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Child Variables As Predictors of Responsiveness to Treatment in Parent-Child Interaction Therapy

Permanent Link: http://ufdc.ufl.edu/UFE0043019/00001

Material Information

Title: Child Variables As Predictors of Responsiveness to Treatment in Parent-Child Interaction Therapy
Physical Description: 1 online resource (40 p.)
Language: english
Creator: POWERS,KAITLYN A
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2011

Subjects

Subjects / Keywords: ADHD -- DISRUPTIVE -- ODD -- PARENT -- PCIT
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Parent behavior management training programs such as Parent-Child Interaction Therapy (PCIT) have been shown to reduce the frequency of disruptive behavior problems in pre-school age children. Research examining these parent training programs suggests that child variables such as initial behavior problems severity, demographic characteristics, and comorbid internalizing disorders may serve as predictors of treatment outcome. Few studies have related such child variables to the speed of therapeutic gains within parent training programs. In this study, children with comorbid Attention Deficit Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD) received PCIT (N=117, 73% male, 77% Caucasian, mean age: 5 years). Pretreatment severity of externalizing symptoms, demographic variables and pretreatment severity of internalizing symptoms were examined as predictors of responsiveness to treatment. Responsiveness to treatment was defined as the number of sessions required to reduce the frequency of a child?s behavior problems to a subclinical level as measured by the Eyberg Child Behavior Inventory (ECBI) Intensity Scale. Only pretreatment severity emerged as a significant predictor of responsiveness to treatment, such that children with higher pretreatment severity needed more sessions to reduce problem behaviors to within normal limits. Child demographic variables and internalizing symptoms did not significantly predict responsiveness to treatment. Therapists should consider initial behavior problem severity when setting expectations for positive changes during treatment for families receiving PCIT and when planning for the clinical resources necessary to complete treatment.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by KAITLYN A POWERS.
Thesis: Thesis (M.S.)--University of Florida, 2011.
Local: Adviser: Boggs, Stephen R.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2012-04-30

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2011
System ID: UFE0043019:00001

Permanent Link: http://ufdc.ufl.edu/UFE0043019/00001

Material Information

Title: Child Variables As Predictors of Responsiveness to Treatment in Parent-Child Interaction Therapy
Physical Description: 1 online resource (40 p.)
Language: english
Creator: POWERS,KAITLYN A
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2011

Subjects

Subjects / Keywords: ADHD -- DISRUPTIVE -- ODD -- PARENT -- PCIT
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Parent behavior management training programs such as Parent-Child Interaction Therapy (PCIT) have been shown to reduce the frequency of disruptive behavior problems in pre-school age children. Research examining these parent training programs suggests that child variables such as initial behavior problems severity, demographic characteristics, and comorbid internalizing disorders may serve as predictors of treatment outcome. Few studies have related such child variables to the speed of therapeutic gains within parent training programs. In this study, children with comorbid Attention Deficit Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD) received PCIT (N=117, 73% male, 77% Caucasian, mean age: 5 years). Pretreatment severity of externalizing symptoms, demographic variables and pretreatment severity of internalizing symptoms were examined as predictors of responsiveness to treatment. Responsiveness to treatment was defined as the number of sessions required to reduce the frequency of a child?s behavior problems to a subclinical level as measured by the Eyberg Child Behavior Inventory (ECBI) Intensity Scale. Only pretreatment severity emerged as a significant predictor of responsiveness to treatment, such that children with higher pretreatment severity needed more sessions to reduce problem behaviors to within normal limits. Child demographic variables and internalizing symptoms did not significantly predict responsiveness to treatment. Therapists should consider initial behavior problem severity when setting expectations for positive changes during treatment for families receiving PCIT and when planning for the clinical resources necessary to complete treatment.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by KAITLYN A POWERS.
Thesis: Thesis (M.S.)--University of Florida, 2011.
Local: Adviser: Boggs, Stephen R.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2012-04-30

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2011
System ID: UFE0043019:00001


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1 CHILD VARIABLES AS PREDICTORS OF RESPONSIVENESS TO TREATMENT IN PARENT-CHILD INTERACTION THERAPY By KAITLYN AMY POWERS A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORID A IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2011

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2 2011 Kaitlyn A. Powers

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3 To my family and friends for your continuous love and support

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4 ACKNOWLEDGMENTS I would like to thank Dr. Stephen Boggs my supervisory committee chair and research advisor, for his support and guidance th roughout this project. I am also grateful to the Child Study Lab for their advice and words of encouragement. I would like to thank the members of my ma ster’s thesis committee, Dr Glenn Ashkanazi, Dr. David Janicke and Dr. William Perlstein, for their in valuable feedback. This project was funded in part by grants from the National Institute of Mental Health (R01 MH60632, RO1 MH072780) to Sheila Eyberg, Ph.D ., Principal Investigator.

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5 TABLE OF CONTENTS page ACKNOWLEDG MENTS .................................................................................................. 4LIST OF TABLES ............................................................................................................ 6ABSTRACT ..................................................................................................................... 7 CHAPTER 1 INTRODUC TION ...................................................................................................... 9Child Behavior Problems .......................................................................................... 9Treatment for Child Be havior Prob lems .................................................................. 10Specific Aims .......................................................................................................... 15Specific Aim 1 ................................................................................................... 15Specific Aim 2 ................................................................................................... 16Specific Aim 3 ................................................................................................... 162 METHOD S .............................................................................................................. 17Partici pants ............................................................................................................. 17Screening M easures ............................................................................................... 18Study Meas ures ...................................................................................................... 20Procedur e ............................................................................................................... 21Screening A ssessment s ................................................................................... 21Treatment ......................................................................................................... 223 RESULT S ............................................................................................................... 25Analysis of Normalit y .............................................................................................. 25Data Anal ysis .......................................................................................................... 25Specific Aim 1: Pre-treatment Externalizin g Behavio r ............................................. 26Specific Aim 2: Child Age, Gender and Minorit y Status .......................................... 26Specific Aim 3: Pre-treatment Internalizi ng Behavio r .............................................. 264 DISCUSSI ON ......................................................................................................... 29Child Characteristics as Predictors of Responsiveness to Treatment ..................... 29Limitations ............................................................................................................... 30Contribution and Futu re Directi ons ......................................................................... 31LIST OF RE FERENCES ............................................................................................... 34BIOGRAPHICAL SKETCH ............................................................................................ 40

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6 LIST OF TABLES Table page 2-1 Participant demographic charac teristics from St udy A an d B ............................. 242-2 CBCL internal cons istency from Study A ............................................................ 242-3 CBCL internal consis tency from Study B ............................................................ 243-1 Outcome measure characte ristics from Study A&B ............................................ 283-2 Hierarchical regression analysi s of child char acterist ics ..................................... 28

