مقایسه برنامه های آموزش رفتاری والدین برای پدران کودکان مبتلا به نقص توجه/بیش فعالی

Few behavioral parent training (BPT) treatment studies for attention-deficit/hyperactivity disorder (ADHD) have included and measured outcomes with fathers. In this study, fathers were randomly assigned to attend a standard BPT program or the Coaching Our Acting-Out Children: Heightening Essential Skills (COACHES) program. The COACHES program included BPT plus sports skills training for the children and parent-child interactions in the context of a soccer game. Groups did not differ at baseline, and father ratings of treatment outcome indicated improvement at posttreatment for both groups on measures of child behavior. There was no significant difference between groups on ADHD-related measures of child outcome. However, at posttreatment, fathers who participated in the COACHES program rated children as more improved, and they were significantly more engaged in the treatment process (e.g., greater attendance and arrival on time at sessions, more homework completion, greater consumer satisfaction). The implications for these findings and father-related treatment efforts are discussed.

Fathers contribute to many aspects of a child’s development. Fathers positively involved with their children (i.e., spending time with a child, supporting the child, and having a close/warm relationship) have children with fewer behavior problems (Amato and Rivera, 1999 and Hurt et al., 2007). Fathers also contribute uniquely to their child’s academic achievement and academic sense of competence (Amato and Gilbreth, 1999 and Forehand et al., 1986). Further, positive father involvement is related to the development of emotion regulation, social cognition, and focused attention, and perhaps due to these factors, appropriate peer relationships (Parke et al., 2002). Importantly, these are aspects of functioning that are among the most pronounced areas of impairment in children with attention-deficit/hyperactivity disorder (ADHD; Fabiano et al., 2006), a chronic disorder characterized by developmentally inappropriate levels of inattention, overactivity, and impulsivity. Thus, for children with ADHD, positive father involvement may be an important treatment-related goal. The inattentive, impulsive, and overactive behaviors characteristic of ADHD challenge parents to effectively manage child behaviors, and over time, parents may develop a parenting approach that includes poor monitoring and inconsistent or punitive discipline strategies. Unfortunately, this type of approach predicts a number of negative adolescent and adult outcomes, including alcohol and substance abuse, delinquency, and academic failure (e.g., Lochman & Wells, 2002). In addition to predicting negative outcomes for children, noncontingent and inconsistent parental discipline predicts the development of future maladaptive parenting strategies (Granic & Patterson, 2006). Therefore, to promote effective parenting skills, behavioral parent training (BPT) interventions have been developed and studied. A typical BPT program teaches the child’s parent how to effectively modify antecedents (e.g., rules, commands) and consequences (e.g., time-out, rewards) for target behaviors (e.g., compliance, noncompliance) as well as modify maladaptive cognitions related to parenting. BPT is an evidence-based treatment for a number of childhood externalizing and internalizing mental health problems (Chorpita et al., 2002). The finding that parent training is an effective treatment is tempered by the fact that adherence to parent training programs is often poor. For example, more than half of the families who enroll in clinical parent training programs never attend treatment or discontinue treatment prematurely (e.g., Barkley et al., 2000, Helfenbaum-Kun and Ortiz, 2007, Kazdin, 1996, Miller and Prinz, 1990 and Prinz and Miller, 1994). Even participants who do regularly attend BPT sessions may arrive late for treatment sessions, fail to complete homework assignments, and/or miss a significant number of sessions (Cunningham, Davis, Bremner, Dunn, & Rzasa, 1993). These rates of attendance and adherence are problematic due to the fact that ADHD is now conceptualized as a chronic condition, and therefore ongoing engagement of families in treatment is necessary (American Academy of Pediatrics, 2001). Researchers have therefore directed attention toward increasing the engagement of parents in BPT (Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004), and fathers of children with ADHD are a specific group that may be targeted by engagement efforts. Studies of Fathers in Parent Training for ADHD Traditionally, men do not engage in help-seeking behavior, be it for medical or mental health services (Addis & Mahalik, 2003). These findings appear to generalize to participation in BPT programs (Fabiano, 2007 and Tiano and McNeil, 2005). Overall, fathers (defined broadly as any primary male caregiver) are underrepresented in studies of treatment outcome for BPT (Fabiano, 2007, Lee and Hunsley, 2006, Phares, 1996a, Phares, 1996b and Tiano and McNeil, 2005). Indeed, when ADHD is considered, there are only three peer-reviewed studies that directly investigate the effectiveness of parenting interventions for fathers (Barkley et al., 2001, Danforth et al., 2006 and Schuhmann et al., 1998; see Fabiano, 2007, for a review). Barkley et al. (2001) compared a parenting program that used a contingency management approach (Barkley, 1997) to a parenting group that combined problem-solving communication training with a contingency management approach for families with an adolescent with ADHD. In this study, fathers in both groups exhibited improvement during active treatment but had some worsening in behavior during a