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Journal of Attention Disorders

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A Comparison of Preferred Treatment Outcomes Between Children With ADHD and Their Parents
Tracey B. Traywick, Angela L. Lamson, John M. Diamond and Sandra Carawan
J Atten Disord 2006; 9; 590
DOI: 10.1177/1087054705286062

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Journal of Attention Disorders
Journal ofetAttention
10.1177/1087054705286062
Traywick al. / Preferred
Disorders
Outcomes of T reatment
Volume 9 Number 4
May 2006 590-597
© 2006 Sage Publications
10.1177/1087054705286062

A Comparison of Preferred Treatment http://jad.sagepub.com


hosted at
http://online.sagepub.com
Outcomes Between Children With ADHD
and Their Parents
Tracey B. Traywick
Angela L. Lamson
John M. Diamond
Sandra Carawan
East Carolina University

Objective: The newest guidelines for the treatment of ADHD call for the formation of an individualized treatment plan based
on collaboration. Because the process of collaboration requires the communication of desired outcomes, the authors’ goal is to
examine the preferred outcomes of treatment for ADHD for children and parents. Method: A preferred outcomes question-
naire is used to gather data. A listing of the outcomes in ranked order is generated for each group. Spearman’s rho is used to
generate comparative data. Results: Our results indicate a significant correlation between the preferred outcomes of the chil-
dren and the parents. There is one outlier regarding the use of medication. Conclusion: The existence of the single outlier con-
cerning the use of medication may infer that an assessment of the child’s feelings regarding a medication regimen is therapeuti-
cally indicated. (J. of Att. Dis. 2006; 9(4)590-597)

Keywords: ADHD; preferred outcomes; treatment plan; biopsychosocial; children; parents

A DHD is one of the most prevalent and impairing


forms of childhood behavioral disorders. Research-
ers have shown that this particular disorder affects an esti-
tal Health. The purpose of the study was to determine the
efficacy of various treatment methods for ADHD, includ-
ing the use of stimulant medication. The Collaborative
mated 3% to 5% of school-aged children (Brown, 2000; Multimodal Treatment Study of Children With ADHD
Szatmari, 1992), and one third to one half of all child (MTA) was conducted during a 14-month period, with the
mental health referrals are related to ADHD (Goldman, final results published in 1999 (MTA Cooperative Group,
Genel, Bezman, & Slanetz, 1998; Popper, 1988). 1999). The initial results of the study indicated that
Although a great deal of controversy regarding the etiol- pharmacotherapy was superior to behavior therapy alone
ogy and course of treatment for ADHD exists among pub- and that a combination of behavior therapy and
lic and professional sectors, ADHD remains a widely pharmacotherapy was only slightly better than medica-
diagnosed disorder among children and adults. tion alone (MTA Cooperative Group, 1999). However,
Although the exact causes of ADHD are still unknown post hoc analyses of the MTA data confirmed that the
at this time, physicians and mental health professionals improvement attained with combination therapy was
have been given the onerous task of finding effective statistically significant over medication therapy alone
methods of treatment for the disorder. The most common (Conners et al., 2001).
forms of treatment to date include the use of psychotropic
medications, behavioral therapy (Hinshaw, Klein, & Treatment Planning
Abikoff, 1998; Pelham & Hinshaw, 1992; Pelham &
Considering that ADHD is a multifaceted disorder
Murphy, 1986), and parent training (Corcoran, 2000;
with no certain etiological model, designing a specific
Schachar et al., 2002). In the 1990s, however, the use of
treatment plan for individuals with this disorder is a com-
stimulant medication in children created an intense con-
troversy among the public, professional, and governing
agencies. This controversy led to a landmark research Authors’ Note: Address correspondence to Tracey B. Traywick at
study on ADHD funded by the National Institute of Men- ttraywick@wesleyshelter.org.