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7 Abstract of Thesis Pres ented to the Graduate School of the University of Florida in Partial Fulf illment of the Requirements for t he Degree of Master of Science CHILD VARIABLES AS PREDICTORS OF RESPONSIVENESS TO TREATMENT IN PARENT-CHILD INTERACTION THERAPY By Kaitlyn A. Powers May 2011 Chair: Stephen R. Boggs Major: Psychology Parent behavior management training programs such as Parent-Child Interaction Therapy (PCIT) have been shown to reduc e the frequency of disruptive behavior problems in pre-school age children. Res earch examining t hese parent training programs suggests that child variables such as initial behavior problems severity, demographic characteristics, and comorbid internalizing disorders may serve as predictors of treatment outcome Few studies have related su ch child variables to the speed of therapeutic gains withi n parent training programs. In this study, children with comorbid Attention Deficit Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD) received PCIT (N=117, 73% male, 77% Caucasian, mean age: 5 years). Pretreatm ent severity of externalizing symptoms, demographic variables and pret reatment severity of in ternalizing symptoms were examined as predictors of responsiveness to treatment. Responsiveness to treatment was defined as the number of sessions requ ired to reduce the fr equency of a child’s behavior problems to a subclinical level as measured by the Eyberg Child Behavior Inventory (ECBI) Intensity Scale. Only pret reatment severity emerged as a significant predictor of responsiveness to treatment, su ch that children with higher pretreatment

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8 severity needed more sessions to reduce pr oblem behaviors to within normal limits. Child demographic variables and internalizin g symptoms did not si gnificantly predict responsiveness to treatment. Therapists s hould consider initial behavior problem severity when setting expectations for pos itive changes during treatment for families receiving PCIT and when plannin g for the clinical resource s necessary to complete treatment.

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9 CHAPTER 1 INTRODUCTION Child Behavior Problems Epidemiological studies estimate that disruptive behavior probl ems are found in up to 22% of school-age children (Sadock & Sa dock, 2003). These behavior problems are frequently diagnosed as Attention Defici t Hyperactivity Disorder (ADHD) and/or Oppositional Defiant Disorder (ODD). ADHD is characterized by a pattern of hyperactive/impulsive behaviors and/or inattent ive behaviors that are more severe than what is developmentally appropriate for a child’s age. The behaviors must manifest before age 7 and must significantly interfer e with a child’s func tioning in multiple domains (e.g. home and school). It is esti mated that between 3 and 7% of children qualify for a diagnosis of ADHD (American Psychiatric Association, 2000). Children diagnosed with ODD exhibit negativ istic, defiant or hostile behavior in excess of the oppositional behavior of a typica lly developing child. An estimated 2 to 16% of children qualify for a diagnosis of ODD (Americ an Psychiatric Association, 2000). Disruptive behaviors in childhood and adole scence represent a significant public health problem and are estimated to be the mo st expensive mental health problem in the United States (Kazdin 1995). Childr en with behavior problems are frequently impaired in import ant areas of functioning, such as in their relationships with parents, peers, and teachers (Landau & Moore 1991). Academ ic achievement is also poor for children with ADHD due to off-task cla ssroom behaviors (DuPaul & Weyandt, 2006; Hinshaw, 1992; McGee, Prior, William, Smart, & Sanson, 2002). Consequently, children with disruptive behavior problem s have elevated school drop-out rates (Gottsfredson & Go ttsfredson, 2001).

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10 Additionally, children and adolescents wit h ADHD or ODD are at increased risk for comorbid psychological disorders. A pproximately 87% of children with ADHD have at least one comorbid disorder and children wit h ODD are also at risk for a variety of psychological problems (Kadesjo & Gillberg, 2001; Mash & Barkley, 2006). Internalizing disorders such as depression and anxiety are more common in children with disruptive behaviors than in children without these behavio rs (Angold, Costello, & Erkanli, 1999; Biederman, Faraone, Mick, Moore, & Lelon, 1996; Loeber & Keenan, 1994). ADHD and ODD also frequently occur togethe r, with rates of comorbid ADHD and ODD as high as 29% in a community sample (Jensen et al., 2001). Children with comorbid ADHD and ODD are considered to be at greater risk fo r more severe disruptive behavior in their adolescence such as delinquent, aggressive, or violent acts (Loeber, Brinthaupt & Green, 1990; Moffitt, 1993). In addition, ch ildren with ODD are at risk to develop more severe disruptive behaviors in their adolescence and may eventually qualify for diagnoses of Conduct Disorder (CD) or even Antisocial Personality Disorder (Fischer, Barkley, Smallish, & Fletcher, 2002). Disrupt ive behavior disorders are also associated with risky behaviors, which can lead to further comorbidity such as substance abuse (Angold et al. 1999; Hawkins, Catalano, & Miller 1992; Loeber & Keenan, 1994;). Treatment for Child Behavior Problems In a recent review of evidence-bas ed treatments for Disruptive Behavior Disorders, results indicated t hat early intervention strategi es designed for preschool age children are most efficacious in reducing pr oblem behaviors. In ad dition, this review suggested that clinicians us e parent-training intervention strategies as a first line approach to treatment (Eyberg, Nelson, & Boggs, 2008). Parent-training programs are

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11 intuitively appealing as parenting is consider ed an important factor in the development of ODD (Patterson, Reid, & Dishion, 1992). One such parent-training program is Par ent-Child Interaction Therapy (PCIT), an evidence-based treatment for preschoolers with disruptive behavior disorders (Eyberg et al., 2008). This therapy has been shown to reduce behavior problems in children immediately following treatment and at l ong-term follow-up (Brestan & Eyberg, 1998; Eyberg, Funderburk, HembreeKigin, McNeil, & Querido, 2001; Eyberg & Robinson, 1982; McNeil, Eyberg, Eisenstadt, Newcomb, & Funderburk, 1991; Sc huhmann, Foote, Eyberg, Boggs, & Algina, 1998). PC IT is based on the principles of both social learning theory and attachment theory. More specif ically, Baumrind’s theory of parenting, highlighting the benefits of the combination of high parental nurturance and high parental demand which constitute the authoritative style of parenting guided the original design of PCIT (Foote, Eyber g, & Schuhmann, 1998). The fi rst portion of the treatment, the Child Directed Interaction (CDI), fo cuses on enhancing parent-child attachment, positive parenting and child social skills wh ich are developed through parent use of play therapy skills. After parents master CDI skills they continue to the second portion of treatment, the Parent-Direct ed Interaction (PDI), which focuses on the use of clear directives and appropriate, consistent follow-th rough as forms of discipline. This portion of treatment aims to reduce child noncom pliance, aggression, and negative attitudes. When parents have mastered these discipline skills, they graduate from treatment. A core component of PCIT is the coaching sessions in which the therapist typically coaches the parent in the CDI and PDI sk ills from behind a one-way mirror while the parent plays with the child (Funderburk & Eyberg, 2010).

