SOCIAL COMPETENCE DEFICITS IN PRESCHOOLERS WITH ADHD AND ODD

Transcription

1 SOCIAL COMPETENCE DEFICITS IN PRESCHOOLERS WITH ADHD AND ODD By NICOLE CHRISTINA GINN A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA

2 2010 Nicole C. Ginn 2

3 To my family for being a continual source of support, encouragement, hope, and laughter 3

4 ACKNOWLEDGMENTS First and foremost, I would like to thank Dr. Sheila Eyberg for her continued guidance, unwavering support, and enthusiasm for my ideas throughout this project. I would also like to thank Drs. Stephen Boggs and Regina Bussing for their invaluable feedback. I am also grateful to the members of the Child Study Lab for their advice, labeled praises, and inspiration that there is a light at the end of the tunnel. Finally, I would like to thank the members of my committee, Dr. Glenn Ashkanazi, Dr. Rus Bauer, and Dr. Stephen Boggs, for their thoughts and suggestions on this manuscript. This project was funded by generous grants from the National Institute of Mental Health (R01 MH60632, R01 MH072780). 4

5 TABLE OF CONTENTS ACKNOWLEDGMENTS... 4 LIST OF TABLES... 6 LIST OF FIGURES... 7 ABSTRACT... 8 CHAPTER 1 INTRODUCTION METHODS page Participants Measures Procedure Assessments Treatment RESULTS PCIT And Social Competence Comorbid Diagnoses and Social Competence Behaviors Associated with Social Competence DISCUSSION Limitations Future Directions LIST OF REFERENCES BIOGRAPHICAL SKETCH

6 LIST OF TABLES Table page 2-1 Participant Demographic Characteristics from Study A and B Participant Demographic Characteristics for Children with Single and Dual Diagnoses Pre to Post Treatment Changes in Social Competence Percentage of Children in Normal, Borderline, and Clinical Range for Social Competence Problems at School

7 LIST OF FIGURES Figure page 3-1 Changes in Social Competence Changes in Social Competence in Children with Single and Dual Diagnoses

8 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science SOCIAL COMPETENCE DEFICITS IN PRESCHOOLERS WITH ADHD AND ODD Chair: Sheila M. Eyberg Major: Psychology By Nicole Christina Ginn May 2010 Children diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) or Oppositional Defiant Disorder (ODD) are likely to have significant deficits in social competence and to be rejected by their peers, to be less popular, and to have fewer friends than control children. Children diagnosed with comorbid ADHD and ODD show greater deficits in social competence than children diagnosed with either ADHD or ODD alone. It is unclear, however, which behavioral components associated with these disorders contribute to deficits in social competence. This study examines the association between children s participation in Parent- Child Interaction Therapy (PCIT) and social competence. It was hypothesized that children would show an increase in social competence following treatment and that higher levels of hyperactive and oppositional behaviors would be associated with lower social competency before treatment. It was further hypothesized that children with comorbid diagnoses would exhibit lower social competence before treatment and less improvement after treatment than children with single diagnoses. Results with 42 children ages 3 to 6 provided support for the primary hypothesis. Across all children, social competence increased after completing PCIT. In addition, higher levels of oppositional behavior, but not hyperactive behavior, predicted lower social competence at pre-treatment. No significant differences, however, were found between 8

9 single- versus dually-diagnosed children at either pre- or post treatment. These findings provide evidence supporting the effectiveness of PCIT for improving social competence deficits in children with ADHD and ODD. 9

10 CHAPTER 1 INTRODUCTION Two of the most common disorders diagnosed in preschool and elementary age children are Attention Deficit Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD). Children with a diagnosis of ADHD are described as exhibiting hyperactive, impulsive, and/or inattentive behaviors at developmentally inappropriate levels such that they significantly interfere with the child s daily functioning (American Psychiatric Association, 2000). The defining features of ODD include negativistic, defiant, disobedient, and hostile behavior toward authority figures (Fossum, Morch, Handegrad, & Drugli, 2007). With some studies estimating that nearly 3-5% of preschool and elementary school age children meet criteria for ADHD and 7-25% meet criteria for ODD, continued research aimed at better understanding these behavior disorders and their impact on children s functioning is imperative (APA, 2000; Offord, Alder, & Bolder, 1986). Children with disruptive behavior problems often experience deficits in social competence, which refers to socially adaptive prosocial behaviors and positive peer relations (Landau & Milich, 1990; Frederick & Olmi, 1994; Henker & Whalen, 1999; Pelham & Bender, 1982; Schachar & Wachsmuth, 1990). Children with ADHD and ODD are typically rejected, nominated as liked least, and categorized as unpopular by their peers (Campbell, 1991; Landau & Moore, 1991; Nijmeijer et al., 2008; Pope, Bierman, & Mumma, 1989). Both teachers and parents rate children with ADHD or ODD as having poorer peer relations and fewer close friendships than control children (Hoza, Mrug, et al. 2005; Nijmeijer et al., 2008). However, children in these two diagnostic groups differ in the types of social functioning deficits they exhibit (Matthys, Cuperus & Van Engeland, 1999). For example, Frankel and Feinberg (2002) found that children with ADHD show more disruptive behavior towards peers whereas children 10