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Traywick et al. / Preferred Outcomes of Treatment 591

plex task. It has been stated that “with the onset of health ment for complex disorders should hinge on the preferred
care reform and the increasing emphasis on clinical outcomes of the consumer. Hence, the data collected in
accountability . . . [it is essential] to systematically this study from a small group of participants regarding
improve care by organizing and documenting the delivery what they want most out of the treatment for ADHD may
of care according to client-oriented outcomes” (Magyary be a starting point for further research in this area.
& Brandt, 2002, p. 557). When clients are faced with
managing a complex condition that involves many issues,
Method
such as ADHD, it may be essential for therapists to help
clients prioritize the issues that are most important to
Participants
them before a treatment plan can be devised.
Participants were recruited at the Pitt County Mental
Purpose Health Center during a regularly scheduled visit. The par-
ents of possible candidates were asked by the attending
Considering the need for extended research on the
nurse if they would be willing to participate in a research
treatment for ADHD, the primary objective of this study
study on ADHD. The sample consists of children, ages 7
is to examine the preferred outcomes of treatment for this
to 16, with a diagnosis of ADHD. Parents or the primary
disorder among children and their parents. The research-
caregiver of these children were also invited to participate
ers aim to discover which outcomes of treatment (as
in the research study. The total number of participants for
delineated by the MTA Study) are most important to chil-
this study was 27 children and 26 parents. There were
dren and to their parents. This study uses a “preferred out-
more male children (63%) who participated than female
comes of treatment” questionnaire designed specifically
children, and there were more female parents (88%) who
for this research to gather preferred outcomes data from
participated than male parents. The majority of partici-
the participants. The researchers also discuss the feasibil-
pants belonged to a racial minority: 67% of the children
ity of using this questionnaire as a means of collecting
were African American and 33% were Caucasian, 65% of
subjective data from this population.
the parents were African American and 35% were Cauca-
sian. The majority of participants (65%) indicated that
Research Questions
their total household income was less than $20,000 per
There are three questions these researchers explore: (a) year.
What do children with ADHD want most out of their
treatment? (b) What do the parents and primary care- Measure
givers of children with ADHD want most out of treat-
The measure developed for this study is in the format
ment? and (c) To what extent do the preferred outcomes
of a visual analogue scale (VAS). The VAS structure was
of the children correspond with the preferred outcomes of
chosen because of the wide use and recognition of the
the parents?
scale (Choinere & Amsel, 1996), the scale’s simplicity,
and the reported reliability in measuring subjective phe-
Importance of Study
nomena (Gift, 1989). A VAS usually consists of a 10 cm
Noting the systemic impact that ADHD has on the lives line anchored on either end by a minimal and maximal
of individuals with the disorder, their families, and the extreme of the subjective state being measured. For the
community at large, research that will enhance our ability purpose of this study, the two anchor points used needed
to assess the preferred outcomes of consumers affected by to convey the idea of extremely important and not impor-
ADHD is therapeutically indicated. After searching vari- tant at all. However, the scale needed to be age appropri-
ous academic databases (i.e., Academic Search Elite, ate and considerate of the fact that children with ADHD
MasterFILE Premire, CINAHL, Health Source: Nursing/ often have learning disabilities and deficits in verbal com-
Academic Edition, MEDLINE, Psychology and Behav- munication (Barkley, 1995). The two end points used
ioral Sciences Collection, Alt HealthWatch, Biomedical were a smiley face and a sad face to indicate agreement or
Reference Collection: Comprehensive, Nursing & Allied disagreement, and the questions used were prefaced with
Health Collection: Comprehensive, and Sociological I want. Examples of questions used might be as follows:
Collection), it was concluded that research on the pre- “I want to make better grades” or “I want to stop taking
ferred outcomes of treatment for ADHD has not been medicine.” The same questionnaire was used with the
explored previously in ADHD research literature. The parents/caregiver with only one adjustment: The ques-
move toward evidence-based research dictates that treat- tions were prefaced with I want my child.

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592 Journal of Attention Disorders