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12 Research supports the use of PCIT to im prove child behavior and parenting skills in multiple populations including children wi th comorbid ODD and mental retardation as well as children with comorbid ODD and Se paration Anxiety Disor der (Bagner & Eyberg, 2007; Chase & Eyberg, 2008, Choate, Pincus, Eyberg, & Barlow, 2005). PCIT has also been deemed one of two well-established and e fficacious treatments for child abuse (Chaffin et al. 2004). Diverse populations such as African American families and Mexican American families who complete PCIT have shown significant improvements in child behavior (Fernandez & Eybe rg, 2009; McCabe & Yeh, 2009). Despite its success in treating behavior pr oblems with diverse children and their parents, some family characteristics hav e been shown to predict negative treatment outcome. For example, mate rnal distress, lower SES, and high parental stress are associated with poor attrition rates, which are associated with reduced child behavior change (Fernandez & Eyberg, 2009; Boggs et al., 2005). Despite these family characteristics, PCIT research has identified no significant child characteristics that are predictive of treatment attrit ion or outcome (Boggs et al., 2005; Werba, Eyberg, Boggs, & Algina, 2006) Treatment outcome research often measures treatment success by examining child behavior post treatment as well as rate s of attrition. To complete PCIT, families must not only master parenting skills, but must also report that their child’s behavior is within normal limits. Therefor e, one measure of treatment success is the number of families who complete the PCIT protocol. Ho wever, because all children who complete PCIT have scores within normal limits on me asures of child behavior problems, the rapidity of a child’s response to treatment is not assessed by this outcome measure

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13 alone. An additional measure of a child’s re sponsiveness to PCIT would be to examine the “dose” of treatment necessa ry to bring the child’s behavior to subclinical levels on parent report measures. To address effect ively predictors of responsiveness to treatment, it is essential to consider the number of sessions needed to obtain clinically significant gains, rather than if significant gains are made, as they always are for those families who complete PCIT. The rationale behind this study is based on parent-management research which suggests child characteristics are an impor tant component in predicting treatment outcome. Several studies have determined that higher initial behavio r problem severity influences outcome negatively (Fossum, Mo rch, Handegard, Drugli, & Larsson, 2009; Reyno & McGrath, 2006; Ruma, Burke, & Thompson, 1996). Researchers have suggested that children with more severe di sruptive behavior disorders may take longer to respond to treatment or that parents of children with more severe behavior problems are less likely to implement the skills they are taught (Ruma et al., 2006). A metaanalysis of predictors of t he efficacy of parent behavior m anagement training programs also indicated that higher severity of ch ild behavior problems at pretreatment is associated with a moderate effect size fo r negative treatment outcomes. Of note, contrasting research has found that a child with higher levels of pre-existing behavioral problems may improve the most following treat ment (Hemphill & Littl efield, 2006; Reyno & McGrath, 2006). The age of the child in a parent-training program has also been considered as a potential important factor in predicting tr eatment outcome. Forehand & Wierson’s (1993) research suggested that younger children may be more likely to succeed in treatment

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14 due to a shorter behavior history, however many studies using both PCIT and other parent training programs have not found that age predicts success in treatment (Ruma et al. 1996, Werba et al. 2006). Parent-training programs are often developed to treat a specific age group, such as preschool age children, elementary-school age children or adolescents, making research on child age as a predictor very difficult due to restricted age range in a given sample. A child’s gender has been considered as a predictor of treat ment outcome as well. In a recent study using the Incredi ble Years program, a par ent training program similar to PCIT, female children were found to have poorer treatment outcomes in terms of more conduct problems at home post-trea tment (Fossum et al 2009). In contrast, multiple studies, including research ev aluating both Incredible Years and PCIT treatment programs, have failed to show a significant relationship between child gender and treatment outcome or attrition (Webs ter-Stratton, 1996; Beauchaine, WebsterStratton, & Reid, 2005). The race or ethnicity of a family and its relationship to treatment outcome is an important area of research that has been neglected in t he past (Mash & Barkley, 2006). Although several interventions for disrupt ive behaviors have found minority status families are more likely to dropout or show fewer treatment gains (Hawkins, Von Cleve, & Catalano, 1991; Holden, Lavigne, & Came ron, 1990; Kazdin, Mazurick, & Bass, 1993), there have been no significant differe nces between African American families compared to Caucasian families in terms of PCIT treatment outcome (Capage, Bennett, & McNeil, 2001; Werba et al., 2006).

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15 High levels of externalizing behaviors are associated with high levels of internalizing behaviors in children ages 2 to 6 years (Gilliom & Shaw, 2004). This association has led researchers to investigate the impact comorbid internalizing symptoms may have on treatment for externalizing problems. In a recent PCIT study children with ODD with Separation Anxiety Disorder (SAD) were shown to make improvements in externalizing behavior comparable to children with ODD only. Additionally, these children made signific ant improvements in their internalizing behaviors, which were not directly targeted during treatment (Chase & Eyberg, 2008). Other researchers using the Incredible Years parent-training program have found children with elevated internalizing symptoms at pre-treatment may respond better to treatment than children without such como rbidity (Beauchaine et al., 2005). Specific Aims The purpose of the present st udy was to examine child characteristics in PCIT, with an emphasis on the effect of these vari ables on the amount of time to attain significant child behavior change. Significant child behavior change (responsiveness to treatment) was defined as t he number of treatment sessi ons necessary to reduce a child’s behavior problems to a s ubclinical level. Operationall y, this was measured as the number of sessions to reach a score of 114 (one half standard deviation below the clinical cut-off) on the Ey berg Child Behavior Inventory (ECBI) Intensity Scale. Specific Aim 1 Specific Aim 1 was to exam ine child pretreatment leve l of externalizing behavior as a predictor of responsiveness to treat ment. We hypothesized that children with a higher level of externalizing behavior at pret reatment would require more PCIT sessions to reduce behavior problems to a subclinica l level. This hypothesis was based on the

