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

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

Subjects

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

Notes

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

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














By

DEBORAH ANN WHITE


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

UNIVERSITY OF FLORDIA


2004



























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















ACKNOWLEDGMENTS

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

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

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

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

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

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

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

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

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

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

and implementation of my research.

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

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

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

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

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

assistant in the College of Nursing Office of Research.

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

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

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









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

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

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

support, and encouragement.















TABLE OF CONTENTS

Page

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

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

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

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

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

CHAPTER

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

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

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

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









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

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

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

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

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

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









APPENDIX

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

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

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

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

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

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

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

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

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

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

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















LIST OF TABLES


Table Page

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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









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

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

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

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















LIST OF FIGURES


Figures Page

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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









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

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

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

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

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

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














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

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

By

Deborah Ann White

May, 2004

Chair: Jennifer H. Elder
Major Department: Nursing

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

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

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

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

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

on father-child interactions.

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

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

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

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

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

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

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









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

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

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

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

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

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

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

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

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

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

were satisfied with the process and outcome of parent training.

Findings reported in our study provide contextual information on the interactions

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

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

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

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














CHAPTER 1
INTRODUCTION

Analysis of the Parent Training Concept

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

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

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

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

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

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

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

weaknesses in parent training interventions create ambiguity in nursing and across

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

training interventions for fathers of children with Attention Deficit Hyperactivity

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

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

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

training for fathers of children with ADHD.

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

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

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

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









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

ADHD. Further study is intended to:

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

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

* Facilitate father-child interactions.

0 Develop and examine a nurse-parent trainer role.

Analyzing the Range of Meaning of the Parent Training Concept

Review of the literature reveals many inconsistencies and weaknesses in the

concept of parent training. Confusing terminology that describes parent training

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

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

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

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

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

challenging problem behaviors in children. Unfortunately, misconceptions in the

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

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

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

Particularly significant is the controversy regarding differing strategies of positive

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

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

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

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









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

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

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

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

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

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

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

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

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

without specific information about the effectiveness of each component.

Related Theoretical Perspectives

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

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

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

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

physiology seem to be particularly applicable to our research.

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

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

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

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

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

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

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

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









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

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

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

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

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

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

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

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

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

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

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

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

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

aggressive behaviors. Interdependent negative behavior between parents and their

children contributes to the evolution of childhood behavior problems.

Ineffective parental management strategies are suggested as the cause for entry

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

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

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

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

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

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

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









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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

empirical assessment of our study.

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

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

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

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

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

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









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

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

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

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

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

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

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

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

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

Furthermore, cognitive development in children may be adversely affected or

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

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

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

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

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

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

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

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

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

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

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

reactions, choice of treatment, and treatment compliance.









Attention Deficit Hyperactivity Disorder (ADHD)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

synergistically interact with behavioral problems, and compound the physiological

deficits in children with ADHD.

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

communication, and socially appropriate behavior. Parent training interventions that

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

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

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









approaches is potentially important for clinicians and researchers involved in developing

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

Theoretical Significance in Nursing

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

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

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

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

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

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

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

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

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

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

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

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

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

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

attain desired goals (King, 1992).

Describing the interaction process within a general system framework and within

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

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

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

harmonious with current educational and behavioral trends that incorporate

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









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

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

study.

Parent Training Research in Nursing

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

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

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

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

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

individualized clinical interventions. Furthermore, advanced practice and doctoral

prepared nurses are knowledgeable and skilled in diverse research methodologies,

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

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

1998).

Particularly interesting within nursing research are multi-component parent

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

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

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

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

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

with knowledge and skills for effective interaction and communication with their

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

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

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









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

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

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

parent training program.

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

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

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

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

conversation. The parent training intervention was designed to address the

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

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

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

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

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

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

with ADHD.

Operationalization of Parent Training

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

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

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

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

training as:

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









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

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

Critical attributes derived from this definition include contextual clarification,

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

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

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

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

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

interventions for problem behavior in children with ADHD.

Statement of the Purpose

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

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

designed for fathers. The specific aims are:

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

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

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

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







Parent Training Process

Mutual Development


Phase 2


Phase 3


Phase 4


Assessment Treatment Intervention Development I Intervention Implementation I Evaluation of


Mutual
Development
Overview of
Techniques

Role-model

Environmental
Changes

Proficiency
Criteria


Parent
Implements
Targeted
Behavior

In-home
Videotaping

Direct
Observations


Data
Analysis

Progress
Assessment

Consumer
Satisfaction


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


Phase I


Parent

Child

Home














CHAPTER 2
REVIEW OF LITERATURE

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

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

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

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

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

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

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

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

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

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

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

complex procedures that discouraged replication.

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

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

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

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

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

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

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

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









interactive, individualized, and comprehensive parent training interventions that address

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

children with ADHD.

Features of ADHD in Young Children

Attention Deficit Hyperactivity Disorder is a chronic psychological condition

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

oppositional disorder and conduct problems.

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

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









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

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

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

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

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

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

Cognitive processes are impaired that coordinate behaviors for assessing social context

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

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

memory, and self-regulation.

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

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

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

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

synergistically with behavioral problems and compound the physiological deficits.

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

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

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

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

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

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

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

frequently).









Characteristics of ADHD

Attention Deficit Hyperactivity Disorder is characterized by inattention and/or

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

and academic impairments, and comorbid conditions.

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

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

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









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

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

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

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

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

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

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

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

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

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

Assessment and Diagnostic Process in Children with ADHD

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

more extremely inappropriate symptoms in each symptom group (inattention,

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

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

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

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

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

symptoms typically worsen in unstructured and minimally supervised situations.

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

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

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

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

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









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

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

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

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

Structured observations in naturalistic and clinical settings assist in distinguishing

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

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

1995).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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









Research on Children with ADHD

Historically, the behavior problems of preschool children were considered

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

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

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

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

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

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

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

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

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

1998).

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

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

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

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

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

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

unknown biological causes (Biederman, 1998).

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

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

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

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

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









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

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

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

1994).

Various interventions that involve medication, parent training, behavior

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

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

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

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

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

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

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

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

McMahon, 1994).

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

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

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

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

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

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

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

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

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









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

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

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

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

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

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

educational services for children with ADHD and their families.

Pharmacotherapy Research

Research involving pharmacotherapy for children with ADHD is extensive.

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

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

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

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

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

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

for research involving behavioral interventions for children with ADHD.

Parent Training Intervention Research

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

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

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

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

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

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

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









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

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

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

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

Empirically supported parent training programs include clinical behavior therapy,

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

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

training interventions and behavioral classroom interventions primarily in outpatient

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

studies identify disruptive children because of symptoms associated with ADHD without

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

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

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

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

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

Contingency management approaches are similar to clinical behavioral therapy,

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

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

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

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

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

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

2000).









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

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

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

mediators that facilitated generalization and maintenance of behavioral effects.

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

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

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

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

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

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

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

behavioral treatments.

Research on parent training interventions for parents of preschool children has

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

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

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

interactions with their children to modify problem behavior with positive reinforcement

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

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

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

1987).

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

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









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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

parents of children with ADHD.









In-Home Parent Training

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

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

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

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

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

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

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

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

settings.

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

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

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

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

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

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

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

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

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

parent training and observation provided essential contextual data about individual

subjects in naturalistic settings.

The Role of Fathers in Childhood Behavior Problems

Reviews of parent training interventions with ADHD children were highly

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









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

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

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

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

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

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

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

interventions that include fathers.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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









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

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

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

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

relationship was reported between father involvement and childhood behavior problems,

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

Kindlon, & Earls, 1995).

Father involvement in childcare during the middle childhood period was

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

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

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

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

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

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

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

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

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

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

interventions for families of children with ADHD.

The Role of Social Reciprocity in Parent Training

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

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

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

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









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

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

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

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

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

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

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

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

contexts.

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

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

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

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

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

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

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

Summary

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

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

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

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

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

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

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






29


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

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

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

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

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

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









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









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









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









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









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

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

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

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









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

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

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









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

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

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














CHAPTER 3
METHOD

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

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

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

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

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

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

intervention is discussed.

Rationale for Use of Single Subject Design

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

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

conduct experimental investigations with an individual, and rigorously evaluate the

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

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

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

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

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

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

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

efficacious, interventions (Kazdin, 1998).









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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

generalizable and extend beyond the condition of the experiment.

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

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

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

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

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

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









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

to incorporate new knowledge into the intervention without compromising the scientific

integrity of the study (Elder, 1997a).

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

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

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

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

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

synthesis of the relationship between the dependent and the independent variables

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

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

components on the individual's behavior.

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

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

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

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

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

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

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

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

Research Plan

Recruitment of Subjects

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

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









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

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

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

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

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

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

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

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

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

and their children chose to participate in our study.

Inclusion Criteria

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

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

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

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

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

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

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

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

child.

Exclusion Criteria

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

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

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









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

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

their child.

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

naturalistic observation include well-maintained subject participation and essential

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

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

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

Instruments for Describing Subjects

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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








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

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

scores are computed for seven dimensions of child psychopathology

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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









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

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

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

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

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

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

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

with caution.

Description of an In-Home Parent Training Intervention for Fathers

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

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

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

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

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

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

videotaped before parent training. The PI provided three parent training sessions for each

father (Table 3-2) in the participant's home over a period of 8- to 12-weeks. Each in-

home training session lasted approximately 1- to 2-hours. Each father received:

* Written instructions for the targeted skills.
* Videotaped instruction including examples of the behavior to be taught.
* Role-modeling demonstrations.
* Opportunity for practicing the parenting strategies and skills with the PI.

Parent Training Session 1 (PT-1) was taught to fathers after 4- to 5-videotaped

father-child play sessions. The parenting strategies for PT-1 included imitation with

animation skill (I/A); following the child's lead in play; increasing positive responses;









and decreasing corrective statements. Fathers were asked play with their children 5-times

each week and to use the parent strategies taught during PT-1.

Parent Training Session 2 (PT-2) began after 4- to 5-videotaped father-child play

sessions that followed PT-1. The fathers were taught skills that involved discipline

strategies in the same manner that was described in PT-1. The fathers were asked to

continue the father and child play sessions 5-times each week and to use the skills taught

during PT-1 and PT-2.

Parent Training Session 3 (PT-3) began after 4- to 5-videotaped father-child play

sessions that followed the PT-2. The fathers received a review of PT-I and PT-2 in the

same manner that was described in PT-1. The fathers were asked to continue the father-

child play sessions 5-times each week, and to use the skills taught during PT-I and PT-2.

A follow-up meeting was scheduled between the PI and the father for a review of the

results that pertained to their father-child interaction.

Procedure for Implementing the Parent Training Intervention

After the fathers gave informed consents and child assents, they were asked to

complete four questionnaires (Table 3-1). The timeline (Table 3-3) and the procedure

(Table 3-4) for instrumentation and videotaping in the home were followed. The PI

videotaped the father-child play sessions in the home (twice each week) at similar times of

the day convenient for fathers and their families.

Condition A Baseline

The PI videotaped the baseline father-child play sessions in the home (twice each

week) for approximately two weeks or until a stable baseline was noted (Table 3-2). The

baseline videotaped sessions consisted of a 15-minute unstructured, in-home, father-child









play session. The PI asked the fathers five questions after every other videotaped father-

child play session. The PI recorded the behavioral responses concurrently. Data

collection and analysis were ongoing.

Condition B Introduction of Parent Training Sessions 1, 2, and 3

The first parent training session followed the completion of the baseline sessions

(Table 3-2). Approximately 4- to 5-father-child play sessions were videotaped for 15-

minutes (twice each week) for approximately two weeks following each of three parent

training sessions for fathers. The PI asked the father five questions after every other

videotaped father-child play session. The PI recorded the targeted behaviors of fathers

and their children concurrently. Data collection and analysis was ongoing. At

completion of the final father-child play session, the fathers were asked to complete

questionnaires. A follow up meeting with parents was scheduled after completion of the

study to discuss the results of their participation, to offer the complete set of videotaped

father-child play sessions, and to offer a compact disc with the parent training

intervention. In addition, mothers were offered instruction pertaining to the parent

training intervention.

Instruments and Procedure for Measuring the Dependent Variables

The PS, INTX, and CBCL were used to measure the dependent variables (Table

3-5). Dependent variables were operationalized (Appendix A). Social validity was

evaluated by a series of questions adapted from Elder's (1995) semi-structured interview

to assess the father's perceptions of the parent training process (Appendix H). The

fathers were asked after every other father-child play session to report perceptions on the

training process on a scale of 1 (positive) to 5 (negative).

0 How typical was your child's behavior during this session?









0 How comfortable are you using the skills you have been taught?

* Do you think that the training that you are doing with your child is working?

* Are you using what you have learned at times other than the videotaped session?

0 Do you think that the presence of the camera and/or investigator affected how you
or your child behaved in this session?

The Therapy Attitude Inventory (Eyberg, 1993) is a brief consumer satisfaction

measure of parent training and family therapy used to assess father satisfaction with the

process and outcome of parent training at completion of the study (Appendix G). A total

of 10-items are included that address the impact of therapy on parenting strategies and the

child's behavior. The father's were asked to rate the items on a scale from 5

(dissatisfaction with treatment or a worsening of problems) to I (maximum satisfaction

with treatment or improvement of problems) at completion of the study. The item ratings

yield a possible score of 5.

In-Home Observation

The PI conducted in-home parent training sessions for fathers at convenient

locations (e.g., living room, family room, or kitchen). The procedure for videotaping the

father-child play sessions was discussed with the father before the study. The PI arrived

at the participants' homes with the videotaping equipment and toys at a time previously

scheduled by the fathers. If the child was ill or unwilling to participate, the session was

rescheduled. Behavioral responses were coded during the 3- to 12-minute segment of the

videotaped father-child play session. The last 3 minutes were used for coding the

behavioral response categories in the event of a problem with videotaping (i.e.,

disruption, mechanical problems). The PI viewed the videotapes and recorded the

frequencies of the targeted father behaviors and the targeted child behaviors.









Each data file was assigned an identification number to maintain the

confidentiality and anonymity of the subjects. Only the subject's identification number

appeared on the data collection instruments. The files and videotapes were stored in a

locked cabinet in the PI's office and will be maintained for 3-years. All files and

videotapes will be destroyed after that time.

The Multiple Option Observation System Experimental Studies Software

(M.O.O.S.E.S.) provided a method for coding and analyzing the observational data

(Tapp, Wheyby, & Ellis, 1995). The data were entered in a laptop computer, labeled,

organized, and stored. M.O.O.S.E.S. allowed the identification of antecedent and

consequent events associated with specific behaviors as well as more general response

categories. This information is available to plan intervention and data collection

procedures for future research.

Behavioral Observer Training

The PI created the videotapes used for training an independent observer. The

independent observer was blind to the conditions under which the videotapes were taken.

The PI followed the observer training sequence developed by Elder (1995):

* Instruction to familiarize observers with the behavioral response categories as
defined in the coding manual.

0 Practice coding the videotapes of role-played interactions that clearly portray the
imitation with animation skill.

* Practice coding pre-existing parent child videotapes not associated with the
current project.

The independent observer randomly selected and coded 25% of videotaped

sessions previously coded by the PI to minimize the potential for bias and observe for

observer drift during the course of our study. The independent observer and PI were









required to establish a criteria level of 80% or greater interrater agreement. Practice

sessions continued until the criteria level was met. Interrater agreement fell below 80%

on two occasions during this study (Table 4-15). The operational definitions (Appendix

A) were reviewed and clarified. The PI and the independent observer practiced coding

behavioral responses until a criterion of 80% was met. Coding was re-instituted.

Behavioral Response Categories

Behavioral response categories from Elder's (1995) research were extended for

use in our study. Behavioral response categories of targeted behaviors (Table 3-5) for

fathers and for children addressed the research questions in our study (Appendix A). The

father's behavioral response categories included initiating behaviors, responding

behaviors (positive responses, corrective responses, and negative responses), initiated

turns with affirmation, and the imitation with animation skill. The child's behavioral

response categories included initiating behavior, responses, tantrum/aggression,

elopement, and initiated turns with affirmation.









Table 3-1. Correspondence between instrumentation and sample characteristics
Measure Instrumentation Purpose
Hollingshead Four Factor Father report Define the individual's social
Index (1975) position
Child Behavior Check List Father report To assess father's perceptions of
(1983) the child's behavior problems
Parenting Scale (1993) Father report To evaluate father effectiveness in
discipline
The Interactions Father report To evaluate father attributions of
Questionnaire (1995) compliance and noncompliance


Table 3-2. In-home parent training intervention for fathers
Condition Intervention for Father Father-Child Play Sessions
A Baseline Minimum of 3 videotaped sessions,
Approximately 3-5 until stable baseline
B Parent Training Session 1 4-5 videotaped sessions
B Parent Training Session 2 4-5 videotaped sessions
B Parent Training Session 3 4-5 videotaped sessions
Follow-up Review of study results


Table 3-3. Timeline for the parent training intervention
Parameters Initial Week Week Week Week Week Week
Visit 1-2 3-4 5-6 7-8 9-10 11-12
Informed Consent X
Baseline Questionnaires: SES,
CBCL, PS, INTX X
Semi-structured interview after
every other videotaping of X X X X X
father-child play session
Follow-up Questionnaires:
CBCL, PS, INTX, TAI X
Parent training session 1 X
Parent training session 2 X
Parent training session 3 X
Condition A X
Baseline sessions (3-4)
Condition B
Follows the baseline sessions X X X X
Completion of Study X X









Table 3-4. Procedure for instrumentation and videotaping
Condition Session Questionnaire
Prior to Baseline In-home meeting with father Informed Consent/Assent
& PI Discussion of project Hollingshead Four Factor Index
Child Behavior Checklist
Parenting Scale
Interactions Questionnaire
Condition A Unstructured father-child play Interview of 5 questions after every
Videotaping of 4-5 sessions other videotaping session
Condition B 4-5 father-child play sessions Interview of 5 questions after every
were videotaped after each other videotaping session
parent training session (1,2,3)
Project Last videotaped father-child Child Behavior Checklist
Completion play session Parenting Scale
Interactions Questionnaire
Therapy Attitude Questionnaire
Follow-up In-home meeting with parents Present parents with videotapes of
& PI father-child play sessions.


Table 3-5. Correspondence among the variables, instruments, and measurements
Variable Instrument Measurement Type of Data
Father behavioral response categories: M.O.O.S.E.S. Frequency Quantitative
Father initiations, Father positive Computerized counts Measure
responses, Father corrective responses, observation
Father negative responses Program
Child behavioral response categories
Child initiations, Child responses,
Child aggression, Child elopement
Parent training skill: M.O.O.S.E.S. Frequency Quantitative
imitating/animating counts measure
Father perceptions of the training Semi-structured Father self- Qualitative
process of the in-home parent training interview report measure.
intervention for fathers
Father satisfaction with the process and Therapy Attitude Father self- Quantitative
outcome of the in-home parent training Inventory (1993) report measure
intervention for fathers














CHAPTER 4
RESULTS

A general description for each father-child dyad during the conditions of our

study is given in this chapter. In addition, each subject's performance across the two

conditions will be discussed (individually and later, as a group). Behavioral responses

for fathers (father initiations, father positive responses, father corrective responses,

imitation with animation, and father-initiated turns with affirmation) and children (child

initiations, child responses, child aggression, child elopement, and child-initiated turns

with affirmation) are discussed, displayed, and analyzed visually in Tables 4-1 to 4-17

and Figures 4-1 to 4-24. This information is critical for determining generalizability of

findings to other fathers and their children with ADHD, replicating the study, and

designing future interventions.

Father and Child Dyad A

Using Hollingshead criteria (1975) the family was estimated within the highest

social strata (Table 4-13). Parents were in their early forties, Caucasian, employed full-

time, and the biological parents of Child A. Two older children (16-year old son and a

20-year old daughter) were the biological children of the mother from a previous

marriage. For the purpose of this discussion a fictitious name was assigned to Child A

(Jordan).

Jordan was 3-years and 7-months at the onset of the study. He received a

diagnosis of ADHD and speech and language delay at 3-years and 6-months from a

behavioral pediatrician. Jordan was prescribed therapy for speech and language delays.









Father A refused to consider ADHD medication for Jordan before and during the study.

The parents discussed concerns about Jordan's aggressive and hyperactive behavior.

Jordan had been asked to leave two previous daycare programs because of problem

behavior. At the time of our study, Jordan was attending a daycare program located near

the mother's workplace. A daycare evaluation revealed that Jordan had academic delays,

hyperactive, aggressive, and impulsive behavior. In addition, he was evaluated for

placement in the county public school early intervention program. Jordan qualified for

the "varying exceptionalities" program. However, the parents chose not to enroll Jordan

because of inconvenience associated with location and extended daycare issues. Jordan

was also evaluated by a for-profit agency for ADHD treatment. The parents were

informed that the agency could provide behavior modification treatment for Jordan

including occupational therapy that would cure ADHD. The parents chose not to enroll

Jordan in additional therapy during our study.

The father's discipline skills (Table 4-1) were assessed before and at completion

of our study using the PS (Arnold et al. 1993). Father A reported greater than average

scores in laxness, overreactivity, verbosity, and total score; minimal changes in scores

were noted before and after our study. Laxness associated with permissive parenting,

overreactivity associated with authoritarian parenting, and father verbosity may seem to

be inconsistent parenting styles. However, Father A exhibited behaviors that supported

the differing styles during the videotaped father-child play sessions. For example, the

father was observed to encourage rough play on occasion and admonish such behavior on

other occasions. Several times the father was observed restraining Jordan in his arms and

presenting a new activity. If Jordan participated in the activity, the father frequently









changed quickly to another activity. If Jordan was distracted or chose to play with a new

toy, the father corrected Jordan or tried to pull him back to the previous activity. On one

occasion, the father offered a block to Jordan. Jordan responded that the block did not fit.

The father praised Jordan. A short time later Jordan gave his father the same block. The

father dismissed Jordan and stated, "You know that block doesn't fit." Jordan

immediately stopped participating and moved to another activity.

The father was verbose during each videotaped session and often asked the same

question 3- or 4-times without waiting for Jordan to respond. Many times the father

would introduce an activity. If Jordan began the activity the father often ceased the

activity. For example, the father mentioned the game "duck, duck, goose". Jordan

immediately started to play the game. The father responded that they could not play the

game at that time. The father allowed rough, physical play in one session and threatened

"time out" as punishment for similar behavior in another session. In summary, the father

demonstrated inconsistent parenting styles. At times he was permissive, while other

times he threatened "time out" if Jordan's behavior did not improve. Intentional

aggressive, angry, or insulting father behavior was not observed.

The father often discussed concerns about Jordan's frequent episodes of

aggression, temper outbursts, and defiance in the home, daycare, and during family

outings. The father stated that it was difficult to provide consequences because he

believed that Jordan was not affected by verbal explanations or the loss of privileges, and

that Jordan did not participate when punished with "time out". The father stated that

effective punishment included placing Jordan in his room and holding the door shut. The

father reported that often the mother interfered with his management of Jordan's problem









behavior and led to frustration and conflict with his wife's behavior. The father asked if

the mother could participate in parent training because she was the primary caretaker, and

the marked differences in their parenting styles reinforced Jordan's problem behavior and

created marital discord. The PI agreed to provide parent training for the mother after the

father-child protocol had been completed.

The Child Behavior Checklist (Achenbach, & Edelbrock, 1983) was used to

assess the child's behavior problems (Table 4-1). The father reported an internalizing T-

score before and at completion of the study that was within the normal range of problem

behavior. However, an externalizing T-score of 74 before and 65 at completion of our

study was reported in the clinical range of problem behavior, and supported the diagnosis

of an externalizing disorder for ADHD. At completion of our study, the father reported

that ADHD problem behaviors decreased from the clinical range to the normal range of

behavior. In contrast, oppositional defiant behaviors were reported to increase from the

borderline to the clinical range of problem behavior. Interestingly, the father reported

attention problems decreased from the clinical range to the borderline range while

aggressive behavior increased from the normal range to the clinical range. Affective

problems were reported to decrease from the borderline clinical range to the normal

range. The father reported that Jordan had significant sleep problems (e.g., did not want

to sleep alone; had trouble falling asleep; had nightmares; resisted bedtime; slept little;

talked in his sleep; and woke often). The father stated that Jordan slept in his room only

if one parent stayed with him the entire night.

The Interactions Questionnaire (Hoza, & Pelham, 1995) was used to assess the

father's beliefs about Jordan's problem behavior before and at completion of our study.









The father reported that Jordan's problem behavior was attributed to the lack of father

effort and poor mood of the father and Jordan. Before parent training, the father stated

that the cause of Jordan's problem behavior was a mystery. The father's reported that his

attempts to discipline Jordan's problem behavior were often ineffective. After the third

parent training session, the father reported that his discipline skills (i.e., limit-setting,

ignoring misbehavior, and time out) were improving. In addition, the father stated that

teacher reports of aggression were less frequent, and Jordan's vocabulary had

significantly increased since the onset of the study. The father stated that communication

with his child had improved, that Jordan was less frustrated, and that Jordan exhibited

fewer tantrums at home. However, the father reported that Jordan's problem behavior

with his mother had not improved and the father's efforts to manage Jordan's problem

behaviors often were thwarted by his wife's interference.

Frequencies of Target Behavior

During Condition A, the father and Jordan participated in four baseline father-

child play sessions (Table 4-3). The PI videotaped two sessions per week in the father's

home. During baseline sessions, the ratio of means for father initiations to child

initiations was approximately 2:1; father initiations were greater than .66 of the total

initiations. The father had few positive responses with an average rate of 15 corrective

statements per session. The father did not respond negatively. There were no incidents

of imitation with animation (I/A). Jordan did not exhibit any incidents of aggression or

elopement. The ratio of father-initiated turns with affirmation (FIT) to child-initiated

turns with affirmation (CIT) was approximately 4:1, greater than .80 of the total initiated

turns with affirmation.









Condition B followed the videotaped baseline sessions. The father was taught the

first parent training session (PT-1) and four father-child play sessions were videotaped

(twice per week). Contrary to Condition A, the ratio of means for child initiations to

father initiations was 1:1; and the child initiations were slighter greater than .50 of the

total initiations. The father's positive responses doubled and increased to an average rate

of 12.5 per session. The father's corrective statements significantly decreased to an

average rate of .7 per session. The father's use of I/A increased to an average rate of 10

per session. The father did not make any negative comments. Jordan exhibited few

incidents of aggression with an average rate of 4.5 per session. There were no incidents

of elopement. The relationship of child responses to I/A was not evident. The ratio of

means for FIT to CIT was 1:1. The CIT were slightly greater than .50 of the total

initiated turns with affirmation.

The second parent training session (PT-2) followed and four father-child play

sessions were videotaped. Similar to PT-1, the ratio means for child initiations to father

initiations were 1:1. The child initiations were greater than .50 of the total initiations.

The father's positive responses decreased to approximately the same rate as baseline,

with an average rate of 6.5 per session. The father's corrective statements increased to an

average rate of 5.3 per session. Incidents of Jordan's aggression increased slightly to an

average rate of 5.8 per session. The father used I/A less than in PT-i with an average rate

of 8.5 per session. The father did not use negative comments. Jordan did not elope at

any time. Similar to PT-1, the ratio of means for FIT to CIT was 1:1; CIT slightly more

than .50 of the total initiated turns with affirmation.









Unfortunately, the child was ill for a week and the winter holidays prevented

scheduling for approximately two weeks. The third parent training session (PT-3) was

given and a booster session followed one week later to review information before

videotaping the father-child play sessions. Comparable to PT-I and PT-2, the ratio of

means for child initiations to father initiations was approximately 1:1. The child

initiations were slighter greater than .50 of the total initiations. The father's positive

responses increased to an average rate of 10.5, approximately twice the baseline rate.

Corrective statements decreased slightly to an average rate of 4 per session. The father

did not use negative comments. The father used I/A an average rate of 4.8, less than .50

of the average rate in PT-1. The child exhibited few incidents of aggression with an

average rate of 2.2 per session. Jordan did not elope at any time. Similar to PT-I and

PT-2, the ratio of means for FIT to CIT remained at 1:1. The CIT were greater than .50

the total initiated turns with affirmation.

Visual Report of Data

The decrease in father initiations and increase in child initiations between

Condition A and Condition B is evident in Figure 4-1. During the third baseline session

Jordan initiated play more often than in the other three baseline sessions. This father-

child play session was more typical of the sessions that followed the parent training

sessions. Jordan and his father played with blocks, shapes, and puzzles. Jordan

responded to the father's initiations and placed a block on a tower when handed a block,

put a shape in the block when handed a shape, and inserted a puzzle piece when handed a

piece. It appeared that child initiating behavior was dependant on the type of father-child

play.









During the first videotaped session after PT-1, the father did not structure or lead

the play as he had during the baseline sessions. Jordan reacted by standing or singing;

running to and from the father; falling into the father; and rough, physical play. The

father expressed concern about Jordan's aggressive behavior following the play session.

The PI advised the father to continue to allow Jordan to lead the activity. Subsequent

videotaped sessions showed that the father continued to allow the child to lead play.

Fewer instances of rough play were noted during the remainder of our study.

Interestingly, Jordan verbalized choices of play, demonstrated creative play, and

initiated play more often than during the baseline sessions. If the father participated in

Jordan's activity, the activity continued. If the father led his child's activity, Jordan

became frustrated, stopped the activity, and chose another activity. For example, Jordan

played with the dog giving it sound and movement. The father took the dog from Jordan

and positioned the dog to box the ears. He explained to Jordan how to position the dog.

Jordan's yelled and cried; took the dog from the father; tossed the dog; and ran to the

chair with another toy. It was evident that the father's response affected the father-child

interaction. It is possible that the targeted behaviors (father initiations, child initiations,

and FIT and CIT) are dependent on the father's responding behavior as well as the type

of father-child play.

Father positive responses and corrective statements changed between Condition A

and Condition B (Figure 4-2). After PT-2, the father's positive responses decreased and

father corrective statements increased. In addition, there was a decrease in the mean of

father initiations and child initiations during videotaped sessions IB#1 through IB#4.

After PT-3, the father positive responses increased and the father's corrective responses









remained fairly stable. Initially, the father expressed difficulty and discomfort with I/A

during parent training. However, the father was observed using I/A (Figure 4-3). After

the second videotaping session IB#2, a dramatic decrease in the father's use of I/A was

evident. Despite a review of I/A, the father was less inclined to use the skill for the

remainder of the study. In addition, the child responses remained relatively stable after

the parent training sessions with a average range of 34 to 41 (Table 4-4). There was no

evidence of a relationship between the child responses and the father's use of I/A.

Interestingly, the child responses remained relatively stable despite a significant decrease

in the father initiations. Further study is needed to determine the influence of father

behavior on child responses.

Significant changes were evident between Condition A and Condition B in FIT

and CIT (Figure 4-5). CIT increased and were more balanced with FIT throughout

Condition B. The increase in CIT and the balanced turn taking between the father and

the child supports the effectiveness of the first parent training component.

Father and Child Dyad B

Using Hollingshead (1975) criteria, the family was estimated to fall in the middle

range of social strata (Table 4-13). The parents were in their mid-thirties, Caucasian,

worked full-time, and the biological parents of a 3-year and 6-months-old son. The father

shared that he quit school in the seventh grade due to academic problems and failure,

difficulty reading, and lack of interest. He stated that he has worked in construction since

adolescence. The father expressed concern that his son may experience similar academic

difficulties in school.

For the purpose of discussion Child B was referred to as Thomas. Thomas

received a diagnosis of ADHD at 3-years and 6-months of age from a behavioral









pediatrician. Thomas was diagnosed with speech and language delays and received

therapy twice per week. The father did not believe that medication was an option and

Thomas was did not receive medication for ADHD during our study. Thomas was asked

to leave three previous daycare programs because of aggressive and hyperactive

behavior. In addition, Thomas was asked not to return to a church daycare program on

Sunday mornings. Throughout the study he attended a preschool program five days each

week. The teacher sent daily reports of aggressive and impulsive behavior to the parents.

Before the study, the father reported greater than average scores in laxness,

overreactivity, verbosity, and total score (Table 4-4). At completion of our study, the

father reported changes in the total score, laxness, and verbosity and no change in

overreactivity. Only the verbosity score was in the normal range of discipline

effectiveness. Thomas did not exhibit incidents of aggression during the videotaped play

sessions. The father did not respond with negative or corrective statements after the

baseline sessions. Following the baseline sessions, the father spoke less often, gave

fewer explanations, and allowed the Thomas to lead the activity. There was no evidence

of overreactivity by the father was observed during the videotaped father-child play

sessions.

Before and at completion of our study, the father reported that his wife was the

disciplinarian and that she structured and planned Thomas's activities, bedtime, and

punishment. The father stated that he did not provide consistent consequences in

response to Thomas's problem behavior and that Thomas was less likely to comply with

his requests or commands. The father expressed support for his wife's strict disciplinary

practices. If Thomas misbehaved or did not comply, the wife provided verbal reprimands









and immediate consequences such as the loss of privileges. For example, Thomas

enjoyed playing with trains. The consequences for problem behavior or negative teacher

reports often included the removal of trains for a period of time. Token reinforcements

for good behavior were granted. For example, Thomas was promised a ride on a train if

he received only positive teacher reports for the entire week. The father stated that

despite the parent's efforts with strict discipline, the child's aggressive behavior had not

changed before our study. The father asked if the mother could participate in parent

training since she was the primary caretaker and the marked variation in their parenting

styles was reinforcing his child's problem behavior. The PI agreed to provide parent

training for the mother after the research protocol had been completed.