The questions on the scale were derived from the six interval. A scatter plot of the parent’s means for each item
domains identified in the MTA Study as areas of impair- versus children’s means for each item was also generated.
ment observed in children with ADHD: core symptoms In the second analysis, the researchers examined the
(i.e., inattention, impulsiveness, restlessness), academics, correlations of the ratings of items on the measure for
relationships with peers, relationships with parents (care- each child-parent pair. A Spearman’s rho statistic was
giver), internalized stress, and oppositional/aggressive generated for each of the 27 child-parent dyads. Again,
behavior (MTA Cooperative Group, 1999). The the statistics were generated using a two-tailed 95% con-
researcher also requested input on other areas of concern fidence interval. The values of the correlation coefficients
from local clinicians currently working with patients for each pair were then recorded as a new variable, and the
diagnosed with ADHD. A seventh category, labeled pro- median, range, and extreme values were then reported.
fessional survey, was developed to address the issues
these clinicians conveyed as important treatment out-
Results
comes. In addition, the questionnaire contains two blank
spaces, allowing the participant the opportunity to The total number of participants for this study was 27
include any additional outcomes he or she considers children and 26 parents. There was 1 parent who had 2
important. children to participate. In the analysis of the child-parent
Given the children’s short attention span, the pairs, this particular parent’s answers were listed twice to
researcher attempted to keep the number of questions create two separate pairings. In the analysis of the rank-
fewer than 20 and the wording at second grade reading ings for each group, the parent’s answers were listed only
level. Prior to use in the study, the questionnaire was once.
administered to a second grade teacher. The teacher pro- Of the 27 children who participated in the study, 85%
vided feedback to the researcher about any problems had a chart diagnosis of ADHD only, 15% were diag-
encountered while completing the measure, and adjust- nosed with ADHD and at least one other comorbid disor-
ments were made accordingly. der. Regarding treatment methods, 78% of the children
were receiving medication only, and 22% were receiving
Outcome Preferences (Parents and Children) medication and counseling. Regarding the use of medica-
tions, 70% of the children were receiving stimulant medi-
The measure for this study included 18 possible out- cation only, whereas 30% were receiving multiple
comes of treatment. The researcher assigned each medications.
response a numerical value (0 to 100) based on the loca-
tion of the participant’s mark on the 100 mm line, which
lies between the happy face and sad face anchor points: Children’s Rankings
The higher the number (closer to the happy face), the The mean of each item on the questionnaire was gener-
stronger the preference for each item. These numerical ated for the children. The items were then ranked in
values were then used to generate statistics. A mean was descending order according to their mean (see Table 1). It
computed for each possible outcome for each group of is of interest that the listing of means reflected a cluster of
participants. Each outcome was then ranked according to three items as ranked highest by the children. It is also of
its mean. A listing of the outcomes in ranked order was interest that these three items described as most important
then generated for the children and for the parents. to the children were all extrinsic and reflected improve-
ments in three different domains of impaired functioning:
Comparison Between Groups improvements in academics (RQ13 better in school),
improvement in core ADHD symptoms (RQ2 listen
The last objective for this study was to generate com- better), and improvements in parent-reported aggressive/
parative data between the children and their parents. The oppositional behavior (RQ18 be good).
researchers conducted two analyses to achieve this objec-
tive. In the first analysis, the Spearman’s rho statistic was Parent’s Rankings
used to estimate the correlation between the children’s
means for each item on the measure and the parent’s The mean of each item on the questionnaire was gener-
means for each item on the measure. The Spearman corre- ated for this parent sample. The items were then ranked in
lation coefficient is nonparametric and is therefore an descending order according to their mean (see Table 2).
appropriate statistic to use with small sample sizes. The The seven items ranked highest by this group of parents
statistic was generated using a two-tailed 95% confidence correspond to five of these categories as follows: internal-

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Traywick et al. / Preferred Outcomes of Treatment 593

Table 1
Children’s Rankings of Preferred Outcomes of ADHD Based on Means
Rank Item Number Description Range Minimum Maximum M SE

1 RQ13 Better in school 56 44 100 90.44 2.61


2 RQ2 Listen better 87 13 100 87.07 3.32
3 RQ18 Be good 91 9 100 85.37 3.89
4 RQ6 Feel good about self 76 24 100 81.33 3.95
5 RQ15 Communicate 92 8 100 80.81 4.96
6 RQ12 Do for self 97 3 100 80.78 4.74
7 RQ4 Hold temper 93 7 100 80.19 5.50
8 RQ16 Adults nice 92 8 100 77.93 4.81
9 RQ5 Feel happier 98 2 100 74.19 5.29
10 RQ11 Stop meds 98 2 100 73.67 7.01
11 RQ3 Remember 94 5 99 72.85 5.19
12 RQ10 Know about ADHD 95 5 100 72.15 5.76
13 RQ7 Teacher like 95 5 100 71.67 5.38
14 RQ17 Family like 96 4 100 70.59 5.30
15 RQ14 More friends 98 2 100 67.85 6.33
16 RQ1 Sit still in class 93 3 96 66.19 6.56
17 RQ9 Adults listen 98 2 100 59.19 6.95
18 RQ8 Child alone 97 1 98 36.48 6.72

