Journal of Abnormal Child Psychology, Vol. 29, No. 6, December 2001, pp.

557572 ( C 2001)

ParentAdolescent Conict in Teenagers With ADHD and ODD1

Gwenyth Edwards,2,3 Russell A. Barkley,2,6 Margaret Laneri,2,4 Kenneth Fletcher,2 and Lori Metevia2,5
Received November 20, 2000; revision received March 14, 2001; accepted May 7, 2001

Eighty-seven male teens (ages 1218 years) with ADHD/ODD and their parents were compared to 32 male teens and their parents in a community control (CC) group on mother, father, and teen ratings of parentteen conict and communication quality, parental self-reports of psychological adjustment, and direct observations of parentteen problem-solving interactions during a neutral and conict discussion. Parents and teens in the ADHD/ODD group rated themselves as having signicantly more issues involving parentteen conict, more anger during these conict discussions, and more negative communication generally, and used more aggressive conict tactics with each other than did parents and teens in the CC group. During a neutral discussion, only the ADHD/ODD teens demonstrated more negative behavior. During the conict discussion, however, the mothers, fathers, and teens in the ADHD/ODD group displayed more negative behavior, and the mothers and teens showed less positive behavior than did participants in the CC group. Differences in conicts related to sex of parent were evident on only a few measures. Both mother and father self-rated hostility contributed to the level of motherteen conict whereas father self-rated hostility and anxiety contributed to fatherteen conict beyond the contribution made by level of teen ODD and ADHD symptoms. Results replicated past studies of motherchild interactions in ADHD/ODD children, extended these results to teens with these disorders, showed that greater conict also occurs in fatherteen interactions, and found that degree of parental hostility, but not ADHD symptoms, further contributed to levels of parentteen conict beyond the contribution made by severity of teen ADHD and ODD symptoms.
KEY WORDS: ADHD attention decit hyperactivity disorder; ODD oppositional deant disorder; family conict; adolescents.

Children with attention decit hyperactivity disorder (ADHD) manifest developmentally inappropriate degrees of inattention and/or hyperactiveimpulsive behavior that arise in childhood, are relatively persistent, and result in
1 This project was supported by grant MH41583 from the National Insti-

tute of Mental Health to the second author. The contents of this paper, however, are solely the responsibility of the authors and do not necessarily represent the ofcial views of this institute. 2 Department of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts. 3 Now in private practice in Sudbury, Massachusetts. 4 Present address: Youth Opportunities Unlimited, Worcester, Massachusetts. 5 Now a homemaker in Westborough, Massachusetts. 6 Address all correspondence to Russell A. Barkley, Department of Psychiatry, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, Massachusetts 01655; e-mail: barkleyr@ummhc.org.

cross-situational impairment (American Psychiatric Association [APA], 1994). Such behavior frequently brings the child with ADHD into conict with others, whether parents (Campbell, 1975; Cunningham & Barkley, 1979), teachers (Whalen, Henker, & Dotemoto, 1980), or peers (Campbell & Paulauskas, 1979; Cunningham & Siegel, 1987). And that conict often results in greater hostility, censure, rejection, and punishment directed at ADHD children, as well as withdrawal from them, than is true of behavior directed at normal children (Cunningham, Benness, & Siegel, 1988; Danforth, Barkley, & Stokes, 1991; Pelham & Milich, 1984). Extensive research on the parentchild interactions of children with hyperactivity, or ADHD, in particular (see Danforth et al., 1991, for a review) nds that hyperactive children are more negative, less compliant, less able 557
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2001 Plenum Publishing Corporation

558 to sustain their compliance, and make more requests for assistance from their mothers than do control children. Mothers of the hyperactive children are less rewarding, more directive, provide more physical assistance, and express more disapproval than do mothers of the control children. Although the direction of inuence in such reciprocal interactions can be difcult to discern, studies employing stimulant medication with hyperactive children routinely nd that reducing the childs ADHD symptoms and improving their compliance via medication often results in signicant declines in maternal control and negativity (Barkley, Karlsson, Pollard, & Murphy, 1985; Humphries, Kinsbourne, & Swanson, 1978). Such results imply that the larger inuence in determining the negativity of these interactions is from child to parent rather than vice versa, although parental behavior is not entirely without inuence (Pollard, Ward, & Barkley, 1984). Subsequent research on the motherchild interactions of hyperactive or ADHD children suggests that greater degrees of motherchild conict may occur in that subset of ADHD children manifesting more symptoms of oppositional deant disorder (ODD; Gomez & Sanson, 1994; Johnston, 1996). Indeed, level of ODD may contribute more to maternal reports of motherchild conict and parenting stress than does ADHD alone (Anastopoulos, Guevremont, Shelton, & DuPaul, 1992; Fischer, 1990; Stormshak, Bierman, McMahon, & Lengua, 2000). The vast majority of research on ADHD generally, and parentchild relations specically, has focused on children, primarily boys, between 5 and 12 years of age. Little research exists on teens with ADHD, most of which comes from follow-up studies of hyperactive children into adolescence (e.g., Barkley, Fischer, Edelbrock, & Smallish, 1990; Gittelman, Mannuzza, Shenker, & Bonagura, 1985; Weiss & Hechtman, 1993). Far less research exists on clinic-referred adolescents with the disorder. This is particularly so for research on parentteen relations. Yet the extent of parentteen conict has been shown to be a signicant determinant of concurrent and later adolescent psychological adjustment (Shek, 1998). Only two studies have examined the nature of motherteen interaction patterns in the families of adolescents having ADHD; these studies suggest that conict is substantially greater than in control groups and is particularly evident in the subset having comorbid ODD (Barkley, Anastopoulos, Guevremont, & Flecther, 1992; Barkley, Fischer, et al., 1991; Fletcher, Fischer, Barkley, & Smallish, 1996). In view of the dearth of information on clinic-referred teens having ADHD, and particularly on their parentteen interactions, the present study sought to investigate further the nature of these interactions in ADHD teens having comorbid ODD. Specically, this study attempted to determine