The father reported on the CBCL (Achenbach, & Edelbrock, 1983) an

internalizing T-score of 62 before and 61 at completion of the study. Both t-scores

remained in the borderline clinical range for problem behavior (Table 4-4). An

externalizing T-score reported a change of 65 in the clinical range to 59 (within the

normal range of problem behavior). A total score of 46 decreased to 43 and remained in

the normal range.

Thomas was reported to be in the borderline clinical range for ADHD, withdrawn,

and aggressive behavior before our study. At completion of our study, the scores were

reported within the normal range of problem behavior. There was a minimal decrease in

pervasive developmental problems, but the score remained in the clinical range. The

father reported that Thomas avoided eye contact; did not answer; had poor peer

relationships; had speech problems; and was disturbed by new things or a change in

routine. In addition, the father reported a normal range of problem behavior associated









with sleep. However, the father discussed his child's problems falling asleep, resisting

bedtime, and not wanting to sleep alone. The father reported that sleep problems had

improved slightly before our study because both parents had been working together to

assist the child at bedtime with a strict schedule. It was also noteworthy that the father

reported that Thomas was more affectionate at the completion of the study. In addition,

the father believed that his child's noncompliance was influenced by a lack of father and

child effort, and poor father and child mood (Table 4.4).

Frequencies of Target Behaviors

Thomas and his father played during four baseline sessions (twice each week)

videotaped by the PI in the subjects' home. The ratio of father initiations to child

initiations was approximately 2:1, with father initiations greater than .66 of the total

initiations (Table 4-6). The father had few positive responses. The father's corrective

statements were greater than twice the average rate of positive responses. The father did

not make any negative comments or use I/A. Thomas did not exhibit incidents of

aggression or elopement. The ratio of means between FIT and CIT was approximately

3:1; FIT greater than .66 of the total initiated turns with affirmation.

After Condition A, the father received the first parent training session (PT-1).

Four father-child play sessions were videotaped (twice during each week). In

comparison to Condition A, there was a significant decrease in the father initiations and

increase in child initiations. The ratio of father initiations to child initiations changed to

2:3, with child initiations greater than .50 of the total initiations. The father's positive

responses increased almost three times the baseline rate with an average rate of 8.8 per

session. There were no corrective statements or negative comments made by the father.

The father used I/A an average rate of 10.2 per session. Thomas did not exhibit any









incidents of aggression and elopement. Another significant change was noted in the ratio

of means of FIT to CIT was approximately 1:2; CIT greater than .66 of the total initiated

turns with affirmation.

The father was taught the second parent training session (PT-2) and five father -

child play sessions were videotaped (twice during each week). Similar to PT-1, the ratio

of father initiations to child initiations was approximately 1:2, with child initiations

greater than .66 of the total initiations. The father's positive responses increased slightly

to an average rate of 10.2, three times the rate of baseline. The father did not exhibit any

corrective or negative statements. The father continued to use I/A with an average rate of

11.8 per session. However, the father stated that he was uncomfortable with the use of

I/A. It was noted during the fourth videotaping session that the use of I/A had dropped

from 15 incidents to 6 per session. For that reason a fifth videotaping session was

arranged. There was not any notable improvement in the use of 1/A in the fifth

videotaped father-child play session. The child did not exhibit any incidents of

aggression or elopement. Similar to PT-i, the ratio of means of FIT to CIT was

approximately 2:3; CIT almost .66 of the total initiated turns with affirmation.

After the fifth videotaped father-child play session, the father was taught the third

parent training session (PT-3). Four father-child play sessions were videotaped. Similar

to PT-I and PT-2, the ratio of father initiations to child initiations was 1:2, with the child

initiations almost .66 of the total initiations. The father's positive responses increased to

five times that of baseline and an average rate of 15 per session. The father did not

correct or provide negative comments. The father continued to use I/A more often with

an average rate of 20, twice the rate reported following PT-1. Thomas did not exhibit any









incidents of aggression or elopement. The ratio of means of FIT to CIT was

approximately 2:3; CIT greater than .5 0 of the total initiated turns with affirmation.

Visual Report of Data

A change in level with minimal variability is evident in father initiations and child

initiations between Condition A and Condition B (Figure 4-6). The father initiations

decreased and Thomas initiated play more often. Thomas demonstrated creative and

imaginative play. For example, Thomas often led the path of a train in various directions

using the fireplace, the father's legs, or blocks while whistling, singing, or saying "choo

choo" in Condition B. The type of father-child play seemed to influence the child

initiations. However, the father-child play session following the PT-3 was quite

different. Thomas attended a monster truck show two days before and was imitating the

monster trucks. Despite the father's attempts to interact, the child played in isolation

with the monster trucks for several minutes.

An increase in the father's positive responses is evident between Condition A and

Condition B (Figure 4-7). The father's corrective statements changed considerably with

only two incidents evident in IB#4. Imitation with animation (I/A) was taught to the

father during the first parent training session (Figure 4.8). The father expressed difficulty

with instructions to act silly and animated. The PI provided ongoing review and

encouragement of I/A throughout Condition B. There was an increase in I/A between

Condition A and Condition B. Conversely, the child responses decreased. Before

session IC# 1, the father and Thomas attended a monster truck show. Thomas played in

isolation with the monster truck toys during father-child play sessions IC#1 and IC#2.

The father used I/A more often in an attempt to interact with Thomas. Despite the

father's attempts to interact, Thomas responded less often. The father initiations between









Condition A and Condition B (Figure 4-9) decreased while the child responses remained

relatively stable with the exception of sessions IB#2 and IC#4. Further study is needed

to determine the influence of father behavior on child responding behavior.

The father spoke often and did not wait for Thomas to respond during Condition

A. After the first parent training session, the father followed his child's lead in play;

waited for Thomas to respond; initiated a turn less often; and increased his use of I/A.

CIT increased and were more balanced with FIT in Condition B (Figure 4-10). Also

noteworthy, CIT increased during second father-child play session following each parent

training session, and then decreased after each subsequent father-child play session. One

reason may be that the father's use of I/A was higher in the first and second father-child

play session following each parent training session. In addition, the father's positive

responses were highest in the second father-child play session following the parent

training sessions. The interesting point is that both CIT and FIT were more balanced

after the third parent training session. The father did not sit back and watch or play in

isolation, while Thomas played intensely with a train or truck. The father built a tower of

blocks, and Thomas used the truck to knock over the tower or the father moved his truck

on the child's arm until the child giggled. In other words, the father continued to interact

with his child. Further study is needed to understand the relationship between I/A and the

child's behavior.

Father and Child Dyad C

Using Hollingshead (1975) criteria the family was estimated to fall in the lower

range of social strata (Table 4-13). The family consisted of an African-American father,

a Caucasian mother in their late thirties, and their biological 5-year and 8-month child.

For the purpose of discussion, the Child C was referred to as James. The father had a 14-









year-old African-American teenage son from a previous marriage who visited

occasionally, but did not live in the home. The father was self-employed and contracted

his services as a handyman for home and business repairs. The mother completed junior

high school and was employed full-time. The father stated that he had a history of drug

and alcohol abuse and that he was drug and alcohol free for seven years. He reported that

he was an active member of Alcoholics Anonymous and Narcotics Anonymous. The

father stated that he was incarcerated several times. In addition, the father reported that

his wife was incarcerated prior to their marriage. He also expressed concern about past

issues of maternal child neglect.

James received a diagnosis of ADHD at 5-years and 8-months of age from a

behavioral pediatrician. James was not prescribed medication for ADHD. The father

was opposed to any type of medication and likened the use of stimulants for the treatment

of ADHD to drug abuse. Before attending kindergarten, James was asked to leave three

daycare programs due to aggressive behavior. James attended kindergarten at the local

public elementary school. The parents expressed concern about daily teacher reports of

aggressive and impulsive behavior. James was referred him for an ADHD evaluation

with a health care provider by his teacher. Initial academic testing within the school

reported that James had a second grade reading level and above average academic skills.

In addition, James was referred for psycho-educational testing and future consideration

for admission into the gifted program.

Before our study, the father reported ineffective discipline evidenced by greater

than average scores in laxness, overreactivity, and the total score (Table 4-7). The father

stated during the parent training sessions that both parents disciplined James. However,









the father did not believe his wife supported his method for discipline. He reported that

she lacked consistency in discipline and did not provide consequences for problem

behavior exhibited by James. The father discussed his wife's lifestyle and his concern

with issues of maternal neglect. The father advised that the inclusion of his wife in the

research project was essential to strengthen family ties and to provide a unified approach

to James' problem behavior. The father was advised that parent training would be

offered to his wife at completion of our study.

The father had a powerful voice and stance. James immediately acknowledged

the father's request or command. James did not exhibit any incidents of problem

behavior, opposition, or aggression throughout the study. The father spoke frequently

and gave lengthy explanations concerning play, a specific toy, or buildings. Often, the

father did not respond to the child's questions or comments. James demonstrated strong

verbal and language skills during interactions with the father. James provided ongoing

reinforcement for the father's behavior in the form of commenting, questioning, and

praise. Laxness on the father's part was not evident during the videotaped sessions.

Father overreactivity was not observed due to the immediate response of the child and

father verbosity was consistently observed throughout the study. However, the father

reported less than average scores on verbosity. Unfortunately, the father did not return

the questionnaires at completion of our study despite the efforts of the PI. Therefore,

comparison between pre-study and post-study father reports was not possible.

Before our study, the father reported on the CBCL (Achenbach, & Edelbrock,

1983) an internalizing T-score of 47, an externalizing T-score of 50, and a total score of

34 (Table 4.7). The father did not report any problem behaviors in the clinical range.









The father stated his child exhibited immature, impatient, and attention- getting behavior;

avoidance of eye contact; and inability to sit still. Somewhat problematic behaviors were

reported as hitting, defiance, and disobedience. The father reported concerns with

destructive child behavior, poor peer relations, loudness, fearlessness, and poor appetite.

In addition, the father believed that his child's problem behavior was influenced by his

child's poor mood. The father expressed certainty that James was deliberate in his

actions; knew right from wrong; and often chose the wrong action.

Frequencies of Target Behaviors

During Condition A, four father-child play sessions were videotaped in the

subjects' home (twice per week). The ratio of father initiations to child initiations was

approximately 2:1, with father initiations greater than .66 of the total initiations (Table 4-

9). The father had few positive responses with an average rate of 2 per session; while the

corrective statements had an average rate of 13 per session. The father did not use any

negative comments or the I/A skill. James did not exhibit any incidents of aggression or

elopement. The ratio of means of FIT to CIT was approximately 2:1; FIT equal to .66 of

the total initiated turns with affirmation.

The first parent training session (PT-1) followed Condition A. Then, five father-

child play sessions were videotaped (twice each week). The PI had difficulty scheduling

the videotaping sessions and several sessions were cancelled en route. The father stated

that he started a second job and he was unable to leave the workplace. The ratio of father

initiations to child initiations was approximately 1:2; child initiations greater than .66 of

the total initiations. In addition, the father's positive responses increased to an average

rate of 9.4, more than three times greater than condition A. The corrective statements

decreased from an average rate of 13 in Condition A to an average rate of 1.6 in









Condition B. The father stated that he was uncomfortable with I/A at the completion of

IA#2. Consequently, I/A was reviewed prior to session IA#3, IA#4, and IA#5. The

average rate of the father's use of I/A remained at 4 per session. Due to the limited use of

I/A during the first four sessions, a fifth videotaping session was scheduled. The average

rate of I/A did not change. James did not exhibit any incidents of aggression or

elopement. The ratio of means between FIT and CIT was approximately 1:2; CIT almost

.66 of the total initiated turns with affirmation.

The father received the second parent training session (PT-2) and four father-child

play sessions were videotaped (twice each week). The PI had difficulties scheduling the

videotaping sessions with the father. Several father-child play sessions were cancelled en

route. The father stated that he and his wife had marital problems, and that he had

considered separation. He reported that both parents had made efforts to work through

the conflict, and he wanted to continue participation in the study. Four father-play

sessions were videotaped. The ratio of father initiations to child initiations was

approximately 1:2; child initiations greater than .66 of the total initiations. The father's

positive responses remained greater than four times the average rate of Condition A with

an average rate of 8.8. The average rate of the father's corrective statements was .8, less

than one per session. The father continued to I/A at approximately the same rate. James

did not exhibit any incidents of aggression or elopement. The ratio of means between

FIT and CIT was approximately 1:1; CIT greater than .50 of the total initiated turns with

affirmation.

The father often spoke, commented, questioned, and instructed James during the

father-child play sessions. James frequently praised the father's efforts. After PT-2, the









father directed play; requested feedback from James regarding the activity; and

responded positively to praise from James. It was interesting that the child continued to

initiate play with little father attention and few positive father responses.

During the third parent training session (PT-3), the father expressed a positive

attitude about the project. He shared that he and his wife continued to have marital

problems, and that he anticipated leaving for employment out of town. The father

planned to continue our study until completion. Two father-play sessions were

videotaped. Several father-child play sessions were cancelled en route. After the final

cancellation, the father stated that he was scheduled to leave for employment in south

Florida and could no longer participate in the study. The father was unable to meet to

cancel his participation in the study and agreed to return the post intervention surveys by

mail. Two phone messages were left on his voicemail. The surveys were not received.

After PT-3, the ratio of father initiations to child initiations for both videotaped

sessions was approximately 2:3; child initiations greater than .50 of the total initiations.

The father had 9 positive responses in the first session and 0 in the second session. The

father did not exhibit any corrective statements in the first session, but exhibited 7 in the

second session. The father did not make any negative comments. The father did not use

I/A in IC#1 and used I/A 7 times during the final session IC#2. James did not exhibit any

incidents of aggression or elopement. The ratio of means of FIT to CIT was 1:1 with

balanced turn taking.

Visual Report of Data

The father decreased initiations and James initiated play more often in Condition

B (Figure 4-11). The father often requested James approval, attention, and help. The

father's positive responses increased, and the father's corrective responses decreased









from Condition A to Condition B (Figure 4-12). Interestingly, a significant decrease in

the father's positive responses was noted during IB#2 and the last videotaped session.

During IB#2, the father directed the activities with his child. During the final videotaped

session, James led the majority of the activities. The father frequently commented and

asked for feedback from James. In addition, the father provided more corrective

statements.

The father verbalized difficulty with I/A following the PT-1 and throughout the

study. Due to the low incidence of I/A following the PT-1, a fifth videotaping session

was scheduled (Figure 4-13). Despite a review of I/A before the third, fourth, and fifth

father-child play sessions, the father did not increase the use of hA. A minimal change in

level in I/A is noted between Condition A and Condition B, with the greatest number of

incidents noted following the second parent training session. There were no occurrences

of I/A during the last videotaped session. A comparison of father initiations and child

responses revealed that child responses remained relatively stable, despite a decrease in

father initiations between Condition A and Condition B (Figure 4-14).

A change in FIT and CIT was evident between Condition A and Condition B

(Figure 4-15). CIT increased and were more balanced with FIT in Condition B. The

father spoke often and did not wait for a child response during Condition A. On the

contrary, the father waited for James to respond and initiated a turn less often during

Condition B until following PT-2. FIT were greater than CIT on two occasions. Father-

child play sessions IB#2 and IC#2 were atypical. During session IB#2, the father

directed the majority of the play and James participated. In addition, there was an

increase in child responses as well as a decrease in the father's positive responses.









During session IC#2, the child directed the majority of the play. The father frequently

commented and/or requested feedback. James' responded to the father's verbosity and

provided positive feedback, answered questions, and did not exhibit frustration or anger;

James continued to participate in the father's activity and initiate play without positive

reinforcement or attention.

Father and Child Dyad D

Using the Hollingshead (1975) criteria, the family was estimated to fall in the

second highest social strata (Table 4-13). The father was self-employed and the owner of

a mid-sized construction business. His wife was a homemaker and was 9-months

pregnant with her third child. After the birth of the newborn, the parents had three

biological male children ages, 8-years, 3-years, and a newborn. For the purpose of

discussion, Child D was referred to as Bobby.

Bobby was diagnosed at 3-years-old by a primary care pediatrician in private

practice. The father stated that Bobby's height and weight were greater than 95% for his

age group and that he appeared older than his age. In addition, Bobby was diagnosed

with speech delay and was receiving therapy. The father refused to consider medication

for Bobby to treat ADHD. Bobby was not prescribed medication for ADHD. An older

brother was diagnosed with ADHD without hyperactivity several years prior because of

academic problems; he took a long-acting stimulant each morning. The father expressed

concern that Bobby may need medication in the future. The father discussed that he had

difficulty with discipline strategies, uncertainty about a course of action, and concern

about Bobby's aggressive behavior towards his older brother. The father expressed

distress that Bobby may have academic difficulties as well as behavioral problems.

Bobby was asked to leave two previous preschool programs before enrolling in a third









preschool five days each week. Frequent teacher reports included complaints of

impulsivity, aggressive behavior (e.g., hitting and tackling), and academic problems.

The parents asked to start our project before the impending birth of their baby.

Both parents verbalized the need to maintain a sense of balance and normalcy within their

home. The father stated that Bobby would benefit from the increased father attention

before the birth and during the first few months of the newborn period. The family often

spent evenings and weekends together in activities that included going to the beach,

boating, four-wheeling, and fishing.

Before our study, the father reported ineffective discipline skills evidenced by

greater than average scores in laxness, overreactivity, verbosity, and the total score

(Table 4-10). Despite the reported decreases in all scores at completion of our study, the

scores remained greater than average. The father showed changes in laxness,

overreactivity, and verbosity throughout our study. For example, Bobby changed the car

ramp three times during one baseline session and the father readjusted the ramp each of

the three times. Following the parent training sessions, the father gave fewer

explanations, asked permission for a toy, waited for Bobby to offer a toy, and asked

permission to participate. Bobby was more verbal and gave many creative explanations

for toys during play after the first parent training session. It was interested that Bobby

often imitated the father's creative play when given the opportunity.

Before and at completion of our study, the father reported an internalizing T-score

of 73 and a total score of 54 on the CBCL (Achenbach, & Edelbrock, 1983). The

externalizing score changed from 83 before the study to 77 at the completion of the study.

Both the internalizing T-score and the externalizing T-score remained in the clinical









range of problem behavior (Table 4-10). In addition, the father reported that Bobby had

affective problems and pervasive developmental problems in the clinical range, and

anxiety and ADHD problems in the borderline range. Withdrawn behavior, sleep

problems, attention problems and aggressive behavior were reported in the clinical range

for problem behavior. Emotionally reactive problems, anxiety, and somatic complaints

were reported in the borderline clinical range of problem behavior. Only oppositional

defiant problem behavior was reported within normal range.

Bobby was known to react with physical aggression, defiance, hitting, destructive

behavior, disobedience, and temper outbursts usually without guilt. The father perceived

Bobby as selfish and easily frustrated. The father stated that Bobby had been cruel to

animals without remorse. For example, he often hit his dog and had hurt neighborhood

animals. The father reported that discipline was difficult because verbal explanations or

the loss of privileges did not seem to have an effect on Bobby's behavior. The father

believed that sending Bobby to his room was the most effective consequence for problem

behavior. However, the father stated that the problem behavior did not change.

Sleep problems reported by the father included Bobby's difficulty with sleep

rituals. He did not want to go to sleep, woke frequently, had nightmares, and did not

want to sleep alone. The father stated that often he would wake in the middle of the night

to find Bobby on the floor at the foot of his bed. The father reported that he and his wife

worked together to assist Bobby at bedtime. The father expressed concern that Bobby

seemed depressed and anxious and noted that Bobby was often withdrawn, avoided eye

contact, and did not respond to questions or commands. In addition, Bobby was

frequently upset when separated from his parents.









The father believed that Bobby's problem behavior was influenced by his child's

effort and mood (Table 4-11). In addition, the father expressed concern about Bobby's

aggressive behavior towards his brother and friends. The father discussed that Bobby's

behavior was increasingly worse with his wife. The father asked if his wife could

participate in parent training since she was the primary caretaker, and she had difficulty

providing consistent discipline for Bobby's problem behaviors. The PI agreed to provide

parent training for the mother after the father-child training protocol was completed.

Frequencies of Target Behaviors

In Condition A, five baseline father-child play sessions were videotaped. The

mother gave birth to the third son after the first videotaped session. Therefore, one week

elapsed before the second videotaping session. The next four baseline sessions were

videotaped (twice per week) in the subjects' home. The ratio of father initiations to child

initiations was approximately 2:1; father initiations greater than .66 of the total initiations

(Table 4-12). The father had few positive responses with an average rate of 5.3, while

the corrective statements were an average rate of 19.8 per sessions. The father did not

make any negative comments. The father used I/A once during B#2 before the first

parent training session. Bobby exhibited four incidents of aggression during B#2 and did

not exhibit any incidents of elopement. The ratio of means of FIT to CIT was

approximately 3:1; FIT almost .75 of the total initiated turns with affirmation.

The father received the first parent training session (PT-1) and four father-child

play sessions were videotaped (twice per week). There was a significant change in

father-child initiated play. The ratio of father initiations to child initiations was

approximately 2:3, almost .66 of the total initiations. The father's positive responses

increased greater than three times in Condition A to an average rate of 19.8. The father's









corrective statements decreased from an average rate of 19.8 to 2.5 per session. The

father did not use any negative comments. The father used I/A without difficulty an

average rate of 13 per session. Bobby exhibited few incidents of aggression with an

average rate of 1.5 per session and did not exhibit any incidents of elopement. The ratio

of means of FIT to CIT was approximately 1:3; CIT almost .75 of the total initiated turns

with affirmation.

During the second parent training session (PT-2), the father expressed the

possibility that he had ADHD, and that he and his son have similar characteristics and

behavior. The father stated that he was not a model student and struggled with

academics, but he excelled in sports. In addition, the father expressed concern that his

son continued to receive negative teacher comments about impulsive and aggressive

behavior (e.g., hitting, shoving, and tackling other children) on a daily basis. The father

stated that play in the home with Bobby and his eight-year old brother before the parent

training sessions involved wrestling and rough play. After the parent training sessions,

the father changed to activities that didn't involve aggressive play.

Father-play sessions were videotaped twice per week. Similar to PT-1, the ratio

of father initiations to child initiations was approximately 2:3, with the child initiations

almost .66 of the total initiations. The average rate of the father's positive responses was

13.5 per session; greater than two times the average rate of Condition A. The father had

an average rate of corrective statements of 1 per session. The father did not use negative

comments. The father continued to use I/A, with an average rate of 14 per session.

Bobby exhibited 3 incidents of aggression in session IB#4 and did not exhibit any









incidents of elopement. The ratio of means between FIT and CIT was approximately 1:3;

CIT greater than .75 of the total initiated turns with affirmation.

The father was taught the third parent training session (PT-3). During the

discussion, the father stated that Bobby's aggressiveness towards the older sibling

continued. For example, Bobby often smacked the older brother in the face while seated

in the car with no provocation. The father reported that discipline skills (e.g., time out

and limit setting) were not helpful and that immediate consequences for problem

behavior were not always possible. The father was advised to deal with aggressive

behavior consistently. A token reward system was reviewed. The father was encouraged

to praise Bobby often for appropriate behavior. In addition, the father was advised that

problem behavior could increase initially. The problem behavior was expected to

decrease with consistent behavior management and discipline strategies.

Father-play sessions were videotaped (twice each week). At the beginning of the

fourth father-child play session, Bobby was uncooperative and the session was

discontinued after 2-minutes. A fifth session was scheduled. However, the child was

tired, angry and uncooperative and the session was rescheduled. During another visit the

father was at home but the child was at a birthday party. A final session was scheduled

and videotaped. Similar to PT- 1 and PT-2, the ratio of father initiations to child

initiations was approximately 2:3. The child initiations were almost .66 of the total

initiations. The father's positive responses continued at an average rate of 10 per session,

twice the rate during Condition A. The father's corrective statements were few with an

average of 3 per session. The father did not use negative comments. The father

continued to increase his use of I/A with an average rate of 17.8 per session, greater than









the average rate following PT-1 and PT-2. The child exhibited 3 incidents of aggression

in session #1, 2 incidents in session #2, and 15 incidents in the final session. There were

no incidents of elopement. The ratio of means of FIT to CIT was approximately 1:4; CIT

greater than .75 of the total initiated turns with affirmation.

Visual Report of Data for Father and Child Dyad D

During Condition A, Bobby played in isolation. The father chose the type of

play, attempted to interact with Bobby, and directed the activity. In contrast, during

Condition B the father initiations decreased and the child initiations increased (Figure 4-

16). After the parent training sessions, Bobby initiated play more often, demonstrated

creative play, and verbalized choices of following play. In addition, the father

commented in response to Bobby's direction of play and was less inclined to direct the

play. The father followed Bobby's directions, requested instructions, and waited for

Bobby's response before initiating an activity.

After the parent training sessions, the father's positive responses increased and the

father's corrective responses decreased (Figure 4-17). The father followed Bobby's lead

in play, requested direction and/or permission from Bobby, and continued to interact with

Bobby. Few corrective statements were made. The father accepted and followed

Bobby's direction during father-child play sessions. Similar play was noted in the

sessions IC#1 and IC#2. The father's desire to follow Bobby's direction seemed to

affirm a sense of competence in Bobby. Bobby gave more directions; played with more

imagination and creativity; and anticipated the father's participation.

The father had no difficulty with I/A after instruction during PT-1, and he used

the skill throughout the study (Figure 4-18). For example, Bobby made car sounds when

moving the truck around the floor; made the truck jump in a twirling fashion; or pushed









the truck across the floor. The father emphasized the truck sounds, made the truck jump

twirling higher, or made the truck spin across the floor. Interestingly, Bobby observed

the father's creative expression and incorporated that into his own play. It appeared that

the father's emphasis and animation of Bobby's activity encouraged Bobby to play with

more confidence and creativity. However, there was no evidence to support that the

father's use of I/A influenced the child responses (Figure 4-18). It was noteworthy, that

the father initiations decreased between Condition A and Condition B while the child

responses remained relatively stable (Figure 4.19).

The FIT decreased and CIT increased in Condition B and remained relatively

stable as compared to Condition A (Figure 4-20). The father spoke often and directed the

play in Condition A. During Condition B, the father allowed Bobby to lead the play,

followed Bobby's directions, waited for Bobby to respond, initiated a turn less often, and

increased his use of I/A. An interesting point is that CIT were relatively high, FIT were

relatively low, and the distance between the two levels was consistent. The father

responded to the child initiations with questions, comments, and requests and completed

the child initiated turn with affirmation. For example, Bobby made a path for the truck,

removed the wave runner, and drove it in the imaginary water. The father asked Bobby

for permission to drive the truck and trailer to the edge of the area and wait for the wave

runner. Bobby gave permission and drove the wave runner on the trailer and instructed

the father to drive the truck to another area. The father responded and continued a

positive reciprocal father-child interaction.

Summary of the Four Father and Child Dyads

A comparison of each subject's demographics, descriptive characteristics, and

performance across the two conditions of this study is discussed. As anticipated, all four









fathers used the parenting strategies and skills that were taught during the in-home parent

training sessions. In addition, all four children responded with positive behavioral

changes following the father's use of parent skills. Comparison of the family

demographics (Table 4-13) shows that the families vary in age, education, and social

strata. Three of four children were in the 3-year-old age range and attended pre-school

full-time. Child C (James) attended kindergarten. Each child was asked to leave at least

two previous daycare programs because of to aggressive behavior. Each family

continued to receive frequent teacher complaints of aggressive behavior from the child's

teacher. In addition, Child A (Jordan), Child B (Thomas), and Child D (Bobby) were

diagnosed with speech and language delays and received therapy. Their fathers reported

academic concerns such as poor recollection of colors, numbers, and/or letters. However,

Child C (James) differed from the other subjects in a number of ways. James was

biracial, 5-year and 8-month in age with academic success and no documented

developmental delays. James was tested for advanced placement in the school system

because of his above average academic abilities.

All four fathers reported that they were self-employed. Each father expressed the

inability to work for an employer. Each father discussed the possibility that he had

ADHD as a child. All fathers stated that they could relate to their children's behavior and

had similar behaviors as children. Father A, Father C, and Father D stated that as

children they were successful (academics or sports). Each father believed that their child

would grow up without problems. Father B left school in junior high because of

academic failure. He expressed concern that Thomas would experience similar failure in

school. Each father was opposed to medication for treatment of ADHD in his child. All









fathers expressed a commitment to participate fully in the study and a desire to improve

their children's behavior without medication.

A comparison of beliefs in Father A, Father B, and Father D about discipline and

attributions for their child's noncompliance is reported in Table 4-14. Because of

missing data, no comparisons about beliefs regarding discipline or noncompliance with

Father C were possible. Before our study, each father reported higher scores that equated

with ineffective and dysfunctional child discipline. At completion of our study, Father A,

Father B, and Father D reported higher scores for the total score, laxness, and

overreactivity. Father B and Father D reported effective discipline practices related to

verbosity compared to a high score in verbosity reported by Father A.

In addition, each father's belief about the noncompliance at completion of our

study was compared (Table 4-14). Several points were assessed parent controlled

behavior (effort and mood) and child controlled behavior (effort and mood). Father A

attributed Jordan's noncompliance to the lack of parent effort (parent control) and

Jordan's poor mood (child control). Father B attributed noncompliance in Thomas to a

lack of the father's effort and poor mood (parent control), his child's lack of effort and

poor mood (child control). Father D attributed Bobby's noncompliance to a lack of his

child's effort and poor mood. In comparison, only Father D attributed his child's

problem behavior completely within his child's control. Father A and Father B attributed

problem behavior within their child's control as well as within their own control.

A comparison of fathers' perception on problem behavior (Table 4-14) revealed

that Child A, Child B, and Child D were reported within the borderline or clinical range

of an externalizing disorder. Child B and Child D were reported within the clinical range









of an internalizing disorder and pervasive developmental problems. Additional problem

behaviors within the clinical range reported for Child A, Child B, and Child D.

Interestingly, each fathers reported significant problems related to their children's sleep

rituals and sleep habits. However, Father B reported that before our study efforts towards

a structured and consistent bedtime ritual had positively influenced his child's bedtime

behavior.

The comparisons of targeted behavior between subjects and across the conditions

of this study are presented with the exclusion of Father C and Child C because of the lack

of data. A comparison of means of father's responding behaviors during Condition A

revealed that each father had less than 6 positive responses and greater than 9 corrective

responses (Figure 4-21). All father initiations ranged between 64 and 70% of the total

initiations (Figure 4-23). All child initiations ranged between 30 and 36%. The FIT

ranged between 66 and 84% and CIT ranged between 16 and 34% of the total initiated

turns with affirmation.

A significant change was noted between Condition A and Condition B. During

Condition B, the fathers had greater than 10 positive responses and 3 or fewer corrective

responses (Figure 4-22). All father initiations ranged between 35 and 46% of the total

initiations (Figure 4-24). The child initiations ranged between 54 and 65%. The FIT

ranged between 24 and 44% and CIT ranged between 56 and 76% of the total initiated

turns with affirmation.

In summary, each of the targeted father behaviors and targeted child behaviors

changed between Condition A and Condition B. The father positive responses increased,

the corrective responses decreased, and I/A increased. The father initiations decreased,









the child initiations increased, FIT decreased, and CIT increased. Clearly, each father

implemented the father skills that were taught during the parent training sessions. Father

B and Father D had the greatest decrease in corrective statements, the highest use of

imitation with animation, and the greatest increase of positive responses. Significant

improvement was evident in each of the fathers' initiations and each of the children's

initiation. A large difference in the initiated turns with affirmation in Father D and Child

D was evident. However, initiated turns with affirmation were more balanced for Father

B and Child B. In addition, Father B reported a decrease in his child's problem behavior

and more effective father discipline at completion of our study (Table 4-5).

Interobserver Agreement

To assess interobserver agreement on the coding of target behaviors, the PI

followed the observer training sequence developed by Elder (1995) described on page 47.

To minimize the potential for bias, a second independent observer coded 25% of the

videotaped father-child videotaped sessions. The independent observer was blind to the

conditions under which the videotapes were taken. The observer and the PI established a

criteria level of 80% or greater interrater agreement before coding the father-child play

sessions. The independent observer randomly selected and coded 25% of the videotaped

sessions to evaluate for observer drift throughout the course of our study. Interobserver

agreement did fall below 80% two occasions during the coding. The operational

definitions were clarified and practice sessions continued until a level of 80% agreement

was obtained. Interobserver reliability was expressed as percentage agreement with a

range between 76 and 93% between two independent observers (Table 4-15).









Social Validity

A semi-structured interview described on page 45 was used to assess the father

perception of the parent training process. The fathers reported perceptions about the

training process on a scale of I to 5 (Table 4-16). The children's behavior was very

typical at a score of one or not typical at a score of 5. All four fathers reported that their

children's behavior during most of the videotaped play sessions was very typical and that

the presence of the camera and/or the PI had a minimal effect on child behavior. Each

father reported comfort with the parent training skills, use of the skills often, and that the

skills worked well.

