TREATMENT OF OPPOSITI ONAL DEFIANT DISORDER IN PRESCHOOLERS WITH OR WITHOUT COMORBID ATTENTION DEFICIT HYPERACTIVITY DISORDER By ERIN MARIE FLOYD A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2005
Copyright 2005 by Erin Marie Floyd
To Keary and my family.
ACKNOWLEDGMENTS I would like to thank my chair, Dr. Sheila Eyberg, for all of her focused attention and wisdom, her constant encouragement and unending enthusiasm for research, and her tireless and beneficial revisions on this current project. I would also like to thank my other committee members, Dr. Stephen Boggs, Dr. Michael Robinson, and Dr. Scott Miller, for their time and suggestions. Additional gratitude is given to Dr. Melanie Nelson and my research labmates for their assistance with this project. iv
TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iv LIST OF TABLES............................................................................................................vii LIST OF FIGURES.........................................................................................................viii ABSTRACT.......................................................................................................................ix CHAPTER 1 INTRODUCTION........................................................................................................1 Definitions....................................................................................................................1 Prevalence.....................................................................................................................2 Comorbidity..................................................................................................................3 Stability.........................................................................................................................5 Significance of the Problem..........................................................................................6 Development of ADHD and Disruptive Behavior Disorders.......................................7 Complications of Comorbidity...................................................................................10 Theoretical and Conceptual Underpinnings of Parent-Child Interaction Therapy.....13 Importance of Early Intervention................................................................................16 Efficacy of PCIT.........................................................................................................16 Outcome of Treatments with Preschoolers.................................................................18 Hypotheses..................................................................................................................19 Demographic Difference Hypotheses..................................................................19 Diagnostic Hypotheses........................................................................................19 Treatment Outcome Hypotheses.........................................................................20 2 METHODS.................................................................................................................24 Participants.................................................................................................................24 Child Diagnostic Issues.......................................................................................25 Pretreatment.........................................................................................................27 Measures.....................................................................................................................33 Screening/Descriptive Measures.........................................................................33 Treatment Outcome Measures.............................................................................37 Procedure....................................................................................................................42 Assessments.........................................................................................................42 v
Treatment.............................................................................................................43 Treatment Integrity..............................................................................................46 Assessment Training...........................................................................................47 3 RESULTS...................................................................................................................48 Internal Consistency...................................................................................................48 Diagnostic Outcome...................................................................................................48 Treatment Outcome....................................................................................................51 The DISC-IV-P ADHD Symptom Count............................................................51 The DISC-IV-P ODD Symptom Count...............................................................53 The DPICS-II Percent Child Compliance...........................................................54 The ECBI Intensity Scale Score..........................................................................55 The REDSOCS Percent Inappropriate Behavior.................................................55 The SCS-T Total Score.......................................................................................56 Clinical Significance...................................................................................................57 4 DISCUSSION.............................................................................................................60 Demographic Difference Hypotheses.........................................................................60 Diagnostic Hypotheses...............................................................................................64 Treatment Outcome Hypotheses.................................................................................65 The DISC-IV-P ADHD Symptom Count............................................................65 The DISC-IV-P ODD Symptom Count...............................................................66 The DPICS-II Percent Child Compliance...........................................................67 The ECBI Intensity Scale Score..........................................................................68 The REDSOCS Percent Inappropriate Behavior.................................................68 The SCS-T Total Score.......................................................................................69 General Discussion.....................................................................................................70 Limitations..................................................................................................................73 Future Directions........................................................................................................74 APPENDIX SCHOOL-RELATED COMPARISONS.....................................................75 REFERENCES..................................................................................................................78 BIOGRAPHICAL SKETCH.............................................................................................97 vi
LIST OF TABLES Table page 1 Comparison of Pretreatment Demographic Data for All Non-CD Participants and All Non-CD Treatment Completers..................................................................29 2 Pretreatment Demographic Data for Non-CD Treatment Dropouts and t Test or 2 Differences with Corresponding Treatment Completers.....................................32 3 Cronbachâ€™s Alphas for Outcome Measures at Both Assessment Points..................49 4 Inter-observer Reliability of REDSOCS and DPICS-II Category Codes................50 5 Mean Scores on Outcome Measures at Both Assessment Points.............................52 6 Non-significant Results for ANOVA Analyses.......................................................57 7 Number of Participants Demonstrating Clinically Significant Change from Pretreatment to Posttreatment in Each Diagnostic Group........................................59 A-1 Comparison of Pretreatment Demographic Data for Treatment Completers Completing School-related Treatment Outcome Measures Versus Those Who Did Not.....................................................................................................................75 A-2 Mean Scores on Outcome Measures at Both Assessment Points for Treatment Completers Completing School-related Treatment Outcome Measures Versus Those Who Did Not.................................................................................................76 A-3 ANOVA Analyses Results for Comparisons of Treatment Completers Completing School-related Treatment Outcome Measures Versus Those Who Did Not.....................................................................................................................77 vii
LIST OF FIGURES Figure page 1 The DISC-IV-P ADHD Symptom Count.................................................................53 2 The DISC-IV-P ODD Symptom Count...................................................................54 3 The DPICS-II Percent Child Compliance................................................................54 4 The ECBI Intensity Scale Score...............................................................................55 5 The REDSOCS Percent Inappropriate Behavior.....................................................56 6 The SCS-T Total Score............................................................................................56 viii
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 TREATMENT OF OPPOSITIONAL DEFIANT DISORDER IN PRESCHOOLERS WITH OR WITHOUT COMORBID ATTENTION DEFICIT HYPERACTIVITY DISORDER By Erin Marie Floyd August 2005 Chair: Sheila M. Eyberg Major Department: Clinical and Health Psychology The current study was designed to evaluate demographic differences as well as clinical presentation and Parent-Child Interaction Therapy (PCIT) outcome differences between preschoolers with Oppositional Defiant Disorder (ODD) only versus those with comorbid ODD and Attention Deficit/Hyperactivity Disorder (ADHD). Participants (ages 3-6 y) met stringent research diagnostic criteria for ODD versus comorbid ODD and ADHD; participants with Conduct Disorder were eliminated from further analyses in order to provide for cleaner diagnostic results. Groups did not differ at pretreatment based on child age, child sex, estimated child verbal IQ, estimated maternal IQ, estimated paternal IQ, or family socioeconomic status, but the ODD only group was comprised of Caucasians except for 1 Asian child and the comorbid ODD and ADHD group was comprised of all other minorities. Treatment completers differed from the original sample only in that they had a higher ix
socioeconomic status. Treatment integrity was assessed, and internal consistency, kappa, and percent agreement were calculated for respective measures. Repeated measures Analyses of Variances indicated that the comorbid group demonstrated more problems overall, as supported by worse pretreatment scores on maternal report of ADHD symptom counts and disruptive behavior, classroom observation of percent inappropriate behavior, and teacher report of social competency. Groups did not differ at pretreatment regarding parent report of ODD symptom counts or laboratory observation of child compliance. Both groups improved across treatment on measurements of all areas except social competency. Groups differed at posttreatment on measurement in the school setting only. Diagnostic status and findings from this study were obtained using a combination of mother report, teacher report, and laboratory and classroom observations by trained independent raters. Data were analyzed for both statistical and clinical significance. The positive behavior changes in both preschoolers with ODD only and those with comorbid ODD and ADHD can be considered additional evidence for the overall effectiveness of PCIT. Results indicate that PCIT does generalize to the treatment of symptoms of ADHD in children with comorbid ODD and ADHD, but a differential lack of generalization to ADHD-related symptoms may be present in the school setting. x
CHAPTER 1 INTRODUCTION Definitions Youngsters with disruptive behaviors display high rates of defiance, hostility, and noncompliance and often exhibit aggressive and destructive behaviors. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association [APA], 2000) separates disruptive behavior disorders into two categories: Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD). Also included in the same section of the DSM-IV is Attention Deficit/Hyperactivity Disorder (ADHD), an additional diagnosis that children with disruptive behavior disorders may receive when they also show high degrees of hyperactive/impulsive behaviors. More specifically, ODD features a â€œrecurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figuresâ€ (APA, 2000, p. 100). To meet diagnostic criteria for ODD, at least 4 of the following 8 behaviors must have occurred often for a period of at least 6 months: loses temper, argues with adults, actively defies or refuses to comply with adultsâ€™ requests or rules, deliberately annoys people, blames others for his or her mistakes or misbehavior, is touchy or easily annoyed by others, is often angry or resentful, or is often spiteful or vindictive. Conduct Disorder is characterized by a â€œrepetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violatedâ€ (APA, 2000, p. 93). Conduct Disorder is often preceded by ODD. Two subtypes of CD are distinguished: childhood-onset and adolescent-onset. Children 1
2 diagnosed with CD before age 10 are classified with childhood-onset type. Such early onset predicts persistent CD and an increased risk in adulthood to develop Antisocial Personality Disorder. For diagnostic purposes, the behavior pattern must have been present for at least 6 months, and at least 3 or more of 15 characteristic behaviors must have been present. The behaviors fit into 4 categories: aggression to people and animals, destruction of property, deceitfulness or theft, and serious violations of societal rules. Attention Deficit/Hyperactivity Disorder refers to a â€œpersistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of developmentâ€ for at least six months (APA, 2000, p. 85). The three subtypes of ADHD include predominantly inattentive type, predominantly hyperactive-impulsive type, and combined type. For the chiefly inattentive subtype, at least 6 of the following symptoms must have been present often: fails to give close attention to details, has difficulty sustaining attention, does not seem to listen, does not follow through on instructions, has difficulty organizing, dislikes tasks requiring sustained mental effort, loses things, is easily distracted, or is forgetful. For the primarily hyperactive-impulsive subtype, at least 6 of the following symptoms must have occurred frequently: fidgets, leaves seat in situations in which remaining seated is expected, runs excessively, has difficulty playing quietly, is often â€œon the go,â€ talks excessively, blurts out answers, has difficulty awaiting turn, or interrupts others. For the combined subtype, the child must meet criteria for both the inattentive and hyperactive-impulsive types. Prevalence Disruptive behavior disorders often emerge in the preschool years (Miller, Koplewicz, & Klein, 1997) and represent the most frequent referral of young children to
3 mental health services (Kazdin, Mazurick, & Siegel, 1994; Offord, Boyle, & Racine, 1991). According to the DSM-IV (APA, 2000), the prevalence of ODD ranges from 2 to 16%, and the occurrence rates for CD range from 1 to 10%, depending on the nature of the population sampled and the method of assessment. The prevalence of ADHD ranges from 3 to 7% in school-age children, again depending on the population sampled and method of assessment (APA, 2000). However, the prevalence of behavior problems in preschool-age children is more common than previously thought (Campbell, 1995). In one of the first studies to examine the prevalence of disruptive behaviors in preschoolers, Richman and Graham (1975) found 15% of 3and 4-year-old children had mild behavior problems, and 7% had moderate to severe problematic behavior. Nonetheless, Oâ€™Brienâ€™s more recent (1996) sample of Midwestern, middle-class parents of toddlers revealed 23% reported clinically significant disruptive behaviors. Ten to 15% of preschool age children were reported to exhibit mild to moderate behavioral disturbances (Campbell, 1995). Webster-Stratton (1998) reported that 22% (parent report) and 8% (teacher report) of Head Start children were in the clinical range of disruptive behavior. Furthermore, Querido and Eyberg (2005) found 15% (parent report) of preschoolers in Head Start were in the clinical range of disruptive behavior. Boys tend to develop ADHD and disruptive behavior disorders earlier and at higher rates than girls do throughout the preadolescent years (McDermott, 1996; Nolan, Gadow, & Sprafkin, 2001; Offord et al., 1987), although stability of the behavior appears comparable for boys and girls (McMahon & Estes, 1997). Comorbidity Multiple studies have examined disruptive behavior disorders in preschoolers (Campbell, 1995; Eyberg & Boggs, 1989; Keenan, Shaw, Delliguadri, Giovannelli, &
4 Walsh, 1998; Keenan, Shaw, Walsh, Delliguadri, & Giovannelli, 1997; Speltz, Greenberg, & DeKlyen, 1990; Webster-Stratton, 1996b), but it is often unclear as to whether the preschool-aged participants met diagnostic criteria for ODD, CD, and/or ADHD (Keenan & Wakschlag, 2000). Pure ODD in preschool age children appears to be the exception. In a previous sample of 100 referred preschoolers with ODD (Boggs, McDiarmid, Eyberg, & Algina, 2005), 27% also met diagnostic criteria for CD. Symptoms such as lying, bullying or threatening, initiating physical fights, being physically cruel to animals, and deliberately destroying property were not uncommon in Boggs and colleaguesâ€™ sample. Although ODD and CD are treated as separate psychological disorder classifications, a preponderance of evidence suggests that ODD is a mild variant or precursor of CD (Cohen & Flory, 1998; Loeber et al., 1998; Pickles et al., 2001; Rutter, Giller, & Hagell, 1998). Evidence also suggests that ODD and CD reflect the same genetic liability (Eaves et al., 2000). Most researchers have tended to combine ODD and CD in their analyses (Keenan & Wakschlag, 2002). Controversy remains as to whether the CD diagnosis should be applied to children at such a young age (Keenan & Wakschlag, 2002). ADHD is commonly comorbid with the disruptive behavior disorders (Barkley, 2003), and evidence suggests that ADHD is a reliable early predictor for development of ODD/CD (Gittelman, Mannuzza, Shenker, & Bonagura, 1985; Lahey, McBurnett, & Loeber, 2000; Loeber, Stouthamer-Lober, Van Kammen, & Farrington, 1991; Mannuzza et al., 1991). Researchers have estimated the co-occurrence of ODD/CD among children with ADHD to range from 20 (Barkley, 1990) to 60% (Biederman, Munir, & Knee,
5 1987). Among children referred for CD, the rate of ADHD has been reported as high as 90% (Abikoff, Klein, Klass, & Ganeles, 1987). Among the preschoolers in Boggs colleaguesâ€™ (2005) sample with ODD and/or CD, 70% had comorbid ADHD. The high degree of comorbidity among ODD/CD and ADHD has raised questions as to whether disturbances in behavior and disturbances in attention/hyperactivity/impulsivity actually represent discrete disorders. Factor analytic studies, however, support the dichotomy (Abikoff & Klein, 1992; Barkley, 2003; Hinshaw, 1987). Furthermore, despite substantial overlap in behaviors, subgroups of children in these two domains differ in several important respects. For example, compared to ADHD, ODD/CD is more strongly associated with low socioeconomic status, maternal rejection, poor parental supervision (Loeber, Brinthaupt, & Green, 1990), and paternal alcohol abuse (Reeves, Werry, Elkind, & Zametkin, 1987; Stewart, DeBlois, & Cummings, 1980; Waschbusch, 2002). In contrast, children with ADHD often display more cognitive and achievement deficits than do children with ODD/CD. Research has indicated that, compared to ODD/CD, ADHD is more strongly associated with lower IQ and lower academic performance as well as substantially lower rates of parental psychopathology (Lahey et al., 1988; McGee, Williams, & Silva, 1984; Schacher, 1991). Thus, much evidence supports the contention that ADHD and ODD/CD are partially independent aspects of child psychopathology (Hinshaw & Lee, 2003). Stability It is important to distinguish between the normal, transient behavior problems of preschool children and the constellation of high-rate behaviors in children with disruptive behavior disorders and/or ADHD. Nonreferred children show many of the individual behaviors seen in diagnosed children, but their behavior problems are fewer and occur
