Behaviour Change

http://journals.cambridge.org/BEC

Additional services for Behaviour Change:

Email alerts: Click here

Subscriptions: Click here
Commercial reprints: Click here
Terms of use : Click here

A Feasibility Study of Enhanced Group Triple P —

Positive Parenting Program for Parents of Children
with Attention-decit/Hyperactivity Disorder

Fiona E. Hoath and Matthew R. Sanders

Behaviour Change / Volume 19 / Issue 04 / December 2002, pp 191 - 206

DOI: 10.1375/bech.19.4.191, Published online: 22 February 2012

Link to this article: http://journals.cambridge.org/abstract_S0813483900001005

How to cite this article:

Fiona E. Hoath and Matthew R. Sanders (2002). A Feasibility Study of Enhanced Group
Triple P — Positive Parenting Program for Parents of Children with Attention-decit/
Hyperactivity Disorder. Behaviour Change, 19, pp 191-206 doi:10.1375/bech.19.4.191

Request Permissions : Click here

Downloaded from http://journals.cambridge.org/BEC, IP address: 139.80.123.36 on 12 Mar 2015

 A Feasibility Study of Enhanced Group
Triple P — Positive Parenting Program
for Parents of Children with
Attention-deficit/Hyperactivity Disorder
Fiona E. Hoath and Matthew R. Sanders
The University of Queensland, Australia

The aim of this randomised controlled trial was to examine the efficacy of an Attention-
deficit/hyperactivity Disorder (ADHD)-specific, Enhanced (Level 5) Group Triple P interven-
tion. Twenty families with a child with clinically diagnosed ADHD aged between 5 and 9
years participated. Families were randomly assigned to either an enhanced intervention group
(Enhanced Group Triple P; EGTP) or a wait list (WL) condition. Using parent reports of child
behaviour, parenting practices and family functioning in addition to teacher reports of child
behaviour in the school environment, parents in the EGTP condition reported significant reduc-
tions in intensity of disruptive child behaviour problems, aversive parenting practices and
increases in parental self-efficacy when compared to the WL condition. Parents’ reports at 3-
month follow-up indicated the gains in child behaviour and parenting practices achieved at
post-intervention were maintained.

A ttention-deficit/hyperactivity disorder
(ADHD) is regarded as a behavioural disor-
der of self-control (Barkley, 1998). It is charac-
terised by excessive, long-term and pervasive
problems with inattention, hyperactivity and
impulsivity (American Psychiatric Association,
1994). Children with ADHD have been found
to be more talkative, negative, defiant, demanding
of others’ time and less able to play or work inde-
pendently (Danforth, Barkley, & Stokes, 1991).
ADHD affects 3–5% of children and is
therefore a significant childhood problem. Also,
children with ADHD are very likely to have
comorbid behavioural, emotional and/or learn-
ing difficulties (Biederman, Newcorn, & Sprich,
1991; Hinshaw, 1992). For example, DuPaul,
McGoey, Eckbert and VanBrakle (2001) found
that Preshoolers meeting DSM-IV criteria for
ADHD had high levels of noncompliance
across many parent–child settings and Szatmari,
Offord and Boyle (1989) found that 70% of
children with ADHD had at least one comorbid
behavioural or emotional disorder. The progno-
sis for children with ADHD is poor. These chil-
dren often have adverse academic and
occupational, social and emotional functioning,
and can even have poor physical health
(Campbell, Breaux, Ewing, & Szumowski,
1986; Moffitt, 1990). Research also suggests
that the more comorbid problems a child has,
and the earlier the problems emerge, the poorer
the outcomes will be for that child (Hinshaw,
Lahey, & Hart, 1993).
The impact of ADHD on families is also
significant. Families with a child who has
ADHD have been shown to experience higher
levels of parenting stress and decreased sense of
parenting competence (Anastopoulos, Guevre-
mont, Shelton, & DuPaul, 1992), and have
increased marital conflict and levels of maternal
depression (Fischer, Barkley, Fletcher, &
Smallish, 1990). Family interactions are also

Address for correspondence: Matthew R. Sanders, School of Psychology, The University of Queensland, Brisbane,
QLD 4072, Australia. Email: m.sanders@psy.uq.edu.au or triplep@psy.uq.edu.au