Edwards, Barkley, Laneri, Fletcher, and Metevia whether previous ndings on motherchild and mother teen interactions in comorbid ADHD/ODD samples could be extended to fatherteen interactions. Only three previous studies have examined fatherchild interactions in ADHD children (Burhmester, Camparo, Christensen, Gonzalez, & Hinshaw, 1992; Johnston, 1996; Tallmadge & Barkley, 1983), and none have studied fatherteen interactions. The previous studies using children found few differences in the fatherchild interactions of children with ADHD relative to normal children but did nd greater conict in the motherchild than in the fatherchild interactions (Buhrmester et al., 1992; Tallmadge & Barkley, 1983). Once again, the presence of ODD appeared to magnify the reports of family conict in the ADHD compared to the control families (Johnston, 1996). Mothers of ADHD children and adolescents have been shown to manifest signicantly greater parenting stress, marital dissatisfaction, and psychological maladjustment (particularly anxiety, depression, and hostility) than mothers of control children (Befera & Barkley, 1983; Breen & Barkley, 1988; Cunningham, Benness, & Siegel, 1988; Mash & Johnston, 1983). This seems to be particularly so for mothers of ADHD children and teens having comorbid ODD (Anastopoulos et al., 1992; Barkley, Anastopoulos, et al., 1992; Barkley, Fischer, et al., 1991). Research suggests that it is the mothers level of hostility, rather than depression, anxiety, or marital discord, that makes a signicant contribution to the degree of conict experienced in these motherteen interactions beyond that contribution made by teen ADHD/ODD symptoms (Barkley, Anastopoulos, et al., 1992). This makes sense from the standpoint of the family coercion theory of childhood social aggression (Patterson, 1982; Patterson, Reid, & Dishion, 1992) in which coercive (hostile) interaction patterns typify other members of the aggressive childs family rather than just that child alone. Once again, however, no research has examined whether fathers of teens having ADHD also manifest greater marital dissatisfaction or anxiety, depression, and hostility than fathers of control teens. Nor has any research examined the degree to which such psychological difculties contribute to the level of fatherteen or motherteen conict in these families beyond that resulting from teen disruptive behavior alone. One previous study of fathers of ADHD children, however did nd them to have more depression, but not hostility, than control fathers, and even this difference was only in those ADHD children having ODD (Johnston, 1996). No prior studies have examined the contribution of parental ADHD symptoms, however, to the extent of parentteen conict. This study, therefore, examined the psychological adjustment (depression, anxiety, hostility, and ADHD) of both fathers and mothers of ADHD/ODD teens and its

Family Conict and ADHD/ODD contribution to parentteen conict. It specically tested the following hypotheses: There will be greater interaction conicts between teens with ADHD/ODD and their mothers than in control families; There will also be greater conicts in the interactions of ADHD/ODD teens with their fathers in comparison to control families; There will be greater conict in motherteen than in the fatherteen interactions in families having ADHD/ODD teens; Parents and teens in families with ADHD/ODD teens will employ more aggressive conict tactics than will control families; Both mothers and fathers of ADHD/ODD teens will show higher levels of hostility, anxiety, depression, and ADHD than will parents of control teens; and Parental hostility will contribute to the degree of parentteen conict beyond that contribution made by the level of teen disruptive behavioral problems (ADHD and ODD symptoms). METHOD Participants This study involved a total of 87 male teens with ADHD/ODD and 32 community control male teens recruited over a 3-year period. The teens with ADHD/ODD and their parents were subsequently assigned to one of two behavioral family therapies for the treatment of parent teen conict. The results of that treatment study are reported in a separate paper (Barkley, Edwards, Laneri, Fletcher, & Metevia, in press-b). All teens enrolled in this study had to be between the ages of 12 and 18 years of age, be the biological child of at least one of the parents living in the home or have been adopted at birth, and have an IQ greater than 80 on the Kaufman Brief Intelligence Test (Kaufman & Kaufman, 1990). Teens were excluded if they had the following conditions: deafness, blindness, severe language delay, cerebral palsy, epilepsy, autism, or psychosis, as established through parental and adolescent interview and history. The teens and parents signed statements of informed consent. The project and consent forms received approval from the institutional review board for research on human subjects. To be considered eligible for the ADHD/ODD group, the adolescent had to meet the following seven criteria: (1) parent and/or teacher complaints of inattention, poor impulse control, and overactivity as established through

559 the screening telephone interview; (2) have at least 12 of the 18 symptoms of ADHD from the DSM-IV criteria as established through the ADHD screening scale (symptoms rated Often or higher) or a T score of 65 or higher on the Inattention scale of the Child Behavior Checklist (Achenbach, 1991); (3) have at least four of the eight symptoms of ODD in the DSM-IV as established through ODD screening scale or have a T score greater than 65 on the aggression scale of the Child Behavior Checklist (CBCL; Achenbach, 1991); (4) meet DSM-IV criteria for both ADHD and ODD or conduct disorder (CD) during the structured clinical interview; (5) either not currently receiving psychoactive medication or, if receiving medication, able to remain at a stable dose through the 18 sessions of behavioral family therapy; (6) not seek any other form of psychiatric or psychological treatment during their participation in this project, and (7) not have any immediately ongoing legal proceedings against them for criminal or status offenses by the local juvenile court authorities that would result in their removal from their family during the active treatment phase of the study. All the ADHD/ODD teens selected were of the Combined Type. More than half of these teens were already receiving treatment, particularly medication, from various mental health specialists for their psychiatric disorders (see Results later). Families with teens having ADHD/ODD were recruited from one of two sources: A clinic specializing in ADHD at a New England medical school and advertisements run periodically in the local city newspaper. This report focuses on the families of the 87 males having ADHD/ODD who completed the entire screening, eligibility, and evaluation procedures. The community control (CC) teens were recruited through advertising in the same community newspaper as above. These teens were screened using the parent report form of the Child Behavior Checklist (completed by mothers). They had to have T scores on all scales below 65 to serve in this control group. Teens also had to have fewer than three symptoms (answers of Often or greater) of inattention and three symptoms of hyperactiveimpulsive behavior from the DSM-IV symptom list as assessed by the ADHD screening scale (see Selection Measures later). This report focuses on the 32 males who completed the entire screening, eligibility, and evaluation procedures. More detailed information on the ow of participants in both groups throughout the recruitment, screening, and evaluation process appears in the reports by Barkley, Edwards, Laneri, Fletcher, & Metevia (in press-a) and Barkley et al. (in press-b). To summarize, there were 32 male teens in the CC group and 87 male teens in the ADHD/ODD group. Concerning minority composition, 86% of all of the teens were Caucasian, 9% were Hispanic, 2% were African

