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Enhancing interactions of fathers and their children with attention deficit hyperactivity disorder

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Enhancing interactions of fathers and their children with attention deficit hyperactivity disorder
Creator:
White, Deborah Ann
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English
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xiii, 153 leaves : ill. ; 29 cm.

Subjects

Subjects / Keywords:
Attention deficit hyperactivity disorder ( jstor )
Behavior modeling ( jstor )
Child psychology ( jstor )
Fathers ( jstor )
Nursing ( jstor )
Older adults ( jstor )
Parent training ( jstor )
Parenting ( jstor )
Parents ( jstor )
Social interaction ( jstor )
Attention Deficit Disorder with Hyperactivity ( mesh )
Behavior Therapy ( mesh )
Department of Nursing thesis Ph.D ( mesh )
Dissertations, Academic -- College of Nursing -- Department of Nursing -- UF ( mesh )
Father-Child Relations ( mesh )
Nursing Evaluation Research ( mesh )
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non-fiction ( marcgt )

Notes

Thesis:
Thesis (Ph.D)--University of Florida, 2004.
Bibliography:
Bibliography: leaves 139-152.
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Deborah Ann White.

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Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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ENHANCING INTERACTIONS OF FATHERS AND THEIR CHILDREN
WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER














By

DEBORAH ANN WHITE


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORDIA


2004



























To the memory of my mother Margaret Ellen McConville-White. Although my
time with her was too short, she is and has always been a source of inspiration and
unwavering strength.
To my children Gregg and Merissa. Of all the blessings in my life, I am most
proud to be their mother.















ACKNOWLEDGMENTS

The pursuit and completion of a doctorate in philosophy has been a challenging

journey of personal and professional growth. I would like to offer my gratitude and

sincere appreciation to each and every person who contributed to the completion of this

dissertation. I am especially grateful to my children, Gregg and Merissa for their belief

in me, and their love, understanding, and support throughout this project.

I gratefully acknowledge the support and encouragement that I received from Dr.

Jennifer Elder. Dr. Elder has been the ideal advisor/chair, mentor, and friend. With her

guidance, support, and patience I was able to complete the dissertation. I am also

appreciative of the opportunity to work as a research assistant in her study with parents of

children with autism. This experience provided valuable insight into the development

and implementation of my research.

I would like to extend my gratitude for the contributions of each committee

member (Dr. Maureen Conroy, Associate Professor of Special Education; Dr. Tanya

Murphy, Associate Professor of Psychiatry; and Dr. Rinda Alexander, Professor of

Nursing). Their unique talents, constructive advice, and guidance were appreciated.

Also, I would like to thank Dr. Carolyn Yucha for the opportunity to work as a research

assistant in the College of Nursing Office of Research.

I am grateful to the National Institute of Nursing Research for the Pre-Doctoral

Fellowship Service Award (NRSA: F31 NR07567 01). This award provided the financial

support necessary to continue my education and research. I am also grateful for the









scholarship support that I received from the College of Nursing. Finally, I would like to

gratefully acknowledge and extend sincere thanks to my family and friends. My father,

Chip, Joe, Cathy, Lori, Linda, Ilona, and Hector provided a constant source of energy,

support, and encouragement.















TABLE OF CONTENTS

Page

ACKNOWLEDGMENTS......................................................................1i

TABLE OF CONTENTS ..................................................................................................... v

LIST OF TABLES ........................................................................................................... viii

LIST OF FIGURES ........................................................................................................ x

ABSTRACT ...................................................................................................................... xii

CHAPTER

1 INTRODUCTION ...................................................................................................... 1

Analysis of the Parent Training Concept .................................................................. 1
Analyzing the Range of Meaning of the Parent Training Concept ....................... 2
Related Theoretical Perspectives .......................................................................... 3
Attention Deficit Hyperactivity Disorder (ADHD) .............................................. 7
Theoretical Significance in Nursing ...................................................................... 8
Parent Training Research in Nursing ............................................................. 9
Operationalization of Parent Training ........................................................... 10
Statement of the Purpose ...................................................................................... 11

2 REVIEW OF LITERATURE ............................................................................. 13

Features of ADHD in Young Children ............................................................... 14
Characteristics of ADHD ................................................................................... 16
Assessment and Diagnostic Process in Children with ADHD ............................ 17
Research on Children with ADHD ...................................................................... 19
Pharmacotherapy Research .......................................................................... 21
Parent Training Intervention Research ......................................................... 21
In-Home Parent Training ............................................................................ 25
The Role of Fathers in Childhood Behavior Problems ...................................... 25
The Role of Social Reciprocity in Parent Training ............................................. 27
Summary ................................................................................................................. 28









3 M ETHOD ................................................................................................................. 37

Rationale for Use of Single Subject Design ........................................................ 37
Research Plan ...................................................................................................... 39
Recruitment of Subjects ............................................................................... 39
Inclusion Criteria ......................................................................................... 40
Exclusion Criteria ......................................................................................... 40
Instruments for Describing Subjects .......................................................... 41
Description of an In-Home Parent Training Intervention for Fathers ......... 43
Procedure for Implementing the Parent Training Intervention .................... 44
Condition A Baseline ............................................................................... 44
Condition B Introduction of Parent Training Sessions 1, 2, and 3 ........... 45
Instruments and Procedure for Measuring the Dependent Variables ........... 45
In-Home Observation .................................................................................. 46
Behavioral Observer Training ...................................................................... 47
Behavioral Response Categories ................................................................. 48

4 RESULTS ................................................................................................................. 51

Father and Child Dyad A ................................................................................... 51
Frequencies of Target Behavior ................................................................. 55
Visual Report of Data .................................................................................. 57
Father and Child Dyad B .................................................................................... 59
Frequencies of Target Behaviors ................................................................. 62
Visual Report of Data .................................................................................. 64
Father and Child Dyad C .................................................................................... 65
Frequencies of Target Behaviors ................................................................. 68
Visual Report of Data .................................................................................. 70
Father and Child Dyad D ................................................................................... 72
Frequencies of Target Behaviors ................................................................. 75
Visual Report of Data for Father and Child Dyad D ................................... 78
Summary of the Four Father and Child Dyads ................................................... 79
Interobserver Agreement .................................................................................... 83
Social Validity .................................................................................................... 84

5 DISCUSSION ........................................................................................................ 104

Interpretation of Findings ...................................................................................... 105
Utility of Single Subject Design in Nursing Research .......................................... 107
Limitations Associated with this Research ........................................................... 109
Implications for Clinical Practice .......................................................................... 111
Recommendations for Future Research ................................................................ 112









APPENDIX

A OPERATIONAL DEFINITIONS FOR DEPENDENT VARIABLES ................. 114

B PARENT TRAINING INTERVENTION FOR FATHERS OF YOUNG
CHILDREN WITH ADHD .................................................................................... 117

G round-R ules ........................................................................................................ 117
H om ew ork ............................................................................................................. 117
Schedule ................................................................................................................ 117
Parent Training Session 1 ...................................................................................... 118
Parent Training Session 2 ...................................................................................... 118
Parent Training Session 3 ...................................................................................... 119

C THE PARENTING SCALE ................................................................................... 120

D INTERACTIONS QUESTIONAIRE .................................................................... 122

E HOLLINGSHEAD FOUR FACTOR INDEX OF SOCIAL STATUS ................. 130

F CHILD BEHAVIOR CHECKLIST ....................................................................... 132

G THERAPY ATTITUDE INVENTORY ................................................................ 136

H SEMI STRUCTURED QUESTIONAIRE ............................................................. 137

R E FER E N C E S ................................................................................................................ 139

BIOGRAPHICAL SKETCH ........................................................................................... 153















LIST OF TABLES


Table Page

2-1 Review of parent training literature ......................................................... 30

3-1 Correspondence between instrumentation and sample characteristics .............. 49

3-2 In-home parent training intervention for fathers ............................................. 49

3-3 Timeline for the parent training intervention ........................................... 49

3-4 Procedure for instrumentation and videotaping ................................................ 50

3-5 Correspondence among the variables, instruments, and measurements ............. 50

4-1 Summary of Father A effectiveness in discipline .............................................. 85

4-2 Summary of Father A beliefs about child noncompliance ................................. 85

4-3 Means of target behaviors for Father A and Child A .................................... 85

4-4 Summary of Father B effectiveness in discipline .............................................. 86

4-5 Summary of Father B beliefs about child noncompliance ............................. 86

4-6 Means of target behaviors for Father B and Child B ........................................ 86

4-7 Summary of Father C effectiveness in discipline ....................................... 87

4-8 Summary of Father C beliefs about child noncompliance ................................. 87

4-9 Means of target behaviors for Father C and Child C ........................................87

4-10 Summary of Father D effectiveness in discipline ...................................... 88

4-11 Summary of Father D beliefs about child noncompliance ................................ 88

4-12 Means of target behaviors for Father D and Child D ........................................ 88

4-13 Comparison of family demographics ............................................................. 89









4-14 Comparison of descriptive data for subjects at completion of study .................. 90

4-15 Mean and range of interobserver agreement ...................................................... 91

4-16 Comparison of means of reported scores of father's perceptions ....................... 91

4-17 Summary of father's satisfaction with parent training ........................................ 91















LIST OF FIGURES


Figures Page

1-1 Parent training process ........................................................................................ 12

4-1 Father A initiations and Child A initiations ........................................................ 92

4-2 Father A responding behaviors .......................................................................... 92

4-3 Child A responses and imitation with animation ............................................... 93

4-4 Father A initiations and Child A responses ........................................................ 93

4-5 Father A and Child A turn taking ........................................................................ 94

4-6 Father B initiations and Child B initiations ........................................................ 94

4-7 Father B responding behaviors ........................................................................... 95

4-8 Child B responses and imitation with animation ............................................... 95

4-9 Father B initiations and Child B responses ........................................................ 96

4-10 Father B and Child B turn taking ........................................................................ 96

4-11 Father C initiations and Child C initiations ........................................................ 97

4-12 Father C responding behaviors ........................................................................... 97

4-13 Child C responses and imitation with animation ............................................... 98

4-14 Father C initiations and Child C responses ........................................................ 98

4-15 Father C and Child C turn taking ........................................................................ 99

4-16 Father D initiations and Child D initiations ........................................................ 99

4-17 Father D responding behaviors .............................................................................. 100

4-18 Child D responses and imitation with animation ................................................... 100









4-19 Father D initiations and Child D responses ............................................................ 101

4-20 Father D and Child D turn taking ................................................................. 101

4-21 Comparison of father responding behavior during Condition A ........................... 102

4-22 Comparison of father responding behaviors during Condition B .......................... 102

4-23 Comparison of target behaviors during Condition A ........................................... 103

4-24 Comparison of target behaviors during Condition B .......................................... 103














Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of
the Requirements for the Degree of Doctor of Philosophy

ENHANCING INTERACTIONS OF FATHERS AND THEIR CHILDREN
WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER

By

Deborah Ann White

May, 2004

Chair: Jennifer H. Elder
Major Department: Nursing

The purpose of this research was to characterize the interactions of four fathers

and their 3- to 6-year-old children with Attention Deficit Hyperactivity Disorder

(ADHD); and evaluate the efficacy of an in-home parent training intervention on father

behaviors, father acquisition of parent training skills, and child behaviors. In addition,

questions were addressed on the social value of the training intervention and the effects

on father-child interactions.

Descriptive data were obtained before and at completion of the study on fathers'

beliefs about effectiveness in discipline, their children's behavior problems, and the

causality of their children's problem behavior. Fathers were taught parenting and

discipline strategies during three in-home parent training sessions. After the parent

training sessions, each father was videotaped in his home during father-child play

sessions (approximately twice per week for 8- to 12-weeks). A single subject, AB design

was used to determine the relationship between the two conditions of our study. Direct









behavioral counts of targeted father behaviors and targeted child behaviors during 10-

minute videotaped sessions were recorded. Interrater reliability was 85% with a range

from 76 to 93%. After parent training, the fathers showed increased use of positive

responses and the imitation with animation skill. In addition, child initiations and child-

initiated turns with affirmation increased. Conversely, a decrease was evident in the

father initiations, corrective responses, and father-initiated turns with affirmation.

Results suggest a consistent positive effect of the parent training intervention on the

fathers' use of parenting strategies, the targeted father behaviors, and the targeted child

behaviors. Despite father reports of minimal improvement in discipline effectiveness and

little change in the child's problem behavior, social validity data indicate that fathers

were satisfied with the process and outcome of parent training.

Findings reported in our study provide contextual information on the interactions

of fathers and their children with ADHD with implications for further research.

Comprehensive parent training interventions that facilitate child-directed play, match

treatment to fathers on the basis of cognition, and incorporate specific father-child play

strategies are essential for further work with fathers of children with ADHD.














CHAPTER 1
INTRODUCTION

Analysis of the Parent Training Concept

The training and use of parents in therapeutic roles as change agents for their

children has been documented in nursing science and the social sciences (Anastopoulos,

Shelton, DuPaul, & Guevremont, 1993; Elder, 1995; Erhardt & Baker, 1990; Gross,

Fogg, & Tucker, 1995; Kazdin, 1997; Sanders, Markie-Dadds, Tully, & Borr, 2000;

Webster-Stratton, 1982, 1984, 1994, 1998). Unfortunately, conceptual problems in the

literature affect the characterization and utility of parent training in current research.

Various conceptual definitions of parent training, confusing professional jargon, and

weaknesses in parent training interventions create ambiguity in nursing and across

disciplines (Elder, 1997b). In addition, little theoretical support is documented for parent

training interventions for fathers of children with Attention Deficit Hyperactivity

Disorder (ADHD) (Schuhman, Foote, Eyberg, Boggs, & Algina, 1998). Consequently,

the synthesis of existing knowledge is essential for concept development, to define parent

training in terms of its critical attributes or essence, and for the characterization of parent

training for fathers of children with ADHD.

This chapter gives an analysis of the parent training concept. Theoretical

perspectives and related concepts are discussed. Theoretical significance of the parent

training concept in nursing and an operational definition are given, followed by an

explanation of a parent training model. This conceptual foundation provides the









theoretical basis for evaluating the parent training intervention for fathers of children with

ADHD. Further study is intended to:

0 Promote the understanding of parent training and expand the base of knowledge
in nursing and among disciplines.

Determine the most effective methods for training fathers of children with
ADHD.

* Facilitate father-child interactions.

0 Develop and examine a nurse-parent trainer role.

Analyzing the Range of Meaning of the Parent Training Concept

Review of the literature reveals many inconsistencies and weaknesses in the

concept of parent training. Confusing terminology that describes parent training

exclusively in professional jargon within a discipline has limited its utility among the

social sciences (Elder, 1997b). In addition, the concept of parent training often has a

negative connotation suggesting that parents lack the innate skills (or choose not to use

the appropriate skills), and must be taught to effectively parent their children. Other

researchers propose "cookbook solutions" and self-help advice for managing difficult and

challenging problem behaviors in children. Unfortunately, misconceptions in the

literature, poorly defined terminology, and confusing jargon have insufficiently described

the complexity of the parent training process. Consequently, providers of parent training

have the burden of proving the exact strategy in each unique situation.

Particularly significant is the controversy regarding differing strategies of positive

reinforcement; and the use of negative reinforcement such as aversive techniques,

extinction, and/or punishment (National Institutes of Health [NIH], 1989). Researchers

have questioned the moral integrity and ethics of aversive, intrusive, and restrictive

practices (LaVigna, & Donellan, 1986). Nonaversive reinforcement alternatives that









achieve similar results have been suggested for children with problem behavior.

Advancement of the parent training concept is challenging, given that few nonaversive

parent training interventions can be replicated to facilitate sound empirical assessment.

Further limitations in the literature include vague diagnoses or criteria for inclusion of

children with disruptive behavior (Table 2-1). For example, children are often identified

as disruptive, rather than accurately diagnosed. Other researchers fail to distinguish

among different parent training approaches, resulting in contradictions in the literature.

Poor generalization is evident across settings from the clinic, hospital, home, and/or

school. A final point is that parent training packages are often evaluated in their entirety,

without specific information about the effectiveness of each component.

Related Theoretical Perspectives

Variations in parent training parallel the diversity of theoretical perspectives. A

review of current research revealed a number of theoretical frameworks that have been

used to describe the complex interactions among parents and their children. Theories of

symbolic interactionism, social-interaction, coercion, self-efficacy, attribution, and

physiology seem to be particularly applicable to our research.

Symbolic interactionism reflects the self, the world, and social action (Bowers,

1988). The self and the world are perceived as dynamic, constructed processes of social

interaction. Individuals cannot be understood outside of the social context (Hutchinson,

2000). Social-interaction theory is derived from symbolic interactionism. This theory

addresses the importance of interactions among parents and their children. Children

respond to the parents' behavior. Parent behavior is affected by feedback that parents

receive from their children. Patterson (1982) suggests that the persistence of positive

effects associated with behavioral effort, is a function of parents' reactions to changes in









their children. Unless improvements in the children's behavior alter the parents'

reactions, the effects will be short-lived. Social-interaction theory is supported by

decades of research on various aspects of parent training (Griest, Forehand, Wells, &

McMahon, 1980; Patterson, Capaldi, & Bank, 1991, Patterson, Reid, & Dishion, 1992).