6 less frequently (Eyberg & Pincus, 1999). Disruptive and ADHD behaviors show a high degree of stability over time. In children with ADHD, although the severity levels of symptoms typically decline over time, ADHD persists in most children across development (Barkley, 2003). Numerous studies have noted a continuity in externalizing behavior problems in both clinic-referred and community samples from the preschool to early elementary school years (Campbell & Ewing, 1990; Egeland, Kalkoske, Gottesman, & Erickson, 1990; Rose, Rose, & Feldman, 1989), from childhood to adolescence (Campbell, 1995; Lahey et al., 1995; Offord et al., 1991), and from childhood to adulthood (Farrington, 1995; Hodgins, 1994; Satterfield & Schell, 1997). Without treatment, early disruptive behavior qualitatively worsens with time (Loeber, 1990; McMahon & Estes, 1997; Olweus, 1979). Kazdin (1987) proposed that disruptive behavior disorders be conceptualized as chronic illnesses with a relatively clear course and a poor prognosis in the absence of treatment. The presence of comorbid ADHD lends to an even more pernicious form of psychopathology than either ODD/CD or ADHD alone (Hinshaw, 1999). Significance of the Problem Epidemiological research suggests that early disruptive behavior problems may be part of a common pathway for a wide range of internalizing and externalizing disorders in adolescence and adulthood (Fischer, Rolf, Hasazi, & Cummings, 1984; Lerner, Inui, Trupin, & Douglas, 1985). Although not all disruptive children maintain mental health problems to adulthood, disruptive behavior and ADHD in preschoolers appear to be the most substantial predictors for later antisocial behavior in both adolescent boys and girls (Kellam et al., 1991; Loeber & Dishion, 1983; White, Moffitt, Earls, Robins, & Silva,
7 1990). In adolescence alone, the costs of such behaviors are high. In 1996, approximately 1.5 million property crimes were committed by juveniles (Federal Bureau of Investigation, 1997). Additional costs to society are incurred through treatment and educational programs, use of law enforcement, and family, security, and emotional damages (Werry, 1997). Furthermore, if left untreated, children with significant disruptive behavior problems are likely to engage in delinquent or criminal behavior in adulthood (Loeber, 1982; Loeber, Green, Keenan, & Lahey, 1995), have increased rates of violence against women (Fagot, Loeber, & Reid, 1988), and also have an elevated risk of psychiatric problems including a higher suicide rate (Puig-Antich, 1982). Collectively, early disruptive behaviors result in tremendous societal costs (Kazdin, 1987; Patterson, DeBaryshe, & Ramsey, 1989). Development of ADHD and Disruptive Behavior Disorders Historically, primarily biological frameworks have been proposed for the development of ADHD, including theories regarding ADHD as representing defective volitional inhibition (Still, 1902), deficient attention, inhibition, arousal, and preference for immediate reward (Douglas, 1972, 1983), and deficient sensitivity to reinforcement (Haenlein & Caul, 1987), or rule-governed behavior (Barkley, 1981, 1989). Recently, Schacher, Tannock, and Logan (1993) proposed that ADHD represents a central deficit in inhibitory and activation processes while Quay (1997) argued that individuals with ADHD have a more specific deficit in the brainâ€™s behavioral inhibition system. Barkley (2001) asserted that the deficit in behavioral inhibition results primarily from genetic and neurodevelopmental origins versus purely social ones, although its expression is thought to be influenced by social factors across development. Barkley proposed a model predicting that deficits in behavioral inhibition lead to deficits in executive functioning,
8 including nonverbal working memory and, subsequently, forgetfulness, poor time management, and lack of forethought. Developmental theorists have proposed alternative pathways in the development of disruptive behavior disorders, including a larger emphasis on environmental factors than found in the biologically based theories of ADHD. Several theories of disruptive behaviors address a childhood-onset trajectory (Frick, 1998; Kazdin, 1985; Loeber, 1991; Patterson et al., 1989). One hypothesized â€œearly starterâ€ pathway (Patterson et al.) is thought to begin in the preschool years and is characterized by high stability of problem behaviors, increased risk factors, and poor outcome. Early-onset disruptive behavior problems unfurl with increasing severity (Loeber & Hay, 1997) in increasingly wider social settings (McMahon, 1994) as the child develops. Behavior characteristics of ODD in the preschool years progress to both aggressive and covert (stealing and lying) behavior problems in middle childhood and to delinquent behaviors, including interpersonal violence, substance abuse, and vandalism, during adolescence (Kumpfer & Alvarado, 2003; Lahey, Loeber, Quay, Frick, & Grimm, 1992). Although almost all adolescents diagnosed with disruptive behavior disorders have had significant behavior problems in early childhood, not all children with disruptive behavior develop antisocial behavior as adults (Hinshaw & Lee, 2003). Webster-Stratton (1995) and Loeber (1982) both found several risk factors that contribute to the continuation of antisocial behaviors, including early onset during the preschool years, high frequency and intensity of disruptive behavior disorders, and occurrence of behavior problems in multiple settings. Thus, early detection and intervention are necessary.
9 Disruptive behavior problems in general originate from multiple interacting child and family factors, and the risk profile for these behavior problems appears to be similar for preschoolers and older children (Keenan & Wakschlag, 2002). Child factors include difficult temperament (Bates, Bayles, Bennett, Ridge, & Brown, 1991), hyperactivity (Loeber & Keenan, 1994), neuropsychological abnormalities affecting social information processing (Crick & Dodge, 1994), and genetic factors that interact with family factors in the development and maintenance of disruptive behaviors (Kazdin, 1987). Additionally, early academic difficulties are associated with behavior problems (Schonfeld, Shaffer, Oâ€™Connor, & Portnoy, 1988; Sturge, 1982), as are poor problem solving and poor social skills (Asarnow & Callan, 1985; Richard & Dodge, 1982; Rubin & Krasnor, 1986). Family factors related to disruptive behaviors include parent antisocial personality disorder (Webster-Stratton, 1995), maternal depression (Forehand, Furey, & McMahon, 1984; Webster-Stratton & Hammond, 1990), stressful life events (Campbell, 1998), anger (Wolfe, 1987), parent conflict about child rearing (Bearss & Eyberg, 1998), social isolation (Dumas & Wahler, 1983), single-parent status, and poverty (Forehand et al.). Parental low education, teenage pregnancy, and parental criminal history or substance abuse also place children at risk for developing disruptive behavior (Webster-Stratton, 1990). Children are at greater risk for disruptive behavior disorders if their parents are physically abusive or highly critical (Reid, Taplin, & Loeber, 1981). Furthermore, the risk of a child developing disruptive behavior problems appears to increase exponentially with exposure to each additional risk factor (Coie et al., 1993; Rutter, 1980). Parent and family factors are thought to influence child behavior through their effect on parenting behaviors (Patterson, Reid, & Dishion, 1992; Tolan, Guerra, &
10 Kendall, 1995). Parentsâ€™ interactions with their young children appear to be the most proximal parental influence on childrenâ€™s behavioral development (Campbell, 1997), and parenting practices continue to play a critical role in the maintenance of disruptive behavior throughout the childâ€™s development (McMahon & Estes, 1997). Complications of Comorbidity Researchers have become aware of the importance of studying comorbidity in order to disentangle correlates and causes of disorders and their outcomes, although few studies have examined disruptive behavior disorders and their comorbidities as independent grouping variables (Carlson, Tamm, & Gaub, 1997). Children with comorbid ODD/CD and ADHD diagnoses have lower ages of onset (Waschbusch, 2002) and more negative features than children with only one or the other disorder. Above and beyond the significant problems associated with ODD/CD, children with comorbid ODD/CD and ADHD have more ODD/CD symptoms and attentional problems, greater symptom severity, and more physical aggression (Carlson et al.; Gadow & Nolan, 2002; see also Hinshaw, 1999; Walker, Lahey, Hynd, & Frame, 1987) as well as a greater range, persistence, and severe form of antisocial behavior than children with ODD or CD alone (Hinshaw, Lahey, & Hart, 1993; Loeber et al., 1995; Rutter et al., 1998). Additionally, children with comorbid ODD/CD and ADHD in general demonstrate lower IQ, in particular verbal IQ, than children with ODD/CD only (Waschbusch, 2002). Researchers have extended this finding to a preschool sample of boys (Speltz, DeKlyen, Calderon, Greenberg, & Fisher, 1999). Compared to children with ODD/CD or ADHD alone, children with ADHD and ODD/CD have more severe underachievement and higher rates of peer rejection (Carlson et al., 1997; see also Hinshaw, 1999), perform more poorly on tests of
11 neuropsychological functioning (Moffitt, 1990), and have overall worse outcomes (Angold, Costello, & Erkanli, 1999; Lynam, 1996), including a greater risk for development of antisocial disorders as adults (Farrington, Loeber, & Van Kammen, 1990). In addition, compared to children with a single diagnosis of ADHD or ODD/CD, children with comorbid ODD/CD and ADHD have even more conflictual interactions with parents (Hinshaw et al., 1993; Johnston, 1996). The parents of such children have a greater level of psychosocial adversity and parental psychopathology, including maternal depression, paternal antisocial behavior, (Hinshaw & Lee, 2003), aggression, substance abuse and dependence (Hill, 2002; Hinshaw & Lee, 2003; Lahey et al., 1988), and a greater level of maternal controllingness (Cunningham & Boyle, 2002). Because the comorbid ODD/CD and ADHD group is at risk for more serious and detrimental forms of psychopathology over time than the ODD/CD group, understanding the family context of this condition is critical (Hinshaw et al., 1993). In preschool years, the addition of early hyperactivity and impulsivity to oppositional and defiant features may increase the risk for parental frustration and subsequent adoption of coercive child-rearing procedures, practices that clearly heighten the risk for accelerated development of antisocial behavior (Patterson, 1982). Additionally, comorbid aggression and ADHD are associated with extremely high rates of peer rejection (Milich & Landau, 1989). Thus, the concurrent presence of ADHD may incur familial and interpersonal processes that put in motion additional developmental processes, exemplifying indirect or cumulative causal processes (Gadow & Nolan, 2002; Rutter, 1989). In sum, the presence of ADHD is associated with increased risk for development of severely antisocial behavior in children with ODD/CD. This risk may be mediated indirectly by family and
12 peer-related problems that add to attentional deficits/hyperactivity and that in turn push toward higher levels of antisocial behavior, or more directly by the role of impulse control problems in fostering early covert antisocial behaviors (Barkley, 2003). The treatment of disruptive behavior disorders has included various approaches. Psychosocial treatments are more frequently used for ODD/CD. Reviews of the literature suggest that behavioral parent training for diagnosed ADHD children is well-established (Pelham, Wheeler, & Chronis, 1998), although not more effectively than with psychostimulant medication (Barkley, 2003). The efficacy of psychosocial treatment of ADHD has been studied almost exclusively with elementary school-age children with ADHD. An exception was Pisterman et al. (1989), who examined the effects of parent management training (PMT) on behavior problems in ADHD preschoolers. Their results indicated significant increases in child compliance to parental requests, and treatment gains were maintained at 3-month follow-up. Their study provided important preliminary support for the psychosocial treatment of disruptive behavior disorders in preschoolers with diagnosed ADHD. In an extension of Pisterman and colleaguesâ€™ (1989) research, Anastopoulos, Shelton, DuPaul, and Guevremont (1993) examined the impact of parent training on ADHD in a group of school-aged children. In addition to investigating the impact of the treatment on child behavior, they examined the effects of parent training on parent functioning. Thirty-four participating children met DSM-III-R criteria for ADHD, 14 of whom had comorbid ODD. Compared to a wait-list control condition, parents who received parent training reported significant improvements in the overall severity of their
13 childâ€™s ADHD symptomatology, as well as several other measures of psychosocial functioning. The investigators did not report whether children met diagnostic criteria for ODD or ADHD at posttreatment. These results lend preliminary support to the notion that parent training can have therapeutic benefits for school-age children with ADHD and their parents. Theoretical and Conceptual Underpinnings of Parent-Child Interaction Therapy Baumrindâ€™s (1967) developmental research associating parenting practices with child outcomes has influenced the development of Parent-Child Interaction Therapy (PCIT; Eyberg & Boggs, 1998). She described the authoritative-authoritarian-permissive parenting theory after finding that parents of preschoolers who were less nurturing, less involved, and more controlling and punitive had more discontent, withdrawn, and mistrustful children. In later work, Baumrind (1991) transformed her typology of parenting styles into one based on two orthogonal constructs â€“ subsequently derived from factor analyses of her data â€“ that she called parenting demandingness and parent responsiveness. She demonstrated that parents who do not adequately meet young childrenâ€™s dual needs for nurturance and for limits are less likely to have successful and healthy adolescents. In related research, the combination of high rates of demandingness [> 1 standard deviation (SD) above the mean for parents in nonproblem families based on behavioral observation data] and low rates of responsiveness (> 1 SD below the mean) was found in 75% of the mothers and fathers of referred, behavior-disordered preschoolers (Calzada, Eyberg, Rich, & Querido, 2005). The strong and consistent relation between certain parenting styles and problematic child outcomes has been shown in many studies (e.g., Azar & Wolfe, 1989; Franz, McClelland, and Weinberger, 1991; Olson, Bates, & Bayles,
14 1990; Power & Chapieski, 1986; Querido & Eyberg, 2005). This research suggests that to promote optimal child outcomes, we must focus on promoting optimal parenting styles and parent-child interactions. Parent training is regarded as the most promising approach for the treatment of early-onset disruptive behavior disorders (Dumas, 1989; Eyberg, 1992), and parent-child treatments are well represented among the empirically supported treatments for children with disruptive behavior disorders (Brestan & Eyberg, 1998). Parent-Child Interaction Therapy (PCIT) is a brief, empirically supported treatment for disruptive young children that emphasizes strengthening the parent-child relationship and changing dysfunctional parent-child interaction patterns. Informed by the developmental psychology literature, PCIT draws on both attachment and social learning theories (Foote, Eyberg, & Schuhmann, 1998). Even when disruptive behavior is strongly associated with biological characteristics such as difficult temperament or comorbid ADHD, many of the difficult attitudes and behaviors are intensified by the parent-child interactional patterns (Eyberg & Boggs, 1998; Greenberg, Speltz, & DeKlyen, 1993; Patterson, 1982). In PCIT, parents are taught specific skills to establish a nurturing and secure relationship with their child while increasing the childâ€™s prosocial behavior and decreasing negative behavior. The treatment focuses on two basic interactions: (a) The Child-Directed Interaction (CDI) is similar to play therapy in that parents engage their child in a play situation with the goal of improving the quality of the parent-child relationship; (b) The Parent-Directed Interaction (PDI) resembles clinical behavior therapy in that parents learn to establish
15 control over disruptive behavior by using specific behavior management techniques as they play with their child. Development of a secure, stable attachment relationship and healthy parent-child interactions is key to the development of a healthy self-concept, optimal emotional/behavioral regulation, and the ability to be empathic to others (see also Grossmann, Grossmann, & Zimmermann, 1999; Hobbs, 1982; Kazdin, 1985). Attachment theory asserts that sensitive and responsive parenting leads the infant to develop a cognitive-affective working model that he or she will be responded to when necessary. Thus, infants whose parents show greater warmth, responsiveness, and sensitivity to the infantâ€™s signals are more likely to develop a secure working model of their relationship and more effective emotional regulation (Ainsworth, Blehar, Waters, & Wall, 1978). Maladaptive attachment is consistently linked to childrenâ€™s aggressive behavior, low social competence, poor coping skills, low self esteem, and poor peer relationships (Coie et al., 1993; Earls, 1980; Jenkins, Bax, & Hart, 1980; Richman, Stevenson, & Graham, 1982; Rutter, 1980). CDI aims to restructure the parent-child relationship and provide the child with a secure attachment to his or her parent. Pattersonâ€™s (1982) coercion theory also provides a transactional account of early disruptive behavior (cf., Foote et al., 1998) in which child disruptive behavior disorders are inadvertently established and/or maintained by the parent-child interactions. While not disputing the importance of either the biological underpinnings of behavior or positive parent responsiveness, social learning theorists emphasize the contingencies that shape the dysfunctional interactions of disruptive children and their parents. PDI specifically addresses these processes by establishing consistent contingencies for the
16 childâ€™s behaviors that are implemented in the context of the positive parent-child relationship established through the CDI interactions. Importance of Early Intervention Early intervention in families with behavior-disordered youngsters may be critical. Disruptive behavior represents the single most important behavioral risk factor for later antisocial behavior (Kellam et al., 1991; Loeber & Dishion, 1983; White et al., 1990). Disruptive behavior problems can be reliably identified in children as young as three (Olweus, 1979; Rich & Eyberg, in press). Evidence also suggests that intervention is more effective at the preschool age than when children are older (Dishion & Patterson, 1992; Ruma, Burke, & Thompson, 1996; Strain, Young, & Horowitz, 1981). Effective treatment of disruptive behavior problems prior to elementary school entry may prevent the associated problems with academic performance and peer relationships that require multiple interventions only a few years later (Campbell, 1997; Reid, 1993; Webster-Stratton & Herbert, 1994). Unfortunately, despite the continuity of behavior problems from preschool to adulthood and the clear need for early intervention, there has been little research into preschool populations. Efficacy of PCIT PCIT outcome research has demonstrated statistically and clinically significant improvements in the disruptive behavior of preschool age children (Eyberg & Robinson, 1982; Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998). Such studies document the superiority of PCIT to wait-list controls (McNeil, Capage, Bahl, & Blanc, 1999) and to parent group didactic training (Eyberg & Matarazzo, 1980) and have compared standard treatment to a PCIT treatment in which the PDI phase of treatment preceded CDI (finding minimal differences) (Eisenstadt, Eyberg, McNeil, Newcomb, & Funderburk, 1993).
