Lessons Learned in Enhancing Behavioral Parent Training for High-Risk Families of Youth with ADHD

Behavioral parent training (BPT) has long been identified as an efficacious treatment approach for children with attention-deficit hyperactivity disorder (ADHD; Pelham & Fabiano, 2008). However, the extant literature indicates that high levels of adversity (e.g., parental psychopathology, high levels of stress) often place families at risk for poor attendance and engagement during BPT, as well as a limited treatment response (Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004). Single-mothers, in particular, experience multiple adversity factors that impact their involvement in BPT, including higher rates of depression and stress, less social support (Cairney, Boyle, Offord, & Racine, 2003), greater practical barriers to treatment participation (Kazdin, Holland, Crowley, & Brenton, 1997; Kazdin & Wassell, 2000), and maladaptive cognitions regarding treatment (e.g., unrealistic expectations for improvement following treatment) and their child’s behavior (e.g., intentionality of misbehavior; Nock & Kazdin, 2001). Thus, it is not surprising that single-mother families are less likely to complete BPT (Kazdin, Mazurick, & Bass, 1993; Kazdin & Mazurick, 1994), improve following BPT (Dumas & Wahler, 1983; Webster-Stratton & Hammond, 1990), and maintain treatment gains over time (Bagner & Eyberg, 2003; Webster-Stratton, 1985). Given the obvious need, we focused our work on developing methods to better engage single-mother families in and maximize outcomes from BPT. The Strategies To Enhance Positive Parenting (STEPP) program (Chacko et al., 2008; 2009; 2012) is a multicomponent, nine-week BPT program held for two and half hours each week. Evidence-based BPT content is presented in a collaborative, large-group format, and material is complemented by videotaped vignettes, therapist-facilitated questions, group discussions, modeling, and role-play by parents. Children participate in a concurrent group-based social skills program. These methods, content, and procedures are common to many BPT programs. Several additions were made to the STEPP program to address major areas identified in the literature that are important to target with single-mothers, including practical barriers to treatment participation, parents’ maladaptive cognitions regarding their child and treatment, depression, social support, and life stressors (see Chacko et al., 2008; 2009, for details). Specifically, several enhancements to the format, delivery, and content of traditional BPT were made, including: (1) an enhanced intake procedure aimed to improve parents’ motivation to engage in treatment. This was accomplished through addressing possible practical barriers to treatment participation, maternal cognitions regarding expectations for treatment, and parental attributions regarding their child’s behavior (McKay, Stoewe, McCadam, & Gonzales, 1998; Nock & Kazdin, 2005). For instance, open-ended questions were asked of single-mothers regarding their expectations about their own and their child’s involvement in treatment (e.g., What role do you think you will have in treatment? In what way do you think your child will be involved in treatment?). Single-mothers were also asked open-ended questions regarding expectations for their child’s improvement (e.g., How fast do you expect to observe improvements in your child’s behavior?) and their attributions regarding locus of control of their child’s behavior and the effects of their parenting on that behavior (e.g., What do you think causes your child to misbehave?). Misconceptions or inappropriate expectations regarding these issues were discussed and clarified with the single-mother during the intake. Last, practical barriers (e.g., childcare, transportation) to ongoing involvement were addressed, and solutions to these barriers were developed during the intake; (2) the incorporation of a subgroup, coping-modeling, problem-solving format within the traditional large group format to improve social support between parents and to increase participation among parents (Cunningham, Davis, Bremner, Dunn, & Rzasa, 1993); (3) the incorporation of a systematic, problem-solving treatment method approach (D’Zurilla & Nezu, 1999) to address parent-initiated problems (e.g., time management, conflicts with relatives) that may either interfere with their parenting or affect their psychosocial functioning (e.g., Kazdin & Whitley, 2003; Pfiffner, Jouriles, Brown, Etscheidt, & Kelly, 1990;); (4) the addition of parent-child interactions within the children’s social skills group to enhance parenting skill acquisition; and (5) the addition of a child motivation enhancement within the children’s social skills group in order to provide children with incentives for attaining within-session and home-based behavioral goals. Engagement and efficacy outcomes demonstrated clear benefits of the STEPP program compared to a wait-list control condition and a traditional, group-based BPT program (Chacko et al., 2009; 2012). More specifically, results demonstrated that, relative to traditional BPT, the STEPP program resulted in acute improvements on measures of oppositional defiant behavior, key areas of impairment (e.g., parent-child and family-related impairment), observational measures of parenting behavior, and parenting stress. Moreover, the STEPP program had significant effects on increased attendance, homework compliance, and greater consumer satisfaction. Recently published analyses also demonstrated that there was a greater propensity for families to attend each session and to complete each homework assignment during the course of the STEPP program than during the course of the traditional BPT program. Survival analyses of time-to-dropout suggest similar patterns of dropout between both treatment groups, although the amount of dropout was significantly attenuated in the STEPP program (10% dropout in the STEPP program compared to 65% dropout in the traditional BPT condition). In addition, compared to traditional BPT, the STEPP program enhanced/improved key empirically related factors hypothesized to affect engagement (e.g., amount and quality of social support between mothers within their group, expectations regarding treatment, perceived barriers to treatment participation), which were targeted within the STEPP program (Chacko et al., 2012). Collectively, the data suggest that there are some clear benefits of the STEPP program relative to a more traditional BPT for single-mother–headed families of school-age youth with ADHD. These effects appear most robust for engagement outcomes. Importantly, there are also clear limitations of this treatment. While outcomes were significantly better for families in the STEPP program relative to the traditional BPT program, STEPP resulted in clinically significant improvements for only a minority of children on ADHD and ODD symptom outcomes, and maintenance of gains, at the group-level, was not observed at 3-month follow-up assessment.