aggressive behavior

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Journal of Behavior Therapy and Experimental Psychiatry 37 (2006) 188–205 www.elsevier.com/locate/jbtep

The outcome of group parent training for families of children with attention-deficit hyperactivity disorder and defiant/aggressive behavior Jeffrey S. Danfortha,, Elizabeth Harveyb, Wendy R. Ulaszekc, Tara Eberhardt McKeed a

Department of Psychology, Eastern Connecticut State University, 83 Windham Street, Willimantic, CT 06226-2295, USA b Department of Psychology, University of Massachusetts, Tobin Hall, Box 27710, Amherst, MA 01003-7710, USA c Department of Psychiatry, The Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1230, New York, New York, 10029-6574, USA d Department of Psychology, Hamilton College, 198 College Hill Road, Clinton, NY 13323, USA Received 31 July 2003; received in revised form 15 March 2005; accepted 10 May 2005

Abstract The effects of group parent training on parent behavior, and on the behavior of 45 children with attention-deficit hyperactivity disorder and defiant aggressive behavior, were evaluated with a pre–post design. Parent training included didactics on the features and etiology of ADHD and its relationship to defiant/aggressive behavior, as well as parenting skills that adhered to parameters established in the Behavior Management Flow Chart (BMFC). The logic that guided the construction of the program and the unique aspects in the form and content of the parent training are identified. Outcome data show that training reduced childrens’ hyperactive, defiant, and aggressive behavior, improved parenting behavior, and reduced parent stress. These data are comparable to previous outcome research evaluating the

Corresponding author. Tel.: +1 860 465 4553; fax: +1 860 465 4541.

E-mail address: [email protected] (J.S. Danforth). 0005-7916/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbtep.2005.05.009

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efficacy of parent training with the BMFC. The advantages of programs that are efficacious in group settings are discussed. r 2005 Elsevier Ltd. All rights reserved. Keywords: Behavior disorders; Parent training; ADHD

1. Introduction Parent training research for families of children with attention-deficit hyperactivity disorder (ADHD) and defiant aggressive behavior has revealed only modest improvements in child compliance and aggression. It is unclear whether parent training programs for such families adequately modify child and parent behavior (Graziano & Diament, 1992; Pelham & Hinshaw, 1992), especially when compared with outcome research examining stimulant medication (Multimodal Treatment Study of Children with ADHD Cooperative Group, 1999). There is far more research on stimulant medication than behavioral treatments for such children (Pelham, Wheeler, & Chronis, 1998). Perhaps this is a factor in the current trend toward psychostimulant treatments. Nonetheless, the controversy surrounding the overuse of psychostimulant medication (LeFever, Arcona, & Antonuccio, 2003), as well as the potential for negative side effects to medication, the failure of research to demonstrate enduring change after the cessation of medication, and the fact that 20–30% of children with ADHD do not have a positive response to stimulant medication (DuPaul, Barkley, & Connor, 1998) demonstrates the need for improved parent training programs. The effects of a typical regimen of stimulant medication wear off by evening (Garland, 1998), so even parents whose children are on an effective dose of medication may benefit from parent training (see also Willis, 2003). Although recent reviews indicate the likelihood that behavioral treatment is effective for ADHD (Pelham et al., 1998), it is unclear whether such treatment is relevant to children diagnosed with comorbid ADHD and other disruptive behavior disorders such as oppositional defiant disorder (ODD). This is important because even though characteristics of ADHD and ODD are highly correlated and a significant proportion of ADHD children have associated disruptive behavior, research suggests that children with co-occurring ADHD/ODD behavior have a distinctive pattern of dysfunction dissimilar to ADHD alone and ODD alone children, and that the etiology of familial transmission is different (Hinshaw, 1994, p. 74–76), implying ‘‘that the comorbid subgroup may be qualitatively distinct from the single disorders’’ (Hinshaw, 1994, p. 75). ‘‘Considerable room for improvement remains in children treated with well established treatments such as parent training’’ (Pelham et al., 1998, p. 197). Recently, a new child behavior management system was designed. This program is called the Behavior Management Flow Chart (BMFC) (Danforth, 1998a). The primary target behavior of the BMFC is noncompliance and other disruptive behaviors such as aggression and tantrums. Danforth (1998a; 2001b) details critical differences in content and mode of presentation between the BMFC and other

