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1 FROM THE CLINIC TO THE CLASSROOM: GENERALIZATION OF PARENT CHILD INTERACTION THERAPY TREATMENT EFFECTS By CARMEN SAMYRA EDWARDS A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTERS OF SCIENCE UNIVERSITY OF FLORIDA 2012
2 2012 Carmen SaMyra Edwards
3 To my family, friends, and loved ones whose endless support and encouragem ent helped make r eaching this milestone possible
4 ACKNOWLEDGEMENTS First and foremost, I would like to acknowledge my advisor and the chair of this thesis, Stephen R. Boggs, Ph.D., ABPP, in addition to Regina Bussing, M.D. and Sheila M. Eyberg, Ph.D., ABPP for their continued support and guidance on this project. I would also like to thank the members of my committee, Dawn Bowers, Ph.D., David Janicke, Ph.D., and Deidre Pereira, Ph.D., as well as members of the Child Study Lab for the ir efforts and feedback. Finally, I would like to recognize the National Institute of Mental Health (R01 MH60632 and R01 MH072780) for providing the grants to fund this research.
5 TABLE OF CONTENTS page AC KNOWLEDGEMENTS ................................ ................................ ................................ ........... 4 LIST OF TABLES ................................ ................................ ................................ ......................... 6 ABSTRACT ................................ ................................ ................................ ................................ ... 7 CHAPTER 1 INTRODUCT ION ................................ ................................ ................................ ................... 9 Presentation in the Classroom ................................ ................................ .......................... 10 Consequences of Disruptive Behavior ................................ ................................ ............ 13 Treatments for Children with Disruptive Behavior Disorders ................................ ....... 14 Parent Child Interaction Therapy ................................ ................................ ...................... 15 2 METHODS ................................ ................................ ................................ ........................... 21 Participants ................................ ................................ ................................ .......................... 21 Measures ................................ ................................ ................................ .............................. 22 Prescreening Measures ................................ ................................ .............................. 22 Outcome Measures ................................ ................................ ................................ ..... 24 Procedures ................................ ................................ ................................ ........................... 26 Pre Screening and Treatment Procedures ................................ .............................. 26 Assessment of Classroom Behavior ................................ ................................ ......... 27 3 RESULTS ................................ ................................ ................................ ............................. 29 Descriptive Data ................................ ................................ ................................ .................. 29 Aim 1: Generalization for the Entire Sample ................................ ................................ .. 30 Aim 2: Differential Generalization across Diagnostic Groups ................................ ...... 30 Power Analysis ................................ ................................ ................................ .................... 32 4 DISCUSSION ................................ ................................ ................................ ...................... 37 Limitations ................................ ................................ ................................ ............................ 41 Future Directions ................................ ................................ ................................ ................. 42 LIST OF REFERENCES ................................ ................................ ................................ ........... 44 BIOGRAPHICAL SKETCH ................................ ................................ ................................ ....... 49
6 LIST OF TABLES Table page 2 1 Age, Sex, and Race of Study Participants ................................ ................................ 28 3 1 Outcome Measures (Pre to Posttrea tment Changes in Observed Classroom Behaviors for the Entire Sample) ................................ ................................ ................. 33 3 2 Outcome Measures (Pre to Posttreatment Changes in Teacher Reported Classroom Behaviors for the Entire Sample) ................................ ............................. 34 3 3 Outcome Measures (Pre to Posttreatment Changes in Observed Classroom Behaviors for ODD only, ADHD only, and Comorbid ODD + ADHD Participants, Respectively) ................................ ................................ ........................... 35 3 4 Outcome Measures (Pre to Posttreatment Changes in Teacher Reported Classroom Behaviors for ODD only, ADHD only, and Comorbid ODD + ADHD Participants, Respectively) ................................ ................................ ............... 36
7 Abstract of Th esis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science FROM THE CLINIC TO THE CLASSROOM: GENERALIZATION OF PARENT CHILD INTERACTION THERAPY TREATMEN T EFFECTS By Carmen SaMyra Edwards May 2012 Cha ir: Stephen Boggs Major: Psychology Parent Child Interaction Therapy (PCIT) is an empirically supported treatment for young children with disruptive behavior disorders and associated difficulties. The behavior problems associated with these disorders frequently impair functioning in more than one setting, making it desirable that treatment programs be designed to address problems both in the home and in the classroom. Although generalization of PCIT treatment effects from the clinic to the home are well established, studies examining generalization to the classroom are limited. The present investigation evaluated the generalization of PCIT treatment effects to the clas sroom using teacher report and observational measures in a sample of 67 elementary school aged children (Mean age = 4.45 years) diagnosed with ADHD only (n=19), ODD only (n=21), or comorbid ADHD/ODD (n=27). Scores obtained from teacher report and observat ional measures were used to evaluate generalization for the entire sample of children, as well as differential generalization between diagnostic groups. Pre to posttreatment changes in the percentage of observed inappropriate behaviors in the classroom we re found for the total sample; however, no other changes were found on other teacher report or direct
8 observation measures either for the entire sample or within the three different diagnostic groups. Although these findings provide some indication of tr eatment generalization, additional strategies targeted towards reducing disruptive behavior in the classroom may be necessary to maximize generalized effects.