The Therapy Attitude Inventory (Eyberg, 1993) described on page 46 was used to

assess the fathers' satisfaction with the process and outcome of parent training

completion of our study. A total of 10-items are included that address the impact of

therapy on parenting skills and the child behavior. The fathers were asked to rate the

items on a scale from 1 (indicating dissatisfaction with treatment or a worsening of

problems) to 5 (indicating maximum satisfaction with treatment or improvement of

problems) at the completion of the study. The item ratings yield a possible score of 5.0

on a scale of 1 to 5. Each father reported satisfaction with the process and the outcome of

the parent training intervention with a score that ranged from 4.0 to 4.4. In summary, the

fathers perceived the parent training intervention as socially valid, reported minimal

reactivity effects, and documented satisfaction with the process and outcome of the

parent training (Table 4-17).









Table 4-1. Summary of Father A effectiveness in discipline
Instrument Before Study Completion of Study
Parenting Scale (1993)*
Total score (3.1) 3.9 3.8
Laxness (2.8) 3.4 3.5
Overreactivity (3.0) 3.9 4.0
Verbosity (3.4) 4.4 3.9
CBCL(1983) **
Internalizing T score 49 37
Externalizing T score 65 74
Total score 46 48
*Scale of 1-7, higher scores = dysfunctional parenting
** Score of 60 & above = clinical range of problem behavior


Table 4-2. Summary of Father A beliefs about child noncompliace
Interactions Questionnaire (1995)* Before Study Completion of Study
Parent effort 4 5
Parent mood 7 6.3
Child mood 6.6 5.6
Child effort 4 6.3
*Scale of l to 10, 1 = really true, 10 = not true at all


Table 4-3. Means of target behaviors for Father A and Child A
Target Behaviors Condition A Condition B
Baseline PT* 1 PT* 2 PT* 3 Mean PT*
Father Initiations/ 70% 46% 47% 45% 46%
Total Initiations
Child Initiations/ 30% 54% 53% 55% 54%
Total Initiation
Child Responses 37 33.2 41.2 41.2 38.5
Father Positive 5.8 12.5 6.5 10.5 7.4
Responses
Father Corrective 15 .7 5.3 4 3
Responses
Imitation/Animation 0 10 8.5 4.8 7.8
Child Aggression 0 4.5 5.8 2.2 4.2
Father Initiated 84% 41% 44% 46% 44%
Turn/ Total Turns
Child Initiated Turn/ 16% 59% 56% 54% 56%
Total Turns
* PT Parent training session









Table 4-4. Summary of Father B effectiveness in discipline
Instrument Before Study Completion of Study
Parenting Scale (1993)*
Total score (3.1) 3.6 3.5
Laxness (2.8) 3.7 3.4
Overreactivity (3.0) 4.0 4.0
Verbosity (3.4) 3.4 2.8
CBCL (1983)**
Internalizing T score 62 61
Externalizing T score 65 59
Total score 46 43
*Scale of 1-7, higher scores = ineffective parenting
**Score of 60 & above = clinical range of problem behavior


Table 4-5. Summary of Father B beliefs about child noncompliace
Interactions Questionnaire (1995)* Before Study Completion of Study
Parent effort 1.3 2.7
Parent mood 7 2.3
Child mood 4.7 2
Child effort 2 2
* Scale of I to 10, 1 = really true, 10 = not true at all


Table 4-6. Means of get behaviors for Father B and Child B
Target Behaviors Condition A Condition B
Baseline PT* 1 PT* 2 PT* 3 Mean PT*
Father Initiations/ 64% 41% 35% 35% 37%
Total Initiations
Child Initiations/ 36% 59% 65% 65% 63%
Total Initiation
Child Responses 32.2 28.5 37.2 33.2 33
Father Positive 3 8.8 10.2 15 11.3
Responses
Father Corrective 8 0 0 0 0
Responses
Imitation/Animation 0 10.5 11.8 20 14.1
Child Aggression 0 0 .4 0 0
Father Initiated 30/69% 18/32% 18/38% 18/40% 36.7%
Turn/ Total Turns
Child Initiated Turn/ 13/31% 38/68% 30/62% 27/60% 63.3%
Total Turns I I
* PT Parent Training Session









Table 4-7. Summary of Father C effectiveness in discipline
Instrument Before Study
Parenting Scale (1993)*
Total score (3.1) 4.1
Laxness (2.8) 4.1
Overreactivity (3.0) 4.0
Verbosity (3.4) 2.9
CBCL**
Internalizing T score 47
Externalizing T score 50
Total score 34
*Scale of 1-7, higher scores = ineffective parenting
** Score of 60 = clinical range of problem behavior


Table 4-8. Summary of Father C beliefs about child noncompliance
Interactions Questionnaire (1995)* Before Study
Parent effort 7
Parent mood 8
Child mood 6
Child effort 8.3
*Scale of I to 10, 1 = really true, 10 = not true at all


Table 4-9. Means of target behaviors for Father C and Child C
Target Behavior Condition A Condition B
Baseline PT* 1 PT* 2 PT* 3 Mean PT*
Father Initiations/ 65% 31% 33% 40% 34.7%
Total Initiations
Child Initiations/ 35% 69% 67% 60% 65.3%
Total Initiation
Child Responses 19 21 22 26 34.3
Father Positive 2 9.4 8.8 4.5 7.7
Responses
Father Corrective 13 1.6 .8 3.5 2
Responses
Imitation/Animation 0 4 4.8 1 3.3
Child Aggression 0 0 0 0 0
Father Initiated 23/66% 18/36% 18/49% 20/50% 45%
Turn/ Total Turns
Child Initiated Turn/ 12/34% 32/64% 19/51% 20/50% 55%
Total Turns I
*PT Parent Training Sessions




Full Text
ENHANCING INTERACTIONS OF FATHERS AND THEIR CHILDREN
WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER
By
DEBORAH ANN WHITE
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORDIA
2004

To the memory of my mother Margaret Ellen McConville-White. Although my
time with her was too short, she is and has always been a source of inspiration and
unwavering strength.
To my children Gregg and Merissa. Of all the blessings in my life, I am most
proud to be their mother.

ACKNOWLEDGMENTS
The pursuit and completion of a doctorate in philosophy has been a challenging
journey of personal and professional growth. I would like to offer my gratitude and
sincere appreciation to each and every person who contributed to the completion of this
dissertation. I am especially grateful to my children, Gregg and Merissa for their belief
in me, and their love, understanding, and support throughout this project.
I gratefully acknowledge the support and encouragement that I received from Dr.
Jennifer Elder. Dr. Elder has been the ideal advisor/chair, mentor, and friend. With her
guidance, support, and patience I was able to complete the dissertation. I am also
appreciative of the opportunity to work as a research assistant in her study with parents of
children with autism. This experience provided valuable insight into the development
and implementation of my research.
I would like to extend my gratitude for the contributions of each committee
member (Dr. Maureen Conroy, Associate Professor of Special Education; Dr. Tanya
Murphy, Associate Professor of Psychiatry; and Dr. Rinda Alexander, Professor of
Nursing). Their unique talents, constructive advice, and guidance were appreciated.
Also, I would like to thank Dr. Carolyn Yucha for the opportunity to work as a research
assistant in the College of Nursing Office of Research.
I am grateful to the National Institute of Nursing Research for the Pre-Doctoral
Fellowship Service Award (NRSA: F31 NR07567 01). This award provided the financial
support necessary to continue my education and research. I am also grateful for the
in

scholarship support that I received from the College of Nursing. Finally, I would like to
gratefully acknowledge and extend sincere thanks to my family and friends. My father,
Chip, Joe, Cathy, Lori, Linda, Ilona, and Hector provided a constant source of energy,
support, and encouragement.
IV

TABLE OF CONTENTS
Page
ACKNOWLEDGMENTS iii
TABLE OF CONTENTS v
LIST OF TABLES viii
LIST OF FIGURES x
ABSTRACT xii
CHAPTER
1 INTRODUCTION 1
Analysis of the Parent Training Concept 1
Analyzing the Range of Meaning of the Parent Training Concept 2
Related Theoretical Perspectives 3
Attention Deficit Hyperactivity Disorder (ADHD) 7
Theoretical Significance in Nursing 8
Parent Training Research in Nursing 9
Operationalization of Parent Training 10
Statement of the Purpose 11
2 REVIEW OF LITERATURE 13
Features of ADHD in Young Children 14
Characteristics of ADHD 16
Assessment and Diagnostic Process in Children with ADHD 17
Research on Children with ADHD 19
Pharmacotherapy Research 21
Parent Training Intervention Research 21
In-Home Parent Training 25
The Role of Fathers in Childhood Behavior Problems 25
The Role of Social Reciprocity in Parent Training 27
Summary 28
v

3METHOD
37
Rationale for Use of Single Subject Design 37
Research Plan 39
Recruitment of Subjects 39
Inclusion Criteria 40
Exclusion Criteria 40
Instruments for Describing Subjects 41
Description of an In-Home Parent Training Intervention for Fathers 43
Procedure for Implementing the Parent Training Intervention 44
Condition A - Baseline 44
Condition B - Introduction of Parent Training Sessions 1, 2, and 3 45
Instruments and Procedure for Measuring the Dependent Variables 45
In-Home Observation 46
Behavioral Observer Training 47
Behavioral Response Categories 48
4 RESULTS 51
Father and Child Dyad A 51
Frequencies of Target Behavior 55
Visual Report of Data 57
Father and Child Dyad B 59
Frequencies of Target Behaviors 62
Visual Report of Data 64
Father and Child Dyad C 65
Frequencies of Target Behaviors 68
Visual Report of Data 70
Father and Child Dyad D 72
Frequencies of Target Behaviors 75
Visual Report of Data for Father and Child Dyad D 78
Summary of the Four Father and Child Dyads 79
Interobserver Agreement 83
Social Validity 84
5 DISCUSSION 104
Interpretation of Findings 105
Utility of Single Subject Design in Nursing Research 107
Limitations Associated with this Research 109
Implications for Clinical Practice 111
Recommendations for Future Research 112
vi

APPENDIX
A OPERATIONAL DEFINITIONS FOR DEPENDENT VARIABLES 114
B PARENT TRAINING INTERVENTION FOR FATHERS OF YOUNG
CHILDREN WITH ADHD 117
Ground-Rules 117
Homework 117
Schedule 117
Parent Training Session 1 118
Parent Training Session 2 118
Parent Training Session 3 119
C THE PARENTING SCALE 120
D INTERACTIONS QUESTIONABLE 122
E HOLLINGSHEAD FOUR FACTOR INDEX OF SOCIAL STATUS 130
F CHILD BEHAVIOR CHECKLIST 132
G THERAPY ATTITUDE INVENTORY 136
H SEMI STRUCTURED QUESTION AIRE 137
REFERENCES 139
BIOGRAPHICAL SKETCH 153
vii

LIST OF TABLES
Table Page
2-1 Review of parent training literature 30
3-1 Correspondence between instrumentation and sample characteristics 49
3-2 In-home parent training intervention for fathers 49
3-3 Timeline for the parent training intervention 49
3-4 Procedure for instrumentation and videotaping 50
3-5 Correspondence among the variables, instruments, and measurements 50
4-1 Summary of Father A effectiveness in discipline 85
4-2 Summary of Father A beliefs about child noncompliance 85
4-3 Means of target behaviors for Father A and Child A 85
4-4 Summary of Father B effectiveness in discipline 86
4-5 Summary of Father B beliefs about child noncompliance 86
4-6 Means of target behaviors for Father B and Child B 86
4-7 Summary of Father C effectiveness in discipline 87
4-8 Summary of Father C beliefs about child noncompliance 87
4-9 Means of target behaviors for Father C and Child C 87
4-10 Summary of Father D effectiveness in discipline 88
4-11 Summary of Father D beliefs about child noncompliance 88
4-12 Means of target behaviors for Father D and Child D 88
4-13 Comparison of family demographics 89
viii

4-14 Comparison of descriptive data for subjects at completion of study 90
4-15 Mean and range of interobserver agreement 91
4-16 Comparison of means of reported scores of father’s perceptions 91
4-17 Summary of father’s satisfaction with parent training 91
IX

LIST OF FIGURES
Figures Page
1 -1 Parent training process 12
4-1 Father A initiations and Child A initiations 92
4-2 Father A responding behaviors 92
4-3 Child A responses and imitation with animation 93
4-4 Father A initiations and Child A responses 93
4-5 Father A and Child A turn taking 94
4-6 Father B initiations and Child B initiations 94
4-7 Father B responding behaviors 95
4-8 Child B responses and imitation with animation 95
4-9 Father B initiations and Child B responses 96
4-10 Father B and Child B turn taking 96
4-11 Father C initiations and Child C initiations 97
4-12 Father C responding behaviors 97
4-13 Child C responses and imitation with animation 98
4-14 Father C initiations and Child C responses 98
4-15 Father C and Child C turn taking 99
4-16 Father D initiations and Child D initiations 99
4-17 Father D responding behaviors 100
4-18 Child D responses and imitation with animation 100
x

4-19 Father D initiations and Child D responses 101
4-20 Father D and Child D turn taking 101
4-21 Comparison of father responding behavior during Condition A 102
4-22 Comparison of father responding behaviors during Condition B 102
4-23 Comparison of target behaviors during Condition A 103
4-24 Comparison of target behaviors during Condition B 103
xi

Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of
the Requirements for the Degree of Doctor of Philosophy
ENHANCING INTERACTIONS OF FATHERS AND THEIR CHILDREN
WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER
By
Deborah Ann White
May, 2004
Chair: Jennifer H. Elder
Major Department: Nursing
The purpose of this research was to characterize the interactions of four fathers
and their 3- to 6-year-old children with Attention Deficit Hyperactivity Disorder
(ADHD); and evaluate the efficacy of an in-home parent training intervention on father
behaviors, father acquisition of parent training skills, and child behaviors. In addition,
questions were addressed on the social value of the training intervention and the effects
on father-child interactions.
Descriptive data were obtained before and at completion of the study on fathers’
beliefs about effectiveness in discipline, their children’s behavior problems, and the
causality of their children’s problem behavior. Fathers were taught parenting and
discipline strategies during three in-home parent training sessions. After the parent
training sessions, each father was videotaped in his home during father-child play
sessions (approximately twice per week for 8- to 12-weeks). A single subject, AB design
was used to determine the relationship between the two conditions of our study. Direct

behavioral counts of targeted father behaviors and targeted child behaviors during 10-
minute videotaped sessions were recorded. Interrater reliability was 85% with a range
from 76 to 93%. After parent training, the fathers showed increased use of positive
responses and the imitation with animation skill. In addition, child initiations and child-
initiated turns with affirmation increased. Conversely, a decrease was evident in the
father initiations, corrective responses, and father-initiated turns with affirmation.
Results suggest a consistent positive effect of the parent training intervention on the
fathers’ use of parenting strategies, the targeted father behaviors, and the targeted child
behaviors. Despite father reports of minimal improvement in discipline effectiveness and
little change in the child’s problem behavior, social validity data indicate that fathers
were satisfied with the process and outcome of parent training.
Findings reported in our study provide contextual information on the interactions
of fathers and their children with ADHD with implications for further research.
Comprehensive parent training interventions that facilitate child-directed play, match
treatment to fathers on the basis of cognition, and incorporate specific father-child play
strategies are essential for further work with fathers of children with ADHD.
xm

CHAPTER 1
INTRODUCTION
Analysis of the Parent Training Concept
The training and use of parents in therapeutic roles as change agents for their
children has been documented in nursing science and the social sciences (Anastopoulos,
Shelton, DuPaul, & Guevremont, 1993; Elder, 1995; Erhardt & Baker, 1990; Gross,
Fogg, & Tucker, 1995; Kazdin, 1997; Sanders, Markie-Dadds, Tully, & Borr, 2000;
Webster-Stratton, 1982, 1984, 1994, 1998). Unfortunately, conceptual problems in the
literature affect the characterization and utility of parent training in current research.
Various conceptual definitions of parent training, confusing professional jargon, and
weaknesses in parent training interventions create ambiguity in nursing and across
disciplines (Elder, 1997b). In addition, little theoretical support is documented for parent
training interventions for fathers of children with Attention Deficit Hyperactivity
Disorder (ADHD) (Schuhman, Foote, Eyberg, Boggs, & Algina, 1998). Consequently,
the synthesis of existing knowledge is essential for concept development, to define parent
training in terms of its critical attributes or essence, and for the characterization of parent
training for fathers of children with ADHD.
This chapter gives an analysis of the parent training concept. Theoretical
perspectives and related concepts are discussed. Theoretical significance of the parent
training concept in nursing and an operational definition are given, followed by an
explanation of a parent training model. This conceptual foundation provides the
1

2
theoretical basis for evaluating the parent training intervention for fathers of children with
ADHD. Further study is intended to:
• Promote the understanding of parent training and expand the base of knowledge
in nursing and among disciplines.
• Determine the most effective methods for training fathers of children with
ADHD.
• Facilitate father-child interactions.
• Develop and examine a nurse-parent trainer role.
Analyzing the Range of Meaning of the Parent Training Concept
Review of the literature reveals many inconsistencies and weaknesses in the
concept of parent training. Confusing terminology that describes parent training
exclusively in professional jargon within a discipline has limited its utility among the
social sciences (Elder, 1997b). In addition, the concept of parent training often has a
negative connotation suggesting that parents lack the innate skills (or choose not to use
the appropriate skills), and must be taught to effectively parent their children. Other
researchers propose “cookbook solutions” and self-help advice for managing difficult and
challenging problem behaviors in children. Unfortunately, misconceptions in the
literature, poorly defined terminology, and confusing jargon have insufficiently described
the complexity of the parent training process. Consequently, providers of parent training
have the burden of proving the exact strategy in each unique situation.
Particularly significant is the controversy regarding differing strategies of positive
reinforcement; and the use of negative reinforcement such as aversive techniques,
extinction, and/or punishment (National Institutes of Health [NIH], 1989). Researchers
have questioned the moral integrity and ethics of aversive, intrusive, and restrictive
practices (LaVigna, & Donellan, 1986). Nonaversive reinforcement alternatives that

3
achieve similar results have been suggested for children with problem behavior.
Advancement of the parent training concept is challenging, given that few nonaversive
parent training interventions can be replicated to facilitate sound empirical assessment.
Further limitations in the literature include vague diagnoses or criteria for inclusion of
children with disruptive behavior (Table 2-1). For example, children are often identified
as disruptive, rather than accurately diagnosed. Other researchers fail to distinguish
among different parent training approaches, resulting in contradictions in the literature.
Poor generalization is evident across settings from the clinic, hospital, home, and/or
school. A final point is that parent training packages are often evaluated in their entirety,
without specific information about the effectiveness of each component.
Related Theoretical Perspectives
Variations in parent training parallel the diversity of theoretical perspectives. A
review of current research revealed a number of theoretical frameworks that have been
used to describe the complex interactions among parents and their children. Theories of
symbolic interactionism, social-interaction, coercion, self-efficacy, attribution, and
physiology seem to be particularly applicable to our research.
Symbolic interactionism reflects the self, the world, and social action (Bowers,
1988). The self and the world are perceived as dynamic, constructed processes of social
interaction. Individuals cannot be understood outside of the social context (Hutchinson,
2000). Social-interaction theory is derived from symbolic interactionism. This theory
addresses the importance of interactions among parents and their children. Children
respond to the parents’ behavior. Parent behavior is affected by feedback that parents
receive from their children. Patterson (1982) suggests that the persistence of positive
effects associated with behavioral effort, is a function of parents’ reactions to changes in

4
their children. Unless improvements in the children’s behavior alter the parents’
reactions, the effects will be short-lived. Social-interaction theory is supported by
decades of research on various aspects of parent training (Griest, Forehand, Wells, &
McMahon, 1980; Patterson, Capaldi, & Bank, 1991, Patterson, Reid, & Dishion, 1992).
Coercion theory is a blend of conceptual views derived from social-interaction
theory that illustrates an escalating cycle of coercive parent-child interactions. Behaviors
of parents and their children are a direct reflection of events occurring in the natural
environment. Parents of hyperactive children provide more commands, reprimands, and
punishment (Barkley, 1990). Patterson et al. (1991, 1992) suggest that a child’s
compliance with parental commands relates to the intensity of the parental directives,
physical abuse, and/or parental hostility. The child’s problem behavior is coupled with
negative parent verbalizations, and results in the parent’s withdrawal or failure to follow
through with a command. Each person is reinforced for increasingly negative and
aggressive behaviors. Interdependent negative behavior between parents and their
children contributes to the evolution of childhood behavior problems.
Ineffective parental management strategies are suggested as the cause for entry
into this coercive cycle (Patterson et al. 1991). Researchers have shown that training
approaches for parents of children with ADHD may effectively manage and improve
problem behaviors (Anastopoulos, Shelton, DuPaul, Guevreont, 1993; Erhardt, & Baker,
1990; Pelham, Wheeler, & Chronis, 1988; Pisterman, Firestone, McGrath, Goodman,
Webster, Mallory, & Goffin, 1992). Thus, parent training interventions for the
management of problem behaviors in children may be a crucial step that halts the child’s
upward spiral of aversive, coercive behavior (Kendziora, & O’Leary, 1993).

5
Self-efficacy theory (Bandura, 1977) is derived from social-learning theory. This
theory has been defined as an estimation of parents’ perception of competence in
performing various tasks (Coleman, & Karraker, 1998). Parents with high efficacy have
greater responsiveness, work diligently to provide positive experiences for their children,
and are better able to deal with the challenges of parenting a difficult child (Mash, &
Johnston, 1983; Elder, 1995). Research on parent training interventions shows improved
maternal self-efficacy, reduced maternal stress, and improved mother-child interactions
(Gross, Fogg, & Tucker, 1995; Webster-Stratton, 1990).
Fathers of children with ADHD face unique challenges (associated with problem
behavior, long-term behavior management, health care, and treatment). Parent training
interventions that target improving a father’s competence, perceptions regarding his
ability to help his child, and effectiveness in discipline may enhance the father’s self-
efficacy and promote positive father-child interactions. Father self-efficacy and effective
parenting skills are crucial in the management of behavior problems in children with
ADHD. Therefore, coercion theory and self-efficacy theory facilitate the
operationalization of specific behaviors targeted for intervention, and provide a basis for
empirical assessment of our study.
Attribution theory has been used to explain the link between parental beliefs and
child behavior (Dix, & Grusec, 1985). Dix & Grusec describe parental beliefs as
expectations with internal and external components. Internal attributes in the child are
traits that include personality, intellectual ability, and temperament. External attributes
are traits that the child is assumed to control (or have the ability to control) such as
intention or mood. Typically, parents are more upset by problem behavior in their

6
children if perceived as an intentional act, a negative disposition, or if parents believe the
child has the knowledge to behave differently. Often, these perceptions result in a
negative parent reaction (Miller, 1995). For example, a child with ADHD hits the father
each time he tries to play with the child. If the father attributes the cause of his child’s
behavior internally, he may be convinced that his child is “mean.” On the contrary, if the
father attributes the cause of hitting externally, the father may perceive the child is trying
to communicate and interact in the only method he knows. Appropriate father beliefs
may alter immediate reactions to the child’s behavior, encourage positive responses, and
result in the father teaching his child to communicate in a socially appropriate manner.
Furthermore, cognitive development in children may be adversely affected or
enhanced by parental flexibility or rigid adherence to previous knowledge, and parental
receptiveness to new knowledge (Miller, 1995). In addition to flexibility and
receptiveness, parental sensitivity to the child may be a critical variable in the parent
training concept. An informed and sensitive parent may have more reliable expectations.
These affective reactions mediate the link between the parent’s attributions for their
children’s problem behavior and the subsequent parent behavior (Miller, 1995; Slep, &
O’Leary, 1998). Parents who believe their child is capable of controlling problem
behavior may be more likely to seek behavioral interventions. On the contrary, parents
who believe their child is incapable of controlling problem behavior may not be
interested in behavior interventions. Hence, a father’s beliefs about the causality of his
child’s problem behavior may be an important factor that influences the father’s
reactions, choice of treatment, and treatment compliance.

7
Attention Deficit Hyperactivity Disorder (ADHD)
Attention Deficit Hyperactivity Disorder (ADHD) is understood as a psychiatric
condition exacerbated by the environment; and identified as a set of dysfunctional
relationships between an individual with a certain predisposition and an environment that
generates particular expectations, demands, and reactions (Weaver, 1993). Current
theories suggest that ADHD is a deficiency in the sensitivity to reinforcement that
typically motivates children to perform work, inhibit behavior, and sustain responses to
assigned tasks (Barkley, 1990; Haenlein, & Caul, 1987). Barkley (1997) asserts that poor
behavioral inhibition is the central impairment in children with ADHD, and results in
deficiencies in self-control. Consequently, individuals with ADHD may be less
sophisticated in manipulating physical and social environments, and have fewer abilities
in self-regulation, attention, and memory (Baird, Stevenson, & Williams, 2000).
Baird et al. (2000) argue that self-inhibition is closely intertwined with the
evolution of language and coordination among areas of the brain (dopaminergic and
noradrenergic systems). Thus, ADHD may be viewed as a disorder of communication as
well as behavior. Cognitive processes that assess social context and communication (and
coordinate behavior) are impaired. Pragmatic social skill deficits are thought to
synergistically interact with behavioral problems, and compound the physiological
deficits in children with ADHD.
In summary, ADHD deficits in physiological systems affect cognitive processes,
communication, and socially appropriate behavior. Parent training interventions that
address physiological deficits, that use behavioral strategies, and that address social skills
increase the magnitude of reinforcement for appropriate behavior in children with ADHD
(Anastopoulos, DuPaul, & Barkley, 1991). Thus, knowledge of parent training

8
approaches is potentially important for clinicians and researchers involved in developing
and evaluating behavior-management interventions for children and their parents.
Theoretical Significance in Nursing
Theories of symbolic interactionism, social-interaction, coercion, self-efficacy,
attribution, and physiology contribute to the operationalization of the parent training
concept, and are consistent with King’s general system framework (1981) and theory of
goal attainment (1992). That is, reciprocal interactions with parents as well as
environmental factors contribute to the nature of relationships. The fundamental belief is
that human beings interact with their environment. An individual’s perceptions, goals,
needs, and values influence this interaction; and contribute to the individual’s health and
ability to function in social roles. Individuals are characterized as rational, perceiving,
controlling, purposeful, time-oriented social beings; that actively participate toward set
goals with a symbolic way of communicating thought, actions, and beliefs. Health is
viewed as a dynamic life experience that implies a continuous adjustment to
environmental stress. These assumptions address the rationality of an individual’s ability
to perceive, interpret, and solve problems; and identify a shared collaborative process of
clients and nurses to exchange information, identify goals, and explore the means to
attain desired goals (King, 1992).
Describing the interaction process within a general system framework and within
the theory of goal attainment helps to operationalize the parent training concept. The
concept of parent training is dynamic and contextually dependent, and useful in the
behavior management of children. Furthermore, King’s description of health is
harmonious with current educational and behavioral trends that incorporate
individualized, intensive, parent training interventions for the treatment of children with

9
ADHD. Therefore, King’s interacting general system framework is used to
operationalize the parent training concept and as the basis for interpreting findings in our
study.
Parent Training Research in Nursing
The science of nursing examines the interactions of individuals within families,
communities, and society to understand the biological human being, the psychology of
human existence, and the sociology of human relationships (American Nurses
Association, 1995). Nurses are unique in their approach to health-care concerns with a
solid theoretical foundation as a basis for developing and interpreting culturally sensitive,
individualized clinical interventions. Furthermore, advanced practice and doctoral
prepared nurses are knowledgeable and skilled in diverse research methodologies,
populations, settings, and interventions (Elder, 1995; Gross, Fogg, & Tucker, 1995;
Tucker, Gross, Fogg, Delaney, & Lapporte, 1997; Webster-Stratton, 1982, 1984, 1994,
1998).
Particularly interesting within nursing research are multi-component parent
training interventions for children with behavior problems (Elder, 1995, 1996; Webster-
Stratton, 1994, 1998). Various approaches to parent training include individual or group
training, didactic counseling, clinic instruction, direct in-home interventions, self-
instructional methods, and school-based interventions. For example, Webster-Stratton
(1984) used a videotaped modeling intervention and group discussion to provide parents
with knowledge and skills for effective interaction and communication with their
conduct-disordered children. Gross, Fogg, and Tucker (1995) used Webster-Stratton’s
(1984) behavioral parent training intervention to test the effectiveness of a parent training
program for promoting positive parent-child relationships among families of toddlers

10
with problem behavior. Webster-Stratton and Hammond (1997) compared three
treatment conditions of a parent training intervention for parents of children with early-
onset conduct problems, to evaluate generalization and clinical effectiveness of existing
parent training program.
Elder (1995) used single subject design methodology to determine the effects of
an in-home, communication program for training parents of handicapped children.
Elder’s research incorporated an in-home parent training intervention with five
components including social play, turn taking, communication, language, and
conversation. The parent training intervention was designed to address the
communicative intent of child behavior and promote social reciprocity (in an effort to
reduce aberrant behaviors and facilitate balanced parent-child interactions). Our study
builds on Elder’s (1995) parent training intervention in a new population. Behavioral
strategies for fathers of young children with ADHD were incorporated into the parent
training intervention in the context of father-child play, to improve father-child
communication, and to promote positive interactions between fathers and their children
with ADHD.
Operationalization of Parent Training
The concept of parent training is dynamic and contextually dependent, is useful
for managing behavior of children, and represents a behavioral phenomenon of
significant interest to nurses. The proposed theoretical associations in parent training are
enhanced by a clear operational definition. Elder (1997, pp.103-104) defines parent
training as:
• A dynamic, interactive, and instructional process by which caretakers (parents)
perceive, assimilate, and use knowledge about their own children in such a way as

11
• To modify maladaptive and/or deficit behaviors, which in turn will promote the
health and general well being of their children and families.
• To facilitate the children’s learning and successful current and future
environmental adaptation within their homes and communities.
Critical attributes derived from this definition include contextual clarification,
assessment, training, intervention development and implementation, and the evaluation of
intervention effectiveness (Figure 1-1). This analysis delineates the dimensions of the
parent training concept, clarifies ambiguities, and provides guidance for our study.
Furthermore, it is expected that this parent training model may bridge gaps in existing
knowledge, and provide a foundation for effective clinical practice and research in
interventions for problem behavior in children with ADF1D.
Statement of the Purpose
The purpose of this research was to characterize the interactions of fathers and
their child with ADHD and evaluate the efficacy of an in-home parent training program
designed for fathers. The specific aims are:
• Characterize the interaction of fathers and their young children with ADHD during
father-child play sessions before father participation in an in-home parent training
intervention for fathers.
• Evaluate the effects of a 12-week in-home parent training intervention (for fathers
of young children with ADHD) on father behaviors and father acquisition of
parenting skills.
• Evaluate the effects of a 12-week in-home parent training intervention (for fathers
of young children with ADHD) on child behaviors.
Assess the social validity of the in-home parent training intervention for fathers.

Parent Training Process
Mutual Development
Phase 1 Phase 2 Phase 3 Phase 4
Assessment Treatment
Intervention Development
Intervention Implementation
Evaluation of
Parent
Mutual
Parent
Data
Development
Implements
Analysis
Child
Targeted
Overview of
Behavior
Progress
Home
Techniques
Assessment
In-home
Role-model
Videotaping
Consumer
Satisfaction
Environmental
Direct
Changes
Observations
Proficiency
Criteria
Figure 1-1. Parent training process (Elder, 1995)

CHAPTER 2
REVIEW OF LITERATURE
The purpose of this review is to provide a general overview of the parent training
concept as it relates to treatment for young children with ADHD. Current research is
given on the characteristics of ADHD and the assessment and the diagnostic process in
children; followed by a review of research on pharmacotherapy, parent training
interventions, social reciprocity, and the role of fathers in childhood behavior problems.
The Nursing Practice Analysis Tool (NPAT) (Moody, 1990) was used to assess
research on parent training interventions for children with problem behavior in several
disciplines (1983-2004) (Table 2-1). Most of the research is considered empirically
supportive. However, few researchers have shown parent training interventions that used
appropriate data collection and analysis for parents of children with ADHD. Many
studies had small sample sizes that were inadequate for the statistical analyses, or used
complex procedures that discouraged replication.
Conceptual ambiguity regarding parent training in the literature (as well as the
lack of research with theoretically based, parent training models) further complicates the
treatment approach for children with ADHD. Equally important is that young children
with ADHD are at substantial risk for future impairment. Parents are often confused and
frustrated by controversial research on stimulant therapy, the efficacy of parent training
approaches, and the lack of appropriate resources. Furthermore, parent training on
behavioral contingencies related to punishment may not be appropriate for parents who
are already prone to violence or abusive interactions. Consequently, there is a need for
13

14
interactive, individualized, and comprehensive parent training interventions that address
parents’ beliefs, family risk factors, obstacles to treatment, and problem behavior in
children with ADHD.
Features of ADHD in Young Children
Attention Deficit Hyperactivity Disorder is a chronic psychological condition
(identifiable in the preschool age range) that occurs more often in boys than girls, and
accounts for 30 to 50% of pediatric mental-health referrals (American Academy of
Pediatrics [AAP], 2000; Multi-Modal Treatment of ADHD Cooperative Group [MTA],
1999; U.S. Public Health Service, 1999). Prevalence rates for ADHD have varied
substantially because of changes in diagnostic criteria, assessment in varied settings,
differences in methods of sample selection, and differences in the nature of the
population studied (American Academy of Child & Adolescent Psychiatry [AACAP],
1997; American Psychiatric Association [APA], 1968, 1980, 1987, 1994; Barkley, 2000).
Currently, the Diagnostic and Statistical Manual for Mental Illness-IV (DSM-IV) cites a
prevalence rate of 3 to 5% in school-age children having ADHD (APA, 1994). Other
studies have reported a prevalence range of 2.5 to 6.4% in elementary school-age
children (DuPaul, 1991; Pelham, Gnagy, Greenslade, & Milich, 1992). Girls with ADHD
share with boys the symptoms of inattention, hyperactivity/ impulsivity, school failure,
and comorbidity with mood, anxiety disorders, and learning disabilities (Faroane,
Biederman, Keenan, & Tsuang, 1991; Gaub, & Carlson, 1997). However, fewer girls
than boys receive a diagnosis of ADHD, possibly due to less prevalent rates of comorbid
oppositional disorder and conduct problems.
The core deficit in ADHD is a failure to inhibit or delay motor responses, while
sensory detection or early information processing is intact (Barkley, 1994, 1997).