Table 2
Parent’s Rankings of Preferred Outcomes of ADHD Based on Means
Rank Item Number Description Range Minimum Maximum M SE

1 RQ6 Feel good about self 36 64 100 91.46 1.52


2 RQ2 Listen better 42 56 98 91.15 1.67
3 RQ3 Remember 28 71 99 90.88 1.47
4 RQ13 Better in school 53 47 100 90.88 2.06
5 RQ18 Be good 47 53 100 90.77 1.96
6 RQ10 Know ADHD 53 46 99 90.27 2.10
7 RQ12 Do for self 37 63 100 90.04 1.75
8 RQ1 Sit still in class 44 54 98 88.88 2.00
9 RQ5 Feel happier 96 3 99 87.27 4.04
10 RQ17 Family like 48 51 99 87.12 2.17
11 RQ16 Adults nice 47 52 99 87.00 2.65
12 RQ9 Adults listen 57 42 99 85.58 2.82
13 RQ7 Teacher like 53 47 100 85.19 3.16
14 RQ15 Communicate 90 10 100 84.50 4.05
15 RQ4 Hold temper 94 4 98 84.27 3.95
16 RQ14 More friends 92 7 99 78.23 4.84
17 RQ8 Child alone 99 1 100 63.62 6.04
18 RQ11 Stop meds 97 1 98 53.73 7.75

izing symptoms (child to feel good about self), core Comparison Between Groups
ADHD symptoms (listen better, remember things better),
academics (better in school), parent-reported behavior The relationship between the means of each item for
(child to be good), and concerns from the professional the group of children and the means of each item for the
survey (know more about ADHD, child to do things for group of parents was explored. The results indicate there
self). is a significant correlation between the two groups,

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594 Journal of Attention Disorders

Figure 1 Table 3
Scatter Plot of Child Versus Parent Group Means Correlation of Child-Parent Pairs Using Spearman’s
(All Available Data) Rho
Rank Extreme Values Median Range
100

13
Highest
90
18
2 1 .983 .569 .978
4 15 12 6 2 .975
16 3 .965
mean scores for children per item

80
11 5
7 17 10 3 4 .918
70 14
1 5 .905
Lowest
9
60 1 .005
2 .039
50 3 .079
4 .098
40 8

30
50 60 70 80 90 100 this group of children was “to listen better” (mean of
mean scores for parents per item 87.07) and third was “to be good” (mean of 85.37).
Although the measure has not been tested for reliability or
validity, these results provide a starting point for further
refinement of the measure.
Spearman ρ(N = 18) = .548, p = .018. A scatter plot of the There is one particular finding from the children’s
child versus parent means of the 18 items provided addi- rankings that bears closer scrutiny. The children ranked
tional information on this correlation (see Figure 1). This Item 8, “I want for people to just leave me alone,” as last
graph revealed agreement between the parents and chil- on the list with a mean of 36.38. This result is surprising
dren on the importance of all the items with the exception considering that children with ADHD often generate a
of RQ11 (stop taking medicine). This one outlier indi- great deal of negative attention and exhibit difficulty in
cated the children considered not taking medicine to be relating to others. Goodyear and Hynd (1992) released a
more important than did the parents. study that indicated that children with ADHD–predomi-
In a second analysis, a Spearman’s rho was generated nantly inattentive were often socially maladjusted and
for the numerical values between the child and his or her had a predisposition for social withdrawal. It has also
parent for each of the 27 child-parent pairs. Descriptive been cited that our society does not possess the ability to
statistics were then generated for this new variable (see handle children with ADHD, and as a result, these chil-
Table 3). These statistics indicate the median value for the dren are often disciplined excessively and/or abused
correlations is ρ = .569, and the range is .978. (Warner, 1995). Considering the social and behavioral
challenges that confront children with ADHD, it is sur-
Discussion prising that a group of children would rank being left
alone as least important.
In the present study, the preferred outcomes of treat-
ment for ADHD were examined. The researchers were Question 2: What Do Parents Want Most Out of
interested in discovering what children and their parents Treatment for Their Child With ADHD?
want most out of treatment for the disorder and to what This question was managed for the parents in the same
extent the children’s preferences correlate with their par- manner as for the children. The results yielded a cluster of
ent’s preferences. The results were used to answer three seven items ranked as most important to the parents: child
questions. to feel good about himself or herself, child to listen better,
child to remember things better, child to do better in
Question 1: What Do Children Want Most Out school, child to be good, to know more about ADHD, and
of Their Treatment for ADHD? child to do things for himself or herself.
The item that ranked the highest with a mean of 90.44 On an intuitive level, the finding that the parents con-
was “to do better in school.” The item ranked second by sidered the most important outcome of treatment to be an

