MMaarrqquueettttee UUnniivveerrssiittyy ee--PPuubblliiccaattiioonnss@@MMaarrqquueettttee Dissertations, Theses, and Professional Dissertations (1934 -) Projects EExxaammiinnaattiioonn ooff aa PPaarreenntt--AAssssiisstteedd,, FFrriieennddsshhiipp--BBuuiillddiinngg PPrrooggrraamm ffoorr AAddoolleesscceennttss wwiitthh AADDHHDD Denise Marie Gardner Marquette University Follow this and additional works at: https://epublications.marquette.edu/dissertations_mu Part of the Clinical Psychology Commons, and the Social Psychology Commons RReeccoommmmeennddeedd CCiittaattiioonn Gardner, Denise Marie, "Examination of a Parent-Assisted, Friendship-Building Program for Adolescents with ADHD" (2015). Dissertations (1934 -). 549. https://epublications.marquette.edu/dissertations_mu/549 EXAMINATION OF A PARENT-ASSISTED, FRIENDSHIP-BUILDING PROGRAM FOR ADOLESCENTS WITH ADHD by Denise M. Gardner, M.S. A Dissertation submitted to the Faculty of the Graduate School, Marquette University, in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy Milwaukee, Wisconsin September 2015 ABSTRACT EXAMINATION OF A PARENT-ASSISTED, FRIENDSHIP-BUILDING PROGRAM FOR ADOLESCENTS WITH ADHD Denise M. Gardner, M.S. Marquette University, 2015 Attention-Deficit/Hyperactivity Disorder (ADHD) is a common childhood disorder that often contributes to impairment in multiple domains, including peer functioning. Specifically, youth with ADHD tend to have fewer friends and lower quality friendships, experience greater peer victimization, and engage in more inappropriate social behaviors than typically developing peers. Researchers have highlighted the need for long-term interventions that directly address peer difficulties, emphasize dyadic friendship-building, and include a parent component. Thus, the current pilot study will examine the effectiveness of PEERS, a parent-assisted, friendship- building program, at establishing mutual friendships and improving current peer relationships in adolescents with ADHD. Participants in the study included 20 adolescents with ADHD (ages 11-16) and their parents. At baseline, adolescents completed measures related to friendship quality, social knowledge, social self-efficacy, get-togethers, and peer conflict. They also participated in a brief observation task as a measure of social interaction behavior. Parents completed measures related to get-togethers and peer conflict. All families completed the Program for the Evaluation and Enrichment of Relational Skills (PEERS), a 14-week intervention. Following the intervention, families completed post-treatment measures and responded to a question regarding the initiation of a new friendship. Analyses were conducted using a series of paired-samples t-tests examining differences from baseline to post-treatment. Results indicated that the majority of parents and adolescents reported the initiation of a new friendship over the course of treatment. Additionally, there was a significant improvement in adolescent social knowledge and a significant increase in hosted get-togethers. Effect sizes for these variables were large. While the remaining variables demonstrated changes in the expected direction, none of the analyses were significant. Effect sizes ranged from small to moderate. The current pilot study demonstrated that, following participation in PEERS, adolescents demonstrated improvement in several peer functioning variables. While some analyses were not significant, moderate to large effect sizes were established for some variables, indicating that small sample size may have contributed to non-significant results. A larger sample will allow for better understanding of the effectiveness of PEERS for youth with ADHD and may highlight components of the program that require modification in order to better target the ADHD population. i ACKNOWLEDGEMENTS Denise M. Gardner, M.S. I would like to thank all those who have supported this research project and my greater academic endeavors. First, I would like to thank the participating families and community partners. I would like to extend my appreciation to my committee members, Dr. Alyson Gerdes, Dr. John Grych, and Dr. Amy Van Hecke, for their guidance and thoughtful feedback regarding this study. I would especially like to thank my advisor, Dr. Gerdes, for her mentorship and support throughout my graduate career. I would like to thank the members of the PEERS research team, who have contributed significant time, effort, and energy toward