follow-up assessment. In addition, there was a considerable rate of attrition in the study, with the highest rates in the group that did not include contingency management training. However, this study is limited because the sample of ADHD participants included only adolescents; how the results might differ with school-age children is unknown. Danforth et al. (2006) conducted a BPT study with 46 mothers and 26 fathers and evaluated outcome by measuring child and parenting behaviors before the intervention and after it ended 8 weeks later. Mothers and fathers reported significant decreases in their child’s ADHD-related behaviors. However, on self-report and objective measures of parenting, fathers did not appear to benefit as much from the intervention as mothers. Mothers’ self-reports indicated improvement on all parenting domains assessed, whereas fathers rated a more inconsistent pattern of results. On an objective measure of parenting— tape-recorded parent and child behaviors during a typical home situation— mothers’ parenting behaviors and mother-child interactions were improved. However, none of these objective measures were significantly improved for fathers. Along with Barkley et al., 2001 and Danforth et al., 2006 highlight the need to measure fathers as distinct participants from mothers and children, as their response to interventions and treatment outcomes may be different. Finally, Schuhmann et al. (1998) reported on fathers who participated in a BPT intervention that used Parent-Child Interaction Therapy with young children with ADHD and/or other disruptive behavior disorders. Fathers clearly benefited, with significant effects of the intervention demonstrated on self-report as well as in observations of parent-child interactions. One limitation of this study was the restricted age range of the children (4 to 6 years old). Further, all three studies included mothers and fathers who attended BPT together, so the impact of BPT for fathers of children with ADHD independent from mothers cannot currently be addressed. Considering the broader literature on BPT for all disruptive behavior disorders, others have also highlighted the lack of information on father participation in and benefit from BPT programs (e.g., Miller and Prinz, 1990, Phares, 1996a and Tiano and McNeil, 2005). Some studies have reported limited improvements attributed to father participation in BPT (e.g., Firestone et al., 1980, Helfenbaum-Kun and Ortiz, 2007 and Martin, 1977), some have reported mixed results (e.g., Anastopoulos and Farley, 2003 and Danforth et al., 2006), and others have reported improvements on the part of fathers’ parenting skills and ratings of child behavior (e.g., Schuhmann et al., 1998 and Webster-Stratton and Hammond, 1997). Other studies that investigated the maintenance of treatment gains from BPT also support father involvement (Bagner and Eyberg, 2003 and Webster-Stratton, 1980). However, the state of the literature is equivocal—there is no clear information on the benefit of father participation on BPT-related outcomes. In addition, available studies have methodological limitations that make any firm conclusions imprudent. These limitations include a lack of father-completed measures (e.g., Martin, 1977), inconsistent father participation across families (e.g., Danforth et al., 2006 and Schuhmann et al., 1998), and in all cases reviewed, mothers were involved in treatment along with fathers, making the independent effect of BPT for fathers difficult to ascertain. This finding of underrepresentation of fathers in the BPT literature is consistent with reviews of the child psychopathology and pediatric literatures (Cassano et al., 2006, Phares and Compas, 1992, Phares et al., 2005 and Phares et al., 2005). Second, most of the studies have methodological limitations or limited generalizability that make widespread recommendations for father BPT tenuous at best (Tiano & McNeil, 2005). Further, only three peer-reviewed studies have specifically addressed father involvement in children with ADHD, even though BPT is a first-line treatment for the disorder (American Academy of Pediatrics, Subcommittee on Attention-Deficit/Hyperactivity Disorder, Committee on Quality Improvement, 2001 and Pelham and Fabiano, 2008). Finally, there is no study to the authors’ knowledge that investigates father participation and benefit from a BPT program, independent from another parent (e.g., the child’s mother) who also participated, which is a critical first step in the investigation of the efficacy of BPT for fathers of children with ADHD. Therefore, a study was conducted to investigate the effectiveness of BPT for fathers of children with ADHD. The present study was conducted to determine whether a novel format of BPT that included sports activities and parent-child interactions in a father-friendly context resulted in improved child outcomes relative to a standard BPT program. Sports activities were emphasized in the current project because behavioral interventions implemented within the context of recreational activities is recognized as an evidence-based treatment for ADHD for children (Pelham & Fabiano, 2008), and interacting with children in such activities is an area in which fathers consistently play a prominent role (Child Trends, 2002 and Russell and Russell, 1987). An additional aim was to investigate whether a program designed explicitly for fathers resulted in increased participation and engagement relative to a standard BPT program. It was hypothesized that fathers in both BPT groups would benefit from their respective programs as measured by ratings of child functioning but that the BPT program that included sports activities would result in increased father engagement, consumer satisfaction, and adherence.