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1 MATERNAL DISCIPLINARY BEHAVIORS AND DISRUPTIVE BEHAVIOR DISORDERS IN PARENT CHILD INTERACTION THERAPY By NADIA NOSHIN BHUIYAN A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT O F THE REQUIREMENTS FOR THE DEGREE OF MASTERS OF SCIENCE UNIVERSITY OF FLORIDA 2012
2 2012 Nadia Noshin Bhuiyan
3 T o my mother and father, Sufia and Ashraf, my sweet furry friends, Minerva, Aubie, and Pakei, and my best friends, including but not limited to Marilee, Tom, and Michael, who all have kept me in high spirits, have nourished me with love and laughter, and without whom I would never have made it to this incredible milestone
4 ACKNOWLEDGEMENTS I thank Dr. Sheila Eyberg for serving as my chair and providing me with her mentorship and guidance on this manuscript. I thank Dr. David Janicke, Dr. Deidre Pereira, and Dr. Dawn Bowers for serving as members of my committee and contributing to this thesis. I thank the memb ers of The Child Study Lab for their constructive feedback and kind words of encouragement throughout the thesis writing process. I thank Nicole Ginn for providing me with advice and inspiration throughout the production of this manuscript. I thank my fami ly for their ever vigilant support and ability to keep my morale high; they have kept me going from the inception to the conclusion of this project. Las tly, I thank all my friends for believing in me every step of the way. This project was funded by the Na tional Institute of Mental Health (R01 MH60632).
5 TABLE OF CONTENTS page ACKNOWLEDGEMENTS ................................ ................................ ............................... 4 LIST OF TABLES ................................ ................................ ................................ ............ 7 LIST OF FIGURES ................................ ................................ ................................ .......... 8 ABSTRACT ................................ ................................ ................................ ..................... 9 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 11 2 METHODS ................................ ................................ ................................ .............. 21 Participants ................................ ................................ ................................ ............. 21 Inclusion and Exclusion Criteria ................................ ................................ ....... 21 Participant Characteristics ................................ ................................ ................ 22 Measures ................................ ................................ ................................ ................ 22 Procedure ................................ ................................ ................................ ............... 26 Pre Treatment Assessment ................................ ................................ .............. 26 Treatment ................................ ................................ ................................ ......... 26 Post Treatment ................................ ................................ ................................ 27 A nalyses ................................ ................................ ................................ ................. 27 3 RESULTS ................................ ................................ ................................ ............... 30 Analysis of Pre Treatment Data ................................ ................................ .............. 30 Opposi tional Defiant Disorder versus Conduct Disorder ................................ ......... 32 Parent Disciplinary Behaviors ................................ ................................ ................. 34 Post Hoc Analyses of Convergent Validity ................................ .............................. 35 4 DISCUSSION ................................ ................................ ................................ ......... 51 APPENDIX A CHILD DIRECTED INTERACTION SKILLS (REPRINTED WITH PERMISSION FROM EYBERG & FUNDERBURK, 2011) ................................ ............................. 63 B SELECT RULES FOR PARENT DIRECTED INTERACTION REPRINTED FROM TEACHER HANDOUT (EYBERG & FUNDERBURK, 2011) ....................... 65 C DISCIPLINARY MEASURES AND EXAMPLES ................................ ..................... 67 LIST OF REFERENCES ................................ ................................ ............................... 68
6 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 72
7 LIST OF TABLES Table P age 2 1 Participant demographic characteristics ................................ ............................. 29 3 1 Mean scores of treatment completer and dropouts at pre treatment .................. 37 3 2 Z scores and significance for tests of equivalence between dropouts versus treatment completers ................................ ................................ .......................... 38 3 3 Pre treatment scores for mothers of children with ODD versus CD .................... 39 3 4 Z scores and significance for tests of equivalence for ODD versus CD .............. 40 3 5 Percentage of total discipline behaviors used in each Daily Discipline Interview category at pre and post treatment ................................ ..................... 41 3 6 Average freque ncy of Daily Discipline Interview category endorsement at pre and post treatment ................................ ................................ ...................... 42 3 7 Pearson correlation matrix for discipline measures ................................ ............ 43
8 LIST OF FIGURES Figure page 3 1 Mean pre treatment scores for mothers of children with ODD and CD on the Daily Discipline Interview ................................ ................................ .................... 44 3 2 Mean pre treatment scores for mothers of children with ODD and CD on the Parent Practices Questionnaire. ................................ ................................ ......... 45 3 3 Mean pre treatment scores for mothers of children with ODD and CD on Parenting Scales Laxness and Overreactivity ................................ ................... 46 3 4 Mean percentages for the three D aily Discipline Interview categories that showed statistically significan t differences at post treatment ............................ 47 3 5 M ean percentages for the three Daily Discipline Interview categories that did not show statis tically significant differences ................................ ...................... 48 3 6 Mean scores of the Parenti ng Practices Questionnaire at p re treatment and post treatment ................................ ................................ ................................ ... 49 3 7 Mean scores of Parenting Scales Laxness and Overreactivity subs cales at pre and post treatment ................................ ................................ ...................... 50
9 Abstract of Thesis Pr esented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Masters of Science MATERNAL DISCIPLINARY BEHAVIORS AND DISRUPTIVE BEHAVIOR DISORDERS IN PARENT CHILD INTERACTION THE RAPY By Nadia Noshin Bhuiyan May 2012 Chair: Sheila Eyberg Major: Psychology The development of disruptive behavior disorders (DBDs) has been associated with authoritarian and inconsistent disciplinary styles, with more severe disciplinary behaviors bei ng associated with more disruptive child behaviors. In Parent Child Interaction Therapy (PCIT), parents learn to alter the coercive cycle of negative parent needs and b) help create a more positive and consistent approach to discipline. The primary goal of this study was to examine generalization of PCIT skills to parental disciplinary style and behaviors in home after treatment. We hypothesized that disciplin ary behaviors would be more negative for mothers of children with severe DBDs. At PCIT completion, we hypothesized that parents would report using fewer negative disciplinary behaviors and more positive disciplinary behaviors. Participants were 61 mother child dyads who successfully completed a study investigating PCIT treatment maintenance. Thirty three children met DSM IV TR criteria for Oppositional Defiant Disorder (ODD) and twenty eight children met DSM IV TR criteria for Conduct Disorder (CD). To mea sure parent responses to child misbehavior,
10 the Daily Discipline Interview (DDI), the Parenting Practi ces Questionnaire (PPQ), and the Parenting Scale (PS) were administered before and after treatment. Results from analyses of variance revealed that there were no significant differences in parenting behaviors between mothers of children with ODD versus CD Additionally, paired samples t tests indicated that maternal reports of disciplinary responses changed significantl y across three of the six DDI categor ies (Critical Non Physical Force, Non C ritical Verbal Force Limit Setting ), the PPQ, and the PS, such that negative parenting behaviors (e.g. shouting, yelling, repeated commands) occurred less fre quently after treatment and positive behaviors (e.g ., tim e out) occurred more fre q uently after treatment These results suggest that for this particular study of maternal disciplinary behaviors, there was no conclusive evidence of disciplinary style being a major determinant in t he development of ODD versus CD for pre school aged children It is possible that factors outside of maternal discipline (e.g., biological parent psychopathology) contribute to a child developing severe DBDs; however, it is also possible that other measures of discipline may be more sens itive to the affects of discipline severity on the development of DBDs. Results also suggest that across 9 different measures of the parenting construct, PCIT can successfully decease negative disciplinary behaviors and increase positive disciplinary behav iors.