15
Inadequate response inhibition creates a deficit in four distinct executive functions:
emotional regulation, nonverbal working memory, speech internalization, and self-
directed play (Barkley, 1990, 1997, 2000). The deficits in executive functioning affect
motor coordination, mental calculation, rule-governed behavior, speech and fluency, and
the evolution of language (Baird et al. 2000; Barkley, 2000). Baird et al. (2000) describe
ADHD as a disorder of communication, with problem behaviors that reflect dysfunction.
Cognitive processes are impaired that coordinate behaviors for assessing social context
and communication. Consequently, children with ADHD are less sophisticated in
manipulating physical and social environments, and have difficulties with attention,
memory, and self-regulation.
Reportedly, children with ADHD lack positive problem-solving skills, react in
coercive ways, anticipate fewer consequences, have social deficits, and have impaired
communication skills (Ladd, Price, & Hart, 1990; Mize, & Cox, 1990; Puttallaz, &
Wasserman, 1990; Slaby, & Guerra, 1988). Deficits in social skills interact
synergistically with behavioral problems and compound the physiological deficits.
Intervention during the preschool years is critical, and may be more effective than
intervention after age seven (Baird et al. 2000). Reasons for this include that young
children have a shorter learning history associated with problem behavior, have fewer
competing external influences, and have fewer cognitive resources for questioning and
challenging behavioral interventions (Hembree-Kigin, & McNeil, 1995). In addition,
young children are more accepting of new behavioral expectations, and exhibit affection
toward their parents (and cooperative behaviors that can be shaped to occur more
frequently).

16
Characteristics of ADHD
Attention Deficit Hyperactivity Disorder is characterized by inattention and/or
hyperactivity-impulsivity with impairment in academic achievement and family and peer
relationships (APA, 1994). The DSM-IV (APA, 1994) defines inattention as failing to
give close attention to detail, difficulty sustaining attention, and poor listening; failing to
finish work, difficulty organizing, and avoidance of sustained mental effort; and losing
things, distractibility, and forgetfulness (APA, 1994). Hyperactivity includes behaviors
such as fidgeting and the inability to stay seated; excessive running, climbing, or talking;
and difficulty playing quietly. Impulsivity is described as blurting out answers, difficulty
in waiting for a turn, and interrupting or intruding on others.
The core clinical features of ADHD may be detected as early as 3-years-old, may
lead to significant social and emotional impairments, and often have comorbid disorders
(Campbell, 1995; Campbell, & Ewing, 1990; Klein, & Manuzza, 1991). Young children
with high levels of socially aggressive behavior constitute a high-risk population for
further impairment in academics, peer relationships, and general adaptive functioning
(emotional and social difficulties), and an earlier onset of conduct disorder, oppositional-
defiant disorder, and antisocial behavior (Barkley, DuPaul, & MacMurray, 1990; Loeber,
1990). There has been considerable debate concerning the legitimacy of hyperactivity as
a diagnosis (Hinshaw, 1994). However, controversy does not exist concerning the
significant number of children who suffer from symptoms associated with ADHD, social
and academic impairments, and comorbid conditions.
Parents of children with ADHD often have high rates of socially aggressive
behavior, harsh child discipline, marital strife, and a high risk of psychiatric disturbances
(Barkley, Guevremont, Anastopoulos, & Fletcher, 1992; Patterson et al. 1992).

17
Furthermore, factors such as a family history of ADHD, psychosocial adversity, and
comorbid conditions all increase the risk of persistence of ADHD symptoms into
adolescence and adulthood (Biederman, 1998). Marakovitz and Campbell (1998)
reported that one-half of children who exhibited problem behaviors at preschool age had
improved by age six. On the contrary, one-half of children continued to exhibit persistent
problems (one-third of which met DSM-III criteria for ADHD). Children with persistent
problems at age six were more likely to have an externalizing disorder at age nine. In
summary, young children diagnosed with ADHD constitute a high-risk population for
significant impairment in adolescence and adulthood. Therefore, the selection of young
children with ADHD for participation in our study is an appropriate strategy.
Assessment and Diagnostic Process in Children with ADHD
The diagnosis of ADHD according to the DSM-IV requires the presence of six or
more extremely inappropriate symptoms in each symptom group (inattention,
hyperactivity, and impulsivity) for at least six months (APA, 1994). Symptoms are
evident before age seven and are inconsistent with the child’s developmental level and
intellectual ability. Functional impairment must be present in two or more settings, with
clinically significant impairment in social, academic, or occupational functioning. Signs
of ADHD may not be observed in highly structured or novel settings. Conversely,
symptoms typically worsen in unstructured and minimally supervised situations.
Assessment of children with behavior problems may include a parent interview, a
child interview, standardized rating scales (Achenbach, 1991; Conners, 1969; Barkley,
1990), behavior observations in naturalistic settings and/or clinical settings, medical
evaluations, speech and language evaluations, and psychological testing. The core of the
assessment process is a structured parent interview to ensure coverage of ADHD

18
symptoms, and to rule out psychiatric or environmental causes of behavioral symptoms
(AACAP, 1997). Reports of behavior, learning, school attendance, academics, social
skills, and psycho-educational testing are essential. Standardized instruments are used to
obtain information from parents, teachers, social workers, and guidance counselors.
Structured observations in naturalistic and clinical settings assist in distinguishing
hyperactive and aggressive behaviors, the teacher’s management style, and characteristics
of the social and academic environment (AACAP, 1997; Vitaro, Trembley, & Gagnon,
1995).
A variety of disorders may be mistaken for ADHD (e.g. impaired vision or
hearing, seizures, head trauma, acute or chronic medical illness, poor nutrition,
insufficient sleep, anxiety disorders, depression, bipolar conditions, mental retardation,
and learning disabilities). Therefore, a medical evaluation is essential to a differential
diagnosis and the determination of comorbid conditions. Included in the medical
evaluation are a complete medical history, a physical exam, and laboratory tests when
indicated by history (e.g., lead level or thyroid function). Clinical assessments of hair
analysis and/or zinc have no empirical support and are not indicated (McGee, Williams,
Anderson, McKenzie, Parnell, & Silva, 1990). The child’s and family’s histories include
questions related to the use of prescribed, over-the-counter, and illicit drugs; lead
screening; thyroid disease; genetic syndromes such as fragile X syndrome and fetal
alcohol syndrome; risk factors such as poor maternal health, smoking, toxemia,
postmaturity; and health problems or malnutrition in infancy. Neurological testing may
be indicated by the medical evaluation. However, brain mapping and neuro-imaging are
not used in the diagnosis of ADHD because of insufficient empirical data (AAP, 2000b).

19
Research on Children with ADHD
Historically, the behavior problems of preschool children were considered
transient processes that resolved as children matured. However, current researchers
assert that children with an early onset of behavior problems in the preschool and
kindergarten years are at a higher risk for emotional and externalizing behavior problems
during later childhood, adolescence, and adulthood (Barkley, DuPaul, & MCMurray,
1990; Campbell, March, Pierce, Ewing, & Szumowski, 1991). In addition, 70% of the
children with ADHD have comorbid conditions that complicate the process of diagnosis
and treatment (MTA, 1999). Research on family heterogeneity of ADHD reveals that
ADHD and major depression share similar familial vulnerabilities; and comorbidity with
conduct disorders and bipolar disorders may be a distinct familial subtype (Biederman,
1998).
No single etiology leads to a diagnosis of ADHD. Emerging neuro-psychological
and neuro-imaging literature suggests that abnormalities exist in the brain’s frontal
networks in children with ADHD (Castellanos, 1997). Data from genetic, family, twins,
and adoption studies points to a genetic origin for some forms of ADHD (Faraone,
Biederman, Keenan, & Tsuang, 1992; Faraone, & Biederman, 1994). Other possible
etiologies include psychological adversity, perinatal insults, low birth weight, and yet-
unknown biological causes (Biederman, 1998).
Researchers have proposed that various environmental toxins (e.g., food
additives, refined sugars, and allergens) produce a causal effect in the development of
ADHD. However, investigations of such associations failed to yield empirical support
(Wolraich, Milich, Stumbo, & Schultz, 1985; Wolraich, Wilson, & White, 1995).
Research supports a correlation between elevated blood lead levels in children with

20
hyperactivity and inattention as well as an association with maternal alcohol consumption
and cigarette smoking during pregnancy (Gittelman & Eskinazi, 1983; Milberger,
Biederman, Faraone, Chen, & Jones, 1996; Streissguth, Bookstein, Barr, & Sampson,
1994).
Various interventions that involve medication, parent training, behavior
modification in the classroom, and combined treatments have been studied extensively in
elementary school-age children with ADHD (Abramowitz, Eckstrand, O’Leary, &
Dulcan, 1992; Anastopoulos et al. 1993; Greenhill, 1998; Mustin, Firestone, Pisterman,
Bennett, & Mercer, 1997; MTA, 1999; Pelham, Wheeler, & Chronis, 1998; Pisterman,
Firestone, McGrath, Goodman, Webster, Mallory, & Goffin, 1992). The limitations of
this research included few long-term studies, only short-term gains of treatment efficacy,
a focus on boys, and a lack of evidence on differential improvement reported for
treatment conditions (Barkley, DuPaul, & McMurray, 1990; Klein, & Mannuzza, 1991;
McMahon, 1994).
In summary, the diagnosis of ADHD in a young child encompasses a complex set
of interacting child and family issues with an enormous impact on society in terms of
financial expense, stress to families, and interference with academic and vocational
activities (Biederman, 1998). Numerous studies have examined potential causes,
behavioral characteristics, and the cognitive, social, and academic impact of ADHD on
children (Barkley, 1996; Castellanos, 1997). Despite extensive research, ADHD remains
a controversial condition with respect to diagnosis and treatment. In many cases family
practice and pediatric clinicians are r quired to make important decisions regarding
diagnosis and treatment without the benefit of sound empirical data. Furthermore, the lay

21
media have perpetuated misconceptions often held by parents of children with ADHD
about vitamin therapy, diet therapy, decreased sugar consumption, poor parenting, and
the side effects of stimulant medication (Wolraich, Milich, Stumbo, & Schultz, 1985;
Wolraich, Wilson, & White, 1995). This is particularly troubling in that parental
involvement appears to be a critical component in the treatment of children.
Consequently, there is a dire need for empirically validated medical, psychological, and
educational services for children with ADHD and their families.
Pharmacotherapy Research
Research involving pharmacotherapy for children with ADHD is extensive.
Empirical study on stimulant therapy for children with ADHD reveals positive short-term
effects in multiple domains of functioning and a lack of evidence for long-term
improvement (Mash & Johnson, 1990; Pelham, Wheeler, & Chronis, 1998; Pelham, &
Lang, 1993; Swanson, McBumett, Christian, & Wigal 1995). Despite the limitations,
pharmacotherapy with stimulants is the current established treatment for ADHD (MTA,
1999). A lack of empirical support for long-term improvement provides the justification
for research involving behavioral interventions for children with ADHD.
Parent Training Intervention Research
Parents have an enormous influence (either positive or negative) on a young
child’s behavioral and emotional development. Unfortunately, parents of children with
ADHD often have high rates of socially aggressive behavior, harsh discipline, marital
conflict, and psychiatric illness (Patterson et al. 1992). These parents are less likely to
assume the cause of child behavior, more likely to use negative parenting strategies, and
more likely to mention medication therapy for their child (Barkley, 1990; Johnston, 1996;
Johnston, Reynolds, Freeman, & Geller, 1998). Coercive parenting practices may

22
adversely affect the development of the preschool child’s social-cognitive skills, and
predict conduct problems (Dodge, Bates, & Pettit, 1992; Eyberg, 1988; McMahon, 1994;
Patterson et al. 1991). Hence, parenting behavior and parent-child interactions are key
processes that affect child behavior (Richters et al. 1995).
Empirically supported parent training programs include clinical behavior therapy,
direct contingency management, cognitive-behavioral interventions, and intensive, multi-
component behavioral treatments. Pelham et al. (1998) reported that behavioral parent
training interventions and behavioral classroom interventions primarily in outpatient
settings are empirically supported treatments for children with ADHD. However, many
studies identify disruptive children because of symptoms associated with ADHD without
an explicit diagnosis. Other concerns include a lack of evidence in reducing children’s
conduct problems and improvement of social skills, and poor generalization of
improvements in social and cognitive skills from the laboratory, hospital, or school to
other settings (Denham, & Alemeida, 1987; Kazdin, Esveldt-Dawson, French, & Unis,
1987; Prinz, Belchman, & Dumas, 1994).
Contingency management approaches are similar to clinical behavioral therapy,
but are characterized by more intensive interventions including token economy systems,
time out, and response cost components. Research has been conducted in controlled
settings by trained individuals and often involved single subject design (Abramowitz et
al. 1992; DuPaul, Guevremont, & Barkley, 1992; Pelham, Carlson, Sams, Vallano,
Dixon, & Hoza, 1993). Treatment effects typically have been larger than the results of
clinical behavior studies, but less than results of pharmacotherapy studies (Pelham et al.
2000).

23
Cognitive behavioral treatments (e.g., verbal self-instruction, problem solving,
cognitive modeling, and social skills training) have been studied in children with ADHD
to promote self-controlled behavior. This approach was designed to provide internal
mediators that facilitated generalization and maintenance of behavioral effects.
Unfortunately, empirical evidence did not support clinically significant changes in the
behavior and/or the academic performance of children with ADHD (Abikoff, &
Gittelman, 1984). Limited, but promising data supports the efficacy of social skills
training and problem-solving interventions when combined with intensive, multi-
component, behavioral treatment packages (Pelham, & Hoza, 1996; Pfiffner, & O’Leary,
1997). Thus, intensive behavior-management treatment packages including parent
training interventions applied across settings may maximize the short-term impact of
behavioral treatments.
Research on parent training interventions for parents of preschool children has
been favorable for the reduction of behavior problems (Barkley, Shelton, Crosswait et al.
2000; Eyberg, & Robinson 1982; Tucker, Gross, Fogg, Delaney, & Lapporte, 1997;
Webster-Stratton, 1998). Parents were taught to use operant procedures during
interactions with their children to modify problem behavior with positive reinforcement
techniques based on Hanf s (1969) two stage training model (Barkley, 1987; Elder, 1995;
Eyberg, 1988; Webster-Stratton, 1982, 1985, 1994). This approach has been effective in
children with a wide range of behavior and maintained as long as a year (Kazdin et al.
1987).
Eyberg (1988) integrates operant methods and traditional play therapy techniques
in a unique approach to parent training for preschool children with problem behavior,

24
known as Parent-Child Interaction Therapy (PCIT). The purpose of PCIT is to create a
positive, mutually rewarding relationship between the parent and the child in the context
of dyadic play situations. Parents are taught relationship-enhancement skills (e.g., praise
and active listening), teaching skills (e.g., to follow the child’s lead in play and avoidance
of questioning, criticizing, or punishing the child), and behavior management skills for
effective discipline (e.g., direct commands and time-out). This approach is widely
utilized in the research of children with problem behavior (Eyberg, & Robinson 1982;
McNeil, Eyberg, Eisenstadt, Newcomb, & Funderburk, 1991; Webster-Stratton 1982,
1985, 1994). It has been adapted for use in children with varying exceptionalities (e.g.,
autism, developmental delay) (Elder, 1995; McElreath, & Hembre-Kigin, 1994).
Similar to the PCIT, Elder’s (1995) research with parents of young autistic
children incorporated a parent training intervention with five components (social play,
turn taking, communication, language, and conversation). Elder’s (1995) in-home, parent
training program is designed to address the communicative intent of child behavior, and
to promote social reciprocity in an effort to reduce aberrant behaviors. Parenting skills
(imitating with animation and expectant waiting) developed by MacDonald (1989) are
taught to parents. These skills are particularly important to facilitate balanced parent-
child interactions. In addition, parents of a child with autism are taught to identify child
initiations; to consistently respond to the child initiations; to give the child adequate time
to respond to parental initiations; and to allow the child to direct the parent-child play
session. This study provided essential information regarding the interactions between the
parents and their children for the development of a new parent training intervention for
parents of children with ADHD.

25
In-Home Parent Training
Seminal work conducted by Baer, Wolf, and Risley (1968) reveals that skills
taught in one setting are not expected to generalize to other settings without planned
systematic implementation. Furthermore, a deliberate change in behavior will not occur
unless the behavior is reinforced regularly in the environment. Therefore, father-child
interventions for problem behavior in children cannot be expected to generalize to home
settings unless the father and child are trained in familiar home environments where
naturally reinforcing activities were more likely to occur. Unfortunately, the majority of
parent training research takes place in clinical and classroom settings, rather than home
settings.
There are several disadvantages to conducting in-home research. These include a
vulnerability to disruption in session scheduling and the possibility that the physical
parameters of the home environment may cause unexpected interruption (Elder, 1995). A
modified structuring of the home setting (e.g., disconnected phone and television) can
minimize distractions. Despite the vulnerability to disruptions in session scheduling,
Elder (1995) found that parent participation was encouraged by in-home parent training
and videotaped father-child play sessions. Elder reported that subjects were more likely
to keep scheduled appointments and participate regularly at home because of the
convenience and decreased expenditure of the family resources. In addition, in-home
parent training and observation provided essential contextual data about individual
subjects in naturalistic settings.
The Role of Fathers in Childhood Behavior Problems
Reviews of parent training interventions with ADHD children were highly
promising (Webster-Stratton, 1993). However, parent training research was comprised

26
primarily of mother and/or classroom training (Cabrera, Tamis-LeMonda, Bradley,
Hofferth, & Lamb, 2000; Pruett, 1998; Webster-Stratton, 1985). Few studies document
the father’s perceptions, father-child interactions, and paternal influences on young
children with problem behavior (Amato, & Rivera, 1999; Hoza et al. 2000; MTA, 1999;
Webster-Stratton, 1985; Yogman, Kindlon, & Earls, 1995). Consequently, paternal
influences on children with ADHD and the patterns of father-child interactions are
largely unexplored. Hence, there is a critical need for research on parent training
interventions that include fathers.
Despite the under-representation of fathers, a growing interest is evident in the
relationship of paternal factors to child and adolescent adjustment (Phares, 1996; Rolf,
Masten, Cicchetti, Neuchterlein, & Weintraub, 1990). Fathers of children with ADHD
were more likely diagnosed with ADHD during their own childhood (Frick, Lahey,
Christ, Loeber, & Green, 1991). Parent psychosocial factors were shown to increase the
likelihood of the development of ADHD in children (Barkley, 1990). However, fathers
of children with ADHD did not have higher rates of depression or higher rates of alcohol
abuse (Cunningham, Benness, & Siegel, 1988; Reeves, Werry, Elkind, & Zametkin,
1987). On the contrary, fathers with a history of substance abuse had children with
higher rates of covert antisocial behaviors (Nigg, & Hinshaw, 1998).
Current research reflects that fathers have complex, multidimensional roles; direct
and indirect patterns of influence; and that the social construction of fatherhood varies
across cultures (Belsky, 1990; Cummings & O’Reilly, 1997; Furstenburg, 1988; Lamb,
1997; O’Hare, 1995; Pleck, & Pleck, 1997; Steinberg, Kruckman, L., & Steinberg, 2000).
Relationships with fathers, stepfathers, and sets of families influence a child’s

27
attachments, social-emotional competencies, and linguistic and cognitive abilities
(Cabrera et al. 2000). Research on father involvement in childcare has shown improved
father-child relationships, more attentive fathers, and fathers that felt intrinsically
important to their children (Amato & Rivera, 1999; Lamb, 1997). An inverse
relationship was reported between father involvement and childhood behavior problems,
cognitive development, and social competence (Amato, & Rivera, 1999; Yogman,
Kindlon, & Earls, 1995).
Father involvement in childcare during the middle childhood period was
associated with greater academic achievement, less emotional distress, and less
delinquent behavior (Furstenberg, & Harris, 1993; Harris, Furstenberg, & Marmer, 1998;
Nord, Brimhall, & West, 1997). In addition, Webster-Stratton (1985) reported significant
improvement in fathers’ attitudes and children’s behavior after a parent training
intervention. In summary, interdependent behavior between a father and a child may
contribute to the evolution of behavior problems and improved treatment outcomes for
fathers and their children. Further exploration is necessary to develop an understanding
of the father’s role, the complex patterns of influence on children, and to facilitate
interventions that support positive father-child interactions. Further research on father-
child interactions will support the development of specific, individualized parent training
interventions for families of children with ADHD.
The Role of Social Reciprocity in Parent Training
Lamb & Easterbrooks (1981) propose that infants are biologically predisposed to
emit signals to which adults are biologically predisposed to respond. If the parent
consistently responds promptly and appropriately to the infant’s signals, the infant
perceives the parent as predictable and reliable. This perception in social reciprocity

28
fosters the formation of secure child and parent attachments. Reciprocal parent and child
turn taking is considered an essential factor in language development (Elder, 1995;
Furrow, Nelson, & Benedict, 1979; Wetherby, 1986). Children with ADHD often have
impairments in speech, language, and communication and may not engage in turn taking
procedures (Baird et al., 2000; Cunningham, Reuler, Blackwell, & Deck, 1981; Conti-
Ramsden, 1990). Consequently, fathers may not be reinforced to continue interactions
with their children. Thus, children with ADHD may have maladaptive deficits in
cognitive processes and communication that create problems in a variety of social
contexts.
Coercive parent-child interaction and parent-controlled interactions may add to
further aberrant behavior in children with ADHD. In contrast, parents are more likely to
adjust their behavior if they are sensitive to the developmental changes in their children’s
abilities and preferences (Lamb, 1997). In addition, Lamb (1997) confirmed the
prominence of play in the father-child interactions and reported that fathers initiated more
physical and idiosyncratic types of play preferred by young children. Hence, father-child
interactions in the context of play may foster communication and turn taking behavior.
Summary
Children with ADHD have an enormous impact on society in terms of financial
expense, stress to families, and academic and vocational impairment (Biederman, 1998).
Parent training has been empirically supported as a powerful tool for clinicians and
researchers in the behavior management of children with ADHD. A major limitation in
current research is the lack of father participation. Consequently, there is a dire need for
empirically validated interventions for fathers and their child with ADHD. Our study
uniquely characterizes the interactions of fathers and their young children with ADHD,

29
provides important contextual data, and empirically evaluates the effects of an in-home
parent training intervention for fathers. Father-child interactions are examined and the
separate components of the parent training intervention are evaluated. Our study
provides valuable information for further development and/or refinement of the parent
training intervention and is critical for the development of a comprehensive in-home,
family-centered intervention for parents and their children with ADHD.

Table 2-1. Review of parent training literature (1983-2004)
Author/Date
Purpose
Major
Concept
Sample
Design
Results
Implications
Anastopoulos,
A.D., Shelton,
T.L., DuPaul, G.J.,
& Guevremont,
D.C.(1993)
To assess the
effects of an
PTP* designed
for parents of
school age
ADHD children
Parent
training
model
36 ADHD
children 6-
11 years &
mothers
Training resulted in
decreased parenting stress,
increased parenting self¬
esteem & improvements in
the severity of child’s
ADHD
Further testing
of model
Barkley, R.A.,
Shelton, T.L.
Crosswait, C.,
Moorehouse,
M.,Fletcher, K.,
Barrett, S.,
Jenkins, &
Metevia, L. (2000)
To compare the
effects of
different
treatment
programs on
behavioral,
social,
emotional &
academic
outcomes
Behavioral
parent
training,
classroom-
based
behavior
modification,
social skills
training
158
preschool
children with
hyperactive,
impulsive, &
inattentive
behavior
2x2
ANCOVA
Poor attendance of parents
in parent training.
Classroom treatment
resulted in reduced
behavioral problems p<
.006 and social skill
impairment
Further research
on long-term
outcome
Cooper, L.,
Wacker, D., Sasso,
G., Reimers, T., &
Donn, L. (1990)
To examine
maintaining
variables for
children with
conduct
disorder
Parent
interventions:
demands &
parent
attention &
ignoring
8 children
with conduct
disorders
Single
subject,
multielement
design across
rapidly
changing
conditions
Identified parental
attention as a factor in
maintaining appropriate
child behavior. Direct
assessment completed in an
outpatient setting
Further
application and
extension of
assessment
procedures

Table 2-1. Continued
Author/Date
Purpose
Major
Concept
Sample
Design
Results
Implications
Elder, J.H. (1995)
To evaluate the
effects of an in-
home
communication
training
program for
parent of
developmentally
delayed children
Parent
training
model
4 mothers &
4 male
children with
delayed
development
, language
impairments
& autistic
features
Single
subject
design, MB
Training resulted in
improved parent-child
interactions over 3
conditions (p<.034)
Further research
on improving
interactions
using SSD, &
using in-home
PTP
Erhardt, D. &
Baker, B. L.
(1990)
To assess the
effects of a PTP
for children
with ADHD
Parent
training
model
2 children &
parents
Single
subject
design/AB
Training resulted in
improvements in parents’
confidence in behavioral
management, decreased
ratings of hyperactivity,
and improved relationships
Further testing
of model
Forehand, R.L.,
Steffe, M.A.,
Furey, W.M., &
Walley, P.B.
(1983)
To examine the
long term
effects of a PTP
Parent
training
model
68 mothers
Quasi-
experimental
Training resulted in
treatment gains perceived
by mothers’ post-study &
at f/u
Further testing
of model
Gross, D. Fogg, L.
& Tucker, S.
(1995)
To examine the
effectiveness of
a PT program
for positive
parent-child
relationships
Parent
training
program
24 parents &
25 2-yr olds
Repeated
measures
ANOVA
Increase in parenting self-
efficacy, decrease in
parenting stress, &
improvement in quality of
parent-toddler interaction
Further testing
of model

Table 2-1. Continued
Author/Date
Purpose
Major
Concept
Sample
Design
Results
Implications
Frankel, F. Myatt,
R., Cantwell, D., &
Feinberg, D.
(1997)
To evaluate the
effects of an
outpatient PTP
for social skills
training
Parent
training
program
57 boys &
17 girls with
ADHD &/or
ODD
Comparison
Training resulted in
improved functioning for
children with and without
ADHD as did children with
ODD
Further testing
of model
Henry, G. (1987)
To compare the
effects of
medication and
symbolic
modeling to a
combined
treatment
package
including
medication
Medication,
symbolic
modeling, &
combined
package
6 children 4-
10 years
with
hyperactivity
Single
subject
design, ABC
case series
Reduction in latency to
initiate compliance when
time out introduced (p< .04)
Suggested
clinical
application of
components of
treatment
package
Kazdin, A.E.,
Exveldt-Dawson,
M.A., French,
N.H., & Unis, A.S.
(1987)
To evaluate the
effects of PTP
& PSST** on
antisocial
behavior in
children
Parent
training
model
Inpatient
psychiatric
children (40)
Comparison
Training resulted in
decreased aggression &
externalizing behavior at
home, school and at 1 year
follow up
Further testing
of model

Table 2-1. Continued
Author/Date
Purpose
Major
Concept
Sample
Design
Results
Implications
Kazdin, A.E.,
Siegel, D.C., &
Bass, D. (1992)
To evaluate the
effects of
problem-solving
skills training
and parent
management
training on
children with
severe antisocial
behavior
Parent
training
model
97 children
referred for
psychiatric
care
Quasi-
experimental
Training resulted in
improved child functioning
across settings and parent
functioning at post¬
treatment & at 1 year
follow up
Further testing
of model
Pisterman, S.,
McGrath, P.,
Firestone, P.,
Goodman, J.,
Webster, I., &
Mallory, R. (1989)
To evaluate the
efficacy of
group PTP
aimed at
improving
compliance of
children with
ADHD
Group parent
training
intervention
46 families
with
preschoolers
with ADHD
Group
comparison
using series
of MANOVA
Training resulted in
significant treatment
effects in experimental
group. Child compliance
& parent control variables
(p< .001)
Further research
on PTP effects
on multiple
behavior
problems
Sonuga-Barke,
E.J., Daley, D.,
Thompson, M.,
Laver-Bradbury,
C., & Weeks, A.
(2001)
To evaluate PTP
for preschool
children with
ADHD
78 children
Comparison
PTP training resulted in
reduced ADHD symptoms
& increased maternal sense
of well being
Further research
of PTP

Table 2-1. Continued
Author/Date
Purpose
Major
Concept
Sample
Design
Results
Implications
Tucker, S., Gross,
D„ Fogg, L.,
Delaney, K., &
Lapporte, R.
(1998)
To examine the
effects of a PTP
at 1 year f/u
Parent
training
model
23 families
& 24
children
Descriptive
F/u from
1995 study
Training resulted in gains
in maternal self-efficacy,
maternal stress, & mother-
child interactions
maintained at 1 year
Further testing
of model
Webster-Stratton,
C.(1984)
To evaluate the
short & long-term
effects of a
videotaped PTP
Parent
training
model
25 boys &
19 girls
Quasi-
experimental
Training resulted in
improvement in parent
attitudes & child behaviors
at 1 month & 1 year,
reductions noncompliant &
deviant behaviors
Further testing
of model
Webster, Stratton,
C.(1985)
To examine father
responses to PTP
Parent
training
model
35 families
Training resulted in
attitudinal improvements &
perceptions of child
behavior problems post¬
study & 1 year f/u
Further testing
of model
Webster-Stratton,
C. Hollinsworth,
T. & Kolpacoff,
M. (1989)
To evaluate the
effects of initial
study effects were
maintained at 1
year
Parent
training
model
114 mothers
& 80 fathers
Training resulted in
improvements that were
maintained 1 year
Further testing
of model

Table 2-1. Continued
Author/Date
Purpose
Major
Concept
Sample
Design
Results
Implications
Webster-Stratton,
C.(1994)
To explore if a
videotape PTP
with a PTP added
to the effects of
the PTP
Parent
training
model
85 families
Repeated
measures
MANOVA,
ANOVAS x2
Training resulted in
improvement in CBCL
problem behavior (though
still in the abnormal range)
in short term range
Further testing
of model
Webster-Stratton,
C.(1998)
To examine the
effects of a PTP
Parent
training
model
394 mothers
Quasi-
experimental
Training resulted in a
decrease in mothers’
critical remarks & greater
involvement in education,
greater social skills in
child, & decreased child
behavior problems
Further testing
of model
W ebster- Stratton,
C., Reid, M.J., &
Hammond, M.
(2001)
To examine the
effects of a PTP
& teacher training
in Head Start
children &
mothers
Parent
training
model
272 mothers
& children &
61 teachers
Quasi-
experimental
Training resulted in
decreased negative
parenting & increased
positive parenting,
decreased behavior
problems in children, &
improved teacher skills
Further testing
of model with
cost-benefits

Table 2-1. Continued
Author/Date
Purpose
Major
Concept
Sample
Design
Results
Implications
Weinberg, H.A.
(1999)
To examine the
effects of a PTP
for ADHD
children
Parent
training
model
34 parents of
25 ADHD
children
Descriptive
Design
Training resulted in
improvement in parental
knowledge of ADHD &
child behavior
management
Further testing
of model
Williams, P.D.,
Elder, J. H„ &
Griggs, C. (1987)
To examine the
effects of a
behavioral
training program
for parents
Parent
training
model
Parents & 47
children
Training resulted in
decreased internalizing
scores-males > females &
an change greater in 2-
parent families
Further testing
of model
*PTP - Parent training programs
**PSst . Problem-solving skills training

