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Social Skills Training for Children with Disruptive Behavior Problems: Comparing the Relative Benefits of Multimodal Versus Traditional Approaches for Children of Single Mothers Brian T. Wymbs, Anil Chacko, Michelle S. Swanger, Elizabeth M. Gnagy, William E. Pelham, Jr., Frances W. Arnold, Lauma P. Pirvics, Maia Griffin, & Laura Herbst University at Buffalo, State University of New York

Introduction

-Children diagnosed with Attention-Deficit Hyperactivity Disorder (ADHD), Oppositional-Defiant Disorder (CD) and Conduct Disorder (CD) are often profoundly impaired in the domain of social functioning (Barkley, 1998; McMahon & Wells, 1998; Whalen & Henker, 1985), demonstrating both pervasive social skills knowledge and performance deficits (Landau & Moore, 1991; Pelham & Bender, 1982). -The degree and pervasiveness of peer relationship impairment among these children is concerning because research has shown that school-age children with ADHD and other disruptive behavior disorders (DBDs) are at a significant risk for continued peer relationship impairment (Bagwell, Molina, Pelham, & Hoza, 2001) and other more pronounced societal difficulties as adolescents (Lynam, 1996). -A common intervention for children exhibiting significant impairment in peer relationships is social skills training (SST; Kavale, Forness, & Walker, 1999; Wymbs & Chronis, in press). Traditional SST programs utilize didactic instruction, group discussion, and role-plays to enhance social skill knowledge, and in vivo practice and contingency management strategies to reinforce social skill performance (Pfiffner, Calzada, & McBurnett, 2000). Despite their popularity among both researchers and practitioners, evidence suggests that traditional SST programs have only achieved limited success with children most in need of treatment (e.g., children with ADHD, ODD, and CD; Kavale, Mathur, Forness, Rutherford, & Quinn, 1997). -Current research has examined the efficacy of multimodal (parent and childfocused) SST programs as an alternative to traditional (child-focused-only) SST programs. These studies investigated the benefit of a combined traditional SST / behavioral parent training (BPT) protocol versus traditional SST-only on the behavioral and social outcomes of children with ADHD and other DBDs (Pfiffner & McBurnett, 1997; Webster-Stratton & Hammond, 1997). [BPT focused on teaching parents how to reinforce their children for using the social skills covered during SST.] Both studies generally found that children in the multimodal SST group demonstrated significantly better behavioral and social outcomes on parent, teacher, and observational measures than children in the traditional SST-only group. The results of these studies appear to suggest that children are more likely to benefit from SST if their parents reinforce their social skill performance. -However, could it be that multimodal SST programs (e.g., Pfiffner & McBurnett, 1999) are more successful than traditional SST programs because of they offer children more frequent in-session rewards for demonstrating improvements in social behavior at home and during each session? -Alternatively, given that children with ADHD and other DBDs are often deficient in adaptive life skills (Stein, Szumowski, Blondis, & Roizen, 1995), could the efficacy of multimodal SST programs be enhanced by adding adaptive life skills training to the sessions? -No studies have compared the responsiveness of children with ADHD, ODD, and CD to enhanced multimodal SST, offering adaptive life skills training as well as in-session rewards for good behavior during the week and during the session, versus regular multimodal SST without adaptive life skills training or in-session rewards for improvements in social behavior at home.

Procedures

-Single mothers of children with behavior problems were recruited from the Western New York area through mailings, school flyers, and newspaper advertisements between the Fall of 2002 ­ Spring 2003 to participate in a study examining the efficacy of two BPT interventions. -In order for families to participate in this study, children were required to meet DSM-IV criteria (APA, 1994) for ADHD assessed using a multi-trait, multimethod, multi-informant intake procedure, including a semi-structured interview with mothers assessing disruptive behavior problems and standardized questionnaires completed by the child's mother and teacher. -Mothers were assigned to take part in one of two 9-week BPT interventions: 1) Enhanced BPT designed to meet the needs (e.g., stress coping) of single mothers of children with disruptive behavior problems (S.T.E.P.P.; Strategies to Enhance Positive Parenting; Chacko et al., 2003), or 2) Traditional BPT (Barkley, 1997). -Children whose mothers were assigned to the S.T.E.P.P. program participated in an enhanced multimodal SST program (EMSST; Wymbs et al., 2002), which is a modified version of the Pfiffner and McBurnett SST program (1997). Children whose mothers were assigned to traditional BPT participated in a regular multimodal SST program (RMSST), which is modeled after the COPE social skills program (Cunningham, Bremner, & Secord, 1998). See Table 1 for a description of these programs.