Coercion theory is a blend of conceptual views derived from social-interaction

theory that illustrates an escalating cycle of coercive parent-child interactions. Behaviors

of parents and their children are a direct reflection of events occurring in the natural

environment. Parents of hyperactive children provide more commands, reprimands, and

punishment (Barkley, 1990). Patterson et al. (1991, 1992) suggest that a child's

compliance with parental commands relates to the intensity of the parental directives,

physical abuse, and/or parental hostility. The child's problem behavior is coupled with

negative parent verbalizations, and results in the parent's withdrawal or failure to follow

through with a command. Each person is reinforced for increasingly negative and

aggressive behaviors. Interdependent negative behavior between parents and their

children contributes to the evolution of childhood behavior problems.

Ineffective parental management strategies are suggested as the cause for entry

into this coercive cycle (Patterson et al. 1991). Researchers have shown that training

approaches for parents of children with ADHD may effectively manage and improve

problem behaviors (Anastopoulos, Shelton, DuPaul, Guevreont, 1993; Erhardt, & Baker,

1990; Pelham, Wheeler, & Chronis, 1988; Pisterman, Firestone, McGrath, Goodman,

Webster, Mallory, & Goffm, 1992). Thus, parent training interventions for the

management of problem behaviors in children may be a crucial step that halts the child's

upward spiral of aversive, coercive behavior (Kendziora, & O'Leary, 1993).









Self-efficacy theory (Bandura, 1977) is derived from social-learning theory. This

theory has been defined as an estimation of parents' perception of competence in

performing various tasks (Coleman, & Karraker, 1998). Parents with high efficacy have

greater responsiveness, work diligently to provide positive experiences for their children,

and are better able to deal with the challenges of parenting a difficult child (Mash, &

Johnston, 1983; Elder, 1995). Research on parent training interventions shows improved

maternal self-efficacy, reduced maternal stress, and improved mother-child interactions

(Gross, Fogg, & Tucker, 1995; Webster-Stratton, 1990).

Fathers of children with ADHD face unique challenges (associated with problem

behavior, long-term behavior management, health care, and treatment). Parent training

interventions that target improving a father's competence, perceptions regarding his

ability to help his child, and effectiveness in discipline may enhance the father's self-

efficacy and promote positive father-child interactions. Father self-efficacy and effective

parenting skills are crucial in the management of behavior problems in children with

ADHD. Therefore, coercion theory and self-efficacy theory facilitate the

operationalization of specific behaviors targeted for intervention, and provide a basis for

empirical assessment of our study.

Attribution theory has been used to explain the link between parental beliefs and

child behavior (Dix, & Grusec, 1985). Dix & Grusec describe parental beliefs as

expectations with internal and external components. Internal attributes in the child are

traits that include personality, intellectual ability, and temperament. External attributes

are traits that the child is assumed to control (or have the ability to control) such as

intention or mood. Typically, parents are more upset by problem behavior in their









children if perceived as an intentional act, a negative disposition, or if parents believe the

child has the knowledge to behave differently. Often, these perceptions result in a

negative parent reaction (Miller, 1995). For example, a child with ADHD hits the father

each time he tries to play with the child. If the father attributes the cause of his child's

behavior internally, he may be convinced that his child is "mean." On the contrary, if the

father attributes the cause of hitting externally, the father may perceive the child is trying

to communicate and interact in the only method he knows. Appropriate father beliefs

may alter immediate reactions to the child's behavior, encourage positive responses, and

result in the father teaching his child to communicate in a socially appropriate manner.

Furthermore, cognitive development in children may be adversely affected or

enhanced by parental flexibility or rigid adherence to previous knowledge, and parental

receptiveness to new knowledge (Miller, 1995). In addition to flexibility and

receptiveness, parental sensitivity to the child may be a critical variable in the parent

training concept. An informed and sensitive parent may have more reliable expectations.

These affective reactions mediate the link between the parent's attributions for their

children's problem behavior and the subsequent parent behavior (Miller, 1995; Slep, &

O'Leary, 1998). Parents who believe their child is capable of controlling problem

behavior may be more likely to seek behavioral interventions. On the contrary, parents

who believe their child is incapable of controlling problem behavior may not be

interested in behavior interventions. Hence, a father's beliefs about the causality of his

child's problem behavior may be an important factor that influences the father's

reactions, choice of treatment, and treatment compliance.









Attention Deficit Hyperactivity Disorder (ADHD)

Attention Deficit Hyperactivity Disorder (ADHD) is understood as a psychiatric

condition exacerbated by the environment; and identified as a set of dysfunctional

relationships between an individual with a certain predisposition and an environment that

generates particular expectations, demands, and reactions (Weaver, 1993). Current

theories suggest that ADHD is a deficiency in the sensitivity to reinforcement that

typically motivates children to perform work, inhibit behavior, and sustain responses to

assigned tasks (Barkley, 1990; Haenlein, & Caul, 1987). Barkley (1997) asserts that poor

behavioral inhibition is the central impairment in children with ADHD, and results in

deficiencies in self-control. Consequently, individuals with ADHD may be less

sophisticated in manipulating physical and social environments, and have fewer abilities

in self-regulation, attention, and memory (Baird, Stevenson, & Williams, 2000).

Baird et al. (2000) argue that self-inhibition is closely intertwined with the

evolution of language and coordination among areas of the brain (dopaminergic and

noradrenergic systems). Thus, ADHD may be viewed as a disorder of communication as

well as behavior. Cognitive processes that assess social context and communication (and

coordinate behavior) are impaired. Pragmatic social skill deficits are thought to

synergistically interact with behavioral problems, and compound the physiological

deficits in children with ADHD.

In summary, ADHD deficits in physiological systems affect cognitive processes,

communication, and socially appropriate behavior. Parent training interventions that

address physiological deficits, that use behavioral strategies, and that address social skills

increase the magnitude of reinforcement for appropriate behavior in children with ADHD

(Anastopoulos, DuPaul, & Barkley, 1991). Thus, knowledge of parent training









approaches is potentially important for clinicians and researchers involved in developing

and evaluating behavior-management interventions for children and their parents.

Theoretical Significance in Nursing

Theories of symbolic interactionism, social-interaction, coercion, self-efficacy,

attribution, and physiology contribute to the operationalization of the parent training

concept, and are consistent with King's general system framework (1981) and theory of

goal attainment (1992). That is, reciprocal interactions with parents as well as

environmental factors contribute to the nature of relationships. The fundamental belief is

that human beings interact with their environment. An individual's perceptions, goals,

needs, and values influence this interaction; and contribute to the individual's health and

ability to function in social roles. Individuals are characterized as rational, perceiving,

controlling, purposeful, time-oriented social beings; that actively participate toward set

goals with a symbolic way of communicating thought, actions, and beliefs. Health is

viewed as a dynamic life experience that implies a continuous adjustment to

environmental stress. These assumptions address the rationality of an individual's ability

to perceive, interpret, and solve problems; and identify a shared collaborative process of

clients and nurses to exchange information, identify goals, and explore the means to

attain desired goals (King, 1992).

Describing the interaction process within a general system framework and within

the theory of goal attainment helps to operationalize the parent training concept. The

concept of parent training is dynamic and contextually dependent, and useful in the

behavior management of children. Furthermore, King's description of health is

harmonious with current educational and behavioral trends that incorporate

individualized, intensive, parent training interventions for the treatment of children with









ADHD. Therefore, King's interacting general system framework is used to

operationalize the parent training concept and as the basis for interpreting findings in our

study.

Parent Training Research in Nursing

The science of nursing examines the interactions of individuals within families,

communities, and society to understand the biological human being, the psychology of

human existence, and the sociology of human relationships (American Nurses

Association, 1995). Nurses are unique in their approach to health-care concerns with a

solid theoretical foundation as a basis for developing and interpreting culturally sensitive,

individualized clinical interventions. Furthermore, advanced practice and doctoral

prepared nurses are knowledgeable and skilled in diverse research methodologies,

populations, settings, and interventions (Elder, 1995; Gross, Fogg, & Tucker, 1995;

Tucker, Gross, Fogg, Delaney, & Lapporte, 1997; Webster-Stratton, 1982, 1984, 1994,

1998).

Particularly interesting within nursing research are multi-component parent

training interventions for children with behavior problems (Elder, 1995, 1996; Webster-

Stratton, 1994, 1998). Various approaches to parent training include individual or group

training, didactic counseling, clinic instruction, direct in-home interventions, self-

instructional methods, and school-based interventions. For example, Webster-Stratton

(1984) used a videotaped modeling intervention and group discussion to provide parents

with knowledge and skills for effective interaction and communication with their

conduct-disordered children. Gross, Fogg, and Tucker (1995) used Webster-Stratton's

(1984) behavioral parent training intervention to test the effectiveness of a parent training

program for promoting positive parent-child relationships among families of toddlers









with problem behavior. Webster-Stratton and Hammond (1997) compared three

treatment conditions of a parent training intervention for parents of children with early-

onset conduct problems, to evaluate generalization and clinical effectiveness of existing

parent training program.

Elder (1995) used single subject design methodology to determine the effects of

an in-home, communication program for training parents of handicapped children.

Elder's research incorporated an in-home parent training intervention with five

components including social play, turn taking, communication, language, and

conversation. The parent training intervention was designed to address the

communicative intent of child behavior and promote social reciprocity (in an effort to

reduce aberrant behaviors and facilitate balanced parent-child interactions). Our study

builds on Elder's (1995) parent training intervention in a new population. Behavioral

strategies for fathers of young children with ADHD were incorporated into the parent

training intervention in the context of father-child play, to improve father-child

communication, and to promote positive interactions between fathers and their children

with ADHD.

Operationalization of Parent Training

The concept of parent training is dynamic and contextually dependent, is useful

for managing behavior of children, and represents a behavioral phenomenon of

significant interest to nurses. The proposed theoretical associations in parent training are

enhanced by a clear operational definition. Elder (1997, pp.103-104) defines parent

training as:

* A dynamic, interactive, and instructional process by which caretakers (parents)
perceive, assimilate, and use knowledge about their own children in such a way as









* To modify maladaptive and/or deficit behaviors, which in turn will promote the
health and general well being of their children and families.

* To facilitate the children's learning and successful current and future
environmental adaptation within their homes and communities.

Critical attributes derived from this definition include contextual clarification,

assessment, training, intervention development and implementation, and the evaluation of

intervention effectiveness (Figure 1-1). This analysis delineates the dimensions of the

parent training concept, clarifies ambiguities, and provides guidance for our study.

Furthermore, it is expected that this parent training model may bridge gaps in existing

knowledge, and provide a foundation for effective clinical practice and research in

interventions for problem behavior in children with ADHD.

Statement of the Purpose

The purpose of this research was to characterize the interactions of fathers and

their child with ADHD and evaluate the efficacy of an in-home parent training program

designed for fathers. The specific aims are:

* Characterize the interaction of fathers and their young children with ADHD during
father-child play sessions before father participation in an in-home parent training
intervention for fathers.

* Evaluate the effects of a 12-week in-home parent training intervention (for fathers
of young children with ADHD) on father behaviors and father acquisition of
parenting skills.

* Evaluate the effects of a 12-week in-home parent training intervention (for fathers
of young children with ADHD) on child behaviors.

* Assess the social validity of the in-home parent training intervention for fathers.







Parent Training Process

Mutual Development


Phase 2


Phase 3


Phase 4


Assessment Treatment Intervention Development I Intervention Implementation I Evaluation of


Mutual
Development
Overview of
Techniques

Role-model

Environmental
Changes

Proficiency
Criteria


Parent
Implements
Targeted
Behavior

In-home
Videotaping

Direct
Observations


Data
Analysis

Progress
Assessment

Consumer
Satisfaction


Figure 1-1. Parent training process (Elder, 1995)


Phase I


Parent

Child

Home














CHAPTER 2
REVIEW OF LITERATURE

The purpose of this review is to provide a general overview of the parent training

concept as it relates to treatment for young children with ADHD. Current research is

given on the characteristics of ADHD and the assessment and the diagnostic process in

children; followed by a review of research on pharmacotherapy, parent training

interventions, social reciprocity, and the role of fathers in childhood behavior problems.

The Nursing Practice Analysis Tool (NPAT) (Moody, 1990) was used to assess

research on parent training interventions for children with problem behavior in several

disciplines (1983-2004) (Table 2-1). Most of the research is considered empirically

supportive. However, few researchers have shown parent training interventions that used

appropriate data collection and analysis for parents of children with ADHD. Many

studies had small sample sizes that were inadequate for the statistical analyses, or used

complex procedures that discouraged replication.

Conceptual ambiguity regarding parent training in the literature (as well as the

lack of research with theoretically based, parent training models) further complicates the

treatment approach for children with ADHD. Equally important is that young children

with ADHD are at substantial risk for future impairment. Parents are often confused and

frustrated by controversial research on stimulant therapy, the efficacy of parent training

approaches, and the lack of appropriate resources. Furthermore, parent training on

behavioral contingencies related to punishment may not be appropriate for parents who

are already prone to violence or abusive interactions. Consequently, there is a need for









interactive, individualized, and comprehensive parent training interventions that address

parents' beliefs, family risk factors, obstacles to treatment, and problem behavior in

children with ADHD.

Features of ADHD in Young Children

Attention Deficit Hyperactivity Disorder is a chronic psychological condition

(identifiable in the preschool age range) that occurs more often in boys than girls, and

accounts for 30 to 50% of pediatric mental-health referrals (American Academy of

Pediatrics [AAP], 2000; Multi-Modal Treatment of ADHD Cooperative Group [MTA],

1999; U.S. Public Health Service, 1999). Prevalence rates for ADHD have varied

substantially because of changes in diagnostic criteria, assessment in varied settings,

differences in methods of sample selection, and differences in the nature of the

population studied (American Academy of Child & Adolescent Psychiatry [AACAP],

1997; American Psychiatric Association [APA], 1968, 1980, 1987, 1994; Barkley, 2000).

Currently, the Diagnostic and Statistical Manual for Mental Illness-IV (DSM-IV) cites a

prevalence rate of 3 to 5% in school-age children having ADHD (APA, 1994). Other

studies have reported a prevalence range of 2.5 to 6.4% in elementary school-age

children (DuPaul, 1991; Pelham, Gnagy, Greenslade, & Milich, 1992). Girls with ADHD

share with boys the symptoms of inattention, hyperactivity/ impulsivity, school failure,

and comorbidity with mood, anxiety disorders, and learning disabilities (Faroane,

Biederman, Keenan, & Tsuang, 1991; Gaub, & Carlson, 1997). However, fewer girls

than boys receive a diagnosis of ADHD, possibly due to less prevalent rates of comorbid

oppositional disorder and conduct problems.

The core deficit in ADHD is a failure to inhibit or delay motor responses, while

sensory detection or early information processing is intact (Barkley, 1994, 1997).









Inadequate response inhibition creates a deficit in four distinct executive functions:

emotional regulation, nonverbal working memory, speech internalization, and self-

directed play (Barkley, 1990, 1997, 2000). The deficits in executive functioning affect

motor coordination, mental calculation, rule-governed behavior, speech and fluency, and

the evolution of language (Baird et al. 2000; Barkley, 2000). Baird et al. (2000) describe

ADHD as a disorder of communication, with problem behaviors that reflect dysfunction.

Cognitive processes are impaired that coordinate behaviors for assessing social context

and communication. Consequently, children with ADHD are less sophisticated in

manipulating physical and social environments, and have difficulties with attention,

memory, and self-regulation.

Reportedly, children with ADHD lack positive problem-solving skills, react in

coercive ways, anticipate fewer consequences, have social deficits, and have impaired

communication skills (Ladd, Price, & Hart, 1990; Mize, & Cox, 1990; Puttallaz, &

Wasserman, 1990; Slaby, & Guerra, 1988). Deficits in social skills interact

synergistically with behavioral problems and compound the physiological deficits.

Intervention during the preschool years is critical, and may be more effective than

intervention after age seven (Baird et al. 2000). Reasons for this include that young

children have a shorter learning history associated with problem behavior, have fewer

competing external influences, and have fewer cognitive resources for questioning and

challenging behavioral interventions (Hembree-Kigin, & McNeil, 1995). In addition,

young children are more accepting of new behavioral expectations, and exhibit affection

toward their parents (and cooperative behaviors that can be shaped to occur more

frequently).









Characteristics of ADHD

Attention Deficit Hyperactivity Disorder is characterized by inattention and/or

hyperactivity-impulsivity with impairment in academic achievement and family and peer

relationships (APA, 1994). The DSM-IV (APA, 1994) defines inattention as failing to

give close attention to detail, difficulty sustaining attention, and poor listening; failing to

finish work, difficulty organizing, and avoidance of sustained mental effort; and losing

things, distractibility, and forgetfulness (APA, 1994). Hyperactivity includes behaviors

such as fidgeting and the inability to stay seated; excessive running, climbing, or talking;

and difficulty playing quietly. Impulsivity is described as blurting out answers, difficulty

in waiting for a turn, and interrupting or intruding on others.

