problem in their preschool children. Parents were recruited through meetings at Head Start centers, through advertisements on bulletin boards and in classified advertising flyers , through referrals from pediatricians and mental health professional s, and through word of mouth by other parents . Families whose primary language was not English or whose children had vocabulary test standard scores under 50 (where 100 is the population mean and 15 the standard deviation ) were excluded. Parents were fully informed as to the nature of the experimental and control interventions and gave written consent. Those families who finished preintervention assessments were randomly assigned (sequentially, by drawing a face-down card from a tabletop) to experimental or minimal treatment control conditions . Experimental group parents were offered extensive training in parent-child interaction skills; control group parents were offered a briefer exposure to a subset of the parent-training information. The control group for the study watched two videotapes: one on the use of time-out (Patterson, 1982) and one on use of positive reinforcement (Research Press, 1983); control group parents also received a pamphlet on parenting suggestions written by the first author. The experimental group intervention included group training involving instruction and role-playing practice and individual sessions involving modeling and practice in conducting sessions of conversation, story reading , and dramatic play with the child. The stories and plays used in the intervention were all designed to model prosocial behavior for the child. Thus, there was an effort to affect the child 's fantasy as a means toward affecting his behavior. Parents were given photocopies of these stories and plays , written by the first author , to use with the child at home . The intervention was delivered to parents by research assistant paraprofessionals. Outcome measures for this postintervention study were taken an average of 139 days after the last group meeting ; for those parents participating in individual sessions with l.Am.Acad. Child Adolesc .Psychiatry, 30:1 .January 1991

PARENT-CHILD INTERACTION TRAINING FOLLOW-UP

the child, the postintervention measures took place an average of 33 days after the last session. Thus, the study was described as something of a mix between posttest results and follow-up. The experimental group improved statistically significantly more than the control group on several measures. These included parent ratings on subscales measuring attention deficit hyperactivity symptoms and internalizing symptoms on a version of the Behar Preschool :Behavior Questionnaire; a parental estimate of the frequency of positive and negative behaviors by the child; and a parental rating of DSM-III-R symptoms of attention deficit hyperactivity disorder in the child. Also significant were 'the ratings of both parent and child behavior in videotapes of parent-child play sessions viewed by assistants blind to ·the intervention status of the subjects. Consumer satisfaction ·was significantly higher in the experimental group, although 'it was high in both groups. The experimental group showed significantly more improvement in self-reported parenting practices only when those parents randomized to the ex·perimental group but attending zero training sessions were eliminated from the sample. Differences in ratings of child behavior by preschool teachers did not attain statistical significance, although they were in a direction favoring the control group. After the posttesting, parents and children received no additional intervention. Sample Characteristics

Ninety-eight parents or caretakers finished the preintervention assessment and were randomly assigned to experimental or control conditions; 50 were assigned to experimental and 48 to control. These 98 parents or caretakers enrolled 105 children into the study (seven parents enrolled two siblings into the study). Follow-up data on 84 children were obtained from 77 caretakers. Forty parents and 45 children were in the experimental group, and 37 parents and 39 children were in the control group. For 56 of the children, teacher ratings were obtained at both preintervention and follow-up. Fiftyfive per cent of those children were in kindergarten at the time of follow-up; the remainder were in a preschool classroom. Of those children, 25 were boys, and 31 were girls. Demographic characteristics of the subsample available for postintervention assessment, a subsample overlapping highly with the one available for follow-up, were presented by Strayhorn and Weidman, 1989. The subsample in the present study has the following characteristics. The children were of average age, 3 years and 9 months, at the beginning of the study on October 1, 1987; thus, at the time of the follow-up in March 1989, they were of average age, 5 years and 2 months. There were 36 males and 48 females. Racial composition was 31% white, 64% black, and 5% other. The percentage of families with both biological parents living together was 42%. The person participating in the training was the biological mother for 90% of the subjects. Fortyfive and one-half percent of the primary caretakers had depression scores on the Beck Depression Inventory representing mild depression or greater; 26% had scores representing moderate depression or greater. For 39% of the J.Am.Acad. Child Adolesc. Psychiatry, 30:1, January 1991

children, their caretakers endorsed eight or more of the 14 DSM-III-R criteria for attention deficit hyperactivity disorder at preintervention; for 32% of children, their caretakers endorsed five or more of the nine criteria for oppositional disorder. Data Collection Strategy