11 with ODD show more hostility and disrespect towards peers as well as adults. Children with ODD also have more peer conflicts and demonstrate more impaired social problem solving skills than children with ADHD, suggesting that social impairments may be more severe in children with a diagnosis of ODD than with ADHD (Gadow & Nolan, 2002; Matthys et al., 1999). The comorbidity of ODD and ADHD ranges from 30-50% in preschool and elementary school children, and not surprisingly more severe problems with social competence are seen in children with both ADHD and ODD (Frankel & Feinberg, 2002; Gadow & Nolan, 2002; Kuhne, Russell, & Tannock, 1997; Spencer, 2006). These deficits have been found to be additive, with children with comorbid diagnoses showing a combination of the unique social deficits and peer problems associated with ADHD and ODD (Frankel & Feinberg, 2002). In a study conducted by Kuhne and colleagues (1997) children with comorbid diagnoses were more likely to be rated by their parents as participating in fewer social activities, having either one or no best friends, and evidencing more loneliness than children with a single ODD or ADHD diagnosis or even children with comorbid ADHD and Conduct Disorder. Children with comorbid ODD and ADHD also show more resistance to treatment effects than singly diagnosed children (Antshel & Remer, 2003; Landau, Milich, & Diener, 1998). With rates of comorbidity increasing, it is increasingly important to investigate the social competence deficits and treatment effects in children with comorbid diagnoses of ADHD and ODD. Children with ODD or ADHD combined with peer problems have even more negative outcomes than those without peer problems (Hoza, Gerdes, et al., 2005). These outcomes include delinquency, substance abuse, academic problems, and school drop out. Problematic peer relations are also associated with the development of additional psychopathologies and higher rates of psychiatric hospitalization (Hoza, Gerdes, et al., 2005; Parker & Asher, 1987). 11

12 Furthermore, children with comorbid ADHD and ODD experience higher rates of delinquency and academic underperformance than children with a single diagnosis of ADHD (Faraone, Biederman, Keenan, & Tsuang, 1991; Loney, Kramer, & Milich, 1981). The association between social competence and maladaptive outcomes continues into adolescence and adulthood. Children who are peer rejected at a young age often have less opportunity to develop their social skills through modeling and practice, which leads to continued peer rejection (Barkley, 1997). With age, peer-rejected children become more cognizant of their rejection, which is related to higher rates of internalizing disorders, especially mood and anxiety disorders, in adolescents with diagnoses of ADHD or ODD (Biederman et al., 2006; Rubin, 1993). These negative outcomes often persist into adulthood. Adults with ADHD frequently report increased rates of depressive feelings and isolation even though many of their ADHD symptoms have decreased over time (Weiss & Hechtman, 1986). Adolescents and adults with childhood diagnoses of ADHD also engage in school and community activities less frequently than controls and have less adaptive occupational outcomes as well (Mannauzza, Klein, Bonagura, Konig, & Shenker, 1988; Parker & Asher, 1987). Although it is well established that problems in social functioning and maladaptive outcomes frequently co-occur with diagnoses of ADHD and ODD, the specific behaviors and mechanisms that contribute most significantly to these social deficits remain unclear (Hoza, Gerdes, et al., 2005). Previous studies have examined the inattentive behaviors often associated with diagnoses of ADHD as possible contributors to social problems and suggest that children with this diagnosis listen less, are frequently off-task, and benefit less from modeling and observing social behaviors in other children due to their inattentiveness (Landau & Milich, 1988). Research has shown evidence of some association between inattentiveness and peer 12

13 rejection; however, more recent studies have focused less on these behaviors and more on children with ADHD and ODD s patterns of interaction with other children (Hoza, Gerdes, et al., 2005; Pope et al., 1989). Children with ADHD often exhibit a pattern of social interaction that is frequently characterized by hyperactive and impulsive behaviors that often include having problems waiting for their turn, interrupting or butting in on others, asking a lot of questions, shouting, and appearing more socially active overall (APA, 2000; Barkley, 1997). Hyperactive behaviors also contribute to interaction styles characterized as being more uninhibited, controlling, or domineering, which can be associated with higher levels of peer dislike and rejection (Whalen & Henker, 1992). An additional domain of behavior that may further contribute to problems with social competence is the oppositional behavior associated with disruptive behavior disorders. This oppositional pattern of interaction seen in children with ODD and often also in children with ADHD is characterized by rule breaking behaviors, aggressive play, non-compliance towards teachers and authority figures, and dominating and overbearing behaviors with peers and in play situations (Cunningham & Siegel, 1987; Erdhardt & Hinshaw, 1994; Milich & Landau, 1982; Pelham & Bender, 1982). Research has found an association between these oppositional behaviors and peer rejection, but this association remains poorly understood (Erdhardt & Hinshaw, 1994; Pelham & Bender, 1982). It is possible that these hyperactive and oppositional behaviors characteristic of ADHD and ODD function as the primary factors contributing to maladaptive outcomes, however, more research is needed to examine the relationship between these specific behavioral domains and social competence deficits. In addition to limited research on the specific behaviors that contribute to social competence deficits, it also remains unclear which interventions are most effective for improving 13