17 Although the therapy focuses on decreasing disruptive behavior in preschoolers, PCIT has been suggested to be applicable to a broad range of presenting problems, including neurological impairment (Miller, Mee, & Eyberg, 1989), developmental disorders (Eyberg & Matarazzo, 1980), chronic illnesses (Miller & Eyberg, 1991) and in child abusive families (Herschell, Calzada, Eyberg, & McNeil, 2002; Urquiza & McNeil, 1996), where the identified patient is usually the parent. Additionally, PCIT has effectively treated mood and anxiety disorders (Pincus, Choate, Eyberg, & Barlow, in press) as well as hyperactivity (Nixon, 2001). PCIT outcome studies have demonstrated important changes in parentsâ€™ interactions with their child, including increased reflective listening and prosocial verbalization, and decreased criticism and sarcasm at treatment completion (Eisenstadt et al., 1993; Schuhmann et al., 1998), as well as significant changes on parentsâ€™ self-report measures of psychopathology (MMPI), personal distress (BDI, PSI), and parenting locus of control (PLOC) (Schuhmann et al., 1998). Additionally, childrenâ€™s inappropriate behaviors have been shown to decrease during treatment (Klein, Werba, & Eyberg, 2001) and the effects of PCIT have been found to generalize to the behavior of untreated siblings (Brestan, Eyberg, Boggs, & Algina, 1997) and to the school setting (McNeil, Eyberg, Eisenstadt, Newcomb, & Funderburk, 1991). Long-term maintenance of the effects of PCIT has been observed as well. Parent ratings of child behavior problems, child activity level, and parenting stress have shown maintenance at 2-year follow-up, with most children remaining free of diagnoses of disruptive behavior disorders over that time (Eyberg et al., 2001). In a comparison of PCIT completers and dropouts at 1to 3-year follow-up, Boggs and colleagues (2004)
18 found significantly fewer symptoms of disruptive behavior for treatment completers, and their mothers reported significantly less parenting stress. Treatment completers were also evaluated at 4to 6-year follow-up and found to maintain their treatment gains over this extended time period (Hood & Eyberg, 2003). Outcome of Treatments with Preschoolers Empirically supported treatments for preschool age children with disruptive behavior (e.g., Eyberg & Boggs, 1998; McMahon & Wells, 1998; Patterson, Dishion, & Chamberlain, 1993; Webster-Stratton, 1996a) have been consistent in a number of findings: (a) statistically significant improvements are found in childrenâ€™s behavior at the end of treatment on parent and teacher rating scales and direct observation measures of children with their parents and teachers; (b) statistically significant changes in family members (mothers, fathers, siblings) of the treated child are found on questionnaire and observational measures of sibling behavior and parenting skills, stress, and feelings of competence as parents; (c) many of the child and family changes are clinically significant (moving from outside to within the normal range after treatment); and (d) the changes are maintained for at least one year for at least 50% of the families who complete treatment. To my knowledge, no systematic research has examined the effectiveness of PMT for children with comorbid ODD and ADHD. This study is focused on the experiences and outcomes of families with children diagnosed with ODD only or with ODD comorbid with ADHD who have completed a PCIT treatment study. (Children meeting pretreatment diagnostic criteria for CD were excluded from analyses in order to provide for a â€œpurerâ€ diagnostic sample.) I examined demographic variables, including child age, race, and sex, estimated child verbal and parent IQ, and family socioeconomic status, as well as the results of diagnostic interview and psychosocial measures to identify any
19 significant preor posttreatment differences between the two groups and to assess change across treatment for both groups. Each group essentially serves as the other groupâ€™s control. Hypotheses Demographic Difference Hypotheses Hypothesis 1. At pretreatment, because children with more significant and more varied problems will likely irritate and attract the concern of parents, teachers, health care providers, and other adults more quickly than those with a single diagnosis and because previous research has found significant differences in age of onset (Waschbusch, 2002), I hypothesize that children comorbid with ODD and ADHD will be referred for treatment at an earlier age and thus the comorbid group will be younger in this study. Additionally, because compared to children with ODD/CD only, children with comorbid ODD/CD and ADHD have demonstrated lower IQ (Speltz et al., 1999; Waschbusch, 2002), I hypothesize that children with comorbid ADHD will have lower estimated verbal IQ (PPVT-III) than children with ODD only. I do not expect differences in child sex, race, estimated parent IQ, or family socioeconomic status between groups. Diagnostic Hypotheses Hypothesis 2. Because PCIT directly treats preschoolersâ€™ disruptive behaviors, I hypothesize that a majority of children in both groups will change from having a diagnosis of ODD before treatment to not meeting diagnostic criteria after treatment. Hypothesis 3. Additionally, Pisterman et al. (1989) found support for the psychosocial treatment of disruptive behavior disorders, Anastopoulos et al. (1993) found support for parent training of ADHD symptom severity, and Nixon (2001) found that PCIT decreased hyperactivity and the likelihood of continuing to meet ADHD criteria.
20 PCIT is appropriate for treatment of children with inattention and overactivity problems. I hypothesize that a majority of the children in the comorbid group will change from having a diagnosis of ADHD before treatment to not meeting diagnostic criteria after treatment. Treatment Outcome Hypotheses Hypothesis 4. Because comorbid ODD and ADHD appears to have a cumulative effect (Gadow & Nolan, 2002) with worse treatment outcomes than found with ODD only (Carlson et al., 1997), children in the comorbid group will have higher ratings of problems than the ODD group on outcome measures both at preand posttreatment, although both groups will improve across treatment. More specifically: Hypothesis 4a. Research has shown that children with comorbid ODD and ADHD typically have more ODD problems than do children with ODD only (see also Hinshaw, 1999). Thus, I hypothesize that children with comorbid ODD and ADHD will have a greater ODD symptom count (DISC-IV-P) than the ODD-only group at both preand posttreatment. Because PCIT involves teaching parents specific skills to decrease negative behavior associated with disruptive behavior disorders, I hypothesize that ODD symptom counts will significantly decrease across treatment in each group. Hypothesis 4b. Because research has shown that children with comorbid ODD and ADHD typically have more attentional problems than children with ODD only (see also Hinshaw, 1999), I hypothesize that children with comorbid ODD and ADHD will have a greater ADHD symptom count (DISC-IV-P) than the ODD-only group at both preand posttreatment.
21 Because PCIT involves teaching parents specific skills to decrease disruptive behavior, and PCIT has been deemed appropriate for working with children who have inattentive and overactive characteristics associated with ADHD (Hembree-Kigin & McNeil, 1995; Nixon, 2001), I hypothesize that ADHD symptom counts will significantly decrease across treatment in each group. Hypothesis 4c. Research has shown that children with comorbid ODD and ADHD typically have more ODD and attentional problems and greater symptom severity than children with ODD only (Gadow & Nolan, 2002; see also Hinshaw, 1999; Walker et al., 1987). Thus, I hypothesize that children with comorbid ODD and ADHD will have higher scores on a parent measure of behavior problems (ECBI Intensity Scale) than the ODD group at both preand posttreatment. Because PCIT addresses disruptive behaviors via improving the parent-child interaction, both groups will significantly improve in ratings on the parent measure of behavior problems across treatment. Hypothesis 4d. In additional to the oppositional and defiant aspect of carrying a diagnosis of ODD, children with comorbid ODD and ADHD are likely to have more difficulty focusing and attending to parental commands than children with ODD only. Additionally, children with comorbid ODD and ADHD have more conflict with their parents than do children with ODD (Hinshaw et al., 1993). I hypothesize that the comorbid group will show a lower rate of child compliance to maternal commands during parent-child interactions, measured with the DPICS-II, than the ODD group at both preand posttreatment. Because PCIT involves teaching parents specific skills to increase child compliance, both groups will significantly improve in observational ratings of child compliance to commands across treatment.
22 Hypothesis 4e. Research has shown that children with comorbid ODD and ADHD typically have more ODD problems and symptom severity than those children with ODD only (Gadow & Nolan, 2002; see also Hinshaw, 1999). Thus, I hypothesize that children with comorbid ODD and ADHD will show a higher percentage of inappropriate classroom behavior on a school observational coding system than the ODD group at both preand posttreatment. Because PCIT addresses disruptive behaviors via improving the parent-child interaction, both groups will significantly improve in observational percent inappropriate scores across treatment. Hypothesis 4f. Parents of children with comorbid disruptive behaviors and ADHD have been found to have higher levels of parental pathology, including maternal controllingness than parents of children with a single diagnosis of ODD (Cunningham & Boyle, 2002). I hypothesize that the mothers of children in the comorbid group will have worse scores on a parental measure of parenting style (Parenting Scale Overreactivity Factor) than mothers of children in the ODD group at both preand posttreatment. Because PCIT addresses parental demandingness via fostering more positive interactions and teaching parents more effective discipline techniques, both groups will significantly improve in maternal scores of parenting style across treatment. Hypothesis 4g. Research has shown that children with comorbid ODD and ADHD typically have more difficulty with social competency and peer acceptance than those with ODD only (Milich & Landau, 1989). I hypothesize that children with comorbid ODD and ADHD will have poorer teacher ratings of social competency (SCS-T) than the ODD group at both preand posttreatment. Because maladaptive attachment is linked to low social competence, poor coping skills, low self esteem, and poor peer relationships
23 (Coie et al., 1993; Earls, 1980; Jenkins et al., 1980; Richman et al., 1982; Rutter, 1980) and PCIT aims to improve the parent-child relationship and subsequently the parent-child attachment, I hypothesize that both groups will significantly improve in teacher ratings of social competency across treatment.