BEHAVIOUR CHANGE
Vol. 19, No. 4 2002 pp. 191–206 191
FIONA E. HOATH AND MATTHEW R. SANDERS
affected. Parent–child interactions have been
found to be significantly more negative and hos-
tile than in comparable families (DuPaul et al.,
2001), particularly during adolescence (Fletcher,
Fischer, Barkley, & Smallish, 1996). Mothers
of children with ADHD have been found to be
less responsive to their children’s questions,
more negative and directive and less rewarding
of desirable behaviours (Danforth et al., 1991).
The presence of comorbid oppositional defiant
disorder (ODD) appears to increase the risk of
negative parent–child interactions (Anastopoulos
et al., 1992). Also, siblings of children with
ADHD have been observed to have higher levels
of conflict than typical child-sibling dyads (Mash
& Johnston, 1983).
A consistent set of family risk factors is
associated with the continuity of preschool
behaviour disorders, such as ADHD or ODD
(Campbell, 1995, 2000). These risk factors
include high levels of maternal depression, mar-
ital conflict and elevated amounts of negative
maternal discipline. Lavigne and colleagues
(1998) also found that low family cohesiveness
and greater family inhibition/control as mea-
sured by the Family Environment Scale (Moos
& Moos, 1981) were correlated with the persis-
tence over time of behaviour disorders first evi-
dent in the preschool years.
Given the significance of family and parent-
ing variables in the development of children
with ADHD, parenting interventions are viewed
as being important in early intervention pro-
grams for these children. Parent management
training (PMT) based on social learning models
(e.g., Patterson, 1982) is an efficacious strategy
used to treat children with disruptive behaviour
disorders (Kazdin, 2000; Sanders & Dadds,
1993). PMT typically teaches parents how to
increase positive interactions with their children
while reducing conflictual and inconsistent par-
enting practices.
Several studies have looked specifically at the
effectiveness of PMT with ADHD children, par-
ticularly of preschool age (Barkley et al., 2000;
Pisterman et al., 1992; Pisterman et al., 1989;
Sonuga-Barke et al., 2001). These studies have
generally found significant improvements in rates
of child compliance and a reduction in frequency
of noncompliant behaviours when comparing
192
treatment to control groups (Pisterman et al.,
1989; Pisterman et al., 1992). In addition,
Pisterman et al. (1992) found that parental
behaviour changed significantly with parents
using commands more appropriately and rein-
forcing child compliance more consistently.
Parents also reported increased sense of compe-
tence. Sonuga-Barke et al. (2001) found that this
type of behavioural parent training was signifi-
cantly more effective than parent counselling
with support or a control group. They suggest
that training in specific behavioural strategies is
the key element of effective psychosocial inter-
vention. However, Barkley et al. (2000), com-
pared school based interventions to PMT, and
found that PMT training was ineffective at
reaching and assisting families largely due to the
failure of many families to attend. Other studies
support the findings that many less educated
parents drop out or attend PMT programs irregu-
larly (Pisterman et al., 1992). The problem of
attrition is a significant factor in the ineffective-
ness of some PMT programs (Kazdin, 1995).
The effectiveness of PMT with primary
school aged students with ADHD has also been
investigated (Anastopoulos, Shelton, DuPaul,
& Guevremont, 1993; Dubey, O’Leary,
& Kaufman, 1983; Weinberg, 1999). These stud-
ies have found similar reductions in the severity
of child disruptive behaviours as were found in
the preschool studies using both group and indi-
vidual intervention programs. Additionally,
reductions in parenting stress, and improvements
in parents’ self-esteem and parental management
of their child’s ADHD behaviours were found
for those families who participated in the pro-
grams (Anastopoulos et al., 1993). However,
contrary to expectations, Anastopoulos et al.
(1993) found no significant reductions in levels
of personal distress and marital satisfaction.
PMT has been shown to be efficient and
cost-effective when provided in groups. How-
ever, not all families benefit. One key problem
with PMT is the high premature termination rate.
Kazdin (1996) found that 40–60% of parents
do not complete a course of PMT. Kazdin (1995)
also cites problems with generalisation to differ-
ent settings and poor maintenance of gains.
Other factors often associated with poor
outcomes for families include situations where
 ADHD AND TRIPLE P: POSITIVE PARENTING PROGRAM
parenting problems are complicated by other
forms of adversity, including low income, single
parenthood status, marital conflict, parental
mood disturbance and high levels of stressful life
events (Webster-Stratton & Hammond, 1990).
The effect of PMT on school-aged children
with ADHD therefore needs further investiga-
tion as the results to date are inconsistent. Issues
that need to be addressed include the high attri-
tion rates and intermittent attendance of parents,
the use of PMT with populations of less edu-
cated and dysfunctional families, the generalisa-
tion and maintenance of gains, addressing the
factors associated with poor outcomes, and
intervention approaches that target both the
child’s disruptive behaviour and attentional
problems and the parenting practices.
The present study examined the efficacy
of an adapted group version of the Triple P
— Positive Parenting Program: an extensively
researched, evidence-based, form of behavioural
family intervention (Sanders, 1999). The Triple P
— Positive Parenting Program aims to promote
positive parenting, assist parents to develop
effective behaviour management strategies for
dealing with a variety of childhood behavioural
difficulties in multiple settings and help create
environments that nurture caring relationships
between parents and their children (Sanders,
Montgomery, & Brechman-Toussaint, 2000). In
addition to improving parenting skills, the pro-
gram aims to improve communication between
parents, reduce parenting stress and increase par-
ents’ sense of competence in their parenting abil-
ities. The program is designed to teach parents
strategies to encourage their child’s social and
language skills, emotional self-regulation, inde-
pendence, and problem-solving abilities. The
content of the program is outlined below in the
methods section.
This study also aimed to address many
of the issues described earlier. High attrition rates
and intermittent attendance were minimised by
having few group sessions (five), and by engage-
ment strategies in sessions. The Triple P —
Positive Parenting Program itself encourages
generalisation and maintenance of gains (Sanders
& Glynn, 1981), and the participants were fol-
lowed up for 3 months following the intervention
to check for short-term maintenance of gains.
The children’s behaviour both at home and at
school were assessed to give an indication of gen-
eralisation of the program. Other studies of Triple
P have shown that improvements in children’s
behaviour did generalise to other settings, and
were maintained over time (Sanders & Christ-
ensen, 1985; Sanders & Dadds, 1982; Sanders
& Plant, 1989). Factors associated with poor
intervention outcomes were addressed by adapt-
ing the program to address the needs of parents
with children with clinically diagnosed ADHD,
and by the addition of one group session that foc-
used on parental mood and stress, coping and
partner support. It was tailored to better meet the
needs of parents of children with clinically diag-
nosed ADHD as it offered them social support
and the opportunity to address family functioning
issues that were not included in the standard
group Triple P program. Finally, the intervention
targeted both parent and child behaviour, through
changes in parenting practices.
It was predicted that compared to a waitlist
(WL) control condition, families receiving an
enhanced Triple P group program (EGTP)
would show:
1. a clinically significant and reliable decrease
in the level of child disruptive and impulsive
behaviours in both home and school envi-
ronments at post-intervention
2. higher levels of parental competence and par-
enting satisfaction levels at post-intervention
3. lower levels of family dysfunction, particu-
larly parental conflict and levels of maternal
stress, anxiety and depression
4. greater concurrent change, over the course
of intervention, in child behaviour and par-
enting practices within individual families
5. decreases in child impulsivity and disruptive
behaviours in home and school environ-
ments and that increases in parental compe-
tence and satisfaction levels and decreases
in family dysfunction would be maintained
at 3-month follow-up.
Method
Participants
The sample consisted of 21 families with a child
with a clinical diagnosis of ADHD, aged
between 5 and 9 years who lived on the northern
193
FIONA E. HOATH AND MATTHEW R. SANDERS
New South Wales/southern Queensland coast-
line. Participants were recruited through a variety
of sources including general practitioners, paedi-
atricians and schools. A community outreach
campaign was used to promote awareness about
the project and included advertisements in local
newspapers, council newsletters, primary school
newsletters and fliers displayed in community
health centres and pediatricians’ offices in the
local area.
A standardised telephone interview was
used to screen families that responded to the
outreach campaign. Families were accepted for
the trial providing they met the following crite-
ria: (a) the target child was aged between 60
and 119 months; (b) parents reported that they
were concerned about their child’s behaviour;
(c) the child showed no sign of developmental
disorder, intellectual impairment or significant
health impairment; (d) the child was not cur-
rently having regular contact with another pro-
fessional or agency for behavioural problems;
and (e) the parents were not currently having
regular contact with another professional
agency for parenting support and were not
intellectually disabled.
All children accepted into the program had
to have a clinical diagnosis of ADHD. In most
cases this diagnosis had been made by a pedia-
trician or mental health professional. To con-
firm that children were elevated in ADHD
symptoms, the HoNOSCA (Health of the
National Outcome Scales for Children and
Adolescents) was administered with parents
(Garralda, Yates, & Higginson, 2000). The
HoNOSCA is a 15-item summary measure of
the child’s symptoms and social and physical
functioning. It was designed for use with chil-
dren and adolescents in clinical settings at the
initial assessment phase and again after inter-
vention to assess levels of change in psychiatric,
social and physical impairments. For admission
to this study the child had to receive a clinical
score over 11 and a behaviour subgroup score
over 3. Inter-rater reliabilities of .82 for psychi-
atric symptoms and .42–.61 for physical and
social impairments have been found for this
measure (Garralda, Yates, & Higginson, 2000).
Overall, 32 families responded to the out-
reach campaign. Twenty-two of these families
194
met the initial telephone screening criteria and
were sent the first questionnaire package. Only
one family did not return the first set of ques-
tionnaires and so was excluded from further
participation in the study. Randomisation of the
sample resulted in 10 families being allocated
to the EGTP condition and 11 families to the
WL condition.
To examine whether there were any differ-
ences between the two groups on the demo-
graphic variables (see Table 1) independent
sample t tests were conducted on the continuous
variables. No significant demographic differ-
ences between groups were observed at pre-
intervention when comparing the target child’s
age in months, t(18) = .84, p = .41, mother’s age,
t(14) = –.21, p = .84, father’s age, t(10) = –.04,
p = .96, number of siblings in the family, t(18)
= .44, p = .66, mother’s number of hours
employed, t(14) = –1.48, p = .16, father’s
number of hours employed, t(11) = .79, p = 45,
total family income, t(17) = –.47, p = .65 and
daily dosage of medication, t(18) = .01, p = .99.
Parents reported their child’s medication type
and dosage during the initial telephone inter-
view. Eight of the 10 children in the EGTP
group were taking stimulant medication com-
pared to 7 out of 11 children in the WL group.
No attempt was made to control the child’s med-
ication during the course of the intervention.
Due to the small sample size, assumptions
for Chi-squared analysis were not met, and
therefore not performed on the dichotomous
demographic variables (i.e., gender, family
structure, and parents’ level of education). Raw
data for these variables is presented in Table 2.
Inspection of these data suggests some differ-
ences between groups may have been present at
pre-intervention. However, as the EGTP condi-
tion appears to consist of less educated and
more single parent families, the study design
is more conservative as this population are gen-
erally at greater risk of attrition.
Measures
Parent Report Measures
Family Background Questionnaire. Much of
this measure is adapted from the Western
Australian Child Health Survey (Zubrick et al.,
 ADHD AND TRIPLE P: POSITIVE PARENTING PROGRAM