Results

-Repeated-measures MANOVAs were computed to assess the effect of time collapsing across treatment groups and to assess for the presence of interactions suggesting between-treatment differences in patterns of social behavior observed at post-treatment. -A significant interaction was found for the number of negative solutions to peer problems reported by children F (1, 27) = 6.67 (p<.05) and a trend for an interaction was found for the variety of positive solutions to peer problems reported by children F (1, 27) = 3.18 (p<.10). -Follow-up pairwise t-tests indicated that increases in both the total number of negative solutions (t=2.27, p<.05) and the variety of positive solutions (t=2.03, p<.10) by children in the EMSST group drove the interactions. No significant change was evident in the RMSST group on either variable. -A significant interaction was also found with parent-reported child assertiveness F (1, 27) = 4.39 (p<.05) and a trend for an interaction was found for parent-report child cooperation F (1, 27) = 2.91 (p<.10). -Follow-up pairwise t-tests indicated that the interactions were driven by significant improvements in assertiveness (t=1.97, p<.05) and cooperation (t=1.98, p<.05) by children in the RMSST group. No significant changes were found in the EMSST on either variable. -Within-subject analyses further indicated that children in both treatments demonstrated significant improvements in parent-reported respectfulness F (1, 25) = 9.59 (p<.01) and self-control F (1, 28) = 6.44 (p<.05). -Within-treatment effect sizes (d; Cohen & Cohen, 1988) were computed for each social skill knowledge and performance variable. Between-treatment effect sizes were not computed owing to numerous between-group differences on knowledge and performance variables observed at pre-treatment (see Table 2). -Effect sizes generally indicated that the RMSST program resulted in little change in social skill knowledge and little to moderate improvement in parentreported social skill performance. In contrast, effect sizes generally indicated that the EMSST program resulted in little change in social skill performance and modest to moderate positive effects in social skill knowledge. Notably, one social skill knowledge variable (number of negative solutions to peer problems reported by children) actually had a strong negative effect with the EMSST, indicating that this variable worsened significantly by the end of treatment.

Discussion

-Children of single-mothers in the RMSST and EMSST programs appeared to make some improvements at post-treatment. Specifically, 1) children in the EMSST reported a greater variety of positive solutions to hypothetical social problems with peers at post-treatment than children in the RMSST group, 2) children in the RMSST group were reported by their mothers to demonstrate improvement in cooperating and being assertive at post-treatment than children in the EMSST group, and 3) children in both groups were reported by their mothers to demonstrate improvements in respectfulness and self-control. -However, the mothers of children in both groups did not report a significant reduction in negative behavior associated with peer relation difficulties nor a significant reduction in the degree of peer relationship impairment at posttreatment. Moreover, children in the EMSST group actually reported more negative solutions to hypothetical social problems with peers at post-treatment. This study highlights the modest effects of time-limited SST (Kavale et al., 1997) and speaks to the need to implement long-term treatment to treat the social impairment of children with ADHD (Pelham & Fabiano, 2000). -Effect size estimates generally demonstrated that there was little difference between the two SST programs in their overall efficacy, with both EMSST ad RMSST resulting in little positive change in both prosocial skills knowledge and performance. Thus, results of this study imply that enhancing the quality of SST by including adaptive life skills training and providing opportunities to earn more frequent in-session rewards appears to add little incremental benefit to the effectiveness of SST when it is an adjunct to BPT.