Permission for the follow-up measurements was formally obtained at the beginning of the study. The parents in the follow-up subsample were contacted by telephone to remind them that questionnaires would be sent to them and to their children's teachers. From these telephone calls, the identity and address of the child's kindergarten or preschool teacher were obtained. Shortly thereafter, questionnaires were sent by mail to the parents and teachers. The intervention ended at various times between October 1987 and May 1988 for the various families; the questionnaires were sent in March 1989. Parents were offered $16.00 and teachers $12.00 in exchange for completing and mailing back the questionnaires by the deadline. Outcome Measures Given at Follow-up By questionnaire, the parents completed the Behar Preschool Behavior Questionnaire, a checklist of the DSM-IIIR criteria for oppositional and attention deficit disorders, ratings of depression items from the Achenbach Child Behavior Checklist, and the Parent Practices Scale. All of these variables were examined in the follow-up outcome evaluation. By questionnaire, the teachers completed, the Behar Questionnaire, the Achenbach depression items, and the ratings of the DSM-III-R criteria for oppositional and attention deficit disorders. Since the authors wished to look at improvement, and since the Behar Scale was the only one of these measures for which there were preintervention ratings by classroom teachers, the Behar instrument was used as the outcome measure for classroom ratings. The children's standard scores on the reading portion of the California Achievement Test were obtained from the records of the Board of Education. Preintervention verbal ability was used as the covariate for this follow-up analysis. Descriptions of Measures Parent Practices Scale (Strayhorn and Weidman, 1988). Items in this instrument have to do with how much approval and disapproval the parent gives the child, how much the parent reads to the child, whether the child is punished for crying, and other aspects of favorable and unfavorable parenting practices. Commands Self-Report. This is a questionnaire developed by the authors in which the parent is presented with hypothetical situations in which a parent issues a command to a child; the respondent is asked to say whether giving the command was a good idea or not a good idea. The score is achieved by counting the number of unreasonable commands the respondent endorses as reasonable. This measure was not given at follow-up, but the gain from preintervention to postintervention was studied as detailed later. Parent Behavior in Play with Child Scale. This is an 139

STRAYHORN AND WEIDMAN

instrument the authors developed wherein observers rate the behavior of parents after watching videotaped parent-child interactions. At pretest and posttest times, the parent and child were provided standard toys and books and directed to spend 25 minutes together however they wished; the ensuing interaction was videotaped and rated by research staff blind to the experimental versus control status of the parents and children . Items on this scale have to do with how successfully the adult communicates enthusiasm about spending time with the child, gives approval to the child, has nondirective conversation with the child, plays imaginatively with the child, and so forth. This instrument in this sample had high internal consistency (coefficient alpha = 0.902) and high interrater reliability (intraclass correlation = 0.945). The mean scores for two raters were used for all analyses. This instrument was not used at follow-up, but the gain from preintervention to postintervention was studied as detailed later. Beck Depression Inventory . The short form of this inventory (Beck, 1967) was used to measure parents' depression at preintervention and postintervention and not at follow-up . Its relevance to this study concerns sample description only. Behar Preschool Behavior Questionnaire . This is a questionnaire with three subscales : hostile-aggressive, anxious, and hyperactive-distractible. Primarily used as a rating scale for preschool teachers and classroom observers, it also has validity as an instrument for parent report on child behavior (Behar, 1977). Parents and preschool or kindergarten teachers were sent these questionnaires at follow-up . The questionnaires were also completed by parents and by preschool teachers (if the child was in preschool) at preintervention and at postintervention. Since the authors' own experience and numerous psychometric studies have indicated that the reliability of a scale rises as the number of degrees allowed as possible choices for the answers is increased (Nunnally, 1978), and since there was an interest in using the Behar as a measure of change rather than comparing the scores of individual children to norms, the Behar Scale was altered to provide seven choices, ranging from "no problem" to "very large problem," rather than the original three choices. To obtain a composite score that gave equal weight to the three factors of the Behar scale, i.e., hostile-aggressive, anxious, and hyperactive-distractible, the z-scores of these three subscales were averaged to get a composite behavior rating score for both parents and teachers. Depression Itemsfrom Teacher Report Form. To measure the construct of depression, both teachers and parents were given the following items from the Achenbach and Edelbrock (1986) Teacher Report Form, using the same sevendegree scale mentioned above: cries , feels unloved, feels worthless, feels guilty , overtired, apathetic , talks about killing self, underactive, unhappy, dislikes school, and withdrawn. Parents' and Teachers' Ratings on Oppositional Disorder and Attention Deficit Hyperactivity Disorder Items from DSM-Ill-R. With minimal changes in wording, parents and teachers were presented with the criteria for these two dis140