9 CHAPTER 1 INTRODUCTION Attention Deficit/Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD) are among the most common childhood disorders observed in both clinical and community populations (American Psychological Association, 1994; Lochman & Salekin, 2003; Saddock & Saddock, 2007). Depending upon the nature of the population samp le and methods of assessment, prevalence rates for ADHD and ODD have been reported to range anywhere from 2% 7% and 2% 30%, respectively (American Psychological Association, 1994; Farmer, Compton, Burns, & Robertson, 2002; Gadow & Nolan, 2002). In add ition to high prevalence rates, the stability and chronicity of aggressive behavior problems observed during childhood further complicate the impairment often associated with a formally diagnosed disruptive behavior disorder (Hetherington, Parke, Gauvain & Locke, 2006; Lochman & Salekin, 2003; Saddock & Saddock, 2007). Children diagnosed with ODD display an enduring pattern of negativistic, disobedient, and hostile behavior (American Psychological Association, 1994; Saddock & Saddock, 2007). The degree to which children with ODD defy authority and engage in disruptive behaviors is excessive in relation to the behavior of their non deviant, same aged peers (Saddock & Saddock, 2007). It is not uncommon for these children to display frequent emotional outb urst and blame others for their mistakes or misbehavior (American Psychological Association, 1994; Saddock & Saddock, 2007). Unlike children with ODD who display deliberate defiance, the behavior problems exhibited by children diagnosed with ADHD are pri marily characterized by uncontrollable hyperactivity, impulsivity, and/or inattention. A formal diagnosis of ADHD
10 requires significant impairment in two or more settings and usually remains undiagnosed until a child enters elementary school (American Psych ological Association, 1994; Hetherington et al., 2006; Saddock & Saddock, 2007; Seib, 2009). Just as children with ODD, children diagnosed with ADHD are sometimes emotionally labile, as they have been observed to be explosive and easily irritated (Saddock & Saddock, 2007). Numerous studies have investigated the immediate and long term impairments associated with a diagnosis of ADHD or ODD, including but not limited to deficits affiliated with common comorbidities. Unfortunately, approximately 50% of clin ic referred children with ADHD eventually receive a comorbid diagn osis of ODD or Conduct Disorder (American Psychological Association, 1994). Studies conducted in this area have found that children who receive an early diagnosis of ODD and/or ADHD are at significantly higher risk for meeting diagnostic criteria for another developmental disorder later, particularly one associated with language im pairment (Biederman et al., 1996; Matthys, Cuperus & Engeland, 1999). Investigators have reported that younger children who receive a comorbid diagnosis of ADHD and ODD not only report exacerbated symptoms in comparison to children who present with a single diagnosis, but that these children are also at greater risk for developing comorbid anxiety and depressive s ymptoms as the disruptive behavi or progresses without treatment (Gadow & Nolan, 2002; Hetherington et al., 2006). Presentation in the Classroom Children with disruptive behavior disorders also experience significant difficulty in school, as adequate int erpersonal skills and the capacity to attend to structured material are essential to achieving academic success. In addition to the deficits associated with
11 the comorbidities previously mentioned, deficits in social competence are frequently observed in c hildren diagnosed with disruptive behavior disorders. For preschoolers and elementary school aged children, these deficits often result in peer rejection, being less popular, and having fewer friends in relatio n to their non disruptive peers (Ginn, 2010). More specifically, children with ODD often have few, if any, friends and perceive interpersonal relationships as unsatisfactory (Saddock & Saddock, 2007). Typically, the symptoms of ODD are most evident during interactions with people whom the child kno ws well and tend to cause more distress to those around the child than to the child him or herself (Saddock & Saddock, 2007). Although maladaptive social exchanges are well documented, children diagnosed with ODD generally do not resort to the physical agg ression or significantly destructive behavior observed in children diagnosed with a more severe Conduct Disorder (Saddock & Saddock, 2007). As previously mentioned children with ADHD can be unpredictable and display emotional lability making it difficult for them to maintain and establish meaningful relationships with their peers (Saddock & Saddock, 2007). The adverse reactions of school administration to ADHD symptomology in the classroom and the lowering of self regard because of perceived inadequacies often combine with the negative reactions of peers, sometimes making school an undesirable environment for children struggling with these difficulties (Saddock & Saddock, 2007). Early intervention for these deficits is imperative as Lochman & Salekin (200 3) noted similar impairments in the social competence of aggressive and disruptive children during middle childhood. Problematic peer relations during childhood are often maintained throughout adolescence as children diagnosed with ODD and/or ADHD have be en reported to experience severe
12 psychopathology, including but not limited to antisocial behavior and substance abuse, in the event that early intervention is not implemented (Farmer et al., 2002; Hetherington et al., 2006; Lochman & Salekin, 2003). In a relationships in school, the literature has shown that the presence of a disruptive in the classr oom. Despite adequate intelligence, children diagnosed with ODD tend to perform poorly, or in more severe cases, even fail school (Saddock & Saddock, 2007). These children often withhold participation during group activities, resist external demands, and insist on solving problems without assistance (Saddock & Saddock, 2007). Results obtained from classroom assessments and standardized achievement tests reveal that children with ADHD function one to two years below grade level despite average intelligence (Hetherington et al., 2006). Hyperactivity and impulsivity are reportedly among the most difficult ADHD symptoms for teachers to manage and often result in a child responding to questions before thinking or being acknowledged, frequently shifting ideas or activities, and failing to remain in their designated area (Hetherington et al., 2006). ADHD is also often characterized by a distinct attention tasks to their e ntirety (Saddock & Saddock, 2007; Hetherington et al., 2006). This attention deficit can sometimes be affiliated with the presence of a comorbid communication and/or learning disorder and substantially impedes the acquisition, retention, and display of kn owledge in the classroom (Saddock & Saddock, 2007). In