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Traywick et al. / Preferred Outcomes of Treatment 595

increase in their child’s self-esteem is interesting because Finding there was not a significant correlation between
it has nothing to do with the child’s behavior. The vast the rankings of the children and parents for the majority
majority of research reiterates again and again that the of child-parent pairs cannot be considered unusual. There
child’s disorganized, disruptive, and socially noxious exits a vast amount of research describing the conflictual
behavior intensifies the discord in parent-child interac- and often oppositional nature of the parent-child relation-
tions (Wells et al., 2000). The parents of children with ship in families with children who have ADHD (Baldwin,
ADHD face a multitude of challenges when it comes to Brown, & Milan, 1995; Barkley, 1995; Wells et al., 2000).
managing their children and frequently become more In addition, there is the self-evident fact that children do
directive and commanding when their children refuse to not undergo treatment for ADHD of their own accord
comply (Barkley, Karlsson, Pollard, & Murphy, 1985). It (Hoza et al., 2000). Taking both of these points into con-
has also been demonstrated that parents often feel over- sideration, it is not unreasonable to expect the likelihood
burdened with providing care for their child and are at of the existence of disagreement for preferred outcomes
greater risk for depression and marital conflict of treatment in the parent-child dyads for this research
(Cunningham, Benness, & Seigel, 1988). Taking all these sample.
findings into consideration, it is surprising that a sample
of parents would list “I want my child to feel good about Limitations
himself or herself” as the most important outcome of
Given that this research is new and that the Preferred
treatment for ADHD.
Outcomes of Treatment for ADHD measure was created
specifically for this study, it is understandable that the
Question 3: To What Extent Do the Preferred
limitations of this research are relatively broad and the
Outcomes of the Children Correlate With the
results should be interpreted with caution. First and fore-
Preferred Outcomes of the Parents?
most, the Preferred Outcomes of Treatment measure has
It was found that the correlation of the rankings of the not been tested for reliability or validity. Although the
children and the rankings of the parents was significant questionnaire was reviewed by a second grade teacher
(p = .018). A scatter plot of the means of the parents in and by a small group of children ages 9 to 12, it cannot be
relation to the means of the children provided additional concluded with any certainty that the researcher actually
information. An examination of this scatter plot exposed measured the subjective information that was intended.
one outlier of the relationship. Item 11, “to stop taking Another limitation of this study was the small sample
medicine,” was ranked much higher by the children than size. The number of participants was 27 children and 26
by the parents. This finding is consistent with other parents. It is not expected that with this sample size, the
research on ADHD (Weiss, Jain, & Garland, 2000). actual distribution of children with ADHD from the gen-
In a report released in 2000, Weiss et al. indicate that it eral population was represented. Hence, the results from
is not unusual for adolescents with ADHD to want to dis- this research cannot be generalized to the broader popula-
continue taking medicine. They go on to say that “before tion. Furthermore, the sample was not cross-cultural or
medication, they see themselves as ‘bad’, but after medi- ethnically diverse. African Americans and Caucasians
cation, they see themselves as ‘mental’ (the worse of the were the only races represented in the study, and the par-
[two] evils)” (Weiss et al., 2000, p. 721). For adolescents, ticipants were all from one small section in eastern North
taking a medicine that profoundly affects their cognitive Carolina. Therefore, cultural differences such as biases
and emotional functioning requires that at some point toward independence and/or determinants of acceptable
they integrate this awareness into their self-image (Weiss behavior were not captured in this study.
et al., 2000). Thus, it is reasonable to consider that the A further limitation of this study that should be empha-
children in this study would express a partiality for sized was the bias inherent in agreeing to participate. It is
discontinuing medication. not unreasonable to consider the possibility that the per-
A second analysis of the raw data was also conducted. sonality traits that contribute to a willingness to take part
A Spearman’s rho correlation statistic was generated for in research may actually exaggerate the skewed property
each of the 27 child-parent pairs. The range was found to of research results. Many parents and children who met
be .978. An interpretation of this statistic provides the the inclusion criterion (ADHD diagnosis) chose not to
conclusion that although as a group the rankings of the participate. It is a principal concern that by not interview-
children correlate significantly with the rankings of the ing this population, some features inherent in ranking
parents, it cannot be assumed that this same correlation outcomes of treatment for ADHD were not captured in
exists between each child-parent dyad. this study.