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widely distributed behavioral parent training programs. Three small sample outcome studies have evaluated the efficacy of parent training using the BMFC with families of children with ADHD and ODD (Danforth, 1998b, 1999, 2001a). Outcome data reveal reduced children’s oppositional and aggressive behavior, improved parenting behavior, and reduced parent stress. These small sample studies were important because ADHD children demonstrate considerable individual differences to behavior management protocols and information about individual response to treatment is lacking (Hoza, Pelham, Sams, & Carlson, 1992; Pelham & Hinshaw, 1992). Nonetheless, an inherent limitation in these previous outcome studies was the small number of participants. The purpose of this study was to evaluate the effects of group parent training, using parameters established in the BMFC, on parent behavior as well as the hyperactive and the aggressive/defiant behavior of their children. Group parent training facilitated evaluation of a larger number of children and parents. Group parent training also has other advantages. Families of children with the most serious child management problems are more likely to participate in group-based parenting services than individual family services. In addition, such groups may be more cost and time effective (Cunningham, Bremner, & Boyle, 1995), allowing services to a greater number of families. Goals of the present study included evaluation of whether the parent training reduced hyperactive, noncompliant, and disruptive child behavior, improved parenting behavior, and reduced parent stress. This study adds to prior BMFC parent training research by studying a significantly larger number of parents and their children with ADHD and aggressive/defiant behavior in groups rather than individual sessions.

2. Method 2.1. Participants Eighty-four families were recruited through advertisements in local newspapers, or were referred from their pediatrician or school nurse, to a university-based parent training program for families with disruptive ADHD children. Forty-nine families met criteria for the study and participated in one of five parent training groups. Participants were 46 mothers and 26 fathers. Target children in these families (45 boys and 4 girls) ranged in age from 4 to 12 (M ¼ 7.19, SD ¼ 2.35). Families with more children at home and families who describe busy schedules are less likely to enroll in parent training programs (Cunningham et al., 1995). Therefore, during the training sessions, undergraduate students provided childcare for the children and their siblings. Children selected to participate met Barkley’s, 1988 diagnostic research criteria for ADHD. The children also met the following criteria: (a) they had a score of at least 80 on the Peabody Picture Vocabulary Test—Revised (Dunn & Dunn, 1981), (b) based on the parent version of the Diagnostic Interview Schedule for Children, Fourth Edition (DISC; Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000) they

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met DSM–IV criteria for ADHD, Combined Type (American Psychiatric Association, 1987), (c) they had a T-score of at least 65 (1.5 SD above the mean) on the hyperactivity factor and the aggression factor of the Behavior Assessment System for Children—Parent Report (BASC, Reynolds & Kamphaus, 1992), and (d) they had a T-score at least 1.5 SD above the mean on the pervasiveness and severity factors of the Home Situations Questionnaire (HSQ; Breen & Altepeter, 1991). Furthermore, based on the DISC (Shaffer et al., 2000) 41 of the children met DSM–IV criteria for ODD (American Psychiatric Association, 1987). None of the children had any other psychological disorders. Mothers’ average age was 37.39 years, and ranged from 24 to 53 years. Fathers’ average age was 38.44 years, and ranged from 25 to 58 years. Mothers and fathers averaged 13.98 and 14.91 years of education, respectively. Families earned an average annual income of $55,000. 2.2. Parent training Parent training followed pre-treatment evaluation. Sessions were conducted in a group format with nine or ten families per group. Sessions were conducted for 75–90 min, for 8 weeks. Five separate groups were conducted. The 1st and 2nd authors conducted the first group. Both are licensed Ph.D. clinical psychologists. During this first group, the 3rd and 4th authors, both doctoral students in clinical psychology, observed the training sessions and participated in regularly scheduled meetings to discuss program implementation. After the first parent training group was completed, the 1st and 3rd authors co-lead two groups at Eastern Connecticut State University, and the 2nd and 4th authors co-lead two groups at the University of Connecticut. To ensure that the parent training program was conducted consistently across groups, the four authors met on a regular basis to discuss implementation of the program. A MANOVA was conducted comparing the change scores on all of the dependent variables across the five groups. No significant differences were found (p4:25 for both mothers and fathers). There were two parts to the parent training: a didactic exchange on theory and background, and skills training. Parents were explicitly encouraged to ask questions and bi-directional interchanges were common in every session. Table 1 presents the topics and schedule for the parent training sessions. Didactics: First, the features and etiology of ADHD and ODD were presented. The development of these didactic materials was based on a review of research that conducted direct observations of interactions between parents and their children with ADHD (Danforth, Barkley, & Stokes, 1991). The analysis of that data focused on the bi-directional effects of child ADHD behavior and parenting behavior. The conceptual basis for understanding the nature of ADHD was Barkley’s (1997) analysis. The training included basic social learning principles and the implications of coercive processes to child noncompliance (Patterson, 1982), especially as they pertained to parent–child interactions in families of children with ADHD ((Danforth et al., 1991). We described how faulty development in subtle but critical child skills could contribute to disturbed parent–child interactions that further exacerbate faulty development. Parent self-blame was dismissed as a reasonable explanation and