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16 previous findings of Fossum et al., 2009; Reyno & McGrath, 2006; and Ruma et al., 1996, suggesting children with more severe behavior problems are more difficult to treat. Specific Aim 2 Specific Aim 2 was to examine child demographic variables as predictors of responsiveness to treatment. Child age, chil d gender and child ethnicity were examined. Given the restricted age range used in PCIT age was not expected to significantly predict responsiveness to treat ment. Gender was also not hypothesized to significantly predict treatment outcome, based on previous PCIT research and treatment outcome research based on other well-known treatm ents for disruptive behavior problems in young children (Werba et al., 2006, Beaucha ine et al. 2005). Ethnicity, or child minority/majority status, was also not hypothesized to significantly predict responsiveness to treatment. This study pr oposed the inclusion of child demographic variables in its analysis because these variables have not been researched using the novel conceptualization of treatment success as responsiveness to treatment. Specific Aim 3 Specific Aim 3 was to exam ine child pretreatment leve l of internalizing symptoms as a predictor of responsiveness to treatm ent. We hypothesized that those children with higher pretreatment levels of internalizing symptoms woul d require fewer sessions of PCIT to reduce their externalizing behavior probl ems to a subclinical le vel. This is based on the research of Beauchaine and collea gues (2005), suggesting mo re rapid treatment gains for children with comorbid exte rnalizing and internalizing behaviors.

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17 CHAPTER 2 METHODS Participants Participants were 117 children, ages 3 to 6, drawn from two larger treatment studies. Study A examined the efficacy of PCIT for children with ADHD and Study B examined the maintenance of treatment fo llowing PCIT for children with ODD. The sample included 54 children from Study A and 63 children from Study B. Both studies’ recruitment was conducted via referrals fr om local physicians, teachers and day care providers. Inclusion criteria for the samples in St udy A and B were as follows: a) the child was between 3 and 6 years of age at entrance into the study; b) the child met diagnostic criteria for ADHD (in Study A), ODD (in Study B) or met criteria for both ADHD and ODD c) the child obtained a standard score of 70 or higher on the Peabody Picture Vocabulary Test – Third edition (PPVT-III, Dunn & Dunn, 1997) and the parent obtained a standard score of 75 or higher on the W onderlic Personnel Test (WPT; Dodrill, 1981); d) the child lived with a prim ary caregiver who was able to attend weekly treatment sessions with the child; e) the child could not have a developmental delay or a history of sensory or motor impairments (e.g. mental retardation or autism). In Study A, children were also required to attend a structur ed daycare, preschool, or elementary school program. Children in Study A we re excluded if they were ta king psychotropic medication for behavior or attentional sym ptoms. In Study B, childr en were permitted to take psychotropic medication, however the familie s were required to maintain medication type and dosage during the study. For purposes of the sample selected for the current study, all children were required to hav e a diagnosis of bot h ADHD and ODD.

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18 Children in the present sample were mo stly male (72.6%) and had a mean age of 4.7 years (SD = 1.04). The children’s ra cial background was as follows: 76.9% Caucasian, 8.5% African American, 2. 6% Asian, and 12.0% other. The mean socioeconomic status for families including in this study was 42.4 (SD = 12.3) based on the Hollingshead (1975) Index wit h a range from 16 to 66 which is indicative of a wide socioeconomic status range am ong study participants. Dem ographic characteristics of children from Study A and B we re compared. The 54 children from Study A did not differ from the 63 children in Study B in racial/et hnic composition. However, the children in Study A were significantly ol der than the children in Study B. In addition, Study A’s sample consisted of 81.5% male children wh ile Study B’s sample consisted of 65.1% male children, representing a significant difference in ge nder. Study A’s sample also had a significantly higher socioeconomic status than Study B’s sample. (see Table 2-1). Screening Measures Diagnostic Interview Schedule for Children – IV – Parent (NIHM DISC-IV-P; Shaffer, Fisher, Lucas, Dulcan, & SchwabStone, 2000). Mothers were administered the DISC-IV-P, a structured diagnos tic interview, at pre-assessment to aid in determining the inclusion criteria of an ADHD or ODD diagnosis. This interview is based on the Diagnostic and Statistical M anual of Mental Disorders cr iteria (DSM-IV; American Psychiatric Association, 1994) and has good test -retest reliability of .79 for ADHD and .54 for ODD (Shaffer et al., 2000). Parent s were administered the ADHD, ODD, Conduct Disorder (CD), Major Depressive Disorder (MDD) and Separation Anxiety Disorder (SAD) modules Child Behavior Checklist (CBCL; Achenbach, 1991; 1992; Achenbach & Rescola, 2000, 2001). Parents were administe red the CBCL at pre-assessment. The

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19 CBCL is a parent-report measure of a child’s emotional and behavioral symptoms. In Study A, parents received the CBCL for 1.55 year olds (Achenbach & Rescola, 2000) or the CBCL for 6-18 year olds (Ac henbach & Rescola, 2001), depending on the age of their child at entrance into the study. In Study B, parents completed the CBCL for 4-18 year olds (Achenbach, 1991) or the CBCL for 2-3 year olds (Achenbach, 1992). Raw scores were converted into standardized T-scores to aid in comparison between versions of this measure. In Study A, ch ildren required a T-score over 61 on the DSMOriented ADHD scale for entrance into the study. In Study B, children required a Tscore over 61 on the Aggressive Behavior Scal e, indicative of clinically significant behavior for entrance into the study. Peabody Picture Vocabular y Test – Third Edition (PPVT-III, Dunn & Dunn, 1997). The PPVT is a measure of receptiv e language ability and was administered to children at pre-assessment as a proxy for cognitive ability. The PPVT is highly correlated with the full scale IQ score on the Wechsler Intelligence Scale for Children, (WISC; Dunn & Dunn, 1997). The PPVT has a split-half reliability range between .86 and .97, and test-retest reliability range fr om .91 to .94 (Dunn & Dunn, 1997). Children were required to attain a score of 70 for inclusion in the studies. Wonderlic Personnel Test (WPT; Dodrill, 1981). THE WPT is a 50-item measure of intellectual ability and was administered to parents at pre-assessm ent as a proxy for cognitive ability. The WPT is well correla ted with the full scale score on the Wechsler Adult Intelligence Scale, achieving a correlati on of .93 (WAIS; Dodr ill, 1981). Parents were required to attain a score of 75 for inclusion in the studies.