560 American, and 3% were Asian. The groups did not differ signicantly in their ethnic composition. This composition reects that generally found in referrals to the clinic from which these families were drawn as well as the city in which this medical school is located. As for parental participation, all 32 mothers of CC teens and 83 of 87 mothers (95%) in the ADHD/ODD group participated in this study. There were 22 fathers in the CC group (69%) who participated and 70 fathers in the ADHD/ODD group (80%). The groups did not differ signicantly in the proportion of fathers participating in the study. Information on the neuropsychological status of the two groups is provided in the paper by Barkley et al. (in press-a). Procedures After passing the telephone and rating scale screenings, all ADHD/ODD teens received an initial evaluation by a PhD level child clinical psychologist before entering the study. This evaluation served to establish the diagnostic status of these participants and that all other eligibility criteria had been met. A second, more senior child clinical psychologist reviewed all chart material from the initial evaluation to ensure that teens met diagnostic criteria for ADHD and ODD or CD, as earlier, before entering the next phase of the study when the dependent measures were collected. Where this second clinician disagreed with the rst on diagnostic status, they met to determine if a consensus could be reached. Where a disagreement continued to exist, the family was removed from consideration for this project. Such disagreement occurred for 9.6% of the teens undergoing this initial evaluation. Thus, all ADHD/ODD teens participating in this project met diagnostic criteria, reected in 100% agreement between the two clinicians in this stepwise diagnostic/review process. Teens and parents who met eligibility requirements for the study during this initial evaluation were then scheduled within 12 weeks for their direct observation of family interactions using the dependent measures (see later). They were provided with the rating scales of family conict to complete at home prior to this next observation session. In this second session, the rating scales of family conict and parental psychological adjustment (see later) were collected at which time the observation of parent teen interactions occurred. In four cases in the CC group (18%), fathers completed and returned their rating scales of parentteen conict and parental adjustment but chose not to attend this direct observation session. This occurred in ve cases for mothers of the CC group (18%). In the ADHD/ODD, this occurred for 14 fathers (20%) and just one of the mothers (1%). During this observation session, parents and teens participated in the neutral discussion

Edwards, Barkley, Laneri, Fletcher, and Metevia period, followed by the conict discussion period, and concluding with the positive discussion period. This same order of the assessment methods was followed for all participants. Participants were paid $50 for participating in this assessment. Selection Measures Parental Interview A structured psychiatric interview created for this project was used with the parents to assess the presence of DSM-IV diagnostic criteria for ADHD, ODD, and conduct disorder in the teens. One part of the interview consisted of questions pertaining to the current status of the family, demographic data, and the academic, social, medical, and mental health histories of the teenagers. A second section collected information on the DSM-IV criteria for ADHD, ODD, and CD (APA, 1994). Parents were instructed that, if their teen was receiving psychiatric medication, their responses should be based on the teens behavior while offmedication. No information is available on the interjudge agreement for this particular structured interview for the disruptive behavior disorders. However, as noted earlier, to be in this study, two clinicians had to agree on the diagnosis of ADHD and ODD or CD. Child Behavior Checklist Parent Form (CBCL; Achenbach, 1991) The 1991 version of this scale provided T scores for specic narrow band scales. The inattention and aggression scales were employed in determining eligibility criteria for the project, as noted earlier. If the teen was receiving medication, the answers were to be based upon how the teen functioned while off-medication. The scale has been used extensively in research on various childhood psychopathologies. Ratings of ADHD/ODD Symptoms Parents completed two rating scales, one containing the items from the DSM-IV for ADHD and the other the symptoms for ODD. Each item on each scale was rated on a 4-point scale (03), using the response format of Not at all, Sometimes, Often, and Very often. The scales were used at the initial screening to insure that teens met eligibility criteria for the number of ADHD and ODD symptoms, as described earlier. Once more, if the teen was receiving medication, the answers were to be based upon how the teen functioned while off-medication. Evidence of reliability comes from prior research showing internal

Family Conict and ADHD/ODD consistency (coefcient ) for the ADHD items as .92 and 1-month test-retest reliability as being .85. Validity has been established through correlations of the ADHD items with other scales assessing hyperactiveimpulsive behavior ranging from .61 to .80 for parent ratings. Signicant differences have also been found between ADHD and control groups (DuPaul, Power, Anastopoulos, & Reid, 1998). The ODD items were added to this scale and do not have prior information on their reliability or validity when used in this format. Kaufmann Brief Intelligence Test (KBIT; Kaufman & Kaufman, 1990) All teens were given this 20-min well-standardized brief intelligence test containing subtests for vocabulary and matrix reasoning. Teens needed a total IQ score of 80 or higher to be eligible for this study. Split-half reliability is .94 and test-retest reliability is .93 for the age span of 1019 years (Kaufman & Kaufman, 1990). Validity has been established through signicant correlations between this test and other lengthier intelligence tests (see Kaufman & Kaufman, 1990, for research review). Dependent Measures All of the measures collected below that pertained to the teenagers behavior were completed based upon the teens current functioning, regardless of whether or not the teen was receiving psychiatric medication. Parental Adjustment Beck Depression Inventory (BDI; Beck, Steer, & Garbin, 1988). This self-report scale, used extensively in research on depression in adults, consists of 21 symptoms. Each item is rated on a 4-point Likert scale (03) in terms of the intensity with which that item has been experienced. Internal consistency of the items averages 0.86 (coefcient ) for psychiatric patients and 0.81 for nonpsychiatric control participants. Test-retest stability of the scale ranges from .62 to .90 (1 week to 4 months), varying with the population studied and the duration between testings. Validity of the scale has been established through its correlation with clinical ratings of depression (r = .72) and with the Hamilton Rating Scale for Depression (r = .73) for psychiatric patients. The scale signicantly differentiates between depressed and nondepressed patients and between depression and anxiety (Beck et al., 1988). The single raw score from the scale was employed here to assess depression in parents.