14 children s social functioning. In general, studies find little change in teacher or peer ratings of social skills following outpatient interventions (Gresham, 1985; Michelson & Wood, 1980). Studies examining the effects of medication used to treat ADHD consistently find that although children often exhibit fewer disruptive and negative behaviors, there is little corresponding increase in positive, more prosocial behaviors in the classroom or in other settings (Hoza, Gerdes, et al., 2005; Landau & Moore, 1991). Further, when children show changes in their social skills during treatment, these changes tend not to generalize to the school or other social settings (Bierman, 1989). For example, social skills training programs have shown limited effectiveness with children exhibiting improved social behaviors within the treatment setting, but only limited generalization of these newly acquired social skills to the child s classroom or social settings (Gresham, 2002; Hoza, Gerdes, et al., 2005). Similarly, behavioral treatments that focus on parent and teacher training in contingency management with token rewards have shown minimal improvements in teacher and peer ratings of social skills, but these gains are limited and still significantly different from normative levels (Pelham & Bender, 1982). Furthermore, in the Multimodal Treatment study of children with ADHD conducted by Hoza, Gerdes, and colleagues (2005), none of children in the treatment groups -- behavior therapy, medication management, or combined treatment-- showed significant reduction in their problems with peers compared with control classmates. It is important, however, to consider the limitations in previous studies examining the effects of various interventions for children s social competence. One of the more consistent limitations in previous studies is the focus on either reducing disruptive behaviors or teaching social skills, rather than combining these targets to improve children s overall social competence. Intervention programs that combine a focus on decreasing disruptive behaviors and increasing 14

15 social skills are much more likely to produce positive results (Hoza, Gerdes, et al., 2005). An additional limitation of previous treatment studies is the use of peer psychometric ratings as an outcome measure. Peer ratings are valid measures of children s social functioning; however, they have also been shown to be extremely stable over time, regardless of actual changes in prosocial behavior with treatment and thus may be less able to capture changes in specific prosocial behaviors following treatment (Hoza, Gerdes, & et al., 2005). Instead, teacher and parent ratings of social behavior have been found to provide the most similar ratings to peer ratings while also serving as a valid measure of specific behavioral changes following treatment. Another limitation of previous studies is the failure to incorporate parental involvement into social skills training programs (Frankel & Feinberg, 2002). Frankel and colleagues (1997) found that peer rejected boys showed increased social skill acquisition when parents were involved in their treatment. The intervention used in this study, Parent-Child Interaction Therapy (PCIT), is an empirically supported treatment for young children with disruptive behavior disorders. PCIT represents an improvement over more singularly focused interventions because it teaches parents skills to decrease their child s behavior problems while also increasing child prosocial behaviors. After completing PCIT, children consistently show decreased disruptive behaviors at home (Boggs, 1990) and in the classroom (McNeil, Eyberg, Eisenstadt, Newcomb, & Funderburk, 1991) that are maintained in both settings over time (Funderburk et al., 1998; Hood & Eyberg, 2003). Additionally, children show increased positive, prosocial behaviors following treatment (Eisenstadt, Eyberg, McNeil, Newcomb, & Funderburk, 1993). PCIT consists of two phases: Child-Directed Interaction (CDI), which focuses on increasing parental warmth and strengthening the parent-child relationship; and Parent-Directed 15

16 Interaction (PDI), which teaches parents a structured and consistent approach to discipline. In CDI, parents learn to follow their child s lead in a play situation while using differential attention to ignore negative behaviors and provide positive attention to prosocial behaviors. In addition to providing positive reinforcement for children s prosocial behaviors, parents also model appropriate sharing and play behaviors with their children. At the completion of PCIT, parents show decreases in criticism as well as increases in prosocial talk and physical warmth towards their child (Eisenstadt et al., 1993). In a study conducted by Webster-Stratton and Hammond (1998), higher levels of parental, especially maternal, praise and physical warmth were positively associated with the development of children s positive social functioning. The increases in maternal praise and warmth in combination with the parental modeling of social behaviors that occurs in PCIT would be expected to lead to increases in children s social competence. In the PDI phase of PCIT, parents learn to give specific, age-appropriate, direct commands to their children and to follow each command with a clear, consistent contingency plan for compliance and non-compliance. Parents are taught to provide positive reinforcement for compliance and a time-out sequence for non-compliance (Herschell, Calzada, Eyberg, & McNeil, 2002). Schuhmann and colleagues (1998) found that following the completion of PCIT, children showed an increase in compliance to parental commands and a decrease in disruptive behaviors in comparison with wait-list controls. As previous research has shown (DuPaul & Henningson, 1993), it is likely that the positive behavioral changes following completion of PCIT would be associated with an increase in social competence. Although the combination of the CDI and PDI phases of PCIT have been related to increases in prosocial behavior and decreases in disruptive behaviors, both thought to be associated with an increase in social competence, little research has been conducted to examine 16