CHAPTER 2 METHODS Participants Participants for this study were drawn from a larger study being conducted by Sheila Eyberg and Stephen Boggs at the University of Florida Health Science Center Psychology Clinic. Boys and girls referred to the Health Science Center Psychology Clinic (85% Caucasian) for treatment of behavior problems were screened for inclusion in the study. The Child Study Lab, designed specifically for the study of young, behavior-disordered children, served as the specialty clinic for these youngsters. Primary referral sources were Shands Hospital physicians in pediatric neurology, child psychiatry, and general pediatrics, although referrals were also received from community mental health practitioners, preschools, and self-referrals. Participants were 98 children between the ages of 3 and 6 years, inclusive, who lived with at least one parent able to participate in treatment with the child, and who met DSM-IV diagnostic criteria for ODD. (Of note is that 2 of an original 100-participant sample did not meet criteria for ODD.) Diagnostic criteria will be further specified later in this section.) Excluded from the study were children who had serious sensory impairments (e.g., deaf, blind), who had a history of psychosis or autism, who obtained Standard Scores below 75 on a measure of receptive language (Peabody Picture Vocabulary Test â€“ Third Edition; PPVT-III; Dunn & Dunn, 1997) or whose parents obtained verbal IQ-equivalent Standard Scores below 75 on the Wonderlic Personnel Test (WPT; Dodrill, 1981). Children who were taking psychotropic medication to help 24
25 manage their behavior problems were not excluded if their medicationâ€™s status and dosage were stabilized for at least one month before enrolling in the study. Additionally, children were not excluded if they met comorbid diagnoses for other childhood disorders including ADHD and Separation Anxiety Disorder (SAD), or if they met diagnostic criteria for Major Depressive Disorder (MDD). Finally, participants were not excluded on the basis of race/ethnicity, sex, or socioeconomic status. However, in an attempt to ensure that differences in problem severity between groups were due to the additional diagnosis of ADHD and not to the significant severity of comorbid CD, children meeting a comorbid diagnosis of CD were excluded from analyses. Of the 98 original participants, 37 children met criteria for CD and were excluded from further analyses. Child Diagnostic Issues The advantages and disadvantages of categorical versus dimensional approaches to diagnosis have been debated. Recently, several researchers have recommended combining these two approaches for the diagnosis of child psychopathology (Eyberg, Schuhmann, & Rey, 1998; Gould, Bird, & Jaramillo, 1993; Jensen, Salzberg, Richters, & Watanabe, 1993, Jensen et al., 1996), primarily to ensure that the diagnoses are related to significant and meaningful levels of impairment and have reasonable relationships to other external validators (Jensen et al., 1996). In this study, research participants had ODD diagnoses based on a combination of the NIMH Diagnostic Interview Schedule for Children-IV-Parent (NIMH DISC-IV-P; Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000) criteria for ODD and a Child Behavior Checklist for 4 to 18 Year Olds (CBCL/4-18; Achenbach, 1991) or Child Behavior Checklist for 2 to 3 Year Olds (CBCL/2-3; Achenbach, 1992) Aggression Scale cutoff score of T > 61. This combination has been recommended by Jensen et al. (1996)
26 for optimal caseness. By using an â€œandâ€ rule requiring both criteria to be met for diagnosis, it is likely that some children were excluded who would otherwise have been accepted on the basis of only a single approach to diagnosis. However, based on an earlier study (Eisenstadt et al., 1993), I expected to exclude few children on the basis of this selection method. In Eisenstadt and colleaguesâ€™ study, preschoolers were selected for treatment based on cutoff scores from a different parent rating scale of disruptive behavior, but data from the CBCL and the Diagnostic Interview for Disruptive Behavior Disorders were collected. Of 30 children accepted for treatment, there was only one child positive on the diagnostic interview measure who was not also positive on the CBCL Aggression Scale. A second important and debated issue is the appropriateness of the diagnostic categories for preschool age children. Oppositional Defiant Disorder is perhaps the least controversial diagnosis in young children. However, in addition to screening the children for ODD, I was interested in assessing comorbidity with ADHD as an independent predictor of outcome in PCIT. I assessed the presence of two additional Axis I disorders (ADHD and CD) that may exist in preschoolers, while acknowledging that researchers do not agree as to whether some actually exist as meaningful categories at this age or whether they can be meaningfully measured in preschoolers (Keenan & Wakschlag, 2002). However, few data exist addressing diagnosis or comorbidity in children of preschool age, and further study, such as the work of Keenan and Wakschlag, is warranted. This study utilized three modules of the DISC-IV-P that addressed symptoms of the disruptive behavior disorders (ODD and CD) and ADHD. This interview has been used
27 with children as young as 4, and researchers in St. Louis and at Columbia University are adapting the DISC-IV-P so that it can be used effectively with children as young as 3 (C. Lucas, personal communication, January 1999). For the initial diagnostic categorization of the 4to 6-year-old children, I required elevated scores (T 61 on externalizing scales; cf., Jensen et al., 1996) on the corresponding CBCL/4-18 scales (Aggressive, Delinquent, Attention, respectively). For the 3-year-old children, the diagnoses were based on the DISC-IV-P categories alone except for ODD, which has a corresponding CBCL/2-3 scale (Aggression). Further, the diagnosis of ADHD specifically requires the symptoms to be present in more than one setting. For this reason, study children who attended school at the time of the pretreatment assessment were required to obtain a clinically elevated score (T 65; Conners, Sitarenios, Parker, & Epstein, 1998) on either the DSM-IV: Inattentive or DSM-IV: Hyperactivity-Impulsive subscale of the Connersâ€™ Teacher Rating Scale-Revised: Long Version (CTRS-R:L; Conners et al.) to receive a diagnosis of ADHD. Pretreatment Thirty-eight (62%) of the children were boys [22 (65%) boys in the ODD only group and 16 (59%) boys in the comorbid ODD and ADHD group], and the racial/ethnic composition of the families was: 50 (82%) Caucasian, 3 (5%) African American, 2 (3%) Hispanic, 1 (2%) Asian, and 5 (8%) Bi-racial children. See Table 1 for further statistics regarding child age, estimated IQs for children, mothers, and fathers, and family Hollingshead scores. At pretreatment, 34 children met diagnostic criteria for ODD only and 27 children met criteria for ODD plus ADHD. Thus, in this sample of children with ODD, 44% had comorbid ADHD.
28 Demographic data were compared for the two diagnostic groups with independent samples t tests or 2 analyses. There was no significant difference between the groups based on child age, child sex, estimated child verbal IQ, estimated maternal IQ, estimated paternal IQ, or family socioeconomic status (see Table 1 for comparison statistics). However, the groups differed on child race, 2 (4, n = 61) = 15.52, p < .01. Of note is that all non-Caucasian children were in the ODD plus comorbid ADHD group except for 1 Asian child. Kazdin and Wassell (1998) estimate 40 to 60% dropout rates for children who enter outpatient therapy, and a 33% dr opout rate was obtained in a previous PCIT study with preschoolers (Werba, Eyberg, Boggs, & Algina, in press). Treatments for families with disruptive behavior-disordered children make many demands on families. Many steps were taken to reduce attrition related to known reasons for dropout (Black & Holden, 1995; Capaldi & Patterson, 1987; Eyberg, Ed ward, Boggs, & Foote, 1998; Prinz & Miller, 1984). Beyond conducting PCIT, therapis ts provided opportunities for parents to discuss life concerns beyond child management , sent birthday and holiday cards to families, as well as provided monetary incentives to families in the form of sibling child care, transportation, parking, a nd gas money. Of the 61 families not excluded due to comorbid CD diagnosis, 21 (34%) dropped out of the current treatment study, resulting in a final sample size of 40 children and families. This dropout rate was similar to those obtained in Werba and colleaguesâ€™ PCIT study with preschoolers. Of the 40 families that completed treatment, 23 (68%) were from the ODD only group, and 17 (63%) were from the ODD plus comorbid ADHD group. There was not a differential dropout rate for the two groups of children, t (59) = .38, p = .71.
Table 1. Comparison of Pretreatment Demographic Data for All Non-CD Participants and All Non-CD Treatment Completers ____________________________________________________________________________________________________________ ODD versus ODD+ADHD ______________________ n M SD Minimum Maximum t or 2 df p ____________________________________________________________________________________________________________ All Non-CD Participants Age 61 4.43 1.07 3.00 6.00 -.60 59 .55 ODD 34 4.35 1.01 3.00 6.00 ODD+ADHD 27 4.52 1.16 3.00 6.00 Child Sex 61 â€“ â€“ â€“ â€“ .19 1 .66 ODD 34 â€“ â€“ â€“ â€“ ODD+ADHD 27 â€“ â€“ â€“ â€“ Child Race 61 â€“ â€“ â€“ â€“ 15.52 4 <.01* ODD 34 â€“ â€“ â€“ â€“ ODD+ADHD 27 â€“ â€“ â€“ â€“ 29 Child IQ 60 103.08 11.32 78.00 129.00 .55 58 .58 ODD 33 103.82 11.16 88.00 129.00 ODD+ADHD 27 102.19 11.67 78.00 125.00 Mother IQ 60 107.45 11.61 80.00 134.00 .09 58 .93 ODD 33 107.58 12.82 80.00 134.00 ODD+ADHD 27 107.30 10.17 86.00 134.00 Father IQ 29 108.62 12.45 85.00 132.00 .61 27 .55 ODD 17 109.82 13.16 85.00 128.00 ODD+ADHD 12 102.19 11.67 78.00 125.00 Hollingshead 61 39.92 13.01 14.00 66.00 .63 59 .53 ODD 34 40.85 13.03 14.00 66.00 ODD+ADHD 27 38.74 13.14 20.00 66.00 All Treatment Completers Age 40 4.55 1.06 3.00 6.00 -.19 38 .85 ODD 23 4.52 1.08 3.00 6.00
30 Table 1. Continued ____________________________________________________________________________________________________________ ODD versus ODD+ADHD ______________________ n M SD Minimum Maximum t or 2 df p ____________________________________________________________________________________________________________ ODD+ADHD 17 4.59 1.06 3.00 6.00 Child Sex 40 â€“ â€“ â€“ â€“ .06 1 .80 ODD 23 â€“ â€“ â€“ â€“ ODD+ADHD 17 â€“ â€“ â€“ â€“ Child Race 40 â€“ â€“ â€“ â€“ 11.87 4 .02* ODD 23 â€“ â€“ â€“ â€“ ODD+ADHD 17 â€“ â€“ â€“ â€“ Child IQ 40 103.55 11.58 83.00 129.00 -.54 38 .59 ODD 23 102.70 11.77 88.00 129.00 ODD+ADHD 17 104.71 11.59 83.00 125.00 Mother IQ 39 108.97 10.74 88.00 134.00 .28 37 .78 ODD 22 109.41 12.44 88.00 134.00 ODD+ADHD 17 108.41 8.37 95.00 121.00 Father IQ 21 111.33 12.99 85.00 132.00 .16 19 .88 ODD 13 111.69 13.73 85.00 128.00 ODD+ADHD 8 110.75 12.60 97.00 132.00 Hollingshead 40 43.48 12.04 17.00 66.00 .50 38 .62 ODD 23 44.30 12.26 17.00 66.00 ODD+ADHD 17 42.35 12.02 22.00 66.00 ____________________________________________________________________________________________________________ Note. *p < .05.
31 Several analyses were conducted in order to ensure that the treatment completers were representative of the in itial groups analyzed at pret reatment. Using independent samples t tests or 2 analyses (with Yatesâ€™ correction as needed for analyses with expected cell counts less than 5), the two groups of treatme nt completers were not found to be significantly different than dropouts from the corresponding diagnostic groups in terms of child age, race, sex, estimated child verbal IQ, estimated maternal IQ, or estimated paternal IQ. However, there was a significant difference between groups based on socioeconomic status in the ODD group, and a trend in the ODD plus ADHD group, in that treatment completers had a higher soci oeconomic status in either diagnostic group. M and SD statistics are listed in Table 1 for tr eatment completers and in Table 2 for treatment dropouts (along with comparison statistics). For the final sample of 40 treatment completers, 25 (63%) of the children were boys [14 (61%) boys in the ODD only group a nd 11 (65%) boys in the comorbid ODD and ADHD group], and the racia l/ethnic composition of the families was: 32 (80%) Caucasian, 2 (5%) African American, 1 ( 3%) Hispanic, 1 ( 3%) Asian, and 4 (10%) Biracial children. See Table 1 for further statistics regarding child age, estimated IQs for children, mothers, and fathers, and family Hollingshead scores. Demographic data were compared for the completers in the two diagnostic groups with independent samples t tests or 2 analyses. Similar to the sample including treatment completers and dropouts, there were no signi ficant differences be tween groups based on child age, child sex, estimated child verbal IQ , estimated maternal IQ, estimated paternal IQ, or family socioeconomic status (see Tabl e 1 for comparison statistics). However, there was a significant difference be tween groups based on child race, 2 (4,n = 40) =
32 Table 2. Pretreatment Demographic Da ta for Non-CD Treatment Dropouts and t Test or 2 Differences with Corresponding Treatment Completers ____________________________________________________________________________________________________________ n M SD Minimum Maximum t or 2 df p ____________________________________________________________________________________________________________ Age 21 4.19 1.08 3.00 6.00 ODD 11 4.00 .77 3.00 5.00 -1.43 32 .16 ODD+ADHD 10 4.40 1.35 3.00 6.00 -.41 25 .69 Child Sex 21 â€“ â€“ â€“ â€“ ODD 11 â€“ â€“ â€“ â€“ .09 1 .77 ODD+ADHD 10 â€“ â€“ â€“ â€“ .12 1 .73 Child Race 21 â€“ â€“ â€“ â€“ ODD 11 â€“ â€“ â€“ â€“ .49 1 .49 ODD+ADHD 10 â€“ â€“ â€“ â€“ .91 3 .82 Child IQ 20 102.15 11.02 78.00 126.00 ODD 10 106.40 9.70 90.00 126.00 .87 31 .39 ODD+ADHD 10 97.90 11.05 78.00 120.00 -1.50 25 .15 Mother IQ 21 104.62 12.87 80.00 134.00 ODD 11 103.91 13.37 80.00 121.00 -1.17 31 .25 ODD+ADHD 10 105.40 12.96 86.00 134.00 -.74 25 .47 Father IQ 8 101.50 7.56 93.00 116.00 ODD 4 103.75 10.28 93.00 116.00 -1.06 15 .31 ODD+ADHD 4 99.25 3.77 95.00 104.00 -1.75 10 .11 Hollingshead 21 33.14 12.31 14.00 55.00 ODD 11 33.64 12.03 14.00 55.00 -2.39 32 .02* ODD+ADHD 10 32.60 13.24 20.00 53.00 -1.96 25 .06 ____________________________________________________________________________________________________________ Note. *p < .05. p < .10
33 11.87, p < .05. Of note again is that all non-Caucasian children continued to be in the ODD plus comorbid ADHD group except for one Asian child. Measures Evaluating child treatment effects is limited by the few standardized measures available to study constructs important to outcome evaluation (see also Eyberg, Schuhmann, et al., 1998). For these reasons, I selected measures with consideration of the discriminative validity and sensitivity of several methods of measurement to capture change in the behaviors of young children in the 2 groups over time. Querido and Eyberg (2005) have normed several of these measures (e.g., CBCL/4-18, CBCL/2-3, CTRS-R:L, DPICS-II percent child compliance, ECBI, and Parenting Scale) with Head Start preschoolers in the same geographic area, North Central Florida, and found no difference from scores of non-Head Start children. Querido and Eyberg also found preliminary evidence of sensitivity for these measures. Screening/Descriptive Measures A demographic questionnaire was used to collect descriptive information about the child and family members including sex, age, race, occupation, and education level. This information was used to assess differences between groups at the pretreatment assessment as well as to calculate family socioeconomic status (SES) as measured by Hollingsheadâ€™s (1975) Four Factor Index. The Child Behavior Checklist for 4 to 18 Year Olds (CBCL/4-18; Achenbach, 1991) is a comprehensive instrument designed to assess the frequency of a variety of specific behaviors in children during the prior 6 months. It consists of 118 behavior-problem items rated by the parent on a 3-point scale from (0) not true, to (2) very true or often true. The items have been factor analyzed into narrow band scales given
34 descriptive labels such as Anxious/Depressed, Withdrawn, and Aggressive, and into two broadband scales of internalizing and externalizing behavior problems. Mean test-retest reliabilities of the problem scales of .89 and .75 over a 1-week and 1-year period, respectively, have been reported. Concurrent validity with the Conners (1973) Parent Questionnaire has also been reported. For research diagnostic purposes, I used the three CBCL narrow-band scales corresponding to the three diagnostic categories of interest (i.e., Attention, Aggression, and Delinquent), in conjunction with the DISC-IV-P, as recommended by Jensen et al. (1993, 1996) for the diagnostic study of child psychopathology. The Child Behavior Checklist for 2 to 3 Year Olds (CBCL/2-3; Achenbach, 1992) is similar in format to the CBCL/4-18 and contains 99 items rated by the parent for frequency in the past 2 months on a 3-point scale. Fifty-nine items have counterparts on the CBCL/4-18, and 40 items are specifically designed for the younger age group. Test-retest reliability of the CBCL/2-3 has been reported to range from .79 to .92 for the problem scales over a one-week period and .56 to .76 over a one-year period (Crawford & Lee, 1991). Interrater agreement has been reported to range from .56 to .76, and concurrent validity has been reported with the Richman Behavior Checklist (1982; Spiker, Kramer, Constantine, & Bryant, 1992). The CBCL/2-3 was used, along with the DISC-IV-P, in the diagnosis of the 3-year-olds. Specifically, I used the Aggression subscale to correspond with the diagnosis of ODD. Although the subscale labeled Destructive appears to measure ADHD, I did not use this scale in diagnosing comorbid disorders in the 3-year-olds.