561 Symptom Checklist 90 Revised (SCL-90-R; Derogatis, 1992). This self-report scale has been used extensively in research on adult psychopathology. It assesses 90 symptoms of various forms of adult psychological maladjustment. T scores are produced for scales assessing anxiety, depression, hostility, phobic anxiety, interpersonal sensitivity, etc. Only the T scores for the anxiety and hostility scales were employed here in the regression analyses (see Results later) as these were the only scales to signicantly distinguish parents of ADHD and normal children, as discussed earlier. When available, both parents completed this scale about themselves. Information on reliability and validity is satisfactory and available in the scale manual (Derogatis, 1992). LockeWallace Marital Adjustment Test (LW-MAT; Locke & Wallace, 1959). This widely used rating scale evaluates marital satisfaction. The scale was used here to evaluate the quality of the relationship between the currently cohabiting adult partners, whether married or not. Numerous studies attest to its validity and utility in distinguishing distressed from nondistressed couples (OLeary & Arias, 1988). The single raw score was employed here to assess relationship satisfaction in the parents and their cohabiting partners. Adult ADHD Rating Scale (Barkley & Murphy, 1998). Each parent, when available, completed two versions of this 18 item rating scale that contained the DSM-IV symptoms for ADHD. Each item was rated on a 4-point scale (03; Not at all, Sometimes, Often, and Very often). One version assesses current symptoms (past 6 months) and the second assesses recall of childhood symptoms between 512 years of age. A total summary score was calculated for the ADHD items for each version. The reliability (coefcient s) obtained in a recently completed study of young adults with ADHD by Barkley is .92 for the inattention items and .91 for the hyperactiveimpulsive items. Evidence for validity comes from studies showing that ratings of current symptoms are signicantly correlated (r = .76) with concurrent ratings provided by spouses, parents, and cohabiting partners about the subjects (Murphy & Barkley, 1996). Validity of the childhood recall version of the scale comes from evidence that self-reports of childhood are correlated signicantly (r = .74) with parental ratings of their recall of the adult subject as a child 512 years of age. Ratings of ParentTeen Conict Conict Behavior Questionnaire (CBQ; Prinz, Foster, Kent, & OLeary, 1979). The scale contains 20 true/false items assessing the quality of communication and level of conict in parentadolescent relationships during the

562 past 2 weeks (e.g., My mother (dad, teen) doesnt understand me, My mom (dad, teen) screams a lot, etc.). Both parents completed this scale about the teen and the teen completed a separate scale about each parent. Each informants scale provided a single score that was the total number of items answered in a negative direction. Internal consistency has been found to be .90 (coefcient ; Robin & Foster, 1989). Test-retest reliability over 68 weeks for clinically referred, distressed families ranged from .37 for teens appraisals of their relations with their mothers, to .84 for teens appraisals of relationships with fathers. Reliability was .57 for mothers appraisal of their relationships with their teens, and .82 for fathers appraisals of their relationship with their teens. Validity evidence comes from studies showing that distressed families report signicantly poorer scores on this scale than nondistressed families do (Robin & Foster, 1989). Issues Checklist (Prinz et al., 1979). This scale covers 44 topics on which parents and teens may have disagreements (e.g., homework, friends, dress, leisure time, use of phone, etc.). It provided a measure of the diversity of family conicts as well as the intensity of disagreements. Each topic required three answers. One was if the parent and teen discussed the topic at all in the past 2 weeks. If so, then they had to answer approximately how many times they discussed it. Finally, they rated how hot the discussions were, with 1 indicating being calm and 5 indicating being very angry. The parents each completed this scale about their teen and the teen completed two scales separately, one for the mother and one for the father. Two scores were obtained from each informants version of the scale: the Number of Conicts and the Mean Anger Intensity. Reliability has been demonstrated through signicant 12-week test-retest correlations (.63.70 for mothers ratings; .73.80 for father ratings; .47.49 for teen ratings of mothers; and .60.72 for teen ratings of fathers). Validity has been established in studies showing agreement averaging 67.5% between parent and teen as to whether a conict issue had been discussed in the prior 2 weeks. Signicant correlations have been obtained between scores on the scale and direct observations of parentteen interaction conicts (.44.52) and scales assessing dissatisfaction in child rearing (.45.55) (Robin & Foster, 1989). Conict Tactics Scale ParentTeen Version (CTSPT). This 18-item scale was adapted from the Conict Tactics Scale (Straus, 1990) used in marital violence research. The items were arranged in order of increasing anger and hostility toward the other person such that Item 1 referred to Discussed an issue calmly, whereas Item 9 was Threatened to hit or throw something at the other person, and Item 18 was Used a knife or red a gun.