13 regards to behavioral concerns, children diagnosed with ADHD also display problems adhering to rules and instructions with multiple steps (Hetherington et al., 2006). This deficiency in rule governed behavior can best be accounted for by difficulties tracking and monitoring behavior over an extended period of time. Consequences of Disruptive Behavior Similar to parents in the home setting, teachers of children with disruptive behavior disorders als o report significant difficulty managing problematic behavior prior to the child receiving treatment. The deliberate defiance and aggression associated with ODD can be disruptive to both the teacher and other students in the classroom, as it often requires 2007). The disciplinary intervention itself could possibly become a distraction and ultimately detract from the time allotted to adequately attend to the academic needs of other st udents in the classroom. Although the hyperactivity observed in children diagnosed with ADHD may also warrant disciplinary action, it is the impulsivity and inability to meet attentional demands that impede academic performance and could potentially resul t in school failure. The attentional and regulatory deficits observed in child engaged and interested in learning (Hetherington et al., 2006). Because teachers are resp onsible for facilitating the academic enrichment of both the disruptive child as well as the other children in the classroom, the amount of time and effort that a teacher n to what most parents and other care providers can readily invest. This lack of time and tolerance results in frequent suspensions and other disciplinary action, academic retention, placement in special education classrooms, and the administration of
14 pre scription medications following school mandated psychiatric evaluations (Hetherington et al., 2006). Treatments for Children with Disruptive Behavior Disorders There is an extensive body of literature focused on available treatments for disruptive behavio r problems in children. Brestan and Eyberg (1998) suggested that age is one of the best indicators of treatment match, as parent behavioral training has been shown to be most effective in treating younger children versus interventions based in cognitive d evelopmental theory that are frequently used to address similar difficulties in adolescents. However, a 2002 review of evidenced based treatments for childhood psychopathology suggested that parent training based interventions can be successfully implemen ted with children as old as 12 years (Farmer et al., 2002). Parent training programs are primarily designed to train parents to interact more effectively and respond more appropriately to their children and have been shown to be effective when delivered i n isolation or when supplemented with prescription medication (Farmer et al., 2002). The superiority of parent behavioral training models has been demonstrated in numerous circumstances; however, other interventions such as social skills groups, communi ty based interventions, problem solving skills training, and modified cognitive behavioral approaches have advantages when treating young children with externalizing disorders (Farmer et al., 2002; Hetherington et al., 2006; Saddock & Saddock, 2007). As a means to update the 1998 Brestan and Eyberg review, Eyberg, Nelson, and Boggs (2008) conducted a systematic review of evidence based psychosocial treatments for children and adolescents with disruptive behavior. These authors reported that only Parent Ch ild Interaction Therapy (Brinkmeyer & Eyberg,
15 2003), and four other evidence based treatments (Helping the Noncompliant Child: Forehand & McMahon, 1981; Parent Management Training Oregon: Patterson, Reid, Jones & Conger, 1975; Triple P: Sanders, 1999; I ncredible Years: Webster Stratton & Reid, 2003) had been implemented early enough to treat preschool aged children with disruptive behavior problems and perhaps prevent the long term consequences of untreated symptoms Although these early intervention fi ndings are promising, it is important to note that behavior change to the classroom following clinic based parent training (PCIT : Bagner, Boggs & Eyberg, 2010; Triple P : McTaggart & Sanders, 2003). The remaining interventions reviewed were supplemented with teacher training or a classroom treatment component (Baker Henningham, 2009; Carlson, Tiret, Bender & Benson, 2011; Hutchings, Lane, Owens & Gwyn, 2004; Webster Stra tton, Reid & Stoolmiller, 2008) making it difficult to evaluate the generalization of treatment effects to the classroom in the absence of school based interventions. These results, in addition to the vast number of school aged children with disruptive beh avior disorders referred for clinical treatment warrants further evaluation of the school based outcomes of clinic based parent training interventions that may be implemented as early as possible with equal efficacy across settings, particularly within the classroom. Parent Child Interaction Therapy Parent Child Interaction Therapy (PCIT) is an empirically supported treatment for young children with disruptive behavior disorders. PCIT is theoretically based on social learning and attachment theories, as associating parenting practices with child outcomes (McNeil & Wagner, 2008). In
16 regards to structure, PCIT is comprised of components similar to those described in stage treatment model and is des igned to improve the overall quality of the parent child interaction by placing heavy emphasis on the concepts of warmth, nurturance and setting conventional boundaries. Treatment begins with the Child Directed Interaction (CDI) phase in which the parent choice. This portion of treatment aims to restructure the parent child relationship by allowing the child to be reinforced by positive parental attention, consequently e nabling the child to develop a warm and secure attachment to their parent. Treatment then progresses to the Parent Directed Interaction (PDI) phase in which the parent is encouraged to engage the child in an activity of their choice. The primary goal of th is phase is to assist parents in setting disciplinary boundaries while simultaneously increasing low rate prosocial behaviors. During this phase of treatment, parents are They are also introduced to a structured time out procedure designed to be implemented whenever the child fails to comply to parental demands. Parents are coached by trained therapists on the implementation of newly learned skills using a one way mirro in the skills learned during the CDI and PDI phases of treatment have been mastered and the child consistently receives parent rated, sub clinical score on the Eyberg Child Behavior Inven tory. Positive treatment outcomes are frequently reported for childr en receiving PCIT (e.g., Eyberg et al., 2001; Matos, Torres, Santiago, Jurado, & Rodriguez, 2006).
17 Problem behaviors have been described to be within normal limits following PCIT as clini cally and statistically significant improvements in both child disruptive behavior and non compliance have been reported (Eidenstadt, Eyberg, McNeil, Newcomb & Funderburk, 1993; Eyberg, 1995; Eyberg & Robinson, 1982; Nixo n, Sweeney, Erickson, & Touyz, 2003 ; Schuhmann, Foote, Eyberg & Boggs, 1998; Zangwill, 1984). Improvements in child behavior have been shown to accompany improvements in parental distress and marital function, which is likely related to the maintenance of treatment effects observed in the target child (Boggs et al., 2004; Eyberg, Edwards, Boggs & Foote, 1998; Eyberg & Robinson, 1982). It is not uncommon for PCIT treatment effects to generalize beyond the clinic setting in which treatment was initially delivered, as positive outcomes have been observed in the home (Boggs, 1990; Harwood & Eyberg, 2006; Hood & Eyberg, 2003; Matos et al., 2006; Nixon, 2001; Nixon et al., 2003; Schuhmann et al., 1998; Seib, 2009) as well as with untreated siblings (Brestan, Eyberg, Boggs & Algina, 1997; Eyberg & Robinson, 1982). Some studies have even suggested some generalization of PCIT treatment effects to the classroom (Bagner et al., 2010; Funderburk et al., 1998; McNeil et al., 1991; Seib, 2009). The enhancement of child prosocial behaviors and over learn ing of compliance to in the classroom (McNeil et al., 1991). The similarities between the consequences and rewards (i.e., social rewards and timeouts) provided by parent s in the clinic and teachers in the classroom may enable the child to adapt more readily to classroom demands upon completing treatment (McNeil et al., 1991). Results obtained from observational measures utilized in studies examining classroom generaliza tion have