17 the efficacy of PCIT on the social functioning of children with disruptive behavioral disorders. Funderburk and colleagues (1998) found an increase in social competence at 12 months following the completion of PCIT; however, their study was limited by a small sample size and did not investigate differences between single and dually diagnosed children. It is important to investigate the effects of PCIT on the social competence of children with single and dual diagnoses using a larger, more representative sample. This study examined the effects of Parent-Child Interaction Therapy on teacher-reports of social competence and adaptive functioning of children with ADHD and ODD. We examined the effectiveness of PCIT for treating deficits in social functioning and hypothesized that children would show a significant increase in teacher rated social competence after the completion of treatment. We also investigated differences in social competence between children with a single diagnosis of either ADHD or ODD and children with comorbid diagnoses of ADHD and ODD. We expected to replicate previous findings showing that children with comorbid diagnoses receive significantly lower teacher-ratings of social competence at pre-treatment than children with a single diagnosis. We further expected to replicate previous findings showing that children with comorbid diagnoses show less improvement than children with single diagnoses of either ADHD or ODD (Gadow & Nolan, 2002; Antshel & Remer, 2003; Landau, Milich, & Diener, 1998). The final aim of this study was to identify specific behavioral components of ADHD and ODD that contribute to problems with social competence. We hypothesized that there would be negative relationships between both hyperactive and oppositional behaviors and social competence at pre-treatment such that children with higher levels of teacher rated hyperactivity and oppositionality would also show lower levels of teacher rated social competence. 17

18 CHAPTER 2 METHODS Participants Participants were 42 children ages 3 to 6 enrolled in one of two larger studies examining group versus individual PCIT for preschoolers with ADHD (Study A) or maintenance treatment following PCIT for preschoolers with ODD (Study B). The sample included 12 children from Study A and 30 children from Study B whose teachers had completed a social competence measure at both pre- and post-treatment. Ten of the children had a single diagnosis of either ODD or ADHD, and 32 had comorbid diagnoses of ADHD plus ODD. Children were referred to the studies for treatment of disruptive behavior by local pediatricians, teachers, and day care providers. For inclusion in the larger studies from which this sample was drawn, children had to meet the DSM-IV criteria for either ADHD, ODD, or both. Children were diagnosed using the Diagnostic Interview Schedule for Children (NIMH DISC-IV-P; Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000). In both studies, children had to attain a standard score of 70 or higher on the Peabody Picture Vocabulary Test- Third Edition (PPVT-III; Dunn& Dunn, 1997) and parents needed to obtain a standard score of 75 or higher on the Wonderlic Personnel Test (WPT; Dodrill, 1981) in order to meet cognitive screening requirements. Children were also required to live with a primary caregiver who was able to attend weekly treatment sessions with the child. Children with a history of sensory or mental impairment (e.g. mental retardation or autism) were excluded from both studies. In addition, children were excluded from Study A if they were taking psychotropic medications for behavior or attentional problems. In Study B, children taking psychotropic medications at the time of enrollment in the study were not excluded, but were required to maintain a consistent medication regimen and dosage schedule for at least one 18

19 month before enrolling in the study and were asked not change medication regimen or dosage during the study treatment. For the current study, children were also excluded if they had missing teacher data at either pre- or post-treatment due to treatment drop out, failure to complete and return teacher questionnaires, or non-enrollment in school, usually due to summer vacation, at the time of post-assessment. There were no differences in demographic variables or social competence scores at pre-treatment between children who were excluded from the study due to missing data at post-treatment and children who had complete data at pre-and post-treatment. Children in the present sample had a mean age of 4.7 years (SD = 1.0) at the time of enrollment in the larger studies, and most of the children were male (76%). The children s racial/ethnic background was 76% Caucasian, 12% African American, 2% Asian, 2% Hispanic, and 7% bi-racial. The mean socioeconomic status (SES) score for families on the Hollingshead (1975) Index was 41.6 (SD = 13.7) with a range from 17 to 66, which is indicative of a wide range of socioeconomic status among the participants. The 12 children from Study A did not differ from the 30 children from Study B on age, sex, racial/ethnic composition, or SES (see Table 2-1). Interestingly, the 10 children with a single diagnosis were significantly older than the 32 children with a dual diagnosis, but did not differ on any additional demographic characteristics (see Table 2-2). Measures Diagnostic Interview Schedule for Children - IV - Parent (NIMH DISC IV-P; Shaffer et al., 2000). The DISC-IV-P is a structured diagnostic interview based on the Diagnostic and Statistical Manual of Mental Disorders criteria (DSM-IV; American Psychiatric Association, 1994). Test-retest reliabilities have been reported at.79 for ADHD and.54 for ODD. Mothers were interviewed using the DISC-IV-P at the pre-treatment assessment to provide one index in determining a diagnosis of ODD or ADHD for inclusion in the larger studies. 19