The core clinical features of ADHD may be detected as early as 3-years-old, may

lead to significant social and emotional impairments, and often have comorbid disorders

(Campbell, 1995; Campbell, & Ewing, 1990; Klein, & Manuzza, 1991). Young children

with high levels of socially aggressive behavior constitute a high-risk population for

further impairment in academics, peer relationships, and general adaptive functioning

(emotional and social difficulties), and an earlier onset of conduct disorder, oppositional-

defiant disorder, and antisocial behavior (Barkley, DuPaul, & MacMurray, 1990; Loeber,

1990). There has been considerable debate concerning the legitimacy of hyperactivity as

a diagnosis (Hinshaw, 1994). However, controversy does not exist concerning the

significant number of children who suffer from symptoms associated with ADHD, social

and academic impairments, and comorbid conditions.

Parents of children with ADHD often have high rates of socially aggressive

behavior, harsh child discipline, marital strife, and a high risk of psychiatric disturbances

(Barkley, Guevremont, Anastopoulos, & Fletcher, 1992; Patterson et al. 1992).









Furthermore, factors such as a family history of ADHD, psychosocial adversity, and

comorbid conditions all increase the risk of persistence of ADHD symptoms into

adolescence and adulthood (Biederman, 1998). Marakovitz and Campbell (1998)

reported that one-half of children who exhibited problem behaviors at preschool age had

improved by age six. On the contrary, one-half of children continued to exhibit persistent

problems (one-third of which met DSM-III criteria for ADHD). Children with persistent

problems at age six were more likely to have an externalizing disorder at age nine. In

summary, young children diagnosed with ADHD constitute a high-risk population for

significant impairment in adolescence and adulthood. Therefore, the selection of young

children with ADHD for participation in our study is an appropriate strategy.

Assessment and Diagnostic Process in Children with ADHD

The diagnosis of ADHD according to the DSM-IV requires the presence of six or

more extremely inappropriate symptoms in each symptom group (inattention,

hyperactivity, and impulsivity) for at least six months (APA, 1994). Symptoms are

evident before age seven and are inconsistent with the child's developmental level and

intellectual ability. Functional impairment must be present in two or more settings, with

clinically significant impairment in social, academic, or occupational functioning. Signs

of ADHD may not be observed in highly structured or novel settings. Conversely,

symptoms typically worsen in unstructured and minimally supervised situations.

Assessment of children with behavior problems may include a parent interview, a

child interview, standardized rating scales (Achenbach, 1991; Conners, 1969; Barkley,

1990), behavior observations in naturalistic settings and/or clinical settings, medical

evaluations, speech and language evaluations, and psychological testing. The core of the

assessment process is a structured parent interview to ensure coverage of ADHD









symptoms, and to rule out psychiatric or environmental causes of behavioral symptoms

(AACAP, 1997). Reports of behavior, learning, school attendance, academics, social

skills, and psycho-educational testing are essential. Standardized instruments are used to

obtain information from parents, teachers, social workers, and guidance counselors.

Structured observations in naturalistic and clinical settings assist in distinguishing

hyperactive and aggressive behaviors, the teacher's management style, and characteristics

of the social and academic environment (AACAP, 1997; Vitaro, Trembley, & Gagnon,

1995).

A variety of disorders may be mistaken for ADHD (e.g. impaired vision or

hearing, seizures, head trauma, acute or chronic medical illness, poor nutrition,

insufficient sleep, anxiety disorders, depression, bipolar conditions, mental retardation,

and learning disabilities). Therefore, a medical evaluation is essential to a differential

diagnosis and the determination of comorbid conditions. Included in the medical

evaluation are a complete medical history, a physical exam, and laboratory tests when

indicated by history (e.g., lead level or thyroid function). Clinical assessments of hair

analysis and/or zinc have no empirical support and are not indicated (McGee, Williams,

Anderson, McKenzie, Parnell, & Silva, 1990). The child's and family's histories include

questions related to the use of prescribed, over-the-counter, and illicit drugs; lead

screening; thyroid disease; genetic syndromes such as fragile X syndrome and fetal

alcohol syndrome; risk factors such as poor maternal health, smoking, toxemia,

postmaturity; and health problems or malnutrition in infancy. Neurological testing may

be indicated by the medical evaluation. However, brain mapping and neuro-imaging are

not used in the diagnosis of ADHD because of insufficient empirical data (AAP, 2000b).









Research on Children with ADHD

Historically, the behavior problems of preschool children were considered

transient processes that resolved as children matured. However, current researchers

assert that children with an early onset of behavior problems in the preschool and

kindergarten years are at a higher risk for emotional and externalizing behavior problems

during later childhood, adolescence, and adulthood (Barkley, DuPaul, & MCMurray,

1990; Campbell, March, Pierce, Ewing, & Szumowski, 1991). In addition, 70% of the

children with ADHD have comorbid conditions that complicate the process of diagnosis

and treatment (MTA, 1999). Research on family heterogeneity of ADHD reveals that

ADHD and major depression share similar familial vulnerabilities; and comorbidity with

conduct disorders and bipolar disorders may be a distinct familial subtype (Biederman,

1998).

No single etiology leads to a diagnosis of ADHD. Emerging neuro-psychological

and neuro-imaging literature suggests that abnormalities exist in the brain's frontal

networks in children with ADHD (Castellanos, 1997). Data from genetic, family, twins,

and adoption studies points to a genetic origin for some forms of ADHD (Faraone,

Biederman, Keenan, & Tsuang, 1992; Faraone, & Biederman, 1994). Other possible

etiologies include psychological adversity, perinatal insults, low birth weight, and yet-

unknown biological causes (Biederman, 1998).

Researchers have proposed that various environmental toxins (e.g., food

additives, refined sugars, and allergens) produce a causal effect in the development of

ADHD. However, investigations of such associations failed to yield empirical support

(Wolraich, Milich, Stumbo, & Schultz, 1985; Wolraich, Wilson, & White, 1995).

Research supports a correlation between elevated blood lead levels in children with









hyperactivity and inattention as well as an association with maternal alcohol consumption

and cigarette smoking during pregnancy (Gittelman & Eskinazi, 1983; Milberger,

Biederman, Faraone, Chen, & Jones, 1996; Streissguth, Bookstein, Barr, & Sampson,

1994).

Various interventions that involve medication, parent training, behavior

modification in the classroom, and combined treatments have been studied extensively in

elementary school-age children with ADHD (Abramowitz, Eckstrand, O'Leary, &

Dulcan, 1992; Anastopoulos et al. 1993; Greenhill, 1998; Mustin, Firestone, Pisterman,

Bennett, & Mercer, 1997; MTA, 1999; Pelham, Wheeler, & Chronis, 1998; Pisterman,

Firestone, McGrath, Goodman, Webster, Mallory, & Goffin, 1992). The limitations of

this research included few long-term studies, only short-term gains of treatment efficacy,

a focus on boys, and a lack of evidence on differential improvement reported for

treatment conditions (Barkley, DuPaul, & McMurray, 1990; Klein, & Mannuzza, 1991;

McMahon, 1994).

In summary, the diagnosis of ADHD in a young child encompasses a complex set

of interacting child and family issues with an enormous impact on society in terms of

financial expense, stress to families, and interference with academic and vocational

activities (Biederman, 1998). Numerous studies have examined potential causes,

behavioral characteristics, and the cognitive, social, and academic impact of ADHD on

children (Barkley, 1996; Castellanos, 1997). Despite extensive research, ADHD remains

a controversial condition with respect to diagnosis and treatment. In many cases family

practice and pediatric clinicians are r.,quired to make important decisions regarding

diagnosis and treatment without the benefit of sound empirical data. Furthermore, the lay









media have perpetuated misconceptions often held by parents of children with ADHD

about vitamin therapy, diet therapy, decreased sugar consumption, poor parenting, and

the side effects of stimulant medication (Wolraich, Milich, Stumbo, & Schultz, 1985;

Wolraich, Wilson, & White, 1995). This is particularly troubling in that parental

involvement appears to be a critical component in the treatment of children.

Consequently, there is a dire need for empirically validated medical, psychological, and

educational services for children with ADHD and their families.

Pharmacotherapy Research

Research involving pharmacotherapy for children with ADHD is extensive.

Empirical study on stimulant therapy for children with ADHD reveals positive short-term

effects in multiple domains of functioning and a lack of evidence for long-term

improvement (Mash & Johnson, 1990; Pelham, Wheeler, & Chronis, 1998; Pelham, &

Lang, 1993; Swanson, McBumett, Christian, & Wigal 1995). Despite the limitations,

pharmacotherapy with stimulants is the current established treatment for ADHD (MTA,

1999). A lack of empirical support for long-term improvement provides the justification

for research involving behavioral interventions for children with ADHD.

Parent Training Intervention Research

Parents have an enormous influence (either positive or negative) on a young

child's behavioral and emotional development. Unfortunately, parents of children with

ADHD often have high rates of socially aggressive behavior, harsh discipline, marital

conflict, and psychiatric illness (Patterson et al. 1992). These parents are less likely to

assume the cause of child behavior, more likely to use negative parenting strategies, and

more likely to mention medication therapy for their child (Barkley, 1990; Johnston, 1996;

Johnston, Reynolds, Freeman, & Geller, 1998). Coercive parenting practices may









adversely affect the development of the preschool child's social-cognitive skills, and

predict conduct problems (Dodge, Bates, & Pettit, 1992; Eyberg, 1988; McMahon, 1994;

Patterson et al. 1991). Hence, parenting behavior and parent-child interactions are key

processes that affect child behavior (Richters et al. 1995).

Empirically supported parent training programs include clinical behavior therapy,

direct contingency management, cognitive-behavioral interventions, and intensive, multi-

component behavioral treatments. Pelham et al. (1998) reported that behavioral parent

training interventions and behavioral classroom interventions primarily in outpatient

settings are empirically supported treatments for children with ADHD. However, many

studies identify disruptive children because of symptoms associated with ADHD without

an explicit diagnosis. Other concerns include a lack of evidence in reducing children's

conduct problems and improvement of social skills, and poor generalization of

improvements in social and cognitive skills from the laboratory, hospital, or school to

other settings (Denham, & Alemeida, 1987; Kazdin, Esveldt-Dawson, French, & Unis,

1987; Prinz, Belchman, & Dumas, 1994).

Contingency management approaches are similar to clinical behavioral therapy,

but are characterized by more intensive interventions including token economy systems,

time out, and response cost components. Research has been conducted in controlled

settings by trained individuals and often involved single subject design (Abramowitz et

al. 1992; DuPaul, Guevremont, & Barkley, 1992; Pelham, Carlson, Sams, Vallano,

Dixon, & Hoza, 1993). Treatment effects typically have been larger than the results of

clinical behavior studies, but less than results of pharmacotherapy studies (Pelham et al.

2000).









Cognitive behavioral treatments (e.g., verbal self-instruction, problem solving,

cognitive modeling, and social skills training) have been studied in children with ADHD

to promote self-controlled behavior. This approach was designed to provide internal

mediators that facilitated generalization and maintenance of behavioral effects.

Unfortunately, empirical evidence did not support clinically significant changes in the

behavior and/or the academic performance of children with ADHD (Abikoff, &

Gittelman, 1984). Limited, but promising data supports the efficacy of social skills

training and problem-solving interventions when combined with intensive, multi-

component, behavioral treatment packages (Pelham, & Hoza, 1996; Pfiffner, & O'Leary,

1997). Thus, intensive behavior-management treatment packages including parent

training interventions applied across settings may maximize the short-term impact of

behavioral treatments.

Research on parent training interventions for parents of preschool children has

been favorable for the reduction of behavior problems (Barkley, Shelton, Crosswait et al.

2000; Eyberg, & Robinson 1982; Tucker, Gross, Fogg, Delaney, & Lapporte, 1997;

Webster-Stratton, 1998). Parents were taught to use operant procedures during

interactions with their children to modify problem behavior with positive reinforcement

techniques based on Hanf's (1969) two stage training model (Barkley, 1987; Elder, 1995;

Eyberg, 1988; Webster-Stratton, 1982, 1985, 1994). This approach has been effective in

children with a wide range of behavior and maintained as long as a year (Kazdin et al.

1987).

Eyberg (1988) integrates operant methods and traditional play therapy techniques

in a unique approach to parent training for preschool children with problem behavior,









known as Parent-Child Interaction Therapy (PCIT). The purpose of PCIT is to create a

positive, mutually rewarding relationship between the parent and the child in the context

of dyadic play situations. Parents are taught relationship-enhancement skills (e.g., praise

and active listening), teaching skills (e.g., to follow the child's lead in play and avoidance

of questioning, criticizing, or punishing the child), and behavior management skills for

effective discipline (e.g., direct commands and time-out). This approach is widely

utilized in the research of children with problem behavior (Eyberg, & Robinson 1982;

McNeil, Eyberg, Eisenstadt, Newcomb, & Funderburk, 1991; Webster-Stratton 1982,

1985, 1994). It has been adapted for use in children with varying exceptionalities (e.g.,

autism, developmental delay) (Elder, 1995; McElreath, & Hembre-Kigin, 1994).

Similar to the PCIT, Elder's (1995) research with parents of young autistic

children incorporated a parent training intervention with five components (social play,

turn taking, communication, language, and conversation). Elder's (1995) in-home, parent

training program is designed to address the communicative intent of child behavior, and

to promote social reciprocity in an effort to reduce aberrant behaviors. Parenting skills

(imitating with animation and expectant waiting) developed by MacDonald (1989) are

taught to parents. These skills are particularly important to facilitate balanced parent-

child interactions. In addition, parents of a child with autism are taught to identify child

initiations; to consistently respond to the child initiations; to give the child adequate time

to respond to parental initiations; and to allow the child to direct the parent-child play

session. This study provided essential information regarding the interactions between the

parents and their children for the development of a new parent training intervention for

parents of children with ADHD.









In-Home Parent Training

Seminal work conducted by Baer, Wolf, and Risley (1968) reveals that skills

taught in one setting are not expected to generalize to other settings without planned

systematic implementation. Furthermore, a deliberate change in behavior will not occur

unless the behavior is reinforced regularly in the environment. Therefore, father-child

interventions for problem behavior in children cannot be expected to generalize to home

settings unless the father and child are trained in familiar home environments where

naturally reinforcing activities were more likely to occur. Unfortunately, the majority of

parent training research takes place in clinical and classroom settings, rather than home

settings.

There are several disadvantages to conducting in-home research. These include a

vulnerability to disruption in session scheduling and the possibility that the physical

parameters of the home environment may cause unexpected interruption (Elder, 1995). A

modified structuring of the home setting (e.g., disconnected phone and television) can

minimize distractions. Despite the vulnerability to disruptions in session scheduling,

Elder (1995) found that parent participation was encouraged by in-home parent training

and videotaped father-child play sessions. Elder reported that subjects were more likely

to keep scheduled appointments and participate regularly at home because of the

convenience and decreased expenditure of the family resources. In addition, in-home

parent training and observation provided essential contextual data about individual

subjects in naturalistic settings.

The Role of Fathers in Childhood Behavior Problems

Reviews of parent training interventions with ADHD children were highly

promising (Webster-Stratton, 1993). However, parent training research was comprised









primarily of mother and/or classroom training (Cabrera, Tamis-LeMonda, Bradley,

Hofferth, & Lamb, 2000; Pruett, 1998; Webster-Stratton, 1985). Few studies document

the father's perceptions, father-child interactions, and paternal influences on young

children with problem behavior (Amato, & Rivera, 1999; Hoza et al. 2000; MTA, 1999;

Webster-Stratton, 1985; Yogman, Kindlon, & Earls, 1995). Consequently, paternal

influences on children with ADHD and the patterns of father-child interactions are

largely unexplored. Hence, there is a critical need for research on parent training

interventions that include fathers.

Despite the under-representation of fathers, a growing interest is evident in the

relationship of paternal factors to child and adolescent adjustment (Phares, 1996; Rolf,

Masten, Cicchetti, Neuchterlein, & Weintraub, 1990). Fathers of children with ADHD

were more likely diagnosed with ADHD during their own childhood (Frick, Lahey,

Christ, Loeber, & Green, 1991). Parent psychosocial factors were shown to increase the

likelihood of the development of ADHD in children (Barkley, 1990). However, fathers

of children with ADHD did not have higher rates of depression or higher rates of alcohol

abuse (Cunningham, Benness, & Siegel, 1988; Reeves, Werry, Elkind, & Zametkin,

1987). On the contrary, fathers with a history of substance abuse had children with

higher rates of covert antisocial behaviors (Nigg, & Hinshaw, 1998).