18 ongoing classroom activities (Bagner et al., 2010; McNeil et al., 1991; Seib, 2009). Bagner and colleagues (2010) noted additional improvements in observed inapp ropriate classroom behaviors including, but not limited to, crying, being out of a designated area, and engaging in aggressive and distracting behaviors. Results obtained from observational measures are supported by findings from the McNeil et al. study ( 1991) as they reported improvements in teacher reports of oppositional classroom behavior, as well as improvements in observed externalizing behaviors. Funderburk and colleagues (1998) evaluated the maintenance of the treatment effects noted in the McNeil et al (1991) study. Results obtained from this study suggested that children with disruptive behavior disorders maintain gains noted on teacher report and observational measures 12 months after treatment completion. In spite of the significance of th ese findings, further investigation into generalization to the classroom of PCIT outcomes is warranted. Of the four studies previously reviewed, only one included children with a primary diagnosis of ADHD (Funderburk et al., 1998). Unfortunately, this st udy included only one ADHD only and one ODD only child in a treatment group comprised of 12 participants making it difficult to examine the effect that PCIT had on isolated ADHD and ODD behaviors in the classroom. In addition, Bagner and colleagues (2010) failed to incorporate teacher reports of classroom behavior into their analysis. Although observational measures can be of value when assessing the impact of potential teacher bias, the observers used in vior during the limited times of the observation sessions. Supplementing such data with teacher reports may provide
19 investigators with an account of externalizing symptoms from someone better acquainted with the child and their typical behavioral patterns Discrepancies between participant characteristics and study design in addition to the utilization of different modes of assessment across studies make it difficult to compare findings and to determine what diagnostic subgroups might be expected to demon strate behavioral improvements in school. The current investigation examines the generalization of PCIT treatment effects to the classroom in a larger sample of preschool aged children diagnosed with ODD only, ADHD only, and ADHD + ODD using both teacher report and observational measures. Specific aims and corresponding hypothesis are as follows: A i m 1 : The first aim of this study was to examine the generalization of PCIT treatment effects to the classroom in a sample of children formally diagnosed with a disruptive behavior disorder. Results obtained from previous studies lead us to expect decreases in the percentage of off task and inappropriate behaviors as measured using direct observation methodology. We also expected to see decreases in the inten sity and number of teacher perceived problematic behaviors, as well as decreases in the frequency of teacher reported ADHD symptoms. Aim 2: The second aim of the study was to determine if the generalization of treatment effects to the classroom varied a All three diagnostic groups (ADHD only, ODD only, and comorbid ODD and ADHD) were expected to show improvements in the intensity and number of perceived problematic behaviors as reported by their teachers. Childre n diagnosed with ODD only or ADHD+ODD were expected to display decreases in the percentage of observed inappropriate and off task behaviors.
20 Children diagnosed with ADHD only or ADHD+ODD were expected to display teacher reported decreases in the number of ADHD Predominantly Inattentive and Predominantly Hyperactive Impulsive Type symptoms. A decrease in the percentage of observed noncompliant behaviors was expected to be observed in children diagnosed with ODD only.
21 CHAPTER 2 METHODS Participants Partici pants were 67 children who had corresponding pre and posttreatment data on at least one of the measures of classroom behavior used in the current study. These participants were recruited from two larger studies examining the efficacy of PCIT in preschool ers diagnosed with ODD and ADHD, respectively. Children were between the ages of 3 and 6 years old and were enrolled in school or daycare when recruited for participation. The following inclusion criteria was required for enrollment in the larger studies : (a) a standard score of 70 or higher on the Peabody Picture Vocabulary Test Third Edition (PPVT III; Dunn & Dunn, 1997) and the Wonderlic Personnel Test (WPT; Dodrill, 1981) had to be obtained by children and parents, respectively, to meet cognitive scr eening requirements (b) absence of a major sensory or mental impairment psychological history, and (c) a child diagnosis of ADHD and/or ODD according to the Diagnostic Interviewin g Schedule for Children (NIMH DISC IV P; Shaffer Fisher, Lucas, Dulcan, & Schwab Stone, 2000) and designated subscales of the Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2000, 2001). It should be noted that a diagnosis of ADHD was corroborated b y both parent and teacher reports obtained during prescreening procedures. In regards to medication status, children enrolled in the larger study examining the effects of PCIT on ODD symptomology were allowed to remain on a stable dose of medication taken for behavioral or attentional difficulties as long as the medication regimen was initiated at least one month prior to beginning treatment. Families for the larger study examining PCIT and ADHD were excluded from
22 participation if the child was taking medi cation for ADHD symptoms at the time of screening. Participants were referred for treatment by pediatricians, psychologists, and other health care professionals. Local schools, churches, and community organizations, such as Head Start, were also sources of participant recruitment. Inclusion in the current study required that participants complete treat ment and have all pre and post treatment data available on at least one measure of classroom behavior. Children in the present sample were predominantly mal e (70.1%) and had a mean age of 4.45 years (SD = .84). The current sample was primarily Caucasian (77.6%), as the remaining participants (22.4%) were self identified as non Caucasian minorities. In regards to diagnostic distribution, 21 (31.3%) of partic ipants received a sole diagnosis of ODD, 19 (28.4%) were diagnosed with ADHD only, and the remaining 27 (40.3%) received a comorbid diagno sis of ODD and ADHD (Table 2 1 ). Measures Prescreening Measures Child Behavior Checklist Th i s a measure comprised o f two forms administered to children in separate age ranges (CBCL; Achenbach & Rescorla, 2000, 2001) The first is a parent rated, 120 item form used to assess the frequency of behavioral and emotional problems in children ages 1.5 to 5 years old (CBCL/1. 5 5; Achenbach & Rescorla, 2000). The second form measures similar behaviors in children ages 6 18 years of age (CBCL/6 18; Achenbach & Rescorla, 2001). Both forms consist of DSM IV oriented scales and syndrome scales, the latter of which also has associ ated global scales. Items on the CBCL are rated on a 3 point Likert scale ranging from Not True (0) to Very True (1) or Often (2). Test retest reliability is adequate as demonstrated by values ranging from .74 (DSM oriented Attention Deficit/Hyperactivit y Problems scale