11 CHAPTER 1 INTRODUCTION Disruptive behavior disorders (DBDs) are described as child and adolescent pscyhopathologies characterized by defiant, aggressive, and hyperactive behaviors that not only negatively affect a emic functioning, but can also disrupt positive parent and child interactions ( Diagnostic and Statistical Manual for Mental Disorders Fourth Edition Text Revision, American Psychiatric Association, 2000; Eyberg & Bussing, 2010). The development of DBDs is associated with negative psychosocial and environmental factors, including higher rates of mental health treatment, substance abuse, comorbid psychiatric psychopathologies, and academic delinquency (Burke, Loeber, & Bihamer, 2002; Campbell, Breaux, Ewing, & Szumoski, 1986; Stormshak, Bierman, McMahon, & Lengua, 2000; Turgay, Binder, & Fishman, 2002). Because DBDs remain among the most common disorders seen in clinical and community health environments (Loeber, Burke, Lahey, Winters, & Zera, 2000; Frick, 19 98) and involve chronically heightened levels of both child and parental distress (Campbell et al., 1986, Stormshak et al., 2000), it is imperative that processes contributing to the development and treatment of DBDs be thoroughly investigated. The DBDs i nclude Oppositional Defiant Disorder (ODD) and Conduct Diso rder (CD; DSM IV TR, 2000 ). Factor analyses of disruptive behaviors show that the behaviors or symptomatology that characterize ODD and CD have distinct and ind ependent loading patterns (Burn s, Wal sh, Owen, & Snell, 1997; Frick et al., 1993; Loeber, Green, Lahey, Frick, & McBurnett, 2000 ; Loeber, Burke, & Pardini, 2008). ODD includes behaviors such as frequent temper tantrums, noncompliance, and argumentativeness whereas CD is a more severe disorde r and is characterized by
12 repetit ive and persistent disregard of human rights and societal norms, such as stealing Both the initial development and later maintenance of ODD and CD have consistently been associated with pa renting discipline styles (Burke et al., 2002; Burke, Pardini, & Loeber, 2008; Frick et al., 1992; Loeber et al., 2000; Snyder, Cramer, Afrank, & Patterson, 2005). Disciplinary method or style is described as an environmental and emotional framework for pa renting behaviors that is aimed at rearing a child in accordance to societal expectations (Darling & Steinberg, 1993). Each disciplinary style consists of particular beliefs that a parent holds about a and involves particular disciplinary practices are limited (Larzalere, S chneider, Larson, & Pike, 1996) but indicate that common forms of discipline include: spanking, removal of privileges, time out, and reasoning (La rzalere et al., 1996; Vittrup & Holden, 2009). initial conceptualization of parenting typologies (Baumrind, Larzelere, & Owens, 2010; Darling & Steinberg, 1993) Specifically, Baum rind descr ibed four parenting categories permissive, authoritarian, authoritative, and neglectful that differ in level of and non punitive; instead of setting rules the parent engages in little control over the parent is punitive and strict; the parent sets rules that are enforced without reason and attempts to engage in full control t engage in disciplinary behaviors that are considered overreactive and harsh. The
13 authoritative parent is supportive but sets standard rules based on reasonable expectations; the parent maintains consistent c follows through with consequences no demands on the child and has Research investigating the effects of disciplinary typologies on child behavior has found that the development and maintenance of DBDs consistently relate to parent disciplinary typol ogies, such that negative, disruptive child behaviors have been associated to punitive, lax, and inconsistent discipline methods characterized by low levels of warmth, support, and parental involvement (Baumrind et al., 2010; Burke, Pardini, & Loeber, 2008 ; Frick et al., 1993; Frick et al., 1992; Lo e ber, et al., 2000; Patterson 1997; Snyder, Cramer, Afrank, & Patterson 2005; Stormshak et al., 2000). In contrast, positive child behaviors have been associated with supportive and consistent disciplinary tech niques (Baumrind et al., 2010; Rodriguez & Eden, 2005). In a functioning, Baumrind and colleagues (2010) found that parents who use authoritat ive disciplinary procedures (e.g. time out, consequences followed by verbal reasoning, and normative spanking) with their preschoolers had adolescents who were better adjusted and competent compared to parents who used authoritarian, per missive, or neglectful disciplinary behaviors. Pare nts using more v erbally forceful language (e.g., screaming, shouting), incon sistency (e.g. unpredictable parental reaction), and aggression (e.g.
14 overreactive physical force, unmeasured spanking, slapping) had adolescents who were more maladjusted and le ss competent. Similarly, higher rates of negative parent child interactions child internalizing problems, and disordered conduct like temper tantrums have been associated with families engaged in low parental supervision and high levels of inconsistency (Burke et al., 2002; Stormshak et al., 2000). In contrast, Rodriguez and Eden (2007) found that the children of parents who endorsed fewer maladaptive parenting behaviors as measured by the Parenting Scale ( 1993) and the Ch ild Abuse Potential Inventory (Milner, 2002), described themselves in a more positive and hopeful manner. In a study of discipline use and child compliance, Larzalere and colleagues (1996) used a parent report measure of daily disciplinary behaviors to as sess the effectiveness of spanking, time out, and the combination of either spanking or timeout with reasoning, on delaying future misbehavior. They found that both spanking and timeout, in combination with reasoning, produced the longest delay in child no ncompliance. Spanking alone (i.e., spanking without an explanation) produced the shortest delay, followed by time out alone. The previously ci ted research investigating the e ffects of authoritarian, permissive, and inconsistent disciplinary strategies on c hild beha viors generally considered the e ffects of discipline on DBDs as a whole, but did not primarily assess discipline as having variable contributions to a child developing ODD versus CD, even though both disorders differ in severity of symptomatology (Burke et al., 2002; DSM IV TR, 2000 ). Frick and colleagues (1993) have suggested that there may be differences in the
15 disciplinary practices used for children that develop ODD versus CD. They found that both groups of children experienced more inconsisten cy and less supervision from parents than undiagnosed children. Although differences between the ODD and CD groups were not significant, the researchers reported data patterns suggesting that parents of children with CD were less involved and showed higher rates of over reactivity, laxness, and overall inconsistency in disciplinary practices than parents of children with ODD. Although these finding are not significant, the question of differing disciplinary behaviors in families of children with ODD versus C D is under researched and deserves more study. Moreover, significant differences in disciplinary behaviors could have a notable impact on the treatment of ODD and CD symptomatology. One purpose of this study is to investigate these patterns of differences in disciplinary behaviors between families of children with ODD versus CD. The relationship between parental disciplinary practices and the development of child interaction (Patterson, 1986; Patt erson & Stouthamer Loeber, 1984) in which punit ive parenting behaviors such as high rate comman ding, shouting, and threatening are consistently related to negative child behaviors (Patterson, 1986; Patterson & Stouthamer Loeber, 1984). Patterson (1986) con ceptualized the development of disruptive child behaviors child other in escalating, increasin gly negative exchanges. parental command. The parent may repeat the command, and if the child then
16 responds, the parent is negatively reinforced for repeating the command. If the child again does not respond, the parent may continue to repeat until the child obeys. In such an interaction, the parent may learn to give repeated commands ( i.e., same time, the child is learning that not obeying a command leads to incr easingly longer periods of time of not having to do what he or she does not want to do (i.e., (e.g., get louder, angrier, more threatening) until the child complie then reinforces the parent (through negative reinforcement) for increasing harshness in discipline to obtain compliance. Within this coercive cycle, it also happens that sometimes instead of escalating worth the trouble). Whenever the parent gives up, the child is again negatively reinforced for persistence in non compliance, and the parent is also negatively reinforced for giving u p commands, though, so the ch ., noncompliance, arguing, yelling) is reinforced either parsimonious explanation, based in social learning theory, for the development of child disruptive behavior and maladaptive paren tal practices and abusiveness. These findings indicate that the relati onship between disciplinary practices and maintenance of engagement in increasingly disruptive conduct (Patterson, 1986). Pa
17 break this cycle in treatment, it would first be necessary to change the parenting style from one characterized by harsh and inconsistent responses to child misbehavior to a style characte rized by empathic, consistent, and effective discipline. Many evidence based treatments (EBTs) for children with DBDs involve the parents as change agents and focus on altering the negative parent child relationship and reducing disruptive child behavior ( Eyberg, Nelson, & Boggs, 1998). Teaching parents the principles and skills of social learning theory can effectively reverse coercive parent child interactions and child disruptive behaviors (Eyberg & Bussing, 2010). Parent Child Interaction Therapy (PCIT ) is an EBT that places emphasis on increasing parental warmth and support as well as consistency in the disciplinary interaction. PCIT targets an increase in child prosocial behaviors and a decrease in attention seeking, disruptive behaviors (Eyberg & Bus sing, 2010). play Responsiveness is conceptualized as expressing warmth, support, and emotional rec iprocity in parenting exchanges with the child, which in turn fosters child autonomous and prosocial behaviors (Baumrind et al., 2010). Demandingness is conceptualized as holding expectations for child behavior in accordance with firm but developmentally a ppropriate boundaries or rules (Baumrind et al., 2010). Authoritative parents set clear By teaching par ents to be both responsive and consistent in following through on
18 of positive reinforcement in which parents consistently withdraw their attention from all disruptive o r unwanted child behaviors and consistently provide positive attention to child behaviors that are incompatible with the unwanted behaviors. As children experience these new consequences to their attention seeking behaviors and learn that acceptable behavi ors receive positive reinforcement, their acceptable, positive reinforcement to the parent for providing contingent positive attention (Eyberg & Bussing, 2010). During the Child Directed Interaction (CDI) phase of PCIT, parents are taught to focuses on fostering a secure attachment between the parent and child (Zisser & Eyberg, 2010). Parents learn to use specific verbal and nonverb behaviors. By using differential social attention consistently with the child, parents learn to avoid providing any kind of attention following negative/disr uptive child behavior and to Positive exchanges result in a reversal of the coercive cycle to a positive cycle, which creates warmth and decreases anger and frustration in the parent child interaction. A reprint of the verbal and nonverbal behaviors from the PCIT Treatment Manual (Eyberg & Funderburk, 2011) can be found in Appendix A. During the second phase of PCIT, Parent Directed Interaction (PDI), parents learn to lead the interaction by communicat ing very clear directives/commands and are taught will respond with either an acceptable (compliant) or unacceptable (noncompliant)
19 behavior, and the parent will again pro vide consistent consequences in the form of positive reinforcement for compliance or removal of positive re inforcement for noncompliance. The goal of the PDI phase of PCIT is to alter the discipline interaction between the parent and child from an exchange that may be inconsistent and inappropriate to an exchange that is consistent and developmentally appropriate for the child. A list of parental rules in PDI can be found in Appendix B. In both CDI and PDI overall parent responses are coached to be consist ent so that all child behaviors result in the parent following through with a specified, expected, and consistent consequence. The primary purpose of this study is to examine generalization of the PDI principles to parental discipline style and behaviors i n the home after PCIT. behaviors, discriminating the positive and negative behaviors and providing consistent differential consequences for the behaviors in their efforts to ch ange them, parents would be expected to be more consistent in their responses to their child, particularly in responses to behaviors that are disruptive. By treatment completion, parents have also been reinforced for their consistent responses by the chang es they have experienced in child relationship quality, particularly around discipline interactions, would be expected to decrease the parents feelings of anger and loss of control that accompany pre t reatment coercive interactions. This study examined the pre and po st treatment disciplinary styles and behaviors of the mothers of children with either ODD or CD who completed PCIT Because previous research has suggested that parents of children with ODD versus CD may
20 differ in the harshness or severity of their parentin g/discipline (Frick et al., 1992 ), our first research question was an exploratory one to compare the mothers of children with ODD versus CD at pre treatment on several measures of discipli nary style and behavior. Based on earlier meta analyses of DBDs (Frick et al., 1992), we expected a pattern of differences in mother reports of disciplinary behaviors, with more severe discipline behaviors being reported by mothers of children with CD. Our styles and beha viors after completing PCIT. Across all mothers we hypothesized that in contrast to their scores at pre treatment, mothers across both diagnostic groups would evidenc e significantly greater use of disciplinary styles and behaviors considered acceptable and effective (i.e., engage in parenting styles that promote positive child functioning), and would, at the same time, report significantly less use of disciplinary meth ods considered unacceptable and/or ineffective (i.e., parenting behaviors that are associated with negative child outcomes).