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Table 1 The schedule for training parents with the BMFC Session

BMFC

Parent training

Number

Step

Topic

Parent homework

1

na

Read parent handout

2 3

1 2–6

4

7–26

Didactic instruction on ADHD, ODD social learning principles, and coercion Commands Wait 5 s after command. Praise. Reprimands Warning for timeout. Timeout. Backup for timeout refusal

5

7–26

Same as Session 4

6

1–26

Review specific difficulties and rehearse all BMFC steps

7

Same

8

Same

Review specific difficulties and rehearse all BMFC steps Didactic Instruction on social learning principles, ODD, ADHD, and coercion. Review specific difficulties and rehearse all BMFC steps

Read. Implement Step 1 Read. Implement Steps 1–6 Read. Select timeout location. Select 2 target behaviors, in addition to noncompliance, for timeout. Create a menu of backup consequences for timeout refusal. Implement Steps 1–6 Read. Review program with child. Implement Steps 1–26 in the home using flow chart as a guide. Read, implement Steps 1–26 using flowchart as a guide. Implement BMFC Steps in the community using wallet-sized copies of BMFC as a guide Same Same

Note: The BMFC Steps correspond to the steps in Fig. 1.

solution. Supplemental written materials corresponding to the didactic instruction and each step of the BMFC were presented to the parents to read during and after training sessions.1 Skills: Parent skills were taught during the second part of training. The parenting skills and the step-wise design of the BMFC were derived from a review of published child behavior management research (Danforth, 1998a). Based upon the review, a task analysis of child behavior management strategies was conducted. The BMFC (Fig. 1) is a flow chart of the task analysis. The flow chart synthesizes the research into a cohesive unit that visually depicts steps that adults may be trained to use to manage disruptive misbehavior displayed by children. Description, explanation, modeling, and role-playing with feedback were the techniques used to teach specific parenting skills. 1

A complete copy of the supplemental written materials that correspond to each session and step of the BMFC is available from the first author.

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5.

OUT

OUT 4.

10. Praise

Praise Yes

Yes

3. 2. Comply?

No

9.

7.

6.

1. Command & Reason

8.

Warn about Timeout

Reprimand

(5 secs)

Comply? (5 secs)

No

Yes

24. 23.

25. No

Another Backup?

193

Seperate

Other Timeout Bhvr.

OUT

18. Warn about Timeout

26.

17. 13.

21.

22. No

Present Backup

19.

Do Timeout Well?

Yes

20. (5-10 secs)

Warn about Backup

12. Do Timeout Well?

No

14.

Yes

Command Impose Timeout

15.

End Timeout

Task still to do?

Yes

KEY No

Adult Response Yes/No Option OUT

16. OUT

Fig. 1. The Behavior Management Flow Chart is a flow chart of steps taught to parents. Rectangles indicate an adult response, diamonds indicate a yes/no option, and circles indicate that the interaction is over.

There are many differences in the format of the BMFC program compared with the Hanf-model (1969) programs described by, for example, both Forehand and McMahon (1981) and Barkley (1987). First, the parenting skills were taught in a forward chaining fashion (see Martin & Pear, 1999, p. 135), in the same order that they are presented in the flow chart and consistent with how the parents were to utilize the strategies in the context of child misbehavior. That is, the first response emitted by parents when they wanted to direct their child was a command, and this was the first skill taught; the second response emitted by the parent was to wait quietly for 5 s, and this was the second skill taught, etc. When parents implemented the program in the home, they were given copies of the BMFC and encouraged to post them in their home. When parents implemented the program in the community, they were given wallet-sized laminated copies of the BMFC and encouraged to keep a copy in the car and on their person when they left home. There are also many detailed differences in the skills taught in the BMFC program (see Danforth, 1998a, pp. 250–251). Strategies to prevent misbehavior included tactics for choosing and presenting effective instructions and commands (BMFC step 1). The definition of compliance explicitly focused on commands requiring an