23 ages 1.5 5) to .94 (Global Externalizing Scale ages 6 18 ) consistency coefficients are adequate as well ranging from .72 (Anxiety Problems) to .91 (Conduct Problems) on the form used to assess children ages 6 18 years old. The form for children ages 1.5 scale. DSM IV oriented scales were used to help determine participant diagnosis while the Externalizing scale was utilized as a measure of treatmen t outcome. Diagnostic Interview Schedule for Children is a structured diagnostic interview administered to parents of children as young as 4 years of age (NIMH DISC IV P; Shaffer et al., 2000) The interview consist five separate modules designed to a ssess ADHD, ODD, Conduct Disorder, Separation Anxiety Disorder, and Major Depressive Disorder, respectively. These modules can be administered together or in isolation and have produced one week test retest reliability coefficients ranging from .54 (ODD a nd Conduct Disorder) to .79 (ADHD) in a sample of parents wi th children ages 9 17 years old (Shaffer et al., 2000). Peabody Picture Vocabulary Test Third Edition is a picture based measure of receptive language in children ages 2 years, 6 months old an d older (PPVT III; Dunn & Dunn, 1997) The PPVT III is a well standardized measure and has been observed to be highly correlated with Full Scale IQ scores obtained on the third edition of the Weschler Intelligence Scale for Children. Split half reliabili ty and test retest reliability coefficients for this measure range from .86 to .97 and .91 to .94, respectively. Wonderlic Personnel Test is a 50 item test designed to screen the intellectual abilities of adults (WPT; Dodrill, 1981) The WPT was highly correlated with Full Scale IQ scores obtained on the Weschler Adult Intelligence Scale (.93) in a sample of 120
24 normal adults. This correlation was not significantly affected by differences in age, sex, education, level of intelligence, or emotional adjus tment. This scale was used a screening measure for participation in the current study. Outcome Measures Revised: Long Version is a 59 item teacher rating scale that measures ADHD behaviors and the symptomology of common co morbid disorders including, but not limited to, ODD. Administration of the CTRS R:L is appropriate for children ages 3 to 17 years old (CTRS R:L; Conners, Sitarenios, Parker, & Epstein, 1998) Items are ranked on a 4 point Likert scale ranging from Not T rue At All (0) to Very Much True (3). The CTRS R:L is comprised of nine subscales, two of which were utilized in the current study (DSM IV TR ADHD Predominantly Inattentive Type and DSM IV TR ADHD Predominantly Hyperactive Impulsive Type). Convergent and discriminant validity for the subscales used in this study have been demonstrated by Conners and colleagues (Conners et al., 1998). Test retest reliability coefficients for the CTRS: R L range from .60 to .90. The CTRS: R L has also demonstrated adequate internal consistency with coefficients ranging from .75 to .90. Revised Edition of the School Observation Coding System is an interval coding system used to record externalizing classroom behaviors in preschool and elementary school aged children (REDSO CS; Jacobs, Boggs, Eyberg, Edwards, Durning, & Querido, 2000) Observations are conducted on three separate occasions during structured class times. Each of the three observation sessions are divided into ten second intervals with three minute breaks betwe en every six intervals resulting in a total of ten minutes, or sixty intervals, of coding time. During these observations, three
25 behavior (Appropriate vs. Inappropriate), (b ) compliance to teacher commands (Comply vs. Non in the ongoing activity (On Task vs. Off Task vs. No Task). These categories have shown significant correlations with the CTRS R:L and successfully discriminate children referred for treatment of school problems from their randomly selected classmates (Jacobs et al., 2000). For the purpose of this study, extra precaution was taken to ensure that classroom observers had no previous c ontact with the participant to prevent the possible occurrence of atypical behavior in the event that the child recognized the observer. It was also of importance to ensure that the observer remained blind to the l bias when coding classroom behavior. Observations were conducted by undergraduate research assistants who on at least one of the three visits were accompanied by a graduate research assistant for coding inter rate r reliability coefficients for this sample ranged from .63 (Comply) to .88 (No Task). Sutter Eyberg Student Behavior Inventory Revised (SESBI R; Eyberg & Pincus, 1999) is a 38 item teacher rating scale of school oriented externalizing behavior in childre n. The SESBI R can be appropriately administered to children ages 2 through 16 and consists of two subscales. The Intensity scale is used to evaluate the frequency of disruptive behaviors in the classroom on a 7 point Likert scale ranging from Never (1) t o Always (7). Internal consistency for the Intensity scale is .98 and test retest reliability, as established with a normative pre school sample, was .87, (Querido & Eyberg, 2003). The second subscale of the SESBI R is the Problem Scale. The Problem sca le is comprised of closed ended questions used to assess teacher tolerance and the degree
26 Independent scores are calculated for each of these subscales. In addition to these s ubscales, factor analysis conducted by Eyberg et al., (1998) revealed an Oppositional Behavior factor and an Attention Problems factor, enabling teachers to assess concurrent ADHD symptomology as well. Separate scores are not calculated for these factors; however, the Oppositional Behavior factor has been shown to significantly predict school conduct referrals and suspensions while the Attention Problems factor significantly predicts future referrals for sc hool oriented learning problems (Lea, 2001). Only the Intensity and Problem scales were included for analysis in the current investigation. Procedures Pre Screening and Treatment Procedures Upon completing the informed consent process, families recruited for participation took part in a pre screening asse ssment consisting of a clinical interview and the completion of a demographic questionnaire. Parents were then administered the Wonderlic and DISC IV P and were asked to complete several measures of child behavior including the ECBI and the CBCL. Childre n participating in the study were administered the PPVT III as a means to further evaluate study eligibility. Prior to initiating treatment, teachers of study participants were mailed a series of measures including the CTRS: R L and the SESBI R. Data obt ained from these measures were used as baseline measurements of externalizing behaviors in the classroom. Families were delivered treatment via weekly therapy sessions conducted by two advanced graduate students. Therapists were trained on PCIT protocol and adhered strictly to the official PCIT treatment manual when delivering treatment (Eyberg and
27 Child Study Laboratory, 1999). Participants recruited from the larger study examining the effects of PCIT on ADHD were randomly assigned to individual or grou p treatment, the latter of which typically involved the participation of two to three families. On the other hand, all children recruited from the study examining the maintenance of PCIT received individualized treatment. Assessment of Classroom Behavior Teachers of the children enrolled in the current study were administered a series pre and posttreatment. These measures included the CTRS R:L and the SESBI R. Upon receiving parental consent, teacher consent, and permission from school administration, a series of REDSOCS observations were conducted. These observations were conducted prior to initiating and upon the completion of treatment and occurred during times i n which the class was expected to engage in structured activities. The observations occurred on three separate days at both pre and posttreatment. The teacher report measures were physically collected at the conclusion of the pre and post treatment observ ation series or were mailed back to the Child Study Lab at the University of Florida. Teachers were paid $25.00 for their participation.