20 Child Behavior Checklist (Achenbach, 1991; 1992; Achenbach & Rescorla, 2000, 2001). The Child Behavior Checklist (CBCL) is a parent-report measure of children s emotional and behavioral problems in the past six months. In Study A, mothers completed either the Child Behavior Checklist for Year Olds (CBCL/1.5-5; Achenbach & Rescorla, 2000) or the Child Behavior Checklist for 6-18 Year Olds (CBCL/6-18; Achenbach & Rescorla, 2001). In Study B, mothers completed the Child Behavior Checklist for 4-18 Year Olds (CBCL/4-18; Achenbach, 1991) or the Child Behavior Checklist for 2 to 3 Year Olds (CBCL/2-3; Achenbach, 1992). Raw scores on all CBCL versions were converted to standard T scores prior to combining scores for analysis. These scores were used in combination with DISC diagnoses to ensure more accurate diagnoses. Eyberg Child Behavior Inventory (ECBI: Eyberg & Pincus, 1999). The ECBI is a 36- item parent-report questionnaire that assesses externalizing behaviors in children between the ages of 2 and 16. The instrument consists of two scales: the Intensity Scale, which measures the frequency of child disruptive behaviors on a 7 point scale ranging from 1(never) to 7(always); and the Problem Scale, which assesses whether or not the parent views the behavior as problematic for themselves on a yes-no scale. The Intensity and Problem Scales demonstrate inter-rater (mother-father) reliability coefficients of.69 and.61; internal consistency coefficients of.95 and.93; and test-retest reliability coefficients of.80 and.85 over a 12 week period and.75 and.75 over a ten month period. This questionnaire was administered weekly in the two larger treatment studies to evaluate treatment progress. Peabody Picture Vocabulary Test-Third Edition (PPVT-III; Dunn & Dunn, 1997). The PPVT-III is a well-standardized test of children s receptive language abilities and was used as a screening measure of children s cognitive abilities in this study. The reported split half 20

21 reliability coefficients range from.86 to.97 with a median of.97, and test-retest reliabilities range from.91 to.94 (Dunn & Dunn, 1997). The PPVT-III is highly correlated with the full scale IQ score of the Wechsler Intelligence Scale for Children (WISC-III) (Altepeter, 1989). Wonderlic Personnel Test (WPT; Dodrill, 1981). The WPT is a 50-item test designed to measure adult s intellectual abilities and was used as a screening measure of parents cognitive abilities in both of the larger studies. The Wonderlic estimate of intelligence has been shown to be highly correlated (.93) with the Wechsler Adult Intelligence Scale Full Scale IQ score (Dodrill, 1981). The Social Competence Scale- Teacher (Bierman, personal communication, 1995). The SCS-T, developed by the Conduct Problems Prevention Research Group, is a 25-item questionnaire designed to assess teachers perceptions of children s social competence skills. The questionnaire consists of three subscales: Prosocial/Communication, Emotion Regulation, and Academic. Examples of items include: shares materials with others and controls temper when there is a disagreement. Teachers rate each of these items on a 5-point Likert scale indicating how well each item describes the child from Not at all (0), to Very Well(4). A total social competence score is derived from all 25 items on the measure, with higher scores indicative of higher levels of social functioning. Past research, however, has also calculated a social competence score using only the 19 items of the Prosocial/Communication and Emotion Regulation subscales (Webster-Stratton & Hammond, 1998). Using this 19-item score, mean scores for a normative, as well, as a high-risk community sample have been compiled. The cutoff for clinically significant social competence problems is a score of 13 and a borderline range is between 13 and 22 (Biermann, personal communication, 1995; Webster-Stratton & Hammond, 1998). For the present study, both the total 25-item social competence score and the 19 item 21