35 The Connersâ€™ Teacher Rating Scale-Revised: Long Version (CTRS-R:L; Conners et al., 1998) is a 59-item teacher rating scale that measures Attention Deficit Hyperactivity Disorder (ADHD) and comorbid disorders. It is appropriate for use with children between the ages of 3 and 17 years. Items are rated on a 4-point Likert scale from (0) Not True At All to (3) Very Much True. The CTRS-R:L yields nine subscale scores including Oppositional, Cognitive Problems/Inattention, Hyperactivity, Anxious-Shy, Perfectionism, Social Problems, and three DSM-IV symptom subscales (DSM-IV: Inattentive, DSM-IV: Hyperactive-Impulsive, and DSM-IV: Total). The CTRS-R:L has shown internal consistency coefficients between .75 and .90 and test-retest reliability correlations between .60 and .90. Conners et al. have demonstrated both convergent and discriminant validity for the CTRS-R:L. I used the DSM-IV: Inattentive and DSM-IV: Hyperactive-Impulsive subscales in conjunction with the DISC-IV-P and CBCL to diagnose ADHD, according to Jensen and colleaguesâ€™ (1993, 1996) criteria. The NIMH Diagnostic Interview Schedule for Children-IV-Parent (NIMH DISC-IV-P; Shaffer et al., 2000) is a structured diagnostic interview for administration to parents. It includes all common mental disorders of children included in the DSM-IV that are not dependent on specialized observations or test procedures. Individual modules of the interview can be administered separately, and 1-week test-retest reliability on administration to parents of 9 to 17 year old children has been reported at .79 for ADHD, .54 for ODD, and .54 for CD (Fisher et al., 1998, cited in Columbia DISC Editorial Board, 1998), which were the diagnoses of interest in this project. Dr. Sheila Eyberg consulted with C. Lucas at Columbia University on the modifications to certain questions needed for developmentally appropriate administration for children as young as 3.
36 Assessors in the current study subsequently indicated â€œyesâ€ to questions asking, â€œDid this start before age 5?â€ if the child was younger than 5 years old. The DISC-IV-P was used in conjunction with the CBCL/4-18, CBCL/2-3, and CTRS-R:L in order to diagnose ODD, CD, and ADHD in the preschoolers and assess qualitative change in diagnosis across treatment in each group. Additionally, because research has shown that children with comorbid ODD and ADHD typically have more ODD and attentional problems than those children with ODD only (see also Hinshaw, 1999), ODD and ADHD symptom counts were totaled separately. These counts were used to assess pretreatment differences between groups as well as to evaluate the impact of treatment on ODD and ADHD symptom counts of children with ODD and those with comorbid ODD and ADHD. The Peabody Picture Vocabulary TestThird Edition (PPVT-III; Dunn & Dunn, 1997) is a well standardized test that measures receptive language in individuals ages 2.6 years through adulthood. Raw scores are converted into standard scores (M = 100; SD = 15). Split half reliability coefficients for children range from .86 to .97, with a median of .94. Test-retest reliabilities range from .91 to .94. The correlation between the PPVT-III and the WISC-III Full Scale IQ is .90. The PPVT-III was used as the cognitive screening measure for target children in this project. The Wonderlic Personnel Test (WPT; Dodrill, 1981) is a 50-item test designed as a screening scale of adults' intellectual abilities. The test score is the number of items answered correctly in 12 minutes. In a sample of 120 normal adults, the Wonderlic estimate of intelligence correlated .93 with the WAIS Full Scale IQ score, and the Wonderlic score was within 10 points of the WAIS IQ score for 90% of the subjects
37 (Dodrill, 1981). Differences in age, sex, education, level of intelligence, and emotional adjustment did not significantly affect observed correlations with the WAIS. Dodrill and Warner (1988) replicated the 1981 findings, and they have been extended to psychiatric (Hawkins, Faraone, Pepple, & Seidman, 1990) and academic settings (McKelvie, 1989). The Wonderlic Full Scale IQ estimate was used as the cognitive screening measure for mothers in this project. Treatment Outcome Measures For this study, I chose measurements based on a priori hypotheses (listed in the introduction) that were driven by findings in the literature of differences between children with ODD and those with ODD plus ADHD. Outcome measures for this study included one behavioral sequence from the DPICS-II, coded during videotaped parent-child interactions, an inappropriate behavior category of a classroom behavior observation system (REDSOCS), mother rating scale measure of disruptive behaviors (ECBI), a teacher rating of social competency (SCS-T), and mother self-report ratings of parenting style (PS). These measures were intended to capture the core differences between children with ODD only and those with comorbid ODD and ADHD before PCIT and to compare changes in child, mother, and parent-child interaction characteristics both across and after treatment. The clinical significance of changes (statistically reliable changes from a pretreatment score that is outside normal limits to a posttreatment or follow-up score that is within normal limits as determined by published cutoff scores; Bessmer, 1996; Conduct Problems Prevention Research Group [CPPRG], 1990; Eyberg & Pincus,1999; Foote, 1999; Jacobs et al., 2000) were examined for the individual families in both groups as well.
38 The Dyadic Parent-Child Interaction Coding System II (DPICS-II; Eyberg, Bessmer, Newcomb, Edwards, & Robinson, 1994) is a revised version of the DPICS (Eyberg & Robinson, 1983), a behavioral coding system that measures the quality of parent-child social interactions. It provides observational measures of parent and child behaviors in the laboratory or clinic during three 5-minute standard situations that vary in the degree of parental control required (child-directed interaction, parent-directed interaction, and clean up, respectively). Categories of parent and child behaviors include 12 verbalization categories (e.g., labeled praise, critical statement), 3 vocalization categories (whine, laugh, yell), and 3 physical behaviors (destructive behavior, positive touch, and negative touch). Several sequences of behavior are also coded (e.g., compliance to commands, answers to questions). Kappa reliabilities for all categories of the DPICS-II have been established (Bessmer, 1996; Foote, 1999). DPICS-II observations at preand posttreatment were videotaped for later computer coding, and therapists coded the parent-child interactions live in each treatment session. Inter-observer reliability for the preand posttreatment observations was assessed by randomly selecting one-third of the assessment videotapes for each family at each observation point to be independently coded by a second observer. DPICS-II has been found sensitive to treatment effects (Schuhmann et al., 1998; Webster-Stratton & Hammond, 1997). One sequence behavior (child compliance) was used in this study. This sequence was combined across the mother-directed interaction and clean up situations and analyzed in this study at both preand posttreatment assessment to evaluate outcome differences between children with ODD only and those with comorbid ADHD, as well as changes across each of the two groups.
39 Percent child compliance was defined as the frequency of child complies divided by the frequency of parent alpha commands (commands that provide an opportunity to comply). Observations at each assessment point involved averaging scores across four 5-min observations (two mother-directed interactions and two clean-ups). The inter-observer reliabilities for the four individual categories used in this study are shown in Table 4. The Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999) is a 36-item parent rating scale of disruptive behavior problems in children between the ages of 2 and 16. The ECBI has two scales: Intensity and Problem. The Intensity Scale of the ECBI measures the frequency of childrenâ€™s behaviors on a 7-point scale from (1) never, to (7) always. The ECBI Intensity Scale includes items reflective of both oppositional and ADHD-related behaviors. The Intensity Scale of the ECBI yields an internal consistency coefficient of .95; an interrater (mother-father) reliability coefficient of .69; and a test-retest reliability coefficient of .80 across 12 weeks and of .75 across 10 months. Paired t test analyses for systematic increases or decreases in scores across time were nonsignificant in all studies. Studies documenting convergent, discriminant, and discriminative validity of the scale have been summarized in the test manual (Eyberg & Pincus, 1999). Treatment outcome results from several studies have shown the ECBI Intensity Scale to be a sensitive measure of treatment change in clinic-referred children (Taylor, Schmidt, Pepler, & Hodgins, 1998; Tynan, Schuman, & Lampert, 1999; Webster-Stratton & Hammond, 1997). The ECBI Intensity Scale score was analyzed in this study at both assessment points in order to evaluate preand posttreatment differences between children with ODD only and those with comorbid ADHD, as well as
40 treatment outcome between the two groups. The pretreatment ECBI Intensity Scale score for one participant was unable to be calculated due to excessive missing items. The internal consistency of the ECBI Intensity Scale for the children in this study is reported in Table 3. The Parenting Scale (PS; Arnold, Oâ€™Leary, Wolff, & Acker, 1993) is a 30-item self-report measure of parental discipline practices. Items were developed to reflect discipline techniques that are associated with childrenâ€™s behavior problems according to theory and/or empirical data. The PS is a 7-point visual analog scale in which parents rate how closely their responses to misbehavior resemble an effective strategy versus a mistake. The PS has three factors: Laxness, Overreactivity, and Verbosity. The authors have reported PS correlations with behavioral observations and parent ratings of child behavior, marital discord, and parental depression. The Overreactivity Factor score was intended to be used to compare mother ratings of discipline practices between ODD diagnosis groups before and after treatment as well as across PCIT. The internal consistency of the ECBI Intensity Scale for the children in this study is reported in Table 3. The Revised Edition of the School Observation Coding System (REDSOCS; Jacobs et al., 2000) is an interval coding system for recording disruptive classroom behaviors of preschool and elementary age children. Behaviors that are coded include Appropriate vs. Inappropriate Behavior, Comply vs. Noncomply vs. No Command, and On-task vs. Off-task vs. No task. In this study, only the Appropriate vs. Inappropriate Behavior category was analyzed, because of a priori hypotheses. Specifically, the Inappropriate Behavior includes the following categories of behaviors: whining, crying,
41 yelling, destructiveness, aggressive behavior, negativism, self-stimulation, demanding attention, disruptive behavior, talking out of order, being out of area, and cheating. The system allows for a variable number of children to be coded alternately during an observation session, and results in 10 minutes of observation time per child during each of three sessions conducted within a 2-week period. Kappa reliability coefficients for the Appropriate vs. Inappropriate Behavior category is .83. The REDSOCS categories have each shown significant correlations with the Conners RCTRS and have successfully discriminated children referred for treatment of school problems from their randomly selected classmates. Specifically, the Inappropriate Behavior category has been found to be significantly correlated to the Conduct, Hyperactivity, Inattention, Hyperkinesis, and Total Scales of the Conners RCTRS. During 30% of all REDSOCS school observations, a second observer accompanied the primary observer and independently recorded data for assessment of inter-observer reliability. The REDSOCS was administered at both assessments to evaluate differences in percent Inappropriate Behavior between groups both at preand posttreatment and across PCIT. The inter-observer reliabilities of the Appropriate vs. Inappropriate Behavior category for the children in this study are reported in Table 4. The Social Competence Scaleâ€”Teacher Report (SCS-T; CPPRG, 1990) is a 25-item teacher-rating scale that assesses tolerance for frustration, peer relationships, communication skills, empathy, and classroom maturity in young children, yielding a total social competence score. Cronbachâ€™s alpha for the total score has been reported to be .98 and has been found to correlate significantly with parent ratings of positive social behavior (Webster-Stratton, 1998). Webster-Stratton has shown the SCS-T is stable over
42 time and sensitive to treatment effects in preschoolers. The SCS-T was completed by the childâ€™s teacher at both assessments to evaluate differences in SCS-T scores between groups both at preand posttreatment and across PCIT. The internal consistency of the SCS-T for the children in this study is reported in Table 3. Procedure Assessments Families were seen for two clinic visits before and immediately following completion of treatment. To foster rapport in the treatment process, the pretreatment assessments were conducted by the familiesâ€™ therapists. In an attempt to minimize bias, the posttreatment assessments were conducted by graduate research assessors not involved with the familiesâ€™ treatment. The first pretreatment assessment visit consisted of a clinical interview and administration of the modified DISC-IV-P with both parents together and an individual administration of the cognitive screening measures to the parents and child. Families who did not meet inclusion criteria were given feedback on the evaluation results and referred to the general psychology clinic for appropriate therapy. For families who met study criteria, the assessors reviewed all study procedures with the family and obtained written informed consent. Next, the DPICS-II observations of the child with his or her mother were videotaped. Mothers then completed questionnaires (CBCL, ECBI, PS). Preand post-assessments each involved two clinic visits to collect parent-child interaction data and interview data. The pretreatment assessment was the most extensive because it included all baseline information that will be used as the basis for developing the prediction models. Families were paid $100 for completion of each of the preand posttreatment assessments.