TABLE 1
Demographic Variables for EGTP and WL Conditions: Continuous

EGTP WL
Variables M SD M SD
Child’s age (months) 95.78 13.28 89.55 18.65
Mother’s age (years) 37.00 6.75 37.67 5.94
Father’s age (years) 40.00 9.85 40.22 7.31
No. of siblings in the family 1.56 1.13 1.36 .81
Mother No. of hours employed 4.11 2.07 11.73 6.99
Father No. of hours employed 40.00 5.00 29.11 16.07
Total Family Income $ 20,833.33 18,526.94 38,550.00 25,646.26
Dosage of Daily Medication 1.28 .87 1.27 1.04
Note: Dosage of Daily Medication = No. of 10mg tablets of stimulant medication induced per day

TABLE 2 1995). Essential biographical data included con-

Demographic Variables for EGTP and WL Conditions:
Categorical
Variables
Gender
No. Males
No. Females
Family Structure
No. Original Family
No. Step Parent Present
No. Sole Parent Family
No. Other
Mother’s Level of Education
No. not completed Year 12
No. completed Year 12
No. completed Tafe/
College Certificate
No. completed University Degree
Father’s Level of Education
No. not completed Year 12
No. completed Year 12
No. completed Tafe/
College Certificate
No. completed University Degree 0
No. completed Trade/Apprentiship1
tact details, the child’s details (name, age, sex,
and date of birth), parents’ marital status and
relationship to the child, current employment
EGTP WL status, educational background and total family
(n = 9) (n =11) income. This assessment booklet also included
family background details such as the names
7 9 and ages of all family members, information on
2 2 family composition, parents’ use of other health
services, and the child’s health and develop-
1 6 ment. Questions relating to whether the child
2 2 took any prescribed medications for their
6 2 behavioural disorder, the type and daily dosage
0 1 were also included.
8 4 Eyberg Child Behaviour Inventory (ECBI;
0 2 Eyberg & Pincus, 1999). The ECBI is a 36-
item measure of parental perceptions of disrup-
1 2 tive behaviour in children aged 2 to 16 years.
0 3 It incorporates a measure of frequency of dis-
ruptive behaviours (Intensity) rated on 7-point
3 5 scales and a measure of the number of disrup-
1 1 tive behaviours that are a problem for parents
(Problem). Each of the 36 items are rated on
0 1 each scale. The ECBI has been shown to have
1 high internal consistency for both the Intensity
1
(r = .95) and Problem (r = .94) scores and good
test-retest reliability (r = .86) (Robinson,
Eyberg, & Ross, 1980). The ECBI is sensitive
to the effects of intervention, allowing the track-
ing of behaviour over time. Alpha coefficients
for the intensity and problem scale respectively
of .94 and .92 were obtained for the study.