Current research reflects that fathers have complex, multidimensional roles; direct

and indirect patterns of influence; and that the social construction of fatherhood varies

across cultures (Belsky, 1990; Cummings & O'Reilly, 1997; Furstenburg, 1988; Lamb,

1997; O'Hare, 1995; Pleck, & Pleck, 1997; Steinberg, Kruckman, L., & Steinberg, 2000).

Relationships with fathers, stepfathers, and sets of families influence a child's









attachments, social-emotional competencies, and linguistic and cognitive abilities

(Cabrera et al. 2000). Research on father involvement in childcare has shown improved

father-child relationships, more attentive fathers, and fathers that felt intrinsically

important to their children (Amato & Rivera, 1999; Lamb, 1997). An inverse

relationship was reported between father involvement and childhood behavior problems,

cognitive development, and social competence (Amato, & Rivera, 1999; Yogman,

Kindlon, & Earls, 1995).

Father involvement in childcare during the middle childhood period was

associated with greater academic achievement, less emotional distress, and less

delinquent behavior (Furstenberg, & Harris, 1993; Harris, Furstenberg, & Mariner, 1998;

Nord, Brimhall, & West, 1997). In addition, Webster-Stratton (1985) reported significant

improvement in fathers' attitudes and children's behavior after a parent training

intervention. In summary, interdependent behavior between a father and a child may

contribute to the evolution of behavior problems and improved treatment outcomes for

fathers and their children. Further exploration is necessary to develop an understanding

of the father's role, the complex patterns of influence on children, and to facilitate

interventions that support positive father-child interactions. Further research on father-

child interactions will support the development of specific, individualized parent training

interventions for families of children with ADHD.

The Role of Social Reciprocity in Parent Training

Lamb & Easterbrooks (1981) propose that infants are biologically predisposed to

emit signals to which adults are biologically predisposed to respond. If the parent

consistently responds promptly and appropriately to the infant's signals, the infant

perceives the parent as predictable and reliable. This perception in social reciprocity









fosters the formation of secure child and parent attachments. Reciprocal parent and child

turn taking is considered an essential factor in language development (Elder, 1995;

Furrow, Nelson, & Benedict, 1979; Wetherby, 1986). Children with ADHD often have

impairments in speech, language, and communication and may not engage in turn taking

procedures (Baird et al., 2000; Cunningham, Reuler, Blackwell, & Deck, 1981; Conti-

Ramsden, 1990). Consequently, fathers may not be reinforced to continue interactions

with their children. Thus, children with ADHD may have maladaptive deficits in

cognitive processes and communication that create problems in a variety of social

contexts.

Coercive parent-child interaction and parent-controlled interactions may add to

further aberrant behavior in children with ADHD. In contrast, parents are more likely to

adjust their behavior if they are sensitive to the developmental changes in their children's

abilities and preferences (Lamb, 1997). In addition, Lamb (1997) confirmed the

prominence of play in the father-child interactions and reported that fathers initiated more

physical and idiosyncratic types of play preferred by young children. Hence, father-child

interactions in the context of play may foster communication and turn taking behavior.

Summary

Children with ADHD have an enormous impact on society in terms of financial

expense, stress to families, and academic and vocational impairment (Biederman, 1998).

Parent training has been empirically supported as a powerful tool for clinicians and

researchers in the behavior management of children with ADHD. A major limitation in

current research is the lack of father participation. Consequently, there is a dire need for

empirically validated interventions for fathers and their child with ADHD. Our study

uniquely characterizes the interactions of fathers and their young children with ADHD,






29


provides important contextual data, and empirically evaluates the effects of an in-home

parent training intervention for fathers. Father-child interactions are examined and the

separate components of the parent training intervention are evaluated. Our study

provides valuable information for further development and/or refinement of the parent

training intervention and is critical for the development of a comprehensive in-home,

family-centered intervention for parents and their children with ADHD.









Table 2-1. Review of parent training literature (1983-2004)
Author/Date Purpose Major Sample Design Results Implications
Concept
Anastopoulos, To assess the Parent 36 ADHD Training resulted in Further testing
A.D., Shelton, effects of an training children 6- decreased parenting stress, of model
T.L., DuPaul, G.J., PTP* designed model 11 years & increased parenting self-
& Guevremont, for parents of mothers esteem & improvements in
D.C. (1993) school age the severity of child's
ADHD children ADHD
Barkley, R.A., To compare the Behavioral 158 2x2 Poor attendance of parents Further research
Shelton, T.L. effects of parent preschool ANCOVA in parent training, on long-term
Crosswait, C., different training, children with Classroom treatment outcome
Moorehouse, treatment classroom- hyperactive, resulted in reduced
M.,Fletcher, K., programs on based impulsive, & behavioral problems p<
Barrett, S., behavioral, behavior inattentive .006 and social skill
Jenkins, & social, modification, behavior impairment
Metevia, L. (2000) emotional & social skills
academic training
outcomes
Cooper, L., To examine Parent 8 children Single Identified parental Further
Wacker, D., Sasso, maintaining interventions: with conduct subject, attention as a factor in application and
G., Reimers, T., & variables for demands & disorders multielement maintaining appropriate extension of
Donn, L. (1990) children with parent design across child behavior. Direct assessment
conduct attention & rapidly assessment completed in an procedures
disorder ignoring changing outpatient setting
conditions I _II









Table 2-1. Continued
Author/Date Purpose Major Sample Design Results Implications
Concept
Elder, J.H. (1995) To evaluate the Parent 4 mothers & Single Training resulted in Further research
effects of an in- training 4 male subject improved parent-child on improving
home model children with design, MB interactions over 3 interactions
communication delayed conditions (p<.034) using SSD, &
training development using in-home
program for ,language PTP
parent of impairments
developmentally & autistic
delayed children features
Erhardt, D. & To assess the Parent 2 children & Single Training resulted in Further testing
Baker, B. L. effects of a PTP training parents subject improvements in parents' of model
(1990) for children model design/AB confidence in behavioral
with ADHD management, decreased
ratings of hyperactivity,
and improved relationships
Forehand, R.L., To examine the Parent 68 mothers Quasi- Training resulted in Further testing
Steffe, M.A., long term training experimental treatment gains perceived of model
Furey, W.M., & effects of a PTP model by mothers' post-study &
Walley, P.B. at f/u
(1983)
Gross, D. Fogg, L. To examine the Parent 24 parents & Repeated Increase in parenting self- Further testing
& Tucker, S. effectiveness of training 25 2-yr olds measures efficacy, decrease in of model
(1995) a PT program program ANOVA parenting stress, &
for positive improvement in quality of
parent-child parent-toddler interaction
relationships









Table 2-1. Continued
Author/Date Purpose Major Sample Design Results Implications
Concept
Frankel, F. Myatt, To evaluate the Parent 57 boys & Comparison Training resulted in Further testing
R., Cantwell, D., & effects of an training 17 girls with improved functioning for of model
Feinberg, D. outpatient PTP program ADHD &/or children with and without
(1997) for social skills ODD ADHD as did children with
training ODD
Henry, G. (1987) To compare the Medication, 6 children 4- Single Reduction in latency to Suggested
effects of symbolic 10 years subject initiate compliance when clinical
medication and modeling, & with design, ABC time out introduced (p< .04) application of
symbolic combined hyperactivity case series components of
modeling to a package treatment
combined package
treatment
package
including
medication
Kazdin, A.E., To evaluate the Parent Inpatient Comparison Training resulted in Further testing
Exveldt-Dawson, effects of PTP training psychiatric decreased aggression & of model
M.A., French, & PSST** on model children (40) externalizing behavior at
N.H., & Unis, A.S. antisocial home, school and at 1 year
(1987) behavior in follow up
children









Table 2-1. Continued
Author/Date Purpose Major Sample Design Results Implications
Concept
Kazdin, A.E., To evaluate the Parent 97 children Quasi- Training resulted in Further testing
Siegel, D.C., & effects of training referred for experimental improved child functioning of model
Bass, D. (1992) problem-solving model psychiatric across settings and parent
skills training care functioning at post-
and parent treatment & at 1 year
management follow up
training on
children with
severe antisocial
behavior
Pisterman, S., To evaluate the Group parent 46 families Group Training resulted in Further research
McGrath, P., efficacy of training with comparison significant treatment on PTP effects
Firestone, P., group PTP intervention preschoolers using series effects in experimental on multiple
Goodman, J., aimed at with ADHD of MANOVA group. Child compliance behavior
Webster, I., & improving & parent control variables problems
Mallory, R. (1989) compliance of (p< .001)
children with
ADHD
Sonuga-Barke, To evaluate PTP 78 children Comparison PTP training resulted in Further research
E.J., Daley, D., for preschool reduced ADHD symptoms of PTP
Thompson, M., children with & increased maternal sense
Laver-Bradbury, ADHD of well being
C., & Weeks, A.
(2001)









Table 2-1. Continued
Author/Date Purpose Major Sample Design Results Implications
Concept
Tucker, S., Gross, To examine the Parent 23 families Descriptive Training resulted in gains Further testing
D., Fogg, L., effects of a PTP training & 24 F/u from in maternal self-efficacy, of model
Delaney, K., & at 1 year f/u model children 1995 study maternal stress, & mother-
Lapporte, R. child interactions
(1998) maintained at 1 year

Webster-Stratton, To evaluate the Parent 25 boys & Quasi- Training resulted in Further testing
C. (1984) short & long-term training 19 girls experimental improvement in parent of model
effects of a model attitudes & child behaviors
videotaped PTP at l month & 1 year,
reductions noncompliant &
deviant behaviors

Webster, Stratton, To examine father Parent 35 families Training resulted in Further testing
C. (1985) responses to PTP training attitudinal improvements & of model
model perceptions of child
behavior problems post-
study & 1 year f/u

Webster-Stratton, To evaluate the Parent 114 mothers Training resulted in Further testing
C. Hollinsworth, effects of initial training & 80 fathers improvements that were of model
T. & Kolpacoff, study effects were model maintained 1 year
M. (1989) maintained at 1
year









Table 2-1. Continued
Author/Date Purpose Major Sample Design Results Implications
Concept
Webster-Stratton, To explore if a Parent 85 families Repeated Training resulted in Further testing
C. (1994) videotape PTP training measures improvement in CBCL of model
with a PTP added model MANOVA, problem behavior (though
to the effects of ANOVAS x2 still in the abnormal range)
the PTP in short term range

Webster-Stratton, To examine the Parent 394 mothers Quasi- Training resulted in a Further testing
C. (1998) effects of a PTP training experimental decrease in mothers' of model
model critical remarks & greater
involvement in education,
greater social skills in
child, & decreased child
behavior problems

Webster-Stratton, To examine the Parent 272 mothers Quasi- Training resulted in Further testing
C., Reid, M.J., & effects of a PTP training & children & experimental decreased negative of model with
Hammond, M. & teacher training model 61 teachers parenting & increased cost-benefits
(2001) in Head Start positive parenting,
children & decreased behavior
mothers problems in children, &
improved teacher skills









Table 2-1. Continued
Author/Date Purpose Major Sample Design Results Implications
Concept
Weinberg, H.A. To examine the Parent 34 parents of Descriptive Training resulted in Further testing
(1999) effects of a PTP training 25 ADHD Design improvement in parental of model
for ADHD model children knowledge of ADHD &
children child behavior
management

Williams, P.D., To examine the Parent Parents & 47 Training resulted in Further testing
Elder, J. H., & effects of a training children decreased internalizing of model
Griggs, C. (1987) behavioral model scores-males > females &
training program an change greater in 2-
for parents parent families

*PTP Parent training programs
**PSST Problem-solving skills training














CHAPTER 3
METHOD

The purpose of this study was to characterize the interactions of fathers and their

young children with ADHD; and evaluate the efficacy of an in-home training program

designed for fathers. This chapter describes the research plan and the rationale for using

of single subject design. Included in the research plan is specific information on the

instruments used to describe subjects, dependent variables, and independent variables. In

addition, a detailed description of the procedure and conditions of the parent training

intervention is discussed.

Rationale for Use of Single Subject Design

Single subject design (SSD) is an important methodological tool often viewed as a

radical departure from traditional research. The unique feature of SSD is the capacity to

conduct experimental investigations with an individual, and rigorously evaluate the

effects of an intervention (Kazdin, 1982). SSD allows for direct observation of specific

behaviors of social significance, the effectiveness of a treatment, and the durability of a

treatment. In addition, SSD methodology makes inferences about the intervention effects

by comparing different conditions presented to the same subject over time. Empirical

evidence that isolates and identifies the determinants of an individual's behavior adds to

an understanding of an individual's interaction with the environment, supports

generalization through replication, and assists in the development of novel, clinically

efficacious, interventions (Kazdin, 1998).









Single subject design (SSD) has contributed to applied and experimental research

as well as a variety of interventions in clinical research (Erhardt, & Baker, 1990; Elder,

1995; Hale, Hoeppner, DeWitt, Coury, Tiracco, & Trommer, 1998; Posavac, Sheridan, &

Posavac, 1999). SSD facilitates experimental investigations with an individual and

provides a rigorous evaluation of intervention effects. Threats to the intemal validity are

unlikely in SSD due to the inherent nature of the design (Kazdin, 1982). If the

experiment is carefully designed and the results are attributed to the effects of the

independent variable with little or no ambiguity; the likelihood that the independent

variable accounts for the change in behavior is high and the study is considered internally

valid. The role of chance is diminished with each replication of behavior.

Failure to determine this relation signals a lack of experimental control as well as

failure to replicate (Johnston, & Pennypacker, 1980). Failure to demonstrate replication

in all subjects leads to a more intensive investigation of the function of the behavior

rather than attributing the findings to chance (Kazdin, 1998). External validity is

primarily addressed in subsequent investigations that alter the conditions of the original

study. If a study is considered externally valid, the results of an experiment are

generalizable and extend beyond the condition of the experiment.

Single subject design methodology has many advantages for the proposed study.

First, SSD facilitates close inspection of an individual interacting in the environment.

Children with ADHD often present with a varied range of behaviors and impairments.

Unexpected variables or outliers, specific to child behaviors and father behaviors provide

useful information for intervention effects and/or refinement (Elder, 1997a). Second,

modifications of an intervention are clearly defined and isolated, closely monitored, and









compared with each subject's own baseline data. Thus, researchers have the opportunity

to incorporate new knowledge into the intervention without compromising the scientific

integrity of the study (Elder, 1997a).

Third, behavior is a continuous process and changes over time as a function of the

influence of its determining variables. SSD gives researchers the opportunity to take

multiple "behavioral snapshots" over time that allow for quantitative and contextual,

descriptions of targeted behaviors (Johnston, & Pennypacker, 1980, 1993). A final point

is that graphic representation facilitates the communication of the data analysis and

synthesis of the relationship between the dependent and the independent variables

(Tawney, & Gast, 1989). The graphed displays are clinically useful when interacting with

families because they clearly illustrate the frequency and effects of specific training

components on the individual's behavior.

A single subject, AB design was used to assess the effects of the parent training

intervention across on each father's acquisition of skills, father behavioral responses, and

child behavioral responses across the training conditions. Each father-child dyad was

used as his own control. The frequencies of the behavioral responses for the fathers and

their children were measured concurrently and compared with baseline data. Visual

analysis was the primary means for organizing and reporting the data analysis and

synthesis. The inspection of specific components of the parent training intervention

provided valuable information for further intervention development and/or refinement.

Research Plan

Recruitment of Subjects

Agreements were formed with Joseph Keeley, Wayne Soven, Colin Condron, and

JoAnn Cook. Each practitioner referred families with young children diagnosed with









ADHD who were interested in this project. Joseph Keeley, MD is a behavioral pediatrician

in private pediatric practice in Orlando, Florida. Wayne Soven, MD and Colin Condron,

MD are pediatricians in private practices in the Orlando area. Jo Ann Cook, ED is a school

psychologist in private practice in Longwood, Florida. Each practitioner serves children

and adolescents with behavioral disorders of all races and socioeconomic groups in three

surrounding counties. The Principal Investigator (PI) contacted each family by phone,

scheduled home visits (with interested fathers who met inclusion criteria), and discussed

our study with interested parents. Fathers of children with ADHD (3- to 6-years of age)

were chosen by purposive sampling and were invited to participate. A total of four fathers

and their children chose to participate in our study.

Inclusion Criteria

Criteria for inclusion required that the children were 3- to 6-years of age without

debilitating sensory or physical impairments, and had a diagnosis of ADHD from a

behavioral pediatrician or a pediatrician according to DSM-IV (APA, 1994). Fathers and

their children were considered for enrollment in this study if they met the inclusion

criteria, gave assent to participate in the study, and had signed consent/assent. Fathers

were defined as biological fathers who resided in the home with their child for at least

one year. Each father agreed to be videotaped and to engage in the parent training

process. Each father signed an additional videotape consent form for himself and his

child.

Exclusion Criteria

A child was excluded from participation in the study if the child's medical history

indicated physical impairments, sensory-impairments, or significant medical problems.