28 Table 2 1. Age, Sex, and Race of Study Participant s Study A (n = 21) Study B (n = 46) TOTAL (N = 67) Age M = 3.91 M = 4.71 M = 4.45 SD = .831 SD = .727 SD = .840 Sex Male 61.9% 73.9% 70.1% Female 38.1% 26.1% 29.9% Race Caucasian 90.5% 71.7% 77.6% Minority 9.5% 28.3% 22.4% *p < .001
29 CHAPTER 3 RESULTS Descriptive analyses and hypotheses testing were conducted using IBM Statistical Package for Social Sciences (SPSS PASW 18.0), whereas all power analyses were conducted using G Power 3 software (Erdfelder, Faul & Buchner, 1996). All variables evaluated in this study wer e assessed for normality. Variables were considered to be normally distributed if the absolute value of skewness and kurtosis did not exceed 1.5 and both the Kolmogorov Smirnov and Shapiro Wilk test of normality were significant beyond the .05 level. Visu al depictions of variable distribution such as histograms with normal distribution curves, Q Q scatter plots, and box and whisker plots were also used to supplement results obtained from the efforts previously mentioned. According to these criteria, all v ariables were judged to be normally distributed with the exception of variables representing the percentage of observed non compliance at pre and post treatment (Pre REDSOCS Non Comply and Post REDSOCS Non Comply). Because of the restricted range in raw non compliance scores, no transformations were implemented as they would have further distorted the data and may have produced misleading findings. Descriptive Data Preliminary analyses were conducted to assess for significant differences in gender, ethni city, and age between children recruited from the two larger studies examining ODD and ADHD, respectively. Goodness of fit chi square analyses were performed to detect differences between the gender and ethnicity of children recruited from the two studies Results from those analyses revealed no significant differences between the two groups; however, results obtained from an independent samples t test
30 indicated that children recruited from the larger study evaluating ODD were significantly younger than c hildren recruited from the ADHD study, t(64) = 3.817, p = .001. An alpha criterion level of .05 was used to assess significance in the previous analyses. See Table 2 1 for demographic data. Aim 1: Generalization for the Entire Sample Paired samples t te sts were performed to assess generalization for the entire sample on all teacher report and observational measures of classroom behavior. Results revealed a significant decrease in the percentage of observed inappropriate behaviors in the classroom follow ing treatment across all children, t(46) = 3.669, p = .001. As described in the REDSOCS manual (Ginn, Seib, Boggs & Eyberg, 2009), inappropriate behaviors were defined as a composite of whining, crying, yelling, cheating, demanding attention, negativism, self stimulation, distracting behavior, talking out of turn, destructive or aggressive behavior, and being out of the assigned area. No additional evidence of treatment generalization was revealed in analyses cond ucted on the entire sample (Table 3 1 and Table 3 2). A im 2: Differential Generalization across Diagnostic Groups Prior to performing the primary analyses, between subject analyses of variances (ANOVA) were performed to assess for any differences that may have existed between the three diagnostic groups at baseline. Bonferroni post hoc analyses were performed to supplement these findings by specifying which diagnostic groups differed significantly from one another. At baseline, teachers of children with a single diagnosis of ODD endorsed fewer ADH D Predominantly Inattentive Type symptoms than did teachers of children with ADHD only, F(2, 38) = 5.206, p = .01 on the CTRS. ODD only children were also rated as displaying significantly fewer ADHD Hyperactive Impulsive Type
31 Symptoms by their teachers o n the CTRS than both children with a single or comorbid diagnosis of ADHD at baseline, F(2, 38) = 5.003, p = .012. With regards to the frequency and intensity of perceived problematic behaviors in the classroom, teachers rated ODD only children as being s ignificantly less problematic, F(2, 37) = 6.209, p = .005, and engaging in significantly fewer disruptive behaviors, F(2, 37) = 9.777, p = .001, than children with a single or comorbid diagnosis of ADHD on the SESBI R. Finally, pre treatment REDSOCS data revealed a significant difference between the ODD only children and those with a single or comorbid diagnosis of ADHD such that the ODD only children were observed to engage in a significantly higher percentage of non compliant behaviors, F(2, 55) = 21.36 6, p =.001. To examine differential generalization across diagnostic groups, separate 3 (ODD only, ADHD only, comorbid ODD and ADHD) x 2 (pre treatment, post treatment) analyses of variance were conducted for each of the REDSOCS behavior coding categories (Inappropriate, Non Comply, and Off Task), the SESBI Intensity scale, SESBI Problem scale, CTRS Inattentive Type scale, and CTRS Hyperactivity/Impulsive Type scale. As a means to correct for preexisting differences between diagnostic groups, analyses of covariance (ANCOVA) were conducted in place of ANOVAs for variables that produced significant pretreatment differences during the preliminary analyses. There were no significant group x time interactions for any measure, suggesting the absence of differen tial generalization between diagnostic groups. However, a significant group main effect was noted for the CTRS such that children with a diagnosis of ODD only were overall rated as displaying ADHD Predominantly Hyperactive Impulsive Type symptoms less fr equently than children diagnosed with
32 ADHD only, F(2, 27) = 4.064, p = .029. A significant effect of time was also noted in the percentage of observed inappropriate behaviors on the REDSOCS F(1, 44) = 12.063, p = .001, corroborating results obtained from the paired samples t tests (Table 3 3 and Table 3 4). Power Analysis Analyses were conducted in G Power to determine if the sample size was sufficient to detect a significant effect with at least 80% power. With regards to assessing generalization for the entire sample, the total sample (N = 67) was not large enough to detect significance with 80% power. Results obtained from power analyses conducted on the sample sizes of the three diagnostic groups revealed similar results, as those samples were also too small in addition to being unequal in size. Further review of effect sizes and sample means suggest that increasing sample size alone may not produce significant results for most measures, as the non signifi cant changes from pre to post treatment wer e often minimal.