195
FIONA E. HOATH AND MATTHEW R. SANDERS
Problem Setting and Behaviour Checklist
(PSBC; Sanders & Woolley, 2003). The PSBC
is a 28-item rating scale that describes how con-
fident parents are at successfully dealing with
their child when the child is displaying a variety
of difficult behaviours in various settings. It
uses a scale from 0 (certain I cannot do it) to
100 (certain I can do it) with intervals of 10.
The scale contains 14 items related to specific
problem behaviours and 14 items related to spe-
cific settings. The total scale has high internal
consistency with an alpha coefficient of .97.
Child Attention Problems Rating Scale
(CAPS; Edelbrock, 1987, as cited in Barkley,
1990). The CAP is a 12-item measure of child
inattention and overactivity. It rates on a 3-point
scale children’s ability to maintain on-task
behaviours for a variety of situations. Seven
items explore the child’s level of attention and
five items explore their activity levels. Alpha
coefficients for the inattention and overactivity
scale respectively of .80, and .55 were obtained
for the study.
The Parenting Scale (PS; Arnold, O’Leary,
Wolff, & Acker, 1993). This 30-item question-
naire measures dysfunctional discipline styles in
parents. It yields a total score based on three fac-
tors: Laxness (permissive discipline); Over-reac-
tivity (authoritarian discipline, displays
of anger, meanness and irritability); and
Verbosity (overly long reprimands or reliance on
talking) as measured on a 7-point scale. The
scale has adequate internal consistency for the
Total score (α = .87), Laxness (α = .87), Over-
reactivity (α = .83) and Verbosity (α = .82)
scales. This scale has been found to discriminate
between parents of clinic and non-clinic chil-
dren. It correlates with self-report measures of
child behaviour, marital discord and depressive
symptoms, and also with observational measures
of dysfunctional discipline and child behaviour.
Parent Problem Checklist (Dadds & Powell,
1991). The PPC is a 16-item questionnaire that
measures inter-parental conflict over child rear-
ing. Parents indicate whether or not each issue
has been a problem during the last 4 weeks on a
Yes/No scale. Parents then rate the extent to
which each issue was a problem on 7-point
196
scale. Six items explore the extent to which par-
ents disagree over rules and discipline for child
misbehaviour, six items rate the amount of open
conflict over child-rearing issues and a further
four items focus on the extent to which parents
undermine each other’s relationship with their
children. The PPC has been found to have high
internal consistency for both the problem and
intensity scales (α = .92) and (α = .96) respec-
tively. It has also been found to have high
test–retest reliability (r = .90),( Dadds &
Powell, 1991).
Relationship Quality Index (RQI; Turner,
Markie-Dadds, & Sanders, 1998). The RQI is a
6-item questionnaire that assesses the degree of
partner satisfaction within the relationship. The
first five items are rated on a 7-point scale from
1 (very strongly disagree) to 7 (very strongly
agree). The last item is measured on a 10-point
scale from 1 (unhappy) to 10 (perfectly happy).
The scale was found to have high internal con-
sistency (α = .98) for this study.
Depression-Anxiety-Stress Scales (DASS;
Lovibond & Lovibond, 1995). The DASS is a
42-item questionnaire that assesses symptoms
of depression, anxiety and stress in adults. Each
item is rated on a 4-point scale from 0 (did not
apply to me at all) to 3 (applied to me very
much, or most of the time). Fourteen items load
on each of the symptom subscales. The scale
has high reliability for the Depression (α = .91),
Anxiety (α = .81), and Stress (α = .89) scales,
and good discriminate and concurrent validity
(Lovibond & Lovibond, 1995a; Lovibond &
Lovibond, 1995b).
Client Satisfaction Questionnaire (CSQ;
Turner, Markie-Dadds, & Sanders, 1998).
This 13-item scale addresses the quality of
service provided; how well the program met
the parent’s needs, increased the parent’s skills
and decreased the child’s problem behaviours;
and whether the parent would recommend
the program to others. The measure has a 7-point
scale for each item with 7 indicating favourable
responses and 1 indicating unsatisfactory
responses. (A maximum score of 91 and a
minimum score of 13 are possible). Internal
 ADHD AND TRIPLE P: POSITIVE PARENTING PROGRAM
consistency was found to be high (α = .93) for
this study.
Teacher Report Measures
Sutter-Eyberg Student Behaviour Inventory-
Revised (SESBI-R; Rayfield, Eyberg, & Foote,
1998). The SESBI-R is a 38-item measure
of teacher perceptions of disruptive behaviour
in children aged 2 to 16 years. It incorporates
a measure of frequency of disruptive behaviours
(Intensity) rated on 7-point scales and a mea-
sure of the number of disruptive behaviours
that are a problem for teachers (Problem).
The SESBI-R has been shown to have high
internal consistency for both Intensity (α =.97)
and Problem (α =.95) scores.
Child Attention Problems Rating Scale
(CAPS; Edelbrock, 1987). The parent version
of this scale was adapted in this study for the
teacher questionnaire booklet. This was
achieved by changing the wording in the scale
from “parent” to “teacher” and from “child” to
“student”. Internal consistency for both the inat-
tentive and overactivity scales were (α = .90)
and (α = .80) respectively.
Design
A randomised group comparison design was
used with two conditions (EGTP and WL) with
measures at three time periods (pre- and post-
intervention and 3-month follow-up)
Procedure
During the initial contact parents’ were pro-
vided with an overview of the project and the
initial inclusion and exclusion criteria were
assessed. A second, semi-structured telephone
interview using the HoNOSCA was adminis-
tered to those families who met the initial inclu-
sion criteria. Families eligible to participate
were sent a pre-intervention assessment pack-
age which included a parent questionnaire,
teacher questionnaire and parental consent form
outlining the program. The child’s current class-
room teacher completed the teacher question-
naires. These assessment packages were
completed and returned to the experimenter
prior to the participants’ randomisation to one
of the two conditions. After the first assessment
packages were returned families were sent let-
ters informing them of their group allocation
and a start date for their program. Those allo-
cated to the WL condition were also informed
that they would receive a second set of ques-
tionnaires to complete in 12 weeks time, prior
to their start date. Families allocated to the
EGTP condition attended five, 2-hour weekly
group sessions with a practitioner at one of two
local state primary schools. After hours sessions
were available to encourage both parents (where
applicable) to attend. These families also took
part in four, 20- to 30-minute individual weekly
telephone consultations starting the week of the
fifth group session. Following completion of the
intervention (approximately 12 weeks after
completion of the preassessment question-
naires), families were sent a second question-
naire package including both parent and teacher
questionnaires.
Families allocated to the WL condition
received no treatment and had no contact with
the researcher for 12 weeks. These families
completed the postassessment, and then partici-
pated in the same group program in which the
EGTP families had participated. Twelve weeks
after families in the EGTP condition had com-
pleted their intervention program a third set of
questionnaires was sent out to families in both
the EGTP and WL conditions.
Intervention Condition
The intervention was an enhanced version of
“Standard Group Triple P” targeting specific
ADHD characteristics. The intervention
involved distributing resources to the parents,
five group sessions and four telephone consulta-
tion sessions.
Each parent received a copy of Every
Parent’s Group Workbook (Sanders, Turner,
& Markie-Dadds, 1997) and three Triple P Tip
Sheets. Attention Deficit Hyperactivity Disorder
(ADHD) (Sanders & Hoath, 2001), was pro-
duced for the purposes of this research and
Supporting Your Partner and Coping With
Stress (Sanders, Turner, & Markie-Dadds,
1998) were also distributed.
197
FIONA E. HOATH AND MATTHEW R. SANDERS
The group program involved teaching parents
17 core child management strategies. Ten of the
strategies are designed to promote children’s
competence and development (i.e., quality time;
talking with children; physical affection; praise;
attention; engaging activities; setting a good
example; Ask Say Do; incidental teaching;
and behaviour charts), and seven strategies
are designed to help parents manage behaviour
(i.e., setting rules; directed discussion; planned
ignoring; clear, direct instructions; logical
consequences; quiet time; and time-out).
In addition, parents were taught a six-step
planned activities routine to enhance generalisa-
tion and maintenance of parenting skills (i.e.,
plan ahead, decide on rules, select engaging act-
ivities, decide on rewards and consequences,
and hold a follow-up discussion with child).
Parents received active skills training and sup-
port from a trained practitioner as described
by Sanders and Dadds (1993). Active skills
training methods included modelling, role-
plays, feedback and the use of specific home-
work tasks.
Throughout the program minor modifica-
tions were made to target ADHD symptoms and
behaviours. The first four sessions followed the
Standard Group Program with minor changes.
Session 1 included psychoeducational informa-
tion on ADHD in the section titled “Causes of
Child Behaviour Problems: Genetic Make-Up”.
The ADHD tip sheet was produced during this
session. Session 2, 3 and 4 followed the stan-
dard program, with additional emphasis placed
on ADHD children’s impulsivity, emotionality
and limited attention span and concentration.
The need for consistency and predictability
in discipline routines was also highlighted due
to ADHD children’s difficulty with forward
planning and lack of insight regarding conse-
quences of their actions. The fifth and final
group session covered “partner/social support”
and “coping skills”. Tip sheets for these topics
were handed out to participants; the “Partner
Support” and “Coping Skills” Triple P videos
were viewed; and a group problem solving
exercise, relaxation techniques and a personal
coping plan were modelled and practised during
this session. Each family received four 20–30
minute telephone consultations. They occurred
198
once per week, with the first consultation being
in the week between the fourth and fifth group
session. These telephone calls followed the
format of the Standard Triple P Group program.
On average parents in the EGTP condition
attended 8 hours of group intervention and
received 94 minutes of telephone consultation
time (average total duration of intervention was
9 hours and 34 minutes).
Treatment Integrity
One practitioner, (a psychologist completing
postgraduate training in psychology) was
trained and supervised in the delivery of the
intervention by a senior clinical psychologist.
Prior to completion of the pre-intervention
questionnaires, the practitioner was not aware
of the intervention groups to which families had
been assigned so as not to bias the telephone
screening interviews. Detailed written protocols
that specified the content of each session, in
session exercises to complete, and homework
tasks, were all developed for the intervention.
The practitioner completed the protocol adher-
ence checklists as did an independent observer.
Analysis of the checklists for each session indi-
cated that 100% of all content, exercises and
homework materials specified for the program
were covered with each group.
Results
Of the 10 families assigned to the active inter-
vention condition, 9 (90%) completed the inter-
vention and post-assessment. Of the 11 families
assigned to the waitlist condition, all (100%)
completed the post-assessment data, with
6 families attending the subsequent intervention
program. Three months following completion
of the program for the intervention conditions,
8 (88%) families from the intervention condi-
tion and 4 (66%) families from the wait list
condition who participated in the subsequent
intervention, completed follow-up data.
Statistical Analysis
Assumptions for multivariate analyses were met
and missing data were collected from parents.
A series of 2 × 2 (Condition × Time) repeated
measures analysis of variance (ANOVA) were
 ADHD AND TRIPLE P: POSITIVE PARENTING PROGRAM

conducted to assess treatment effects on three
sets of outcome variables (child behaviour, par-
enting skills and family dysfunction). Repeated
measures multivariate analysis of variance
(MANOVA) using three cluster groups of
dependant variables were not used due to the
small sample size not meeting the assumptions
for this test (Tabachnick & Fidell, 1996).
Treatment effects were reflected in significant
Condition × Time interactions. Paired t tests
were performed post hoc to confirm significant
differences within conditions were present over
time. Probability levels for the paired t tests were
one-tailed as all hypotheses were directional.
Short-term Intervention Effects
Child Disruptive Behaviour
The results for parent and teacher reports of
child disruptive behaviour are shown in Table 3.
A significant interaction effect for the ECBI
intensity scale was observed when comparing
the EGTP and WL condition. At post-interven-
tion, a significant interaction effect was
observed, with parents in the EGTP condition
reporting significantly lower levels of disruptive
child behaviour on the ECBI intensity scale
than the WL condition. Post-hoc comparisons
using paired samples t tests were significant for
the EGTP and WL condition, t(8) = 4.75,
p < .001 and t(10) = 1.96, p = .04 respectively.
A significant main effect for time but not for
condition was also observed. There was a sig-
nificant reduction in ECBI intensity scores for
both groups over the first 12 weeks (pre-
to post-assessment for EGTP group).
At post-intervention, there were no signifi-
cant interaction effects for parents’ reports
of the number of child disruptive behaviours
as measured by the ECBI problem scale. A sig-
nificant main effect for time but not for condition
was found. There was a significant reduction in
ECBI problem scores for both groups over