orders from the DSM -III-R. Respondents were asked to endorse each item as "true" or "not true" about the child; the number of criteria endorsed as true were counted. Verbal Ability Measures. In order to get a very reliable measure of the child's vocabulary , the standard scores of the following three tests were averaged : the Peabody Picture Vocabulary Test-Revised, versions L and M (Dunn and Dunn, 1981), and the Gardner Expressive One-Word Picture Vocabulary Test (Gardner, 1979). These tests were given at preintervention and postintervention times and were used as covariates in the study of achievement test scores in the present analysis. Achievement Test Results. The public school system that most of these children entered at kindergarten gave the Califomia Achievement Test (CTBIMcGraw-Hill, 1987) in April of the kindergarten year. The total reading standard score was examined as an outcome measure of academic achievement. Parent Participation in Intervention In the subsample that makes up the analysis for this article, 40 experimental group parents came for preintervention and follow-up assessments; of these, 35 showed up for at least one training session; 26 completed the "training exercises" curriculum; 17 had at least one monitored play session with their children; 14 met the criterion level of performance in the mastery learning paradigm for sessions . The average parent participated in approximately 12.5 hours of training. In the results reported below, the experimental group was defined as all families randomized to that group , even the 13% of them who came to 0 intervention sessions . This was done so as not to confound effects of self-selection of parents with treatment effects. This method is "conservative" in that it works against finding positive intervention effects-that is, it increases Type 2 errors and decreases Type 1 errors. Blind Nature of Ratings Obviously the parents who participated in the interventions were not blind to the intervention status. At postintervention time, the videotape raters were blind to the subjects' intervention status as they rated interactions . At follow-up, it was assumed that the teachers would be blind to intervention status, since the intervention had taken place the previous year and there would be no reason for the new teachers to know any details of the experiment. However, to check out the possibility that the parents could have unblinded the teachers through conversations with them, brief telephone interviews were conducted with 18 out of the 36 teachers who sent in follow-up ratings. Not one of these 18 teachers was even aware that the study contained two groups , much less what the two groups were or what group the child was in. Data Analysis As explained in Cohen and Cohen (1983), the preferred method for analysis of change is multiple regression of the postscore outcome variable as a function of the prescore of that variable and the experimental status dichotomy. A very J.Am. Acad. Child Ado/esc. Psychiatry, 30:1, January 1991

PARENT-CHILD INTERACTION TRAINING FOLLOW-UP TABLE

Outcome Measure Parent Practices Scale Parent Behar Composite Parent rating, child depression Teacher Behar Composite Teacher Behar Hostile Teacher Behar Anxious Teacher Behar Hyperactive California Achievement Test Reading

1. Effect of the Intervention N (experimental)

Partial Correlations-

36 34 36 25 25 25 25

43 43 44 30 31 31 30

0.17 -0.048 -0.064 -0.27 -0.22 -0.22 -0.29

0.34 0.096 0.13 0.57 0.45 0.44 0.60

0.14 0.68 0.57 0.046 0.11 0.11 0.035

14

24

0.17

0.36

0.31

N (control)

aPartialcorrelations are of group membership with postintervention outcome measures, with prescores partialled out. Signs of partial correlations reflect directions of scoring of the instrument. bD values represent the difference in improvement between experimental and control groups, in standard deviation units. Signs of D-scores are defined so that a positive score means a better result for the experimental group. cp values are for the significance of the partial correlation.