CHAPTER 3
METHOD
The purpose of this study was to characterize the interactions of fathers and their
young children with ADHD; and evaluate the efficacy of an in-home training program
designed for fathers. This chapter describes the research plan and the rationale for using
of single subject design. Included in the research plan is specific information on the
instruments used to describe subjects, dependent variables, and independent variables. In
addition, a detailed description of the procedure and conditions of the parent training
intervention is discussed.
Rationale for Use of Single Subject Design
Single subject design (SSD) is an important methodological tool often viewed as a
radical departure from traditional research. The unique feature of SSD is the capacity to
conduct experimental investigations with an individual, and rigorously evaluate the
effects of an intervention (Kazdin, 1982). SSD allows for direct observation of specific
behaviors of social significance, the effectiveness of a treatment, and the durability of a
treatment. In addition, SSD methodology makes inferences about the intervention effects
by comparing different conditions presented to the same subject over time. Empirical
evidence that isolates and identifies the determinants of an individual’s behavior adds to
an understanding of an individual’s interaction with the environment, supports
generalization through replication, and assists in the development of novel, clinically
efficacious, interventions (Kazdin, 1998).
37

38
Single subject design (SSD) has contributed to applied and experimental research
as well as a variety of interventions in clinical research (Erhardt, & Baker, 1990; Elder,
1995; Hale, Hoeppner, DeWitt, Coury, Tiracco, & Trommer, 1998; Posavac, Sheridan, &
Posavac, 1999). SSD facilitates experimental investigations with an individual and
provides a rigorous evaluation of intervention effects. Threats to the internal validity are
unlikely in SSD due to the inherent nature of the design (Kazdin, 1982). If the
experiment is carefully designed and the results are attributed to the effects of the
independent variable with little or no ambiguity; the likelihood that the independent
variable accounts for the change in behavior is high and the study is considered internally
valid. The role of chance is diminished with each replication of behavior.
Failure to determine this relation signals a lack of experimental control as well as
failure to replicate (Johnston, & Pennypacker, 1980). Failure to demonstrate replication
in all subjects leads to a more intensive investigation of the function of the behavior
rather than attributing the findings to chance (Kazdin, 1998). External validity is
primarily addressed in subsequent investigations that alter the conditions of the original
study. If a study is considered externally valid, the results of an experiment are
generalizable and extend beyond the condition of the experiment.
Single subject design methodology has many advantages for the proposed study.
First, SSD facilitates close inspection of an individual interacting in the environment.
Children with ADHD often present with a varied range of behaviors and impairments.
Unexpected variables or outliers, specific to child behaviors and father behaviors provide
useful information for intervention effects and/or refinement (Elder, 1997a). Second,
modifications of an intervention are clearly defined and isolated, closely monitored, and

39
compared with each subject’s own baseline data. Thus, researchers have the opportunity
to incorporate new knowledge into the intervention without compromising the scientific
integrity of the study (Elder, 1997a).
Third, behavior is a continuous process and changes over time as a function of the
influence of its determining variables. SSD gives researchers the opportunity to take
multiple “behavioral snapshots” over time that allow for quantitative and contextual,
descriptions of targeted behaviors (Johnston, & Pennypacker, 1980, 1993). A final point
is that graphic representation facilitates the communication of the data analysis and
synthesis of the relationship between the dependent and the independent variables
(Tawney, & Gast, 1989). The graphed displays are clinically useful when interacting with
families because they clearly illustrate the frequency and effects of specific training
components on the individual’s behavior.
A single subject, AB design was used to assess the effects of the parent training
intervention across on each father’s acquisition of skills, father behavioral responses, and
child behavioral responses across the training conditions. Each father-child dyad was
used as his own control. The frequencies of the behavioral responses for the fathers and
their children were measured concurrently and compared with baseline data. Visual
analysis was the primary means for organizing and reporting the data analysis and
synthesis. The inspection of specific components of the parent training intervention
provided valuable information for further intervention development and/or refinement.
Research Plan
Recruitment of Subjects
Agreements were formed with Joseph Keeley, Wayne Soven, Colin Condron, and
Jo Ann Cook. Each practitioner referred families with young children diagnosed with

40
ADHD who were interested in this project. Joseph Keeley, MD is a behavioral pediatrician
in private pediatric practice in Orlando, Florida. Wayne Soven, MD and Colin Condron,
MD are pediatricians in private practices in the Orlando area. Jo Ann Cook, ED is a school
psychologist in private practice in Longwood, Florida. Each practitioner serves children
and adolescents with behavioral disorders of all races and socioeconomic groups in three
surrounding counties. The Principal Investigator (PI) contacted each family by phone,
scheduled home visits (with interested fathers who met inclusion criteria), and discussed
our study with interested parents. Fathers of children with ADHD (3- to 6-years of age)
were chosen by purposive sampling and were invited to participate. A total of four fathers
and their children chose to participate in our study.
Inclusion Criteria
Criteria for inclusion required that the children were 3- to 6-years of age without
debilitating sensory or physical impairments, and had a diagnosis of ADHD from a
behavioral pediatrician or a pediatrician according to DSM-IV (APA, 1994). Fathers and
their children were considered for enrollment in this study if they met the inclusion
criteria, gave assent to participate in the study, and had signed consent/assent. Fathers
were defined as biological fathers who resided in the home with their child for at least
one year. Each father agreed to be videotaped and to engage in the parent training
process. Each father signed an additional videotape consent form for himself and his
child.
Exclusion Criteria
A child was excluded from participation in the study if the child’s medical history
indicated physical impairments, sensory-impairments, or significant medical problems.
A father was excluded from participation in the study if the father’s medical history

41
indicated psychiatric illness or sensory problems (i.e., speech and language disorders,
hearing loss) that might affect the father’s ability to receive training and/or interact with
their child.
Parent training sessions were conducted in the home by the PI. The advantages of
naturalistic observation include well-maintained subject participation and essential
contextual, in-depth data. Therefore, a room in each home was chosen for videotaping
that; minimized distractions; supported uninterrupted interactions; allowed the observer
to unobtrusively record data; and remained constant throughout the investigation.
Instruments for Describing Subjects
Four instruments (Table 3-1) were used to describe the participants in this study;
the Hollingshead Four Factor Index (1975); the Child Behavior Checklist (Achenbach, &
Edelbrock, 1983); the Parenting Scale (Arnold, O’Leary, Wolff, & Acker, 1993); and the
Interaction Questionnaire (Hoza, & Pelham, 1995). This descriptive information was
critical for determining the generalizability of findings to other fathers and their children
with ADHD, for replicating the research, and for designing future interventions.
Hollingshead Four Factor Index (1975) was used to assess socioeconomic factors
(Appendix E). This instrument is a widely used measure in research of children and
families, and provides information relevant to the study population (Bussing, Zima, &
Belin, 1998; Saxon, & Reilly, 1998). The Four Factor Index is based on the concept that
social status is a multidimensional construct. Socioeconomic status is estimated based on
an individual’s occupation, education, gender, and marital status.
The Child Behavior Checklist (CBCL) (Achenbach, & Edelbrock, 1983) was used
to assess the father’s perceptions of the child’s behavior problems before participation
and at completion of the study (Appendix F). The CBCL consists of 118-items

42
associated with behavior problems. The items constitute multiple scales for two broad¬
band groupings (externalizing and internalizing behavior) in all sex and age groups. T-
scores are computed for seven dimensions of child psychopathology
(emotionally/reactive, anxious/depressed, somatic complaints, withdrawn, sleep
problems, attention problems, and aggressive behavior) and five syndromes (affective
problems, anxiety problems, pervasive developmental problems, ADHD problems, and
oppositional defiant problems). The intraclass correlations are .98 for interparent
agreement and .84 for test-retest reliability (Achenbach, 1991, 1992).
The Parenting Scale (PS) (Arnold, O’Leary, Wolff, & Acker, 1993) was used to
measure father effectiveness in child discipline before participation and at completion of
the study (Appendix C). This instrument is a self-report consisting of 30-items that
represent a parent mistake as the anchor at one end of a 7-point scale with an effective
solution as the opposing anchor. The PS was scored in terms of three subscales (laxness,
overreactivity, and verbosity) and a total score. Higher scores indicate ineffective or
dysfunctional parental discipline. Arnold et al. (1993) reported an internal consistency
estimate of .84 for the total score, and 2-week test-retest reliability of .84. Hoza et al.
(2000) reported an internal consistency of .86 in mothers and .83 in fathers.
The Interactions Questionnaire (INTX) (Hoza, & Pelham, 1995) was given to
fathers before and at completion of the study, to assess the fathers’ beliefs about their
children’s noncompliance in hypothetical interactions (Appendix D). This questionnaire
consists of 60-items and builds upon previous research (Sobol, Ashbourne, Earn, &
Cunningham, 1989; Bugental, & Sherron, 1983). Fathers were asked to rate each of ten
reasons for their child’s noncompliance from 1 (really true) to 10 (not really at all). Hoza

43
et al. (2000) analyzed only subscales that assessed beliefs about problem behaviors
related to the child’s lack of effort and bad mood. Each subscale was scored across three
scenarios. Higher scores indicated less endorsement of insufficient effort or bad mood as
a reason for noncompliance. The internal consistency for the child’s lack of effort
subscale was .87 for mothers and .88 for fathers and the child’s bad mood subscale was
.85 for mothers and .86 for fathers. The INTX is a new instrument (not fully validated)
and test-retest reliability has not been examined. Therefore, findings must be interpreted
with caution.
Description of an In-Home Parent Training Intervention for Fathers
The current research builds on Elder’s (1995) parent training intervention by
focusing on a new population. Behavioral strategies and discipline skills specific to the
Parent-Child Interaction Therapy (Eyberg, 1988) in the context of father-child play were
incorporated into our parent training intervention (Appendix B). The PI provided the
necessary equipment (e.g., video camera, videotapes, and toys) for use during
videotaping of the father-child play sessions. Baseline father-child play sessions were
videotaped before parent training. The PI provided three parent training sessions for each
father (Table 3-2) in the participant’s home over a period of 8- to 12-weeks. Each in-
home training session lasted approximately 1- to 2-hours. Each father received:
• Written instructions for the targeted skills.
• Videotaped instruction including examples of the behavior to be taught.
• Role-modeling demonstrations.
• Opportunity for practicing the parenting strategies and skills with the PI.
Parent Training Session 1 (PT-1) was taught to fathers after 4- to 5-videotaped
father-child play sessions. The parenting strategies for PT-1 included imitation with
animation skill (I/A); following the child’s lead in play; increasing positive responses;

44
and decreasing corrective statements. Fathers were asked play with their children 5-times
each week and to use the parent strategies taught during PT-1.
Parent Training Session 2 (PT-2) began after 4- to 5-videotaped father-child play
sessions that followed PT-1. The fathers were taught skills that involved discipline
strategies in the same manner that was described in PT-1. The fathers were asked to
continue the father and child play sessions 5-times each week and to use the skills taught
during PT-1 and PT-2.
Parent Training Session 3 (PT-3) began after 4- to 5-videotaped father-child play
sessions that followed the PT-2. The fathers received a review of PT-1 and PT-2 in the
same manner that was described in PT-1. The fathers were asked to continue the father-
child play sessions 5-times each week, and to use the skills taught during PT-1 and PT-2.
A follow-up meeting was scheduled between the PI and the father for a review of the
results that pertained to their father-child interaction.
Procedure for Implementing the Parent Training Intervention
After the fathers gave informed consents and child assents, they were asked to
complete four questionnaires (Table 3-1). The timeline (Table 3-3) and the procedure
(Table 3-4) for instrumentation and videotaping in the home were followed. The PI
videotaped the father-child play sessions in the home (twice each week) at similar times of
the day convenient for fathers and their families.
Condition A - Baseline
The PI videotaped the baseline father-child play sessions in the home (twice each
week) for approximately two weeks or until a stable baseline was noted (Table 3-2). The
baseline videotaped sessions consisted of a 15-minute unstructured, in-home, father-child

45
play session. The PI asked the fathers five questions after every other videotaped father-
child play session. The PI recorded the behavioral responses concurrently. Data
collection and analysis were ongoing.
Condition B - Introduction of Parent Training Sessions 1,2, and 3
The first parent training session followed the completion of the baseline sessions
(Table 3-2). Approximately 4- to 5-father-child play sessions were videotaped for 15-
minutes (twice each week) for approximately two weeks following each of three parent
training sessions for fathers. The PI asked the father five questions after every other
videotaped father-child play session. The PI recorded the targeted behaviors of fathers
and their children concurrently. Data collection and analysis was ongoing. At
completion of the final father-child play session, the fathers were asked to complete
questionnaires. A follow up meeting with parents was scheduled after completion of the
study to discuss the results of their participation, to offer the complete set of videotaped
father-child play sessions, and to offer a compact disc with the parent training
intervention. In addition, mothers were offered instruction pertaining to the parent
training intervention.
Instruments and Procedure for Measuring the Dependent Variables
The PS, INTX, and CBCL were used to measure the dependent variables (Table
3-5). Dependent variables were operationalized (Appendix A). Social validity was
evaluated by a series of questions adapted from Elder’s (1995) semi-structured interview
to assess the father’s perceptions of the parent training process (Appendix H). . The
fathers were asked after every other father-child play session to report perceptions on the
training process on a scale of 1 (positive) to 5 (negative).
• How typical was your child’s behavior during this session?

46
• How comfortable are you using the skills you have been taught?
• Do you think that the training that you are doing with your child is working?
• Are you using what you have learned at times other than the videotaped session?
• Do you think that the presence of the camera and/or investigator affected how you
or your child behaved in this session?
The Therapy Attitude Inventory (Eyberg, 1993) is a brief consumer satisfaction
measure of parent training and family therapy used to assess father satisfaction with the
process and outcome of parent training at completion of the study (Appendix G). A total
of 10-items are included that address the impact of therapy on parenting strategies and the
child’s behavior. The father’s were asked to rate the items on a scale from 5
(dissatisfaction with treatment or a worsening of problems) to 1 (maximum satisfaction
with treatment or improvement of problems) at completion of the study. The item ratings
yield a possible score of 5.
In-Home Observation
The PI conducted in-home parent training sessions for fathers at convenient
locations (e.g., living room, family room, or kitchen). The procedure for videotaping the
father-child play sessions was discussed with the father before the study. The PI arrived
at the participants’ homes with the videotaping equipment and toys at a time previously
scheduled by the fathers. If the child was ill or unwilling to participate, the session was
rescheduled. Behavioral responses were coded during the 3- to 12-minute segment of the
videotaped father-child play session. The last 3 minutes were used for coding the
behavioral response categories in the event of a problem with videotaping (i.e.,
disruption, mechanical problems). The PI viewed the videotapes and recorded the
frequencies of the targeted father behaviors and the targeted child behaviors.

47
Each data file was assigned an identification number to maintain the
confidentiality and anonymity of the subjects. Only the subject’s identification number
appeared on the data collection instruments. The files and videotapes were stored in a
locked cabinet in the Pi’s office and will be maintained for 3-years. All files and
videotapes will be destroyed after that time.
The Multiple Option Observation System Experimental Studies Software
(M.O.O.S.E.S.) provided a method for coding and analyzing the observational data
(Tapp, Wheyby, & Ellis, 1995). The data were entered in a laptop computer, labeled,
organized, and stored. M.O.O.S.E.S. allowed the identification of antecedent and
consequent events associated with specific behaviors as well as more general response
categories. This information is available to plan intervention and data collection
procedures for future research.
Behavioral Observer Training
The PI created the videotapes used for training an independent observer. The
independent observer was blind to the conditions under which the videotapes were taken.
The PI followed the observer training sequence developed by Elder (1995):
• Instruction to familiarize observers with the behavioral response categories as
defined in the coding manual.
• Practice coding the videotapes of role-played interactions that clearly portray the
imitation with animation skill.
• Practice coding pre-existing parent child videotapes not associated with the
current project.
The independent observer randomly selected and coded 25% of videotaped
sessions previously coded by the PI to minimize the potential for bias and observe for
observer drift during the course of our study. The independent observer and PI were

48
required to establish a criteria level of 80% or greater interrater agreement. Practice
sessions continued until the criteria level was met. Interrater agreement fell below 80%
on two occasions during this study (Table 4-15). The operational definitions (Appendix
A) were reviewed and clarified. The PI and the independent observer practiced coding
behavioral responses until a criterion of 80% was met. Coding was re-instituted.
Behavioral Response Categories
Behavioral response categories from Elder’s (1995) research were extended for
use in our study. Behavioral response categories of targeted behaviors (Table 3-5) for
fathers and for children addressed the research questions in our study (Appendix A). The
father’s behavioral response categories included initiating behaviors, responding
behaviors (positive responses, corrective responses, and negative responses), initiated
turns with affirmation, and the imitation with animation skill. The child’s behavioral
response categories included initiating behavior, responses, tantrum/aggression,
elopement, and initiated turns with affirmation.

49
Table 3-1. Correspondence between instrumentation and sample characteristics
Measure
Instrumentation
Purpose
Hollingshead Four Factor
Index (1975)
Father report
Define the individual’s social
position
Child Behavior Check List
(1983)
Father report
To assess father’s perceptions of
the child’s behavior problems
Parenting Scale (1993)
Father report
To evaluate father effectiveness in
discipline
The Interactions
Questionnaire (1995)
Father report
To evaluate father attributions of
compliance and noncompliance
Table 3-2. In-home parent training intervention for fathers
Condition
Intervention for Father
Father-Child Play Sessions
A
Baseline
Minimum of 3 videotaped sessions,
Approximately 3-5 until stable baseline
B
Parent Training Session 1
4-5 videotaped sessions
B
Parent Training Session 2
4-5 videotaped sessions
B
Parent Training Session 3
4-5 videotaped sessions
Follow-up
Review of study results
Table 3-3. Timeline for the parent training intervention
Parameters
Initial
Visit
Week
1-2
Week
3-4
Week
5-6
Week
7-8
Week
9-10
Week
11-12
Informed Consent
X
Baseline Questionnaires: SES,
CBCL, PS, INTX
X
Semi-structured interview after
every other videotaping of
father-child play session
X
X
X
X
X
Follow-up Questionnaires:
CBCL, PS, INTX, TAI
X
Parent training session 1
X
Parent training session 2
X
Parent training session 3
X
Condition A
Baseline sessions (3-4)
X
Condition B
Follows the baseline sessions
X
X
X
X
Completion of Study
X
X

50
Table 3-4. Procedure for instrumentation and videotaping
Condition
Session
Questionnaire
Prior to Baseline
In-home meeting with father
& PI Discussion of project
Informed Consent/Assent
Hollingshead Four Factor Index
Child Behavior Checklist
Parenting Scale
Interactions Questionnaire
Condition A
Unstructured father-child play
Videotaping of 4-5 sessions
Interview of 5 questions after every
other videotaping session
Condition B
4-5 father-child play sessions
were videotaped after each
parent training session (1,2,3)
Interview of 5 questions after every
other videotaping session
Project
Completion
Last videotaped father-child
play session
Child Behavior Checklist
Parenting Scale
Interactions Questionnaire
Therapy Attitude Questionnaire
Follow-up
In-home meeting with parents
&PI
Present parents with videotapes of
father-child play sessions.
Table 3-5. Correspondence among the variables, instruments, and measurements
Variable
Instrument
Measurement
Type of Data
Father behavioral response categories:
Father initiations, Father positive
responses, Father corrective responses,
Father negative responses
Child behavioral response categories
Child initiations, Child responses,
Child aggression, Child elopement
M.O.O.S.E.S.
Computerized
observation
Program
Frequency
counts
Quantitative
Measure
Parent training skill:
imitating/animating
M.O.O.S.E.S.
Frequency
counts
Quantitative
measure
Father perceptions of the training
process of the in-home parent training
intervention for fathers
Semi-structured
interview
Father self-
report
Qualitative
measure.
Father satisfaction with the process and
outcome of the in-home parent training
intervention for fathers
Therapy Attitude
Inventory (1993)
Father self-
report
Quantitative
measure

CHAPTER 4
RESULTS
A general description for each father-child dyad during the conditions of our
study is given in this chapter. In addition, each subject’s performance across the two
conditions will be discussed (individually and later, as a group). Behavioral responses
for fathers (father initiations, father positive responses, father corrective responses,
imitation with animation, and father-initiated turns with affirmation) and children (child
initiations, child responses, child aggression, child elopement, and child-initiated turns
with affirmation) are discussed, displayed, and analyzed visually in Tables 4-1 to 4-17
and Figures 4-1 to 4-24. This information is critical for determining generalizability of
findings to other fathers and their children with ADHD, replicating the study, and
designing future interventions.
Father and Child Dyad A
Using Hollingshead criteria (1975) the family was estimated within the highest
social strata (Table 4-13). Parents were in their early forties, Caucasian, employed full¬
time, and the biological parents of Child A. Two older children (16-year old son and a
20-year old daughter) were the biological children of the mother from a previous
marriage. For the purpose of this discussion a fictitious name was assigned to Child A
(Jordan).
Jordan was 3-years and 7-months at the onset of the study. He received a
diagnosis of ADHD and speech and language delay at 3-years and 6-months from a
behavioral pediatrician. Jordan was prescribed therapy for speech and language delays.
51

52
Father A refused to consider ADHD medication for Jordan before and during the study.
The parents discussed concerns about Jordan’s aggressive and hyperactive behavior.
Jordan had been asked to leave two previous daycare programs because of problem
behavior. At the time of our study, Jordan was attending a daycare program located near
the mother’s workplace. A daycare evaluation revealed that Jordan had academic delays,
hyperactive, aggressive, and impulsive behavior. In addition, he was evaluated for
placement in the county public school early intervention program. Jordan qualified for
the “varying exceptionalities” program. However, the parents chose not to enroll Jordan
because of inconvenience associated with location and extended daycare issues. Jordan
was also evaluated by a for-profit agency for ADHD treatment. The parents were
informed that the agency could provide behavior modification treatment for Jordan
including occupational therapy that would cure ADHD. The parents chose not to enroll
Jordan in additional therapy during our study.
The father’s discipline skills (Table 4-1) were assessed before and at completion
of our study using the PS (Arnold et al. 1993). Father A reported greater than average
scores in laxness, overreactivity, verbosity, and total score; minimal changes in scores
were noted before and after our study. Laxness associated with permissive parenting,
overreactivity associated with authoritarian parenting, and father verbosity may seem to
be inconsistent parenting styles. However, Father A exhibited behaviors that supported
the differing styles during the videotaped father-child play sessions. For example, the
father was observed to encourage rough play on occasion and admonish such behavior on
other occasions. Several times the father was observed restraining Jordan in his arms and
presenting a new activity. If Jordan participated in the activity, the father frequently

53
changed quickly to another activity. If Jordan was distracted or chose to play with a new
toy, the father corrected Jordan or tried to pull him back to the previous activity. On one
occasion, the father offered a block to Jordan. Jordan responded that the block did not fit.
The father praised Jordan. A short time later Jordan gave his father the same block. The
father dismissed Jordan and stated, “You know that block doesn’t fit.” Jordan
immediately stopped participating and moved to another activity.
The father was verbose during each videotaped session and often asked the same
question 3- or 4-times without waiting for Jordan to respond. Many times the father
would introduce an activity. If Jordan began the activity the father often ceased the
activity. For example, the father mentioned the game “duck, duck, goose”. Jordan
immediately started to play the game. The father responded that they could not play the
game at that time. The father allowed rough, physical play in one session and threatened
“time out” as punishment for similar behavior in another session. In summary, the father
demonstrated inconsistent parenting styles. At times he was permissive, while other
times he threatened “time out” if Jordan’s behavior did not improve. Intentional
aggressive, angry, or insulting father behavior was not observed.
The father often discussed concerns about Jordan’s frequent episodes of
aggression, temper outbursts, and defiance in the home, daycare, and during family
outings. The father stated that it was difficult to provide consequences because he
believed that Jordan was not affected by verbal explanations or the loss of privileges, and
that Jordan did not participate when punished with “time out”. The father stated that
effective punishment included placing Jordan in his room and holding the door shut. The
father reported that often the mother interfered with his management of Jordan’s problem

54
behavior and led to frustration and conflict with his wife’s behavior. The father asked if
the mother could participate in parent training because she was the primary caretaker, and
the marked differences in their parenting styles reinforced Jordan’s problem behavior and
created marital discord. The PI agreed to provide parent training for the mother after the
father-child protocol had been completed.
The Child Behavior Checklist (Achenbach, & Edelbrock, 1983) was used to
assess the child’s behavior problems (Table 4-1). The father reported an internalizing T-
score before and at completion of the study that was within the normal range of problem
behavior. However, an externalizing T-score of 74 before and 65 at completion of our
study was reported in the clinical range of problem behavior, and supported the diagnosis
of an externalizing disorder for ADHD. At completion of our study, the father reported
that ADHD problem behaviors decreased from the clinical range to the normal range of
behavior. In contrast, oppositional defiant behaviors were reported to increase from the
borderline to the clinical range of problem behavior. Interestingly, the father reported
attention problems decreased from the clinical range to the borderline range while
aggressive behavior increased from the normal range to the clinical range. Affective
problems were reported to decrease from the borderline clinical range to the normal
range. The father reported that Jordan had significant sleep problems (e.g., did not want
to sleep alone; had trouble falling asleep; had nightmares; resisted bedtime; slept little;
talked in his sleep; and woke often). The father stated that Jordan slept in his room only
if one parent stayed with him the entire night.
The Interactions Questionnaire (Hoza, & Pelham, 1995) was used to assess the
father’s beliefs about Jordan’s problem behavior before and at completion of our study.

55
The father reported that Jordan’s problem behavior was attributed to the lack of father
effort and poor mood of the father and Jordan. Before parent training, the father stated
that the cause of Jordan’s problem behavior was a mystery. The father’s reported that his
attempts to discipline Jordan’s problem behavior were often ineffective. After the third
parent training session, the father reported that his discipline skills (i.e., limit-setting,
ignoring misbehavior, and time out) were improving. In addition, the father stated that
teacher reports of aggression were less frequent, and Jordan’s vocabulary had
significantly increased since the onset of the study. The father stated that communication
with his child had improved, that Jordan was less frustrated, and that Jordan exhibited
fewer tantrums at home. However, the father reported that Jordan’s problem behavior
with his mother had not improved and the father’s efforts to manage Jordan’s problem
behaviors often were thwarted by his wife’s interference.
Frequencies of Target Behavior
During Condition A, the father and Jordan participated in four baseline father-
child play sessions (Table 4-3). The PI videotaped two sessions per week in the father’s
home. During baseline sessions, the ratio of means for father initiations to child
initiations was approximately 2:1; father initiations were greater than .66 of the total
initiations. The father had few positive responses with an average rate of 15 corrective
statements per session. The father did not respond negatively. There were no incidents
of imitation with animation (I/A). Jordan did not exhibit any incidents of aggression or
elopement. The ratio of father-initiated turns with affirmation (FIT) to child-initiated
turns with affirmation (CIT) was approximately 4:1, greater than .80 of the total initiated
turns with affirmation.

56
Condition B followed the videotaped baseline sessions. The father was taught the
first parent training session (PT-1) and four father-child play sessions were videotaped
(twice per week). Contrary to Condition A, the ratio of means for child initiations to
father initiations was 1:1; and the child initiations were slighter greater than .50 of the
total initiations. The father’s positive responses doubled and increased to an average rate
of 12.5 per session. The father’s corrective statements significantly decreased to an
average rate of .7 per session. The father’s use of I/A increased to an average rate of 10
per session. The father did not make any negative comments. Jordan exhibited few
incidents of aggression with an average rate of 4.5 per session. There were no incidents
of elopement. The relationship of child responses to I/A was not evident. The ratio of
means for FIT to CIT was 1:1. The CIT were slightly greater than .50 of the total
initiated turns with affirmation.
The second parent training session (PT-2) followed and four father-child play
sessions were videotaped. Similar to PT-1, the ratio means for child initiations to father
initiations were 1:1. The child initiations were greater than .50 of the total initiations.
The father’s positive responses decreased to approximately the same rate as baseline,
with an average rate of 6.5 per session. The father’s corrective statements increased to an
average rate of 5.3 per session. Incidents of Jordan’s aggression increased slightly to an
average rate of 5.8 per session. The father used I/A less than in PT-1 with an average rate
of 8.5 per session. The father did not use negative comments. Jordan did not elope at
any time. Similar to PT-1, the ratio of means for FIT to CIT was 1:1; CIT slightly more
than .50 of the total initiated turns with affirmation.

57
Unfortunately, the child was ill for a week and the winter holidays prevented
scheduling for approximately two weeks. The third parent training session (PT-3) was
given and a booster session followed one week later to review information before
videotaping the father-child play sessions. Comparable to PT-1 and PT-2, the ratio of
means for child initiations to father initiations was approximately 1:1. The child
initiations were slighter greater than .50 of the total initiations. The father’s positive
responses increased to an average rate of 10.5, approximately twice the baseline rate.
Corrective statements decreased slightly to an average rate of 4 per session. The father
did not use negative comments. The father used I/A an average rate of 4.8, less than .50
of the average rate in PT-1. The child exhibited few incidents of aggression with an
average rate of 2.2 per session. Jordan did not elope at any time. Similar to PT-1 and
PT-2, the ratio of means for FIT to CIT remained at 1:1. The CIT were greater than .50
the total initiated turns with affirmation.
Visual Report of Data
The decrease in father initiations and increase in child initiations between
Condition A and Condition B is evident in Figure 4-1. During the third baseline session
Jordan initiated play more often than in the other three baseline sessions. This father-
child play session was more typical of the sessions that followed the parent training
sessions. Jordan and his father played with blocks, shapes, and puzzles. Jordan
responded to the father’s initiations and placed a block on a tower when handed a block,
put a shape in the block when handed a shape, and inserted a puzzle piece when handed a
piece. It appeared that child initiating behavior was dependant on the type of father-child
play.