21 CHAPTER 2 METHODS Participants Participants were drawn from the archival database of a larger study that investigated long term tr eatment gains following completion of PCIT. One hundred boys and girls between the ages of 3 and 6 were enrolled in the larger study after being referred to the study by multiple sources, including pediatricians, child mental health specialists, teachers, and self referrals. Inclusion and Exclusion C riteria Inclusion crite ria for the larger study were as follows: (a) the child had to meet DSM IV TR (2000 ) criteria for the diagnosis of ODD and (b) the child had to live with at least one parent able to part icipate in treatment. As part of the inclusion criteria in the study, children had to meet diagnostic criteria for ODD on the National Institute of Mental Health Diagnostic Interview Schedule for Children Four Parent (NIMH IV P DISC, Shaffer, Fisher, Lucas Dulcan, & Schwab Stone, 1997) and receive a standard score of 61 or above on the Child Behavior Checklist Aggression Subscale (Achenbach 1991; 1992). Children were excluded from the original study if they obtained a standard score below 70 on a measure of receptive language skills (Peabody Picture Vocabular y Test Third Edition; PPVT III Dunn & Dunn, 1997), if their parent obtained a standard score below 75 on a cognitive screening measure (Wonderlic Personnel Test, WPT; Dodrill, 1981), or if the child h ad a major sensory or developmental impairment (e.g ., blindness, autism spectrum disorder). Children were not excluded if they were taking psychotropic medication to manage their behavior as long as their dosage was stabilized for at least one month prior to entering the study. Children who met criteria for
22 the following co morbid mental health diagnoses were not excluded from the study: Conduct Disorder, Major Depressive Disorder (MDD) Separation Anxiety Disorder (SAD) and Attention Deficit Hyperactivity Disorder (ADHD) For the pu rpose of this study of discipline behaviors, families who did not complete treatment were excluded. Based on this criterion, 39 families were excluded, leaving a total of 61 mother child dyads. Part icipant C haracteristics The 6 1 mother child dyads included 40 boys (65.6%) and 21 girls (34.4%) with a mean age of 4.48 ( SD = 1.15). By parent report, th e majority of the children were Caucasian (75%) however 4 (7%) were African American, 2 (3%) were Hispanic, 1 (2%) was Asian, and 7 0 ( SD = 9.27). Majority of mothers participating in the study reported to be Caucasian (51%). Mean income of part icipants within this study was $38,207 ( SD = $27,578). Participant characteristic s can be found in Table 2 1. Measures National Institute of Mental Health Diagnostic Interview Schedule for Children IV Parent (NIMH DISC IV P; Shaffer, Fisher, Lucas, Dulcan, & Schwab Stone, 1997). At the pre treatment assessment, graduate student traine d assessors administered the computerized NIMH DISC IV P structured in terview to mothers to secure the presence of a diagnosis of ODD. Individual modules of interest (CD, ADHD, MDD) can be admin istered separately. One week test retest reliability on admini stration to parents of 9 to 17 year old children has been reported at .54 for ODD, .54 for CD, .79 for ADHD (Fisher et al., 1998, cited in Columbia DISC Editorial Board, 1998). The NIMH DISC IV P w as administered at pre and post treatment assessments.
23 Chi ld Behavior Checklist Aggression Subscale (CBCL, Achenbach 1991; 1992). At the pre treatment assessment, mothers filled out the CBCL for 4 18 Year Olds (CBCL/4 18) or the CBCL for 2 3 Year Olds (CBCL/2 3; Achenbach, 1992), which are parent rating scales as during the past 6 months. It consists of 118 behavior problem items rated by the parent on a 3 point likert scale from (0) not true to (2) very true or often true. Mean test reliabilities of the problem scales have been reported at .89 and .75 over a 1 week and 1 year period, respectively. Internal consistency for the CBCL subscales ranged from .72 to .96 (Achenbach, 1991). Peabody Picture Vocabulary Test (PPVT III; Dunn & Dunn, 1997) Children w ere administered the Peabody Picture Vocabulary Test III (PPVT III) at the pre treatment assessment as a screening measure of cognitive functioning for inclusion in the study. The PPVT III is a standardized non verbal measure of receptive learning. Interna l consistency alpha coefficients for children have been reported to range from .92 to .98. Split half reliability coefficients for children have been reported to range from .86 to .97. Test retest reliability coefficients for children have been reported to range from .91 to .94 (Dunn & Dunn, 1997). Wonderlic Personnel Test (WPT: Dodrill & Warner, 1988). Mothers were administered the Wonderlic Personnel Test (WPT) at the pre treatment assessment as a screening measure of cognitive functioning for inclusion in the study. Correlations between the WPT and the Wechsler Adult Intelligence Scale (WAIS) were shown to be at .75 (Dodrill & Warner, 1988 ) with correlations with the Full Scale IQ of the Wechsler Adult In telligence Scale at .93 ( Wechsler, 1981).
24 Parent Daily Report (PDR, Chamberlain & Reid, 1987). The PDR was administered to parents over the telephone fo r five consecutive days at the pre treatment assessment and five consecutive days at the post treatment assessment to obtain information on the daily fre quency of child disruptive behaviors. The PDR has been shown to have test retest reliability of .62 to .82 (Chamberlain & Reid, 1987). Chamberlain and Reid (1987) found moderate internal consistency and concurrent validity with direct observations of child disruptive behaviors. Daily Discipline Interview (DDI, Webster Stratton & Spitzer, 1991). A modification of the DDI was created for the study. Specifically, parental disciplinary responses were categorized into the following six categories: Physical Forc e, Critical Non Physical Force, Non C ritical Verbal Force, Reasoni ng/Teaching, Lack of Response and Limit Setting. The DDI is a 24 hour recall instrument administered via telephone along with the PDR. For every problem behavior that parents reported on th e PDR parents were asked to report their disciplinary response to that behavior (e.g., ed and later organized into six categories of disciplinary behaviors previously mentioned. De scriptions of the categories can be found in Appendix C. The original DDI categories were reported to have inter rater reliability ranging from .94 for Physical Force, .94 for Critical Verbal Force, .97 for Limit Setting, and .87 for R easoning /Teaching Te st retest re liability ranging from .45 for Critical Physical F orce, .59 for Critical Verbal Force, .43 for Limit Setting, and .51 for Reasoning/ Teaching. Internal consistency coefficients were as follows: .62 for Physical Force, .74 for Critical Verbal For ce, .59 for Limit Setting, and .67 for Reasoning/ Teaching. Inter rater reliability was not assessed in this study.
25 Parenting Practices Scale/Questionnaire (PPQ/PPS, Strayhorn & Weidman, 1988). The Parenting Practi ces Questionnaire (PPQ) is a 34 item six p oint likert scale that was adm inistered to mothers at the pre treatment assessment and at the post treatment assessment. The PPQ is a parent self report questionnaire of disciplinary behaviors and parent child interactions. Higher scores are indicative of more ineffective parenting behaviors. The instrument was shown to have good internal consistency and 6 month stability (Strayhorn & Weidman, 1988). In the present study, internal consistency for the PPQ was .75. An example of a test item is in Appendix C. Two subscales of the Parenting Scale (PS), Laxness and Overreact ivity, were administered at pre and post treatment assessments to assess parent responses to child misbehavior that are unresponsi ve or overresponsive, respectively. The PS is a 30 item, 7 point parent rating scale of disciplinary b ehaviors where higher scores (e.g ., 7) are indicative of more ineffective parentin g behaviors and lower scores ( e. g. 1) are indicative or more effective parenting behaviors. Internal consistency coefficients were .82 (Overreactivity) and .83 (Laxness). For these two subscales, the test retest reliability for the PS ranged from .82 (Laxness) to .83 (Overreactivity). Both subscales were highly correlated wi th 1993). In the present study, the internal consistency of the Laxness scale was .87 and for the Overreactivity subscale was .74 Examples of questions reprinted from the questionnaire are in Appendix C.