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20 Conners’ Teacher Rating Scale – Revised: Long Version (CTRS-R:L; Conners; 1997). The CTRS is a 59-item teacher-rati ng scale used to measure ADHD symptoms as well as ODD symptoms fo r children between the ages of 3 and 17. The CTRS-R:L has good psychometric properties with a test-re test reliability coefficients between .60 and .90 (Conners, 1997). For inclusion in Study A, teacher’s responses were required to place the child in the clinically signif icant range on either of the ADHD relevant subscales: the DSM-IV: Hyperactive/Impulsi ve or DSM-IV: Inat tention subscale. Study Measures Demographic and Background Questionnaire. Parents were administered a questionnaire at pre-treatment that collected information such as parent and child gender, age, race/ethnicity as well as occu pation, and education level of the parent. Child characteristics examined in the present study (child gender, age, race/ethnicity), were determined by parents’ responses on this questionnaire. Child Behavior Checklist (CBCL; Achenbach, 1991; 1992; Achenbach & Rescola, 2000, 2001). As described above, the CBCL was used at pre-assessment to aid in the diagnosis of ADHD or ODD and to det ermine if a child met inclusion criteria. In the present study, the Exte rnalizing behavior scale T-sc ore and the Internalizing behavior scale T-score were used as measur es of Externalizing behavior problem severity and Internalizing behavior problem se verity. Raw scores were converted to Tscores to facilitate comparison between diffe rent versions of the CBCL. The four versions of the CBCL all have good internal consistency reliability ranging from .89 to .96 on the Internalizing behavior and Extern alizing behavior subscales (Achenbach, 1991; 1992; Achenbach & Rescola, 2000, 2001). The internal consistency estimate for the present sample was calculated for t he Internalizing behavior and Externalizing

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21 behavior subscales and all internal consist ency values had a Cronbach’s alpha of 0.75 and above (see Table 2-2 and Table 2-3). Eyberg Child Behavior Inventory – Intensity Scale (ECBI; Eyberg & Pincus, 1999). The ECBI is a 36-item parent-report measure for ch ildren ages 2 and 16 that measures externalizing behavior. This ques tionnaire produces two subscales, the Intensity Scale, a measure of the frequen cy of child disruptive behaviors, and the Problem Scale, a measure of whether a par ent interprets a behavior as a problem. The Intensity Scale was used in this study and is measured on a 7-point Likert-type scale where parents rate frequency of behavior from Never (1) to Always (7) in the previous week. The ECBI – Intensity Scale has good psychometric propert ies, yielding an internal consistency coefficient of .95, a 12week period test-retest reliability coefficient of .80 and a 10-month period test-retest reliabi lity coefficient of .75 (Eyberg & Pincus, 1999). This measure was administered both at pre-assessment and at every treatment session. In this study, the ECBI was used as an indication of child responsiveness to treatment, such that a child was determined to have responded significantly to treatment at the session a parent rated a child at or below 114 on the Intensity Scale. The ECBI has been shown to be sensitive to changes in behavior, as may occur in treatment (Taylor, Schmidt, Pepler, & Hodgins, 1998; Webster-Stratton & Hammond, 1997). Procedure Screening Assessments Families completed an informed consent process approved by the University of Florida Institutional Review Board for the Protection of Human Participants and then completed a pre-treatment assessment to dete rmine if a family met inclusion criteria. Parents were required to complete ques tionnaires including the demographic and

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22 background questionnaire, CBCL and ECBI. In addition, parents were administered the DISC-IV-P and a Clinical Interview and comple ted the WPT. The child was administered the PPVT-III. Treatment Families in Study A who met eligibility crit eria were randomized to receive either individual PCIT or group PCIT with 2-3 ot her families. Families in Study B who met eligibility criteria received individual PCIT. Therapy took place weekly and was administered by two therapists who followed t he official PCIT trea tment manual for each session (Eyberg and Child Study Laboratory, 1999). Therapists conducted therapy in a child play room, equipped with an observation room with a one-way mirror to facilitate therapist coaching a parent to learn skills duri ng play with their child. In addition, a “bugin-the-ear” device was used to transmit c oaching statements from the therapist’s microphone in the observation room to t he parent’s ear in the play room. The first portion of PCIT, the ChildDirected Interaction (CDI), focused on enhancing parent-child attachment, positive par enting and child social skills. Parents were instructed in play therapy skills such as increasing child positive behaviors through labeled praise and decreasing child negat ive behaviors through the removal of attention. To move on to the next phase of treatment, parents were required to achieve CDI mastery criteria by dem onstrating appropriate use of play therapy skills during a coding period with no t herapist coaching. Families who achieved CDI mastery cr iteria moved on to the second phase of treatment, or the Pare nt-Directed Interaction (PDI) phas e. In this phase, parents were taught to use clear directives and appropria te, consistent follow-through as forms of behavior management and discipline. Parents were required to meet PDI mastery

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23 criteria by demonstrating an ability to provide clear direct commands and follow-through with labeled praise or the appropriate time-out procedur e for noncompliance. Families graduated from treatment when parents had achieved CDI and PDI mastery, had rated the child’s disruptive behavio r within 0.5 standard deviations of the normative range on the ECBI (an Intensity Score of 114), and re ported that they were confident in their ability to effectively manage the child’s behavior without ther apist guidance.

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24 Table 2-1. Participant Demographic Characteristics from Study A and B Study A & B Study A Study B M/% SDM/%SDM/%SD t (115)p N 117 5463 Child age (years) 4.7 1.045.00.824.51.15 2.990.003* Child gender (% male) 72.6 81.565.1 -2.000.048* Child race/ethnicity -0.69 0.493 Caucasian 76.9 77.876.2 African American 8.5 11.16.3 Asian American 2.6 1.93.2 Other 12.0 9.314.3 Family SES 42.4 12.345.0 10.340.213.5 2.140.034* Note: N = 117 *p .05 Table 2-2. CBCL Internal Consistency from Study A N (items) Cronbach's Alpha N (subjects) CBCL years 1.5-5 Internalizing Subscale 36 0.85 42 Externalizing Subscale 24 0.86 42 CBCL years 6-18 Internalizing Subscale 30 0.75 10 Externalizing Subscale 24 0.79 10 Table 2-3. CBCL Internal C onsistency from Study B N (items) Cronbach's Alpha N (subjects) CBCL years 2-3 Internalizing Subscale 25 0.80 27 Externalizing Subscale 25 0.87 17 CBCL years 4-18 Internalizing Subscale 30 0.78 46 Externalizing Subscale 31 0.83 46