TABLE 3
Means and Standard Deviations for EGTP and WL Conditions, Pre- and Post-intervention
on Child Outcome Variables

EGTP WL
Dependent Pre Post Pre Post
Variable M SD M SD M SD M SD
ECBI
-Intensity 164.22 28.13 125.22 35.63 159.73 41.08 148.36 40.29
-Problem 23.00 6.73 13.78 13.00 19.55 10.31 16.82 9.98
CAP Overactivity
-Parent 7.11 1.9 6.33 1.58 7.64 2.11 7.36 1.63
-Teacher 4.14 1.77 3.43 1.13 5.36 2.91 4.73 3.29
CAP Inattention
-Parent 8.56 2.70 8.11 2.37 9.36 3.20 9.18 2.18
-Teacher 5.57 3.69 4.43 2.70 8.09 4.32 6.91 4.48
PSBC 70.21 17.20 80.31 17.14 62.14 20.66 58.93 20.61
PS
-Laxness 2.67 1.05 2.56 .96 3.09 1.00 2.93 1.03
-Over-reactivity 3.76 1.03 3.13 1.09 3.80 1.12 3.60 1.05
-Verbosity 4.16 1.28 3.17 .98 3.78 1.15 3.97 1.11
SESBI
-Intensity 128.63 42.21 123.00 35.49 127.82 51.01 124.27 47.42
-Problem 10.33 10.76 10.67 9.27 11.45 10.43 11.73 10.10
Note:ECBI = Eyberg Child Behaviour Inventory; CAP = Child Attention Problems; PSBC = Problem Setting and Behaviour
Checklist; PS = Parenting Scale; SESBI = Sutter-Eyberg Student Behaviour Inventory.

199
FIONA E. HOATH AND MATTHEW R. SANDERS
the first 12 weeks (pre- to post-assessment for
EGTP group).
At post-intervention a significant interaction
effect for the PSBC was observed when com-
paring the EGTP and EL conditions. Parents of
children in the EGTP condition showed signifi-
cantly higher levels of confidence in success-
fully dealing with their child’s disruptive
behaviours in a variety of settings compared
to the WL condition. Post hoc comparisons
using paired samples t tests were not significant
for the EGTP and WL condition, t(7) = –1.71,
p = .13 and t(9) = 1.54, p = .16 respectively.
There were no significant main effects for time
or condition found.
Child Attention Problems
Results of the CAP overactivity as reported
by both parents and teachers and the SESBI
intensity and problem scales failed to reach
clinically significant levels for any treatment
effects or interactions (Table 3). At post-inter-
vention, parent and teacher reports on the CAP
inattention subscale failed to reach significance
for any treatment effects or interactions.
Parenting Skills
The results of the Parenting Skills measures
are displayed in Table 3. At post-intervention,
parent rating of laxness as measured by the PS
laxness subscale failed to reach significance for
any treatment effects or interactions.
At post-intervention, parent rating of over-
reactivity as measured by the PS failed to reach
significance for an interaction effect. A signifi-
cant main effect for time was observed, but not
for condition. There was a significant reduction
in over-reactivity scores on the PS for both
groups over the first 12 weeks (pre- to post-
assessment for EGTP group).
At post-intervention, a significant interac-
tion effect for the PS verbosity subscale was
observed when comparing the EGTP and WL
conditions. Parents in the EGTP condition
reported significant reductions in their use
of verbosity as measured by the PS verbosity
subscale when compared to the WL condition.
Post hoc comparisons using a paired samples
t test found a statistically significant decrease
200
in PS verbosity scores from pre-intervention
to post-intervention for the EGTP condition,
t(8) = 2.45, p = .02 but not for the WL condi-
tion, t(10) = –1.00, p = .34. No significant main
effects for time or condition were found.
Family Functioning
At post-intervention there were no-significant
interaction effects between the EGTP and WL
condition on any of the family functioning
outcome measures (Table 4). Maternal levels
of depression, anxiety and stress as measured
by the DASS all produced non-significant
interaction effects. Significant main effects
for time were found on all three DASS sub-
scales, but not for condition. There was a signif-
icant reduction in depression, anxiety and stress
scores on the DASS for both groups over
the first 12 weeks (pre- to post-assessment for
EGTP group).
At post-intervention, parents’ reports of
inter-parental conflict over child-rearing as mea-
sured by the PPC problem subscale failed
to reach significance for an interaction effect.
However, both conditions revealed a significant
main effect for time but not for condition.
There was a significant reduction in reports
of inter-parental conflict over child-rearing for
both groups over the first 12 weeks (pre- to post-
assessment for EGTP group).
At post-intervention, parent report of the
intensity of inter-parent conflict over child rear-
ing as measured by the PPC intensity subscale
failed to reach significance for any treatment
or interaction effects.
At post-intervention, parent report on the
degree of partner satisfaction within the relation-
ship as measured by the RQI failed to reach sig-
nificance for any treatment or interaction effects.
Clinical Significance of Intervention Outcome
The results indicate that the intervention
resulted in significant reductions in parents’
reports of the intensity of children’s disruptive
behaviours, parents’ self-report of reduction
in verbosity and improvements in parental
self-efficacy. The clinical significance of these
changes was assessed using the reliable change
index (RCI) as described by Jacobson & Truax,
 ADHD AND TRIPLE P: POSITIVE PARENTING PROGRAM

TABLE 4
Means and Standard Deviations for EGTP and WL Conditions, Pre- and Post-intervention
on Family Functioning Variables

EGTP WL
Dependent Pre Post Pre Post
Variables M SD M SD M SD M SD
DASS
- Depression 9.44 10.18 3.33 3.74 8.27 9.62 4.18 3.55
- Anxiety 5.33 6.96 1.11 1.54 3.64 4.37 2.82 4.54
- Stress 12.56 12.49 5.22 4.87 14.45 9.51 11.18 7.25
PPC
- Problem 9.00 4.76 2.50 2.08 6.70 5.89 5.56 5.68
- Intensity 44.00 16.51 27.75 11.73 40.30 27.18 35.89 22.32
RQI 33.50 17.14 38.25 5.32 29.20 12.13 34.22 7.58
Note: DASS = Depression, Anxiety, Stress Scale; PPC = Parent Problem Checklist; RQI = Relationship Quality Index.

TABLE 5 range or clinically reliable change on at least

Program Satisfaction Ratings for EGTP group one parenting variable on the PS (i.e., normal
parenting maintained, or more dysfunctional
Parents (n = 9)
parenting improved). Given this criteria, 77% of
Question M SD families in the EGTP compared to 18% in the
Quality of service received 6.67 .71 WL condition underwent concurrent clinically
Type of program 6.22 1.20 reliable change over the intervention period.
Program met child’s needs 5.78 1.39
Program met parent’s needs 5.56 1.67 Consumer Satisfaction
Amount of help received 6.56 .73 There was a high level of parent satisfaction
Effectiveness in dealing with the intervention. On a 7-point scale, where
with child behaviour 6.56 1.01 1 is least and 7 is most, overall mean satisfac-
Effectiveness in dealing tion ratings of 6.14 (.73) were obtained. Table 5
with family issues 6.33 1.00 illustrates the mean ratings for each question as
Improvement in relationship 5.80 1.64 reported by parents.
with partner (n = 5)
Overall satisfaction with program 6.44 1.01 3-Month Follow-up
Would you come back to Triple P 5.89 1.36 Completed data sets were available on 8 of the
Learnt skills applicable 9 families in the EGTP condition. Parent reports
to other family members 6.11 .93 of disruptive child behaviour problems and par-
Child’s behaviour at this point 6.00 .87 enting styles are presented in Table 6. For the
Feelings about child’s behaviour 6.22 .83
ECBI intensity scale, ECBI problem scale and
PS over reactivity subscale repeated measures
ANOVA’s showed a significant main effect for
1991. As the program was preventatively time. Paired samples t tests revealed that mean
oriented, the criteria for a positive response to scores on the dependent variables at follow-up
the program was defined as requiring clinically were not significantly different from those
reliable change on the ECBI intensity score obtained at posttreatment. Repeated measures
(i.e., an improvement in child behaviour) in ANOVAs failed to reveal significant main
addition to maintenance within the normal effects for time on all other outcome variables.