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immediate response, not a delayed response. In addition to the typical alpha command (e.g., Forehand & McMahon, 1981, p. 76), parents were instructed to get their child to attend by getting within 3 m, establishing eye contact, and using the child’s name. Reasons for the directive were included in the body of the commands, and the child was not required to repeat the command back. The need to quietly wait 5 s and allow their children time to respond to direction (BMFC step 2) was a skill that many parents reported as difficult. Praise was emphasized throughout. Praise was presented the moment the child initiated compliance (BMFC step 4). Expressions of effective reprimands (BMFC Step 6) included details about adult proximity to the child, the need for immediate reprimands (at 5 s), eye contact, firmness, volume, brevity, without pointing a finger at the child. Praise was also presented if the child initiated compliance after a warning for timeout (BMFC step 9). Timeout (BMFC steps 12–14) is a complex step that required two parent training sessions. It is also an important and necessary step (see Danforth, 1998a, pp. 240–241). Timeout components included frequent previews of the procedure with the child to reduce timeout resistance. The previews were conducted at home by the parents. Children were not physically guided to timeout and the hyperactive children were not required to sit in a chair. Timeout duration was 1 min/year of developmental age, with 1–2 min of calm behavior required before timeout release. Training also included how to evaluate whether the child was completing the timeout well, and ending timeout in a calming manner without requiring the child to process the event at that moment or promise that they will not repeat the behavior. As part of the homework after training session four, parents were given the option of selecting up to two individually defined target behaviors, in addition to noncompliance, for which timeout would be the consequence. If these additional timeout target behaviors were emitted, parents immediately moved to the diamond above step 12 on the BMFC (Fig. 1) and sent the child directly to timeout without a warning. Typical additional target behaviors included physical aggression and tantrums. Homework for this session also required parents to select effective and practical locations for timeout in the home and community. Efforts to ensure that timeout did not function to allow escape or avoidance of task demands are incorporated in BMFC steps 15–18. Parents were trained to respond effectively when the child refused timeout. As part of the homework after training session four, parents also created an individualized rotating menu of potential backup consequences, one of which was presented if the child refused to go to timeout (BMFC step 22). As part of their backup menu, all parents selected the possible consequence of not allowing the child to continue whatever activity they were currently engaged in for the remainder of that day (e.g., playing with cars). Other potential backup consequences selected by parents included loss of a special privilege for one day, loss of television or screen-time, no playing with other children, no playing outside, loss of special food treats (e.g., dessert), and early bedtime. Back-up consequences were presented that day and never carried over to the following day. Among the parents who completed both pre- and post-training measures, mothers attended an average of 7.38 sessions (range of 5–8 sessions) out of eight, and fathers

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attended an average of 6.33 sessions (range of 3–8 sessions). Three of the fathers completed four or fewer sessions of parent training. These fathers were retained in the analyses because they all had spouses in the program who audiotaped the sessions and went over the material with them at home. No parents were dropped from the analyses because of low attendance. Correlations between number of sessions attended and post-data were not significant for either mothers or fathers. 2.3. Measures Pre–post comparisons were used to evaluate parent training. Because participants in behavioral parent training research do not show uniform degrees of change across outcome measures (Forehand, Griest, & Wells, 1979), three types of outcome measures were used: (a) pre–post administration of standardized rating scales assessing parents’ perceptions of child behavior, self-reported parenting behavior, and parent stress, (b) pre–post telephone interviews to assess behavior in the home, and (c) pre–post home-based audiotape recordings of child behavior and parent behavior management responses. Two weeks passed between the last parent training session and the post-test. Rating scales: To assess disruptive child behavior, parents completed the BASC (Reynolds & Kamphaus, 1992). The BASC is a comprehensive rating scale that assesses a wide range of childhood behavioral disorders. The hyperactivity and aggression factors were used for this study. Research on the psychometric properties of the BASC suggests fine reliability and validity (Reynolds & Kamphaus, 1992), particularly with ADHD children (Ostrander, Weinfurt, Yarnold, & August, 1998). To assess the pervasiveness and severity of child noncompliance behavior across home settings, parents completed the HSQ. Each parent rated his/her child’s defiant behavior across 16 different home settings. Previous research reports satisfactory reliability and validity data (Altepeter & Breen, 1989; Breen and Altepeter, 1991). To assess dimensions of parent behavior, parents completed the following selfreport scales: Parent discipline behavior was assessed using the Parenting Scale (Arnold, O’Leary, Wolff, & Acker, 1993), a 30-item self-report scale that yields robust factors for two dysfunctional parenting styles, overreactive and lax parenting. The overreactive factor indicates the degree to which parenting behavior is tainted with anger and irritability and the laxness factor indicates the degree to which parents acquiesce to child demands, fail to follow through, and present praise after misbehavior. These two parenting styles parallel the authoritarian and permissive parenting styles described by Baumrind (1966). The scale has demonstrated good reliability and validity (Arnold et al., 1993). Satisfactory normative data illustrate that the scale discriminates between parents of children with and without ADHD (Harvey, Danforth, Ulaszek, & Eberhardt, 2001). This scale is important because research with the Parenting Scale shows that parents of boys with ADHD are more likely to report using overreactive and lax strategies than parents of typical boys (Keown & Woodward, 2002). General childrearing was measured using the Modified Child Rearing Practices Report (MCRPR), a 40-item self-report measure of child rearing values and practices. The MCRPR has adequate reliability (Rickel &