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25 CHAPTER 3 RESULTS Analysis of Normality Before conducting study analyses, normality was assessed for all study measures. Skewness and kurtosis were ex amined and an absolute value greater than 1.5 was used to indicate significant skewne ss or kurtosis. All measures were normally distributed based on this requirement. Visual inspection of normality graphs was also performed and indicated normality assumptions were met for all study measures. Data Analysis Descriptive statistics were examined for the CBCL Externalizing Scale and CBCL Internalizing Scale. Study A and Study B par ticipants were compared and their mean Tscores did not differ significantly. The pres ent sample’s mean CBCL Externalizing Tscore was within the clinically significant range as was the mean CBCL Internalizing Tscore. The outcome variable of number of sessions to reach 114 or less on the ECBI was also examined. Study A and Study B participants were compared and their mean number of sessions did not differ significant ly. The mean number of sessions to reach an ECBI score of 114 or less was 10.41 sessions ( SD = 6.38 ) (see Table 3-1). A hierarchical multiple linear regr ession was conducted to assess child characteristics as predictors of responsiven ess to treatment. Predictors were entered into blocks in a hierarchical fashion to a ssess the contribution of successive predictors after controlling for previously entered pr edictors. In Block 1, mother’s CBCL Externalizing T-score was entered into t he regression. In Bl ock 2, demographic characteristics of child age, child gender and child minority status were entered simultaneously into the regression. In Block 3, mother’s CBCL Internalizing T-score was

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26 entered into the regression. The outcome va riable in the regression was the number of sessions required until a mother rated her ch ild as a 114 or lower score on the ECBIIntensity Scale. A summary of statisti cal results can be found in Table 3-2. Specific Aim 1: Pre-treatment Externalizing Behavior Initially, mother’s CBCL Externalizing T-score was entered into the regression equation. This model was significant (F (1, 116) = 6.63, p =.01) and accounted for 6% of the variance in number of sessions. The Exter nalizing Scale score was significant (B = 0.20, p=.01) and indicated that as the Exte rnalizing T-score increased, the number of sessions to reach the responsivene ss criterion also increased. Specific Aim 2: Child Age, Gender and Minority Status After controlling for the va riance explained by externalizing behavior in Block 1, child demographic variables were considered in Block 2. Model 2 (which included Block 1 and Block 2) was not significant (F (4, 113) = 2.28, p = .07) and although the variance explained by Model 2 increased from 6% in M odel 1 to 8% in Model 2, this was not significant. Individual variabl es in this model were examined and revealed that only the Externalizing Scale score was a significant pr edictor of responsiveness to treatment (B = 0.20, p = .01). Specific Aim 3: Pre-treatment Internalizing Behavior After controlling for the variance explained by externa lizing behavior in Block 1 and child demographic variables in Block 2, mo ther’s CBCL Internalizing scale T-score was entered in Block 3. Model 3 (which included Block 1, Block 2 and Block 3) was significant (F (5, 112) = 2.29, p = .05), although the increase in variance explained from 8% in Model 2 to 10% in model 3 was not signi ficant. Individual variables in this model

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27 were examined and revealed that once again, onl y the Externalizing Scale score was a significant predictor of responsiveness to treatment (B = 0.28, p = .004).

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28 Table 3-1. Outcome Measure Char acteristics from Study A&B Study A & B St udy A Study B MSDMSDMSD t (115)p CBCL Ext. T-score 71.557.6370.78.4272.226.91 -1.040.299 CBCL Int. T-score 61.488.7860.988.2061.899.27 -1.020.31 Sessions to ECBI Criterion 10.41 6.389.55.8111.196.78 -1.440.145 Note: N = 117 *p < .05 Table 3-2. Hierarchical Regression Analysis of Child Characteristics Predictors B SE B R 2 R 2 F Model Block 1 Externalizing (CBCL) 0.20* 0.08 0.24 0.06 6.63* Block 2 Externalizing (CBCL) 0.20* 0.08 0.24 Age (months) 0.00 0.05 0.01 Gender 2.07 1.32 0.14 Race 0.11 1.43 0.01 0.08 0.02 2.28 Block 3 Externalizing (CBCL) 0.28* 0.10 0.34 Age (months) 0.00 0.05 0.01 Gender 2.06 1.31 0.14 Race 0.15 1.42 0.01 Internalizing (CBCL) 0.12 0.08 0.17 0.10 0.02 2.29* Note: N = 117 *p .05

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29 CHAPTER 4 DISCUSSION Child Characteristics as Predictors of Responsiveness to Treatment This study examined child characte ristics as possible predictors of responsiveness to treatment in PCIT. Resu lts confirmed our hypothesis that child pretreatment level of externalizing behavior is a significant predictor of responsiveness to treatment. In this sample children with higher externa lizing behavior required more PCIT sessions to reduce behavior problems to a subclinical level. This finding suggested that although behavior problem seve rity may not predict level of behavior change or attrition in PCIT (Boggs et al., 2005; Werba et al., 2006), it does predict slower responsiveness to treatment. Thes e results are consistent with Ruma and colleagues (2006) research t hat suggested more severe disruptive behaviors are resistant to change and require multiple doses of therapy before behav ior falls within the normal range. Child age, gender, and minority status were also examined and we re not found to predict significantly responsiv eness to treatment. Previous PCIT research supports this finding in terms of treatment outcome and attrition (Capage, Bennett, & McNeil, 2001; Werba et al., 2006). Our research extends this finding to suggest that commonly examined child demographic variables al so do not predict the dose-response relationship in PCIT. This result is contrary to findings in the In credible Years program suggesting female children have poorer treatm ent outcomes (Fossum et al. 2009) as well as research suggesting that younger children may be more likely to succeed in treatment (Forehand & Wierson, 1993).

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30 Contrary to our final hypothesis, child pretreatment level of internalizing symptoms was not found to predict significa ntly responsiveness to treatment. Although this is not consistent with the findings of Beauchaine and colleagues (2005), which suggests comorbid externalizing and intern alizing behavior in children may predict more rapid response to treatment, previous PCIT research supports the present study’s finding. Chase and Eyberg (2008) reported no significant diffe rences in externalizing behavior improvements in children with ODD when compared to children with ODD and SAD, suggesting that an internalizing comorb idity neither helps nor harms treatment outcome. Our research ext ended this finding to responsiveness to treatment, and indicated that a child’s level of interna lizing symptoms is not related to the time necessary to demonstrate a positive im pact on their externalizing symptoms. Limitations This study’s findings should be interpreted in light of several limitations. Analyses were calculated using secondary data analysis of two previous PCIT studies. This constrained measurement of child char acteristics and behavior change to measures already within Study A and B’s protocols. Addi tionally, Study A provided PCIT in either individual or group format, which may have di fferentially influenced responsiveness to treatment. Only parent-report me asures were used to assess child characteristics and behavior change. Although these measures have good psychometric properties and have demonstrated utility in evaluating treat ment outcome, parental rating of child variables may have been influenced by parent char acteristics that were not included in the analysis. Therapist or teacher report measures were not used in this study and may have added to the assessment of responsiv eness to treatment. Direct observation measures of child behavior were not used at each treatment session; however such