useful summary statistic from that regression is reported, i.e., the magnitude and significance of the partial correlation of the group membership dichotomy with follow-up scores, with prescores "partialled out. " The square of this number answers the question, "How much of that variance in the follow-up score not accounted for by the prescore was explained by the intervention?" The D statistic is also reported (Cohen, 1977), which summarizes how much more the experimental group improved than did the control group, in terms of a standard deviation unit based on the weighted sum of the standard deviations of both groups at preintervention. According to the rules of thumb presented in Cohen (1977), D values of 0.2, 0.5, and 0.8 may be considered to represent small, medium, and large effect sizes, respectively. In order to give a more descriptive representation of what happened for the two groups, a regressed gain score (Cohen and Cohen, 1983) was computed for the composite teacher • behavior rating, and means and standard deviations of the . gain scores for the experimental and the control group are reported, respectively. The question was raised as to whether the relation between the intervention and the outcome measures might be confounded with the sex of the child or with school grade (i.e., preschool or kindergarten status) at the time of follow-up. To answer this question the correlations of outcome variables and the experimental status dichotomy with sex and follow-up grade were inspected. Next, a regression equation was formed that statistically controlled or "partialled out" the effects of these variables from the relation between experimental status and outcome. In order to study the possible mechanism for significant improvements found in the experimental group with respect to attention deficit-hyperactivity symptoms, the correlation between improvement in these symptoms according to teacher ratings and improvement of the parents in parenting variables from preintervention to postintervention was examined. It was reasoned that if changes in parent behavior were correlated with improvements in children's classroom behavior, it would be more difficult to dismiss improvement J.Am. Acad. Child Adolesc. Psychiatry, 30:1, January 1991

in classroom behavior as a Type 1 error. Regressed change scores were formed for the following: classroom hyperactivity ratings from pretest to follow-up, the parent practices scale, the parent commands measure, and the parent behavior in videotaped play with the child from preintervention to postintervention. The Pearson correlations of the gain scores in parenting with gain scores in classroom behavior were examined, taking into account when computing significance levels the two degrees of freedom lost by correlating two gain scores. The question of how much the Behar subscales correspond to DSM items and items chosen as depression items was approached by examining Pearson correlations among these measures. All significance tests referred to herein are two-tailed. Results

Effect of Intervention

Table 1 presents significance levels and effect sizes for the outcome variables listed above. To summarize, the composite rating by teachers of children's behavior showed significantly greater improvement by the experimental group than the control group. In examining the individual subscales of the teacher rating scale, the attention-deficit-hyperactivity subscale showed significantly greater improvement for the experimental group; the other two subscales showed effects in the desired direction but failed significance, as did the parent ratings. The achievement test scores failed to reach significance, but the N of subjects who attended kindergarten was too small to conclude much from this analysis. For the teachers' composite Behar scale, formed by averaging z-scores, the experimental group improved by an average of 0.18 units (standard deviation was 0.72 units), whereas the control group deteriorated by an average of 0.21 units (standard deviation was 0.67 units). Results after Adjustment for Sex and School Grade

In the present sample, the sex of the child was not sig-

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STRA YHORN AND WEIDMAN TABLE

Outcome Measure Teacher Behar Composite Teacher Behar Hostile Teacher Behar Anxious Teacher Behar Hyperactive

2. Effect of the Intervention on Teacher Ratings with Adjustment for School Grade at Follow-up

N (control)

N (experimental)

25 25 25

30 31 31

25

30

Db

p

- 0.32 -0.23 - 0 .25

0 .68 0.48 0 .51

0.018 0 .089 0 .074

- 0.36

0 .77

0.0084

Partial Correlations"

"Partial correlations are of group member ship with postintervention outcome measures, with prescores and school grade partialled out. bD values represent the difference in adjusted gain scores between experimental and control groups in standard deviation units .

nificantly related to the behavior outcome variables (the point-biserial correlation with composite teacher rating was 0.06; p = 0.67). Controlling for the child's sex did not alter the results. Controlling for grade at follow-up also did not appreciably alter the results with parent-rated behavior. Grade at follow-up, however, was related to teacher-rated outcome, with the kindergarten children rated as significantly less well behaved than the preschoolers (the pointbiserial correlation of grade with composite Behar teacher rating was = 0.34; p = 0.01). There were more experimental children in the less-favorably rated kindergarten classes (58% of experimental children, 52% of control children; difference not significant by chi-square). The interrelation of variables was such that school grade at followup was a "suppressor variable" that had attenuated the apparent effect of the intervention in the analysis presented in Table 1. When school grade was included in the regres sion equations to adjust for its effects, the effects of the intervention on follow-up teacher ratings were further in favor of the experimental group. These results are presented in Table 2. When adjusted for school grade, the two-tailed p values for all subscales of the teacher ratings are under 0.1, the p value for the hyperactivity subscale is less than 0.01, and the effect size for the hyperactivity subscale is "large. " Test for Confounding by Subsample Available When it was noticed that the effects at follow -up were different from those at postintervention, the question was raised of whether the differences could have resulted simply from the different subsamples available at each of those testing occasions . Accordingly, the subsample available at follow-up was selected and the postintervention results were reanalyzed for that subset of subjects. The results resembled the previously reported preintervention results more than the follow-up results and confirm the impression that changes took place over time between postintervention and followup. Correlations of Improvement in Parent Behavior with Improvement in Children's Classroom Behavior The correlations between improvement in parenting, by the three measures of this construct, and the improvement in child classroom hyperactivity are given in Table 3. In the authors' previous study, the variable most sensitive to intervention effects was the blind ratings of parent behavior in the videotaped interactions with the child. The parents' 142