43 Also, between the two visits at each assessment, graduate research assessors observed the child in his or her classroom on 3 occasions using the REDSOCS coding system and gave the teacher two rating scale measures (CTRS-R:L, SCS-T) to complete and return to the assessors during the third school visit. The teachers were paid $20 for completion of these measures. Of note is that no children were in a special school setting. Following the pretreatment assessment, all families participated in PCIT. Therapy was provided at the University of Florida Psychology Clinic. PCIT was conducted by co-therapy teams who were unaware of the studyâ€™s hypotheses. The lead therapists were graduate students in clinical psychology with prior training and experience as PCIT therapists. The co-therapists were graduate students in clinical psychology who have completed the PCIT training workshop and read the treatment manuals, have observed a prior case, and have participated in group PCIT supervision. Lead therapists were assigned to cases randomly and arranged the date and time of the first therapy appointment to occur within approximately one week following completion of the pretreatment assessment. Treatment PCIT (Eyberg, 1974; Eyberg & Boggs, 1998; Hembree-Kigin & McNeil, 1995) has similarities to other parent training approaches for disruptive behavior-disordered children but may be identified by certain core features. First, both the child and parents are involved in treatment sessions, and progress through treatment is determined by changes in the parent-child interaction rather than changes in specific child behaviors. In most sessions, after a 5-min observation to code the current status of the interactions, the therapists coach the parents extensively during parent-child play
44 situations. This second core feature enables the therapists to shape parentsâ€™ interactional behaviors directly, as the interactions are occurring, and to shape the childâ€™s interactional behaviors directly as well, via the parents. The coaching, which is typically done from an observation room using a bug-in-ear microphone, provides immediate feedback to both members of the dyad on their interaction skills. A third core feature of PCIT is its emphasis on responsive parenting in addition to discipline and control. The parent-child treatments share a legacy attributed to the early work of Hanf (1969) in which parents were trained first to change child behavior by attending selectively to the childâ€™s positive play behavior before learning to use time out to change behavior (Foote et al., 1998). In PCIT, there is perhaps a greater emphasis than in other treatments based on the Hanf model on shaping nurturant parenting and related nonverbal communication skills in the early phase of treatment. Fourth, the parents practice and experience the actual time out procedure first while being coached and supported by the therapists. The parents must demonstrate facility and confidence with the procedures before they use them with their child independently. Parents of disruptive behavior-disordered children often have great difficulty following through with discipline procedures effectively (such as taking their child to a time out chair without giving multiple, repeated commands, explanations, and arguing). Parents of behavior-disordered children also have great difficulty, emotionally, ignoring their childâ€™s behaviors (typically yelling, crying, whining, or sassing) on the time out chair. Finally, PCIT is assessment driven, and treatment is not ended until treatment goal criteria are met. Sessions are guided by the observational data collected in the first 5 minutes of the parent-child interaction, and the family reviews a summary sheet of these
45 weekly data at the end of each session to evaluate their progress toward the mastery criteria and determine their skill targets for homework practice. The interaction data determine when the family moves from one phase of treatment to the next, and they provide one of the criteria for termination. Families continue in treatment until three goals are met: (a) parents meet criterion skill levels during parent-child interactions; (b) children obtain scores within the normal range on a standardized parent-rating scale of disruptive behavior (ECBI); and (c) children no longer meet DSM-IV criteria for ODD. PCIT sessions are conducted once a week and are one hour in length. The principles and skills of the interactions are first presented to the parents alone using modeling and role playing, followed by coaching sessions in which the parents take turns being coached interacting with their child or observing their spouse being coached with the child. Parents are asked to practice the skills at home during daily play sessions with their child (5 minutes each day during the CDI phase of treatment; 10-15 minutes a day during the combined CDI and PDI phase). The first phase of treatment, CDI, continues until parents demonstrate mastery of the skills during the 5-min coding interval at the start of the session. Mastery of the PDI skills is demonstrated when 75% of the parentsâ€™ commands are direct rather than indirect, and when, after child responses to commands, there is 75% appropriate parent follow-through (i.e., praise after compliance and initiation of the time out procedure after noncompliance). The final PCIT session includes specific discussion of what families need to do to maintain treatment gains and how to deal with setbacks or new problems that arise in the future. Families are also told that if problems come up in the future that they need help with, they should call us. Additionally, they were informed that an advanced graduate
46 student would contact them to conduct a posttreatment assessment in the following week, and that the posttreatment evaluation would be similar to the pretreatment assessment. For the 40 families that completed treatment in this study, the average number of sessions was 16 (M = 16.43; SD = 5.80). There was no significant difference between the groups based on number of treatment sessions, t(37) = .66, p =.52. (Unequal variances were assumed due to significant Leveneâ€™s test of unequal variances, F = 6.52, p < .05.) Treatment Integrity To help ensure treatment integrity, lead therapists were trained by (a) reading treatment manuals and related chapters on PCIT; (b) attending DPICS-II coder training meetings and reaching criteria for reliable coding; (c) attending weekly PCIT group supervision sessions for three months prior to treating research families in the project; and (d) participating in ongoing weekly group PCIT supervision sessions during the project. Therapists used a treatment manual that has been developed for the treatment under investigation in this study. To evaluate treatment integrity, all therapy sessions were videotaped. Half (50%) of the session tapes from each family were randomly selected for integrity checking by undergraduate research assistants who reviewed the tapes and recorded, on an integrity check form incorporated into the treatment manual, the elements of each session that were covered by the therapists. From this subset of tapes, 50% were again randomly selected and checked independently by a second undergraduate assistant to provide an inter-observer reliability estimate of the treatment integrity data. This procedure was used in an earlier PCIT study (Schuhmann et al., 1998), in which 97% accuracy was found with the treatment protocol, and percent agreement inter-observer
47 reliability was 96%. In the current study, accuracy was 90% with the treatment protocol, and percent agreement inter-observer reliability was 94%. Assessment Training Assessors participated in weekly coder training meetings in which they initially learned the DPICS-II and a computer coding program for recording all occurrences of the DPICS-II behaviors during parent-child interactions in real time. Coder training in DPICS-II was guided by â€œThe Workbookâ€ (Eyberg, Edwards, Bessmer, & Litwins, 1994), a coder training manual that accompanies the coding manual. Coders first mastered written training exercises, coded written transcripts of parent-child interactions, and then practiced scoring pre-coded videotaped interactions from earlier studies until they reached 90% Pearson reliability with each other. Coders then had to demonstrate reliabilities of .80 on all DPICS-II category codes with criterion tapes before coding research tapes. To avoid observer drift, observers attended weekly training sessions to discuss observational procedures, reviewed definitions of behaviors, and viewed and discussed difficult interactional sequences. In the coder training meetings, the assessors also learned the REDSOCS school observation coding system. Coders initially practiced this less complex, interval coding system by coding videotapes of children in therapy groups using an audiotape and dual-jack earplug for timing, until they achieved 90% agreement reliability on all categories of the REDSOCS. The school reliability data were collected for one of the three observations of each study child at each assessment point.
CHAPTER 3 RESULTS Internal Consistency To establish internal consistency, Cronbachâ€™s alpha was calculated for each outcome measure (ECBI Intensity Scale, PS Overreactivity Factor, SCS-T Total Score) (see Table 3). Due to low internal consistency of the PS Overreactivity Factor for the ODD only group at both assessments, further analyses were not performed on this scale. Kappa inter-observer reliabilities (Cohenâ€™s kappa, Fleiss, 1981) and percent agreement were calculated for 50% of observations at the preand posttreatment assessments: REDSOCS percent Inappropriate Behavior and each DPICS-II category code (mother Direct Commands, mother Indirect Commands, child Compliance, and child No Opportunity to Comply) (see Table 4). Diagnostic Outcome Qualitative examination of ODD and ADHD diagnoses was conducted in order to determine categorical change in diagnosis status [according to Jensen et al. (1996) criteria] of ODD and ADHD across treatment for each group. McNemar analysis indicated that ADHD diagnosis status significantly changed across treatment, p < .05. (The McNemar test was not applicable for analysis of ODD diagnosis change across treatment due to the lack of variability in ODD diagnosis status at pretreatment.) Frequency data indicated that, predictably, 100% of participants in each group met criteria for ODD at pretreatment, whereas 4 (17%) in the ODD only and 3 (20%) in the comorbid ODD and ADHD group met criteria for ODD at posttreatment. Expectedly, no 48
49Table 3. Cronbachâ€™s Alphas for Outcome Measures at Both Assessment Points ____________________________________________________________________________________________________________ Pretreatment Posttreatment _____________________ _____________________ Instrument Scale Diagnostic Group n Cronbachâ€™s Alpha n Cronbachâ€™s Alpha ____________________________________________________________________________________________________________ ECBI Intensity Scale ODD 22 .81 23 .90 ODD+ADHD 17 .65 16 .94 PS Overreactivity Factor ODD 23 .55 22 .59 ODD+ADHD 17 .81 16 .66 SCS-T Total Score ODD 17 .98 13 .97 ODD+ADHD 10 .87 9 .95 ____________________________________________________________________________________________________________ Note. ECBI = Eyberg Child Behavior Inventory. PS = Paren ting Scale. SCS-T = Social Competency Scaleâ€”Teacher Report.
50Table 4. Inter-observer Reliability of REDSOCS and DPICS-II Category Codes ____________________________________________________________________________________________________________ Category Code Pretreatment Posttreatment ____________________________ ____________________________ Percent Agreement Kappa Percent Agreement Kappa ____________________________________________________________________________________________________________ REDSOCS Percent Inappropriate Behavior 72% .69 77% .78 DPICS-II Mother Verbalizations Direct Command 68% .62 77% .73 Indirect Command 70% .66 71% .69 DPICS-II Child Verbalizations Compliance 82% .75 88% .76 No Opportunity to Comply 85% .68 80% .68 ____________________________________________________________________________________________________________
51 children in the ODD only group and 100% of the children in the comorbid group met criteria for ADHD at pretreatment, whereas 2 (9%) in the ODD only and 4 (29%) in the comorbid ODD and ADHD group met criteria for ADHD at posttreatment. Treatment Outcome Table 5 shows the mean scores of the outcome variables for families in both the ODD only and comorbid ODD and ADHD groups at preand posttreatment assessment points. A General Linear Model (GLM) approach was utilized to determine pretreatment differences between groups and the association between pretreatment diagnosis and treatment outcome. Analyses consisted of 2 (ODD only and comorbid ODD and ADHD groups) X 2 (time) repeated measures Analyses of Variances (ANOVAs), to determine group X time interaction effects and group and time main effects for each outcome measure. Separate ANOVAs were conducted to test each of the theoretically-driven hypotheses regarding the outcome measures. Univariate analyses were chosen because each measure was of independent scientific interest. Although the dependent variables are likely empirically correlated to some extent, ANOVA statistical procedures were chosen over a MANOVA design because of a desire to examine constructs separately. Effect sizes and power were also reported for analyses. The DISC-IV-P ADHD Symptom Count The interaction of time and group was significant, F(1,35) = 8.30, p < .01, 2 = .19, power = .80. Additionally, the main effect of time was significant, F(1,35) = 49.29, p < .01, 2 = .59, power = 1.00.
52Table 5. Mean Scores on Outcome M easures at Both Assessment Points ____________________________________________________________________________________________________________ Pretreatment Posttreatment ________________ ________________ Instrument Scale Group n M SD n M SD ____________________________________________________________________________________________________________ DISC-IV-P ADHD Symptom Count ODD 23 9.43 5.09 22 6.68 5.07 ODD+ADHD 17 14.00 3.28 15 7.07 4.64 ODD Symptom Count ODD 23 5.91 1.16 22 3.50 1.87 ODD+ADHD 17 6.12 1.54 15 2.20 1.82 DPICS-II Percent Child Compliance ODD 23 .53 .22 22 .79 .19 ODD+ADHD 16 .52 .21 16 .73 .20 ECBI Intensity Scale ODD 22 158.91 19.38 23 94.09 20.08 ODD+ADHD 17 171.29 15.74 16 87.44 23.81 REDSOCS Percent Inappropriate Behavior ODD 18 .22 .10 14 .16 .08 ODD+ADHD 10 .34 .15 8 .26 .13 SCS-T Total Score ODD 17 3.17 .92 13 3.07 .81 ODD+ADHD 10 1.97 .40 9 2.32 .66 ____________________________________________________________________________________________________________
53 Overall, children with comorbid ODD and ADHD met criteria for more ADHD symptoms at pretreatment, children in both diagnostic groups met criteria for fewer ADHD symptoms across treatment, and there was no difference between diagnostic groups after treatment. 0246810121416PretreatmentPosttreatmentTimeNumber of Symptoms ODD Alone ODD PlusADHD Figure 1. The DISC-IV-P ADHD Symptom Count The DISC-IV-P ODD Symptom Count The main effect of time was significant, F(1,35) = 79.46, p < .01, 2 = .69, power = 1.00. The interaction of group and time as well as the main effect of group were not significant (see Table 6). Overall, there were no significant differences between diagnostic groups at either time point, but children in both diagnostic groups met criteria for fewer ODD symptoms across treatment.
54 01234567PretreatmentPosttreatmentTimeNumber of Symptoms ODD Alone ODD PlusADHD Figure 2. The DISC-IV-P ODD Symptom Count The DPICS-II Percent Child Compliance The main effect of time was significant, F(1,36) = 33.29, p < .01, 2 = .48, power = 1.00. The interaction of group and time as well as the main effect of group were not significant (see Table 6). Overall, there were no significant differences between diagnostic groups at either time point, but both diagnostic groups improved in percent child compliance across treatment. 00.10.20.30.220.127.116.11.80.9PretreatmentPosttreatmentTimePercent ODD Alone ODD PlusADHD Figure 3. The DPICS-II Percent Child Compliance
55 The ECBI Intensity Scale Score The interaction of time and group was significant, F(1,36) = 4.47, p < .05, 2 = .11, power = .54. The main effect of time was significant, F(1,36) = 268.94, p < .01, 2 = .88, power = 1.00. Overall, children with comorbid ODD and ADHD were rated by their mothers as having more disruptive behavior than children with ODD only at pretreatment, children in both diagnostic groups improved in maternal rating of disruptive behavior across treatment, and there was no difference between diagnostic groups after treatment. 020406080100120140160180PretreatmentPosttreatmentTimeIntensity Scale Score ODD Alone ODD PlusADHD Figure 4. The ECBI Intensity Scale Score The REDSOCS Percent Inappropriate Behavior The main effect of time was significant, F(1,19) = 9.95, p < .01, 2 = .34, power = .85. Additionally, the main effect of group was significant, F(1,19) = 6.45, p < .05, 2 = .25, power = .67. The interaction of group and time was not significant (see Table 6). Overall, children with comorbid ODD and ADHD were endorsed by trained observers as demonstrating a higher percentage of inappropriate behavior than children with ODD
56 only at both preand posttreatment, and both diagnostic groups improved in percent inappropriate behavior across treatment. 00.050.10.150.18.104.22.1680.4PretreatmentPosttreatmentTimePercent ODD Alone ODD PlusADHD Figure 5. The REDSOCS Percent Inappropriate Behavior The SCS-T Total Score The main effect of group was significant, F(1,16) = 9.81, p < .01, 2 = .38, power = .84. The interaction of group and time as well as the main effect of time were not significant (see Table 6). Overall, there was no significant change in social competency across time, but children with ODD only were endorsed by teachers as having better social competence than children with ODD and ADHD at both preand posttreatment. 00.511.522.533.5PretreatmentPosttreatmentTimeTotal Score ODD Alone ODD PlusADHD Figure 6. The SCS-T Total Score
57 Clinical Significance Examination of clinical significance adds to group level results a dimension of meaningfulness of change for the child and family (Kazdin & Kendall, 1998). Group means do not indicate the proportion of families who have recovered due to treatment, and standard statistical comparisons may not reflect the practical importance of treatment effects. In this study, clinically significant change was indicated if the magnitude of change was statistically reliable and if, at the posttreatment assessment, the family returned to normal functioning on the variable of interest (Jacobson, Roberts, Berns, & McGlinchey, 1999). Table 6. Non-significant Results for ANOVA Analyses ________________________________________________________________________ Instrument Scale F df p 2 power ________________________________________________________________________ DISC-IV-P ADHD Symptom Count Group Effect 3.07 1,35 .09 .08 .40 ODD Symptom Count Group Effect 2.39 1,35 .06 .38 .33 Interaction 3.66 1,35 .06 .10 .46 DPICS-II Child Percent Compliance Group Effect .32 1,36 .58 .01 .09 Interaction .32 1,36 .58 .01 .09 ECBI Intensity Scale Group Effect .43 1,36 .52 .01 .10 REDSOCS Percent Inappropriate Behavior Interaction .48 1,19 .50 .03 .10 SCS-T Total Score Time Effect 1.16 1,16 .30 .07 .17 Interaction 1.74 1,16 .21 .10 .24 ________________________________________________________________________ To determine whether the magnitude of change was reliable, I utilized Jacobson and Truaxâ€™s (1991) criteria for the Reliable Change Index (RCI) in order to ensure that the degree of change during therapy was of sufficient magnitude to exceed the margin of measurement error. The RCI was calculated for each treatment completer by subtracting
58 the posttreatment from pretreatment score and dividing by the standard error of the difference between the two scores. Children with a RCI larger than 1.96 were considered to have demonstrated reliable cha nge/improvement (Jacobson et al., 1999). For Jacobson and colleaguesâ€™ (1999) sec ond criteria, I also used Jacobson and Truaxâ€™s (1991) criteria for the Recovery Index (RI). To determine the RI, I first determined the cut-off point for clinically significant change, defined as cut-off scores published by test authors, if they existed. If a childâ€™s posttreatment scores fell below the cut-off, the child was considered recovered. These cut-off values were used to assess posttreatment scores on the depe ndent variables of interest. Clinically significant change scores are listed in Table 7. Of note is that, due to a lack of normative data for the corresponding percentage co mposite score, clinical significance for the DPICS-II child compliance wa s based on using a cut-off of the mean minus 1 SD below the mean of child compliance ra w score normative data averaged for PDI and CU. Overall, all children, ex cept for one in the comorbid ODD and ADHD group, improved on at least one of the six meas ures, and over 87% of the children in the ODD and 71% of the children in the co morbid ODD and ADHD group improved on at least half of the measures. This suggests that the positive results are due to relatively consistent improvements across i ndividual children, ra ther than to a positive response for only a small subsample of the diagnostic groups.