Edwards, Barkley, Laneri, Fletcher, and Metevia The rst 10 items referred to verbal forms of conict (insulting, sulking, threatening, etc.) whereas the nal 8 referred to physical forms of conict (throwing something at another, pushing, slapping, hitting, threatening with a weapon, etc.). For each item, respondents were asked to indicate if the tactic was used during the past year and, if so, with what frequency. The scale contained two sections, one providing a report by the parent about behavior toward their teen and the second about the teens behavior toward them. The teens completed this same scale but did so twice, once with regard to their interactions with their mother and the second with regard to their interactions with their father. The section in the scale referring to the teen included all 18 items. For the section of the scale referring to the parent, only the rst 12 items were used here with the highest item referring to Pushed, grabbed, or shoved the teen. The reason for not including the remaining six more violent items is that we did not wish to elicit answers that could be construed as possibly constituting child abuse because state reporting requirements would have mandated that we initiate such a report. The only score used here was the Worst Tactic, representing the highest item (most hostile action) that had been used by the parent toward the teen or teen toward that parent in the previous year. To our knowledge, the scale has not been previously employed in studies of parentteen conict but has been used extensively in research on marital conict and more recently in studies of dating violence among teenagers (Foshee, 1996). Evidence of reliability comes from past studies of maritally violent couples using the CTS in which coefcient alphas ranged from .80 (men) to .86 (women) (Dunford, 2000). Evidence of validity comes from studies employing the scale in national studies of marital violence (Straus & Gelles, 1986). Corresponding agreement between husbands and wives on the wives violent behavior were 88% for clinical dyads and 95% for community dyads (Jouriles & OLeary, 1985). Higher scores on the scale also are signicantly predictive of marital dissolutions over a 4-year follow-up period (Rogge & Bradbury, 1999). Direction Behavioral Observations of ParentTeen Interactions. Conict Rating System (CRS; Christensen & Heavey, 1990; Christensen & Shenk, 1991; Heavey, Layne, & Christensen, 1993) has been used in previous studies of dyadic conict during marital interactions. It is an expanded version of the observational form used by Christensen and Heavey (1990) to characterize the behavior of couples during problem-solving discussions. To our knowledge, it has not been used to study problem solving in parentteen discussions. The CRS is composed of 15 behavioral dimensions along which each participant in the interaction is rated by an observer using a 9-point

Family Conict and ADHD/ODD scale. There are 10 dimensions reecting negative communication (e.g., blames, accuses, criticizes the other person, pressures the other to change, withdraws from the interaction, avoids discussing the problem, interrupts the other person, dominates the discussion) and 5 reecting positive communication (e.g., suggests possible solutions, expresses self clearly, shows positive affect, expresses understanding and acceptance of partners feelings). Reports of coefcient alphas of .80.83 (positive) and .66 (negative) come from studies of marital interaction conict (Heavey et al., 1993; Berns, Jacobson, & Gottman, 1999). Interobserver agreement (intraclass correlations) in these same studies was .84.89 (positive) and .84.85 (negative). Separate positive and negative communication scale scores were computed here by summing the ratings across the respective items for each scale. In this study, coefcient alphas were .84.86 (negative) and .87.89 (positive) for mothers across the neutral and conict discussion periods (see later), .76.80 (negative) and .89.91 (positive) for fathers across these same discussions, and .89.90 (negative) and .94.95 (positive) for teens in these same discussions. Parents and teens were seated in a clinic room with a one-way observation mirror and intercom and asked to engage in three types of discussions. All discussions were videotaped. The rst discussion lasted 15 min and involved planning a vacation given unlimited funds and was called the Neutral Discussion. The next discussion, called the Conict Discussion, required the parents and adolescent to discuss and attempt to resolve the ve angriest conicts the mother reported on her version of the Issues Checklist, described earlier. This situation lasted 15 min. Following the Conict Discussion, participants engaged in a brief Positive Discussion period so as to reduce the level of hostility among family members elicited by the Conict Discussion before permitting them to depart the clinic. Each person had to list approximately ve positive characteristics they noticed in the other person and then describe these to each other, giving examples that illustrated each positive feature. This session lasted 10 min. For this study, only scores from the Neutral and Conict Discussions were used. At the end of this discussion period, each participant was asked to rate on a scale of 0 (not at all) to 9 (very similar) just how similar this discussion was to those taking place at home on these problem topics. These discussions involved at least one of the parents and the teen in all instances. Where the second parent was available, they also participated in these same discussions with the other parent and the teen. Approximately 68% of the control group and 60% of the ADHD/ODD group involved such triadic as opposed to dyadic discussions with the teens. This difference was not signicant ( 2 = 0.50, df = 1, p = .48).

563 The videotapes of the two discussions were coded using the CRS described earlier. The observer was required to watch the entire videotape of the discussion period and then complete the CRS for each participant in the discussion separately. The observers were trained by the rst author in the use of this coding system based on instructions developed by Christensen and Heavey (1990) and provided by Heavey to this project. The observer was blind to group membership of the families. Interobserver reliability was conducted on 20% of the videotapes by using a second observer also trained in this system who was also blind to group membership. Agreement was examined using intraclass correlations on the scores from the two observers for mothers, fathers, and teens (collapsed) across both discussions (collapsed). Results were .82 (negative scale) and .64 (positive scale). RESULTS Initial Subject Characteristics Initial demographic characteristics as well as the measures employed as selection criteria for each group are reported in Table I. The two groups did not differ in age or grade levels, or in the ages or education of the mothers and fathers. The ADHD/ODD group, however, had a signicantly lower IQ than did the control group. As expected from the use of these measures as selection criteria, the ADHD/ODD group had a signicantly more DSM-IV symptoms of both ADHD and ODD and signicantly higher CBCL attention and aggression scores than did the CC group. The proportion of each group meeting DSM-IV criteria for ODD was 93% for the ADHD/ODD group and 12% for the control group ( 2 = 74.60, df = 1, p < .001). Of the four CC teens with ODD, three had just the bare minimum of four symptoms and one had six symptoms. The proportion of each group having CD (with or without ODD) was 62% for the ADHD/ODD group and 9% for the control group ( 2 = 26.03, df = 1, p < .001). The three CC teens having CD had the bare minimum number of symptoms of three. A total of 67.7% of the control group and 68.7% of the ADHD/ODD group had parents who were currently married ( 2 = 1.80, df = 3, p = .61). Approximately 97% of the mothers of control teens and 92% of the mothers of the ADHD/ODD group were the biological mothers ( 2 = 1.35, df = 3, p = .72). Ninety-one percent of the CC group and 82% of the ADHD/ODD group were the biological fathers ( 2 = 2.28, df = 3, p = .52). Comparisons on the measures listed in Table I between teens whose fathers did and did not participate found no signicant differences within the ADHD group and just one