TABLE 3. Correlation s of Improvement in Parenting Behaviors from Preintervention to Postintervention with Improvement in Child Classroom Hypera ctivity from Preintervention to Follow-up

Parent Practices Child classroom Hyperacti vity

r = 0.2 8 N = 51 p = 0.055

Commands r N p

Videotaped Play

= 0 .19 = 51 = 0 .19

r N p

= 0 .38 = 49 = 0.0085

gain scores in the videotape measure from preintervention to postintervention predicted the child's improvement on teacher hyperactivity scores from preintervention to followup with r = 0.38; this result was significant at the 0.01 level. The similar analysis for the parent practices scale yielded r = 0.28 and p = 0.055. Relation of Behar Subscales to DSM Items and Achenbach Items An examination of the follow-up measures reveals that the Behar subscales of hostile-aggressive and hyperactivedistractible measure constructs similar to the DSM oppositional-defiant disorder items and attention deficit hyperactivity disorder items, respectively. For parents , the correlations between the Behar subscale and the corresponding DSM scale ratings were 0.62 and 0.74, respectively. For teachers, the correlations between the Behar subscale and the corresponding DSM scale ratings were 0.85 and 0.85, respectively. Furthermore, there was an overlap between the Behar anxious subscale (which has been called internalizing , because it contains depressive-like items as well) and the depression-related items selected from the Achenbach scale . For the parents, the correlation between the Behar anxious and the Achenbach items was 0.69 ; for the teachers, the correlation was 0 .80 . These correlations approach those found in split-half correlations of a single measure. Thus, they strengthen confidence in the clinical relevance of the Behar subscales. Discussion The results at follow-up 1 year after the postintervention measures are surprising. At postintervention positive effects as rated by parents with lack of significant generalization to classroom ratings were reported (Strayhorn and Weidman, 1989) and other investigators were cited who had also found such results (Forehand and McMahon, 1981, p. 153). The effects on teachers' ratings 1 year after intervention thus represents a "sleeper" effect and one that was not l .Am.Acad. Child Adolesc.Psychiatry, 30:1 ,l anuary 1991

PARENT-CHILD INTERACTION TRAINING FOLLOW-UP

expected from previous findings. It certainly demands replication. There is a possibility that any significant finding is a Type 1 error. However, the fact that the improvement in parent behavior toward the child during the intervention time, as measured by the blindly rated videotapes of parent-child interaction, is correlated at r = 0.38 with the improvement ,in the child's classroom hyperactivity does strengthen the notion that the classroom behavior improvement actually has something to do with the intervention. The children who 'improved most in the classroom tended to be the ones whose parents had improved the most in the videotaped interaction. '(The experimental group parents had made highly significant and large gains, relative to the control group, on the videotape measure at postintervention.) The fact that attention deficit symptoms seemed to be the behavior most sensitive to the intervention, according to the parents at postintervention and according to the teachers at follow-up, additionally strengthens the idea that the results do not represent chance findings. How can the positive effects on blind teacher ratings be explained? A fIrst guess as to the follow-up effects on teacher ratings is that some sustained time of improved parent-child interaction was required before such improvement affected the child's classroom behavior. A second possibility is that the children's classroom behavior had actually improved at postintervention, but that teachers' opinions about the child were rather crystallized from impressions formed earlier in the year. How can the lack of significant improvement at follow-up on the parent ratings be explained? An optimistic 'guess is that the parents' expectations of the children gradlually adjusted over time, so that improved behavior noted at postintervention became, for the average experimental group parent, simply the expected norm by the time of follow-up. Another possibility is that the parents had simply forgotten their improved parenting patterns by the time of follow-up, and the children responded accordingly to the .parents, while still retaining some positive habits with the teachers at school. It is in some way surprising that any positive effects at follow-up were seen at all, given that 13% of the followup sample failed to attend even one intervention training session, and only 14 out of 40 experimental group parents met the criterion for mastery learning of the material presented. The investigators certainly were not able to provide, via an average of 12.5 hours per parent, instruction doing justice to the vast set of skills involved in parent-child interaction. It can be guessed that much larger effect sizes could be seen if many more hours of training could be delivered to the average parent. The question of how to motivate parents to spend the time necessary to receive the intervention is as large a challenge, or larger, than that of what to include in the intervention itself. The finding of significant effects on classroom attention deficit symptom ratings leads to speculation on how this intervention may have helped these symptoms. Perhaps (I) a protective factor against attention deficit hyperactivity disorder symptoms is learned competence in sustaining attenJ.Am.Acad. Child Adolesc.Psychiatry, 30:1, January 1991