26 Procedure Pre T reatment A ssessment At the pre treatment assessment, families were screened for the inclusion and exclusi on criteria. Parents completed questionnaires that included questions about demographics (e.g., eth nicity, a ge, and average yearly income), parent report measures symptomatology and disciplinary behaviors. Graduate student assessors administered a structured diagnostic interview to the mother about the child (NIHM DISC IV P; Shaffer et al., 1997 ). The parent and the child were then observed in three standardized play based interactions (child led play, parent led play, and clean up). The parenting behaviors measures, specifically the DDI, the PPQ, and the Laxness and Overreactive sub s cales of the PS, were administered. Treatment Therapists in the study were advanced doctoral students with over one year of previous training in PCIT. Therapis ts followed the PCIT Treatment protocol for each session (Eyberg, 1999) and attended weekly supervision with two PCIT Master Trainers and licensed psychologists. All sessions were tape recorded, and 50 % of the sessions were checked; o f those, 50% were checked by a second observer to calculate in ter rater reliability of the session integrity checks. Treatment integrity was 97%, with an inter rater reliability coefficient of .97. Parent child dyads received weekly sessions of PCIT. In the first phase of PCIT, called the Child Directed Interaction (CDI), parents use respectively. Therapists coached the mother s to use the skills to decrease disruptive
27 behaviors, increase positive opposite behaviors, and improve parent child positive interactions. Once parents reached mastery criteria for CDI, parents began the Parent Directed Interaction (PDI) phase of treatment. Parent s were taught and coached to positive behaviors and ignoring (i.e., withdrawing positive attention from the child) the ly struc tured, consistent and predictable way. In order to graduate, mothers had to 1) master CDI and PDI skills, 2) report normative behaviors on a parent report measure of child disru ptive behaviors, and 3) express their own. The mean number of sessions attended by participants among the total archived study was 13.67 ( SD = 7.19). Post T reatment Parent child dyads were re administere d all procedures used at the pre treatment assessment approximately three weeks afte r completing treatment. Asses sors re administered the DDI by telephone for five consecutive days in addition to the PPQ and the two PS subscales (Laxness and Overreactivity) Analyses Selective a ttritio n. To assess for selective attrition, pre treatment score s across the three questionnaires (DDI, PPQ, PS) will be assessed using a one way analysis of variance (ANOVA) with drop out status as the independent variable and the parenting measure scores as the independent variable. Aim o ne To assess the diffe rence in parenting behaviors among families of children with ODD versus CD before treatment, a one way ANOVA was conducted with
28 diagnosis as the independent variable and pre treatment DDI PPQ, and PS scores as the dependent variable s Aim t wo To assess our major hypothesis concerning the predicted changes over treatment on a range of measures assessing different aspects of the concept of parental discipline, we had specific hypotheses for change on each of the 9 measures: we hypothesized that the endors ement of using Critical Physical Force, Critical Non Physical Force, Non Critical Verbal Force, and Reasoning/Teaching would decrease in rates of usage at post treatment. Although PCIT does not universally address each of these parenting behaviors, if a pa rent was observed using one of these behaviors, the therapist would describe how it functions to maintain the coercive behaviors and would remain focused on coaching parents to use other methods that would be successful. It was hypothesized that the endors ement of using Limit Setting would increase in rates of usage at post treatment. For the PPQ, PS Laxness, and PS Overreactivity, where higher scores are indicative of more ineffective parenting, it was hypothesized that there would be a decrease in parent self report of ineffective parenting behaviors. Comparing measures of parenting styles Three measurements of disciplinary behaviors, the DDI, the PPQ, and the PS, will be used to observe changes in parenting techniques across multiple domains of discip line, including frequency of parenting responses and utilization of ineffective and effective parenting styles. Correlations of the disciplinary measurements will be used to observe associations among the measurements
29 Table 2 1 Participant demographic c haracteristics M SD Mother Age 39.30 9.46 Child Age 4.48 1.15 Average Income 38,307 27,578 n % Child Sex Male 40 66 Child Ethnicity European American 46 75 .00 African American 4 7.0 Hispanic 2 3.0 Asian Ame rican 1 2.0 Biracial 8 13 .00 Note : N = 61.
30 CHAPTER 3 R ESULTS Analysis of Pre Treatment Data To assess for the possibility of selective attrition within participants in the current study and to account for differences in parenting behaviors that m ay have contributed to treatment dropout status, analyses of variance (ANOVAs) were conducted with dropout status as the independent variable and pre treatment DDI category scores, PPQ scores, PS Laxness scores, and PS Overreactivity scores as the dependen t variables, respectively. Evaluation of pre treatment scores indicated normally distributed DDI Critical Non Physical Force (skewness = 0.97, SE = 0.24; kurtosis = 0.46, SE = 0.48), DDI Non Critical Verbal Force (skewness = 0.91, SE = 0.24; kurtosis = 0 .60, SE = 0.48), DDI Limit Setting (skewness = 1.10, SE = 0.24; kurtosis = 1.29, SE = 0.48), PPQ (skewness = 0.40, SE = 0.25; kurtosis = 0.14, SE = 0.49), PS Laxness (skewness = 0.48, SE = 0.24; kurtosis = 0.12, SE = 0.48), and PS Overreactivity (skewne ss = 0.43, SE = 0.24; kurtosis = 0.044, SE = 0.48). DDI Physical Force (skewness = 2.06, SE = 0.24; kurtosis = 5.71, SE = 0.48), DDI Reasoning (skewness = 2.82, SE = 0.24; kurtosis = 12.5, SE = 0.48) and DDI Lack of Response (skewness = 2.34, SE = 0.24; k urtosis = 7.78, SE = 0.48) were normally skewed but leptokurtic, indicating that data point s clustered in the center of the distribution but were notably peaked. Although ANOVAs can be robust to non normality, non normally distributed categories were also analyzed using the Kruskal Wallis nonparametric ANOVA. Analyses of pre treatment scores for treatment completers and treatment non completers using the one way ANOVA revealed no significant differences
31 on any measures of parenting discipline. Of note, anal yses of non normally distributed categories using the Kruskal Wallis non parametric ANOVA showed a significant difference in pre treatment scores for the DDI Physical Force category, such that families who dropped out of treatment reported more frequent us age of discipline that fit within this category than families who completed treatment, 2 (2, N = 99) = 4.05, p = .04, d = 0.08. Analysis of the effect size for this difference in reporting on the DDI Physical Force category suggests that the difference is significant but not meaningful. Pre treatment means and ANOVA results for dropout and completers can be found in Table 3 1 Pre treatment measures were also evaluated for equivalence between the participants who completed versus dropped out of treatment. Specifically, two sided equivalency tests were conducted using a 10% mean difference equivalency interval to side d test determined whether a 90% confidence interval fell into the equivalency interval of the two group means. Results revealed that the groups were not statistically equivalent to one another for any DDI category, for the PPQ, or for either PS measure Th ese findings indicate that despite the absence of a significant difference between the two groups, the groups were also not statistic ally equivalent on any measure (i.e., measures did not have scores within 10% of one another) at pre treatment. Patterns of maternal reports showed that treatment dropout families had marginally higher scores on the PPQ, DDI Physical Force, DDI Teaching/Reasoning, and DDI Limit Setting, but marginally lower scores on both PS Laxness and Overreactivity as well as all other DDI categories
32 Results of equivalency testing ( z scores and associated p values) can be found in Table 3 2 Oppositional Defiant Disorder versus Conduct Disorder One way analyses of variance (ANOVA) were conducted to evaluate parenting behaviors endorsed b y mothers of children with ODD versus CD on three questionnaires investigating disciplinary behaviors (six DDI categories, the PPQ, PS Laxness, and PS Overreactivity). Evaluation of distributions indicated normally distributed pre treatment PPQ (skewness = .71, SE = .31; kurtosis = 1.10, SE = .61), PS Laxness (skewness = .67, SE = .31; kurtosis = .18, SE = .61), and PS Overreactivity (skewness = .45, SE = .31; kurtosis = .25, SE = .25). Distribution for individual DDI categories indicated normally distribut ed pre treatment scores for Critical Non P hysical Force (skewness = .94, SE = .31; kurtosis = .51, SE = .60), Non Critical Verbal Force (skewness = 1.0, SE = .31; kurtosis = .60, SE = .60), and Limit Setting (skewness = 1.20, SE = .31; kurtosis = .71, SE = .60). DDI Physical Force (skewness = 1.79, SE = .31; kurtosis = 4.23, SE = .61) and DDI Lack of Response (skewness = 2.36, SE = .31; kurtosis = 7.61, SE = .61 ) were normally skewed but leptokurtic, indicating that scores were generally clustered at the c enter of the distribution but were also peaked. DDI Teaching/Reasoning was positively skewed (skewness = 3.82, SE = .31) and highly leptokurtic (kurtosis = 20.5, SE = .61), indicating that scores clustered towards the lower end of the spectrum and were hig hly peaked. Kruskal Wallis nonparametric ANOVAs, in addition to parametric ANOVAs, were used in the analyses of the non normally distributed measures. Experimentwise error rate was controlled with the Dunn Bonferroni correction, which required p < .005 fo r ANOVAs to be considered significant. Analyses of the