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Table I. Participant Selection Characteristics for Each Group Control Measures Adolescent age (years) Adolescent IQ (KBIT) Adolescent school grade Mother age (years) Mother education (years) Father age (years) Father education (years) # ADHD symptoms Teen # ODD symptoms Teen Teen CBCL attention Teen CBCL aggression Mean 14.9 113.5 9.4 42.1 14.0 44.6 14.8 0.6 0.6 51.0 51.8 SD 1.5 9.2 1.6 3.8 2.3 4.9 3.4 1.4 1.4 2.1 4.2 ADHD/ODD Mean 14.8 103.7 8.9 42.7 14.7 45.1 14.5 13.2 5.9 72.9 71.3 SD 1.5 10.0 1.7 6.0 2.1 6.3 2.9 5.6 2.0 9.2 10.8 t 0.57 4.72 1.59 0.53 1.43 0.36 0.39 18.87 15.38 20.07 13.61 p< .001 .001 .001 .001 .001

Note. ADHD attention decit hyperactivity disorder; SD standard deviation; t results of the t test; p probability value for the t test if signicant ( p < .05); KBIT Kaufman Brief Intelligence Test; CBCL Child Behavior Checklist T score (parent versionmother report); ODD oppositional deant disorder.

in the control group: teens whose fathers did not participate had mothers with less years of education than did teens whose fathers did participate. In the ADHD/ODD group, 58.6% were taking psychiatric medication. No one in the control group was on medication. The medicated and nonmedicated ADHD/ ODD participants were compared on all dependent measures pertaining to the teen (e.g., age, IQ, CBCL, ADHD, and ODD ratings by parents and teens, teen and parent reports of parentteen conict, etc.), of which there were 52 such measures. Given the large number of t tests, signicance was set at p < .01. The groups did not differ significantly on any measures. Therefore, these two subgroups of ADHD/ODD youth were considered to be comparable and collapsed for purposes of this study. Because the ADHD/ODD group differed signicantly from the CC group in IQ, it was necessary to determine if IQ needed to be covaried in any subsequent group comparisons. Pearson correlations were computed between the teen IQ scores and all of the dependent measures, using the entire sample. Only three of the 32 correlations were signicant ( p < .05). This is nearly the number that might be expected to be signicant by chance alone (2). Nevertheless, to err on the conservative side, IQ was used as a covariate in the analyses of these three dependent measures (indicated by a in Table II).

tionships with their teen ( p < .01 set for each measure). Signicant group differences were found on all measures. The ADHD/ODD group manifested signicantly more issues of conict, more anger intensity during those conicts, poorer parentteen communication (CBQ), and more aggressive conict tactics as reported by both parents than did the control group. Teens completed these same ve measures separately about their mothers and fathers ( p set at <.01). The ADHD/ODD group reported signicantly higher levels of anger during the motherteen conicts and poorer mother teen communication than did teens in the CC group. The ADHD/ODD group also reported more anger intensity during their conicts with their fathers, poorer fatherteen communication, and use of more aggressive conict tactics by their father toward them than did teens in the CC group.

Observations of ParentTeen Interactions Mothers, fathers, and teens rated the similarity of the neutral and conict discussion periods to those that occurred at home concerning a neutral or conict topic ( p set at <.017). For the neutral discussion, both mothers (Mean = 5.8; SD = 2.4) and teens (Mean = 4.6; SD = 2.8) in the ADHD/ODD group rated these discussions as being signicantly less similar to discussions of neutral topics that occur at home than did mothers (Mean = 7.0; SD = 1.5) and teens (Mean = 6.1, SD = 2.0) in the CC group (Mothers: t = 3.03, df = 68.3 [unequal variances], p = .003; Teens: t = 3.09, df = 56.8 [unequal variances], p = .003). The groups did not differ on any

Parental and Teen Reports of ParentTeen Conict (Table II) Five measures were collected separately from mothers and fathers about the extent of conict in their rela-

Family Conict and ADHD/ODD

Table II. Ratings of ParentTeen Conict Control Measures Mother ratings IC: No. of issues IC: Anger intensitya CBQ ratinga CTS: M worst tactic CTS: T worst tactic Father ratings IC: No. of issues IC: Anger intensity CBQ ratinga CTS: F worst tactic CTS: T worst tactic Teen on mother IC: No. of issues IC: Anger intensity CBQ rating CTS: M worst tactic CTS: T worst tactic Teen on father IC: No. of issues IC: Anger intensity CBQ rating CTS: F worst tactic CTS: T worst tactic Mean SD N ADHD/ODD Mean SD N F p<

565

15.8 1.6 3.9 6.7 7.8 14.5 1.4 4.1 6.9 7.7 12.1 1.5 4.0 6.5 8.7 9.0 1.2 1.4 5.1 7.1

6.8 0.6 4.4 3.7 3.1 6.8 0.4 3.6 3.8 3.6 6.4 0.6 4.1 3.7 3.2 6.3 0.6 2.2 3.8 3.9

32 30 30 32 31 22 22 20 22 22 32 32 32 31 32 24 24 25 25 26

22.1 2.3 13.9 10.6 11.4 19.9 2.0 12.0 10.5 10.7 13.9 2.2 7.9 8.4 10.0 12.5 2.2 7.8 8.3 9.3

7.4 0.6 4.1 2.1 3.0 7.8 0.6 5.4 2.6 2.8 5.7 0.7 5.1 3.4 3.0 6.3 0.9 6.1 4.0 3.7

83 83 83 83 83 69 69 70 69 70 84 84 84 84 84 75 75 75 76 76

17.46 21.54 108.29 51.13 32.21 8.36 16.37 29.70 24.87 16.14 2.08 22.64 4.65 6.30 3.91 5.50 23.56 25.67 12.63 6.10

.001 .001 .001 .001 .001 .005 .001 .001 .001 .001 ns .001 .001 ns ns ns .001 .001 .001 ns