Dependent Measures

Social Skill Knowledge:

-Wally Problem-Solving Measure-Child report (Webster-Stratton, Reid, & Hammond, 2001)

-Measured the variety and total number of positive solutions for hypothetical social problems, and the total number of negative solutions for hypothetical social problems.

Limitations

-Results of the present study are limited to families headed by single-mothers. Given that single-mothers are at-risk for depression and using ineffective parenting techniques (Chacko et al., 2003), it is possible that they were not able to effectively reinforce their child's use of prosocial behavior in this study, thus leading to a reduction in the amount opportunities their children could earn rewards. -Since some of the mothers took part in a parent strategies course (S.T.E.P.P.) that included teaching techniques to better cope with stress and challenging negative cognitions, it is possible that their post-treatment ratings regarding their child's social behavior were inflated due to the mothers' learning ways to positively attend to their child's behavior and more appropriately managing their own stress (Wymbs et al., 2002).

Social Skill Performance:

-Social Skills Rating System-Maternal Report (Gresham & Elliott, 1990)

-Measures how often children exhibit prosocial skills (cooperation, assertiveness, respectfulness, self-control) -Scale: 0=Not at all, 1=Sometimes, 2=Very Often

Table 1. Components of Both Multimodal SST Programs

RMSST Social skills reviewed in-session Listening, Complimenting, Helping/Sharing, Good Sportsmanship, Following Instructions, Ignoring Provocation, Making an Appropriate Complaint None EMSST Listening, Complimenting, Helping/Sharing, Good Sportsmanship, Following Instructions, Ignoring Provocation, Making an Appropriate Complaint Packing and Organizing Backpack, Folding Clothes, Setting the Kitchen Table, Making a Lunch, Making Simple Snacks Board games

-SNAP-Maternal Report (Atkins, Pelham, & Licht, 1985)

-Sum of several questions assessing for the presence of negative behaviors related to peer interaction difficulties (e.g., bossiness) -Scale for each question: 0=Not at all, 1=Just a little, 2=Pretty much, 3=Very much

Conclusion

-This study highlights the need to continue evaluating whether BPT or SST is the active ingredient accounting for the positive effects of multimodal SST for children with ADHD and other DBDs. Webster-Stratton and Hammond (1997) compared both BPT-only and BPT + SST to a waitlist control group and found that both groups were superior to the control group on parent and teacher report measures as well as observations across home and laboratory settings at posttreatment. The only difference between the two groups was that children in the BPT + SST group generated significantly more positive solutions to hypothetical social problem scenarios than did children in the BPT-only group. However, knowing that most children with ADHD and other DBDs do not have difficulty knowing what to do in social situations (Barkley, 1998), this between-group difference appears to be a moot point. Thus, it appears that the results of Webster-Stratton & Hammond's (1997) study suggest that SST adds little incremental benefit to the effect of BPT on the social behavior of children. -Future research should seek to extend the results of their study by conducting a clinical trial comparing the behavioral and social outcomes of children with ADHD and other DBDs randomly assigned to BPT-only and BPT +SST conditions. It is expected that the results of this study would demonstrate that multimodal SST programs (i.e. BPT + SST) do not result in significantly better social behavior in children with ADHD and other DBDs than BPT-only programs, thus confirming that BPT is truly the active component in multimodal SST programs.

Study Goal

-To examine the degree to which children with ADHD, ODD, and CD respond differentially to enhanced multimodal SST, with adaptive life skills training and opportunities to earn bonus in-session rewards for demonstrating proper social behavior at home and during sessions, versus regular multimodal SST, without adaptive life skills training and frequent in-session rewards.