the completion of this project. I would especially like to thank my collaborator, Kelsey Weinberger, for her considerable contribution to this project. I would like to thank several individuals who have supported me throughout this project and my graduate career. I would like to thank my family who have supported me through the ups and downs of my graduate school career. I also would like to thank my fiancé, Ben, who has supported me from both near and far in my quest to complete graduate school. Finally, I would like to thank my fellow graduate students, who have provided support and friendship throughout all of my graduate school endeavors. ii TABLE OF CONTENTS ACKNOWLEDGMENTS………………………………………………………...……i LIST OF TABLES...………………………………………………..…………………………….iii CHAPTER I. INTRODUCTION………………………………………………………………….…1 A. ADHD in Children and Adolescents.………………………...….…..2 B. Peer Relationships and Friendships in Children and Adolescents with ADHD..……………………………………………….………..3 C. Peer Functioning Interventions for ADHD.…………………….…..13 D. Program for the Evaluation and Enrichment of Relational Skills.…..18 E. Current Study…….……………………………………………….…19 II. METHOD………………………………………………………………………….....21 A. Recruitment...……………………………………………………..…21 B. Participants……………………………………………………..……21 C. Procedure………………………….…...………………………….....23 III. RESULTS………………………………………….………………..……………....32 A. Data Analytic Plan…………………………………………….……..32 B. Primary Analyses………………………………………………….....32 IV. DISCUSSION..…………………………………………………………………..….36 A. Limitations………………………………………………………..….40 B. Clinical Implications and Future Directions…………………..……..40 V. BIBLIOGRAPHY………………………………………………………………..…..43 iii LIST OF TABLES I. Demographic Characteristics………………………………………………..23 II. Means, Standard Deviations, and Ranges of Outcome Measures…………..30 III. Mean Differences in Adolescent and Parent Measures from Baseline to Post- treatment…………………………………………………………………….34 1 INTRODUCTION Attention-Deficit/Hyperactivity Disorder (ADHD) is a common childhood disorder affecting between 3% and 7% of school-aged children (American Psychiatric Association [APA], 2000). Between 50% and 85% of children with ADHD continue to meet diagnostic criteria and experience impairment in adolescence (Barkley, Fischer, Edelbrock, & Smallish, 1990; Hurtig, Ebeling, Taanila, Mieuttenen, et al., 2007). In addition to symptoms of inattention and hyperactivity/impulsivity, children and adolescents with ADHD experience significant functional impairment in academic, familial, and peer functioning (APA, 2000). They tend to have fewer friends and lower quality friendships and experience greater peer victimization than typically developing peers (Hoza, 2007). While previous research has demonstrated that many children with ADHD continue to meet diagnostic criteria and experience impaired peer relationships in adolescence, the majority of treatment research continues to focus on school-aged populations (Hurtig et al., 2007). Given that adolescence is typically the time when teens begin to take more responsibility for the development and maintenance of their peer relationships, adolescence may be a crucial time to assess peer functioning and implement peer interventions for teens with ADHD (Mikami, 2010). Historically, interventions aimed at improving peer functioning in children with ADHD have been implemented as part of larger behaviorally-focused interventions that also include parent training, with few programs focusing solely and intensively on dyadic friendship-building (Frankel, Myatt, Cantwell, & Feinberg, 1997; Hoza, 2007; MTA Cooperative Group, 1999). Recently, researchers have highlighted the need for long-term 2 interventions that directly address peer relationship difficulties with an emphasis on dyadic peer relationships, rather than peer group acceptance (Hoza, 2007; Mikami, 2010; Normand, Schneider, Lee, Maisonneuve, Kuehn, et al., 2011). Although friendship- building programs, such as the Program for the Evaluation and Enrichment of Relational Skills (PEERS), which targets dyadic peer relationships, have demonstrated positive outcomes for several populations, there are no published studies on the effectiveness of PEERS or other similar programs for adolescents with ADHD (Frankel & Myatt, 2007; Frankel & Whitham, 2011; Laugeson, Frankel, Mogil, & Dillon, 2009). Thus, the current study will examine the effectiveness of PEERS, a parent-assisted, friendship- building program, at establishing mutual friendships and