201
FIONA E. HOATH AND MATTHEW R. SANDERS
TABLE 6
Parents’ Report on Child Disruptive Behaviour and Parenting Styles at 3-Month Follow-up
Pre-treatment
(n = 8)
Variable M SD
ECBI- Intensity 161.25 28.52 126.38
- Problem 21.88 6.22
PSBC 75.99 17.19
PS- Laxness 2.59 1.10
- Over Reactivity 3.88 1.13
- Verbosity 4.13 1.46
Note: ECBI = Eyberg Child Behaviour Inventory; PSBC = Problem Setting and Behaviour Checklist; PS = Parenting Scale.
Discussion
The primary aim of the present study was
to examine the efficacy of an enhanced Triple P
group program on child disruptive behaviours,
attentional problems, parenting skills and
family functioning within families including a
child aged 5 to 9 years with ADHD. The study
has found some empirical support for the effi-
cacy of an EGTP that consisted of 5 group
sessions and four 30-minute telephone consult-
ations. Several hypotheses were supported or
partially supported.
First, parents in the EGTP condition report-
ed significantly lower levels of child disruptive
behaviours at post-intervention than parents
in the WL condition. Overall, 75% of families
in the EGTP condition who had a clinically ele-
vated score on the ECBI intensity rating showed
clinically reliable change (Jacobson & Truax,
1991), with 83% of those scores moving from
the clinically elevated to the normal range
of functioning. The WL condition showed 42%
of families who had a clinically elevated score
on the ECBI intensity rating showed clinically
reliable change; however, none of these scores
moved into the normal range of functioning.
Parents’ ratings of child behaviour using the
ECBI problem scale found an effect for time,
providing some evidence that a reduction in the
intensity of disruptive child behaviour is accom-
panied in a reduction in the number of problem
behaviours. However, as the reduction was
202
Post-treatment Follow-up
(n = 8) (n = 8)
M SD M SD
37.91 114.25 37.07
12.75 13.50 8.50 8.75
81.28 18.27 85.36 13.89
2.38 .92 2.23 1.18
3.13 1.25 2.35 1.05
3.13 .84 3.18 1.02
found in both groups, only tentative conclusions
should be drawn.
Second, the hypothesised increase in parent-
ing competence was partially supported. Parents
in the EGTP condition had significantly imp-
roved at post-intervention on measures of ver-
bosity in discipline responses compared to the
WL condition. This was supported to some
extent by a time effect for over-reactivity by
parents in discipline responses. No significant
differences at post-intervention were found
in laxness in parental responses to discipline.
Additionally, parents in the EGTP condition
reported significantly higher levels in their abil-
ity to respond to their child’s specific difficult
behaviours in a variety of settings at post-inter-
vention than parents in the WL condition.
Third, although there were no differences
between the two groups on measures of family
functioning, depression, anxiety and stress were
all lower at the 12-week follow-up (post-inter-
vention for EGTP group). Possible reasons for
this are discussed below.
Fourth, the hypothesis that more families
in the EGTP condition than the WL condition
would report concurrent change in both child
behaviour and parenting practices was sup-
ported. Concurrent change on the ECBI inten-
sity score and on at least one parenting variable
on the PS was found for 77% of families in the
EGTP condition compared to 18% in the WL
condition. These results provide strong support
for the inclusion of measures of concurrent
 ADHD AND TRIPLE P: POSITIVE PARENTING PROGRAM
change in assessing the effectiveness of parent-
ing interventions.
Finally, it was hypothesised that changes
observed in child behaviour, parenting compe-
tence and family functioning outcomes at post-
intervention would be maintained at 3-month
follow-up. This was supported with all imp-
rovements for the EGTP condition at post-inter-
vention in both the child disruptive behaviours
and parenting competence being maintained
at follow-up.
Many of these results are consistent with
those of Bor, Sanders, and Markie-Dadds
(2002) and Sanders, Markie-Dadds, Tully,
and Bor (2000). These studies reported results
for individually administered Triple P interven-
tions for families with a child with ADHD.
They found that the intervention resulted in sig-
nificant improvements in disruptive behaviour
(Bor et al., 2001; Sanders et al., 2000), and sig-
nificant reductions in parental laxness, over-
reactivity and verbosity (Bor et al., 2001).
We suggest that because the intervention
was group based, the results of the present
study were not as conclusive as the previous
studies. The results may reflect the lack of indi-
vidualised coaching and feedback which is usu-
ally provided by the facilitator to parents during
practice sessions. Small sample sizes and large
standard deviations also diminished the statisti-
cal power of the comparisons.
Some hypotheses were not supported. The
teacher reports for both the intensity and number
of disruptive child behaviours showed no signif-
icant differences between groups at post-inter-
vention. No support for improvements in child
attentional problems were found in either the
home or school environments, and there were no
effects on parental conflict and stress. Several
explanations can be offered for these results.
First, the means for intensity and number
of disruptive child behaviours and the CAP
inattentive subscale were within the normal
range, albeit towards the upper limit. This may
have prevented detection of change due to floor
effects. Floor effects may also have prevented
detection of differences between groups on
changes in anxiety, depression and stress as
measured by the DASS. Scores in the normal
range on this scale at pre-intervention may indi-
cate an atypical population of ADHD families,
as high levels of parenting stress, anxiety and
depression are typically associated with this
group (Sheridan, Dwyer, and Sanders, 1997).
Second, the majority of children in the study
were medicated. The medication could have
reduced disruptive behaviours in the very struc-
tured setting of school and may have been suffi-
cient to control attentional problems. It was
impossible to control for medication, and due
to the small sample size, comparisons between
medicated and unmedicated children were not
possible. Small sample sizes also made it diffi-
cult to detect changes in parental conflict,
as two thirds of the sample did not have a part-
ner, reducing further the number of participants
completing the PPC.
The study also aimed to address issues aris-
ing from the literature. The attrition rate of the
current study was 5% at post-intervention,
which is very low and comparable to the
4% reported by Zubrick et al. (2003) in their
intervention using a standard group Triple P
program (4 × 2 hour sessions and 4 × 30 minute
telephone consultations). However, only 55% of
parents went on to complete an intervention fol-
lowing a 12-week wait. Although many prob-
lems did reduce for this group during this time,
the reductions were not as significant as they
were for the intervention group, and the mean
disruptive behaviour score for the WL group
was still in the elevated range at 12 weeks. This
underscores the importance of offering parents
interventions at the right time, in order to retain
parents in the intervention. Individually admin-
istered programs appear to have higher attrition
rates reported at 28% and 20% respectively for
Bor et al. (2001) and Sanders et al. (2000). This
may be due to a combination of factors includ-
ing: the program modifications specifically tar-
geting ADHD behaviours; the group format
allowing parents to share their experiences with
other families undergoing similar difficulties;
and the reduction in the number of sessions par-
ents needed to physically attend in comparison
to individually administered Triple P programs
(average of 10 and 12 sessions) (Sanders et al.,
2000; Bor et al., 2001).
Although the follow-up was only 3 months,
gains were maintained for this time. Other studies
203
FIONA E. HOATH AND MATTHEW R. SANDERS
of Triple P have shown that improvements are
maintained for 12 months post-intervention
(Sanders et al. 2000) and that changes gener-
alise to different situations (e.g., Sanders and
Dadds, 1982). Changes in this study did not
appear to generalise to school, but possible rea-
sons for this have been discussed earlier. The
intervention did address some factors associated
with poor outcomes and depression, anxiety and
stress did reduce over the 12 weeks of interven-
tion. Finally, the conservative use of the RCI
(Jacobson & Truax, 1991) to determine concur-
rent change on child disruptive behaviour and
parenting practices provides the strongest sup-
port for the programs effectiveness. Families
who participated in the EGTP condition were
four times more likely to undergo clinically sig-
nificant change than those in the WL condition.
Overall, parents were highly satisfied with
the intervention. As parents reported significant
reductions in child disruptive behaviours and
improvements in parental competence, this
is not surprising. Satisfaction ratings for this
intervention were similar to those of other stud-
ies (Sanders et al., 2000; Bor et al., 2001).
Although it would have been desirable to
control children’s medication during the trial
this was not possible. It is unlikely that any sys-
tematic bias has affected the results as the
effects of medications was randomised across
conditions. And although the power of the anal-
ysis was low there was sufficient statistical
power to detect significant outcomes on the key
dependent variables targeted by the interven-
tion, namely disruptive behaviour.
Overall, the results of this pilot study are
promising and point to the need for further
research into the efficacy of an Enhanced Triple
P group program designed to meet the needs of
families with a child with ADHD. To enable
more statistically meaningful data analyses, a
larger sample needs to be recruited as current
results show positive trends but the statistical
power of the results is diminished by the small
sample size. The initial intake criteria could
also be modified to ensure both child disruptive