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Biasatti, 1982) and validity (Jones, Rickel, & Smith, 1980) and contains two factors, restrictiveness (undesired) and nurturance (desired). Parent stress has been associated with ADHD (Anastopoulos, Guevremont, Shelton, & DuPaul, 1992; Mash & Johnston, 1990) and disruptive child behavior (Eyberg, Boggs, & Rodriguez, 1992) suggesting that the stress adversely affects parental functioning (Anastopoulos, Shelton, DuPaul, & Guevremont, 1993). The Parenting Stress Index—Short Form (PSI, Abidin, 1995) was used to evaluate child characteristics and parent characteristics that may have been a source of stress to the parent/child relationship. Telephone interviews: The Parent Daily Report (PDR; Chamberlain & Reid, 1987), a 34-item checklist of child problem behaviors, served as a parent observation instrument that provided a measure of disruptive behavior in the home setting. Three times per week, 2 weeks during pre-treatment and 2 weeks during post-treatment, undergraduate research assistants conducted telephone interviews with parents who reported if any of the 34 child behavior problems (e.g., aggression, stealing) had occurred in the previous 24 h. Six telephone calls over a 2-week period with the PDR are sufficient to establish a stable estimate of the level of problem behavior (Chamberlain & Reid, 1987). Scores were calculated by summing the number of problem behaviors reported by parents each week. Home recordings: To evaluate specific parent discipline behaviors and child disruptive behavior in the home setting, parents were asked what time of day they typically had the most difficulty with their child. Based on this and information from the HSQ, we co-operatively selected a 1-h period for parents to use a micro-cassette recorder at home, both at pre- and post-treatment. Parents wore the inconspicuous recorders on their waist for 1 h at the same day and time during both pre- and postassessment. Following completion of the program, undergraduate research assistants were trained in the use of a coding scheme for the tapes. These raters were unaware of the hypothesis of the study, and the results of other outcome data. Intraclass correlations were calculated to determine reliability for each code described below.2 An event-based coding system was designed to record the occurrence of specific parent and child behaviors. Codes were developed by identifying parent and child behaviors that the training program sought to change, focusing on those behaviors that did not depend heavily on the coder seeing the interaction. Four parent codes were developed. The Argue code was used when the parent quarreled with their child about their child’s behavior. The Repeat code was used when a command, reprimand, or warning was repeated. The Praise code was used when a parent presented praise or positive affection to the child. Finally, whenever a parent indicated irritation, annoyance, frustration, or anger towards the child, the statement was rated on a 6- point scale from 6 ¼ ‘‘very harsh’’ to 1 ¼ ‘‘slightly annoyed’’. These Negative Tone ratings were summed for each parent. During the coding, two of the raters overlapped on 27% of the tapes. Intraclass correlations for 2

A complete version of the manual with comprehensive definitions and coding rules for the home-based audio recordings is available from the second author.

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the codes were as follows: Argue ¼ .70, Repeat ¼ .94, Praise ¼ .88 and Negative Tone ¼ .84. Two child codes were developed. The same audiotapes utilized for the parenting assessment were used to code child behavior. Child behaviors were coded on both mothers’ and fathers’ audiotapes. The Noncomply code was used when the child did not comply with a command made by a parent. The General Verbal Misbehavior code was used when the child engaged in vocal misbehavior such as talking back, defiance, arguing, or swearing. Intraclass correlations based on frequencies for these two codes were .82 and .84, respectively.

3. Results Repeated measures 1-way ANOVAs were conducted comparing pre-/post-scores for the dependent variables. An a-level of .05 was used for all statistical tests. Measures of effect size are presented to provide information about the strength of the relationship between the independent variable and the dependent variable (Cohen, 1992). Four mothers and two fathers (parents of four children) dropped out of the study before parent training was completed. Data from mothers and fathers are presented separately. Table 2 presents the scores from the parent rating scales designed to assess child behavior. There was a significant decrease in scores on the BASC hyperactive factor for mothers and fathers. There was also a significant decrease on the BASC aggression factor for mothers and fathers. As assessed by the BASC, effect sizes were very large for mothers’ hyperactivity, large for mothers’ aggression and fathers’ hyperactivity, and medium for fathers’ aggression (Cohen, 1992). The pervasiveness of noncompliance in the home was assessed with the HSQ number of problem settings factor. This factor identified a significant decrease in the pervasiveness of noncompliance as evaluated by mothers and fathers. The severity of noncompliance in the home was assessed by the HSQ severity score factor. This factor identified a significant decrease in the severity of noncompliance as evaluated by mothers and fathers. As assessed by the HSQ, effect size was medium for number of problem settings and large to very large for severity of noncompliance. The bottom of Table 2 presents data on the average weekly score (the score was the sum of the number of problem behaviors reported by parents each week) from the PDR telephone interviews conducted for 2 weeks during both pre- and posttreatment. Repeated measures 1-way ANOVAs illustrated a significant decrease in the number of behavior problems reported by mothers and fathers. Effect sizes were large for mothers and medium for fathers. Table 3 presents the scores from the self-report parent rating scales designed to assess parenting behavior. There was a significant decrease in scores on the Parenting Scale overreactive factor for mothers and fathers from pre- to post-test. There was also a significant decrease on the Parenting Scale laxness factor for mothers and fathers. As assessed by the Parenting Scale, effect sizes were very large for mothers’ overreactive behavior and laxness, large for fathers’ overreactive behavior, and medium for fathers’ laxness.