59 Table 7. Number of Participants Demonstrating Clinically Significant Change from Pretreatment to Posttreatment in Each Diagnostic Group Instrument Scale Group n RCI Criterion Cutoff ValueCriterion Clinically Significant Change DISC-IV-P ADHD Symptom Count ODD 22 14 10 7 ODD+ADHD 15 14 6 6 ODD SymptomCount ODD 22 16 10 10 ODD+ADHD 15 14 11 11 DPICS-II Raw Child Compliance ODD 22 13 16 13 ODD+ADHD 16 8 12 8 ECBI IntensityScale ODD 22 22 22 22 ODD+ADHD 16 16 16 16 REDSOCS Percent Inappropriate Behavior ODD 13 7 1 0 ODD+ADHD 8 5 1 1 SCS-T TotalScore ODD 11 4 11 4 ODD+ADHD 7 4 8 4
CHAPTER 4 DISCUSSION Demographic Difference Hypotheses Historically, the majority of literature on disruptive behavior disorders has included male samples (Hinshaw & Park, 1999) or too few girls to allow for separate analyses (Carlson et al., 1997). This study adds to recent growing data examining disruptive behavior disorders in preschool girls. As predicted, no difference was found in child sex between the diagnostic groups. The ratio of boys to girls in each diagnostic group was comparable to approximate 3:2 proportions reported in other preschool samples (e.g., Gadow & Nolan, 2002) and elementary school samples (e.g., Carlson et al.). There was no difference in socioeconomic status between diagnostic groups in the original sample or between diagnostic groups who completed treatment. However, results of the current study support research findings suggestive that low income parents are more likely to drop out of parent training programs (Wahler, 1988). A significant number of families with lower socioeconomic status in the ODD group dropped out of treatment, such that poorer ODD families dropped out of the study. Also a trend was found for lower SES families in the ODD plus ADHD group to drop out, such that, again, poorer families overall tended to drop out. This finding indicates that, although major steps were taken to ensure the retention of these families by addressing known reasons for drop out (e.g., providing opportunities for parents to discuss life concerns beyond child management, sending birthday and holiday cards to families, and providing 60
61 monetary incentives to families in the form of sibling child care, transportation, parking, and gas money) (Black & Holden, 1995; Capaldi & Patterson, 1987; Eyberg, Edwards, et al., 1998; Prinz & Miller, 1984), further exploration of how to meet patientsâ€™ SES-related needs is warranted in order to address potential barriers to treatment. Contrary to that hypothesized, no difference was found in child age between groups at pretreatment. Although research has shown an earlier age of onset for children with comorbid ODD/CD and ADHD than for children with just ODD/CD (August & Stewart, 1982; Biederman et al., 1996; Paternite, Loney, & Roberts, 1995; Stewart & Behar, 1983; Sullivan, Kelso, & Stewart, 1990), closer examination reveals that these studies used retrospective parent recall to assess the age at which disruptive behavior first emerged. Additionally, participants in four of the studies were exclusively boys, and the fifth study included only 6 girls, so such results may not be fully representative of populations including girls. Whereas age-related findings of the current study are not consistent with what would be predicted from many of these earlier studies, results of this study are consistent with more recent research findings for preschoolers with similar demographics in both community and clinic settings (Gadow & Nolan, 2002). As predicted, no difference was found between diagnostic groups in estimated parent IQ. The lack of difference in estimated child verbal IQ between groups was unexpected given consistent research findings that children with comorbid ODD/CD and ADHD demonstrate lower IQ, including verbal IQ, than children with ODD/CD only (e.g., Waschbusch, 2002). Of note is that Goldstein (1987) indicated that additional factors may need to be taken into account when interpreting these IQ results, such that poor verbal ability may be specific to children with attentional difficulties. Consistent
62 with Nolan et al. (2001), Barkley (2003) reports that preschool-age ADHD is typically exemplified by more hyperactivity-impulsivity whereas ADHD subtypes requiring the presence of inattention have onsets occurring at later ages than fully captured by the present study (Combined Type: ages 5-8; Inattentive Type: ages 8-12). Nevertheless, Goldsteinâ€™s (1987), Nolan and colleaguesâ€™ (2001), and Barkleyâ€™s (2003) results do not explain the findings of the current study, as the difference found in estimated verbal IQ between children with ODD/CD only and comorbid ODD/CD and ADHD has been extended to the preschool age (Speltz et al., 1999). Although Speltz et al. (1999) found differences in verbal IQ using the original PPVT with a population of preschoolers diagnosed with ODD, their study was unclear as to whether participants were screened for CD. Considering subtypes of the comorbid state is important because children with comorbid ADHD/CD differ from children with comorbid ADHD/ODD in that the former demonstrate decreased general IQ (August, Realmuto, Joyce, & Hektner, 1999), as well as lower verbal IQ specifically (Waschbusch, 2002). Thus, the current studyâ€™s comorbid ODD and ADHD group might not differ from the ODD group as much as they would if they met criteria for CD instead of ODD. [Additionally, a preliminary comparison of the original 98 participants in this study, in which participants with a diagnosis of CD were not ruled out, indicated that children with comorbid ODD/CD and ADHD did demonstrate a trend toward lower PPVT-III estimated verbal IQ scores (M = 100.20, SD = 13.06) than children with ODD/CD only (M = 104.73, SD = 1.52), t(95) = 1.88, p = .06. Such a result supports the soundness of the current studyâ€™s absent finding.] Many studies have examined verbal IQ difference between ADHD only and comorbid ODD/CD and ADHD as well as between ODD/CD only and comorbid
63 ODD/CD and ADHD (Waschbusch, 2002). However, there has been limited research, and particularly in the preschool population, that has examined verbal IQ differences between ODD only and comorbid ODD and ADHD while partialing out effects of CD. Consequently, this study extends the current literature regarding the effect of (or lack thereof) ADHD comorbidity on estimated verbal IQ in preschoolers with ODD only. Further investigation is warranted in order to ensure the stability of the current studyâ€™s finding and to evaluate potential confounds unique to this study. Research has documented inconsistent race findings amongst diagnostic groups (Lahey, Miller, Gordon, & Riley, 1999), and I predicted no difference in child race between preschoolers with ODD only and those with comorbid ODD and ADHD. However, results of the current study indicated that all non-Caucasian children were in the ODD plus ADHD comorbid group except for 1 child. The findings of this study are consistent with Gadow and Nolanâ€™s (2002) study in which 100% of their clinical sample of Head Start preschoolers with ODD only were Caucasian while their Head Start preschoolers with comorbid ODD and ADHD were 50% Caucasian. (The result did not hold for their comparison community sample of preschoolers.) In a study of teacher report of symptomatology, Nolan et al. (2001) found that, for all age groups (3-5, 6-12, and 13-18), a significantly higher percentage of African American children were rated as meeting screening criteria for ADHD than Caucasian children. Research has indicated that minorities may be over-diagnosed as a result of race bias on the use of diagnostic criteria by clinicians (Garb, 1998). Alternative, compared to Caucasians, African Americans and Latinos have demonstrated a reluctance to seek mental health treatment for their children (McMiller & Weisz, 1996). Many
64 people from different cultures see mental illness as shameful and delay treatment until symptoms reach crisis proportions (Surgeon General, 2000). Such research is consistent with the current studyâ€™s finding of more minorities in the diagnostic group identified as having greater problems at pretreatment, the comorbid ODD and ADHD group. Thompson, Bazile, and Akbar (2004) identified key barriers to service utilization amongst minorities, including stigma, lack of knowledge, lack of affordability, lack of trust, impersonal service, and lack of cultural understanding. There is a call for research regarding empirical data on syndromes in children and on the cultural mechanisms that may explain onset and prognosis of these disorders (Canino, Canino, & Arroyo, 1998) as well as a need to analyze differential attitudes toward and utilization of mental health services amongst individual minority groups. The significant racial difference between groups held when all 98 children were preliminarily analyzed. Of 24 minorities in the entire current study, only 3 minorities were in either the ODD only or comorbid ODD and CD groups, indicating a stable finding across both ODD and ODD/CD preschoolers. Complications of interpreting results surrounds this interesting finding: the nonequivalence of the ODD only and comorbid ODD and ADHD group at pretreatment with regard to race indicates that differences in demographics or treatment outcomes between groups cannot be interpreted independent of race. However, one can identify that, despite race or diagnosis, both groups improved across treatment in all areas except social competence. Diagnostic Hypotheses Frequency data indicated that approximately only a fifth of the participants, regardless of diagnostic group, met criteria for ODD after PCIT. Additionally, a tenth of the children in the ODD only group met diagnostic criteria for ADHD at posttreatment
65 while less than a third of the participants in the comorbid ODD and ADHD group continued to meet criteria for ADHD at posttreatment. Thus, the current study extends support for the use of PMT, particularly via PCIT, with ADHD symptoms when comorbid with ODD. Further studies in which an additional ADHD only group is included in analyses are needed in order to more fully untangle effects of PCIT on each diagnosis as it compares to a comorbid group. Treatment Outcome Hypotheses The treatment outcome hypothesis related to parenting stress was unable to be analyzed due to compromised internal consistency in the Overreactivity Factor of the Parenting Scale. The rest of the treatment outcome results for each measure are examined individually in this section and are then summarized in a general discussion to follow. Diagnostic groups did not differ at posttreatment on any measures except those directly assessing behaviors in the school setting; this finding is discussed in the general discussion section. The DISC-IV-P ADHD Symptom Count Predictably, and consistent with literature findings of increased overall symptom severity in children with comorbid ODD and ADHD beyond those in children with ODD only (Gadow & Nolan, 2002; see also Hinshaw, 1999), participants in the comorbid ODD and ADHD group were endorsed by mothers as having a significantly higher DISC-IV-P ADHD symptom count than the ODD only group at pretreatment. This finding is far from unexpected due to the nature of criteria differentiating the diagnoses of ADHD and ODD. As hypothesized, both children with ODD only and those with comorbid ODD and ADHD improved in ADHD symptom counts across treatment. This result is consistent
66 with research suggesting that PCIT is appropriate for working with children who have overactive characteristics associated with ADHD (Hembree-Kigin & McNeil, 1995; Nixon, 2001). PCIT directly addresses problematic behavior via improving the parent-child interaction and teaches parents specific skills to improve such behavior. Findings from the current study indicate that results hold for the comorbid ODD and ADHD group. The DISC-IV-P ODD Symptom Count Whereas research has shown that children with comorbid ODD and ADHD typically have more ODD problems than do children with ODD only (see also Hinshaw, 1999), no difference was found in the DISC-IV-P ODD symptom count between groups at pretreatment. This unpredicted result is unlikely due to the restricted range in study inclusion criteria (between 4 and 8 DISC-IV-P symptoms) because other studies have found differences in ODD symptom counts (e.g., Biederman et al., 1996). The finding may be reflective of age-related differences in symptom severity between preschoolers versus older children, such as those participants used by Biederman et al. Alternatively, the null finding may reflect a difference in methodology used to assess ODD symptom counts. For example, the current study calculated symptom counts from the DISC-IV-P whereas Biederman et al. utilized the Structured Clinical Interview for DSM-III-R (SCID). Further investigations accounting for diagnostic assessment methodology are warranted in order to rule out potential methodological confounds in the current study. As predicted, both diagnostic groups improved in DISC-IV-P ODD symptomatology across treatment. The current study thus replicates a history of research documenting a decrease in ODD as a result of participation in PCIT. PCIT directly addresses ODD symptomatology via teaching parents specific skills to decrease negative
67 behavior associated with disruptive behavior disorders, and results hold for preschoolers with comorbid ODD and ADHD. The DPICS-II Percent Child Compliance Similar to the DISC-IV-P ODD symptom count, and not as predicted, there was no difference between diagnostic groups in DPICS-II percent child compliance to maternal commands at preor posttreatment. Perhaps measurement of child compliance taps into the dimension of oppositional behavior only and assessment of this symptom is not adequately sensitive for capturing the additive effects of ADHD-related difficulties with focus and inattention. More likely, though, is that the amount of inattention and difficulty with focus that would be needed to significantly differentiate the preschooler groups is not significantly greater than the problems with focus and attention that are seen in a lesser degree in non-ADHD preschoolers. Similar to the DISC-IV-P ODD symptom count, the null finding may be reflective of age-related differences in symptom severity between preschoolers versus older children, such as those participants used by Biederman et al. (1996). As discussed above, Barkley (2003) and Nolan et al. (2001) indicate that preschool-age ADHD is typically exemplified by more hyperactivity whereas ADHD subtypes meeting inattention diagnostic criteria have onsets occurring at later ages than fully captured by the present study. Future investigation utilizing an ADHD only comparison group will be helpful to disentangle potential methodological confounds of the current study. As hypothesized, both children with ODD only and those with comorbid ODD and ADHD improved in observational ratings of child compliance to commands across treatment. The current study replicates findings indicating that youngsters with disruptive behavior disorders improve in DPICS-II percent child compliance after
68 participating in PCIT (Eisenstadt et al., 1993; McNeil et al., 1991; Nixon et al., 2001). PCIT involves teaching parents specific skills to increase child compliance, and results hold for the comorbid ODD and ADHD group. The ECBI Intensity Scale Score As predicted, and consistent with literature findings of increased overall symptom severity in children with comorbid ODD and ADHD beyond those in children with ODD only (Gadow & Nolan, 2002; see also Hinshaw, 1999), the comorbid ODD and ADHD group demonstrated worse scores than the ODD only group on maternal ratings of disruptive behavior at pretreatment. Also, as hypothesized, both children with ODD only and those with comorbid ODD and ADHD improved in ECBI Intensity Scale ratings across treatment. This result is consistent with multiple PCIT studies documenting improvement in child disruptive behavior across treatment, including better ECBI scores in particular. PCIT directly addresses disruptive behaviors via improving the parent-child interaction and teaches parents specific skills to improve disruptive behavior, and findings from the current study indicate that results hold for preschoolers with comorbid ODD and ADHD. The REDSOCS Percent Inappropriate Behavior As predicted, and consistent with literature findings of increased overall symptom severity in children with comorbid ODD and ADHD beyond those in children with ODD only (Gadow & Nolan, 2002; see also Hinshaw, 1999), the comorbid ODD and ADHD group demonstrated a significantly higher REDSOCS percentage of inappropriate behavior than the ODD only group at both preand posttreatment. Additionally, both diagnostic groups improved in their percentage of inappropriate behavior scores across treatment. These results are consistent with McNeil and colleaguesâ€™ (1991) finding of