33 differences in disciplinary behaviors between mothers of children with ODD and mothers of children with CD were not significant. Pre treatment means and ANOVA results can be found in Table 3 3 Means o f all DDI categories, the PPQ, and the two PS measures can be found in Figures 3 1, 3 2, and 3 3. Pre treatment scores were also evaluated for equivalence between mothers of children with ODD versus CD. Equivalence testing involved analyses of the two gro ups to assess whether maternal reporting for children with ODD was within 10% of the report for children with CD. Results revealed that the groups were not statistically equivalent for all DDI categories, for the PPQ, nor for the PS subscales, which sugges ts that the two groups were neither statistically equivalent nor statistically significant at pre treatment across disciplinary measures. For the PPQ, maternal reports showed that mothers of children with CD appeared to endorse slightly more negative paren ting behaviors than mothers of children with ODD. Similarly, DDI category data showed that mothers of children with CD had marginally higher scores for Non Critical Verbal Force, Limit Setti ng Teaching/Reasoning, and Lack of Response. Of note, removing th e Dunn Bonferroni adjustment for alpha inflation indicated a statistically significant difference in maternal endorsement of Teaching/Reasoning behaviors, with mothers of children with CD reporting a higher frequency of these behaviors compared to mothers of children with ODD [ F (1, 57) = 5.71, p = .02, d = 0.60. In contrast, mothers of children with ODD endorsed marginally higher frequencies of behaviors within the DDI Physical Force and DDI Critical Non Physical Force categories ; moreover, they endorsed sl ightly higher levels of underresponsiveness and overresponsiveness on the PS Laxness and PS
34 Overreactivity subscales, respectively. Results of equivalency testing (z scores and associated p values) can be found in Table 3 4 Parent Disciplinary Behaviors Among the 61 families who completed treatment, 41 had complete post treatment DDI data, 60 had complete post treatment PPQ data, and 59 had complete PS Laxness and Overreactivity data. Paired samples t tests were conducted to compare pre and post treatmen t scores on the various disciplinary constructs represented by the DDI categories, the PPQ, and the PS Laxness and Overreactivity. Pre and post treatment mean comparison data for all disciplinary measures can be found in Tables 3 5 and 3 6. For the DDI ca tegories, the percentages of total discipline behaviors reported in each DDI category was calculated to assess the total portions at which parents used each category at pre treatment and at post treatment for pre post comparison (e.g., for family 999, moth er reported using Physical Force 70%, Limit Setting 10%, and Lack of Response 20% at pre treatment and used Physical Force 20%, Limit Setting 60%, and Teaching 10% at post treatment). This percentage may give a clearer picture of the extent of change in ea ch type of discipline following treatment. Analyses of pre to post treatment frequency of use for the six DDI categories showed significant improvements in parental use of disciplinary procedures on the following DDI categories: Critical Non Physical Forc e, t (40) = 4.93, p = .001, d = 1.05 ; Non Critical Verbal Force, t (40) = 3.21, p = .003, d = .57 ; and Limit Setting, t (40) = 6.54, p = .001, d = 1.28 Table 3 5 shows the percentages for each type of discipline used by mothers at the pre treatment assessm ent and at post treatment assessment. An analysis of percentage change showed that the DDI Critical Non Physical Force decreased from a total endorsement of 25% ( SD = 15.8) at pre treatment to a
35 total endorsement of 9% ( SD = 14.8 ) at post treatment. Simil arly, DDI Non Critical Verbal Force decreased from a total endorsement of 18% ( SD = 15.6) at pre treatment to a total endorsement of 10% ( SD = 9.7 ) at post treatment. For DDI Limit Setting, scores increased from a total endorsement of 39% ( SD = 22%) at pr e treatment to a total endorsement of 70% ( SD = 27%) at post treatment. Effect sizes for the changes of DDI mean comparisons indicate that the change in use of Critical Non Physical Force, Non Critical Verbal Force, and Limit Setting at post treatment was statistically significant and meaningful. Analyses of pre to post treatment disciplinary styles showed significant changes in ineffective parenting behaviors on the PPQ, t (58) = 10.82, p = .001, d = 1.32 the PS Laxness subscale t (59) = 8.02, p = .001, d = 1. 1 2 and the PS Overreactivity subscale t (59) = 11.85, p = .001, d = 1.87 Effect sizes for these measures indicate that the change in disciplinary behaviors was statistically significant and meaningful. There were no significant differences in use of DDI Physical Force, DDI Reasoning, or DDI Lack of Response between the pre and post treatment assessments. Figures of pre and post treatment means can be found in Figures 3 4, 3 5, 3 6, and 3 7. Post H oc Analyses of Convergent Validity We examined the co nvergent validity among the disciplinary measures used to examine parental discipline. A correlation matrix of the pre treatment s cores for the DDI the PPQ, and the PS subscales was analyzed. Experimentwise error rate was controlled using the Dunn Bonferr oni correction, which required p < .01 for correlation coefficients to be considered significant. There were no significant correlations found among the measures of disciplinary behaviors, suggesting that these measures were
36 likely evaluating different asp ects of discipline/parenting constructs. The correlation matrix for the discipline measures can be found in Table 3 7
37 Table 3 1. Mean scores of treatment completer and dropouts at pre t reatment Measure Completers (n = 61) Dropouts (n = 36) F p d K W Test p Daily Discipline Interview M SD M SD Physical Force 2.19 2.76 2.81 10.3 0 0.20 0.65 0.08 0.04 Critical Non Physical Force 9.29 7.12 6.83 6.03 3.03 0.09 0.37 Non Critical Verbal Force 7.06 5.95 6.08 4.81 0.71 0.40 0.18 Limit Setting 12.06 8.04 12.64 9.14 0.11 0.75 0.07 Teaching 3.06 4.43 3.72 4.52 0.50 0.48 0.15 0.82 Lack of Response 2.51 3.25 1.72 2.40 1.61 0.21 0.28 0.19 Parenting Practices Questionnaire 57.30 19.9 0 57.30 13.9 0 0.01 1.00 0.01 Parenting Scale Laxness 3.00 1 .10 3.00 1.03 0.01 0.91 0.02 Overreactivity 3.37 0.74 3.11 0.95 2.36 0.13 0.31 Note: Dropout n = 36; Treatment completer n = 6 1 K W Test = Kruskal Wallis Test.
38 Table 3 2. Z s cores and s i gnificance for tests of equivalence between dropouts versus tre atment c ompleters Discipline Measures Dropouts Completers Z 1 p Z 2 p Within 10% M SD M SD Daily Discipline Interview Physical Force 2.81 10.3 2.19 2.76 0.66 0.51 0.25 0.80 No Critical Non Physical Force 6.83 6.03 9.29 7.12 1.26 0.21 2.22 0.03* No Non Critical Verbal Force 6.08 4.81 7.06 5.94 0.32 0.75 1.37 0.17 No Reasoning/ Teaching 3.72 4.52 3.06 4.44 1.11 0.27 0.31 0.76 No Limit Setting 12.6 0 9.14 12.1 0 8.04 1.04 0.30 0.39 0.70 No Lack of Response 1.72 2.40 2.51 3.25 1.00 0.32 1.55 0.12 No Parenting Practices Questionnaire 57.3 0 13.9 0 57.3 0 12.9 0 2.07 0.039* 0.12 0.91 No Parenting Scale Laxness 3.07 1.03 3.09 1.08 0.30 0.19 1.48 0.14 No Overreactivity 3.11 0.95 3.37 0.74 0.30 0.76 3.34 0.001* No Note: Two sided equivalency tests were conducted using a 10% mean difference equivalency interval. Each one sided z test determines whether a 90% confidence interval falls into the equivalency interval of the two group means. Non significance indicates that the one sided z test is not within 10% of one the other z test. Both z tests must be significant for treatment completer group scores to be considered statistically equivalent to treatment dropout scores. signifies significant equivalency test. For these an alyzes, z test results indicate that mothers who completed treatment and mothers who dropped out of treatment did not have statistically equivalent scores on each of the disciplinary measures administered at the pre treatment assessment.
39 Table 3 3. Pre treatment scores for mothers of c hildren with ODD versus CD Measure ODD CD F p d KS Test p M SD M SD Daily Discipline Interivew Physical Force 2.52 3.07 2.04 2.41 0 .43 0.51 0.17 0.52 Critical Non Physical Force 9.03 7.80 8. 93 6.38 0.03 0.96 0.01 Non Critical Verbal Force 6.21 6.14 7.93 5.81 1.21 0.28 0.29 Limit Setting 11.24 7.97 12.41 7.97 0.32 0.58 0.15 Teaching 1.84 2.23 4.59 6.05 5.71 0.02 0.60 0.02 Lack of Response 3.25 1.72 2.40 0.18 0.68 0.11 0.34 Parenti ng Practices Questionnaire 55.50 13.5 58.80 12.30 0.95 0.33 0.26 Parenting Scale Laxness 3.14 1.11 2.98 1.10 0.33 0.57 0.14 Overreactivity 3.46 0.77 3.22 0.74 1.45 0.23 0.32 Note: Oppositional Defiant Disorder ( ODD ) n = 33; Conduct Disorder ( CD ) n = 28. p < .005 required for significance according to Dunn Bonferroni correction.
40 Table 3 4 Z s cores and significance for tests of e quivalence for ODD versus CD Discipline Measures ODD CD Z 1 p Z 2 p Within 10% M SD M S D Daily Discipline Interview Physical Force 2.52 3.07 2.04 2.41 1.02 0.31 0.32 0.75 No Critical Non Physical Force 9.03 7.80 8.93 6.38 0.54 0.59 0.43 0.67 No Non Critical Verbal Force 6.21 6.14 7.93 5.81 0.61 0.54 1.29 0.20 No Teachin g 1.84 2.23 4.59 6.05 0.32 0.75 0.37 0.71 No Limit Setting 11.2 0 7.67 12.4 0 7.97 0.02 0.98 1.11 0.27 No Lack of Response 2.38 3.58 2.74 3.03 0.14 0.89 0.69 0.49 No Parenting Practices Questionnaire 55.5 0 13.5 0 58.8 0 12.3 0 0.67 0.50 2. 63 0.01* No Parenting Scale Laxness 3.14 1.11 2.98 1.10 1.65 0.010 0.54 0.59 No Overreactivity 3.46 0.76 3.22 0.74 3.00 0.003* 0.54 0.59 No Note: ODD = Oppositional Defiant Disorder, CD = Conduct Disorder. Two sided equivalency tests were co nducted using a 10% mean difference equivalency interval. Each one sided z test determines whether a 90% confidence interval falls into the equivalency interval of the two group means. Non significance indicates that the one sided z test is not within 10% of the other z test. Both z tests must be significant for ODD group scores to be considered equivalent to CD group scores. signifies significant equivalency test. For this study, equivalency testing showed that mothers of children with ODD did not have s tatistically equivalent scores to mothers of children with CD at the pre treatment assessment.