Note. ADHD attention decit hyperactivity disorder; SD standard deviation; F results of the F test; p probability value for the F test if signicant ( p < .01); ODD oppositional deant disorder; IC Issues Checklist; CBQ Conict Behavior Questionnaire; CTS Conict Tactics Scale; M mother; T teen; F father. a Indicates that IQ served as a covariate in the analysis of this measure.

of the conict discussion ratings, with both groups rating these discussions as reasonably similar to conict discussions occurring at home (Mean ratings between 6.0 and 7.2 for the ADHD/ODD and CC groups out of a possible 9 maximum score). Positive and negative interaction scores were coded for each participant in each discussion using the CRS system, thus yielding six measures for each discussion period ( p set at <.008). These measures are shown in Table III. Results indicated that teens in the ADHD/ODD group were observed to be signicantly more negative during the neutral discussion than were teens in the CC group. No other comparisons reached signicance. However, in the conict discussion period, mothers and teens in the ADHD/ODD group displayed signicantly less positive behavior whereas mothers, fathers, and teens in this group demonstrated signicantly more negative behavior than did those in the comparison group. Because some of these direct observations were dyadic (mothers and teens) whereas most others were triadic (mothers, fathers, and teens), a subsequent analysis

was done to determine if the group differences noted earlier for mother and teen behavior were affected by the fathers participating in these discussions. The foregoing analyses for mother and teen measures were re-computed using family composition (dyadic vs. triadic) as a separate factor in the analyses along with that of teen grouping (ADHD/ODD vs. CC). Because of the very small sample sizes for the dyadic family composition factor in some cells, signicance was set at p < .05 to maximize power. For the neutral discussion period, the family composition factor was not signicant on any measure nor was its interaction with the grouping factor. For the conict discussion period, no main effect for family composition was noted on either the mothers or teens positive or negative behavior. However, a signicant interaction of composition with teen grouping was noted on teen negative behavior ( F = 4.44, df = 1/95, p = .038). Pair-wise contrasts indicated that within the CC group, teens demonstrated signicantly less negative behavior when the father was present (Mean = 34.7, SD = 17.9) than when absent from this discussion (Mean = 23.1, SD = 8.9). In the

566

Edwards, Barkley, Laneri, Fletcher, and Metevia

Table III. Direct Observations (CRS) From Neutral and Conict Discussion Periods Control Measures Neutral discussion Mother positive Father positive Teen positive Mother negative Father negative Teen negative Conict discussion Mother positive Father positive Teen positive Mother negative Father negative Teen negative Mean SD N ADHD/ODD Mean SD N F p<

38.1 34.8 34.0 17.3 18.3 18.6 37.5 34.7 33.9 23.8 25.0 26.5

5.2 9.0 8.5 8.8 9.2 7.5 5.4 10.3 9.1 9.1 10.2 13.3

27 18 28 26 18 26 27 18 28 27 18 28

36.3 34.4 28.5 18.9 20.7 31.6 31.9 30.5 21.1 33.5 35.8 47.1

7.7 8.0 11.6 9.7 8.0 16.5 7.8 8.6 10.5 10.8 11.1 18.3

81 56 86 82 56 86 82 56 85 82 54 84

1.20 0.02 5.43 0.56 1.13 15.12 12.02 2.88 33.11 17.22 13.30 30.14

ns ns ns ns ns .001 .001 ns .001 .001 .001 .001

Note. ADHD attention decit hyperactivity disorder; ODD oppositional deant disorder; SD standard deviation; F results of the F test; p probability value for the F test if signicant ( p < .01).

ADHD/ODD group, this difference was not signicant (Means = 43.3 vs. 49.1, SDs = 18.8 vs. 17.9, respectively). CC and ADHD/ODD teens in the dyadic interactions were not signicantly different in their level of negative behavior. However, ADHD/ODD teens in the triadic interactions were signicantly more negative than were CC teens. Thus, the presence of the father during motherteen conict discussions may help to suppress teen negativity in the CC group but not in the ADHD/ODD group. This same interaction was also marginally signicant for mothers negative behavior ( F = 3.77, df = 1/92, p = .055) and showed much the same pattern in pair-wise comparisons. Comparison of MotherTeen Versus FatherTeen Conicts One purpose of this study was to determine if the severity of parentteen interaction conicts varied as a function of sex of the parent. To evaluate this issue, the ratings collected from mothers on the ve measures assessing such conict (IC, CBQ, and CTS) were compared to those collected from fathers using that subset of participants within each group on which data were available from both mothers and fathers ( N s: ADHD/ODD = 65, Control = 22). For each measure, a 2 (groups) 2 (parents) ANOVA was computed with repeated measures on the last factor ( p set at <.01). The main effects for group were ignored in these analyses as they have already been reported earlier. Of interest here was any main effect for sex of the parent or any interaction of it with the grouping factor. Only one main effect for parent was signicant, and

this indicated that mothers reported higher levels of anger intensity (Mean = 2.10, SD = 0.70) in conict discussions with their teens than did fathers (Mean = 1.77, SD = 0.57; F = 6.77, df = 1/85, p = .01). No other main effects or interaction terms reached this level of signicance. These analyses were then repeated using the teens ratings of their mothers and fathers on these same ve measures for that subset of participants from whom teen ratings were available for both parents ( N s: ADHD/ODD = 75; Control = 25; p set at <.01). The main effect for the teens worst tactic used toward their parents was significant, with teens reporting that they employed a signicantly more hostile tactic toward their mothers (Mean = 9.75, SD = 3.2) than toward their fathers (Mean = 8.60, SD = 3.80; F = 13.37, df = 1/97, p < .001). No other main effects for sex of parent or interactions of this factor with the grouping factor were signicant. Finally, these analyses were conducted on the parents positive and negative interactive behavior scores from the CRS for both the neutral and the conict discussion periods where both parents had participated in these discussions ( N s: ADHD/ODD = 44; Control = 19; p set at <.012). There were no signicant main effects for sex of parent or any interaction of sex with group. Parental Psychological Adjustment Signicance for the mothers and fathers self-reports on the BDI, the two SCL-90 scales, the LW-MAT score, and for the ADHD symptoms, both current and childhood was set at <.008 for each set of measures. Mothers in the

Family Conict and ADHD/ODD ADHD/ODD group reported signicantly higher levels of hostility (SCL-90; t = 3.23, df = 113, p = .002) and depression (BDI; t = 4.82, df = 113, p < .001) than did mothers in the CC group. No other differences were signicant. Fathers of the ADHD/ODD group reported signicantly higher levels of childhood ADHD than did fathers in the CC group (t = 3.22, df = 89, p = .002). No other comparisons reached this level of signicance.