58
During the first videotaped session after PT-1, the father did not structure or lead
the play as he had during the baseline sessions. Jordan reacted by standing or singing;
running to and from the father; falling into the father; and rough, physical play. The
father expressed concern about Jordan’s aggressive behavior following the play session.
The PI advised the father to continue to allow Jordan to lead the activity. Subsequent
videotaped sessions showed that the father continued to allow the child to lead play.
Fewer instances of rough play were noted during the remainder of our study.
Interestingly, Jordan verbalized choices of play, demonstrated creative play, and
initiated play more often than during the baseline sessions. If the father participated in
Jordan’s activity, the activity continued. If the father led his child’s activity, Jordan
became frustrated, stopped the activity, and chose another activity. For example, Jordan
played with the dog giving it sound and movement. The father took the dog from Jordan
and positioned the dog to box the ears. He explained to Jordan how to position the dog.
Jordan’s yelled and cried; took the dog from the father; tossed the dog; and ran to the
chair with another toy. It was evident that the father’s response affected the father-child
interaction. It is possible that the targeted behaviors (father initiations, child initiations,
and FIT and CIT) are dependent on the father’s responding behavior as well as the type
of father-child play.
Father positive responses and corrective statements changed between Condition A
and Condition B (Figure 4-2). After PT-2, the father’s positive responses decreased and
father corrective statements increased. In addition, there was a decrease in the mean of
father initiations and child initiations during videotaped sessions IB#1 through IB#4.
After PT-3, the father positive responses increased and the father’s corrective responses

59
remained fairly stable. Initially, the father expressed difficulty and discomfort with I/A
during parent training. However, the father was observed using I/A (Figure 4-3). After
the second videotaping session IB#2, a dramatic decrease in the father’s use of I/A was
evident. Despite a review of I/A, the father was less inclined to use the skill for the
remainder of the study. In addition, the child responses remained relatively stable after
the parent training sessions with a average range of 34 to 41 (Table 4-4). There was no
evidence of a relationship between the child responses and the father’s use of I/A.
Interestingly, the child responses remained relatively stable despite a significant decrease
in the father initiations. Further study is needed to determine the influence of father
behavior on child responses.
Significant changes were evident between Condition A and Condition B in FIT
and CIT (Figure 4-5). CIT increased and were more balanced with FIT throughout
Condition B. The increase in CIT and the balanced turn taking between the father and
the child supports the effectiveness of the first parent training component.
Father and Child Dyad B
Using Hollingshead (1975) criteria, the family was estimated to fall in the middle
range of social strata (Table 4-13). The parents were in their mid-thirties, Caucasian,
worked full-time, and the biological parents of a 3-year and 6-months-old son. The father
shared that he quit school in the seventh grade due to academic problems and failure,
difficulty reading, and lack of interest. He stated that he has worked in construction since
adolescence. The father expressed concern that his son may experience similar academic
difficulties in school.
For the purpose of discussion Child B was referred to as Thomas. Thomas
received a diagnosis of ADHD at 3-years and 6-months of age from a behavioral

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pediatrician. Thomas was diagnosed with speech and language delays and received
therapy twice per week. The father did not believe that medication was an option and
Thomas was did not receive medication for ADHD during our study. Thomas was asked
to leave three previous daycare programs because of aggressive and hyperactive
behavior. In addition, Thomas was asked not to return to a church daycare program on
Sunday mornings. Throughout the study he attended a preschool program five days each
week. The teacher sent daily reports of aggressive and impulsive behavior to the parents.
Before the study, the father reported greater than average scores in laxness,
overreactivity, verbosity, and total score (Table 4-4). At completion of our study, the
father reported changes in the total score, laxness, and verbosity and no change in
overreactivity. Only the verbosity score was in the normal range of discipline
effectiveness. Thomas did not exhibit incidents of aggression during the videotaped play
sessions. The father did not respond with negative or corrective statements after the
baseline sessions. Following the baseline sessions, the father spoke less often, gave
fewer explanations, and allowed the Thomas to lead the activity. There was no evidence
of overreactivity by the father was observed during the videotaped father-child play
sessions.
Before and at completion of our study, the father reported that his wife was the
disciplinarian and that she structured and planned Thomas’s activities, bedtime, and
punishment. The father stated that he did not provide consistent consequences in
response to Thomas’s problem behavior and that Thomas was less likely to comply with
his requests or commands. The father expressed support for his wife’s strict disciplinary
practices. If Thomas misbehaved or did not comply, the wife provided verbal reprimands

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and immediate consequences such as the loss of privileges. For example, Thomas
enjoyed playing with trains. The consequences for problem behavior or negative teacher
reports often included the removal of trains for a period of time. Token reinforcements
for good behavior were granted. For example, Thomas was promised a ride on a train if
he received only positive teacher reports for the entire week. The father stated that
despite the parent’s efforts with strict discipline, the child’s aggressive behavior had not
changed before our study. The father asked if the mother could participate in parent
training since she was the primary caretaker and the marked variation in their parenting
styles was reinforcing his child’s problem behavior. The PI agreed to provide parent
training for the mother after the research protocol had been completed.
The father reported on the CBCL (Achenbach, & Edelbrock, 1983) an
internalizing T-score of 62 before and 61 at completion of the study. Both t-scores
remained in the borderline clinical range for problem behavior (Table 4-4). An
externalizing T-score reported a change of 65 in the clinical range to 59 (within the
normal range of problem behavior). A total score of 46 decreased to 43 and remained in
the normal range.
Thomas was reported to be in the borderline clinical range for ADHD, withdrawn,
and aggressive behavior before our study. At completion of our study, the scores were
reported within the normal range of problem behavior. There was a minimal decrease in
pervasive developmental problems, but the score remained in the clinical range. The
father reported that Thomas avoided eye contact; did not answer; had poor peer
relationships; had speech problems; and was disturbed by new things or a change in
routine. In addition, the father reported a normal range of problem behavior associated

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with sleep. However, the father discussed his child’s problems falling asleep, resisting
bedtime, and not wanting to sleep alone. The father reported that sleep problems had
improved slightly before our study because both parents had been working together to
assist the child at bedtime with a strict schedule. It was also noteworthy that the father
reported that Thomas was more affectionate at the completion of the study. In addition,
the father believed that his child’s noncompliance was influenced by a lack of father and
child effort, and poor father and child mood (Table 4.4).
Frequencies of Target Behaviors
Thomas and his father played during four baseline sessions (twice each week)
videotaped by the PI in the subjects’ home. The ratio of father initiations to child
initiations was approximately 2:1, with father initiations greater than .66 of the total
initiations (Table 4-6). The father had few positive responses. The father’s corrective
statements were greater than twice the average rate of positive responses. The father did
not make any negative comments or use I/A. Thomas did not exhibit incidents of
aggression or elopement. The ratio of means between FIT and CIT was approximately
3:1; FIT greater than .66 of the total initiated turns with affirmation.
After Condition A, the father received the first parent training session (PT-1).
Four father-child play sessions were videotaped (twice during each week). In
comparison to Condition A, there was a significant decrease in the father initiations and
increase in child initiations. The ratio of father initiations to child initiations changed to
2:3, with child initiations greater than .50 of the total initiations. The father’s positive
responses increased almost three times the baseline rate with an average rate of 8.8 per
session. There were no corrective statements or negative comments made by the father.
The father used I/A an average rate of 10.2 per session. Thomas did not exhibit any

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incidents of aggression and elopement. Another significant change was noted in the ratio
of means of FIT to CIT was approximately 1:2; CIT greater than .66 of the total initiated
turns with affirmation.
The father was taught the second parent training session (PT-2) and five father -
child play sessions were videotaped (twice during each week). Similar to PT-1, the ratio
of father initiations to child initiations was approximately 1:2, with child initiations
greater than .66 of the total initiations. The father’s positive responses increased slightly
to an average rate of 10.2, three times the rate of baseline. The father did not exhibit any
corrective or negative statements. The father continued to use I/A with an average rate of
11.8 per session. However, the father stated that he was uncomfortable with the use of
I/A. It was noted during the fourth videotaping session that the use of I/A had dropped
from 15 incidents to 6 per session. For that reason a fifth videotaping session was
arranged. There was not any notable improvement in the use of I/A in the fifth
videotaped father-child play session. The child did not exhibit any incidents of
aggression or elopement. Similar to PT-1, the ratio of means of FIT to CIT was
approximately 2:3; CIT almost .66 of the total initiated turns with affirmation.
After the fifth videotaped father-child play session, the father was taught the third
parent training session (PT-3). Four father-child play sessions were videotaped. Similar
to PT-1 and PT-2, the ratio of father initiations to child initiations was 1:2, with the child
initiations almost .66 of the total initiations. The father’s positive responses increased to
five times that of baseline and an average rate of 15 per session. The father did not
correct or provide negative comments. The father continued to use I/A more often with
an average rate of 20, twice the rate reported following PT-1. Thomas did not exhibit any

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incidents of aggression or elopement. The ratio of means of FIT to CIT was
approximately 2:3; CIT greater than .50 of the total initiated turns with affirmation.
Visual Report of Data
A change in level with minimal variability is evident in father initiations and child
initiations between Condition A and Condition B (Figure 4-6). The father initiations
decreased and Thomas initiated play more often. Thomas demonstrated creative and
imaginative play. For example, Thomas often led the path of a train in various directions
using the fireplace, the father’s legs, or blocks while whistling, singing, or saying “choo
choo” in Condition B. The type of father-child play seemed to influence the child
initiations. However, the father-child play session following the PT-3 was quite
different. Thomas attended a monster truck show two days before and was imitating the
monster trucks. Despite the father’s attempts to interact, the child played in isolation
with the monster trucks for several minutes.
An increase in the father’s positive responses is evident between Condition A and
Condition B (Figure 4-7). The father’s corrective statements changed considerably with
only two incidents evident in IB#4. Imitation with animation (I/A) was taught to the
father during the first parent training session (Figure 4.8). The father expressed difficulty
with instructions to act silly and animated. The PI provided ongoing review and
encouragement of I/A throughout Condition B. There was an increase in I/A between
Condition A and Condition B. Conversely, the child responses decreased. Before
session IC#1, the father and Thomas attended a monster truck show. Thomas played in
isolation with the monster truck toys during father-child play sessions IC#1 and IC#2.
The father used I/A more often in an attempt to interact with Thomas. Despite the
father’s attempts to interact, Thomas responded less often. The father initiations between

65
Condition A and Condition B (Figure 4-9) decreased while the child responses remained
relatively stable with the exception of sessions IB#2 and IC#4. Further study is needed
to determine the influence of father behavior on child responding behavior.
The father spoke often and did not wait for Thomas to respond during Condition
A. After the first parent training session, the father followed his child’s lead in play;
waited for Thomas to respond; initiated a turn less often; and increased his use of I/A.
CIT increased and were more balanced with FIT in Condition B (Figure 4-10). Also
noteworthy, CIT increased during second father-child play session following each parent
training session, and then decreased after each subsequent father-child play session. One
reason may be that the father’s use of I/A was higher in the first and second father-child
play session following each parent training session. In addition, the father’s positive
responses were highest in the second father-child play session following the parent
training sessions. The interesting point is that both CIT and FIT were more balanced
after the third parent training session. The father did not sit back and watch or play in
isolation, while Thomas played intensely with a train or truck. The father built a tower of
blocks, and Thomas used the truck to knock over the tower or the father moved his truck
on the child’s arm until the child giggled. In other words, the father continued to interact
with his child. Further study is needed to understand the relationship between I/A and the
child’s behavior.
Father and Child Dyad C
Using Hollingshead (1975) criteria the family was estimated to fall in the lower
range of social strata (Table 4-13). The family consisted of an African-American father,
a Caucasian mother in their late thirties, and their biological 5-year and 8-month child.
For the purpose of discussion, the Child C was referred to as James. The father had a 14-

66
year-old African-American teenage son from a previous marriage who visited
occasionally, but did not live in the home. The father was self-employed and contracted
his services as a handyman for home and business repairs. The mother completed junior
high school and was employed full-time. The father stated that he had a history of drug
and alcohol abuse and that he was drug and alcohol free for seven years. He reported that
he was an active member of Alcoholics Anonymous and Narcotics Anonymous. The
father stated that he was incarcerated several times. In addition, the father reported that
his wife was incarcerated prior to their marriage. He also expressed concern about past
issues of maternal child neglect.
James received a diagnosis of ADHD at 5-years and 8-months of age from a
behavioral pediatrician. James was not prescribed medication for ADHD. The father
was opposed to any type of medication and likened the use of stimulants for the treatment
of ADHD to drug abuse. Before attending kindergarten, James was asked to leave three
daycare programs due to aggressive behavior. James attended kindergarten at the local
public elementary school. The parents expressed concern about daily teacher reports of
aggressive and impulsive behavior. James was referred him for an ADHD evaluation
with a health care provider by his teacher. Initial academic testing within the school
reported that James had a second grade reading level and above average academic skills.
In addition, James was referred for psycho-educational testing and future consideration
for admission into the gifted program.
Before our study, the father reported ineffective discipline evidenced by greater
than average scores in laxness, overreactivity, and the total score (Table 4-7). The father
stated during the parent training sessions that both parents disciplined James. However,

67
the father did not believe his wife supported his method for discipline. He reported that
she lacked consistency in discipline and did not provide consequences for problem
behavior exhibited by James. The father discussed his wife’s lifestyle and his concern
with issues of maternal neglect. The father advised that the inclusion of his wife in the
research project was essential to strengthen family ties and to provide a unified approach
to James’ problem behavior. The father was advised that parent training would be
offered to his wife at completion of our study.
The father had a powerful voice and stance. James immediately acknowledged
the father’s request or command. James did not exhibit any incidents of problem
behavior, opposition, or aggression throughout the study. The father spoke frequently
and gave lengthy explanations concerning play, a specific toy, or buildings. Often, the
father did not respond to the child’s questions or comments. James demonstrated strong
verbal and language skills during interactions with the father. James provided ongoing
reinforcement for the father’s behavior in the form of commenting, questioning, and
praise. Laxness on the father’s part was not evident during the videotaped sessions.
Father overreactivity was not observed due to the immediate response of the child and
father verbosity was consistently observed throughout the study. However, the father
reported less than average scores on verbosity. Unfortunately, the father did not return
the questionnaires at completion of our study despite the efforts of the PI. Therefore,
comparison between pre-study and post-study father reports was not possible.
Before our study, the father reported on the CBCL (Achenbach, & Edelbrock,
1983) an internalizing T-score of 47, an externalizing T-score of 50, and a total score of
34 (Table 4.7). The father did not report any problem behaviors in the clinical range.

68
The father stated his child exhibited immature, impatient, and attention- getting behavior;
avoidance of eye contact; and inability to sit still. Somewhat problematic behaviors were
reported as hitting, defiance, and disobedience. The father reported concerns with
destructive child behavior, poor peer relations, loudness, fearlessness, and poor appetite.
In addition, the father believed that his child’s problem behavior was influenced by his
child’s poor mood. The father expressed certainty that James was deliberate in his
actions; knew right from wrong; and often chose the wrong action.
Frequencies of Target Behaviors
During Condition A, four father-child play sessions were videotaped in the
subjects’ home (twice per week). The ratio of father initiations to child initiations was
approximately 2:1, with father initiations greater than .66 of the total initiations (Table 4-
9). The father had few positive responses with an average rate of 2 per session; while the
corrective statements had an average rate of 13 per session. The father did not use any
negative comments or the I/A skill. James did not exhibit any incidents of aggression or
elopement. The ratio of means of FIT to CIT was approximately 2:1; FIT equal to .66 of
the total initiated turns with affirmation.
The first parent training session (PT-1) followed Condition A. Then, five father-
child play sessions were videotaped (twice each week). The PI had difficulty scheduling
the videotaping sessions and several sessions were cancelled en route. The father stated
that he started a second job and he was unable to leave the workplace. The ratio of father
initiations to child initiations was approximately 1:2; child initiations greater than .66 of
the total initiations. In addition, the father’s positive responses increased to an average
rate of 9.4, more than three times greater than condition A. The corrective statements
decreased from an average rate of 13 in Condition A to an average rate of 1.6 in

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Condition B. The father stated that he was uncomfortable with I/A at the completion of
IA#2. Consequently, I/A was reviewed prior to session IA#3, IA#4, and IA#5. The
average rate of the father’s use of I/A remained at 4 per session. Due to the limited use of
I/A during the first four sessions, a fifth videotaping session was scheduled. The average
rate of I/A did not change. James did not exhibit any incidents of aggression or
elopement. The ratio of means between FIT and CIT was approximately 1:2; CIT almost
.66 of the total initiated turns with affirmation.
The father received the second parent training session (PT-2) and four father-child
play sessions were videotaped (twice each week). The PI had difficulties scheduling the
videotaping sessions with the father. Several father-child play sessions were cancelled en
route. The father stated that he and his wife had marital problems, and that he had
considered separation. He reported that both parents had made efforts to work through
the conflict, and he wanted to continue participation in the study. Four father-play
sessions were videotaped. The ratio of father initiations to child initiations was
approximately 1:2; child initiations greater than .66 of the total initiations. The father’s
positive responses remained greater than four times the average rate of Condition A with
an average rate of 8.8. The average rate of the father’s corrective statements was .8, less
than one per session. The father continued to I/A at approximately the same rate. James
did not exhibit any incidents of aggression or elopement. The ratio of means between
FIT and CIT was approximately 1:1; CIT greater than .50 of the total initiated turns with
affirmation.
The father often spoke, commented, questioned, and instructed James during the
father-child play sessions. James frequently praised the father’s efforts. After PT-2, the

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father directed play; requested feedback from James regarding the activity; and
responded positively to praise from James. It was interesting that the child continued to
initiate play with little father attention and few positive father responses.
During the third parent training session (PT-3), the father expressed a positive
attitude about the project. He shared that he and his wife continued to have marital
problems, and that he anticipated leaving for employment out of town. The father
planned to continue our study until completion. Two father-play sessions were
videotaped. Several father-child play sessions were cancelled en route. After the final
cancellation, the father stated that he was scheduled to leave for employment in south
Florida and could no longer participate in the study. The father was unable to meet to
cancel his participation in the study and agreed to return the post intervention surveys by
mail. Two phone messages were left on his voicemail. The surveys were not received.
After PT-3, the ratio of father initiations to child initiations for both videotaped
sessions was approximately 2:3; child initiations greater than .50 of the total initiations.
The father had 9 positive responses in the first session and 0 in the second session. The
father did not exhibit any corrective statements in the first session, but exhibited 7 in the
second session. The father did not make any negative comments. The father did not use
I/A in IC#1 and used I/A 7 times during the final session IC#2. James did not exhibit any
incidents of aggression or elopement. The ratio of means of FIT to CIT was 1:1 with
balanced turn taking.
Visual Report of Data
The father decreased initiations and James initiated play more often in Condition
B (Figure 4-11). The father often requested James approval, attention, and help. The
father’s positive responses increased, and the father’s corrective responses decreased

71
from Condition A to Condition B (Figure 4-12). Interestingly, a significant decrease in
the father’s positive responses was noted during IB#2 and the last videotaped session.
During IB#2, the father directed the activities with his child. During the final videotaped
session, James led the majority of the activities. The father frequently commented and
asked for feedback from James. In addition, the father provided more corrective
statements.
The father verbalized difficulty with I/A following the PT-1 and throughout the
study. Due to the low incidence of I/A following the PT-1, a fifth videotaping session
was scheduled (Figure 4-13). Despite a review of I/A before the third, fourth, and fifth
father-child play sessions, the father did not increase the use of I/A. A minimal change in
level in I/A is noted between Condition A and Condition B, with the greatest number of
incidents noted following the second parent training session. There were no occurrences
of I/A during the last videotaped session. A comparison of father initiations and child
responses revealed that child responses remained relatively stable, despite a decrease in
father initiations between Condition A and Condition B (Figure 4-14).
A change in FIT and CIT was evident between Condition A and Condition B
(Figure 4-15). CIT increased and were more balanced with FIT in Condition B. The
father spoke often and did not wait for a child response during Condition A. On the
contrary, the father waited for James to respond and initiated a turn less often during
Condition B until following PT-2. FIT were greater than CIT on two occasions. Father-
child play sessions IB#2 and IC#2 were atypical. During session IB#2, the father
directed the majority of the play and James participated. In addition, there was an
increase in child responses as well as a decrease in the father’s positive responses.

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During session IC#2, the child directed the majority of the play. The father frequently
commented and/or requested feedback. James’ responded to the father’s verbosity and
provided positive feedback, answered questions, and did not exhibit frustration or anger;
James continued to participate in the father’s activity and initiate play without positive
reinforcement or attention.
Father and Child Dyad D
Using the Hollingshead (1975) criteria, the family was estimated to fall in the
second highest social strata (Table 4-13). The father was self-employed and the owner of
a mid-sized construction business. His wife was a homemaker and was 9-months
pregnant with her third child. After the birth of the newborn, the parents had three
biological male children ages, 8-years, 3-years, and a newborn. For the purpose of
discussion, Child D was referred to as Bobby.
Bobby was diagnosed at 3-years-old by a primary care pediatrician in private
practice. The father stated that Bobby’s height and weight were greater than 95% for his
age group and that he appeared older than his age. In addition, Bobby was diagnosed
with speech delay and was receiving therapy. The father refused to consider medication
for Bobby to treat ADHD. Bobby was not prescribed medication for ADHD. An older
brother was diagnosed with ADHD without hyperactivity several years prior because of
academic problems; he took a long-acting stimulant each morning. The father expressed
concern that Bobby may need medication in the future. The father discussed that he had
difficulty with discipline strategies, uncertainty about a course of action, and concern
about Bobby’s aggressive behavior towards his older brother. The father expressed
distress that Bobby may have academic difficulties as well as behavioral problems.
Bobby was asked to leave two previous preschool programs before enrolling in a third

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preschool five days each week. Frequent teacher reports included complaints of
impulsivity, aggressive behavior (e.g., hitting and tackling), and academic problems.
The parents asked to start our project before the impending birth of their baby.
Both parents verbalized the need to maintain a sense of balance and normalcy within their
home. The father stated that Bobby would benefit from the increased father attention
before the birth and during the first few months of the newborn period. The family often
spent evenings and weekends together in activities that included going to the beach,
boating, four-wheeling, and fishing.
Before our study, the father reported ineffective discipline skills evidenced by
greater than average scores in laxness, overreactivity, verbosity, and the total score
(Table 4-10). Despite the reported decreases in all scores at completion of our study, the
scores remained greater than average. The father showed changes in laxness,
overreactivity, and verbosity throughout our study. For example, Bobby changed the car
ramp three times during one baseline session and the father readjusted the ramp each of
the three times. Following the parent training sessions, the father gave fewer
explanations, asked permission for a toy, waited for Bobby to offer a toy, and asked
permission to participate. Bobby was more verbal and gave many creative explanations
for toys during play after the first parent training session. It was interested that Bobby
often imitated the father’s creative play when given the opportunity.
Before and at completion of our study, the father reported an internalizing T-score
of 73 and a total score of 54 on the CBCL (Achenbach, & Edelbrock, 1983). The
externalizing score changed from 83 before the study to 77 at the completion of the study.
Both the internalizing T-score and the externalizing T-score remained in the clinical

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range of problem behavior (Table 4-10). In addition, the father reported that Bobby had
affective problems and pervasive developmental problems in the clinical range, and
anxiety and ADHD problems in the borderline range. Withdrawn behavior, sleep
problems, attention problems and aggressive behavior were reported in the clinical range
for problem behavior. Emotionally reactive problems, anxiety, and somatic complaints
were reported in the borderline clinical range of problem behavior. Only oppositional
defiant problem behavior was reported within normal range.
Bobby was known to react with physical aggression, defiance, hitting, destructive
behavior, disobedience, and temper outbursts usually without guilt. The father perceived
Bobby as selfish and easily frustrated. The father stated that Bobby had been cruel to
animals without remorse. For example, he often hit his dog and had hurt neighborhood
animals. The father reported that discipline was difficult because verbal explanations or
the loss of privileges did not seem to have an effect on Bobby’s behavior. The father
believed that sending Bobby to his room was the most effective consequence for problem
behavior. However, the father stated that the problem behavior did not change.
Sleep problems reported by the father included Bobby’s difficulty with sleep
rituals. He did not want to go to sleep, woke frequently, had nightmares, and did not
want to sleep alone. The father stated that often he would wake in the middle of the night
to find Bobby on the floor at the foot of his bed. The father reported that he and his wife
worked together to assist Bobby at bedtime. The father expressed concern that Bobby
seemed depressed and anxious and noted that Bobby was often withdrawn, avoided eye
contact, and did not respond to questions or commands. In addition, Bobby was
frequently upset when separated from his parents.

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The father believed that Bobby’s problem behavior was influenced by his child’s
effort and mood (Table 4-11). In addition, the father expressed concern about Bobby’s
aggressive behavior towards his brother and friends. The father discussed that Bobby’s
behavior was increasingly worse with his wife. The father asked if his wife could
participate in parent training since she was the primary caretaker, and she had difficulty
providing consistent discipline for Bobby’s problem behaviors. The PI agreed to provide
parent training for the mother after the father-child training protocol was completed.
Frequencies of Target Behaviors
In Condition A, five baseline father-child play sessions were videotaped. The
mother gave birth to the third son after the first videotaped session. Therefore, one week
elapsed before the second videotaping session. The next four baseline sessions were
videotaped (twice per week) in the subjects’ home. The ratio of father initiations to child
initiations was approximately 2:1; father initiations greater than .66 of the total initiations
(Table 4-12). The father had few positive responses with an average rate of 5.3, while
the corrective statements were an average rate of 19.8 per sessions. The father did not
make any negative comments. The father used I/A once during B#2 before the first
parent training session. Bobby exhibited four incidents of aggression during B#2 and did
not exhibit any incidents of elopement. The ratio of means of FIT to CIT was
approximately 3:1; FIT almost .75 of the total initiated turns with affirmation.
The father received the first parent training session (PT-1) and four father-child
play sessions were videotaped (twice per week). There was a significant change in
father-child initiated play. The ratio of father initiations to child initiations was
approximately 2:3, almost .66 of the total initiations. The father’s positive responses
increased greater than three times in Condition A to an average rate of 19.8. The father’s

76
corrective statements decreased from an average rate of 19.8 to 2.5 per session. The
father did not use any negative comments. The father used I/A without difficulty an
average rate of 13 per session. Bobby exhibited few incidents of aggression with an
average rate of 1.5 per session and did not exhibit any incidents of elopement. The ratio
of means of FIT to CIT was approximately 1:3; CIT almost .75 of the total initiated turns
with affirmation.
During the second parent training session (PT-2), the father expressed the
possibility that he had ADHD, and that he and his son have similar characteristics and
behavior. The father stated that he was not a model student and struggled with
academics, but he excelled in sports. In addition, the father expressed concern that his
son continued to receive negative teacher comments about impulsive and aggressive
behavior (e.g., hitting, shoving, and tackling other children) on a daily basis. The father
stated that play in the home with Bobby and his eight-year old brother before the parent
training sessions involved wrestling and rough play. After the parent training sessions,
the father changed to activities that didn’t involve aggressive play.
Father-play sessions were videotaped twice per week. Similar to PT-1, the ratio
of father initiations to child initiations was approximately 2:3, with the child initiations
almost .66 of the total initiations. The average rate of the father’s positive responses was
13.5 per session; greater than two times the average rate of Condition A. The father had
an average rate of corrective statements of 1 per session. The father did not use negative
comments. The father continued to use I/A, with an average rate of 14 per session.
Bobby exhibited 3 incidents of aggression in session IB#4 and did not exhibit any

77
incidents of elopement. The ratio of means between FIT and CIT was approximately 1:3;
CIT greater than .75 of the total initiated turns with affirmation.
The father was taught the third parent training session (PT-3). During the
discussion, the father stated that Bobby’s aggressiveness towards the older sibling
continued. For example, Bobby often smacked the older brother in the face while seated
in the car with no provocation. The father reported that discipline skills (e.g., time out
and limit setting) were not helpful and that immediate consequences for problem
behavior were not always possible. The father was advised to deal with aggressive
behavior consistently. A token reward system was reviewed. The father was encouraged
to praise Bobby often for appropriate behavior. In addition, the father was advised that
problem behavior could increase initially. The problem behavior was expected to
decrease with consistent behavior management and discipline strategies.
Father-play sessions were videotaped (twice each week). At the beginning of the
fourth father-child play session, Bobby was uncooperative and the session was
discontinued after 2-minutes. A fifth session was scheduled. Flowever, the child was
tired, angry and uncooperative and the session was rescheduled. During another visit the
father was at home but the child was at a birthday party. A final session was scheduled
and videotaped. Similar to PT-1 and PT-2, the ratio of father initiations to child
initiations was approximately 2:3. The child initiations were almost .66 of the total
initiations. The father’s positive responses continued at an average rate of 10 per session,
twice the rate during Condition A. The father’s corrective statements were few with an
average of 3 per session. The father did not use negative comments. The father
continued to increase his use of I/A with an average rate of 17.8 per session, greater than

78
the average rate following PT-1 and PT-2. The child exhibited 3 incidents of aggression
in session #1,2 incidents in session #2, and 15 incidents in the final session. There were
no incidents of elopement. The ratio of means of FIT to CIT was approximately 1:4; CIT
greater than .75 of the total initiated turns with affirmation.
Visual Report of Data for Father and Child Dyad D
During Condition A, Bobby played in isolation. The father chose the type of
play, attempted to interact with Bobby, and directed the activity. In contrast, during
Condition B the father initiations decreased and the child initiations increased (Figure 4-
16). After the parent training sessions, Bobby initiated play more often, demonstrated
creative play, and verbalized choices of following play. In addition, the father
commented in response to Bobby’s direction of play and was less inclined to direct the
play. The father followed Bobby’s directions, requested instructions, and waited for
Bobby’s response before initiating an activity.
After the parent training sessions, the father’s positive responses increased and the
father’s corrective responses decreased (Figure 4-17). The father followed Bobby’s lead
in play, requested direction and/or permission from Bobby, and continued to interact with
Bobby. Few corrective statements were made. The father accepted and followed
Bobby’s direction during father-child play sessions. Similar play was noted in the
sessions IC#1 and IC#2. The father’s desire to follow Bobby’s direction seemed to
affirm a sense of competence in Bobby. Bobby gave more directions; played with more
imagination and creativity; and anticipated the father’s participation.
The father had no difficulty with I/A after instruction during PT-1, and he used
the skill throughout the study (Figure 4-18). For example, Bobby made car sounds when
moving the truck around the floor; made the truck jump in a twirling fashion; or pushed

79
the truck across the floor. The father emphasized the truck sounds, made the truck jump
twirling higher, or made the truck spin across the floor. Interestingly, Bobby observed
the father’s creative expression and incorporated that into his own play. It appeared that
the father’s emphasis and animation of Bobby’s activity encouraged Bobby to play with
more confidence and creativity. However, there was no evidence to support that the
father’s use of I/A influenced the child responses (Figure 4-18). It was noteworthy, that
the father initiations decreased between Condition A and Condition B while the child
responses remained relatively stable (Figure 4.19).
The FIT decreased and CIT increased in Condition B and remained relatively
stable as compared to Condition A (Figure 4-20). The father spoke often and directed the
play in Condition A. During Condition B, the father allowed Bobby to lead the play,
followed Bobby’s directions, waited for Bobby to respond, initiated a turn less often, and
increased his use of I/A. An interesting point is that CIT were relatively high, FIT were
relatively low, and the distance between the two levels was consistent. The father
responded to the child initiations with questions, comments, and requests and completed
the child initiated turn with affirmation. For example, Bobby made a path for the truck,
removed the wave runner, and drove it in the imaginary water. The father asked Bobby
for permission to drive the truck and trailer to the edge of the area and wait for the wave
runner. Bobby gave permission and drove the wave runner on the trailer and instructed
the father to drive the truck to another area. The father responded and continued a
positive reciprocal father-child interaction.
Summary of the Four Father and Child Dyads
A comparison of each subject’s demographics, descriptive characteristics, and
performance across the two conditions of this study is discussed. As anticipated, all four

80
fathers used the parenting strategies and skills that were taught during the in-home parent
training sessions. In addition, all four children responded with positive behavioral
changes following the father’s use of parent skills. Comparison of the family
demographics (Table 4-13) shows that the families vary in age, education, and social
strata. Three of four children were in the 3-year-old age range and attended pre-school
full-time. Child C (James) attended kindergarten. Each child was asked to leave at least
two previous daycare programs because of to aggressive behavior. Each family
continued to receive frequent teacher complaints of aggressive behavior from the child’s
teacher. In addition, Child A (Jordan), Child B (Thomas), and Child D (Bobby) were
diagnosed with speech and language delays and received therapy. Their fathers reported
academic concerns such as poor recollection of colors, numbers, and/or letters. However,
Child C (James) differed from the other subjects in a number of ways. James was
biracial, 5-year and 8-month in age with academic success and no documented
developmental delays. James was tested for advanced placement in the school system
because of his above average academic abilities.
All four fathers reported that they were self-employed. Each father expressed the
inability to work for an employer. Each father discussed the possibility that he had
ADHD as a child. All fathers stated that they could relate to their children’s behavior and
had similar behaviors as children. Father A, Father C, and Father D stated that as
children they were successful (academics or sports). Each father believed that their child
would grow up without problems. Father B left school in junior high because of
academic failure. He expressed concern that Thomas would experience similar failure in
school. Each father was opposed to medication for treatment of ADHD in his child. All

81
fathers expressed a commitment to participate fully in the study and a desire to improve
their children’s behavior without medication.
A comparison of beliefs in Father A, Father B, and Father D about discipline and
attributions for their child’s noncompliance is reported in Table 4-14. Because of
missing data, no comparisons about beliefs regarding discipline or noncompliance with
Father C were possible. Before our study, each father reported higher scores that equated
with ineffective and dysfunctional child discipline. At completion of our study, Father A,
Father B, and Father D reported higher scores for the total score, laxness, and
overreactivity. Father B and Father D reported effective discipline practices related to
verbosity compared to a high score in verbosity reported by Father A.
In addition, each father’s belief about the noncompliance at completion of our
study was compared (Table 4-14). Several points were assessed parent controlled
behavior (effort and mood) and child controlled behavior (effort and mood). Father A
attributed Jordan’s noncompliance to the lack of parent effort (parent control) and
Jordan’s poor mood (child control). Father B attributed noncompliance in Thomas to a
lack of the father’s effort and poor mood (parent control), his child’s lack of effort and
poor mood (child control). Father D attributed Bobby’s noncompliance to a lack of his
child’s effort and poor mood. In comparison, only Father D attributed his child’s
problem behavior completely within his child’s control. Father A and Father B attributed
problem behavior within their child’s control as well as within their own control.
A comparison of fathers’ perception on problem behavior (Table 4-14) revealed
that Child A, Child B, and Child D were reported within the borderline or clinical range
of an externalizing disorder. Child B and Child D were reported within the clinical range

82
of an internalizing disorder and pervasive developmental problems. Additional problem
behaviors within the clinical range reported for Child A, Child B, and Child D.
Interestingly, each fathers reported significant problems related to their children’s sleep
rituals and sleep habits. However, Father B reported that before our study efforts towards
a structured and consistent bedtime ritual had positively influenced his child’s bedtime
behavior.
The comparisons of targeted behavior between subjects and across the conditions
of this study are presented with the exclusion of Father C and Child C because of the lack
of data. A comparison of means of father’s responding behaviors during Condition A
revealed that each father had less than 6 positive responses and greater than 9 corrective
responses (Figure 4-21). All father initiations ranged between 64 and 70% of the total
initiations (Figure 4-23). All child initiations ranged between 30 and 36%. The FIT
ranged between 66 and 84% and CIT ranged between 16 and 34% of the total initiated
turns with affirmation.
A significant change was noted between Condition A and Condition B. During
Condition B, the fathers had greater than 10 positive responses and 3 or fewer corrective
responses (Figure 4-22). All father initiations ranged between 35 and 46% of the total
initiations (Figure 4-24). The child initiations ranged between 54 and 65%. The FIT
ranged between 24 and 44% and CIT ranged between 56 and 76% of the total initiated
turns with affirmation.
In summary, each of the targeted father behaviors and targeted child behaviors
changed between Condition A and Condition B. The father positive responses increased,
the corrective responses decreased, and I/A increased. The father initiations decreased,

83
the child initiations increased, FIT decreased, and CIT increased. Clearly, each father
implemented the father skills that were taught during the parent training sessions. Father
B and Father D had the greatest decrease in corrective statements, the highest use of
imitation with animation, and the greatest increase of positive responses. Significant
improvement was evident in each of the fathers’ initiations and each of the children’s
initiation. A large difference in the initiated turns with affirmation in Father D and Child
D was evident. However, initiated turns with affirmation were more balanced for Father
B and Child B. In addition, Father B reported a decrease in his child’s problem behavior
and more effective father discipline at completion of our study (Table 4-5).
Interobserver Agreement
To assess interobserver agreement on the coding of target behaviors, the PI
followed the observer training sequence developed by Elder (1995) described on page 47.
To minimize the potential for bias, a second independent observer coded 25% of the
videotaped father-child videotaped sessions. The independent observer was blind to the
conditions under which the videotapes were taken. The observer and the PI established a
criteria level of 80% or greater interrater agreement before coding the father-child play
sessions. The independent observer randomly selected and coded 25% of the videotaped
sessions to evaluate for observer drift throughout the course of our study. Interobserver
agreement did fall below 80% two occasions during the coding. The operational
definitions were clarified and practice sessions continued until a level of 80% agreement
was obtained. Interobserver reliability was expressed as percentage agreement with a
range between 76 and 93% between two independent observers (Table 4-15).