improving current peer relationships in adolescents with ADHD. ADHD in Children and Adolescents ADHD is one of the most common disorders of childhood, accounting for 1/3 to 1/2 of all referrals for mental health services (Mash & Wolfe, 2013). Therefore, children with ADHD are likely to be present in nearly every classroom in the United States (Hoza, 2007; McQuade & Hoza, 2008). Considerable gender differences have been observed in the prevalence of ADHD, with higher prevalence rates in boys than girls (Faraone, Sergeant, Gillberg, & Biederman, 2003). The APA has identified three subtypes of ADHD, including Predominantly Inattentive Presentation (ADHD-I), Predominantly Hyperactive/Impulsive Presentation (ADHD-HI), and Combined Presentation (ADHD-C; APA, 2013). In order to meet criteria for one of the ADHD subtypes, children must exhibit at least six symptoms of inattention and/or hyperactivity/impulsivity in two or 3 more settings, as rated by parents and teachers (APA, 2013). Additionally, the symptoms of inattention and/or hyperactivity/impulsivity must cause significant impairment in academic, socioemotional, and/or familial functioning (APA, 2013). ADHD is best diagnosed through a comprehensive assessment battery that includes structured and unstructured interviews with parents and teachers, symptom questionnaires, observations of the child, and cognitive testing (Barkley, 2006; 1997). Common treatment recommendations for ADHD include stimulant medication and behavior modification programs, which typically consist of parent training and a school intervention (Barkley, 2006). Previous research has demonstrated that the most effective treatment for some children with ADHD is a combination of stimulant medication, behavior modification, and social skills training (Mrug, Hoza, & Gerdes, 2001, MTA Cooperative Group, 1999). Research has demonstrated that stimulant medication functions to reduce negative behaviors in the classroom and peer contexts, whereas behavioral approaches serve to teach and reinforce appropriate behaviors and skills (Hoza, 2007). Further review of specific peer functioning interventions will be provided in detail later. Peer Relationships and Friendships in Children and Adolescents with ADHD Importance of childhood peer relationships and friendships As children age, they spend increasingly more time in the company of peers. By the time they reach adolescence, individuals spend nearly one third of their day with peers (Sibley, Evans, & Serpell, 2010). Previous research has examined peer relationships according to both dyadic and group contexts (Bagwell, Brooke, Molina, 4 Pelham, & Hoza, 2001; Blachman & Hinshaw, 2002; Mikami, 2010; Normand et al., 2011). A dyadic relationship, or friendship, refers to a voluntary connection created between two children with expectations for mutual support, validation, and companionship (Schneider, Weiner, & Murphy, 1994). Conversely, peer group acceptance is defined as the status of being liked by the majority of one’s peer group and being disliked by few members of one’s peer group (Mikami, 2010). Recently, researchers have highlighted the importance of distinguishing between dyadic friendship and peer group acceptance when examining children’s peer functioning (Hoza, 2007; Mikami, 2010). Previous studies have provided mixed results on the protective function of mutual friendships against future negative peer relationships (Bollmer, Milich, Harris, & Maras, 2005; Frankel & Whitham, 2011; Mrug, Molina, Hoza, Gerdes, et al., 2012; Newcomb & Bagwell, 1995). For example, Bollmer and colleagues (2005) found that the presence of at least one mutual friendship during childhood appeared to compensate for the consequences of peer rejection and victimization and lead to better adjustment and acquisition of social competence. These results have been replicated in clinical populations as well. For example, Cardoos and Hinshaw (2011) found that the presence of one mutual friendship reduced the likelihood of peer victimization in girls with ADHD. In contrast, Mrug and colleagues (2012) found that the presence of a mutual friendship did not appear to protect against the negative impact of peer rejection. One potential explanation for these findings is that friendship quality and characteristics are important factors in protection against negative outcomes, and that friendships lacking these qualities may be insufficient in buffering against peer rejection (Mrug et al., 2012).