33 Table 3 1. Outcome Measures (Pre to Posttreatment Changes in Observed Classroom Behaviors for the Entire Sample) Pre (n = 47) Post (n = 47) M SD M SD t r p Inappropriate 28.26 16.88 19.53 13.29 3.669 .276 .001* Non Comply 6.67 10.89 5.78 10.64 1.017 .041 .314 Off Task 26.78 18.13 23.07 12.07 1.316 .120 .180 p < .001
34 Table 3 2. Outcome Measures (Pre to Posttreatment Changes in Teacher Reported Classroom Behavior s for the Entire Sample) Pre Post n M SD M SD t r p CTRS Inattentive 32 67.69 13.99 64.59 13.06 1.728 .114 .094 CTRS Hyperactive Impulsive 32 68.22 13.37 66.69 13.07 .616 .058 .542 SESBI Intensity 36 141.56 48.78 149.78 47.69 1.171 .085 .250 SESBI Problem 36 18.14 10.74 18.50 10.82 1.316 .017 .180
35 Table 3 3. Outcome Measures (Pre to Posttreatment Changes in Ob served Classroom Behaviors for ODD only, ADHD only, and Comorbid ODD + ADHD Participants, Respectively) ODD (N=19) Pre ADHD (N=16) ADHD+ODD (N=19) ODD (N=19) Post ADHD (N=16) ADHD+ODD (N=19) M SD M SD M SD M SD M SD M SD F 2 p Inappropriate* 22.25 11.39 22.25 11.39 31.68 18.99 14.26 9.12 14.26 9.12 24.04 17.38 .114 .005 .892 Non Comply 26.24 22.11 26.24 22.11 2.74 2.50 16.95 16.56 16.95 16.56 2.31 2.45 .168 .008 .846 Off Task 24.58 15.00 24.58 15.00 28.98 20.52 19.78 8.0 8 19.78 8.08 24.04 17.38 .228 .010 .797 *p < .001
36 Table 3 4 Outcome Measures (Pre to Posttreatment Changes in Teacher Reported Classroom Behavior s for ODD only, ADHD only, and Comorbid ODD + ADHD Participants, Respectively) Pre Post O DD ADHD ADHD+ODD ODD ADHD ADHD+ODD n M SD n M SD n M SD M SD M SD M SD F p CTRS Inattentive 9 58.89 13.75 9 73.56 12.32 13 70.38 11.77 59.00 12.56 68.78 16.09 65.85 11.12 .039 .003 .962 CTRS Hyperactive Impulsive* 9 60.32 15.11 9 73.56 12.78 13 71.92 6.26 55.11 12.01 74.67 12.67 68.15 8.54 .773 .231 .387 SESBI Intensity 9 7.00 8.21 12 21.86 8.09 14 17.83 11.06 12.00 13.40 20.08 7.25 20.14 11.54 .097 .006 .908 SESBI Problem 8 106.21 51.43 13 172.33 35.47 14 148.21 31.85 112.89 59.39 171.00 22.92 151.86 44.36 .084 .005 .920 *p < .05
37 CHAPTER 4 DISCUSSION The present stu dy examined the generalization of PCIT treatment effects to the classroom in a sample of children diagnosed with ODD and/or ADHD. Although it was encouraging to see some posttreatment means trending in the desired direction, overall teachers reported no s ignificant changes in externalizing behavior problems in the classroom. Similar results were obtained from an observational measure of classroom behavior; however, observational data did suggest significant improvements in the percentage of inappropriate classroom behaviors observed across the entire group of treated children. These behaviors included being aggressive and destructive, talking out of turn, being out of the designated area, and other behaviors that were considered distracting and not conduci ve to an enriched learning experience in the classroom. Overall, these results suggest that in this sample, PCIT alone may have had only minimal effects on the presentation of disruptive behaviors in the classroom in children formally diagnosed with ADHD and/or ODD. We first hypothesized that teachers would report significant improvements in the intensity and number of perceived problematic behaviors as reported on the SESBI R. We also expected teachers to endorse fewer ADHD symptoms in children who comp leted treatment. Neither of these hypotheses were supported, as teachers actually reported no changes in either the intensity or number of teacher perceived problematic behaviors in the classroom. These findings are contradictory to previous findings sugg esting significant decreases in teacher reports of disruptive, oppositional behavior in the classroom following PCIT (McNeil et al., 1991). This may be attributed to differences in the diagnoses of children in the two studies. The present study included
38 m ore children with ADHD only and comorbid ADHD than in the sample studied by McNeil et al. (1991). In fact, the latter study included no chi ldren diagnosed only with ADHD. Findings from the current study could be an indication that clinic based PCIT may no t be sufficient to significantly influence the classroom behavior of children with ADHD symptoms. Further research is needed to clarify the discrepancy between the findings of these two studies and pinpoint why generalization may not have been evident in t he current sample. decreases in the percentage of inappropriate classroom behaviors across the entire group of treated children. However, direct observation measures failed to d etect significant decreases in the percentage of non compliant and off task behaviors in the classroom for these same children. The lack of generalization of treatment effects to the percentage of observed non compliant behaviors could possibly be explaine d by the low frequency of commands given by teachers during our standard observation sessions. The opportunity to comply to teacher commands could vary considerably depending upon the task at hand or the individual characteristics of the teacher. Childre n were generally presented with only one to four opportunities to comply to teacher commands during the typical ten minute observation session, consequently making changes in the rate of compliance to commands difficult to detect. The absence of a signific ant decrease in the percentage of observed off task behaviors not only failed to support our hypothesis regarding observed classroom behavior for the entire sample, but was also different from previous findings of generalized effects to the classroom (Bagn er et al., 2012; Seib, 2009). Bagner and
39 colleagues (2010) reported results similar to Seib (2009) with regard to finding significant decreases in off task behavior in their samples. Just as with teacher reports, the discrepancy between findings regardi ng observed off task behavior may be accounted for by the exclusion of ADHD only participants in those studies. In addition, in the previous studies, children with ADHD symptoms may have been receiving pharmacological interventions that could improve their ability to respond to behavioral treatment. This may suggest that PCIT in isolation may not be as effective at influencing classroom off task behavior when the more severe attentional impairments associated with unmedicated ADHD are present. Aim 2 was fo cused on assessing differential generalization across diagnostic groups using both teacher report and observational measures of classroom behavior. We hypothesized that teachers would report decreases in the intensity and number of perceived problematic b ehaviors for all three diagnostic groups. Teachers were also expected to report decreases in the presentation of ADHD symptoms in children with a single or comorbid diagnosis of ADHD following PCIT. Neither of these hypotheses were supported, as none of the reported decreases were large enough to reach significance. Although these findings differ from those obtained by McNeil and colleagues (1991) and those obtained by Seib (2009) on an observational measure of off task behaviors, they are similar to find ings obtained from teacher reports in the Seib (2009) study. With regard to observed classroom behavior, we expected to see decreases in the percentage of off task and inappropriate behaviors in children with a single or comorbid diagnosis of ODD, as wel l as a decrease in the percentage of non compliant behaviors