behaviours and at least one family adversity
factor associated with ADHD are reported in
the clinically elevated range on one of the out-
come measures at pre-intervention. This would
204
allow for a more meaningful investigation into
the effects of the additional group session on
family adversity factors. Independent observa-
tions of child behaviour would also provide
more reliable indications of clinically signifi-
cant change in both the home and school envi-
ronment. This would allow for a more thorough
investigation into the generalisation effects of
the program across settings (e.g., home, school,
community). In addition, a comparison between
the enhanced group program, a standard group
program and individually administered pro-
grams should be made to determine if the inclu-
sion of a fifth group session significantly
reduces family adversity factors and results in
better child and family outcomes. This would
assist in determining the efficacy of the group
program for educational settings, where finan-
cial, time and human resources are already
stretched and a group program could be utilised
to service the needs of more families in a
shorter space of time than individually adminis-
tered programs.
Editor Note
Manuscript Received: 23/9/02
Accepted: 25/3/03
References
American Psychiatric Association. (1994). Diagnostic
and statistical manual of mental disorders (4th ed.).
Washington, DC: Author.
Anastopoulos, A.D., Guevremont, D.C., Shelton, T.L.,
& DuPaul, G.J. (1992). Parenting stress amongst
families of children with attention deficit hyperactiv-
ity disorder. Journal of Abnormal Child Psychology,
20(5), 503–520.
Anastopoulos, A.D., Shelton, T.L., DuPaul, G.J.,
& Guevremont, D.C. (1993). Parent training for
attention deficit hyperactivity disorders: Its impact
on parent functioning. Journal of Abnormal Child
Psychology, 21, 581–596.
Arnold, D.S., O’Leary, S.G., Wolff, L.S., & Acker, M.M.
(1993). The Parenting Scale: A measure of dysfunc-
tional parenting in discipline situations. Psych-
ological Assessment, 5, 137–144.
Barkley, R.A. (1998). Attention deficit hyperactivity
disorder: A handbook for diagnosis and treatment
(2nd ed.). New York: Guilford Press.
Barkley, R.A., Shelton, T.L., Crosswait, C., Moorehouse,
M., Fletcher, K., Barrett, S., et al. (2000). Multi-
method psycho-educational intervention for
 ADHD AND TRIPLE P: POSITIVE PARENTING PROGRAM
preschool children with disruptive behaviour:
Preliminary results at post-treatment. Journal of
Child Psychology and Psychiatry, 41, 319–332.
Biederman, J., Newcorn, J., & Sprich, S. (1991). Comorb-
idity of Attention Deficit Hyperactivity Disorder with
conduct, depression, anxiety and other disorders.
American Journal of Psychiatry, 148, 564.
Bor, W., Sanders, M.R., & Markie-Dadds, C. (2002).
The effects of the Triple P-Positive parenting pro-
gram on preschool children with co-occuring disrup-
tive behavior and attentional/hyperactive difficulties.
Journal of Abnormal Child Psychology, 30(6),
571–587.
Campbell, S.B. (1995). Behavior problems in preschool
children: A review of recent research. Journal
of Child Psychology and Psychiatry, 36, 113–149.
Campbell, S.B. (2000). Attention-Deficit/Hyperactivity
Disorder: A developmental view. In A.J. Sameroff,
M. Lewis, & S.M. Miller (Eds.), Handbook of devel-
opmental psychopathology (2nd ed., pp. 383–401).
New York: Kluwer Academic/Plenum.
Campbell, S.B., Breaux, A.M., Ewing, L.J., &
Szumowski, E.K. (1986). Correlates and predictors
of hyperactivity and aggression: A longitudinal study
of parent referred problem preschoolers. Journal of
Abnormal Child Psychology, 14, 425–440.
Dadds, M.R., & Powell, M.B. (1991). The relationship
of interparental conflict and global marital adjust-
ment to aggression, anxiety, and immaturity
in aggressive and nonclinic children. Journal of
Abnormal Child Psychology, 19, 553–567.
Danforth, J.S., Barkley, R.A., & Stokes, T.F. (1991).
Observations of parent-child interactions with
hyperactive children: Research and clinical implica-
tions. Clinical Psychology Review, 11, 703–727.
Dubey, D.R., O’Leary, S.G., & Kaufman, K.F. (1983).
Training parents of hyperactive children in child
management: A comparative outcome study. Journal
of Abnormal Child Psychology, 11, 229–246.
DuPaul, G.J., McGoey, K.E., Eckert, T.L., & VanBrakle,
J. (2001). Preschool children with Attention-
Deficit/Hyperactivity Disorder: Impairments
in behavioural, social and school functioning.
Journal of the American Academy of Child and
Adolescent Psychiatry, 40, 508–515
Eyberg, S.M., & Pincus, D. (1999). Eyberg Child
Behavior Inventory and Sutter-Eyberg Student
Behavior Inventory-Revised: Professional manual.
Odessa, FL: Psychological Assessment Resources.
Fischer, M., Barkley, R., Fletcher, K., & Smallish, L.
(1990). The adolescent outcome of hyperactive chil-
dren diagnosed by research criteria, II: Academic,
attentional, and neuropsychological status. Journal
of Consulting and Clinical Psychology, 58, 580–588.
Fletcher, K.E., Fischer, M., Barkley, R.A., & Smallish,
L. (1996). A sequential analysis of the mother-ado-
lescent interactions of ADHD, ADHD/ODD,
and normal teenagers during neutral and conflict dis-
cussions. Journal of Abnormal Child Psychology,
24, 271–297.
Garralda, M.E., Yates, P., & Higginson, I. (2000). Child
and adolescent mental health service use HoNOSCA
as an outcome measure. British Journal of Psych-
iatry, 177, 52–58.
Jacobson, N.S., & Truax, P. (1991). Clinical significance:
A statistical approach to defining meaningful change
in psychotherapy research. Journal of Consulting
and Clinical Psychology, 59, 12–19.
Hinshaw, S.P. (1992). Externalizing behaviour problems
and academic underachievement in childhood and
adolescence: Causal relationships and underlying
mechanisms. Psychological Bulletin, 111, 127–155.
Hinshaw, S.P., Lahey, B.B., & Hart, E.L. (1993). Issues
of taxonomy and comorbidity in the development of
conduct disorder. Special Issue: Toward a develop-
mental perspective on conduct disorder. Develop-
ment and Psychopathology, 5, 31–49.
Kazdin, A.E. (1995). Conduct disorder in childhood and
adolescence (Developmental Clinical Psychology
and Psychiatry, Volume 9). London: Sage
Publications.
Kazdin, A.E. (1996). Dropping out of child psychother-
apy: Issues for research and implications for prac-
tice. Clinical Child Psychology and Psychiatry,
1, 133–156
Kazdin, A.E. (2000). Psychotherapy for children and
adolescents: Directions for research and practice.
New York: Oxford University Press.
Lavigne, J.V., Arend, R., Rosenbaum, D., Binns, H.J.,
Christoffel, K.K., & Gibbons, R.D. (1998).
Psychiatric disorders with onset in the preschool
years: II. Correlates and predictors of stable case
status. Journal of the American Academy of Child
and Adolescent Psychiatry,37(12), 1255–1261
Lovibond, P.R., & Lovibond, S.H. (1995a). Manual for
the Depression Anxiety Stress Scales (2nd ed.).
Sydney, New South Wales, Australia: Psychology
Foundation of Australia.
Lovibond, P.R., & Lovibond, S.H. (1995b). The structure
of negative emotional states: Comparison of the
Depression Anxiety Stress Scales (DASS) with the
Beck Depression and Anxiety Inventories.
Behaviour Research and Therapy, 33, 335–343.
Markie-Dadds, C, Turner, K.M.T., & Sanders, M.R.
(1998). Triple P tip sheet series for positive parent-
ing. Brisbane: Families International Publishing.
Mash, E.J., & Johnston, C. (1983). Sibling interactions
of hyperactive and normal children and their rela-
tionship to reports of maternal stress and self-
esteem. Journal of Clinical Child Psychology,
12, 91–99.
Moffitt, T.E. (1990). Juvenile delinquency and attention
deficit disorder: Boys’ developmental trajectories
from age 3 to age 15. Child Development, 61,
557–566.
205
FIONA E. HOATH AND MATTHEW R. SANDERS
Moos, R.H. & Moos, B.S. (1981). Family Environment
Scale (Manual). Palo Alto, California: Consulting
Psychologists Press.
Patterson, G.R. (1982). Coercive family process. Eugene,
OR: Castalia.
Pisterman, S., Firestone, P., McGrath, P., Goodman, J.T.,
Webster, I., Mallory, R., & Goffin, B. (1992). The
role of parent training in treatment of preschoolers
with ADHD. American Journal of Orthopsychiatry,
62, 397–408.
Pisterman, S., McGrath, P., Firestone, P., Goodman, J.T.,
Webster, I., & Mallory, R. (1989). Outcome
of parent-mediated treatment of preschoolers with
attention deficit disorder with hyperactivity. Journal
of Consulting and Clinical Psychology, 57, 628–635.
Rayfield, A., Eyberg, S.M., & Foote, R. (1998). Revision
of the Sutter-Eyberg student behavior inventory:
Teacher ratings of conduct problem behavior.
Educational and Psychological Measurement, 58,
88–98.
Robinson, E.A., Eyberg, S.M., & Ross, A.W. (1980).
The standardization of an inventory of child conduct
problems. Journal of Clinical Child Psychology,
9, 22–29.
Sanders, M.R. (1999). Triple P — Positive Parenting
Program: Towards an empirically validated multi-
level parenting and family support strategy for the
prevention of behaviour and emotional problems
in children. Clinical Child and Family Psychology
Review, 2, 71–90.
Sanders, M.R., & Christensen, A.P. (1985). A compari-
son of the effects of child management and planned
activities training in five parenting environments.
Journal of Abnormal Child Psychology, 13(1),
101–117.
Sanders, M.R., & Dadds, M.R. (1982). The effects of
planned activities and child management procedures
in parent training: An analysis of setting generality.
Behavior Therapy, 13, 452–461.
Sanders, M.R., & Dadds, M.R. (1993). Behavioural
family intervention. Needham Heights, MA: Allyn
and Bacon.
Sanders, M.R., & Glynn, T. (1981). Training parents
in behavioral self-management: An analysis of gen-
eralization and maintenance. Journal of Applied
Behavior Analysis, 14, 223–237.
Sanders, M.R. & Hoath, F.E. (2001). Triple P — Tip
Sheet: Attention Deficit Hyperactivity Disorder
(ADHD). [Brochure]. Unpublished.
Sanders, M.R., Markie-Dadds, C., Tully, L.A., & Bor, W.
(2000). The Triple P — Positive Parenting Program:
A comparison of enhanced, standard and self-
directed behavioural family intervention for parents
of children with early onset conduct problems.