41 Table 3 5. Percentage of total discipline behaviors used in each Daily Discipline Interview c ate gory at pre and post t reatment Measures Pre Treatment Post Trea tment Daily Discipline Interview (%) M SD M SD t d p PF 10 .0 16.7 4 .0 15.8 1.36 0.37 0.18 CNPF 25 .0 15.8 9 .0 14.8 4.93 1.05 <0.001* NCVF 18 .0 15.3 10 .0 12.6 3.21 0.57 0.003* LS 39 .0 22.3 7 .0 27.3 6.54 1.28 <0.001* T/R 9 .0 12.8 5 .0 9.5 1. 61 0.35 0.12 LR 13 .0 31.7 3 .0 7.5 1.94 0.24 0.06 Parenting Practices Questionnaire 57 .0 13.0 40.9 11.3 10.8 0 1.32 < 0.001* Parenting Scale Laxness 3.1 1.1 2 0 0.8 8.02 1.12 < 0.001* Overreactivity 3. 4 0. 8 2 0 0. 7 11.9 0 1.87 < 0.001* Note: PF = Phy sical Force, CNPF = Critical Non Physical Force, NCVF = Non Critical Verbal Force, LS = Limit Setting, T/R = Teaching/Reasoning, LR = Lack of Response. p < .005 required for significant difference using Dunn Bonferroni correction.
42 Table 3 6. Average f req uency of Daily Discipline Interview category endorsement at pre and post t reatment Measures Post Treatment Scores Post Treatment Scores DDI Category M SD M SD Critical Physical Force 3.54 2.74 1.50 1.00 Critical Non Physical Force 11.1 0 6.70 3.45 3.17 Non Critical Verbal Force 7.09 4.22 3.46 2.70 Limit Setting 12.55 7.80 12.54 9.76 Teaching/Reasoning 5.15 5.72 2.50 1.20 Lack of Response 3.37 2.68 3.75 5.50 Note. DDI = Daily Discipline Interview. Average scores and standard devia tions of Daily Discipline Interview Category Endorsement at the pre treatment assessment and at the post treatment assessment.
43 Table 3 7. Pearson correlation matrix for discipline m easures 1 2 3 4 1 PPQ Correlation 1 .000 .314 .127 .207 Signific ance .014 .338 .112 2 PS Laxness Correlation 1 .000 .007 .008 Significance .96 0 .95 3 PS Overreactivity Correlation 1 .076 Significance .564 4 DDI Total Correlation 1 .000 Significance Note: PPQ = 1, PS Laxness = 2, P S Overreactivity = 3, DDI Total = 4. None of the correlations are significant at p < .01 as requir ed by Dunn Bonferroni correction
44 Figure 3 1 Mean pre treatment scores for mothers of children with Oppositional Defiant Disor der (ODD) and mothers of children with Conduct Disorder (CD). PF = Physical Force, CNPF = C ritical Non Physical Force, NCVF = Non Critical Verbal Force, LS = Limit Setting, T/R = Teaching/Reasoning, LR = Lack of Response. DDI = Daily Discipline Interview. There are no significant differences in the average frequency of disciplinary actions between diagnostic groups. For all categories, p < .005 required for significance, as det ermined by the Dunn Bonferroni correction Of note, removing the Dunn Bonferroni adjustment for alpha inflation indicated a statistically significant difference in maternal endorsement of Teaching/Reasoning behaviors, with mothers of children with CD reporting a higher frequency of these behaviors compared to mothers of children with O DD [ F (1, 57) = 5.71, p = .02, d = 0.6 0.
45 Figure 3 2 Mean pre treatment scores for the Parent Practices Questionnaire (PPQ) for mothers of children with ODD (Oppositional Defiant Disorder) versus CD (Conduct Disorder). There are no significant differences in mother reports of disciplinary action between diagnostic groups For all categories, p < .005 required for significance, as determined by the Dunn Bonferroni correction.
46 Figure 3 3. Mean pre treatment scores for Overreactivity [ F (1, 60) = 0.823, p = .569] and Laxness [ F (1, 60) = 1.45, p = .233] on the Parenting Scale (PS) for mothers of children with Oppositional Defiant Disorder ( ODD ) versus Conduct Disorder ( CD ) showed no significant differ ences in mother reports of disciplinary action between diagnostic groups. For all categories, p < .005 required for significance, as det ermined by the Dunn Bonferroni correction
47 Figure 3 4. Mean percentages for the 3 Daily Di scipline Interview ( DDI ) categories that showed statistically significant differences at post treatment. For all categories, p < .005 was required for significance, as determined by the Dunn Bonferroni correction. There was a significant decrease in the ra tes at which parents used Critical Non Physical Force, t (40) = 4.93, p = .001, d = 1.05 and Non Critical Physical Force, t (40) = 3.21, p = .003 d = 0.57 There was a significant increase in endorsement of Limit Setting, t (40) = 6.54 p = .001, d = 1.28
48 Figure 3 5. Mean percentages for the three Daily Discipline Interview (DDI) categories that did not show statistically significant differences. For all categories, p < .005 was required for significance as determined by Dun n Bonferroni correction
49 Figure 3 6 Mean scores of the Parenting Practices Questionnaire (PPQ) at pre treatment and post treatment. For the PPQ, p < .005 required for significance, as det ermined by the Dunn Bonferroni corre ction There was a significant decrease in maternal report of ineffective pa renting behaviors on the PPQ, t (58) = 10.58, p < .001, d = 1.32
50 Figure 3 7. Mean scores of Parenting Scales (PS) Laxness and Overreactivity subsca les at pre and post treatment. For all categories, p < .005 required for significance, as det ermined by the Dunn Bonferroni correction Mothers reported significant decrease in the use of underresponsive disciplinary style on the Laxness subscale, t (5 9) = 8.02 p < 001, d = 1.12, and in use of overly punitive disciplinary style on the Overreactivity subscale t (59) = 11.58, p < .001, d = 1.87
51 CHAPTER 4 DISCUSSION Because Disruptive Behavior Disorders (DBDs) are consistently associated with family dysf unction, mental health care use, and child and adolescent delinquency, it is crucial to not only identify factors that may contribute to their maintenance, but to also identify treatment options that reduce the likelihood of their escalation (Pardini & Fit e, 2010). Specific types of parental disciplinary actions have been linked to the exacerbation of defiant child behaviors (Baumrind et al., 2010; Burke et al., 2008; Frick et al., 1993 ; Loeber, et al., 2000; Pardini & Fite, 2010; Patterson, 1997; Snyder et al., 2005), with more severe disciplinary behaviors being associated with higher levels of child disruptive behavior (Frick et al., 1992; Frick et al., 1993). In a longitudinal study investigating the effects of parenting typologies on adolescent function ing, Baumrind and colleagues (2010) found that the authoritative parenting style is associated with higher levels of adolescent competency and social functioning than are the authoritarian, permissive, or disengaged styles. Additionally, they found that di sciplinary actions involving forcefulness and aggression (e.g. shouting ), c ontribute to lower competence and more mala djustment among adolescents. Using a sample of mothers who successfully completed PCIT for the treatment of DBDs, this study investigated the pattern of disciplinary behaviors of mothers of children with ODD and CD. This study also examined the change in disciplinary behaviors subsequent to completing PCIT. As an additional analysis, the three disciplinary questionnaires (Arnold et al., 199 3; Strayhorn & Weidman, 1988; Webster Stratton & Spitzer, 1988) were used to investigate the convergent validity among the discipline measures.