40 observed in children diagnosed with ODD only. Our study provided evidence for a decrease in the percentage of observed inappropriate behaviors in children with a single or comorbid diagnosis of ODD; however, it failed to support our hypotheses regarding the percentage of non compliant behaviors observed in children diagnosed with ODD only. As previously mentioned, the lack of generalization of treatment effects to the percentage of observed non compliant behaviors could possibly be explained by the low frequency of commands given and the limited opportunity for children to comply to commands in the classroom. The lack of change in the percentage of observed off task behaviors is different from t he outcome of previous PCIT studies, and as discussed above, may be explained by the exclusion of ADHD participants receiving a concurrent pharmacological intervention in the present sample. Despite failure to find differential generalization of PCIT treat ment effects across students and their behavior in the classroom varied as a function of diagnosis. At pre treatment, teachers of children with a single diagno sis of ODD endorsed fewer ADHD Predominantly Inattentive Type symptoms than did teachers of children with ADHD only. ODD only children were also rated as displaying significantly fewer ADHD Hyperactive Impulsive Type Symptoms by their teachers than both ch ildren with a single or comorbid diagnosis of ADHD. With regards to the frequency and intensity of perceived problematic behaviors in the classroom, teachers rated ODD only children as being significantly less problematic and engaging in significantly few er disruptive behaviors than children with a single or comorbid d iagnosis of ADHD. Finally, pre treatment REDSOCS data revealed a significant difference between the ODD only
41 children and those with a single or comorbid diagnosis of ADHD such that the ODD o nly children were observed to engage in a significantly higher percentage of non compliant behaviors. Althou gh the primary focus of Aim 2 was to determine if pre to posttreatment ng to see if differences in classroom presentation could be used to tailor treatment by selecting teacher reported problem behaviors specific to the target child and their diagnosis to be addressed during treatment. More specifically, coaching parents to ignore problematic behaviors similar to those exhibited in the classroom during pretreatment observations and to praise positive opposites of these behaviors in the clinic and at home may help facilitate generalization of change to the classroom. In ligh t of efforts to enhance teacher reports by supplementing them with classroom behavior. Unrealistic expectations of treatment outcome and stigmatizing perceptions of the target child are just two examples of how teacher bias could adversely affect their perceptions of classroom behavior. It is also not uncommon for participants to have dif ferent teachers by the time they complete treatment. Consequently, significant improvements that would have been clearly noticeable to a teacher who has spent a substantial amount of time with the target child may be more subtle when reported by a teacher who may not know the child as well. Limitations It is important that the limitations of this study be considered when interpreting the findings. Because this study was a secondary data analysis, it was impossible to compare our findings to those of a r andomized no treatment control group. Thus we are
42 unable to determine if the improvements in directly observed inappropriate behavior were due to PCIT or to the passage of time alone. It is also important to acknowledge differences between the two larger studies from which participants were recruited. The study examining the efficacy of PCIT with children with ODD allowed participants to maintain a stable medication regimen. On the other hand, children taking prescription medication for externalizing sym ptoms were excluded from participation in the study examining PCIT and ADHD. Excluding these participants made it difficult to assess the additive benefits that prescription medications may have had on the effects of PCIT on treating isolated ADHD symptom s. With regard to the design of the present study, the small and unequal sizes of the diagnostic groups may have hindered our ability to detect possible generalization of treatment effects. These limitations could also explain our failure to replicate fin dings obtained from previous studies. Obtaining larger, equally distributed samples would allow more power to detect differences between groups and produce results that may be more widely generalizable. Future Directions Further investigation is essential to determine strategies that may facilitate the generalization of PCIT treatment effects to the classroom. Despite several similarities, ADHD and ODD have distinct characteristics and present differently in the school setting. This observation was furth er supported by our finding regarding differences in proposed to treat ADHD and ODD as separate entities, with prescription medication being the gold standard treatment for ADHD and behavioral therapy being optimal for children diagnosed with ODD (Saddock & Saddock, 2007; Hetherington et al., 2006)
43 Additional research is needed to determine if prescription medication may facilitate generalized change to the classroom for children whose behaviors are too severe to be treated with PCIT alone. It would also be interesting to examine how the implementation of a supplementary, yet compatible school based intervention, such as Teacher Child Interaction Therapy (Macintosh, 2010) or The Level System (McNeil & Filcheck, 2004), would influence the generalization of treatment effects to the classroom. Training both parents and teachers on the underlying principles of PCIT could possibly promote consistency in the way in which parent s and teachers deliver rewards and punishments in t he home and classroom settings. Increased consistency among parents and teachers may make it easier for the child to adhere to rules and regulations in the classroom, because the consequences associated w ith deviating from classroom limits will be similar to those implemented in the home. In the event that a complimentary school based i ntervention is unavailable, pre treatment teacher reports and direct observation data collected during classroom observati ons could be used to tailor treatment in a manner that would address the behaviors that are perceived to be most proble matic in the classroom setting. Future research should investigate the most effective and efficient ways to tailor clinic based PCIT for
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49 BIOGRAPHICAL SKETCH Carmen SaMyra Edwards was born and raise d in Charlotte, North Carolina. She was an active and dedicated student at West Charlotte High School as she was involved in several extra curricular activities and graduated within the top 1 percent of her class. Carmen lived in Charlotte until moving t o Orangeburg, South Carolina to attend South Carolina State University for college. She excelled there as well as she graduated in 3.5 years with a 4.0 cumulative grade point average. After graduating in 2008, Carmen returned to Charlotte to work as an a ssistant research administrator in the Department of Psychology at Johnson C. Smith University. In August of 2010, Carmen was accepted into the Doctoral Program for Clinical and Health Psychology at the University of Florida. Carmen currently works as a graduate assistant in the Child Study Lab under the mentorship of Stephen R. Boggs, Ph.D.