A father was excluded from participation in the study if the father's medical history









indicated psychiatric illness or sensory problems (i.e., speech and language disorders,

hearing loss) that might affect the father's ability to receive training and/or interact with

their child.

Parent training sessions were conducted in the home by the PI. The advantages of

naturalistic observation include well-maintained subject participation and essential

contextual, in-depth data. Therefore, a room in each home was chosen for videotaping

that; minimized distractions; supported uninterrupted interactions; allowed the observer

to unobtrusively record data; and remained constant throughout the investigation.

Instruments for Describing Subjects

Four instruments (Table 3-1) were used to describe the participants in this study;

the Hollingshead Four Factor Index (1975); the Child Behavior Checklist (Achenbach, &

Edelbrock, 1983); the Parenting Scale (Arnold, O'Leary, Wolff, & Acker, 1993); and the

Interaction Questionnaire (Hoza, & Pelham, 1995). This descriptive information was

critical for determining the generalizability of findings to other fathers and their children

with ADHD, for replicating the research, and for designing future interventions.

Hollingshead Four Factor Index (1975) was used to assess socioeconomic factors

(Appendix E). This instrument is a widely used measure in research of children and

families, and provides information relevant to the study population (Bussing, Zima, &

Belin, 1998; Saxon, & Reilly, 1998). The Four Factor Index is based on the concept that

social status is a multidimensional construct. Socioeconomic status is estimated based on

an individual's occupation, education, gender, and marital status.

The Child Behavior Checklist (CBCL) (Achenbach, & Edelbrock, 1983) was used

to assess the father's perceptions of the child's behavior problems before participation

and at completion of the study (Appendix F). The CBCL consists of 118-items








associated with behavior problems. The items constitute multiple scales for two broad-

band groupings (externalizing and internalizing behavior) in all sex and age groups. T-

scores are computed for seven dimensions of child psychopathology

(emotionally/reactive, anxious/depressed, somatic complaints, withdrawn, sleep

problems, attention problems, and aggressive behavior) and five syndromes (affective

problems, anxiety problems, pervasive developmental problems, ADHD problems, and

oppositional defiant problems). The intraclass correlations are .98 for interparent

agreement and .84 for test-retest reliability (Achenbach, 1991, 1992).

The Parenting Scale (PS) (Arnold, O'Leary, Wolff, & Acker, 1993) was used to

measure father effectiveness in child discipline before participation and at completion of

the study (Appendix C). This instrument is a self-report consisting of 30-items that

represent a parent mistake as the anchor at one end of a 7-point scale with an effective

solution as the opposing anchor. The PS was scored in terms of three subscales (laxness,

overreactivity, and verbosity) and a total score. Higher scores indicate ineffective or

dysfunctional parental discipline. Arnold et al. (1993) reported an internal consistency

estimate of .84 for the total score, and 2-week test-retest reliability of .84. Hoza et al.

(2000) reported an internal consistency of .86 in mothers and .83 in fathers.

The Interactions Questionnaire (INTX) (Hoza, & Pelham, 1995) was given to

fathers before and at completion of the study, to assess the fathers' beliefs about their

children's noncompliance in hypothetical interactions (Appendix D). This questionnaire

consists of 60-items and builds upon previous research (Sobol, Ashbourne, Earn, &

Cunningham, 1989; Bugental, & Sherron, 1983). Fathers were asked to rate each often

reasons for their child's noncompliance from 1 (really true) to 10 (not really at all). Hoza









et al. (2000) analyzed only subscales that assessed beliefs about problem behaviors

related to the child's lack of effort and bad mood. Each subscale was scored across three

scenarios. Higher scores indicated less endorsement of insufficient effort or bad mood as

a reason for noncompliance. The internal consistency for the child's lack of effort

subscale was .87 for mothers and .88 for fathers and the child's bad mood subscale was

.85 for mothers and .86 for fathers. The INTX is a new instrument (not fully validated)

and test-retest reliability has not been examined. Therefore, findings must be interpreted

with caution.

Description of an In-Home Parent Training Intervention for Fathers

The current research builds on Elder's (1995) parent training intervention by

focusing on a new population. Behavioral strategies and discipline skills specific to the

Parent-Child Interaction Therapy (Eyberg, 1988) in the context of father-child play were

incorporated into our parent training intervention (Appendix B). The PI provided the

necessary equipment (e.g., video camera, videotapes, and toys) for use during

videotaping of the father-child play sessions. Baseline father-child play sessions were

videotaped before parent training. The PI provided three parent training sessions for each

father (Table 3-2) in the participant's home over a period of 8- to 12-weeks. Each in-

home training session lasted approximately 1- to 2-hours. Each father received:

* Written instructions for the targeted skills.
* Videotaped instruction including examples of the behavior to be taught.
* Role-modeling demonstrations.
* Opportunity for practicing the parenting strategies and skills with the PI.

Parent Training Session 1 (PT-1) was taught to fathers after 4- to 5-videotaped

father-child play sessions. The parenting strategies for PT-1 included imitation with

animation skill (I/A); following the child's lead in play; increasing positive responses;









and decreasing corrective statements. Fathers were asked play with their children 5-times

each week and to use the parent strategies taught during PT-1.

Parent Training Session 2 (PT-2) began after 4- to 5-videotaped father-child play

sessions that followed PT-1. The fathers were taught skills that involved discipline

strategies in the same manner that was described in PT-1. The fathers were asked to

continue the father and child play sessions 5-times each week and to use the skills taught

during PT-1 and PT-2.

Parent Training Session 3 (PT-3) began after 4- to 5-videotaped father-child play

sessions that followed the PT-2. The fathers received a review of PT-I and PT-2 in the

same manner that was described in PT-1. The fathers were asked to continue the father-

child play sessions 5-times each week, and to use the skills taught during PT-I and PT-2.

A follow-up meeting was scheduled between the PI and the father for a review of the

results that pertained to their father-child interaction.

Procedure for Implementing the Parent Training Intervention

After the fathers gave informed consents and child assents, they were asked to

complete four questionnaires (Table 3-1). The timeline (Table 3-3) and the procedure

(Table 3-4) for instrumentation and videotaping in the home were followed. The PI

videotaped the father-child play sessions in the home (twice each week) at similar times of

the day convenient for fathers and their families.

Condition A Baseline

The PI videotaped the baseline father-child play sessions in the home (twice each

week) for approximately two weeks or until a stable baseline was noted (Table 3-2). The

baseline videotaped sessions consisted of a 15-minute unstructured, in-home, father-child









play session. The PI asked the fathers five questions after every other videotaped father-

child play session. The PI recorded the behavioral responses concurrently. Data

collection and analysis were ongoing.

Condition B Introduction of Parent Training Sessions 1, 2, and 3

The first parent training session followed the completion of the baseline sessions

(Table 3-2). Approximately 4- to 5-father-child play sessions were videotaped for 15-

minutes (twice each week) for approximately two weeks following each of three parent

training sessions for fathers. The PI asked the father five questions after every other

videotaped father-child play session. The PI recorded the targeted behaviors of fathers

and their children concurrently. Data collection and analysis was ongoing. At

completion of the final father-child play session, the fathers were asked to complete

questionnaires. A follow up meeting with parents was scheduled after completion of the

study to discuss the results of their participation, to offer the complete set of videotaped

father-child play sessions, and to offer a compact disc with the parent training

intervention. In addition, mothers were offered instruction pertaining to the parent

training intervention.

Instruments and Procedure for Measuring the Dependent Variables

The PS, INTX, and CBCL were used to measure the dependent variables (Table

3-5). Dependent variables were operationalized (Appendix A). Social validity was

evaluated by a series of questions adapted from Elder's (1995) semi-structured interview

to assess the father's perceptions of the parent training process (Appendix H). The

fathers were asked after every other father-child play session to report perceptions on the

training process on a scale of 1 (positive) to 5 (negative).

0 How typical was your child's behavior during this session?









0 How comfortable are you using the skills you have been taught?

* Do you think that the training that you are doing with your child is working?

* Are you using what you have learned at times other than the videotaped session?

0 Do you think that the presence of the camera and/or investigator affected how you
or your child behaved in this session?

The Therapy Attitude Inventory (Eyberg, 1993) is a brief consumer satisfaction

measure of parent training and family therapy used to assess father satisfaction with the

process and outcome of parent training at completion of the study (Appendix G). A total

of 10-items are included that address the impact of therapy on parenting strategies and the

child's behavior. The father's were asked to rate the items on a scale from 5

(dissatisfaction with treatment or a worsening of problems) to I (maximum satisfaction

with treatment or improvement of problems) at completion of the study. The item ratings

yield a possible score of 5.

In-Home Observation

The PI conducted in-home parent training sessions for fathers at convenient

locations (e.g., living room, family room, or kitchen). The procedure for videotaping the

father-child play sessions was discussed with the father before the study. The PI arrived

at the participants' homes with the videotaping equipment and toys at a time previously

scheduled by the fathers. If the child was ill or unwilling to participate, the session was

rescheduled. Behavioral responses were coded during the 3- to 12-minute segment of the

videotaped father-child play session. The last 3 minutes were used for coding the

behavioral response categories in the event of a problem with videotaping (i.e.,

disruption, mechanical problems). The PI viewed the videotapes and recorded the

frequencies of the targeted father behaviors and the targeted child behaviors.









Each data file was assigned an identification number to maintain the

confidentiality and anonymity of the subjects. Only the subject's identification number

appeared on the data collection instruments. The files and videotapes were stored in a

locked cabinet in the PI's office and will be maintained for 3-years. All files and

videotapes will be destroyed after that time.

The Multiple Option Observation System Experimental Studies Software

(M.O.O.S.E.S.) provided a method for coding and analyzing the observational data

(Tapp, Wheyby, & Ellis, 1995). The data were entered in a laptop computer, labeled,

organized, and stored. M.O.O.S.E.S. allowed the identification of antecedent and

consequent events associated with specific behaviors as well as more general response

categories. This information is available to plan intervention and data collection

procedures for future research.

Behavioral Observer Training

The PI created the videotapes used for training an independent observer. The

independent observer was blind to the conditions under which the videotapes were taken.

The PI followed the observer training sequence developed by Elder (1995):

* Instruction to familiarize observers with the behavioral response categories as
defined in the coding manual.

0 Practice coding the videotapes of role-played interactions that clearly portray the
imitation with animation skill.

* Practice coding pre-existing parent child videotapes not associated with the
current project.

The independent observer randomly selected and coded 25% of videotaped

sessions previously coded by the PI to minimize the potential for bias and observe for

observer drift during the course of our study. The independent observer and PI were









required to establish a criteria level of 80% or greater interrater agreement. Practice

sessions continued until the criteria level was met. Interrater agreement fell below 80%

on two occasions during this study (Table 4-15). The operational definitions (Appendix

A) were reviewed and clarified. The PI and the independent observer practiced coding

behavioral responses until a criterion of 80% was met. Coding was re-instituted.

Behavioral Response Categories

Behavioral response categories from Elder's (1995) research were extended for

use in our study. Behavioral response categories of targeted behaviors (Table 3-5) for

fathers and for children addressed the research questions in our study (Appendix A). The

father's behavioral response categories included initiating behaviors, responding

behaviors (positive responses, corrective responses, and negative responses), initiated

turns with affirmation, and the imitation with animation skill. The child's behavioral

response categories included initiating behavior, responses, tantrum/aggression,

elopement, and initiated turns with affirmation.









Table 3-1. Correspondence between instrumentation and sample characteristics
Measure Instrumentation Purpose
Hollingshead Four Factor Father report Define the individual's social
Index (1975) position
Child Behavior Check List Father report To assess father's perceptions of
(1983) the child's behavior problems
Parenting Scale (1993) Father report To evaluate father effectiveness in
discipline
The Interactions Father report To evaluate father attributions of
Questionnaire (1995) compliance and noncompliance


Table 3-2. In-home parent training intervention for fathers
Condition Intervention for Father Father-Child Play Sessions
A Baseline Minimum of 3 videotaped sessions,
Approximately 3-5 until stable baseline
B Parent Training Session 1 4-5 videotaped sessions
B Parent Training Session 2 4-5 videotaped sessions
B Parent Training Session 3 4-5 videotaped sessions
Follow-up Review of study results


Table 3-3. Timeline for the parent training intervention
Parameters Initial Week Week Week Week Week Week
Visit 1-2 3-4 5-6 7-8 9-10 11-12
Informed Consent X
Baseline Questionnaires: SES,
CBCL, PS, INTX X
Semi-structured interview after
every other videotaping of X X X X X
father-child play session
Follow-up Questionnaires:
CBCL, PS, INTX, TAI X
Parent training session 1 X
Parent training session 2 X
Parent training session 3 X
Condition A X
Baseline sessions (3-4)
Condition B
Follows the baseline sessions X X X X
Completion of Study X X









Table 3-4. Procedure for instrumentation and videotaping
Condition Session Questionnaire
Prior to Baseline In-home meeting with father Informed Consent/Assent
& PI Discussion of project Hollingshead Four Factor Index
Child Behavior Checklist
Parenting Scale
Interactions Questionnaire
Condition A Unstructured father-child play Interview of 5 questions after every
Videotaping of 4-5 sessions other videotaping session
Condition B 4-5 father-child play sessions Interview of 5 questions after every
were videotaped after each other videotaping session
parent training session (1,2,3)
Project Last videotaped father-child Child Behavior Checklist
Completion play session Parenting Scale
Interactions Questionnaire
Therapy Attitude Questionnaire
Follow-up In-home meeting with parents Present parents with videotapes of
& PI father-child play sessions.


Table 3-5. Correspondence among the variables, instruments, and measurements
Variable Instrument Measurement Type of Data
Father behavioral response categories: M.O.O.S.E.S. Frequency Quantitative
Father initiations, Father positive Computerized counts Measure
responses, Father corrective responses, observation
Father negative responses Program
Child behavioral response categories
Child initiations, Child responses,
Child aggression, Child elopement
Parent training skill: M.O.O.S.E.S. Frequency Quantitative
imitating/animating counts measure
Father perceptions of the training Semi-structured Father self- Qualitative
process of the in-home parent training interview report measure.
intervention for fathers
Father satisfaction with the process and Therapy Attitude Father self- Quantitative
outcome of the in-home parent training Inventory (1993) report measure
intervention for fathers














CHAPTER 4
RESULTS

A general description for each father-child dyad during the conditions of our

study is given in this chapter. In addition, each subject's performance across the two

conditions will be discussed (individually and later, as a group). Behavioral responses

for fathers (father initiations, father positive responses, father corrective responses,

imitation with animation, and father-initiated turns with affirmation) and children (child

initiations, child responses, child aggression, child elopement, and child-initiated turns

with affirmation) are discussed, displayed, and analyzed visually in Tables 4-1 to 4-17

and Figures 4-1 to 4-24. This information is critical for determining generalizability of

findings to other fathers and their children with ADHD, replicating the study, and

designing future interventions.

Father and Child Dyad A

Using Hollingshead criteria (1975) the family was estimated within the highest

social strata (Table 4-13). Parents were in their early forties, Caucasian, employed full-

time, and the biological parents of Child A. Two older children (16-year old son and a

20-year old daughter) were the biological children of the mother from a previous

marriage. For the purpose of this discussion a fictitious name was assigned to Child A

(Jordan).

Jordan was 3-years and 7-months at the onset of the study. He received a

diagnosis of ADHD and speech and language delay at 3-years and 6-months from a

behavioral pediatrician. Jordan was prescribed therapy for speech and language delays.









Father A refused to consider ADHD medication for Jordan before and during the study.

The parents discussed concerns about Jordan's aggressive and hyperactive behavior.

Jordan had been asked to leave two previous daycare programs because of problem

behavior. At the time of our study, Jordan was attending a daycare program located near

the mother's workplace. A daycare evaluation revealed that Jordan had academic delays,

hyperactive, aggressive, and impulsive behavior. In addition, he was evaluated for

placement in the county public school early intervention program. Jordan qualified for

the "varying exceptionalities" program. However, the parents chose not to enroll Jordan

because of inconvenience associated with location and extended daycare issues. Jordan

was also evaluated by a for-profit agency for ADHD treatment. The parents were

informed that the agency could provide behavior modification treatment for Jordan

including occupational therapy that would cure ADHD. The parents chose not to enroll

Jordan in additional therapy during our study.

The father's discipline skills (Table 4-1) were assessed before and at completion

of our study using the PS (Arnold et al. 1993). Father A reported greater than average

scores in laxness, overreactivity, verbosity, and total score; minimal changes in scores

were noted before and after our study. Laxness associated with permissive parenting,

overreactivity associated with authoritarian parenting, and father verbosity may seem to

be inconsistent parenting styles. However, Father A exhibited behaviors that supported

the differing styles during the videotaped father-child play sessions. For example, the

father was observed to encourage rough play on occasion and admonish such behavior on

other occasions. Several times the father was observed restraining Jordan in his arms and

presenting a new activity. If Jordan participated in the activity, the father frequently









changed quickly to another activity. If Jordan was distracted or chose to play with a new

toy, the father corrected Jordan or tried to pull him back to the previous activity. On one

occasion, the father offered a block to Jordan. Jordan responded that the block did not fit.