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Table 2 Repeated measures 1-way ANOVAs for the child rating scales and the PDR telephone interview Pre M

Post SD

BASCa hyperactivity Mothers 82.13 (7.63) Fathers 79.68 (12.12) BASCa aggression Mothers 73.40 (10.33) Fathers 73.60 (12.00) HSQb number of problem settings Mothers 12.57 (2.32) Fathers 12.12 (2.55) HSQb severity score Mothers 5.47 (0.89) Fathers 5.11 (1.38) PDRc telephone interview Mothers 63.86 (19.88) Fathers 52.54 (24.28)

M

SD

df

F

p

Effect size

70.95 70.33

(11.84) (10.40)

41 22

47.79 20.54

.0001 .0002

1.15 .83

64.24 66.46

(12.24) (12.26)

41 22

39.96 7.08

.0001 .014

.81 .59

11.00 10.83

(2.78) (3.12)

41 22

16.56 4.77

.0002 .04

.62 .45

4.11 4.08

(1.17) (1.45)

41 22

33.38 12.27

.0001 .002

1.31 .74

47.18 36.92

(18.57) (21.86)

38 23

49.21 20.18

.0001 .0002

.87 .68

a

BASC ¼ Behavior Assessment System for Children. HSQ ¼ Home Situations Questionnaire. c PDR ¼ Parent Daily Report.  po.05. po.01. po.001. b

For mothers there was a significant decrease in restrictiveness complemented by a significant increase in nurturance as measured by the MCRPR. There were no such significant changes indicated for father behavior on the MCRPR. Effect sizes as assessed by the MCRPR were generally small. Finally, the PSI reflects significantly less stress after parent training for mothers and fathers. Effect size was large for mother stress and medium for father stress. Data collected with home-based audio recordings of parenting behavior are presented in the top of Table 4. There was a significant decrease in parental argumentative behavior for mothers but not fathers. There was no significant change in the rate of repeated directions or praise for either mothers or fathers, although there was a trend towards mothers praising more and repeating less. Finally, there was a significant decrease in the rate of maternal negative tone. No such change was indicated for father behavior. With the exception of a medium effect size for mothers’ arguementative behavior and a large effect size for mothers’ negative tone, effect sizes for parent change as assessed by the home audiotapes were small. Data collected with home-based audio recordings of child behavior are presented in the bottom of Table 4. Child noncompliance in the presence of mothers decreased significantly, with a large effect size. There was not a significant change in child noncompliance in the presence of fathers. Child general verbal misbehavior in the

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Table 3 Repeated measures 1-way ANOVAs for the parent rating scales Pre M

Post SD

M

SD

Parenting scale, overreactive factor Mothers 3.80 (0.99) 2.59 (0.82) Fathers 3.77 (0.77) 3.01 (1.82) Parenting scale, laxness factor Mothers 3.26 (0.69) 2.07 (0.70) Fathers 3.18 (1.16) 2.59 (1.08) Modified child rearing practices report, restrictiveness factor Mothers 3.54 (0.65) 3.32 (0.60) Fathers 3.86 (0.70) 3.91 (0.63) Modified child rearing practices report, nurturance factor Mothers 5.54 (0.69) 5.73 (0.63) Fathers 5.35 (0.90) 5.55 (0.78) Parenting stress index Mothers 110.36 (16.59) 98.71 (16.19) Fathers 103.96 (14.01) 97.04 (14.26)

df

F

p

Effect size

41 23

79.33 16.49

.0001 .0005

1.3 .96

41 23

160.84 11.12

.0001 .003

1.71 .53

40 23

7.42 0.40

.01 .53

.35 .08

40 23

5.19 1.70

.03 .21

.29 .24

41 23

29.07 6.98

.0001 .015

.71 .49

 po.05. po.01. po.001

presence of mothers decreased significantly, with a medium effect size. There was not a significant change in child general verbal misbehavior in the presence of fathers.