52 To obtain a comprehensive picture of parental disciplinary behaviors, three instruments measuring several aspe cts of the discipline construct and utilizing multiple methods of discip linary behavior assessment (i.e. 24 hour recall phone interview and self report methods) were used to characterize the parental discipline used before and after PCIT. We used an adapt ed version of Webster aily Discipline Interview (DDI) to evaluate the frequency with which parents engaged in six categories of disciplinary behaviors across a spa n of five days (Critical Physical Force, Critical Non Physical Force, Non Critical Verbal Force, Limit Setting, Reasoning /Teaching, and Lack of Response). Two subscales within the P arenting Scale (PS) Laxness and Overreactivity, were used to assess maternal endorsement of unresponsiveness and overresponsive parenti ng. The P arenting Practices Questionnaire (PPQ) was used to characterize overall ineffective versus effective disciplinary actions. In a review of measures of parental discipline and nurturance developed and utilized from 1978 to 1999, Locke and Prinz (200 2) evaluated 78 questionnaires and reported the DDI, the PS, and the PPQ to be psychometrically adequate and useful in assessing disciplinary behaviors. To investigate any contributions of pre treatment disciplinary behavior to selective attrition, matern al disciplinary behaviors within families that completed treatment were compared to the maternal disciplinary behaviors within families that dropped out of treatment. Results revealed a significant difference in maternal endorsement of behaviors only withi n the DDI Physical Force category using a non parametric analysis of variance; however, the small effect size suggests that the difference may not be meaningful and likely does not contribute to current literature investigating factors
53 contribution to trea tment attrition. Although all other measures of discipline showed no significant differences between dropout and completion families, equivalency testing indicated that performance in the two groups was not statistically equivalent at pre treatment. Non eq uivalency for pre treatment scores suggests that mothers within the two groups did not identically endorse all discipline measures; however, analyses of group mean patterns did not indicate that either group maintained consistently higher or lower scores Results of these pre treatment analyses of mothers who dropped out of treatment versus mothers who completed treatment currently suggest that maternal through wit h t reatment versus discontinue treatment prematurely. In a separate study conducted with the same mother child dyad database, Fernandez and Eyberg (2009) suggest ed that factors that predicted selective attrition included lower socioeconomic status, maternal u se of Negative Talk, lower rates of maternal Praise, and maternal distress. In order to assess for differences in disciplinary behaviors between mothers of children with ODD versus CD, maternal responses from the two diagnostic groups were compared on six categories of the DDI, the PPQ, and two subscales of the PS. After implementing a Dunn Bonferroni adjustment, o ur analyses of the disciplinary practices of mothers of children with ODD versus CD at the pre treatment assessment revealed no significant diff erences in parenting behaviors based on the child diagnosis Follow up e valuation s of non equivalency for all six DDI categories, the PPQ, and the two PS subscales (Laxness and Over r eactivity) did not consistently suggest that disciplinary behaviors in fa milies of children with CD were more severe than the
54 disciplinary behaviors in families of children with ODD. The higher rates of verbal forcefulness (e.g., Non Critical Verbal Force), negligence (e.g., Lack of Response), and overall use of ineffective (PP Q) and inconsistent discipline (e.g., slight elevations across Non Critical Verbal Force, Lack of Response, Limit Setting, and Teaching/Reasoning) regarding a pattern of elevated frequencies of ineffective discipline for families of children with CD. However, by multiple methods of measurement of disciplinary behaviors, analyses of maternal reporting patterns in this study also showed that mothers of children with ODD reported slightly higher rates of disciplinary behaviors that were considered punitive or harsh (e.g., DDI Physical Force and DDI Critical Non Physical Force) and well as inconsistent (pattern of elevation on the PS Laxness and PS Overreactivity subscales ). Overall, after implementing multiple measures investigating parental harshness, negligence, and inconsistency, the patterns of reporting show ed that the severity of disciplinary behaviors was not consistently worse for mothers of children with CD, but v aried across the nine measures of disciplinary behaviors. (1992 ) findings, which found patterns of higher rates of harshness, negligence, and inconsistency in families of children with more severe DBDs, this current study did n ot contribute to literature supporting consistently worse disciplinary behaviors reported by mother s of children with CD Of note, the fact that pre treatment comparisons of disciplinary behaviors of mothers of children with ODD versus CD showed no signif icant differences must be interpreted cautiously. It is possible that real differences in parenting are present but were not tapped into by the measures selected in this study. Additionally, with such
55 young children in our sample, it is also possible that sufficiently accurate. Studying somewhat older children, Frick and colleagues (1992) found that in addition to ineffective disciplinary practices, severe parent psychopathology and substance abuse also related to more sev ere conduct problems. In their meta analysis, these authors found that antisocial personality disorder (ASPD) in a biological parent substantially increased the likelihood of a CD diagnosis, suggesting a possible familial or genetic influence on the develo pment of CD (Frick et al., 1992). Moreover, another meta analysis examining DBDs found that child chemical neurofunctioning (e.g., cortisol levels), intelligence, and social cognition, as well as parental smoking and psychopathology were either a predispos ing or maintaining factor for child DBDs (Burke et al., 2002). The results from these meta analyses examining family factors related to the development of ODD and CD suggest that parental psychopathology may be one of the primary parenting variables affec ting the development of child psychopathology, with disorder (Burke et al., 2002; Frick et al., 1992). The meta analyses also suggest that in addition to parent fact ors, there may be biological child factors as well as genetic factors that predispose children toward disruptive behaviors and possibly to distinct DBDs. Our study was not able to add new knowledge to the question of factors differentially affecting the de velopment of ODD versus CD in young children. Pre to post treatment changes in disciplinary behaviors on measures observing daily reports of actual parent responses to disruptive behaviors (DDI), as well as rating scale of parenting typology and effective ness (two PS subscales and PPQ) were
56 evaluated for families that successfully completed PCIT. Results revealed that when using multiple questionnaires regarding the disciplinary behavior construct, mothers reported a decrease in use of certain ineffective disciplinary strategies and an increase in use of effective disciplinary strategies after completing PCIT. Maternal reports on the DDI revealed that there was a decrease in endorsement of disciplinary behaviors that can contribute to the persistence of Pat were organized into the categories of Critical Non Physical Force (e.g., shouting, threatening, screaming) and Non Critical Verbal Force (e.g., repeated commands, nattering) M oreover, there was an increase in endorsement of disciplinary behaviors that were organized into the Limit Setting category (e.g., privilege removal, time out), a category that included the structured and consistent disciplinary sequence taught to parents during PCIT. In addition to changes in the DD I that indicated decreases in ineffective disciplinary responses and increases in effective disciplinary responses, parents endorsed using fewer lax behaviors (e.g. not implementing consequence ) and fewer overreactive behaviors (e.g., holding a grudge aga inst the child for noncomplying ) on the PS and more effective disciplinary behaviors on the PPQ at post treatment. Maternal endorsement of strict and harsh parenting b ehaviors within the DDI Critical Non Physical Force category, DDI Non Critical Verbal Fo rce category, and the PS Overreactivity subscale, in addition to their endorsement of unresponsive and neglectful parenting behaviors within the PS Laxness subscale may indicate that before starting PCIT, parents used disciplinary responses that were incon sistent and that permissive parenting styles. Results of post treatment discipline use may indicate that
57 after learning to use a type of discipline characterized by support, c onsistency, negative punishment (i.e., removing a privilege to decrease noncompliant behaviors), and positive reinforcement (i.e., providing positive attention to increase appropriate behaviors), mothers shifted from the use of more authoritarian, permissi ve, and overall inconsistent disciplinary styles to the use of more authoritative and consistent discipline behaviors. Moreover, because parents reported to engage in fewer behaviors that initiated the coercive cy cle described by Patterson (1986 ), such as shouting and repeated commands, results support that PCIT may have reduced the frequency at which parents started or exacerbated the coercive cycle. At treatment completion, analyses of disciplinary behaviors showed slight but non significant decreases in the proportions by which families endorsed behaviors falling into the Critical Physical Fo rce (e.g ., sp anking, hitting), Reasoning/Teaching (e.g ., explanation of discip line), and Lack of Response (e.g ., no follow through) categories Because of limited en dorsement of behaviors organized within these categories overall, it may be possible that this particular study did not appropriately capture the maintenance or change of parenting behaviors characterized by these categories. Additionally, it is possible t hat at treatment completion, parents maintained their use of behaviors within these categories but also increased their use of more consistent and effective limit setting behaviors. Because multiple measures of the disciplinary behavior construct were used in this study, an additional analysis conducted involved an evaluation of convergent validity among the measures. An evaluation of the correlations among the DDI, the PPQ, the PS Laxness, and the PS Overreactivity measures revealed no significant similari ties in
58 maternal reporting behaviors, which suggests that the measures may have observed uncorrelated aspects of the disciplinary behavior co nstruct. These results provide support for PCIT showing global and generalized changes in disciplinary behaviors, both in the rate of daily discipline used and in the type of discipline style implemented at home. Overall, this study suggests that PCIT may have successfully led to generalization of the utilization of more effective parenting behaviors within the home. Limitations s trengths and future d irections Several limitations should be considered when interpreting the results of this study. In comparing parenting behaviors between mothers of children with ODD and mothers of children and CD, a significant concern was the limited statistical power. There was a modest sample size in the present study ( N = 61), which may have a contributing role in limiting the significance of some of the statistical comparisons conducted. A post hoc power analysis revealed that on t he basis of the mean and the between groups comparison effect size observed in the present study ( d = 0.115), an N of approximately 326 would have been needed to obtain statistical power at the recommended 0.80 level (Cohen, 1988). In future studies, inves tigators should maintain awareness of the effects of sample size on treatment effects; when possible, tests that are robust to the effects of small or moderate sample sizes should be used. This study was a secondary data analysis of an investigation that provided treatment to a single group of participants, thus researchers were not able to compare findings regarding maternal disciplinary behaviors to a randomized control group that did not undergo concurrent treatment Because there was no control group, a causal