69 improvement in REDSOCS classroom inappropriate behavior across PCIT with preschoolers and early elementary children who have disruptive behavior in general. However, the findings of the current study go one step further by disentangling treatment effects on children with ODD only as well as those with comorbid ODD and ADHD. Further research including an ADHD only group will be helpful for elucidating effects unique to that diagnostic group. The SCS-T Total Score Children, despite diagnostic status, improved across treatment in all treatment outcome measures except the SCS-T. As predicted by research that has shown that children with comorbid ODD and ADHD typically have more difficulty with social competency and peer acceptance (as rated by parents) than those with ODD only (Gadow & Nolan, 2002; Milich & Landau, 1989), preschoolers in the comorbid group were rated by teachers as demonstrating worse social competence than those in the ODD only group at both preand posttreatment. Unfortunately, neither diagnostic group appeared to improve in social competency across treatment, as had been predicted. The lack of change is not likely interpretable as a lack of measurement sensitivity to treatment changes because Webster-Stratton (1998) has shown the SCS-T is sensitive to treatment effects in preschoolers. McNeil and colleaguesâ€™ (1991) study of preschoolers and early elementary school age children indicated that their PCIT group participants did display more advanced social competencies after treatment. However, because the PCIT group did not demonstrate better social behavior than control children at posttreatment, they concluded a lack of treatment effects in peer relationships and hypothesized that social gains may be attributable to regression to the mean, normal maturational changes in social
70 development, or instability of retest scores on the measure of young children. The current study does not replicate McNeil and colleaguesâ€™ finding of improved social competency but appears to support the notions that, as McNeil et al. proposed, PCIT may not generalize beyond behavior problems or, very likely, second-order generalization first to school and then to peer socialization skills may take longer to achieve than the length of PCIT treatment. Future research involving follow-up assessments is needed to answer such a question. General Discussion Regarding pretreatment scores, a pattern emerged in which worse scores in the comorbid ODD and ADHD group might have been due to endorsement of salient ADHD-related symptomatology above and beyond symptoms associated with ODD alone. More specifically, the preschoolers in the comorbid ODD and ADHD group differed from their ODD-only counterparts on measures including ADHD-related items, as opposed to the DISC-IV-P ODD symptom count and DPICS-II percent child compliance in which scores were seemingly confined to the dimension of oppositional behavior only. Consistent with the literature (Waschbusch, 2002), the comorbid ODD and ADHD group appeared to have more problems in general, as supported by worse scores on more measures at pretreatment. Findings from this study indirectly support the notion that the greater severity and pervasive nature of symptomatology in comorbid ODD and ADHD are attributable to a cumulative effect, as opposed to an interactional effect (Waschbusch, 2002). Again, future research including an ADHD only group is needed to elucidate treatment effects unique to that diagnostic group. McNeil et al. (1991) proposed that PCIT may be less effective for the treatment of ADHD than for ODD/CD and called for future study of the differential responsiveness of
71 children in these diagnostic categories. The current study partially met this demand and concludes that, as compared to children with ODD only, PCIT does generalize to the treatment of several symptoms of ADHD in children with comorbid ODD and ADHD. Moreover, treatment outcome measures that distinguished diagnostic groups at pretreatment, in that the comorbid ODD and ADHD group performed worse, did not do so at posttreatment except in the school setting. Overall, both groups improved across treatment in all areas except social competency. The lack of change in social competency is explained above. Although both groups improved in school-related inappropriate behavior across treatment, the differential school performance between groups at posttreatment may reflect a differential generalization of treatment of ADHD-related symptoms in the school setting. Future research is needed to justify this tentative conclusion. [Additionally, analyses comparing children who participated in school-related treatment outcome measures (REDSOCS and SCS-T) versus those who did not found no differences between groups in demographic data or on any treatment outcome measures (see Appendix)]. Treatment outcome scores amongst diagnostic groups were originally hypothesized to differ at posttreatment because children with comorbid ODD and ADHD have demonstrated worse treatment outcomes than for those with ODD only (Carlson et al., 1997). However, this hypothesis seems to lack support after considering the mostly null findings for posttreatment differences in the current study as well as lack of difference between groups found in psychosocial treatment outcome studies when less stringent criteria are utilized to define ODD/CD and comorbid ODD and ADHD groups (e.g., Hartman, Stage, & Webster-Stratton, 2003; Webster-Stratton, Reid, & Hammond, 2001).
72 This study was designed to analyze a â€œpureâ€ ODD sample without comorbid CD. Such a design is a strength of the study in that results contribute to the literature by filling in gaps regarding treatment outcome studies of ODD and its comorbidity with ADHD. Another strength of the current study is the use of Jensen and colleaguesâ€™ (1996) research criteria in that results add to the growing literature using more stringent criteria for establishing diagnoses and subsequently allowing for a better empirical understanding of the nature and severity of disruptive behavior disorders in preschoolers. However, I may have subsequently underestimated diagnoses. Diagnostic status was based on the data of multiple raters, thus reducing potential bias based on rater effects. Findings from this study were obtained using three different methods of measurement in multiple settings (i.e., mother report, teacher report, and laboratory and classroom observations by trained independent raters), and improvement in treatment outcomes was not limited to a particular method of measurement or rater. Additionally, data were analyzed with both statistical and clinical significance testing. Statistical significance testing indicated that children improved overall, but clinical significance testing suggested that certain such improvements did not meet normal-range standards. Change scores on several individual measures were not impressive; for example, some children still had clinically significant levels of ODD and ADHD symptomatology at posttreatment. However, statistical significance testing indicated that children were not meeting ODD and ADHD diagnostic criteria after PCIT. The two versions of significance testing are not in direct conflict in that children may have continued to meet the threshold number of symptoms for a diagnosis, but results suggest that additional diagnostic criteria, such as the requirement for symptomatology to cause
73 clinically significant impairment in functioning, were not being met. Overall, a majority of children improved on at least half of the measures, thus suggesting the effectiveness of PCIT in achieving improvements that are meaningful in the daily lives of families. The positive behavior changes in both preschoolers with ODD only and those with comorbid ODD and ADHD can be considered additional evidence for the overall effectiveness of PCIT. Limitations Several methodological limitations must be considered for this study. First, children in the comorbid ODD and ADHD group were anticipated to and did demonstrate greater problems in more treatment outcome measures before treatment than did the ODD only group. There is a possibility that greater behavioral change in the comorbid group (when groups differed at pretreatment but did not differ at posttreatment) could be attributed to regression toward the mean because they had more room for improvement. Subsequently, results may be due more to a regression artifact than to treatment effects (Hsu, 1989). However, the comorbid ODD and ADHD group was not consistently worse on all treatment outcome measures at pretreatment, and improvement in scores was not constant across measures that differentiated groups at pretreatment. Additionally, change in the posttreatment scores exceeded the estimated magnitude of potential regression to the mean (Hopkins, 2000), suggesting true change in the treatment outcome measures. In light of these reasons, there appears to be less evidence to believe that better outcomes in the comorbid ODD and ADHD group after treatment are due to regression to the mean. An alternative explanation is that results may be reflective of strong effects of PCIT, particularly in non-school settings.
74 A second limitation is that the combination of numerous statistical analyses and a relatively small sample size may have resulted in Type I and Type II errors, respectively. Testing multiple hypotheses at a set alpha level increases the expected number of Type I errors (Finner & Roters, 2002). Some findings may have achieved statistical significance by chance. The results of the current study may be considered tentative until they are replicated in a larger sample of preschoolers with guaranteed power to ensure the reliability of results. Future Directions In addition to the above-mentioned need for further PCIT outcome studies comparing not only ODD only and comorbid ODD and ADHD groups but also including an ADHD only group, and the need for follow-up analyses of results, there is a need for continued work in the area of distinguishing clinical features of comorbidity from underlying disorders. Additionally, the results of the current study indirectly contribute to the controversial debate regarding the appropriateness of differentiating ODD from CD in preschoolers by identifying a distinguishing feature, estimated verbal IQ, at least when comorbid with ADHD. Further studies, such as that of Brinkmeyer (2005), are needed to more adequately assess the clinical presentation differences between and the effects of treatment, specifically PCIT, on preschoolers meeting diagnostic criteria for either ODD or CD.
APPENDIX SCHOOL-RELATED COMPARISONS Table A-1. Comparison of Pretreatment Demographic Data for Treatment Completers Completing School-related Treatment Outcome Measures Versus Those Who Did Not ________________________________________________________________________ School versus Non-school _____________________ n M SD Minimum Maximum t or 2 df p ________________________________________________________________________ Age 40 4.55 1.06 3.00 6.00 -1.96 38 .06 School 30 4.73 .98 3.00 6.00 Non-School 10 4.00 1.15 3.00 6.00 Child Sex 40 â€“ â€“ â€“ â€“ .04 1 .85 School 30 â€“ â€“ â€“ â€“ Non-School 10 â€“ â€“ â€“ â€“ Child Race 40 â€“ â€“ â€“ â€“ 5.50 4 .24 School 30 â€“ â€“ â€“ â€“ Non-School 10 â€“ â€“ â€“ â€“ Child IQ 40 103.55 11.58 83.00 129.00 1.52 38 .14 School 30 101.97 10.36 83.00 128.00 Non-School 10 108.30 14.22 88.00 129.00 Mother IQ 39 108.97 10.74 88.00 134.00 1.32 37 .20 School 29 107.66 11.45 88.00 134.00 Non-School 10 112.80 7.58 104.00 128.00 Father IQ 21 111.33 12.99 85.00 132.00 1.10 19 .28 School 17 109.82 12.42 85.00 128.00 Non-School 4 117.75 15.33 97.00 132.00 Hollingshead 40 43.48 12.04 17.00 66.00 .65 38 .52 School 30 44.33 11.58 17.00 66.00 Non-School 10 40.90 13.66 20.00 59.00 ________________________________________________________________________ 75
Table A-2. Mean Scores on Outcome Measures at Both Assessment Points for Treatment Completers Completing School-related Treatment Outcome Measures Versus Those Who Did Not ____________________________________________________________________________________________________________ Pretreatment Posttreatment ________________ ________________ Instrument Scale Group n M SD n M SD ____________________________________________________________________________________________________________ DISC-IV-P ADHD Symptom Count School 30 10.97 4.84 28 7.11 5.09 Non-School 10 12.60 5.23 9 6.00 4.12 ODD Symptom Count School 30 6.00 1.29 28 3.29 1.92 Non-School 10 6.00 1.49 9 2.00 1.73 DPICS-II Percent Child Compliance School 29 .53 .23 28 .75 .21 Non-School 10 .50 .19 10 .79 .16 ECBI Intensity Scale School 30 162.10 17.24 29 93.69 22.63 Non-School 9 171.67 22.57 10 84.60 17.77 REDSOCS Percent Inappropriate Behavior School 28 .26 .13 22 .20 .11 76 Non-School â€“ â€“ â€“ â€“ â€“ â€“ SCS-T Total Score School 27 2.72 .96 21 2.78 .85 Non-School â€“ â€“ â€“ â€“ â€“ â€“ ____________________________________________________________________________________________________________
77 Table A-3. ANOVA Analyses Results for Comparisons of Treatment Completers Completing School-related Treatment Outcome Measures Versus Those Who Did Not ________________________________________________________________________ Instrument Scale F df p 2 power ________________________________________________________________________ DISC-IV-P ADHD Symptom Count Time Effect 40.70 1,35 <.01* .54 1.00 Group Effect .03 1,35 .86 <.01 .05 Interaction 3.48 1,35 .07 .09 .44 ODD Symptom Count Time Effect 70.15 1,35 <.01* .67 1.00 Group Effect 1.51 1,35 .23 .04 .22 Interaction 2.62 1,35 .11 .07 .35 DPICS-II Child Percent Compliance Time Effect 31.88 1,36 <.01* .47 1.00 Group Effect .05 1,36 .82 <.01 .06 Interaction .38 1,36 .54 .01 .09 ECBI Intensity Scale Time Effect 204.57 1,36 <.01* .85 1.00 Group Effect <.01 1,36 .94 <.01 .05 Interaction 1.32 1,36 .26 .04 .20 ________________________________________________________________________ Note. *p < .05. p < .10
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BIOGRAPHICAL SKETCH Erin Marie Floyd was born December 24, 1977, at Fort Ord, California, to Dr. Richard S. and Elaine M. Neary. She majored in psychology with a minor in statistics at the University of Georgia (UGA). A member of the Honors Program at UGA, Erin obtained the William T. James Award for the outstanding senior undergraduate psychology major and the Judge Horace B. Russell Prize for the best-written undergraduate work in psychology. She graduated summa cum laude, with highest honors, First Honor Graduate, with a Bachelor of Science degree in May 2000. In July of the same year, Erin entered the Clinical and Health Psychology doctoral program at the University of Florida. She obtained her Master of Science degree in Psychology in May 2002 and won the Graduate Deanâ€™s Scholar Award for the most outstanding graduate student in the College of Health Professions. She completed her internship at the Medical College of Georgia/Department of Veterans Affairs Consortium in Augusta, GA. Erin intends to complete a clinical child psychology postdoctoral fellowship at the Medical College of Georgia and work in the field of clinical child psychology. 97