4. Discussion Multiple outcome measures suggest that group training for parents of ADHD children with defiant and aggressive behavior, according to parameters described in the BMFC (Danforth, 1998a), reduced childrens’ hyperactive, aggressive, and oppositional behavior. Data also indicate improved parenting behavior, and reduced parental stress. Prior to the parent training, the children in the sample had serious behavior problems. The average pre BASC score for hyperactive and aggressive behavior was more than two standard deviations above the mean. Some of the success may have been a product of variables that were unique to the structure of the BMFC training program. For example, parenting skills were taught in a forward chaining manner (Martin & Pear, 1999). Presenting parents with copies of the BMFC to which to refer may have facilitated generalization across settings. In a sense, parents had constant access to a visual representation of the empirical literature on child behavior management. Evaluations of parent training programs should take the medium of information presentation into consideration because the mode of presentation (e.g., forward chaining, the flow chart, group setting) may influence the effectiveness of the training program (O’Dell, Mahoney, Horton, &

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Table 4 Repeated measures 1-way ANOVAs for the home audiotapes, parent and child behavior Pre M

Post SD

Parent argue Mothers 8.86 (11.97) Fathers 5.52 (7.88) Parent repeat Mothers 25.76 (17.99) Fathers 20.08 (20.26) Parent praise Mothers 7.29 (8.31) Fathers 5.52 (7.04) Parent negative tone Mothers 55.57 (45.59) Fathers 27.56 (30.48) Child noncomply Mothers 36.86 (28.16) Fathers 24.00 (24.60) Child general verbal misbehavior Mothers 20.02 (19.47) Fathers 14.40 (14.85)

M

SD

df

F

p

Effect size

3.95 3.32

(3.52) (4.92)

37 18

7.52 0.49

.009 .49

.63 .35

20.95 19.74

(17.08) (20.78)

37 18

2.62 0.02

.11 .88

.27 .02

10.46 6.63

(10.09) (7.13)

37 18

3.64 0.77

.06 .39

.34 .16

28.33 35.53

(23.21) (63.00)

37 18

15.96 0.50

.0003 .49

.74 .17

21.38 18.89

(12.58) (14.93)

37 18

13.01 1.50

.0009 .20

.76 .26

11.82 11.37

(12.65) (10.45)

37 18

10.25 0.29

.003 .60

.51 .24

po.01. po.001.

Turner, 1979). The content differences between the BMFC and other behavioral parent training programs (see Danforth, 1998a, 2001b) may also account for change in parent and child behavior. The content of the didactic training materials and the skills trained were based on reviews of empirical literature (c.f., Danforth, 1998a; Danforth et al., 1991) thus providing a logical explanation for the observed changes. When such an explicit premise guides the construction of a treatment program, then interpretation of the results is facilitated (Barkley, 2000). The dropout rate of 9.15% was good (c.f., Cunningham, Bremner, & Secord-Gilbert, 1993) and this reflects parent willingness to engage in the program. The parenting data are consistent with previous research using the Parenting Scale. For example, Keown and Woodward (2002) show how (a) overreactive parenting influences the extent of child conduct problems among boys with ADHD, and (b) that boys whose mothers use lax parenting are two times more likely to be hyperactive. The present study found that after parent training, both overreactive and lax parenting were reduced. This may account for some declines in child disobedience and hyperactivity. Poor parent skills in setting limits may prevent the development of internal self-control by children with ADHD (Campbell, 1990). This is consistent with the conceptualization of self-control in children with ADHD (Barkley, 1997) that was presented in the didactic portion of the parent training. This supports the idea that proactive strategies such as effective commands, slow pacing,