22 Prosocial/Communication and Emotion Regulation subscale scores were calculated to compare our sample with normative and high-risk population data. The SCS-T has been shown to be stable over time and sensitive to treatment effects in preschoolers, and the scores correlate significantly with parent measures of positive child social behaviors (Webster-Stratton, 1998). In this study, the internal consistency (Cronbach s alpha) was.96. Conners Teacher Rating Scale-Revised: Long Version (CTRS-R: L; Conners, 1997). The CTRS-R: L is a 59-item teacher-rating scale that measures children s school behaviors including ADHD-related behaviors and other problem behaviors, including those related to ODD. 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 Not True At All, to Very Much True. The CTRS-R: L yields a total of nine subscale scores; however, we used scores from only two of the subscales Oppositional and Hyperactivity. The CTRS-R: L has shown test-retest reliability coefficients between.60 and.90. In this study, Cronbach s alpha was.91 for the Oppositional subscale and.89 for the Hyperactivity subscale of the CTRS-R: L. Procedure Assessments After completing the informed consent process, families took part in a pre-treatment assessment. During this assessment the child s primary caregiver completed a demographic questionnaire, clinical interview, and several questionnaires including the ECBI and CBCL. The graduate student assessor also administered the DISC-IV-P and the Wonderlic to the primary caregiver and the PPVT-III to the child to further assess study eligibility. Before treatment started for the family, the child s preschool or elementary teacher was mailed a packet of questionnaires including the CTRS-R: L and the Social Competence Scale-T to assess the child s oppositional and hyperactive behaviors as well as the child s social functioning and competence 22

23 in the classroom at pre-treatment. Following treatment completion, families participated in a post-treatment assessment and were asked again to complete a demographic questionnaire, clinical interview, and additional outcome measures. The child s teacher again completed the SCS-T to assess any significant changes in children s social functioning since pre-treatment. Treatment Families participated in weekly PCIT sessions conducted by two advanced graduate students who were trained extensively in the PCIT protocol. In Study A, families had been randomized to either individual therapy or group therapy with 2-3 other families and two therapists. In Study B, however, all families participated in individual treatment. Therapy sessions took place in a playroom, and during much of the session therapists coached the parent from an observation room adjoining the playroom, using a one-way mirror and sound system with a bug-in-the-ear transmission from therapist to parent at the same time as the parent was practicing new skills while playing with their child. Therapists followed the official PCIT treatment manual for each session (Eyberg and Child Study Laboratory, 1999). In the first phase of treatment, the Child-Directed Interaction (CDI) phase, parents learned skills such as labeled praise and imitation of the child s play in order to increase the positivity and warmth in their interactions. After achieving pre-determined skill levels indicating the mastery of CDI skills, families moved to the Parent-Directed Interaction (PDI) phase of treatment, which focuses on teaching parents an effective discipline procedure for dealing with child noncompliance. Parents learn to use simple, direct commands followed by labeled praise for child compliance and a timeout sequence following noncompliance. Treatment is completed when the family meets predetermined criteria including parent mastery of CDI and PDI skills, a reduction of the child s problem behaviors to within one-half standard deviation of the normative range on the ECBI, and parental report of confidence in managing their child s behavior. The mean number of 23

24 treatment sessions for families in the present study was (SD = 5.3). Children with a single diagnosis of either ADHD or ODD did not differ from children with comorbid ADHD+ODD in total number of sessions or length of treatment. 24

25 Table 2-1. Participant Demographic Characteristics from Study A and B Study A (n=12) Study B (n=30) M / % SD M/% SD t(40) p Child age (years) Child sex (% male) a Child race/ethnicity -.70 b Caucasian African American Asian American Hispanic Biracial Family SES a Due to a small sample size of females, Fisher s Exact test was used to compare the number of males and females in each study. b Due to small minority sample size, Fisher s Exact test was used to compare the number of Caucasian and minority groups in each study. Table 2-2. Participant Demographic Characteristics for Children with Single and Dual Diagnoses Single (n = 10) Dual (n = 32) M / % SD M/% SD t(40) p Child age (years) * Child sex (% male) a Child race/ethnicity b Caucasian African American Asian American Hispanic Biracial Family SES *p <.05. a Due to a small sample size of females, Fisher s Exact Test was used to compare the number of males and females in each diagnosis group b Due to small minority sample size, Fisher s Exact test was used to compare the number of Caucasian and minority groups in each diagnosis group. 25

26 CHAPTER 3 RESULTS PCIT And Social Competence Before conducting analyses, data were normalized using a square root transformation. To examine our first hypothesis, a paired-samples t test was conducted to analyze pre-to post-treatment changes in children s social competence. Using the full 25-item SCS-T measure, teacher ratings of child social competence at post-treatment (M = 44.60, SD = 20.95) were significantly higher than pre-treatment scores (M = 39.67, SD = 19.74), t(41) = , p =.05, d =.26 (See Figure 3-1). These findings suggest that children exhibit higher levels of social functioning in the classroom after completing PCIT.To compare the current sample with normative and high risk samples, social competence scores using only the Prosocial/Communication and Emotion Regulation subscales were also calculated. Using scores from the 19-item SCS-T, post-treatment social competence scores (M = 34.26, SD = 16.09) remained significantly higher than pre-treatment scores (M = 30.48, SD = 15.37), t(41) = -1.94, p =.50, d =.24. At pre-treatment, 14% of children fell into the borderline range for problems with social competence, and 17% fell into the clinical range. After PCIT, the percentage of children falling into the clinical range decreased to 7%, and 21% of children were classified as having borderline problems with social competence. (See Table 3-2). Comorbid Diagnoses and Social Competence To address our second hypothesis, we used a one way analysis of variance controlling for children s age to examine the differences in social competence scores between children with a single diagnosis of either ADHD or ODD and children with dual diagnoses of ADHD and ODD. At pre-treatment, although children with single diagnoses (M = 50.10, SD = 6.03) had, on average, higher scores than children with dual diagnoses (M = 36.41, SD = 3.37), the difference 26