59 relationship of the effects of PCIT on disciplinary behaviors cannot be determined. Additionally, without a control group, it is unclear whether factors outside of the completion of PCIT (e.g., selective attrition, reporting bias, therapist contac t) also contributed to differences in disciplinary behaviors (Shadish, Cook, & Campbell, 1988). Future studies should consider implementing treatment with a control group to allow for casual inferences of t reatment effects. One possible design for a random ized control treatment w ould be to have two groups receive treatment but non concurrently (e.g., immediate treatment group and wait list treatment group ) to provide a controlled basis of comparison of treatment effects Because mothers were considered pri mary caregivers within this study, another limitation that should be considered is that investigators only used mother data to assess disciplinary behaviors before and after treatment. It is possi ble that other participants (e.g ., father, partner) may have reported contrasting disciplinary behavior changes at post the primary disciplinarian at home, it would be important for investigators to collect disciplinary information from that pa rticipant, in addition to the mother to be able to make inferences about overall changes in disciplinary behaviors at home. To obtain a more comprehensive picture of the effects of treatment on disciplinary behaviors future directions should include analy zing disciplinary behavior reports of all caregivers participating in treatment. The results of this study relied on maternal report of disciplinary behaviors, which could have been influenced by reporting biases or social desirability effects (i.e ., pare nt may underreport certain negative disciplinary behaviors to appear more positive to the
60 investigators ; parent may be forgetful of past disciplinary techniques). Two separate studies investigating the extent of reporting biases on self report measures fou nd that some participants, particularly those with social desirability personality characteristics, are more likely to respond in a manner that makes the participant appear more appropriate than in actuality ( Adams et al., 2005; Bradshaw, Donohou, Cross, U rgelles, & Allen, 2011 ). For example, a mother may report lower rates of behaviors within the Critical Non Physical Force category than actually implemented to appear more socially appropriate to the assessor. The authors of the two studies found that p art icipants who endorsed characteristics of personality traits emphasizing social desirability were more likely to report their behaviors in a more positive manner than actually observed in behavioral observations. In this study of disciplinary behaviors, pa rents were seeking a parent training treatment program and were admitted into treatment regardles s of their parenting behaviors. Because inclusion criteria did not consider self reports of disciplinary behaviors, parents may not have been as motivated or c ompelled to engage in false reporting of disciplinary behaviors at the pre treatment assessment. Similarly, because PCIT graduation criteria did not require parents to report specific types of disciplinary behaviors to successfully complete treatment it i s possible that parents were not as motivated to over report positive disciplinary behaviors and under report negative disciplinary behaviors at the post treatment assessment In addition to using a multiple measure format to obtain a global idea of disci plinary behaviors, another particular strength of this study was the use of a 24 hour recall measurement that allowed for the collection of daily disciplinary behaviors
61 (Webster Stratton & Spitzer, 1991) Because the 24 hour recall format of the DDI asks f or parents to report disciplinary actions that occurred only within the last 24 hours (as opposed to reports that request for discipline used in the past 6 months), the measure is not as likely to be negatively affected by inaccurate recall or respondent b ias that can occur because of forgetfulness over past disciplinary behaviors (Reynolds, Johnson, & Silverstein, 1989; Webster Stratton & Spitzer, 1991). Additionally, t he 24 hour recall format of the DDI has been found to be comparable to behavioral observ ations of disciplinary behaviors (Webster Stratton & Spitzer, 1991) which likely may not be as influenced by the e ffects of social desirability. To reduce likelihood of a social desirability effect or respondent bias, future studies can also analyze behav ioral observations of disciplinary behaviors implemented by families during treatment to be able to cross check self reported disciplinary behaviors. Obtaining reports of parental disciplinary behaviors from other individuals who are well acquaint ed with t he parent and child ( e. g., other caregivers, teacher ) may provide a more comprehensive and accurate picture of parental disciplinary styles because of the reduced likelihood of other respondents being influenced by the social desirability effect. Additiona lly, utilizing a measure assessing p ersonality characteristics such as social desirability may help researchers identify participants who would be most likely to engage in socially desirable reporting. Although there was a significant increase in parental endorsement of behaviors organized within the DDI Limit Setting category at post treatment, it is c urrently unknown whether mothers specifically engaged in the limit setting behaviors they were taught during PCIT or if they engaged in other limit setting behaviors. It is possible that
62 although parents reported using more limit setting, parents engaged in behaviors that differed from what was used during treatment (i.e., structured time out sequence) An important future direction for the study of disciplin ary behaviors in PCIT will be to focus particularly on the Limit Setting category and to differentiate between effective and ineffective limit setting behaviors endorsed by mothers. Overall, this study contributed to current literature investigating disci plinary behaviors among parents of children with DBDs. T he current study suggests that parents of children with DBDs, prior to treatment ta rgeting disciplinary practices, are likely to endorse high levels of harshness, laxness, and overall inconsistency in their disciplinary behaviors with their children ; howeve r, after learning a structured and authoritative disciplinary method, parents can report a change in their disciplinary style to incorporate behaviors that are structured, developmenta lly appropriate and consistent. This change in disciplinary style is likely to increase engagement in disciplinary behaviors that are effective in reducing the frequency at which the parents initiate and maintain the parent child coercive cycle.
63 APPENDIX A CHILD DIRECTED INTERACTION SKILLS (REPRINTED WITH PERMISSION FROM EYBERG & FUNDERBURK 2011) Do Skills REASON EXAMPLES PRAISE Labeled Praises tell your child exactly what you like Increases the behavior that is praised Shows approval Improves chi esteem Makes you and your child feel good Thank you for sharing! putting the crayons away. Nice drawing. REFLECT Reflections repeat or paraphrase what your child says Lets child lead the conversation Shows inter est Demonstrates acceptance and understanding Improves child's speech Increases verbal communication Child: I drew a tree. Parent: Yes, you made a tree. Child: The doggy has a black nose. Parent: The dog's nose is black. Child: I like to play with t he blocks. Parent: These blocks are fun. IMITATE Imitation copies what your child is doing with the toys Lets your child lead Shows your child that you approve of the activity Makes the game fun for your child imitation of appropr iate things you do Child: I put a nose on the potato head. Parent: I'm putting a nose on Mr. Potato Head too. Child (drawing circles on a piece of paper) Parent: I'm going to draw circles on my paper just like you. DESCRIBE Behavioral Descriptions child is doing Lets child lead Shows interest Teaches concepts Models speech for your child on the task thoughts about the activity You're making a tower. You drew a square. You are putting together Mr. Potato Head. You put the girl inside the fire truck. Enthusiasm Enthusiasm means that you act happy and natural when you play with your child Lets your child know that you are enjoying the time you are spending together Increases the war mth of the play Child (carefully placing a blue Lego on a tower). Parent (gently touching the child's back): You are REALLY being gentle with the toys.
64 REASON EXAMPLES COMMANDS Commands tell your child what to do Takes the lead awa y from your child Can cause conflict Indirect Commands: Let's play with the farm next. Could you tell me what animal this is? Direct Commands: Give me the pigs. Please sit down next to me. Look at this. QUESTIONS Questions call for your child t o give an answer Leads the conversation Many questions are commands and require an answer May seem like you aren't listening to your child or that you disagree We're building a tall tower, aren't we? What sound does the cow make? What are you buildin g? Do you want to play with the train? You're putting the girl in the red car? Criticism and Sarcasm Criticism and sarcasm express disapproval Gives attention to negative behavior May lower your child's self esteem Creates angry feelings in interac tion Teaching child negative social behavior That was really stupid. I don't like your attitude where it goes Stop it Can you do anything right?
65 APPENDIX B SELECT RULES FOR PARENT DIRECTED INTERACTI ON REPRINTED FROM TEACHER HANDOUT (EYBERG & FUNDERBURK, 2011) RULE REASON EXAMPLES Commands should be direct rather than indirect Leaves no question that the child is being told to do something. Does not imply a choice, nor suggest that the teacher might do the task for the child. R educes confusion for the young children. Please come sit with the group. Take your pencil out. Draw a circle. Instead of Will you come sit with the group? Would you like to draw a circle? Comma nds should be positively stated Tells child what "to do" rather than what "not to do." behavior Provides a clear statement of what the child can or should do. Come sit beside me. Instead of Don't run around the room! Put your hands in your pocket. Instead of Stop touching my desk. Commands should be given one at a time Helps child to remember the whole command Helps teacher to determine if child completed entire command Put your backpack in your cubby. Commands shoul d be specific rather than vague Permits children to know exactly Get down off the chair. Instead of Be careful. Talk in a quiet voice. Instead of Behave! Commands should be explained before they are given or after they are obeyed Avoids encouraging child to ask tactic. Avoids giving child attention for not obeying. Teacher : Sit in your seat. Child: Why? Teacher : (ignores, or uses timeout warning if child disobeys). Child: Obeys Teacher : Good listening!
66 Commands should be given politely and respectfully Increases likelihood child will listen better. Avoids child learning to obey only if yelled at. Child: (Banging block on table) Teacher : (in a normal tone of voice) Please hand me the block. Instead of Teacher : (said loudly) Hand me that block this instant!
67 APPENDIX C DISCIPLINARY MEASURES AND EXAMPLES Measure Examples Daily Discipline Interview Physical Force Hitting, Slapping, Spanking, Shoving, Pulling Critical Non Physical Force Shouting, Threatening, Yelling, Screaming Non Critical Verbal Force Questions Limit Setting Removal of privileges, Time Out, Separation from other children Reasoning/Teaching Giving alternatives, explain ing consequences Lack of Response/No Follow Through Not following through with consequences, Letting behavior go, Allowing child to continue misbehavior Parenting Practices Questionnaire How often do you tell your child to do something with an irritated or angry tone of voice? 0. Never 1. Less than once a week 2. About once a week 3. About three or four times a week 4. About once a day 5. Several times each day 6. Many times each day Parenting Scale Laxness When my child misbehaves: I do something right away 0 --0 --0 --0 I do something about it later Overreactivity I am picky and on my 0 --0 --0 --0 I am no more picky and on back than usual
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72 BIOGRAPHICAL SKETCH Nadia Noshin Bhuiyan was born in Honolulu, Hawaii, and raised partly in Tallahassee, Florida and Auburn, Alabama. After graduating from Auburn High School in 2006, she started her undergraduate career study ing biological sciences at Auburn University. She was involved in multiple research labs, but after working in two psychology labs focusing on parent child relationships and autism spectrum disorders, she decided to focus her studies in the area of child p sychology. She graduated s umma c um l aude with a Bachelor of Arts degree in p sychology in May 2010 from Auburn University. Ms. Bhuiyan is currently attending University of Florida in pursuit of a Masters of Science degree and a Doc torate of Philosophy degr ee in clinical and health p sychology, with a focus on clinical child psychology. Her research interests include parent child relationships, social skills training, and development and treatment of the symptoms of pervasive developmental disorders. She is a member of the Child Study Lab at the University of Flori da, where she works as an assessor and therapist for an NIMH funded grant studying the use of Parent Child Interaction Therapy in individual and group formats for children meeting diagnostic criteria for Attention Deficit/Hyperactivity Disorder.