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596 Journal of Attention Disorders

Conclusion Conners, C. K., Epstein, J. N., March, J. S., Angold, A., Wells, K. C.,
Klaric, J., et al. (2001). Multimodal treatment of ADHD in the
MTA: An alternative outcome analysis. Journal of the American
Generally, the results of this study indicate that the Academy of Child & Adolescent Psychiatry, 40, 159-167.
children were most concerned with doing better in school Corcoran, J. (2000). Family treatment of preschool behavior prob-
and their parents were most concerned with increasing lems. Research on Social Work Practice, 10, 547-581.
their child’s self-esteem. The parents and children, as a Cunningham, C., Benness, B., & Seigel, L. (1988). Family function-
group, tend to agree on the rankings of the outcomes of ing, time allocation, and parental depression in the families of nor-
mal and ADHD children. Journal of Clinical Child Psychology, 17,
treatment. The only outlier to this correlation was the
169-177.
issue of medication. The children considered stopping Gift, A. G. (1989). Visual analogue scales: Measurement of subjective
medication as more important than the parents. The corre- phenomena. Nursing Research, 38, 286-288.
lations between the children and parents did not extend to Goldman, L. S., Genel, M., Bezman, R. J., & Slanetz, P. J. (1998).
individual child-parent pairs. Diagnosis and treatment of attention-deficit/hyperactivity disorder
Given the exploratory nature of this research, there are in children and adolescents. Journal of the American Medical
Association, 279, 1100-1206.
several points to consider. Clinicians should be informed Goodyear, P., & Hynd, G. W. (1992). Attention deficit disorder with
that parents and children do have preferences for treat- (ADD/H) and without (ADD/WO) hyperactivity: Behavioral and
ment outcomes for ADHD. Children and parents can neuropsychological differentiation. Journal of Clinical and Child
express these subjective preferences, which, in turn, can Psychology, 21, 273-305.
better inform treatment planning. If disagreement exists Hinshaw, S. P., Klein, R. G., & Abikoff, H. (1998). Childhood attention
deficit hyperactivity disorder: Nonpharmacologic and combina-
between the child and parent as to the goals of treatment,
tion treatments. In P. E. Nathan & J. Gorman (Eds.), Treatments
this discrepancy may need to be addressed directly by the that work (pp. 26-41). New York: Oxford University Press.
clinician to provide better care for the child. Hoza, B., Owens, J. S., Pelham, W. E., Swanson, J. M., Conners, C. K.,
Systemic clinicians who regard incorporating multiple Hinshaw, S. P., et al. (2000). Parent cognitions as predictors of child
family members in treatment as an integral component of treatment response in attention-deficit/hyperactivity disorder.
therapy may find the measures used in this study espe- Journal of Abnormal Child Psychology, 28, 569-592.
Magyary, D., & Brandt, P. (2002). A decision tree analysis and clinical
cially beneficial. These measures may provide a means of paths for the assessment and management of children with ADHD.
joining and communicating at a more subjective level Issues in Mental Health Nursing, 23, 553-565.
than would be possible by just asking these families what Pelham, W. E., & Hinshaw, S. P. (1992). Behavioral interventions for
they want most out of treatment. The results of this study ADHD. In S. M. Turner, K. S. Calhoun, & H. E. Adams (Eds.),
and the implications derived from them may be viewed as Handbook of clinical behavior therapy (2nd ed., pp. 259-283).
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Traywick et al. / Preferred Outcomes of Treatment 597

Tracey B. Traywick, MS, is a graduate from the Marriage and Family John M. Diamond, MD, is a professor and head of the Division of
Therapy Program at East Carolina University. Child and Adolescent Psychiatry at East Carolina University, Brody
School of Medicine.
Angela L. Lamson, PhD, is an assistant professor at East Carolina
University in the Department of Child Development and Family Rela- Sandra Carawan, MS, is a graduate from the Marriage and Family
tions, Marriage and Family Therapy Program. Therapy Program at East Carolina University.

Downloaded from http://jad.sagepub.com by joana melo on April 27, 2009