27 was not significant. We also used a one way analysis of covariance controlling for pre-treatment scores and children s age to examine differences in social competence scores between children with single (M = 38.24, SD = 5.05) and dual diagnoses (M = 46.58, SD = 2.76) at post-treatment, and again group differences were not significant. (See Figure 3-2). Behaviors Associated with Social Competence Multiple regression was used to examine the hypothesized relationships between teacherrated child hyperactive and oppositional behaviors and social competence at pre-treatment. Results indicated that children who scored higher on teacher-rated oppositional behavior also had lower (worse) scores on teacher-rated social competence at pre-treatment, β= -.53, t(38)=-2.98, p <.01. There was no relationship, however, between teacher-rated hyperactive behavior and social competence in this sample. 27

28 Table 3-1. Pre to Post Treatment Changes in Social Competence Variable Pre Post t(41) N M SD M SD SCS-T (25 item) * Single Diagnosis Dual Diagnosis SCS-T (19 item) * *p <.05 Table 3-2. Percentage of Children in Normal, Borderline, and Clinical Range for Social Competence Problems at School Normal Borderline Range Range a Clinical Sample: SCS-T (19 item) Clinical Range b Pre-Treatment Post-Treatment High Risk Community Sample: SCS-T (19 item) a Borderline = raw score b Clinical < 13 raw score

29 Figure 3-1. Changes in Social Competence Figure 3-2. Changes in Social Competence in Children with Single and Dual Diagnoses 29

30 CHAPTER 4 DISCUSSION This study examined the social competence deficits and the specific behavioral components associated with problematic social functioning of children referred to PCIT for treatment of ODD, ADHD, or both. Teachers rated children as exhibiting more social skills and showing higher levels of social functioning following the completion of PCIT. Additionally, higher levels of teacher rated oppositional behaviors were associated with lower levels of social competence at pre-treatment. These results suggest that the problematic social skills associated with children diagnosed with ADHD or ODD are improved along with their primary diagnostic symptoms following the completion of PCIT. Our primary hypothesis that children s social competence in the classroom would improve following the completion of PCIT was supported. This finding suggests that the improvement in prosocial behavior evidenced during treatment generalizes to children s behavior in the classroom. This result is especially important because previous research examining various behavioral treatments, social skills training programs, and medication trials have shown little change in teacher ratings of social skills following interventions (Bierman, 1989; Gresham, 1985; Michelson & Wood, 1980). These improvements in the classroom provide initial support that PCIT s multifaceted approach may serve as an effective treatment program not only for reducing disruptive behavior and improving the parent-child relationship, but also for increasing social competence in preschool and elementary school-age children. It is important to note, that unlike previous research suggesting that most children with ADHD and ODD have significant social competence deficits (Frederick & Olmi, 1994; Henker & Whalen, 1999; Landau & Milich, 1990; Pelham & Bender, 1982; Schachar & Wachsmuth, 1990), only 31% of our study sample were rated as having borderline or clinically significant 30

31 problems with social competence before starting treatment It is possible, however, that our measure of teacher-rated social competence, which focused mainly on specific prosocial classroom behaviors, did not fully capture the peer relationship problems addressed in previous studies that frequently utilized peer psychometric ratings as a measure of social functioning. Despite the fact that a relatively small percentage of our study sample was rated as having social competence problems initially, this percentage significantly decreased following treatment. The number of children with clinically significant social competence problems in our clinical sample at post-treatment, however, remained above an at-risk community sample described by Webster- Stratton & Hammond (1998). This finding suggests that although social skills are generally improved in the classroom at the completion of PCIT, children may continue to struggle with some specific social skills deficits and problem behaviors in the classroom. Our second hypothesis, that children with comorbid diagnoses of ODD and ADHD would have lower levels of teacher-rated social competence at pre-treatment than children with a single diagnosis, was not supported. This finding is in contrast to previous research which has asserted that children with dual diagnoses experience more severe problems with social competence (Frankel & Feinberg, 2002; Gadow & Nolan, 2002; Kuhne, Russell, & Tannock, 1997). One possible explanation for our discrepant finding is that because our sample size was limited, we constructed our single diagnosis group by combining children with a single diagnosis of ADHD with those who had a single diagnosis of ODD. Previous research, however, examined only one category (either ODD or ADHD) in the single diagnosis group. Because children with ODD may present with different social difficulties than children with a diagnosis of ADHD, it is possible that by combining these two diagnostic groups into one category we were unable to examine the unique differences associated with each disorder. Our study also 31