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31 measures would have provided an import ant additional measure of child behavior change across sessions. Although pretreatment child externalizing behavior wa s a significant predictor of responsiveness to treatment and resulted in significant regression models, these models predicted only 6-10% of the varianc e in responsiveness to treatment. This finding suggests a large portion of the varian ce in responsiveness to treatment lies in variables outside the child characteri stics examined in the present study. A final limitation of this study lies in its possible sample size problems. This sample consisted of mostly male Cauc asian children, and this homogenous sample may have limited the ability to detect signific ant gender or minority st atus differences in responsiveness to treatment. A larger repr esentation of female children and minority status children may have revealed signific ant demographic predictors. Additionally, this sample consisted of a restricted age range of children from 3 year s to 7 years old. A sample with a larger age range of child ren may have detected age effects. Contribution and Future Directions This study provided pertinent clinical information which may immediately impact patients. Therapists using PCIT should co nsider responsiveness to treatment when estimating treatment length and they ma y anticipate more sessions needed to see clinically significant behavior change in t heir most severe pati ents. Additionally, therapists should be aware of child charac teristics that are not predictive of responsiveness to treatment such as child demographic variables and co-morbid internalizing symptoms. Ther apists could use this information to confidently recommend PCIT to children from a variety of backgroun ds or with co-morbid depression or anxiety.

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32 The novel conceptualization and use of the responsiveness to treatment variable in this study contributes significantly to the treatment outcome literature. Previous research has typically examined only chang es in behavior from pre-treatment to posttreatment or attrition rates to determine efficacy and feasibility. Responsiveness to treatment begins to shed light on the proc ess occurring before a treatment success or failure. In essence, this new variable allows researchers to examine the efficiency of treatment, in addition to the e fficacy of treatment. As increasing num bers of treatments are proven efficacious, patients may be faced with multiple therapy options, each with years of rigorous supporting research. Effi cacious treatments may bolster their appeal to therapists and patient by examining the e fficiency of their treatment, which may lead to further cost effectiveness studies. Future research may focus on other va riables that predict responsiveness to treatment in PCIT, such as family characte ristics or parents’ perceptions and attitudes towards treatment. Unlike child characterist ics, family and parent characteristics significantly predict treatment outcome and attrition in PCIT (Boggs et al., 2005; Fernandez & Eyberg, 2009; Werba et al., 2006), and thus may account for some of the remaining variance in predicting responsiven ess to treatment. Additionally, family and parent characteristics could be considered in conjunction with child characteristics to reveal complex mediator or moderator models of responsi veness to treatment. Finally, responsiveness to treatment may be examined in treatments outside of PCIT or other parent-management programs. Va luable information could be gained by determining not only the type of patient who will show signi ficant treatment gains, but also the type of patient who will respond quickly to availabl e treatments. Both effective treatment and

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33 efficient treatment are highly desir able outcomes for tr eatment development researchers as they will help assure appropr iate and rapid interventions for consumers of behavioral health services.

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34 LIST OF REFERENCES Achenbach, T.M. (1991). Manual for the Child Behavior Checklist/4-18 and the 1991 profile. Burlington, VT: University of Ve rmont Department of Psychiatry. Achenbach, T.M. (1992). Manual for the Child Behavior Checklist/2-3 and 1992 profile. Burlington, VT: University of Ve rmont Department of Psychiatry. Achenbach, T.M., & Rescorla, L.A. (2000). Manual for ASEBA Preschool Forms & Profiles. Burlington, VT: University of Vermo nt, Research Center for Children, Youth & Families. Achenbach, T.M., & Rescorla, L.A. (2001). Manual for ASEBA School-age Forms & Profiles. Burlington, VT: University of Vermo nt, Research Center for Children, Youth & Families. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (DSM-IV) (4th ed.). Washington, DC: Author. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (DSM-IV-TR) (4th ed., text revision). Washington, DC: Author. Angold, A., Costello, E.J., & Er kanli, A. (1999). Comorbidity. Journal of Child Psychology and Psychiatry, 40, 57-88. doi: 10. 1111/1469-7610.00424\ Bagner, D.M. & Eyberg, S.M. (2007). Parent-C hild Interaction Therapy for Disruptive Behavior in Children with Mental Retar dation: A Randomized Controlled Trial. Journal of Clinical Child and Adolescent Psychology, 36 (3), 418-429. Beauchaine, T.P., Webster-Stratton, C., & Re id, M.J. (2005). Medi ators, Moderators, and Predictors of 1-Year Outcomes Among Children Treated for Early-Onset Conduct Problems: A Latent Growth Curve Analysis. Journal of Consulting and Clinical Psychology, 73(3), 371388. doi: 10.1037/0022-006X.73.3.371 Biederman, J., Faraone, S.V., Mick, E., Moore, P., & Lel on, E. (1996). Child Behavior Checklist findings further support Comorbidity between ADHD and major depression in a referred sample. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 734-742. doi: 10.1097/ 00004583-100606000-00013 Boggs, S.R., Eyberg, S.M., Edwa rds, D.L., Rayfield, A., Jac obs, J., Bagner, D., & Hood, K.K. (2005). Outcomes of Parent-Child Interaction Therapy: A Comparison of Treatment Completers and Study Dr opouts One to Three Years Later. Child & Family Behavior Therapy, 26 (4), 1-22. doi: 10.1300 /J019v26n04_01 Butler, A.M & Eyberg, S.M. (2006). Parent-child interact ion therapy and ethnic minority children. Vulnerable children a nd youth studies, 1(3), 246-255. doi: 10.1080/17450120 600973577