84
Social Validity
A semi-structured interview described on page 45 was used to assess the father
perception of the parent training process. The fathers reported perceptions about the
training process on a scale of 1 to 5 (Table 4-16). The children’s behavior was very
typical at a score of one or not typical at a score of 5. All four fathers reported that their
children’s behavior during most of the videotaped play sessions was very typical and that
the presence of the camera and/or the PI had a minimal effect on child behavior. Each
father reported comfort with the parent training skills, use of the skills often, and that the
skills worked well.
The Therapy Attitude Inventory (Eyberg, 1993) described on page 46 was used to
assess the fathers’ satisfaction with the process and outcome of parent training
completion of our study. A total of 10-items are included that address the impact of
therapy on parenting skills and the child behavior. The fathers were asked to rate the
items on a scale from 1 (indicating dissatisfaction with treatment or a worsening of
problems) to 5 (indicating maximum satisfaction with treatment or improvement of
problems) at the completion of the study. The item ratings yield a possible score of 5.0
on a scale of 1 to 5. Each father reported satisfaction with the process and the outcome of
the parent training intervention with a score that ranged from 4.0 to 4.4. In summary, the
fathers perceived the parent training intervention as socially valid, reported minimal
reactivity effects, and documented satisfaction with the process and outcome of the
parent training (Table 4-17).

85
Table 4-1. Summary of Father A effectiveness in discipline
Instrument
Before Study
Completion of Study
Parenting Scale (1993)*
Total score (3.1)
3.9
3.8
Laxness (2.8)
3.4
3.5
Overreactivity (3.0)
3.9
4.0
Verbosity (3.4)
4.4
3.9
CBCL(1983) **
Internalizing T score
49
37
Externalizing T score
65
74
Total score
46
48
*Scale of 1-7, higher scores = dysfunctional parenting
**Score of 60 & above = clinical range of problem behavior
Table 4-2. Summary of Father A belie!
's about child noncompliance
Interactions Questionnaire (1995)*
Before Study
Completion of Study
Parent effort
4
5
Parent mood
7
6.3
Child mood
6.6
5.6
Child effort
4
6.3
* Scale of 1 to 10, 1 = really true, 10 = not true at all
Table 4-3. Means of target behaviors for Father A and Child A
Target Behaviors
Condition A
Baseline
PT* 1
PT* 2
Condition B
PT* 3
Mean PT*
Father Initiations/
Total Initiations
70%
46%
47%
45%
46%
Child Initiations/
Total Initiation
30%
54%
53%
55%
54%
Child Responses
37
33.2
41.2
41.2
38.5
Father Positive
Responses
5.8
12.5
6.5
10.5
7.4
Father Corrective
Responses
15
.7
5.3
4
3
Imitation/Animation
0
10
8.5
4.8
7.8
Child Aggression
0
4.5
5.8
2.2
4.2
Father Initiated
Turn/ Total Turns
84%
41%
44%
46%
44%
Child Initiated Turn/
Total Turns
16%
59%
56%
54%
56%
* PT - Parent training session

86
Table 4-4. Summary of Father B effecl
iveness in discipline
Instrument
Before Study
Completion of Study
Parenting Scale (1993)*
Total score (3.1)
3.6
3.5
Laxness (2.8)
3.7
3.4
Overreactivity (3.0)
4.0
4.0
Verbosity (3.4)
3.4
2.8
CBCL (1983)**
Internalizing T score
62
61
Externalizing T score
65
59
Total score
46
43
* Scale of 1-7, higher scores = ineffective parenting
**Score of 60 & above = clinical range of problem behavior
Table 4-5. Summary of Father B beliefs about child noncompliance
Interactions Questionnaire (1995)*
Before Study
Completion of Study
Parent effort
1.3
2.7
Parent mood
7
2.3
Child mood
4.7
2
Child effort
2
2
* Scale of 1 to 10, 1 = really true, 10 = not true at all
Table 4-6. Means of target behaviors for Father B and Child B
Target Behaviors
Condition A
Baseline
PT* 1
Condition B
PT* 2 PT* 3
Mean PT*
Father Initiations/
Total Initiations
64%
41%
35%
35%
37%
Child Initiations/
Total Initiation
36%
59%
65%
65%
63%
Child Responses
32.2
28.5
37.2
33.2
33
Father Positive
Responses
3
8.8
10.2
15
11.3
Father Corrective
Responses
8
0
0
0
0
Imitation/Animation
0
10.5
11.8
20
14.1
Child Aggression
0
0
.4
0
0
Father Initiated
Turn/ Total Turns
30/69%
18/32%
18/38%
18/40%
36.7%
Child Initiated Turn/
Total Turns
13/31%
38/68%
30/62%
27/60%
63.3%
* PT - Parent Training Session

87
Table 4-7. Summary of Father C effect
iveness in discipline
Instrument
Before Study
Parenting Scale (1993)*
Total score (3.1)
4.1
Laxness (2.8)
4.1
Overreactivity (3.0)
4.0
Verbosity (3.4)
2.9
CBCL**
Internalizing T score
47
Externalizing T score
50
Total score
34
* Scale of 1-7, higher scores = ineffective parenting
** Score of 60 = clinical range of problem behavior
Table 4-8. Summary of Father C beliel
's about child noncompliance
Interactions Questionnaire (1995)*
Before Study
Parent effort
7
Parent mood
8
Child mood
6
Child effort
8.3
* Scale of 1 to 10, 1 = really true, 10 = not true at all
Table 4-9. Means of target behaviors for Father C and Child C
Target Behavior
Condition A
Baseline
PT* 1
PT* 2
Condition B
PT* 3
Mean PT*
Father Initiations/
Total Initiations
65%
31%
33%
40%
34.7%
Child Initiations/
Total Initiation
35%
69%
67%
60%
65.3%
Child Responses
19
21
22
26
34.3
Father Positive
Responses
2
9.4
8.8
4.5
7.7
Father Corrective
Responses
13
1.6
.8
3.5
2
Imitation/ Animation
0
4
4.8
1
3.3
Child Aggression
0
0
0
0
0
Father Initiated
Turn/ Total Turns
23/66%
18/36%
18/49%
20/50%
45%
Child Initiated Turn/
Total Turns
12/34%
32/64%
19/51%
20/50%
55%
*PT - Parent Training Sessions

88
Table 4-10. Summary of Father D effectiveness in discipline
Instrument
Before Study
Completion of Study
Parenting Scale (1993)*
Total score (3.1)
4.4
3.96
Laxness (2.8)
3.8
3.36
Overreactivity (3.0)
4.5
4.2
Verbosity (3.4)
4.3
3.57
CBCL**
Internalizing T score
73
73
Externalizing T score
83
77
Total score
54
54
* Scale of 1-7, higher scores = ineffective parenting
** Score of 60 & above = clinical range of problem behavior
Table 4-11. Summary of Father D beliefs about child noncompliance
Interactions Questionnaire (1995)*
Before Study
Completion of Study
Parent effort
8.33
7.66
Parent mood
8.66
8.66
Child mood
7.66
7.66
Child effort
6.33
6.33
* Scale of 1 to 10, 1 = really true, 10 = is not true at all
Table 4-12. Means of target
behaviors for
"ather D and Child D
Target Behavior
Condition A
Condition B
Baseline
PT*-1
PT-2
PT-3
Mean
Father Initiations/ Total
Initiations
69
38
37
38
37.7%
Child Initiations/ Total
Initiation
31
62
63
62
62.3%
Child Responses
38
31
35
33
33
Father Positive Response
5.3
19.8
13.5
10
14.3
Father Corrections
19.8
2.5
1
2.5
2
Imitation/Animation
.2
13
14
17.8
14.9
Child Aggression
1
1.5
0
5
2.2
Father Initiated Turn/
Total Turns
48/73%
21/28%
20/23%
16/21%
23.7
Child Initiated Turn/ Total
Turns
18/27%
55/72%
61/77%
56/79%
76.3
* PT - Parent Training Sessions

89
Table 4-13. Comparison of family demographics
Subject
Age
(years)
Race
Education
Social
Strata*
Child’s
Age
Father A
41
Caucasian
B.A.
5
3-years &
Mother A
40
Caucasian
M.S.
7-months
Father B
31
Caucasian
Junior High
3
3-years &
Mother B
31
Caucasian
Some College
6-months
Father C
35
African/American
High School
2
5-years &
Mother C
33
Caucasian
Junior High
9-months
Father D
28
Caucasian
A.D.
4
3-years &
Mother D
28
Caucasian
Some College
1-month
*Hollingshead Four Factor Index (1975)

90
Table 4-14. Comparison of descriptive data for subjects at completion of study
Descriptive Data
Child A/Jordan
Child B/Thomas
Child D/Bobby
Parenting Scale*
Total Score (3.1)**
3.8
3.5
3.96
Laxness (2.8)
3.5
3.4
3.36
Overreactivity (3.0)
4.0
4.0
4.2
Verbosity (3.4)
3.9
2.8
3.57
Interactions
Questionnaire**
Parent Effort
Yes
Yes
No
Parent Mood
No
Yes
No
Child Effort
No
Yes
Yes
Child Mood
Yes
Yes
Yes
CBCL ***
Disorder
Internalizing T
37
61
73
Externalizing T
74
59
77
Total Score
48
43
54
CBCL*** Syndrome
Affective Problems
C
N
C
Anxiety Problems
N
N
B
PDD
N
C
C
ADHD Problems
N
N
B
OD Problems
C
N
N
CBCL ***
Psychopathology
Emotional/Reactive
N
N
B
Anxious
N
N
B
Somatic Complaints
N
N
B
Withdrawn
N
C
C
Sleep Problems
C
N
C
Attention Problems
B
N
C
Aggressive
C
N
C
* Parenting Scale - Scale of 1-7, higher scores=dysfunctional parenting
** Interaction Scale - Y=Yes, N=No
***CBCL - Scale of 1-100, 60 & above = clinical range of problem behavior
CBCL Associated Problem Scales - B = borderline clinical, C = clinical, N = normal

91
Table 4-15.
Vlean and range of interobserver agreement
Subject
Reliability Checks
Mean Percentage of
Agreement
Range of Agreement
Child A
4
84
76-87
Child B
4
86
81-93
Child C
4
85
82-90
Child D
4
83
76-92
Table 4-16. Comparison of means of reported scores of father’s perceptions
Semi-Structured Interview*
Child A
Child B
Child C
Child D
Typical child behavior
1.9
1.1
1.0
1.6
No effect of camera/PI
2.1
2.1
1.0
1.5
Training working well
2.0
2.1
2.3
1.2
Training used often
1.5
2.9
2.2
1.8
Father comfort with skill
1.7
2.3
2.2
1.0
* Scale of 1 - 5, 1 = typical, 5 = not typical
Table 4-17. Summary of father’s satisfaction with parent training
Therapy Attitude Inventory*
Total Score
Father A
4.0
Father B
4.4
Father C
**
Father D
4.0
*Scale of 1 to 5, 1 = dissatisfied, 5 = satisfiec
** Father C did not return survey

92
Figure 4-1. Father A initiations and Child A initiations
Baseline Parent Training Intervention
Figure 4-2. Father A responding behaviors

93
Figure 4-3. Child A responses and imitation with animation
Figure 4-4. Father A initiations and Child A responses

94
Figure 4-5. Father A and Child A turn taking
Figure 4-6. Father B initiations and Child B initiations

95
B1B2 B3 B4 IA1 IA2 IA3 IA4 IB1 IB2 IB3 IB4 IB5 IC1 IC2 IC3 IC4
Sessions
Figure 4-7. Father B responding behaviors
B1 B2 B3 B4 IA1 IA2 IA3 IA4 IB1 IB2 IB3 IB4 IB5 IC1 IC2 IC3 IC4
Sessions
Figure 4-8. Child B responses and imitation with animation

96
B1 B2 B3 B4 IA1 IA2 IA3 IA4 IB1 IB2 IB3 IB4 IB5 IC1 IC2 IC3 IC4
Sessions
Figure 4-9. Father B initiations and Child B responses
B1 B2 B3 B4 IA1 IA2 IA3 IA4 IB1 IB2 IB3 IB4 IB5 IC1 IC2 IC3 IC4
Sessions
Figure 4-10. Father B and Child B turn taking

97
B1 B2 B3 B4 IA1 IA2 IA3 IA4 IA5 IB1 IB2 IB3 IB4 IC1 IC2 IC3 IC4
Sessions
Figure 4-11. Father C initiations and Child C initiations
Baseline Parent Training Intervention
Figure 4-12. Father C responding behaviors

98
Baseline Parent Training Intervention
jssions
Figure 4-13. Child C responses and imitation with animation
Sessions
Figure 4-14. Father C initiations and Child C responses

99
Baseline Parent Training Intervention
Figure 4-15. Father C and Child C turn taking

# of Behaviors Observed (S' * of Behaviors Observed
100
Baseline Parent Training Intervention
Sessions
ure 4-17. Father D responding behaviors
Sessions
Figure 4-18. Child D responses and imitation with animation

101
Sessions
Figure 4-19. Father D initiations and Child D responses
Sessions
Figure 4-20. Father D and Child D turn taking

102
Subject
Figure 4-21. Comparison of father responding behavior during Condition A
Figure 4-22. Comparison of father responding behaviors during Condition B

103
S Father Initiations
0 Child Initiations
â–  Father Initated
Turns
B Child Initiated
Turns
B C
Father and Child Dyad
Figure 4-23. Comparison of target behaviors during Condition A
H Father Initiations
H Child Initiations
â–  Father Initiated
Turns
B Child Initiated
Turns
Figure 4-24. Comparison of target behaviors during Condition B

CHAPTER 5
DISCUSSION
The parent training strategies for fathers of children with ADHD in our study
were based on Elder’s (1995) research. The basic assumption is that father-child
behaviors are interdependent. Equally important in our study is the observation that
problem behaviors in children are a function of the father’s reaction to the child.
Reciprocal father-child interaction coupled with deficits in a child’s cognitive processes,
communication, and social skills often results in negative father reactions. This in turn,
may create a cycle of coercion that escalates between the father and the child. As a
result, negative and aggressive behaviors are reinforced and contribute to the evolution of
childhood behavior disorders (Patterson et al. 1991). In addition to coercive interactions,
a father’s beliefs about competence, the ability to parent effectively, and the cause of his
child’s problem behavior may predict childhood behavior disorders and influence the
father’s compliance with treatment strategies. This can negatively affect treatment
outcomes (Hoza et al. 2000; Slep, & O’Leary, 1998). On the contrary, accurate father
interpretation of behavior and realistic beliefs may facilitate positive interactions between
fathers and their children (Dix, & Grusec, 1985).
The purpose of our study was to characterize the interactions of four fathers and
their young children with ADHD, and to evaluate the efficacy of an in-home parent
training intervention for fathers on father behavior, father acquisition of parent training
skills, and child behavior. In addition, questions were addressed on the social value of
the parent training intervention and the effects on father-child interactions. Results from
104

105
our study support and validate this parent training model (Elder, 1995) and research in a
new population, fathers of young children with ADHD. The nurse conducted in-home
parent training intervention for fathers was shown to promote positive father-child
interaction. These findings are consistent with King’s description of a social-
interactional approach in nursing practice, whereby nurses engage clients as active
participants in a shared collaborative process, and contribute to all aspects of patient care
(King, 1981, 1992). In addition, our study addressed the effects of the naturalistic
environment on learning by conducting the parent training invention for fathers within
the home. Single subject design (SSD) provided the means to investigate the interactions
between the fathers and their children. The utility of SSD methodology in our study will
be discussed as well as study limitations, clinical implications, and recommendations for
future research.
Interpretation of Findings
The description of each father-child dyad included the socioeconomic status,
father beliefs regarding child problem behaviors, father effectiveness in discipline, and
father beliefs regarding causality of problem behavior. The assessment of behaviors
during Condition A and Condition B provided valuable information regarding patterns of
father-child communication and interaction. The parent training intervention was
individualized based on the needs of the each father and child. All fathers were trained to
assess their children’s behavior and ultimately set realistic behavior goals. The fathers
were taught to use parenting strategies and skills during interactions with their children in
their home, while continuing to assess their children’s behavior and adapt the parenting
strategies and skills to obtain maximum benefit. The use of Elder’s (1995) parent
training model was essential for the development and the implementation of our parent

106
training intervention for fathers of young children with ADHD. Despite minimal
improvement reported by fathers regarding effectiveness in discipline and their children’s
problem behavior, social validity data indicate that fathers were satisfied with the process
and outcome of the parent training.
At completion of our study, fathers reported modest reductions in scores on the
CBCL (Achenbach, & Edelbrock, 1983) with the exception of Father C due to a lack of
data. The modest reductions were within the clinical range of an externalizing disorder,
ADHD, and attention problems. In addition, the fathers reported modest reductions in
scores on laxness, overreactivity, verbosity, and total scores. Despite the modest
reductions, the scores remained in the dysfunctional range of parenting effectiveness in
discipline.
A comparison of the frequencies of targeted father behaviors and targeted child
behaviors across conditions was used to evaluate each father’s proficiency with parenting
strategies and their children’s behavior progress. The results obtained by using direct
behavioral counts for all four fathers and their children showed an increase in each
father’s use of imitation with animation, father positive responses, child initiations, and
child initiated turns with affirmation. Conversely, there were decreases in the father
initiations, father corrective statements, and FIT. All four fathers and their children
demonstrated a ratio of 2:1 of father initiations to child initiations during Condition A.
On the contrary, the ratio of father initiations to child initiations in Condition B was
reversed with the child initiations greater than at least one-half of the total initiations.
Similarly, the ratio of means of FIT to CIT in all four father and child dyads reversed
from Condition A to Condition B; CIT greater than one-half of the total initiated turns

107
with affirmation. Thus, fathers who were taught to use parenting strategies in father-
child interactions; engaged in the parent training process, positively reinforced
appropriate child behavior, and facilitated child led play. As a result, significantly
improved father-child interactions were evident.
Also noteworthy is that Father-Child B and Father-Child D showed substantial
changes in targeted father behaviors and targeted child behaviors. Most evident was each
father’s consistent use of I/A throughout Condition B as well as increased positive
responses and few corrective statements. Father B reported the most significant
reduction in his child’s problem behavior to the normal range of externalizing behavior,
ADHD, and attention problems. A summary of data for each father-child dyad as well as
commonalties and differences among the dyads was discussed in Chapter 4 on page 51.
The results suggest a consistent, positive effect of the parent training intervention on each
father’s use of the parenting skills, targeted father behaviors, and targeted child
behaviors.
Utility of Single Subject Design in Nursing Research
The single subject, AB design was chosen to examine the relationship between
Condition A and Condition B. Continuous assessment of repeated observations of each
father’s targeted behaviors and each child’s targeted behaviors provided the means to
empirically investigate and analyze the individual behaviors. Each subject was exposed
to the experimental conditions (parent training intervention), and was used as his own
control. Repeated behavioral observations revealed that father-child interactions were
often dependent on the type of play. It is unlikely that another method of inquiry would
have been sensitive enough to detect the subtle changes during father-child play. This

108
illustrates how SSD methodology may discover and/or establish relationships not directly
related to the main research question.
In our study, treatment integrity was assessed to determine that the parent training
intervention was implemented as intended and to strengthen the internal and external
validity. Typically, threats to internal validity in SSD are controlled and visual inspection
of data eliminates Type 1 error. Subject reactivity was assessed in regard to the camera
effect on the child behavior following every other videotaped father-child play session.
Elder (1995) suggests that initial camera-conscious behavior in subjects is minimized as
subjects are accustomed to the observers and/or cameras. At the completion of this study,
all fathers reported only minimal effects of the camera in the majority of the father-child
play sessions. Elder (1999) suggests that videotape methodology surpasses direct
behavioral observations with regard to detecting extraneous variables and strengthens
internal validity. Videotaped behavioral observations provided opportunities for more
accurate pictures of target behaviors over time and eliminated confounding variables in
the environment. The interobserver agreement that was reported in our study was .85
with a range of agreement between .76 and .93. Thus, our study showed that the
replication of behaviors was likely due to the parent training intervention versus chance.
The external validity of our study and the likelihood of Type 2 error were
addressed. Generalization of the relationship between parent training and the target
behaviors across settings was not assessed. Consequently, the meaningfulness of the
interpretations of this study under different circumstances may be suspect. However, a
lack of generalization across settings is not considered a limitation in current research.
SSD has no less generality and possibly greater generality than findings from group

109
research (Kazdin, 1998). Future research and replication of this study across settings that
include the home and daycare or school and a multiple baseline design may enhance
generalization.
Limitations Associated with this Research
There are a number of limitations regarding the findings of our study. First, only
fathers were invited to participate. Valuable data regarding the effects of the parent
training intervention on the mother’s behavior was not available. This leads one to
question if mother-child interactions would differ from father-child interactions following
the parent training intervention? The fathers often complained that their spouses were
not aware of the parenting strategies and interfered with discipline efforts to manage their
children’s problem behavior. Would the inclusion of mothers improve the outcome of
this study? Future research including mothers is essential for determining the effects of
this parent training intervention on father-child interactions as well as mother-child
interactions.
Second, all four children referred for participation in this study were males
diagnosed with ADHD. This leads one to question if father-daughter interactions differ
from father-son interactions? Future research should include fathers and their daughters
diagnosed with ADHD to characterize their interactions and determine the effects of the
parent training intervention on father-daughter interactions.
Third, the question of how the parent training intervention affected each father’s
stress level or sense of competence was not addressed in this study. Assessment of the
mother and father beliefs related to stress and competence as well as parenting
effectiveness may yield important data regarding the effects of the parent training
intervention on father-child interactions. Pisterman et al. (1992) reported that parent

110
beliefs following parent training were found to decrease parent stress and improve
competence in families of preschoolers with ADHD. Decreased parental stress and
improved competence were found to provide immediate benefit and had the potential for
preempting dysfunctional cycles that led to behavior disorders and prolonged family
pathology. Future research should consider the assessment of parent beliefs regarding
parental stress, competence and effectiveness before the parent training, at completion of
the study, and longitudinally.
Fourth, each child received a recent diagnosis of ADHD and was reported to be in
good health prior to their participation in this study. However, there was no information
from the health care provider regarding comorbid conditions and/or developmental delays
or disorders. Before our study, the parents discussed concerns regarding their children’s
academics and/or speech delays. Clearly, problem behaviors reported by fathers
suggested the possibility of depression, anxiety disorder, oppositional disorder, and
pervasive developmental disorder. This investigator’s nursing experience suggests that
children with ADHD often have comorbid conditions that are difficult to assess and
diagnose in young children. Future research should address this concern.
Fifth, the results of this study must be interpreted with caution. Despite the father
reports of satisfaction with the parent training process and perceived benefits to their
children at home, at school or daycare, and outside of the home; the findings were not
studied across settings or for maintenance of treatment effects. Furthermore, only one
father and child dyad was African-American. Further research is necessary to determine
the generalizability of findings, and the maintenance of the treatment effects in the home
and the school environment. Culturally specific issues should be addressed for further

Ill
development of a comprehensive, multi-component treatment package for children with
ADHD.
Implications for Clinical Practice
Our study provides essential, contextual information about the interactions of
fathers and their children with ADHD, and the efficacy of an in-home parent training
intervention for fathers. In addition, this research builds on previous work cited in the
literature and addresses the need for more information regarding fathers and their
children with ADHD. The findings reported in our study have a number of clinical
implications for the effective treatment of young children with ADHD. First, fathers
were taught a set of reinforcing parenting strategies and skills to use during father-child
interactions. The fathers positively reinforced appropriate child behaviors and facilitated
child led play when taught to identify and respond consistently to child initiations, give
the child adequate time to respond to father initiations, and allow the child to direct the
father-child play sessions. Significantly improved father-child interactions and father
satisfaction were evident following the implementation of this parent training
intervention. Parent training interventions that assist in the characterization of father-
child interactions and the evaluation of effects on father-child interactions may promote
positive, reciprocal father-child behaviors and ultimately improve father-child
communication and interactions.
Second, each father’s belief about problem behavior in himself and in his child,
effectiveness in discipline, and the causality of his child’s problem behaviors influence
the treatment outcomes across settings (Hinshaw, Owens, Wells et al., 2000; Hoza et al.,
2000; Wells, Epstein, Hinshaw et al., 2000). Dysfunctional discipline is reflective of
reactive parenting and linked to reciprocal, coercion parent-child interactions, and the

112
subsequent development of serious impairment in children with ADHD. Each father
reported that he had undiagnosed ADHD as a child and “grew out of it.” The fathers
reported modest improvement in discipline effectiveness and problem behavior in their
children. Attributions for problem behavior in their children were mixed. Therefore,
comprehensive multi-component packages with parent training as one component that
addresses father beliefs and individualizes treatments may improve discipline practices in
fathers and positively influence treatment outcomes.
Recommendations for Future Research
Limited information is evident in the literature on father-child interactions and the
father’s influence on his child’s behavior (MTA, 1999; Webster-Stratton, 1985).
However, there is substantial support that parent training approaches are a powerful tool
for clinicians and researchers in the behavior management of children with problem
behavior. Consequently, there is a dire need for empirically validated interventions for
fathers and their children with ADHD. Training fathers parenting strategies to improve
father-child interactions and appropriately discipline their children’s problem behavior
may be a crucial step in halting children’s increasingly coercive behavior. Furthermore,
our study of an in-home, parent training intervention for fathers of young children with
ADHD provided essential, contextual information related to father-child interactions with
implications for research.
Several questions have risen from this study. Each father requested that his wife
receive parent training. Future research should address whether the inclusion of mothers
would strengthen the effectiveness of the parent training intervention and if a measure of
parenting stress and/or marital conflict would add to the understanding of father behavior.
In addition, it is important to determine why fathers expressed difficulty with imitation

113
with animation (I/A) and if the presence of the PI during the videotaped father-child play
sessions adversely affected the training process. More specifically, would fathers use I/A
more often if an observer other than the PI videotaped the father-child play sessions?
Further questions address the relationship of problem behaviors with a diagnosis of
ADHD. Each father reported significant child sleep problems. Future research could
characterize and document the presence of sleep problems in children with ADHD. Also
important is the fact that every father believed that he had ADHD as a child. This leads
one to wonder if fathers with a history of ADHD differ from fathers without ADHD. In
addition, the type of play the fathers and children engaged in seemed to play an important
role in the training process. Further work is needed to examine how the various types of
play may influence father-child interactions.
A search to capture the diversity of father’s characteristics, cultural influences,
and father’s beliefs on father-child interactions is essential. Children with supportive,
reciprocal and sensitive relationships with parents are more likely to be well adjusted
than children with less satisfying relationships (Lamb, 1997). Research with fathers and
mothers regarding their beliefs, parenting practices, and interactions with their children is
essential to the development of comprehensive, multi-component treatment packages,
that facilitate child-directed play, match treatment to fathers on the basis of cognition,
and incorporate specific father and child play. The challenge for future research is to
understand the complex patterns of father-child interactions as well as mother-child
interactions and answer substantive questions that promote and support parent-child
interactions and positive treatment outcomes across settings.

APPENDIX A
OPERATIONAL DEFINITIONS FOR DEPENDENT VARIABLES
Imitating/animating: the movement cycle that begins within 5 seconds of a child’s
initiation (e.g., child utters a vocalization or jumps up and down) and the father imitates
the child’s behavior in an animated manner (e.g., exaggerated affect or lively movement).
Father initiations are verbal or physical cues. Verbal cues are commands given to
the child to perform a specific behavior (e.g., “Give me the book”.); comments indicating
a specific item or event (e.g., “That is a book.”), and questions including inflection to
elicit, direct, or sustain the child’s attention (e.g., “What is that?”).
Physical cues are defined as active transfer of an object from father to child,
gestures, and physical structure (e.g., taking the child’s hand to assist in picking up a toy
or turning the child’s head to have eye contact with the child)
Father positive responding behavior is the movement cycle that begins with the
occurrence of a child behavior and ends after the father initiates the requested movement
or offers a positive comment (e.g., praise or thanking child), or a physical gesture (e.g.,
high five, pat on back, or a hug) within 5 seconds. Facial expressions such as smiling are
included only if accompanied by praise or gesture (e.g., high-five or a pat on back).
Father negative responding behavior is the movement cycle that begins with the
occurrence of a child behavior and ends after the father corrects the child verbally or
physically (within 5 seconds of the child action) in a way that conveys anger, negative
affect, or displeasure. The father’s response may be a reprimand, critical, and/or
corrective comment made about the child’s behavior (e.g., “Sit down right now”).
114

115
Father corrective responding behavior is the movement cycle that begins with the
occurrence of a child behavior and ends after the father corrects the child verbally or
physically (within 5 seconds of the child action) with a command in the form of a prompt
in a way that does not conveys anger, negative affect, or displeasure about the child’s
behavior.
Father no responding behavior is the movement cycle that begins with the
occurrence of a child behavior and ends without a father response (within 5 seconds of
the child action).
Father total responses are the sum of positive responding, negative responding,
and corrective responding behaviors.
Father limit-setting is the movement cycle that begins with a child’s misbehavior
(e.g., aggression or tantrum) and ends with a father-initiated consequence to child
misbehavior within 5 seconds.
Father ignoring misbehavior is the movement cycle that begins with a child’s
misbehavior (e.g., whining, pouting, tantrums, talking back, facial grimaces, brief crying,
or baby talk) and ends without a father response within 5 seconds.
Father-initiated turn with affirmation is the movement cycle that begins with a
father initiation (either a verbal or physical cue) and ends with a child response.
Child-initiated turn with affirmation is the movement cycle that begins with a
child initiation and ends with a father’s response.
Child initiations are either verbal initiations or physical initiations.
Verbal initiations are goal-directed intelligible or unintelligible vocalizations of a
child to elicit or maintain a father’s attention.

116
Physical initiations include active, child-initiated transfer of an object to the
father, child gestures, or physical touching.
Child responses are the movement cycle that begins with the occurrence of a
father’s verbal command or request and ends after the child responds within 5 seconds to
the father’s requested movement.
Child tantrum/aggression are clearly audible crying sounds emitted by the child
associated with kicking and/or flailing arms; hitting, biting, pinching, kicking, pulling or
pushing father; throwing an object at the father; spitting at father; pushing into fathers
body; not playing with toys appropriately; ripping or tearing objects; pounding on tables,
walls, or floors with a closed fist or object; throwing objects; cursing or yelling at father;
verbal threats; or dropping to floor.
Child elopement is defined as leaving the play area.