The father praised Jordan. A short time later Jordan gave his father the same block. The

father dismissed Jordan and stated, "You know that block doesn't fit." Jordan

immediately stopped participating and moved to another activity.

The father was verbose during each videotaped session and often asked the same

question 3- or 4-times without waiting for Jordan to respond. Many times the father

would introduce an activity. If Jordan began the activity the father often ceased the

activity. For example, the father mentioned the game "duck, duck, goose". Jordan

immediately started to play the game. The father responded that they could not play the

game at that time. The father allowed rough, physical play in one session and threatened

"time out" as punishment for similar behavior in another session. In summary, the father

demonstrated inconsistent parenting styles. At times he was permissive, while other

times he threatened "time out" if Jordan's behavior did not improve. Intentional

aggressive, angry, or insulting father behavior was not observed.

The father often discussed concerns about Jordan's frequent episodes of

aggression, temper outbursts, and defiance in the home, daycare, and during family

outings. The father stated that it was difficult to provide consequences because he

believed that Jordan was not affected by verbal explanations or the loss of privileges, and

that Jordan did not participate when punished with "time out". The father stated that

effective punishment included placing Jordan in his room and holding the door shut. The

father reported that often the mother interfered with his management of Jordan's problem









behavior and led to frustration and conflict with his wife's behavior. The father asked if

the mother could participate in parent training because she was the primary caretaker, and

the marked differences in their parenting styles reinforced Jordan's problem behavior and

created marital discord. The PI agreed to provide parent training for the mother after the

father-child protocol had been completed.

The Child Behavior Checklist (Achenbach, & Edelbrock, 1983) was used to

assess the child's behavior problems (Table 4-1). The father reported an internalizing T-

score before and at completion of the study that was within the normal range of problem

behavior. However, an externalizing T-score of 74 before and 65 at completion of our

study was reported in the clinical range of problem behavior, and supported the diagnosis

of an externalizing disorder for ADHD. At completion of our study, the father reported

that ADHD problem behaviors decreased from the clinical range to the normal range of

behavior. In contrast, oppositional defiant behaviors were reported to increase from the

borderline to the clinical range of problem behavior. Interestingly, the father reported

attention problems decreased from the clinical range to the borderline range while

aggressive behavior increased from the normal range to the clinical range. Affective

problems were reported to decrease from the borderline clinical range to the normal

range. The father reported that Jordan had significant sleep problems (e.g., did not want

to sleep alone; had trouble falling asleep; had nightmares; resisted bedtime; slept little;

talked in his sleep; and woke often). The father stated that Jordan slept in his room only

if one parent stayed with him the entire night.

The Interactions Questionnaire (Hoza, & Pelham, 1995) was used to assess the

father's beliefs about Jordan's problem behavior before and at completion of our study.









The father reported that Jordan's problem behavior was attributed to the lack of father

effort and poor mood of the father and Jordan. Before parent training, the father stated

that the cause of Jordan's problem behavior was a mystery. The father's reported that his

attempts to discipline Jordan's problem behavior were often ineffective. After the third

parent training session, the father reported that his discipline skills (i.e., limit-setting,

ignoring misbehavior, and time out) were improving. In addition, the father stated that

teacher reports of aggression were less frequent, and Jordan's vocabulary had

significantly increased since the onset of the study. The father stated that communication

with his child had improved, that Jordan was less frustrated, and that Jordan exhibited

fewer tantrums at home. However, the father reported that Jordan's problem behavior

with his mother had not improved and the father's efforts to manage Jordan's problem

behaviors often were thwarted by his wife's interference.

Frequencies of Target Behavior

During Condition A, the father and Jordan participated in four baseline father-

child play sessions (Table 4-3). The PI videotaped two sessions per week in the father's

home. During baseline sessions, the ratio of means for father initiations to child

initiations was approximately 2:1; father initiations were greater than .66 of the total

initiations. The father had few positive responses with an average rate of 15 corrective

statements per session. The father did not respond negatively. There were no incidents

of imitation with animation (I/A). Jordan did not exhibit any incidents of aggression or

elopement. The ratio of father-initiated turns with affirmation (FIT) to child-initiated

turns with affirmation (CIT) was approximately 4:1, greater than .80 of the total initiated

turns with affirmation.









Condition B followed the videotaped baseline sessions. The father was taught the

first parent training session (PT-1) and four father-child play sessions were videotaped

(twice per week). Contrary to Condition A, the ratio of means for child initiations to

father initiations was 1:1; and the child initiations were slighter greater than .50 of the

total initiations. The father's positive responses doubled and increased to an average rate

of 12.5 per session. The father's corrective statements significantly decreased to an

average rate of .7 per session. The father's use of I/A increased to an average rate of 10

per session. The father did not make any negative comments. Jordan exhibited few

incidents of aggression with an average rate of 4.5 per session. There were no incidents

of elopement. The relationship of child responses to I/A was not evident. The ratio of

means for FIT to CIT was 1:1. The CIT were slightly greater than .50 of the total

initiated turns with affirmation.

The second parent training session (PT-2) followed and four father-child play

sessions were videotaped. Similar to PT-1, the ratio means for child initiations to father

initiations were 1:1. The child initiations were greater than .50 of the total initiations.

The father's positive responses decreased to approximately the same rate as baseline,

with an average rate of 6.5 per session. The father's corrective statements increased to an

average rate of 5.3 per session. Incidents of Jordan's aggression increased slightly to an

average rate of 5.8 per session. The father used I/A less than in PT-i with an average rate

of 8.5 per session. The father did not use negative comments. Jordan did not elope at

any time. Similar to PT-1, the ratio of means for FIT to CIT was 1:1; CIT slightly more

than .50 of the total initiated turns with affirmation.









Unfortunately, the child was ill for a week and the winter holidays prevented

scheduling for approximately two weeks. The third parent training session (PT-3) was

given and a booster session followed one week later to review information before

videotaping the father-child play sessions. Comparable to PT-I and PT-2, the ratio of

means for child initiations to father initiations was approximately 1:1. The child

initiations were slighter greater than .50 of the total initiations. The father's positive

responses increased to an average rate of 10.5, approximately twice the baseline rate.

Corrective statements decreased slightly to an average rate of 4 per session. The father

did not use negative comments. The father used I/A an average rate of 4.8, less than .50

of the average rate in PT-1. The child exhibited few incidents of aggression with an

average rate of 2.2 per session. Jordan did not elope at any time. Similar to PT-I and

PT-2, the ratio of means for FIT to CIT remained at 1:1. The CIT were greater than .50

the total initiated turns with affirmation.

Visual Report of Data

The decrease in father initiations and increase in child initiations between

Condition A and Condition B is evident in Figure 4-1. During the third baseline session

Jordan initiated play more often than in the other three baseline sessions. This father-

child play session was more typical of the sessions that followed the parent training

sessions. Jordan and his father played with blocks, shapes, and puzzles. Jordan

responded to the father's initiations and placed a block on a tower when handed a block,

put a shape in the block when handed a shape, and inserted a puzzle piece when handed a

piece. It appeared that child initiating behavior was dependant on the type of father-child

play.









During the first videotaped session after PT-1, the father did not structure or lead

the play as he had during the baseline sessions. Jordan reacted by standing or singing;

running to and from the father; falling into the father; and rough, physical play. The

father expressed concern about Jordan's aggressive behavior following the play session.

The PI advised the father to continue to allow Jordan to lead the activity. Subsequent

videotaped sessions showed that the father continued to allow the child to lead play.

Fewer instances of rough play were noted during the remainder of our study.

Interestingly, Jordan verbalized choices of play, demonstrated creative play, and

initiated play more often than during the baseline sessions. If the father participated in

Jordan's activity, the activity continued. If the father led his child's activity, Jordan

became frustrated, stopped the activity, and chose another activity. For example, Jordan

played with the dog giving it sound and movement. The father took the dog from Jordan

and positioned the dog to box the ears. He explained to Jordan how to position the dog.

Jordan's yelled and cried; took the dog from the father; tossed the dog; and ran to the

chair with another toy. It was evident that the father's response affected the father-child

interaction. It is possible that the targeted behaviors (father initiations, child initiations,

and FIT and CIT) are dependent on the father's responding behavior as well as the type

of father-child play.

Father positive responses and corrective statements changed between Condition A

and Condition B (Figure 4-2). After PT-2, the father's positive responses decreased and

father corrective statements increased. In addition, there was a decrease in the mean of

father initiations and child initiations during videotaped sessions IB#1 through IB#4.

After PT-3, the father positive responses increased and the father's corrective responses









remained fairly stable. Initially, the father expressed difficulty and discomfort with I/A

during parent training. However, the father was observed using I/A (Figure 4-3). After

the second videotaping session IB#2, a dramatic decrease in the father's use of I/A was

evident. Despite a review of I/A, the father was less inclined to use the skill for the

remainder of the study. In addition, the child responses remained relatively stable after

the parent training sessions with a average range of 34 to 41 (Table 4-4). There was no

evidence of a relationship between the child responses and the father's use of I/A.

Interestingly, the child responses remained relatively stable despite a significant decrease

in the father initiations. Further study is needed to determine the influence of father

behavior on child responses.

Significant changes were evident between Condition A and Condition B in FIT

and CIT (Figure 4-5). CIT increased and were more balanced with FIT throughout

Condition B. The increase in CIT and the balanced turn taking between the father and

the child supports the effectiveness of the first parent training component.

Father and Child Dyad B

Using Hollingshead (1975) criteria, the family was estimated to fall in the middle

range of social strata (Table 4-13). The parents were in their mid-thirties, Caucasian,

worked full-time, and the biological parents of a 3-year and 6-months-old son. The father

shared that he quit school in the seventh grade due to academic problems and failure,

difficulty reading, and lack of interest. He stated that he has worked in construction since

adolescence. The father expressed concern that his son may experience similar academic

difficulties in school.

For the purpose of discussion Child B was referred to as Thomas. Thomas

received a diagnosis of ADHD at 3-years and 6-months of age from a behavioral









pediatrician. Thomas was diagnosed with speech and language delays and received

therapy twice per week. The father did not believe that medication was an option and

Thomas was did not receive medication for ADHD during our study. Thomas was asked

to leave three previous daycare programs because of aggressive and hyperactive

behavior. In addition, Thomas was asked not to return to a church daycare program on

Sunday mornings. Throughout the study he attended a preschool program five days each

week. The teacher sent daily reports of aggressive and impulsive behavior to the parents.

Before the study, the father reported greater than average scores in laxness,

overreactivity, verbosity, and total score (Table 4-4). At completion of our study, the

father reported changes in the total score, laxness, and verbosity and no change in

overreactivity. Only the verbosity score was in the normal range of discipline

effectiveness. Thomas did not exhibit incidents of aggression during the videotaped play

sessions. The father did not respond with negative or corrective statements after the

baseline sessions. Following the baseline sessions, the father spoke less often, gave

fewer explanations, and allowed the Thomas to lead the activity. There was no evidence

of overreactivity by the father was observed during the videotaped father-child play

sessions.

Before and at completion of our study, the father reported that his wife was the

disciplinarian and that she structured and planned Thomas's activities, bedtime, and

punishment. The father stated that he did not provide consistent consequences in

response to Thomas's problem behavior and that Thomas was less likely to comply with

his requests or commands. The father expressed support for his wife's strict disciplinary

practices. If Thomas misbehaved or did not comply, the wife provided verbal reprimands









and immediate consequences such as the loss of privileges. For example, Thomas

enjoyed playing with trains. The consequences for problem behavior or negative teacher

reports often included the removal of trains for a period of time. Token reinforcements

for good behavior were granted. For example, Thomas was promised a ride on a train if

he received only positive teacher reports for the entire week. The father stated that

despite the parent's efforts with strict discipline, the child's aggressive behavior had not

changed before our study. The father asked if the mother could participate in parent

training since she was the primary caretaker and the marked variation in their parenting

styles was reinforcing his child's problem behavior. The PI agreed to provide parent

training for the mother after the research protocol had been completed.

The father reported on the CBCL (Achenbach, & Edelbrock, 1983) an

internalizing T-score of 62 before and 61 at completion of the study. Both t-scores

remained in the borderline clinical range for problem behavior (Table 4-4). An

externalizing T-score reported a change of 65 in the clinical range to 59 (within the

normal range of problem behavior). A total score of 46 decreased to 43 and remained in

the normal range.

Thomas was reported to be in the borderline clinical range for ADHD, withdrawn,

and aggressive behavior before our study. At completion of our study, the scores were

reported within the normal range of problem behavior. There was a minimal decrease in

pervasive developmental problems, but the score remained in the clinical range. The

father reported that Thomas avoided eye contact; did not answer; had poor peer

relationships; had speech problems; and was disturbed by new things or a change in

routine. In addition, the father reported a normal range of problem behavior associated









with sleep. However, the father discussed his child's problems falling asleep, resisting

bedtime, and not wanting to sleep alone. The father reported that sleep problems had

improved slightly before our study because both parents had been working together to

assist the child at bedtime with a strict schedule. It was also noteworthy that the father

reported that Thomas was more affectionate at the completion of the study. In addition,

the father believed that his child's noncompliance was influenced by a lack of father and

child effort, and poor father and child mood (Table 4.4).

Frequencies of Target Behaviors

Thomas and his father played during four baseline sessions (twice each week)

videotaped by the PI in the subjects' home. The ratio of father initiations to child

initiations was approximately 2:1, with father initiations greater than .66 of the total

initiations (Table 4-6). The father had few positive responses. The father's corrective

statements were greater than twice the average rate of positive responses. The father did

not make any negative comments or use I/A. Thomas did not exhibit incidents of

aggression or elopement. The ratio of means between FIT and CIT was approximately

3:1; FIT greater than .66 of the total initiated turns with affirmation.

After Condition A, the father received the first parent training session (PT-1).

Four father-child play sessions were videotaped (twice during each week). In

comparison to Condition A, there was a significant decrease in the father initiations and

increase in child initiations. The ratio of father initiations to child initiations changed to

2:3, with child initiations greater than .50 of the total initiations. The father's positive

responses increased almost three times the baseline rate with an average rate of 8.8 per

session. There were no corrective statements or negative comments made by the father.

The father used I/A an average rate of 10.2 per session. Thomas did not exhibit any









incidents of aggression and elopement. Another significant change was noted in the ratio

of means of FIT to CIT was approximately 1:2; CIT greater than .66 of the total initiated

turns with affirmation.

The father was taught the second parent training session (PT-2) and five father -

child play sessions were videotaped (twice during each week). Similar to PT-1, the ratio

of father initiations to child initiations was approximately 1:2, with child initiations

greater than .66 of the total initiations. The father's positive responses increased slightly

to an average rate of 10.2, three times the rate of baseline. The father did not exhibit any

corrective or negative statements. The father continued to use I/A with an average rate of

11.8 per session. However, the father stated that he was uncomfortable with the use of

I/A. It was noted during the fourth videotaping session that the use of I/A had dropped

from 15 incidents to 6 per session. For that reason a fifth videotaping session was

arranged. There was not any notable improvement in the use of 1/A in the fifth

videotaped father-child play session. The child did not exhibit any incidents of

aggression or elopement. Similar to PT-i, the ratio of means of FIT to CIT was

approximately 2:3; CIT almost .66 of the total initiated turns with affirmation.

After the fifth videotaped father-child play session, the father was taught the third

parent training session (PT-3). Four father-child play sessions were videotaped. Similar

to PT-I and PT-2, the ratio of father initiations to child initiations was 1:2, with the child

initiations almost .66 of the total initiations. The father's positive responses increased to

five times that of baseline and an average rate of 15 per session. The father did not

correct or provide negative comments. The father continued to use I/A more often with

an average rate of 20, twice the rate reported following PT-1. Thomas did not exhibit any









incidents of aggression or elopement. The ratio of means of FIT to CIT was

approximately 2:3; CIT greater than .5 0 of the total initiated turns with affirmation.

Visual Report of Data

A change in level with minimal variability is evident in father initiations and child

initiations between Condition A and Condition B (Figure 4-6). The father initiations

decreased and Thomas initiated play more often. Thomas demonstrated creative and

imaginative play. For example, Thomas often led the path of a train in various directions

using the fireplace, the father's legs, or blocks while whistling, singing, or saying "choo

choo" in Condition B. The type of father-child play seemed to influence the child

initiations. However, the father-child play session following the PT-3 was quite

different. Thomas attended a monster truck show two days before and was imitating the

monster trucks. Despite the father's attempts to interact, the child played in isolation

with the monster trucks for several minutes.

An increase in the father's positive responses is evident between Condition A and

Condition B (Figure 4-7). The father's corrective statements changed considerably with

only two incidents evident in IB#4. Imitation with animation (I/A) was taught to the

father during the first parent training session (Figure 4.8). The father expressed difficulty

with instructions to act silly and animated. The PI provided ongoing review and

encouragement of I/A throughout Condition B. There was an increase in I/A between

Condition A and Condition B. Conversely, the child responses decreased. Before

session IC# 1, the father and Thomas attended a monster truck show. Thomas played in

isolation with the monster truck toys during father-child play sessions IC#1 and IC#2.