tion to verbally encoded information, and (2) such learned competence in the child is promoted by practice in and reinforcement for longer and longer periods of time in listening to stories, conversing with parents, and participating in dramatic play. This intervention program also emphasized parental influence of the child representing a benign form of moral indoctrination and an improvement in the quality of the parent-child relationship, as contrasted with some parent training programs that have emphasized more of a contractual quid pro quo in which compliance is exchanged for parental rewards. It remains to be seen how crucial these content differences are. References Achenbach, T. M. & Edelbrock, C. (1986), Manualfor the Teacher's Report Form and Teacher Version of the Child Behavior Profile. Burlington, Vermont: University Associates in Psychiatry. Baum, C. G. & Forehand, R. (1981), Long term follow-up assessment of parent training by use of multiple outcome measures. Behavior Therapy 12:643-652. Beck, A. T. (1967), Depression: Clinical, Experimental and Theoretical Aspects. New York: Harper & Row. Behar, L. B. (1977), The Preschool Behavior Questionnaire. J. Abnorm. Child Psychol., 5:265-275. CTB/McGraw-Hili (1987), California Achievement Tests, Forms E and F: Technical Report. Monterey, CA: CTB/McGraw-Hili. Cohen, J. (1977), Statistical Power Analysis for the Behavioral Sciences, Revised Edition. New York: Academic Press. - - & Cohen, P. (1983), Applied Multiple Regression/Correlation Analysisfor the Behavioral Sciences, Second Edition. Hillsdale, NJ: Lawrence Erlbaum Associates. Dumas, J. E. (1989), Treating antisocial behavior in children: child and family approaches. Clinical Psychology Review, 9:197-222. Dunn, L. M. & Dunn, L. M. (1981), Peabody Picture Vocabulary Test-Revised. Circle Pines, MN: American Guidance Service. Forehand, R. L. & McMahon, R. J. (1981), Helping the Noncompliant Child: A Clinician's Guide to Parent Training. New York: Guilford Press. Gard, G. C. & Berry, K. K. (1986), Oppositional children: taming tyrants. Journal of Clinical Child Psychology, 15:148-158. Gardner, M. F. (1979), Expressive One-Word Picture Vocabulary Test. Novato, CA: Academic Therapy Publications. Kazdin, A. E. (1987), Treatment of antisocial behavior in children: current status and future directions. Psychol. Bull .. 102:187-203. - - Esveldt-Dawson, K., French, N. H. & Unis , A. S. (1987), Effects of parent management training and problem-solving skills training combined in the treatment of antisocial child behavior. J. Am. Acad. Child Adolesc. Psychiatry. 26:416-424. Nunnally, J. C. (1978), Psychometric Theory. Second Edition. New York: McGraw-Hill. Patterson, G. R. (1982), Time out. (Videotape). Eugene, OR: Northwest Family & School Corporation. Pisterman, S., McGrath. P.. Firestone. P.. Goodman. J. T., Webster, I. & Mallory, R. (1989). Outcome of parent-mediated treatment of preschoolers with attention deficit disorder with hyperativity. J. Consult. Clin, Psychology. 57:628-635. Research Press (1983). Parents and children: A Positive Approach to Child Management, (Videotape). Champaign, IL: Research Press. Strayhorn. J. M. & Weidman. C. S. (1988), A parent practices scale and its relation to parent and child mental health. J. Am. Acad. Child Adolcsc. P.\'\'chiatrv.27:613-618. - - & Weidman. C. S. (1989), Reduction of attention deficit and internalizing symptoms in preschoolers through parent-child interaction training. J. Am. Acad. Child Adolesc. Psychiatry, 28:888896. Webster-Stratton, C., Hollinsworth, T. & Kolpacoff, M. (1989), The long-term effectiveness and clinical significance of three cost-effective training programs for families with conduct-problem children. J. Consult. Clin. Psychology, 57:550-553

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