-Impairment Rating Scale (IRS; Fabiano et al., 1999)

-Likert-like question asking informants to indicate the degree of peer relationship impairment of their children. -Scale: 0 =No problem/Definitely does not need treatment or special services 6 = Extreme Problem/Definitely does need treatment or special services) Group Activities Adaptive life skills practiced in-session

Board games

Hypotheses

-It is expected that children with ADHD, ODD, and/or CD participating in this study will demonstrate improvements in both social skill knowledge and performance as a result of participating in both multimodal, BPT + SST programs. -It is expected that children in the enhanced multimodal SST program will demonstrate significantly better outcomes across social skill knowledge and performance indices than children in the regular multimodal SST program.

Participants

Group Number of subjects Average age % Male % Caucasian % African-American % Other % Comorbid ODD Average Pre-treatment Inattention Symptom Severity-Mother a EMSST 16 7.69 (2.06) 70.6 37.5 25.0 47.5 76.5 2.04 (0.62) 1.93 (0.58) 1.33 (0.77) 1.87 (0.93) 1.55 (0.70) 1.20 (0.92) RMSST 18 8.83 (2.33) 61.1 50.0 27.8 22.2 94.4 1.94 (0.71) 2.12 (0.57) 1.80 (0.78) 1.70 (0.74) 1.62 (0.83) 1.40 (0.92)

Behavior management strategies Contingent Rewards

Point system, social Point system, social reinforcement, time out reinforcement, time out Computer games earned based on insession behavior Computer games earned based on insession behavior; weekly prizes earned based on in-session behavior and use of social skills taught at home with parents

Table 2. CIM data at 6-month follow-up

RMSST Pre-Treatment effect. Social Skills Knowledge b Wally-Total # of Positive Solutions Wally-Variety of Positive Solutions Wally-Total # of Negative Solutions Social Skills Performance c SSRS-Cooperation SSRS-Assertiveness SSRS-Respectfulness SSRS-Self-Control SNAP-Negative Behaviors IRS-Peer Relations Impairment

d d d d e e

References

For a list of references and a copy of the poster, please write your email address on the paper provided or send a request via email to [email protected]

EMSST Post-Treatment M (SD) 16.53 (3.07) 9.07 (1.62) 1.60 (2.23) 9.00 (3.07) 12.76 (3.25) 11.50 (3.03) 9.17 (3.08) 10.44 (5.09) 3.94 (2.08) da 0.07 -0.13 0.23 0.52 0.45 0.69 0.65 0.08 0.31 Pre-Treatment M (SD) 14.47 (2.17) 8.33 (1.54) 1.93 (1.71) 8.50 (2.56) 12.46 (2.67) 9.86 (2.71) 9.14 (3.06) 7.07 (3.97) 2.88 (1.71) Post-Treatment M (SD) 14.86 (4.35) 9.43 (2.17) 4.57 (5.27) 8.07 (3.35) 11.71 (3.15) 10.86 (4.35) 9.87 (2.80) 5.86 (4.11) 2.73 (1.71) da

b Child a

Average Pre-treatment HyperactivityImpulsivity Symptom Severity-Mother a Average Pre-treatment Oppositional-Defiant Symptom Severity-Mother a Average Pre-treatment Inattention Symptom Severity-Teacher a Average Pre-treatment HyperactivityImpulsivity Symptom Severity-Teacher a Average Pre-treatment Oppositional-Defiant Symptom Severity-Teacher a

Positive scores indicate a positive effect of treatment. report report

M (SD) 16.28 (3.39) 9.33 (2.06) 2.06 (2.04) 7.06 (3.73) 11.28 (3.27) 9.00 (3.62) 7.06 (3.23) 10.89 (5.82) 4.50 (1.79)

0.18 0.71 -1.54 -0.17 -0.32 0.37 0.24 0.30 0.09

c Maternal d

Higher scores indicate greater use of social skill. scores indicate better social behavior with peers.

Center for Children and Families Web Address:

http://wings.buffalo.edu/adhd

e Lower

Note: There were no significant pre-treatment between-group differences on any variable. a Average score assigned to each DSM-IV symptom endorsed on the Disruptive Behavior Disorder (DBD) rating scale (0=Not at all present, 3=Very much present; Pelham, Gnagy, Greenslade, & Milich, 1992).

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