The father used I/A more often in an attempt to interact with Thomas. Despite the

father's attempts to interact, Thomas responded less often. The father initiations between









Condition A and Condition B (Figure 4-9) decreased while the child responses remained

relatively stable with the exception of sessions IB#2 and IC#4. Further study is needed

to determine the influence of father behavior on child responding behavior.

The father spoke often and did not wait for Thomas to respond during Condition

A. After the first parent training session, the father followed his child's lead in play;

waited for Thomas to respond; initiated a turn less often; and increased his use of I/A.

CIT increased and were more balanced with FIT in Condition B (Figure 4-10). Also

noteworthy, CIT increased during second father-child play session following each parent

training session, and then decreased after each subsequent father-child play session. One

reason may be that the father's use of I/A was higher in the first and second father-child

play session following each parent training session. In addition, the father's positive

responses were highest in the second father-child play session following the parent

training sessions. The interesting point is that both CIT and FIT were more balanced

after the third parent training session. The father did not sit back and watch or play in

isolation, while Thomas played intensely with a train or truck. The father built a tower of

blocks, and Thomas used the truck to knock over the tower or the father moved his truck

on the child's arm until the child giggled. In other words, the father continued to interact

with his child. Further study is needed to understand the relationship between I/A and the

child's behavior.

Father and Child Dyad C

Using Hollingshead (1975) criteria the family was estimated to fall in the lower

range of social strata (Table 4-13). The family consisted of an African-American father,

a Caucasian mother in their late thirties, and their biological 5-year and 8-month child.

For the purpose of discussion, the Child C was referred to as James. The father had a 14-









year-old African-American teenage son from a previous marriage who visited

occasionally, but did not live in the home. The father was self-employed and contracted

his services as a handyman for home and business repairs. The mother completed junior

high school and was employed full-time. The father stated that he had a history of drug

and alcohol abuse and that he was drug and alcohol free for seven years. He reported that

he was an active member of Alcoholics Anonymous and Narcotics Anonymous. The

father stated that he was incarcerated several times. In addition, the father reported that

his wife was incarcerated prior to their marriage. He also expressed concern about past

issues of maternal child neglect.

James received a diagnosis of ADHD at 5-years and 8-months of age from a

behavioral pediatrician. James was not prescribed medication for ADHD. The father

was opposed to any type of medication and likened the use of stimulants for the treatment

of ADHD to drug abuse. Before attending kindergarten, James was asked to leave three

daycare programs due to aggressive behavior. James attended kindergarten at the local

public elementary school. The parents expressed concern about daily teacher reports of

aggressive and impulsive behavior. James was referred him for an ADHD evaluation

with a health care provider by his teacher. Initial academic testing within the school

reported that James had a second grade reading level and above average academic skills.

In addition, James was referred for psycho-educational testing and future consideration

for admission into the gifted program.

Before our study, the father reported ineffective discipline evidenced by greater

than average scores in laxness, overreactivity, and the total score (Table 4-7). The father

stated during the parent training sessions that both parents disciplined James. However,









the father did not believe his wife supported his method for discipline. He reported that

she lacked consistency in discipline and did not provide consequences for problem

behavior exhibited by James. The father discussed his wife's lifestyle and his concern

with issues of maternal neglect. The father advised that the inclusion of his wife in the

research project was essential to strengthen family ties and to provide a unified approach

to James' problem behavior. The father was advised that parent training would be

offered to his wife at completion of our study.

The father had a powerful voice and stance. James immediately acknowledged

the father's request or command. James did not exhibit any incidents of problem

behavior, opposition, or aggression throughout the study. The father spoke frequently

and gave lengthy explanations concerning play, a specific toy, or buildings. Often, the

father did not respond to the child's questions or comments. James demonstrated strong

verbal and language skills during interactions with the father. James provided ongoing

reinforcement for the father's behavior in the form of commenting, questioning, and

praise. Laxness on the father's part was not evident during the videotaped sessions.

Father overreactivity was not observed due to the immediate response of the child and

father verbosity was consistently observed throughout the study. However, the father

reported less than average scores on verbosity. Unfortunately, the father did not return

the questionnaires at completion of our study despite the efforts of the PI. Therefore,

comparison between pre-study and post-study father reports was not possible.

Before our study, the father reported on the CBCL (Achenbach, & Edelbrock,

1983) an internalizing T-score of 47, an externalizing T-score of 50, and a total score of

34 (Table 4.7). The father did not report any problem behaviors in the clinical range.









The father stated his child exhibited immature, impatient, and attention- getting behavior;

avoidance of eye contact; and inability to sit still. Somewhat problematic behaviors were

reported as hitting, defiance, and disobedience. The father reported concerns with

destructive child behavior, poor peer relations, loudness, fearlessness, and poor appetite.

In addition, the father believed that his child's problem behavior was influenced by his

child's poor mood. The father expressed certainty that James was deliberate in his

actions; knew right from wrong; and often chose the wrong action.

Frequencies of Target Behaviors

During Condition A, four father-child play sessions were videotaped in the

subjects' home (twice per week). The ratio of father initiations to child initiations was

approximately 2:1, with father initiations greater than .66 of the total initiations (Table 4-

9). The father had few positive responses with an average rate of 2 per session; while the

corrective statements had an average rate of 13 per session. The father did not use any

negative comments or the I/A skill. James did not exhibit any incidents of aggression or

elopement. The ratio of means of FIT to CIT was approximately 2:1; FIT equal to .66 of

the total initiated turns with affirmation.

The first parent training session (PT-1) followed Condition A. Then, five father-

child play sessions were videotaped (twice each week). The PI had difficulty scheduling

the videotaping sessions and several sessions were cancelled en route. The father stated

that he started a second job and he was unable to leave the workplace. The ratio of father

initiations to child initiations was approximately 1:2; child initiations greater than .66 of

the total initiations. In addition, the father's positive responses increased to an average

rate of 9.4, more than three times greater than condition A. The corrective statements

decreased from an average rate of 13 in Condition A to an average rate of 1.6 in









Condition B. The father stated that he was uncomfortable with I/A at the completion of

IA#2. Consequently, I/A was reviewed prior to session IA#3, IA#4, and IA#5. The

average rate of the father's use of I/A remained at 4 per session. Due to the limited use of

I/A during the first four sessions, a fifth videotaping session was scheduled. The average

rate of I/A did not change. James did not exhibit any incidents of aggression or

elopement. The ratio of means between FIT and CIT was approximately 1:2; CIT almost

.66 of the total initiated turns with affirmation.

The father received the second parent training session (PT-2) and four father-child

play sessions were videotaped (twice each week). The PI had difficulties scheduling the

videotaping sessions with the father. Several father-child play sessions were cancelled en

route. The father stated that he and his wife had marital problems, and that he had

considered separation. He reported that both parents had made efforts to work through

the conflict, and he wanted to continue participation in the study. Four father-play

sessions were videotaped. The ratio of father initiations to child initiations was

approximately 1:2; child initiations greater than .66 of the total initiations. The father's

positive responses remained greater than four times the average rate of Condition A with

an average rate of 8.8. The average rate of the father's corrective statements was .8, less

than one per session. The father continued to I/A at approximately the same rate. James

did not exhibit any incidents of aggression or elopement. The ratio of means between

FIT and CIT was approximately 1:1; CIT greater than .50 of the total initiated turns with

affirmation.

The father often spoke, commented, questioned, and instructed James during the

father-child play sessions. James frequently praised the father's efforts. After PT-2, the









father directed play; requested feedback from James regarding the activity; and

responded positively to praise from James. It was interesting that the child continued to

initiate play with little father attention and few positive father responses.

During the third parent training session (PT-3), the father expressed a positive

attitude about the project. He shared that he and his wife continued to have marital

problems, and that he anticipated leaving for employment out of town. The father

planned to continue our study until completion. Two father-play sessions were

videotaped. Several father-child play sessions were cancelled en route. After the final

cancellation, the father stated that he was scheduled to leave for employment in south

Florida and could no longer participate in the study. The father was unable to meet to

cancel his participation in the study and agreed to return the post intervention surveys by

mail. Two phone messages were left on his voicemail. The surveys were not received.

After PT-3, the ratio of father initiations to child initiations for both videotaped

sessions was approximately 2:3; child initiations greater than .50 of the total initiations.

The father had 9 positive responses in the first session and 0 in the second session. The

father did not exhibit any corrective statements in the first session, but exhibited 7 in the

second session. The father did not make any negative comments. The father did not use

I/A in IC#1 and used I/A 7 times during the final session IC#2. James did not exhibit any

incidents of aggression or elopement. The ratio of means of FIT to CIT was 1:1 with

balanced turn taking.

Visual Report of Data

The father decreased initiations and James initiated play more often in Condition

B (Figure 4-11). The father often requested James approval, attention, and help. The

father's positive responses increased, and the father's corrective responses decreased









from Condition A to Condition B (Figure 4-12). Interestingly, a significant decrease in

the father's positive responses was noted during IB#2 and the last videotaped session.

During IB#2, the father directed the activities with his child. During the final videotaped

session, James led the majority of the activities. The father frequently commented and

asked for feedback from James. In addition, the father provided more corrective

statements.

The father verbalized difficulty with I/A following the PT-1 and throughout the

study. Due to the low incidence of I/A following the PT-1, a fifth videotaping session

was scheduled (Figure 4-13). Despite a review of I/A before the third, fourth, and fifth

father-child play sessions, the father did not increase the use of hA. A minimal change in

level in I/A is noted between Condition A and Condition B, with the greatest number of

incidents noted following the second parent training session. There were no occurrences

of I/A during the last videotaped session. A comparison of father initiations and child

responses revealed that child responses remained relatively stable, despite a decrease in

father initiations between Condition A and Condition B (Figure 4-14).

A change in FIT and CIT was evident between Condition A and Condition B

(Figure 4-15). CIT increased and were more balanced with FIT in Condition B. The

father spoke often and did not wait for a child response during Condition A. On the

contrary, the father waited for James to respond and initiated a turn less often during

Condition B until following PT-2. FIT were greater than CIT on two occasions. Father-

child play sessions IB#2 and IC#2 were atypical. During session IB#2, the father

directed the majority of the play and James participated. In addition, there was an

increase in child responses as well as a decrease in the father's positive responses.









During session IC#2, the child directed the majority of the play. The father frequently

commented and/or requested feedback. James' responded to the father's verbosity and

provided positive feedback, answered questions, and did not exhibit frustration or anger;

James continued to participate in the father's activity and initiate play without positive

reinforcement or attention.

Father and Child Dyad D

Using the Hollingshead (1975) criteria, the family was estimated to fall in the

second highest social strata (Table 4-13). The father was self-employed and the owner of

a mid-sized construction business. His wife was a homemaker and was 9-months

pregnant with her third child. After the birth of the newborn, the parents had three

biological male children ages, 8-years, 3-years, and a newborn. For the purpose of

discussion, Child D was referred to as Bobby.

Bobby was diagnosed at 3-years-old by a primary care pediatrician in private

practice. The father stated that Bobby's height and weight were greater than 95% for his

age group and that he appeared older than his age. In addition, Bobby was diagnosed

with speech delay and was receiving therapy. The father refused to consider medication

for Bobby to treat ADHD. Bobby was not prescribed medication for ADHD. An older

brother was diagnosed with ADHD without hyperactivity several years prior because of

academic problems; he took a long-acting stimulant each morning. The father expressed

concern that Bobby may need medication in the future. The father discussed that he had

difficulty with discipline strategies, uncertainty about a course of action, and concern

about Bobby's aggressive behavior towards his older brother. The father expressed

distress that Bobby may have academic difficulties as well as behavioral problems.

Bobby was asked to leave two previous preschool programs before enrolling in a third









preschool five days each week. Frequent teacher reports included complaints of

impulsivity, aggressive behavior (e.g., hitting and tackling), and academic problems.

The parents asked to start our project before the impending birth of their baby.

Both parents verbalized the need to maintain a sense of balance and normalcy within their

home. The father stated that Bobby would benefit from the increased father attention

before the birth and during the first few months of the newborn period. The family often

spent evenings and weekends together in activities that included going to the beach,

boating, four-wheeling, and fishing.

Before our study, the father reported ineffective discipline skills evidenced by

greater than average scores in laxness, overreactivity, verbosity, and the total score

(Table 4-10). Despite the reported decreases in all scores at completion of our study, the

scores remained greater than average. The father showed changes in laxness,

overreactivity, and verbosity throughout our study. For example, Bobby changed the car

ramp three times during one baseline session and the father readjusted the ramp each of

the three times. Following the parent training sessions, the father gave fewer

explanations, asked permission for a toy, waited for Bobby to offer a toy, and asked

permission to participate. Bobby was more verbal and gave many creative explanations

for toys during play after the first parent training session. It was interested that Bobby

often imitated the father's creative play when given the opportunity.

Before and at completion of our study, the father reported an internalizing T-score

of 73 and a total score of 54 on the CBCL (Achenbach, & Edelbrock, 1983). The

externalizing score changed from 83 before the study to 77 at the completion of the study.

Both the internalizing T-score and the externalizing T-score remained in the clinical









range of problem behavior (Table 4-10). In addition, the father reported that Bobby had

affective problems and pervasive developmental problems in the clinical range, and

anxiety and ADHD problems in the borderline range. Withdrawn behavior, sleep

problems, attention problems and aggressive behavior were reported in the clinical range

for problem behavior. Emotionally reactive problems, anxiety, and somatic complaints

were reported in the borderline clinical range of problem behavior. Only oppositional

defiant problem behavior was reported within normal range.

Bobby was known to react with physical aggression, defiance, hitting, destructive

behavior, disobedience, and temper outbursts usually without guilt. The father perceived

Bobby as selfish and easily frustrated. The father stated that Bobby had been cruel to

animals without remorse. For example, he often hit his dog and had hurt neighborhood

animals. The father reported that discipline was difficult because verbal explanations or

the loss of privileges did not seem to have an effect on Bobby's behavior. The father

believed that sending Bobby to his room was the most effective consequence for problem

behavior. However, the father stated that the problem behavior did not change.

Sleep problems reported by the father included Bobby's difficulty with sleep

rituals. He did not want to go to sleep, woke frequently, had nightmares, and did not

want to sleep alone. The father stated that often he would wake in the middle of the night

to find Bobby on the floor at the foot of his bed. The father reported that he and his wife

worked together to assist Bobby at bedtime. The father expressed concern that Bobby

seemed depressed and anxious and noted that Bobby was often withdrawn, avoided eye

contact, and did not respond to questions or commands. In addition, Bobby was

frequently upset when separated from his parents.









The father believed that Bobby's problem behavior was influenced by his child's

effort and mood (Table 4-11). In addition, the father expressed concern about Bobby's

aggressive behavior towards his brother and friends. The father discussed that Bobby's

behavior was increasingly worse with his wife. The father asked if his wife could

participate in parent training since she was the primary caretaker, and she had difficulty

providing consistent discipline for Bobby's problem behaviors. The PI agreed to provide

parent training for the mother after the father-child training protocol was completed.

Frequencies of Target Behaviors

In Condition A, five baseline father-child play sessions were videotaped. The

mother gave birth to the third son after the first videotaped session. Therefore, one week

elapsed before the second videotaping session. The next four baseline sessions were

videotaped (twice per week) in the subjects' home. The ratio of father initiations to child

initiations was approximately 2:1; father initiations greater than .66 of the total initiations

(Table 4-12). The father had few positive responses with an average rate of 5.3, while

the corrective statements were an average rate of 19.8 per sessions. The father did not

make any negative comments. The father used I/A once during B#2 before the first

parent training session. Bobby exhibited four incidents of aggression during B#2 and did

not exhibit any incidents of elopement. The ratio of means of FIT to CIT was

approximately 3:1; FIT almost .75 of the total initiated turns with affirmation.

The father received the first parent training session (PT-1) and four father-child

play sessions were videotaped (twice per week). There was a significant change in

father-child initiated play. The ratio of father initiations to child initiations was

approximately 2:3, almost .66 of the total initiations. The father's positive responses

increased greater than three times in Condition A to an average rate of 19.8. The father's









corrective statements decreased from an average rate of 19.8 to 2.5 per session. The

father did not use any negative comments. The father used I/A without difficulty an

average rate of 13 per session. Bobby exhibited few incidents of aggression with an

average rate of 1.5 per session and did not exhibit any incidents of elopement. The ratio

of means of FIT to CIT was approximately 1:3; CIT almost .75 of the total initiated turns

with affirmation.