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and timeout previews, as well as firm limits, help children with hyperactive behavior learn to control their own behavior. There are advantages for such programs that are efficacious in group parent training settings. Families of children with the most serious disruptive behavior problems are more likely to participate in group-based parent training than individual sessions. Furthermore, groups with at least three participants are more cost effective, and the type of social support available in the group setting may contribute to the reduction in parental stress (Cunningham et al., 1995). Cost effectiveness is a critical component of parent training research for families of children with ADHD. The argument could be made that pharmacotherapy is comparatively less cost and time intensive than parent training. If behavioral treatment interventions are to be widely used, then cost and time spent on resources is a variable that should be considered. These child and parent data are comparable to previous outcome research evaluating the efficacy of parent training with the BMFC for families with ADHD/ ODD children (Danforth, 1998b, 1999, 2001a). This suggests that the BMFC parent training program may be an effective component of treatment for disruptive behavior disorders. These data complement prior research. Earlier research used small n designs with a total of 13 child participants. A total of 45 children and 65 parents completed participation in this study. An increased number of children and parents allows for a greater sense of uniformity of data to emerge. Nonetheless, the overall sample size remained small. Thus, medium and large effects may have been detected, but smaller effects may have been missed. With greater power, particularly for fathers, more significant effects may have been found. The pre–post design does not rule out the possibility that this population would have shown recovery without an intervention. However, it is unlikely that spontaneous recovery could fully account for the changes observed in this study. Such recovery is unlikely for three reasons. First, substantial research indicates that ADHD and associated defiant/aggressive behavior do not decline spontaneously but remain stable into adolescence (Abramowitz, Kosson, & Seidenberg, 2004; Barkley, Fischer, Smallish, & Fletcher, 2004; Barkley, 2004). In young adults with childhood onset ADHD, even mood and personality disorders are mediated by the severity of their disruptive behavior (Fischer, Barkley, Smallish, & Fletcher, 2002). Furthermore, parenting practices that account for much of the variance in the correlation between hyperactivity and conduct disorder are stable through the progression from ADHD to the co-morbid condition of ADHD with conduct disordered disruptive behavior. Researchers believe that the bi-directional effects of hyperactive child behavior and faulty parent discipline are the context for such development (Patterson, DeGarmo, & Knutson, 2000). This analysis is the foundation of the approach that guided the construction of the BMFC (see Danforth et al., 1991). Second, the psychometric qualities of the standardized rating scales used to evaluate the outcome are good. Specifically, test–retest reliability indicates the extent to which the rating scales yield consistent results over repeated administrations. If the rating scales possess good test–retest reliability, then the resulting scores should be expected to be relatively stable across the pre-test/post-test administrations, which

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would minimize the degree to which error variance would result in changes in the scores. The test–retest reliability is .84 for the BASC hyperactive and aggressive factors, the Parenting Scale, and the Parent Stress Index. Test–retest reliability for the HSQ number of problem settings and severity score factors is .83 and .89, respectively for mothers, and .60 and .63, respectively for fathers. It seems reasonable, therefore, to attribute the changes in these rating scales to the parent training rather than regression to the mean. Finally, the effect sizes associated with outcome measures support the efficacy of the treatment program. Measures of effect size provided information about the strength of the relationship between the parent training and the dependent variables. There were eight outcome measures from the standardized child behavior rating scales and based upon Cohen’s (1992) criteria, two of the effect sizes were very large and three others were large. Direct measures of mothers’ reports of hyperactivity and aggression were all large to very large, as was mothers’ report on the PDR measuring disruptive behavior in the home. Only the number of problem settings factor from the HSQ had consistent medium effect sizes. Effect sizes on the Parenting Scale factors were typically large to very large, as was mothers’ report of stress form the PSI. Thus, (a) prior research attesting to the stability of ADHD, defiant child behavior, and parenting behaviors associated with both, (b) strong test–retest reliability of the child and parenting scales, and (c) good effect sizes, together support the contention that the changes identified following the parent training program were not likely solely a result of spontaneous recovery or uncontrolled secondary variables. The parent training seemed to have a greater effect for mother/child dyads. Lack of father involvement, which seems to be typical in parent training research (Phares, 1992) reduced statistical power making it difficult to gain an accurate understanding of the efficacy of the program for fathers. Thus, the father effects may have to be interpreted with caution. Additional limitations in this line of inquiry need to be addressed in future research. Although we have argued that the large effects sizes observed in this study are unlikely to be solely due to spontaneous recovery, a notreatment or wait-list control group, with random assignment of participants would allow one to tease apart the effects of the intervention from spontaneous recovery. Comparative efficacy with other parent training programs has yet to be conducted. Although all of the previous research with the BMFC conducted follow-up analysis at 6-months, follow-up analysis was lacking in this study. In earlier research, the same person who developed it, with the inherent risk of experimental bias, evaluated the program. The current study was conducted in two settings with three additional researchers, none of whom participated in the program development, thus attenuating the potential for experimental bias. Nonetheless, independent research is necessary to replicate and confirm these data. Treatment fidelity was not independently verified, so it is not possible to confirm that treatment was conducted as described. However, a detailed description of the treatment is available for replication (Danforth, 1998a). This study represents ongoing efforts to evaluate the impact of the BMFC training protocol on parent behavior and clinically significant disruptive child behavior.

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Behavioral parent training with the BMFC seems as if it would be an effective component of treatment for families with disruptive ADHD/ODD children. Parent training with the BMFC might be an effective component of a treatment package for families with ADHD/ODD children that also includes other parent-focused, childfocused, or school-based interventions.

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