32 used only one measure of social competence. It is possible that social competence differences between groups found in earlier studies utilizing peer ratings were not captured by the particular teacher measure that we selected. Our hypothesis that children with a dual diagnosis would have lower levels of social competence after treatment completion than children with a single diagnosis was also not supported. Although this finding does not suggest the two groups were equal at post-treatment, it does suggest that children with comorbid ADHD and ODD may be less resistant to treatment than previously thought (Antshel & Remer, 2003; Landau, Milich, & Diener, 1998). Previous research, however, has shown that the difference in treatment efficacy between children with a single diagnosis of either ADHD or ODD and children with comorbid ADHD and ODD disappears when parents are involved in treatment (Frankel et al., 1997; Pfiffner, & McBurnett, 1997). Further research is needed to investigate the mediating effects of parental involvement in relations between children with comorbid diagnoses and social competence outcomes. Our final hypothesis that higher levels of both oppositional and hyperactive behavioral symptoms would be related to poorer social competence at pre-treatment was only partially supported. We found that oppositional behaviors, but not hyperactive behaviors were related to social competence at pre-treatment. This finding lends support to previous research suggesting that it is specifically an oppositional interaction style, characterized by rule-breaking, aggressive, and dominating behaviors, that serves as the main behavioral component contributing to problems with children s social functioning and peer relations (Cunningham & Siegel, 1987; Erdhardt & Hinshaw, 1994; Milich & Landau, 1982; Pelham & Bender, 1982). Further investigation of this finding may be instrumental in helping to design more targeted interventions for children with disruptive behavior problems. 32

33 Limitations It is important to consider the limitations of this study when interpreting the findings. This project was a secondary data analysis that combined two previously conducted studies, and because of this we were unable to compare our findings to a randomized control group without treatment. Although the studies used highly similar treatment protocols, there were a few important differences between the two studies. Perhaps the most notable difference between Study A and B is that Study B allowed children to enter the study as long as they were on a wellmanaged consistent medication treatment whereas children on medication were not included in Study A. It is also important to note that Study A provided treatment in group and individual formats, whereas Study B offered only individual treatment. It is possible that children s participation in the group treatment format, which includes time in a child playroom with other children in group treatment, may have a differential impact on children s social functioning than individual treatment. No significant differences were found between the demographic variables and pre-treatment SCS-T scores in individuals in Study A versus Study B, however, it is possible that different study mechanisms contributed to changes in children s social competence in each study. This study used only teacher-report measures to assess children s social competence and behaviors in the classroom. Using only one informant can increase the possibility of responder bias and motivation. In addition, the teachers awareness that the child was participating in treatment may have impacted their responses at post-treatment. Alternatively, it is possible that children s changes in social competence were not fully captured at post-treatment due to teachers biases and previous views of the child s social behaviors in the classroom. It is also possible that there were different teachers at pre- and post-treatment due to children moving from one, daycare, preschool, or classroom, to another. Future studies should consider using multiple 33

34 measures of social competence, including other children s sociometric ratings, to ensure a more complete representation of children s social functioning in the classroom. The sample in this study was limited due to teachers failure to complete and/or return measures at either pre-or post-treatment. The sample also contained an unequal number of participants in the two diagnostic groups with 32 participants with a dual diagnosis and 10 participants with a single diagnosis. With such a high rate of comorbidity between ADHD and ODD, these unequal groups of participants are not surprising. It is possible, however, that the differences in group size contributed to our failure to replicate past research differences in social competence between singly- and dually-diagnosed children. It would be interesting to see if a future study with a larger sample size and more equal groups were able to replicate previous research findings. Additionally, with a larger sample size we would be able to examine the unique differences in social competence exhibited among children with a single diagnosis of either ADHD or ODD. Future Directions This study highlighted the value of assessing children s social competence using multiple measures during the initial screening for PCIT. The identification of children with significant social competence deficits at pre-treatment would be instrumental in determining specific behaviors to focus on in treatment. There is a further need to continue to examine the underlying mechanisms contributing to deficits in social competence in order to help focus treatment aims better. Children with clinically significant problems with social competence may also especially benefit from the group treatment format that allows interaction with other children their age. Future research is needed to investigate the differences in social competence outcomes between children who participate in group versus individual PCIT. It will also be important to continue to examine the long-term social competence outcomes following the completion of treatment in 34

35 order to assess whether the improvements in children s social functioning following PCIT are maintained over time. 35

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