During the second parent training session (PT-2), the father expressed the

possibility that he had ADHD, and that he and his son have similar characteristics and

behavior. The father stated that he was not a model student and struggled with

academics, but he excelled in sports. In addition, the father expressed concern that his

son continued to receive negative teacher comments about impulsive and aggressive

behavior (e.g., hitting, shoving, and tackling other children) on a daily basis. The father

stated that play in the home with Bobby and his eight-year old brother before the parent

training sessions involved wrestling and rough play. After the parent training sessions,

the father changed to activities that didn't involve aggressive play.

Father-play sessions were videotaped twice per week. Similar to PT-1, the ratio

of father initiations to child initiations was approximately 2:3, with the child initiations

almost .66 of the total initiations. The average rate of the father's positive responses was

13.5 per session; greater than two times the average rate of Condition A. The father had

an average rate of corrective statements of 1 per session. The father did not use negative

comments. The father continued to use I/A, with an average rate of 14 per session.

Bobby exhibited 3 incidents of aggression in session IB#4 and did not exhibit any









incidents of elopement. The ratio of means between FIT and CIT was approximately 1:3;

CIT greater than .75 of the total initiated turns with affirmation.

The father was taught the third parent training session (PT-3). During the

discussion, the father stated that Bobby's aggressiveness towards the older sibling

continued. For example, Bobby often smacked the older brother in the face while seated

in the car with no provocation. The father reported that discipline skills (e.g., time out

and limit setting) were not helpful and that immediate consequences for problem

behavior were not always possible. The father was advised to deal with aggressive

behavior consistently. A token reward system was reviewed. The father was encouraged

to praise Bobby often for appropriate behavior. In addition, the father was advised that

problem behavior could increase initially. The problem behavior was expected to

decrease with consistent behavior management and discipline strategies.

Father-play sessions were videotaped (twice each week). At the beginning of the

fourth father-child play session, Bobby was uncooperative and the session was

discontinued after 2-minutes. A fifth session was scheduled. However, the child was

tired, angry and uncooperative and the session was rescheduled. During another visit the

father was at home but the child was at a birthday party. A final session was scheduled

and videotaped. Similar to PT- 1 and PT-2, the ratio of father initiations to child

initiations was approximately 2:3. The child initiations were almost .66 of the total

initiations. The father's positive responses continued at an average rate of 10 per session,

twice the rate during Condition A. The father's corrective statements were few with an

average of 3 per session. The father did not use negative comments. The father

continued to increase his use of I/A with an average rate of 17.8 per session, greater than









the average rate following PT-1 and PT-2. The child exhibited 3 incidents of aggression

in session #1, 2 incidents in session #2, and 15 incidents in the final session. There were

no incidents of elopement. The ratio of means of FIT to CIT was approximately 1:4; CIT

greater than .75 of the total initiated turns with affirmation.

Visual Report of Data for Father and Child Dyad D

During Condition A, Bobby played in isolation. The father chose the type of

play, attempted to interact with Bobby, and directed the activity. In contrast, during

Condition B the father initiations decreased and the child initiations increased (Figure 4-

16). After the parent training sessions, Bobby initiated play more often, demonstrated

creative play, and verbalized choices of following play. In addition, the father

commented in response to Bobby's direction of play and was less inclined to direct the

play. The father followed Bobby's directions, requested instructions, and waited for

Bobby's response before initiating an activity.

After the parent training sessions, the father's positive responses increased and the

father's corrective responses decreased (Figure 4-17). The father followed Bobby's lead

in play, requested direction and/or permission from Bobby, and continued to interact with

Bobby. Few corrective statements were made. The father accepted and followed

Bobby's direction during father-child play sessions. Similar play was noted in the

sessions IC#1 and IC#2. The father's desire to follow Bobby's direction seemed to

affirm a sense of competence in Bobby. Bobby gave more directions; played with more

imagination and creativity; and anticipated the father's participation.

The father had no difficulty with I/A after instruction during PT-1, and he used

the skill throughout the study (Figure 4-18). For example, Bobby made car sounds when

moving the truck around the floor; made the truck jump in a twirling fashion; or pushed









the truck across the floor. The father emphasized the truck sounds, made the truck jump

twirling higher, or made the truck spin across the floor. Interestingly, Bobby observed

the father's creative expression and incorporated that into his own play. It appeared that

the father's emphasis and animation of Bobby's activity encouraged Bobby to play with

more confidence and creativity. However, there was no evidence to support that the

father's use of I/A influenced the child responses (Figure 4-18). It was noteworthy, that

the father initiations decreased between Condition A and Condition B while the child

responses remained relatively stable (Figure 4.19).

The FIT decreased and CIT increased in Condition B and remained relatively

stable as compared to Condition A (Figure 4-20). The father spoke often and directed the

play in Condition A. During Condition B, the father allowed Bobby to lead the play,

followed Bobby's directions, waited for Bobby to respond, initiated a turn less often, and

increased his use of I/A. An interesting point is that CIT were relatively high, FIT were

relatively low, and the distance between the two levels was consistent. The father

responded to the child initiations with questions, comments, and requests and completed

the child initiated turn with affirmation. For example, Bobby made a path for the truck,

removed the wave runner, and drove it in the imaginary water. The father asked Bobby

for permission to drive the truck and trailer to the edge of the area and wait for the wave

runner. Bobby gave permission and drove the wave runner on the trailer and instructed

the father to drive the truck to another area. The father responded and continued a

positive reciprocal father-child interaction.

Summary of the Four Father and Child Dyads

A comparison of each subject's demographics, descriptive characteristics, and

performance across the two conditions of this study is discussed. As anticipated, all four









fathers used the parenting strategies and skills that were taught during the in-home parent

training sessions. In addition, all four children responded with positive behavioral

changes following the father's use of parent skills. Comparison of the family

demographics (Table 4-13) shows that the families vary in age, education, and social

strata. Three of four children were in the 3-year-old age range and attended pre-school

full-time. Child C (James) attended kindergarten. Each child was asked to leave at least

two previous daycare programs because of to aggressive behavior. Each family

continued to receive frequent teacher complaints of aggressive behavior from the child's

teacher. In addition, Child A (Jordan), Child B (Thomas), and Child D (Bobby) were

diagnosed with speech and language delays and received therapy. Their fathers reported

academic concerns such as poor recollection of colors, numbers, and/or letters. However,

Child C (James) differed from the other subjects in a number of ways. James was

biracial, 5-year and 8-month in age with academic success and no documented

developmental delays. James was tested for advanced placement in the school system

because of his above average academic abilities.

All four fathers reported that they were self-employed. Each father expressed the

inability to work for an employer. Each father discussed the possibility that he had

ADHD as a child. All fathers stated that they could relate to their children's behavior and

had similar behaviors as children. Father A, Father C, and Father D stated that as

children they were successful (academics or sports). Each father believed that their child

would grow up without problems. Father B left school in junior high because of

academic failure. He expressed concern that Thomas would experience similar failure in

school. Each father was opposed to medication for treatment of ADHD in his child. All









fathers expressed a commitment to participate fully in the study and a desire to improve

their children's behavior without medication.

A comparison of beliefs in Father A, Father B, and Father D about discipline and

attributions for their child's noncompliance is reported in Table 4-14. Because of

missing data, no comparisons about beliefs regarding discipline or noncompliance with

Father C were possible. Before our study, each father reported higher scores that equated

with ineffective and dysfunctional child discipline. At completion of our study, Father A,

Father B, and Father D reported higher scores for the total score, laxness, and

overreactivity. Father B and Father D reported effective discipline practices related to

verbosity compared to a high score in verbosity reported by Father A.

In addition, each father's belief about the noncompliance at completion of our

study was compared (Table 4-14). Several points were assessed parent controlled

behavior (effort and mood) and child controlled behavior (effort and mood). Father A

attributed Jordan's noncompliance to the lack of parent effort (parent control) and

Jordan's poor mood (child control). Father B attributed noncompliance in Thomas to a

lack of the father's effort and poor mood (parent control), his child's lack of effort and

poor mood (child control). Father D attributed Bobby's noncompliance to a lack of his

child's effort and poor mood. In comparison, only Father D attributed his child's

problem behavior completely within his child's control. Father A and Father B attributed

problem behavior within their child's control as well as within their own control.

A comparison of fathers' perception on problem behavior (Table 4-14) revealed

that Child A, Child B, and Child D were reported within the borderline or clinical range

of an externalizing disorder. Child B and Child D were reported within the clinical range









of an internalizing disorder and pervasive developmental problems. Additional problem

behaviors within the clinical range reported for Child A, Child B, and Child D.

Interestingly, each fathers reported significant problems related to their children's sleep

rituals and sleep habits. However, Father B reported that before our study efforts towards

a structured and consistent bedtime ritual had positively influenced his child's bedtime

behavior.

The comparisons of targeted behavior between subjects and across the conditions

of this study are presented with the exclusion of Father C and Child C because of the lack

of data. A comparison of means of father's responding behaviors during Condition A

revealed that each father had less than 6 positive responses and greater than 9 corrective

responses (Figure 4-21). All father initiations ranged between 64 and 70% of the total

initiations (Figure 4-23). All child initiations ranged between 30 and 36%. The FIT

ranged between 66 and 84% and CIT ranged between 16 and 34% of the total initiated

turns with affirmation.

A significant change was noted between Condition A and Condition B. During

Condition B, the fathers had greater than 10 positive responses and 3 or fewer corrective

responses (Figure 4-22). All father initiations ranged between 35 and 46% of the total

initiations (Figure 4-24). The child initiations ranged between 54 and 65%. The FIT

ranged between 24 and 44% and CIT ranged between 56 and 76% of the total initiated

turns with affirmation.

In summary, each of the targeted father behaviors and targeted child behaviors

changed between Condition A and Condition B. The father positive responses increased,

the corrective responses decreased, and I/A increased. The father initiations decreased,









the child initiations increased, FIT decreased, and CIT increased. Clearly, each father

implemented the father skills that were taught during the parent training sessions. Father

B and Father D had the greatest decrease in corrective statements, the highest use of

imitation with animation, and the greatest increase of positive responses. Significant

improvement was evident in each of the fathers' initiations and each of the children's

initiation. A large difference in the initiated turns with affirmation in Father D and Child

D was evident. However, initiated turns with affirmation were more balanced for Father

B and Child B. In addition, Father B reported a decrease in his child's problem behavior

and more effective father discipline at completion of our study (Table 4-5).

Interobserver Agreement

To assess interobserver agreement on the coding of target behaviors, the PI

followed the observer training sequence developed by Elder (1995) described on page 47.

To minimize the potential for bias, a second independent observer coded 25% of the

videotaped father-child videotaped sessions. The independent observer was blind to the

conditions under which the videotapes were taken. The observer and the PI established a

criteria level of 80% or greater interrater agreement before coding the father-child play

sessions. The independent observer randomly selected and coded 25% of the videotaped

sessions to evaluate for observer drift throughout the course of our study. Interobserver

agreement did fall below 80% two occasions during the coding. The operational

definitions were clarified and practice sessions continued until a level of 80% agreement

was obtained. Interobserver reliability was expressed as percentage agreement with a

range between 76 and 93% between two independent observers (Table 4-15).









Social Validity

A semi-structured interview described on page 45 was used to assess the father

perception of the parent training process. The fathers reported perceptions about the

training process on a scale of I to 5 (Table 4-16). The children's behavior was very

typical at a score of one or not typical at a score of 5. All four fathers reported that their

children's behavior during most of the videotaped play sessions was very typical and that

the presence of the camera and/or the PI had a minimal effect on child behavior. Each

father reported comfort with the parent training skills, use of the skills often, and that the

skills worked well.

The Therapy Attitude Inventory (Eyberg, 1993) described on page 46 was used to

assess the fathers' satisfaction with the process and outcome of parent training

completion of our study. A total of 10-items are included that address the impact of

therapy on parenting skills and the child behavior. The fathers were asked to rate the

items on a scale from 1 (indicating dissatisfaction with treatment or a worsening of

problems) to 5 (indicating maximum satisfaction with treatment or improvement of

problems) at the completion of the study. The item ratings yield a possible score of 5.0

on a scale of 1 to 5. Each father reported satisfaction with the process and the outcome of

the parent training intervention with a score that ranged from 4.0 to 4.4. In summary, the

fathers perceived the parent training intervention as socially valid, reported minimal

reactivity effects, and documented satisfaction with the process and outcome of the

parent training (Table 4-17).









Table 4-1. Summary of Father A effectiveness in discipline
Instrument Before Study Completion of Study
Parenting Scale (1993)*
Total score (3.1) 3.9 3.8
Laxness (2.8) 3.4 3.5
Overreactivity (3.0) 3.9 4.0
Verbosity (3.4) 4.4 3.9
CBCL(1983) **
Internalizing T score 49 37
Externalizing T score 65 74
Total score 46 48
*Scale of 1-7, higher scores = dysfunctional parenting
** Score of 60 & above = clinical range of problem behavior


Table 4-2. Summary of Father A beliefs about child noncompliace
Interactions Questionnaire (1995)* Before Study Completion of Study
Parent effort 4 5
Parent mood 7 6.3
Child mood 6.6 5.6
Child effort 4 6.3
*Scale of l to 10, 1 = really true, 10 = not true at all


Table 4-3. Means of target behaviors for Father A and Child A
Target Behaviors Condition A Condition B
Baseline PT* 1 PT* 2 PT* 3 Mean PT*
Father Initiations/ 70% 46% 47% 45% 46%
Total Initiations
Child Initiations/ 30% 54% 53% 55% 54%
Total Initiation
Child Responses 37 33.2 41.2 41.2 38.5
Father Positive 5.8 12.5 6.5 10.5 7.4
Responses
Father Corrective 15 .7 5.3 4 3
Responses
Imitation/Animation 0 10 8.5 4.8 7.8
Child Aggression 0 4.5 5.8 2.2 4.2
Father Initiated 84% 41% 44% 46% 44%
Turn/ Total Turns
Child Initiated Turn/ 16% 59% 56% 54% 56%
Total Turns
* PT Parent training session









Table 4-4. Summary of Father B effectiveness in discipline
Instrument Before Study Completion of Study
Parenting Scale (1993)*
Total score (3.1) 3.6 3.5
Laxness (2.8) 3.7 3.4
Overreactivity (3.0) 4.0 4.0
Verbosity (3.4) 3.4 2.8
CBCL (1983)**
Internalizing T score 62 61
Externalizing T score 65 59
Total score 46 43
*Scale of 1-7, higher scores = ineffective parenting
**Score of 60 & above = clinical range of problem behavior


Table 4-5. Summary of Father B beliefs about child noncompliace
Interactions Questionnaire (1995)* Before Study Completion of Study
Parent effort 1.3 2.7
Parent mood 7 2.3
Child mood 4.7 2
Child effort 2 2
* Scale of I to 10, 1 = really true, 10 = not true at all


Table 4-6. Means of get behaviors for Father B and Child B
Target Behaviors Condition A Condition B
Baseline PT* 1 PT* 2 PT* 3 Mean PT*
Father Initiations/ 64% 41% 35% 35% 37%
Total Initiations
Child Initiations/ 36% 59% 65% 65% 63%
Total Initiation
Child Responses 32.2 28.5 37.2 33.2 33
Father Positive 3 8.8 10.2 15 11.3
Responses
Father Corrective 8 0 0 0 0
Responses
Imitation/Animation 0 10.5 11.8 20 14.1
Child Aggression 0 0 .4 0 0
Father Initiated 30/69% 18/32% 18/38% 18/40% 36.7%
Turn/ Total Turns
Child Initiated Turn/ 13/31% 38/68% 30/62% 27/60% 63.3%
Total Turns I I
* PT Parent Training Session









Table 4-7. Summary of Father C effectiveness in discipline
Instrument Before Study
Parenting Scale (1993)*
Total score (3.1) 4.1
Laxness (2.8) 4.1
Overreactivity (3.0) 4.0
Verbosity (3.4) 2.9
CBCL**
Internalizing T score 47
Externalizing T score 50
Total score 34
*Scale of 1-7, higher scores = ineffective parenting
** Score of 60 = clinical range of problem behavior


Table 4-8. Summary of Father C beliefs about child noncompliance
Interactions Questionnaire (1995)* Before Study
Parent effort 7
Parent mood 8
Child mood 6
Child effort 8.3
*Scale of I to 10, 1 = really true, 10 = not true at all


Table 4-9. Means of target behaviors for Father C and Child C
Target Behavior Condition A Condition B
Baseline PT* 1 PT* 2 PT* 3 Mean PT*
Father Initiations/ 65% 31% 33% 40% 34.7%
Total Initiations
Child Initiations/ 35% 69% 67% 60% 65.3%
Total Initiation
Child Responses 19 21 22 26 34.3
Father Positive 2 9.4 8.8 4.5 7.7
Responses
Father Corrective 13 1.6 .8 3.5 2
Responses
Imitation/Animation 0 4 4.8 1 3.3
Child Aggression 0 0 0 0 0
Father Initiated 23/66% 18/36% 18/49% 20/50% 45%
Turn/ Total Turns
Child Initiated Turn/ 12/34% 32/64% 19/51% 20/50% 55%
Total Turns I
*PT Parent Training Sessions




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