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35 Capage, L.C., Bennett, G.M., & McNeil, C. B. (2001). A comparis on between African American and Caucasian children referred for treatment of disruptive behavior disorders. Child & Family B ehavior Therapy, 23(1), 1-14. doi: 10.1300/J019v23n01_01 Chaffin, M., Silovsky, J.F., F underburk, B., Valle, L.A., Brest an, E.V., Balachova, T., Jackson, S., Lensgraf, J., & Bonner, B.L. (2004). Parent-Child Interaction Therapy with Physically Abusive Parent s: Efficacy for Reducing Future Abuse Reports. Journal of Consulting and Clinical Psychology, 72(3), 500-510. doi: 10.1037/0022-006X.72.3.500 Chase, R.M. & Eyberg, S.M. (2008). Clinic al presentation and treat ment outcome for children with comorbid externalizi ng and internalizing symptoms. Anxiety Disorders, 22, 273-282. doi: 10.1016/j.janxdi s.2007.03.006 Choate, M.L., Pincus, D.B., Eyberg, S.M ., & Barlow, D.H. (2005). Parent-Child Interaction Therapy for Treatment of Separation Anxiety Disorder in Young Children: A Pilot Study. Cognitive and Behavioral Practice, 12, 126-135. doi: 10.1016/S1077-7229(05)80047-1 Conners, C.K. (1997). Conners’ rating scales: Revised technical manual North Towanda, NY: MultiHealth Systems. Dodrill, C.B. (1981). An econom ical method for the evaluation of general intelligence in adults. Journal of Consulting and Clinical Psychology, 56, 145-147. doi: 10.1037/0022-006X.49.5.668 Dunn, L.M., & Dunn, L.M. (1997) Examiner’s manual for the PPVT-3: Peabody Picture Vocabulary Test-Third Edition. Circle Pines: MN: American Guidance Service. DuPaul, G.J., & Weyandt, L. L. (2006). School-based Intervention for Children with Attention Deficit Hyperactivity Dis order: Effects on academic, social and behavioural functioning. International Journal of Disability, Development and Education, 53 (2), 161-176. doi: 10.1080/10349120600716141 Eyberg, S.M., Funderburk, B.W., Hembree-Kigin, T.L., McNeil, C.B., & Querido, J.G. (2001). Parent-Child Interaction Ther apy with behavior problem children: One and two year maintenance of trea tment effects in the family. Child & Behavior Therapy, 23, 1-19. doi: 10.1300/J019v23n04_01 Eyberg, S.M. & Robinson, E.A. (1982). Parent-child interact ion training: Effects on family functioning. Journal of Clinical Child Psychology, 11, 130-137. doi: 10.1207/s15374424jccp1102_6

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37 Hawkins, J.D., Von Cleve, E., & Catalano, R.F. (1991). Reducing early childhood aggression: Results of a pr imary prevention program. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 208-217. doi: 10.1097/00004583-19 9103000-00008 Hinshaw, S.P. (1992). Externalizing behavior problems and academic underachievement in childhood and adolesc ence: Causal relationships and underlying mechanisms. Psychological Bulletin, 111, 127-155. doi: 10.1037/0033-2909. 111.1.127 Hemphill, S.A. & Littlefield, L. (2006). Child and Family Predictors of Therapy Outcome for Children with Behavioral and Emoti onal Problems. Child Psychiatry and Human Development, 36(3), 329349. doi: 10.1007/s10578-005-0006-1 Holden, G.W., Lavigne, V.V. & Cameron, A.M. (1990). Probing th e continuum of e effectiveness in parent training: Charac teristics of parents and preschoolers. Journal of Clinical Child Psychology, 19 2-8. doi: 10.1207/ s15374424jccp1901_1 Hollingshead, A.B. (1975). Four factor index of social status. New Haven, CT: Yale University Press. Jensen, P.S., Hinshaw, S.P., Swanson, J.M ., Greenhill, L.L., Conner s, C.K., Arnold, L.E., et al. (2001). Findings from the NI MH Multimodal Treatment Study of ADHD (MTA): Implications an d applications for primary care providers. Journal of Developmental and Behavioral Pediatrics, 22, 60-73. doi: 0196-206X/00/22010060 Kadesjo, B., & Gillberg, C. ( 2001). The comorbidity of ADHD in the general population of Swedish school-age children. Journal of Child Psychology and Psychiatry, 42, 487-492. doi: 10.1111 /1469-7610.00742 Kazdin, A.E. (1995). Child, parent and family dysfunction as predictors of outcome in cognitive-behavioral treatment of antisocial children. Behaviour Research and Therapy, 33(3), 271-281. doi: 10.1016/0005-7967(94)00053-M Kazdin, A.E., Mazurick, J.L., & Bass, D. (1 993). Risk for attriti on in treatment of antisocial children and families. Journal of Abnormal Child Psychology, 14, 315329. doi: 10.1207/ s15374424jccp2201_1 Landau, S. & Moore, L. (1991). So cial skills deficits in childr en with attention-deficithyperactivity. Reading and Writing Quarterly: Over coming Learning Difficulties, 14 83-105.

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39 Ruma, P.R., Burke, R.V., & Thompson, R.W. (1996). Group Parent Training: Is it Effective for Children of All Ages? Behavior Therapy, 27, 159-169. doi: 10.1015/S0005-7894(96)80012-8 Sadock, B.J., & Sadock, V.A. (2003). Disr uptive Behavior Disorders. In Kaplan & Sadock’s, Synopsis of Psychiatry (9th Edition, pp. 1232-1240). Philadelphia: Lippincott Williams & Wilkins. Schaffer, D., Fisher, P., Lucas, C.P., Dulcan, M.K. & Schwab-Stone, M.E. (2000). NIMH diagnostic interview schedule for child ren version IV (NIMH DISC-IV): description, differences from previous ve rsions, and reliability of some common diagnoses. Journal of the American Academy of Child & Adolescent Psychiatry, 39, 28-38. doi: 10.109 7/00004583-200001000-00014 Schuhmann, E.M., Foote, R., Ey berg, S.M., Boggs, S., & Algina, J. (1998). Parent-Child Interaction Therapy: Interim report of a randomized trial with a short-term maintenance. Journal of Clinical Child Psychology, 27, 34-45. doi: 10.1207/s15374424jccp2701_4 Taylor, T.K., Schmidt, F., P epler, D. & Hodgins, C. (1998) A comparison of eclectic treatment of Webster-Stratton’s parents and children series in a children’s mental health center: A randomized controlled trial. Behavior Therapy, 29(2), 221-240. doi: 10.1016/S00057894(98)80004-X Webster-Stratton, C. (1996). Early-Onset Conduct Problems: Does Gender Make a Difference? Journal of Consulting and Cl inical Psychology, 64(3), 540-551. doi: 10.1037/0022-006X.64.3.540 Webster-Stratton, C. & Hamm ond, M. (1997). Treating childr en with early-onset conduct problems: A comparison of ch ild and parent interventions. Journal of Consulting and Clinical Psychology, 65 (1), 93-109. doi: 10. 1037/0022-006X.65.1.93 Werba, B.E., Eyberg, S.M., Boggs, S.R., & Algina, J. ( 2006). Predicting Outcome in Parent-Child Interaction Therapy: Success and Attrition. Behavior Modification, 30, 618-646. doi: 10.1177/0145445504272977

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40 BIOGRAPHICAL SKETCH Kaitlyn Amy Powers graduated from Syracu se University with a Bachelor of Science degree in psychology in May 2009. She graduated with hi ghest honors as a summa cum laude student. She is currently pur suing a doctoral degree in clinical and health psychology with a concentration in child clinical psychology at the University of Florida. Kaitlyn’s research interests incl ude parent-child interactions, prevention of disruptive behavior disorders, and devel opment of web-based interventions.