APPENDIX B
PARENT TRAINING INTERVENTION FOR
FATHERS OF YOUNG CHILDREN WITH ADHD
Ground-Rules
• Remember that your involvement is CRITICAL to the success of this program.
• Remember that consistency is CRITICAL to the success of this program.
• Please let the person videotaping know if there has been a change in routine,
environment, health, or anything else that might affect the child or father at the
time of videotaping.
• Please state if and when the child had medication and the dose..
• You have a right to say “I just don’t feel like doing this today”. Please let us
know in advance when possible.
• I am an “intruder” in your home. Be honest with me if I am inconveniencing you
in any way. I will work hard to comply with your schedules.
Homework
• Review handouts each day prior to the father-child play session.
• Use child-directed play strategies and the imitating with animation technique
during a 15-minute father-child play session five times per week.
• Continue to model appropriate behaviors throughout day in various settings when
interacting with child.
• Love your child, demonstrate love to your child often, and praise your child often.
Schedule
You are asked to use the strategies and the imitating with animation skill each day
in different settings. I will contact you at the end of week, following the second
videotaped father-child play session (date) . If you have
questions we will discuss and review the child-directed play strategies and the imitating
117

118
with animation skill. Two father-child play sessions will be videotaped the following
week. An additional videotaped father-child play session may be necessary. Then we
will begin the next training session.
Parent Training Session 1
Child-directed Play Strategies for Father
Discussion and handouts
How to play with your child
Follow your child’s lead
Imitating with animation (I/A)
Praise
Use of strategies during play
Observe videotape demonstrations of behaviors
Role-modeling
Parent Training Session 2
Child Discipline Strategies for Father
Discussion and handouts
Limit-setting
Ignoring misbehavior
Timeout
Use of strategies during play
Observe videotape demonstrations of behaviors
Role-modeling

119
Parent Training Session 3
Review of Parent Training Session 1 and 2
Child-directed Play Strategies for Father
Child Discipline Strategies for Father

APPENDIX C
THE PARENTING SCALE (ARNOLD, O’LEARY, WOLFF, & ACKER, 1993)
At one time or another, all children misbehave or do things that could be harmful, that are "wrong, " or that parents
don't like. Examples include:
hitting someone whining throwing food *
coming home late f orgetting homework not picking up toys
lying having a tantrum refusing to go to bed
wanting a cookie before dinner arguing back running into the street
Parents have many different ways or styles of dealing with these types ofproblems. Below are items that describe
some styles of parenting
For each item, fill in the circle that best describes your style of parenting during the past two months.
SAMPLE ITEM:
At meal time ...
I let my child decide
how much to eat.
o-o-o-o-o-o-o
I decide how much
my child eats.
1.
When my child misbehaves..
I do something
O-O-O-O-O-O-O
I do something about
right away.
it later.
2.
Before I do something about a problem ...
I give my child several
O-O-O-O-O-O-O
I use only one reminder
reminders or warnings.
or warning.
3.
When I’m upset or under stress ...
I am picky and on my
O-O-O-O-O-O-O
I am no more picky
child’s back.
than usual.
4.
When 1 tell my child not to do something...
* i say very little.
O-O-O-O-O-O-O
I say a lot.
5.
When my child pesters me...
I can ignore
O-O-O-O-O-O-O
I can’t ignore
'' the pestering.
the pestering.
6.
When my child misbehaves ..
I usually get into a long
O-O-O-O-O-O-O
I don’t get into an
argument with my child.
argument.
7.
I threaten to do things that..
I am sure I can
O-O-O-O-O-O-O
i know 1 won’t
carry out.
actually do.
120

121
8. I am the kind of parent that...
sets limits on what my O—O—O—O—O—O—O
child is allowed to do.
9. When my child misbehaves...
I give my child a 0—0—0—0—0—0—0
long lecture.
10. When my child misbehaves ...
I raise my voice O-O-O-O-O-O-O
or yell.
11. If saying no doesn’t work right away...
I take some other 0—0—0—0—0—0—0
kind of action.
12. When I want my child to stop doing something ...
I firmly tell my child 0~0~O—0—0—0—0
to stop.
13. When my child is out of my sight...
I often don’t know what 0—0—0—0—0—0—0
my child is doing.
14. After there’s been a problem with my child ...
I often hold a grudge. 0—0—0—0—0—0—0
15. When we're not at home ...
I handle my child the 0—0—0—0—0—0—0
way I do at home.
16. When my child does something I don’t like...
I do something about it O—0—0—0—O—O-O
every time it happens.
17. When there’s a problem with my child...
things buildup and I do 0—0—0—0—0—0—0
tilings that 1 don’t mean
to do.
18. When ray child misbehaves) I spank, slap, grab, or hit my child...
never or rarely. O—O—O—O—O—O—O
lots my child do whatever
he or she wants.
I keep my talks short
and to the point.
I speak to my child
calmly.
1 keep talking and try to
get through to my child.
I coax or beg my child
to stop.
I always have a good idea
of what my child is doing.
things get back to
normal quickly.
I let my child get away
with a lot more.
1 often let it go.
things don’t get our
of hand.
most of the time.

APPENDIX D
INTERACTIONS QUESTIONAIRE (HOZA, & PELHAM, 1995)
Interactions Questionnaire
Site (site use only) (Hoza, Milich, & Pelham, 1991
Subject ID # (site use only) based on Sobol et al, 1989;
Bugental & Shennun, 1984)
Relationship to Child Hoza-AO
Date page 1 of 8
In this questionnaire, we want to know how much you think
different reasons explain successful and unsuccessful interactions with
your child. There are no right or wrong answers to the questions. For
each item below, simply circle the number for each statement that best
shows how true you think the statement is. Do NOT MARK AN
ANSWER THAT IS BETWEEN TWO NUMBERS. =
1) Imagine you are talking on the telephone and you ask your child
to stop interrupting you and he stops. Why would this be?
a) He stopped interrupting but I don't know why. It was just one of
those things that I cannot explain.
I 2 3 i 5 S 1 8 8 IQ
Really Not true
True at all
b) He stopped interrupting because getting a child to stop interrupting
a phone call is easy.
1 2 3_ 4 5 6 2 S 2 111
Really Not true
True at all
c) He stopped interrupting because I made a special effort that day to
get him to stop.
1 2 1 á 5 6 1 a _2 IH
Really Not true
True at all
d) He stopped interrupting because I was in a good mood that day.
1 2 3 4 5 6 7 8 9 IQ
Really Not true
True at all
e) He stopped interrupting because he is good at following directions.
123456789 IQ
Really Not true
True at all
f) He stopped interrupting because basically I am a good parent.
1 2 3 4 5 6 —7 S 8 IQ
Really
True
Not true
at all
122

123
Subject ID#
.(for site use only)
INTX page 2 of 8
g) He stopped interrupting because basically he is a good child.
J 2 3 * 5 6 7 8 9 10
Really Not true
True at all
h) He stopped interrupting because he was in a good mood that day.
1 2 3 4 5 6 1 8 9 10
Really Not true
True at all
i) He stopped interrupting because I am good at getting a child to
follow directions.
1 2 3 4 5 6 7 8 9 10
Really Not true
True at all
j) He stopped interrupting me because he made a special effort that
day to please me.
1 2 _3 4 5 6 7 8 9 10
Really Not true
True at all
2) Suppose you ask your child to clean up his room and he does NOT
do it Why would this be?
a) He did nfflt clean up his room because basically I am a bad parent
1 2 3 4 5 6 7 8 9 12
Really Not true
True at all
b) He did nfli clean up his room because I am no! good at getting a
child to follow directions.
1 -2- 3. 4 _5 6 7 8 9 IQ
Really Not true
True at all
c) He did not clean up his room because I did nal make a special effort
that day to get him to do it.
123456789 12
Really Not true
True at all
d) He did not clean up his room because he is nat good at following
directions.
1 2 3 4 5 6 7 8 9 IQ
Really Not true
True at all

124
Subject H>#_
_(for site use only) INTX page 3 of 8
e) He did not clean up his room because getting a child to clean up his
room is hard.
i 2 a 4 5 6_ 7 8 9 IQ
Really
True
Not true
at all
f) He did not clean up his room because he was in a bad mood that day.
1 2 2 4 5 £ Z 8 9 IQ
Really
True
Not true
at all
g) He did not clean up his room because I was in a bad mood that day.
I 2 2 4 5 6 7 8 9 10
Really
True
Not true
at all
h) He did not clean up his room because basically he is a difficult child.
1 2 3 4 5 6 2 8 2 IQ
Really
True
Not true
at all
i) He did not clean up his room because he did net make a special
effort that day to please me.
I 2 2 4 5. 6 1 8 9 IQ
Really
True
Not true
at all
j) He did not clean up his room but I don't know why. It was just one
of those things that I cannot explain.
I 2 3 4 5 6.7 8 9 IQ
Really Not true
True at all
3) Suppose you ask your child to come in from playing outside and
he does it. Why would this be?
a) He came in from playing outside but I don't know why. It was just
one of those things that I cannot explain.
1 2 .3. 4 5 6 1 8 9 IQ
Really Not true
True at all
b) He came in from playing outside
1 2 2 4 5
Really
True
because basically he is a good child.
6 7 8 .9 IQ
Not true
at all

125
Subject ID# (site uSe only) INTX page 4 of 8
c) He came in from playing outside because I made a special effort
that day to get him to do it.
12 3 4
5 6 7
8
9 10
Really
Not true
True
at all
d) He came in from playing outside because he
is good at following
directions.
i 2 3 4
5 6 7
fi
9 10
Really
Not true
True
at all
e) He came in from playing outside because getting a
child to come in
from playing outside is easy.
12 3 4
5 6 7
fi
9 10
Really
Not true
True
at all
f) He came in from playing outside because he was in a good mood that
day.
12 3 4
5 6 7
8
9 10
Really
Not true
True
at all
g) He came in from playing outside because I am good at getting a
child to follow directions.
1 2 3 4 5 S Z S § 12
Really
True
Not true
at all
h) He came in from playing outside because I was in a good mood that day.
J 2 3 4 5 fi 1 S 2 12
Really
True
Not true
at all
i) He came in from playing outside because basically I am a good parent.
1 2 3 4 5 6 7 8 9 10
Really
True
Not true
at all
j) He came in from playing outside because he made a special effort
that day to please me.
1 2 3 á 5 fi 1 8 2_ 12
Really
True
Not true
at all

126
Subjet ID#_
_(site use only)
INTX page 5 of 8
4) Imagine you are talking on the telephone and you ask your child
to stop interrupting you and he does NOT stop. Why would this be?
a) He did not stop interrupting because getting a child to stop
interrupting a phone call is hard.
1 2 2 4 5 S Z a 2 12
Really
True
Not true
at all
b) He did not stop interrupting because I was in a bad mood that day.
1 2 2 4 5 S Z S__ 2 12
Really
True
Not true
at all
c) He did not stop interrupting but I don't know why. It was just one
of these things that I cannot explain.
1 2 2 4 5 6 8 2 12
Really
True
Not true
at all
d) He did not stop interrupting because basically he is a difficult child.
12345678 .9 12
Really
True
Not true
at all
e) He did not stop interrupting because he was in a bad mood that day.
1 2 3 4 5 6 Z 8 2 12
Really
True
Not true
at all
f) He did not stop interrupting because he is sal good at following
directions.
1 2 3 4 5 6 7 S 2 12
Really
True
Not true
at all
g) He did not stop interrupting because he did nat make a special
effort that day to please me.
12 3 456789 12
Really
True
Not true
at all
h) He did not stop interrupting because I did not make a special effort
that day to get him to stop.
1 2 3 4 5 6 7 8 9 IQ
Really
True
Not true
at all

127
Subject ID#.
.(site use only)
INTX page 6 of 8
i) He did nfll stop interrupting because I am qq! good at getting a child
to follow directions.
i 2 2—i—5—s i a a ia
Really
True
Not true
at all
j) He did pot stop interrupting because basically I am a bad parent.
1 2 2 4 5 6. „I 8 9 10
Really Not true
True at all
5) Suppose you ask your child to come in from playing outside and
he does NOT do it. Why would this be?
a)He did not come in from playing outside because I am net good at
getting a child to follow directions.
1 2 3 4 5 6 7 8 9 10
Really Not true
True at all
b) He did not come in from playing outside because basically he is a
difficult child.
1 2 3 4 5 6 7 8 9 Ifl
Really Not true
True at all
c) He did not come in from playing outside because I was in a bad
mood that day.
1 2 3 4 5 fi Z S 8 1Ü
Really
True
Not true
at
d) He did not come in from playing outside because getting a child to
come in from playing outside is hard.
1 2 3 4 5 6 7 8 9 10
Really
True
Not true
at all
e) He did not come in from playing outside but I don't know
was just one of those things that I cannot explain.
1 2 3 4 5 6 7 8 2_
why. It
in
Really
True
Not true
at all

128
Subject ID# (site use only) INTX page 7 of 8
f) He did not come in from playing outside because he was in a bad
mood that day.
123,456789 10
Really Not true
True at all
g) He did noLcome in from playing outside because I did nai make a
special effort that day to get him to do it.
1 2 2 4 5 6 1 8 9 10
Really Not true
True at all
h) He did nat come in from playing outside because basically I am a
bad parent.
123456789 10
Really Not true
True at all
i) He did not come in from playing outside because he is not good at
following directions.
1 2 3 4 5 6 7 8 9 10
Really Not true
True at all
j) He did not come in from playing outside because he did oat make a
special effort that day to please me.
123456789 10
Really Not true
True at all
6) Suppose you ask your child to clean up his room and he does it
Why would this be?
a) He cleaned up his room because getting a child to clean up his room
is easy.
1 2 3 4 5 _6 1 S 9 IQ
Really Not true •
True at all
b) He cleaned up his room because basically he is a good child.
1 2 3 4 ¿ 6 1 S 9 IP.
Really Not tâ„¢15
True at 311

129
Subject ID#_
_(site use only)
INTX page 8 of 8
c) He cleaned up his room because basically I am a good parent.
1 -2 2 i 5 S 7 8 .9 10
Really
True
Not true
at all
d) He cleaned up his room because he was in a good mood that day.
1 2 2 á 5 6 1 S 9 .. IQ
Really
True
Not true
at all
e) He cleaned up his room because I was in a good mood that day.
123456789 10
Really
True
Not true
at all
f) He cleaned up his room because I am good at getting a child to
follow directions.
123456789 10
Really
True
Not true
at all
g) He cleaned up his room because he is good at following directions.
1 2 3 4 5 6 7 8 9 IQ
Really
True
Not true
at all
h) He cleaned up his room because I made a special effort that day to
get him to do it.
1 2 _ 3 4 5 6 7 9 _a IQ
Really
True
Not true
at all
i) He cleaned up his room because he made a special effort that day to
please me.
1 2 2 á 5 6 1 8 9 IQ
Really
True
Not true
at all
j) He cleaned up his room but I don't know why. It was just one of
those things that I cannot explain.
1 2 3 4 _5 6 7 8 9 IQ
Really
True
Not true
at all

APPENDIX E
HOLLINGSHEAD FOUR FACTOR INDEX OF SOCIAL STATUS (1975)
Hpllingsjtfftd on SES
7
Graduate degree
6
College education
5
Partial college (at least one year)
4
High school graduate
3
Partial high school (10th or 11th)
2
Junior high (9th grade)
1
Less than 7th grade
Points
tt-.T'ii:.:,-. .1
Occupational Key
Occupational Cateoorv Score
9
Higher executive, major professional, proprietor of big business
8
Administrator, less professional, proprietor of mid-sized business
7
Smaller business owner, farm owner, manager, minor
professionals
Technicians, semiprofessional, small business owner
Clerical/sales, small farm/business owner
Skilled manual worker, craftsman, tenant farmer
Machine operator and semiskilled worker
1
Unskilled worker
Farm laborers and menial service workers (includes those
dependent on welfare)
Page 3 of3
•8
130

131
â– gajicdu un oc-o Page 2 of 3
HOLLINGSHEAD four factor index of social status
Case A: Only one partner or single person employed:
FACTOR
Occupation
Education
SCALE SCORE
FACTOR WEIGHT
SCORE X WEIGHT
3
Total:
Case B: Both husband and wife are gainfitlly employed:
HUSBAND’S FACTOR
SCALE SCORE
FACTOR WEIGHT
SCORE X WEIGHT
Occupation
1
Education
3
Total:
WIFE'S FACTOR
SCALE SCORE
FACTOR WEIGHT
SCORE X WEIGHT
Occupation
5
Education
3 i
Total:
Sum of Wife Total and Husband Total:
Divide Sum of Wife and Husband by 2:
http://wbarratt.indstate.edu/666/hollingshead.htm â– 
7/3/01

APPENDIX F
CHILD BEHAVIOR CHECKLIST (ACHENBACH, & EDELBROCK, 19983)
to answer all items. CHILD BEHAVIOR CHECKLIST FOR AGES 1Va - 5 For office um only
CHILD'S Firs! Middle Last
FULL NAME
PARENTS' USUAL TYPE OF WORK, oven If not working now. Phase
be specific—for example, auto mechanic, high schoolteacher, homemaker,
laborer, lathe operator, shoe salesman, army sergeant
FATHERS
TYPE OF WORK
CHILD'S GENDER CHILD'S AGE
â–¡ Boy 0 Girl
CHILD'S ETHNIC
GROUP
OR RACE
TODAYS DATE
Mo. Date Yr.
CHILD'S BIRTHDATE
Mo. Date Yr.
MOTHER'S
TYPE OF WORK
THIS FORM FILLED OUT BY: (print your full name)
Your relationship to child:
â–¡ Mother â–¡ Father â–¡ Other (specify)'.
Please fill out this form to rt
behavior even if other people m
additional comments beside
provided on page 2. Be sure
sflect your view of (he child's
gut not agree. Feel free to write
each item and in the space
o answer all items.
Below is a list of items that describe children. For each item that describes the child now or within the past 2 months, please carde
the 2 if the item is very true or often true of the child. Circle the 1 if the item is somewhat or sometimes true of the child. If the
item is not true of the child, drde the 0. Please answer all items as well as you can, even if some do not seem to apply to the child.
0 “ Not True (a* far as you know) 1 = Somewhat or Sometimes True 2 * Very True or Often True
0
1
2
1. Aches or pains (without medical cause; do
0
1
2
30.
Easily jealous
not include stomach or headaches)
0
1
2
31.
Eats or drinks things that are not food—don't
0
1
2
2. Acts too young for age
include sweets (describe):
0
1
2
3. Afraid to try new things
0
1
2
4. Avoids looking others in the eye
0
1
2
32.
Fears certain animals, situations, or places
0
1
2
5. Can't concentrate, cant pay attention for long
/describe):
0
1
2
6. Can't sit still, restless, or hyperactive
0
1
2
7. Can’t stand having things out of place
0
1
2
33.
Feelings are easily hurt
0
1
2
8. Can't stand waiting; wants everything now
0
1
2
34.
Gets hurt a lot, accident-prone
0
1
2
9. Chews on things that aren't edible
0
1
2
35.
Gets in many fights
0
1
2
10. Clings to adults or too dependent
0
1
2
36.
Gets into everything
0
1
2
11. Constantly seeks help
0
1
2
37.
Gets too upset when separated from parents
0
1
2
12. Constipated, doesn't move bowels (when not
0
1
2
38.
Has trouble getting to sleep
sick)
0
1
2
39.
Headaches (without medical cause)
0
1
2
13. Cries a tot
0
1
2
40.
Hits others
0
1
2
14. Cruel to animals
0
i
2
41.
Holds his/her breath
0
1
2
15. Defiant
0
1
2
42.
Hurts animals or people without meaning to
0
1
2
16. Demands must be met immediately
0
1
2
43.
Looks unhappy without good reason
0
1
2
17. Destroys his/her own things
0
1
2
44.
Angry moods
0
1
2
16. Destroys things belonging to his/her family
0
1
2
45.
Nausea, feels sick (without medical cause)
or other children
0
1
2
46.
Nervous movements or twitching
0
1
2
19. Diarrhea or loose bowels (when not sick)
(describe):
0
1
2
20. Disobedient
0
1
2
21. Disturbed by any change in routine
0
1
2
47.
Nervous, highstrung, or tense
0
1
2
22. Doesn't want to sleep atone
0
1
2
46.
Nightmares
0
1
2
23. Doesn't answer when people talk to him/her
0
1
2
49.
Overeating
0
1
2
2d Doesn't ear well (describe!:
0
1
2
50.
Overtired
0
1
2
51.
Shows panic for no good reason
0
1
2
25 Doesn’t get along with other children
0
1
2
52.
Painful bowel movements (without medical
0
1
2
26. Doesn't know how to have fun; acts like a
cause)
little adult
0
1
2
53.
Physically attacks people
0
1
2
27. Doesn't seem to feel guilty after misbehaving
0
1
2
54.
Picks nose, skin, or other parts of body
0
1
2
28. Doesn't want to go out of home
(describe!:
Ú
1
2
29. Easily frustrated
Be sun
you have answered all Items. Then see other tide.
Copyright 2000 T. Achenbach & L. Rescoria
ASEBA, University of Vermont. 1 S. Prospect St., Buriington, VT 05401-3456 Web: http://Checltlist.uvm.edu
UNAUTHORIZED REPRODUCTION IS ILLEGAL 7-2Í-00 Edition
132

133
P/ease prtnf your answers. Be sure to answer all ¡tarns.
0 = Not True (as far as you know) 1 » Somewhat or Sometimes True 2 - Very True or Often Tru«
0
1
2
55.
Plays with own sex parts too much
0
1
2
79.
Rapid shifts between sadness and
0
t
2
56.
Poorly coordinated or clumsy
excitement
0
1
2
57.
Problems with eyes (without medical cause)
(describe):
0
1
2
80.
Strange behavior (deacribe):
0
1
2
81.
Stubborn, sullen, or irritable
0
1
2
58.
Punishment doesn't change his/her behavior
0
1
2
82.
Sudden changes in mood or feelings
0
1
2
59.
Quickly shifts from one activity to another
0
1
2
83
Sulks a lot
0
1
2
60.
Rashes or other skin problems (without
0
1
2
84
Talks or cries out in sleep
medicsl cause)
0
1
2
85.
Temper tantrums or hot temper
0
1
2
61.
Refuses to eat
0
1
z
86
Too concerned with neatness or cleanliness
0
1
2
62.
Refusea to play active games
0
1
2
87.
Too fearful or anxious
0
1
2
63.
Repeatedly rocks head or body
0
1
2
88.
Uncooperative
0
1
2
64.
Resists going to bed at night
0
1
2
89.
Underactive, slow moving, or lacks energy
0
1
2
65.
Resists toilet trainina (describe!:
0
1
2
90.
Unhappy, sad. or depressed
0
1
2
91.
Unusually loud
Upset by new people or situations
0
1
2
66.
Screams a lot
0
1
2
92.
0
1
2
67.
Seems unresponsive to affection
(describe):
0
1
2
68.
Self-conscious or easily embarrassed
0
1
2
69.
Selfish or won't share
0
1
2
93.
Vomiting, throwing up (without medical cause)
0
1
2
70.
Shows little affection toward people
0
1
2
94.
Wakes up often at night
0
1
2
71.
Shows little interest in things around hinVher
0
1
2
95.
Wanders away
0
1
2
72
Shows too little fear of getting hurt
0
1
2
96.
Wants a lot of attention
0
1
2
73.
Too shy or timid
0
1
z
97.
Whining
0
1
2
74.
Sleeps less than most children during day
0
1
2
98.
Withdrawn, doesn't get involved with others
and/or niaht (describe!:
0
1
2
99.
100.
Worries
Please write in any problems the child has
that were not listed above.
0
1
2
75.
Smears or plays with bowel movements
0
1
2
76.
Speech oroblem (describe):
0
1
2
0
1
2
0
1
2
77.
Stares into space or seems preoccupied
0
1
2
0
1
2
78
Stomachaches or cramps (without medical
Please be sure you have answered all Uems.
cause)
Underline any you are concerned about.
Does the child have any illneia or disability (either physical or mental)? □ No O Yes—Please describe:
What concerns you most about the child?
Please describe the best things about the child:
PACE 2
itt rrn

134
LANGUAGE DEVELOPMENT SURVEY FOR AGES 18-35 MONTHS
For office use only
Iid*
The Language Development Survey assesses children’s word combinations and vocabulary. By carefully
completing the Language Development Survey, you can help us obtain an accurate picture of your child’s developing
language. Please print your answers. Be sure to answer all items.
I.Was your child bom earlier than the usual 9 months after conception?
□ No □ Yes—how many weeks early? weeks early.
II.How much did your child weigh at birth? pounds ounces or grams
III.How many ear infections did your child have before age 24 months?
â–¡ 0-2 â–¡ 3-5 â–¡ 6-8 â–¡ 9 or more
IV.Is any language beside English spoken in your home?
□ No □ Yes—please list the languages: _
V.Has anyone in your family been slow in learning to talk?
□ No □ Yes—please list their relationships to your child; for example, brother, father:
VI. Are you worried about your child’s language development?
□ No □ Yes—why? .
VII. Does your child spontaneously say words in any language? (not just imitates or understands words)?
□ No □ Yes—if yes. please complete item VIH and page 4.
VIII. Does your child combine 2 or more words into phrases? For example: “more cookie," “car bye-bye."
□ No □ Yes—please print 5 of your child’s longest and best phrases or sentences.
For each phrase that is not in English, print the name of the language.
1. .
2.
3.
4.
5.
Be sure you have answered all items. Then see other side.
pages

135
Please cu-cle each word that yoimchild says SPONTANEOUSLY (not just imitates or understands). If your child says
non-English versions of words on the list, circle the English word and write the first letter of the language (e.g., S for
Spanish). Please indude words even if they are not pronounced clearly or are in “baby talk” (for example; “baba”
for bottle).
FOODS
ANIMALS
ACTIONS
1. apple
55. bear
107. bath
2. banana
56. bee
108. breakfast
3. bread
57. bird
109. bring
4. butter
58. bug
110. catch
S. cake
59. bunny
111. clap
6. candy
60. cat
112. close
7. cereal
61. chicken
113. come
8. cheese
62. cow
114. cough
9. coffee
63. dog
115. cut
10. cookie
64. duck
116. dance
11. crackers
65. elephant
117. dinner
12. drink
66. fish
118. doodoo
13. egg
67. frog
119. down
14. food
68. horse
120. eat
15. grapes
69. monkey
121. feed
16. gum
70. pig
122, finish
17. hamburger
71. puppy
123. fix
18. hotdog
72. snake
124. get
19. ice cream
73. tiger
125. give
20. juice
74. turkey
126. go
21. meat
75. turtle
127. have
22. milk
128. help
23. orange
BODY PARTS
129. hit
24. pizza
76. arm
130. hug
25. pretzel
77. belly button
131. jump
26. raisins
78. bottom
132. kick
27. soda
79. chin
133. kiss
28.soup
80. ear
134. knock
29. spaghetti
81. elbow
135. look
30. tea
82. eye
136. love
31. toast
83, face
137. lunch
32. water
84. finger
138. make
85. foot
139. nap
TOYS
86. hair
140. open
33. ball
87. hand
141. outside
34. balloon
88. knee
142. pattycake
35. blocks
89. leg
143. peekaboo
36. book
90. mouth
144. peepee
37. crayons
91. neck
145. push
38. doll
92. nose
146. read
39. picture
93. teeth
147. ride
40. present
94. thumb
148. run
41. slide
95. toe
149. see
42. swing
96. tummy
150. show
43. teddy bear
151. shut
VEHICLES
152. sing
OUTDOORS
97. bike
153. sit
44. flower
98. boat
154. sleep
45. house
99. bus
155. stop
46. moon
100. car
156. take
47. rain
101. motorcycle
157. throw
48. sidewalk
102. plane
158. tickle
49. sky
103. stroller
159. up
50. snow
104. train
160. walk
51. star
105. trolley
161. want
52. street
53.sun
54. tree
106. truck
162. wash
HOUSEHOLD
MODIFIERS
OTHER
163. bathtub
216. all gone
264. any letter
164. bed
217. all right
265. away
165. blanket
218. bad
266. booboo
166. bottle
219. big
267. byebye
167. bowl
220. black
268. excuse me
168. chair
221. blue
269 here
169. clock
222. broken
270. hi, hello
170. crib
223. clean
271. in
171. cup
224. cold
272. me
172. door
225. dark
273. meow
173. floor
226. dirty
274. my
174. fork
227. dry
275. myself
175. glass
228. good
276. nightnight
176. knife
229. happy
277.no
177. light
230. heavy
278. off
178. mirror
231. hot
279. on
179. pillow
232. hungry
280. out
180. plate
233. little
281. please
181. potty
234. mine
282. Sesame St.
182. radio
235. more
283. shut up
183. room
236. nice
284.thank you
184. sink
237. pretty
285. there
185. soap
238. red
286. under
186. spoon
239. stinky
287. welcome
187. stairs
240. that
288. what
188. table
241. this
289. where
189. telephone
242. tired
290. why
190. towel
243. wet
291. woofwoof
191. trash
244. white
292. yes
192. T.V.
245. yellow
293. you
193. window
246. yucky
294. yumyum
295. any number
PERSONAL
CLOTHES
194. brush
247. belt
PEOPLE
195. comb
248. boots
296. aunt
196. glasses
249. coat
297.baby
197. key
250. diaper
298. boy
198. money
251. dress
299. daddy
199. paper
252. gloves
300. doctor
200, pen
253. hat
301. girl
201. pencil
254.jacket
302. grandma
202. penny
255. mittens
303. grandpa
203. pocketbook
256. pajamas
304. lady
204. tissue
257. pants
305.man
205. tooth brush
258. shirt
306. mommy
206. umbrella
259. shoes
307. own name
207. watch
260. slippers
308. pet name
261. sneakers
309. uncle
PLACES
262. socks
310. name of TV
208. church
263. sweater
or story
209. home
character
210. hospital
211. library
Other words your child says,
212. park
Including non-English words:
213.school
214. store
215. zoo
FACE 4
-no w)07 /TT /7A

APPENDIX G
THERAPY ATTITUDE INVENTORY (EYBERG, 1993)
160
Appendix
Child's Name.
THERAPY ATTITUDE INVENTORY
Parent's Name
. Date.
Directions: Please circle the response for each question which best expresses how you
honestly feel.
1. Regarding techniques of disciplining, I feel I have learned
1. nothing
2.
very little
3.
a few new
4.
several
5. very many
techniques
useful
useful
techniques
techniques
2.
Regarding techniques for leaching my child new skills. 1 feel 1 have learned
1. nothing
2.
very little
3.
a few new
4.
several
5. very many
techniques
useful
useful
techniques
techniques
3.
Regarding the relationship between myself and my child, 1 feel we get along
1. much
2.
somewhat
3.
the same
4.
somewhat
5. very much
worse
worse
as before
better
better
than
than
than
than
before
before
before
before
4.
Regarding my confidence in my ability to discipline my child, 1 feel
1. much less
2.
somewhat
3.
the same
4.
somewhat
5. much
confident •
less
more
more
confident
confident
confident
5.
6.
8.
9.
10.
The major behavior problems that my child presented at home before the program
started are at this lime
1. considerably 2. somewhat 3. the same 4. somewhat 5. greatly
worse worse improved improved
I feel that my child's compliance to my commands or requests is at this time
1. considerably 2. somewhat 3. the same 4. somewhat 5. greatly
worse worse improved improved
Regarding the progress my child has made in his/her general behavior, I am
1. very 2. somewhat 3. neutral 4. somewhat 5. very
dissatisfied dissatisfied satisfied satisfied
To what degree has the treatment program helped with other general personal or
family problems not directly related to your child in the program!
1. hindered 2. hindered 3. neither 4. helped 5. helped
much slightly helped somewhat very much
more than nor
helped hindered
I feel the type of program that was used to help me improve the behavior of my
child was
1. very poor 2. poor 3. adequate 4. good 5. very good
My general feeling about the program I participated in, is
1. (disliked 2. I disliked 3. I feel 4. I liked it 5. I liked it
¡I very it neutral somewhat very much
much somewhat
© 1974 Sheila Eyberg. Ph.U.
. i-nn-r irr rrn
136

APPENDIX H
SEMI STRUCTURED QUESTIONAIRE (ELDER, 1995)
Baseline Questionnaire
1. How typical was the child’s behavior during this session?
1 2 3 4 5
Very typical Not typical at all
2. Do you think that the presence of the camera and/or investigator affected how you
or your child did in this session?
1 2 3
Not affecting at all
4 5
Affecting very much
137

Questionnaire Following Parent Training
1. How typical was your child’s behavior during this session?
1
behavior very typical
behavior not typical at all
2. Do you think that the presence of the camera and/or investigator affected how you or your child did in this session?
1 2
camera/investigator not affecting at all
4 5
camera/investigator affecting very much
3. Do you think that the training you are using with your child is working?
1 2
training working very well
4 5
training not working well at all
4. Are you using what you have learned at times other than the videotaped session?
1
used very often
not using at all
5. How comfortable are you using the strategies that you were taught?
1
very comfortable with skill
2
3
4
5
no comfortable with skill

REFERENCES
Abikoff, H., & Gittelman, R. (1984). Does behavior therapy normalize the classroom
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BIOGRAPHICAL SKETCH
Deborah Ann White is a pediatric nurse practitioner with nursing experience that
spans almost three decades. She is currently providing primary health care to pediatric
patients in a community health care center in Sanford, Florida. Deborah received her
undergraduate degree from West Liberty State College. She graduated with a master’s
degree from the University of Florida as a clinical specialist in community health nursing
and as a pediatric nurse practitioner. Deborah received certification from the Pediatric
Nursing Certification Board and has been active in local and national nursing
organizations. She served as the President and President-elect (1999-2003) for the local
National Pediatric Nurse Practitioner Association (NAPNAP) chapter and was nominated
for the National Office of Chapter’s Coordinator in the upcoming NAPNAP 2004 spring
election.
Deborah was inducted as a member of Sigma Theta Tau, (Alpha Theta Chapter)
and is active in the Florida Nurses Association. She completed her Doctor of Philosophy
in May, 2004 at the University of Florida. Deborah was the recipient of a Pre-doctoral
National Research Service Award from the National Institute of Nursing Research for her
research with fathers and children with Attention Deficit Hyperactivity Disorder. She has
spoken at local and national conferences on health-related issues.
153

I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy. ^,
( n
Jetmifer H. Islder, Chair
Associate Professor of Nursing
I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Rinda J. Alexam
Professor of Nursing
I certify that 1 have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
fMáiiLuÚÚm&C
Maureen A. Conroy \J
Associate Professor of Special Education
I certify that 1 have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Tan
Associate
rofessor of Psychiatry
This dissertation was submitted to the Graduate Faculty of the College of Nursing
and to the Graduate School and was accepted as partial fulfillment of the requirements for
the degree of Doctor of Philosophy.
May, 2004
Dean, College of Nursing
Dean, Graduate School

UNIVERSITY OF FLORIDA
1262 08555 2858



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