Journal of Consulting and Clinical Psychology, 68,
624–640.
Sanders, M.R., Montgomery, D.T., & Brechman-
Toussaint, M.L. (2000). The mass media and the
206
prevention of child behavior problems: The evalua-
tion of a television series to promote positive out-
comes for parents and their children. Journal
of Child Psychology and Psychiatry, 41, 939–948.
Sanders, M.R., & Plant, K. (1989). Programming for
generalization to high and low risk parenting situa-
tions in families with oppositional developmentally
disabled preschoolers. Behavior Modification, 13(3),
283–305.
Sanders, M.R., Turner, K.M.T., & Markie-Dadds, C.
(1997). Every parent’s group workbook. QLD:
Families International Publishing Pty Ltd.
Sanders, M.R., Turner, K.M.T., & Markie-Dadds, C.
(1998). Every parent’s guide to coping with stress.
QLD: Families International Publishing Pty Ltd.
Sanders, M.R., & Woolley, M.L. (2003). The role of
global, domain and task-specific self-efficacy in pre-
dicting parenting practices in a clinic and community
samples. Manuscript in preparation.
Sheridan, J., Dwyer, S.B., & Sanders, M.R. (1997).
Parenting and family support for children with
ADHD. Journal of Early Childhood Studies, 22,
15–23.
Sonuga-Barke, E.J.J., Daley, D., Thompson, M., Laver-
Bradbury, C., & Weeks, A. (2001). Parent-based
therapies for preschool attention-deficit/hyperactiv-
ity disorder: A randomised, controlled trial with
a community sample. Journal of American Academy
of Child and Adolescent Psychiatry, 40, 402–408.
Szatmari, P., Offord, D.R., & Boyle, M.H. (1989).
Ontario Child Health Study: Prevalence of attention
deficit disorder with hyperactivity. Journal of Child
Psychology and Psychiatry, 30, 219–230.
Tabachnick, B.G., & Fidell, F.S. (Eds.). (1996). Using
multivariate statistics (3rd ed.). California:
HarperCollins
Turner, M.T., Markie-Dadds, C., & Sanders, M.R.
(1998). Facilitator’s manual for Group Triple P.
Brisbane: Families International Publishing.
Webster-Stratton, C., & Hammond, M. (1990). Pred-
ictors of treatment outcome in parent training for
families with conduct problem children. Behavior
Therapy, 21, 319–337.
Weinberg, H.A. (1999). Parent training for attention-
deficit hyperactivity disorder: Parental and child out-
comes. Journal of Clinical Psychology, 55, 907–913.
Zubrick, S.R., Northey, K., Silburn, S.R., Williams,
A.A., Blair, E., Robertson, D., et al. (2003).
Prevention of child behaviour problems via univer-
sal implementation of a group behavioural family
intervention. Manuscript in preparation.
Zubrick, S.R., Silburn, S.R., Garton, A., Burton, P.,
Dalby, R., Carlton, J., et al. (1995). Western Aust-
ralia Child Health Survey: Developing health and
well-being in the nineties (No. 4303.5). Perth,
Western Australia: Australian Bureau of Statistics
and the Institute for Child Health Research.