567 The contribution of parental psychological maladjustment to the MotherTeen Conict scores was then examined using stepwise multiple regression. The entire sample was used in this analysis. Independent variables were entered in three blocks, corresponding to teen, mother, and father characteristics, respectively. Block 1 comprised the mothers ratings of the teens severity of ADHD and ODD, using raw scores derived from the ADHD/ODD Rating Scale and the teens KBIT IQ score. Block 2 consisted of the mothers ratings of their own depression (BDI), anxiety (SCL-90), hostility (SCL-90), and current ADHD symptoms (Adult ADHD Rating Scale). Block 3 consisted of these same scores from the fathers self-ratings. The results are displayed in Table IV. Although teen ratings of ODD accounted for a substantial portion of the variance in the MotherTeen Conict score (41%), and teen ADHD made an additional signicant contribution (3%), two parental characteristics also contributed signicantly to motherteen conicts. These were the mothers and fathers own self-ratings of hostility, which accounted for 3.4 and 1.8% of the variance, respectively, in the MotherTeen Conict factor scores. The same approach was employed to study the contribution of these three blocks of variables to the Father Teen Conict factor scores. Except in this case, the fathers ratings of the teens ADHD and ODD symptoms were employed in the rst block, the fathers self-ratings were entered in the second block, and the mothers selfratings were entered last. These results also appear in Table IV. Once again, the teens ODD and ADHD symptoms made signicant contributions to the FatherTeen Conict scores (40 and 6% of the variance, respectively). Beyond these, however, two father self-ratings also made a signicant contribution: father hostility (6%) and anxiety (2%) scores from the SCL-90. In short, some aspects of

Contribution of Parental Self-Rated Maladjustment to Parental Ratings of ParentTeen Conict The nal aim of this study was to examine the extent to which parental anxiety, depression, hostility, and ADHD may have contributed to parentteen conict beyond that contribution made by the severity of teen ADHD and ODD symptoms. Multiple regression was used to address this issue. First, however, the ve ratings collected from mothers (IC, CBQ, and CTS) were reduced through principal components factor analysis using varimax rotation (SPSS version 9.0). This indicated that these ve measures formed a single signicant component having an Eigenvalue of 2.94 and accounting for 58.9% of the variance. No other components received Eigenvalues of greater than 1.00. The range of factor loadings was .641 .840. A single factor score (MotherTeen Conict) therefore was created using factor loadings for these maternal ratings. Next, the same analysis was applied to the same ve father ratings, yielding the same result. The single factor solution gave an Eigenvalue of 2.52, accounting for 50.4% of the variance. Factor loadings here ranged from .60 to .778. Consequently, a single factor score (FatherTeen Conict) was created for the father ratings as well.

Table IV. Regression Analyses Showing the Contribution of Parent Maladjustment to Mother and Father Ratings of ParentTeen Conict (After Controlling for Teen ADHD, ODD, and IQ) Dependent measure Motherteen conict factor Teen ODD (mother rated) Teen ADHD (mother rated) Mother hostility (SCL-90) Father hostility (SCL-90) FatherTeen conict factor Teen ODD (father rated) Teen ADHD (father rated) Father hostility (SCL-90) Father anxiety (SCL-90) R R2 R 2 change Betaa F change df p

.644 .667 .692 .705 .630 .676 .722 .736

.415 .445 .478 .496 .396 .457 .521 .541

.415 .030 .034 .018 .396 .061 .063 .020

.411 .207 .165 .140 .382 .272 .353 .169

83.02 6.17 7.47 4.06 76.80 13.05 15.21 5.05

1/117 1/116 1/115 1/114 1/117 1/116 1/115 1/114

<.001 .014 .007 .046 <.001 <.001 <.001 .026

Note. ADHD attention decit hyperactivity disorder rating scale score; ODD oppositional deant disorder rating scale score; SCL-90 Symptom Checklist 90 T -score. a Beta coefcients are standardized.

568 parental psychological adjustment make signicant contributions to parentteen conict besides the important contribution made by teen levels of disruptive behavior (ADHD/ODD). DISCUSSION The ndings serve to both replicate and extend the results of earlier research on the parentchild and parent teen interactions of children and teens with ADHD and ODD. As in earlier studies, the present one found a substantial degree of conict between the teens with ADHD/ ODD and their mothers. The mothers of the teens with comorbid ADHD and ODD had more issues on which they had conicts with their teens, more anger in these conicts, used more aggressive tactics, and reported poorer communication with their teens than did CC mothers. These maternal reports were largely corroborated by the teens own reports. As in our earlier studies of ADHD teens (Barkley, Anastopoulos, et al., 1992; Barkley, Fischer, et al., 1991), increased conict between mothers and teens was directly observed during problem-solving discussions. The level of ODD symptoms more than the ADHD symptoms contributed most to motherteen conict; a result found in earlier studies of ADHD children (Anastopoulos et al., 1992; Gomez & Sanson, 1994; Johnston, 1996). This study also extended these ndings on mother teen relations to the interactions of fathers with ADHD/ ODD teens. Like mothers, fathers of the ADHD/ODD group also reported more conict issues, more anger, more aggressive conict tactics, and poorer communication than did CC fathers. Again, teen reports largely corroborated these results. However, the teens did not see themselves as using more aggressive conict tactics with either their fathers or their mothers than did the teens in the CC group, in contrast to both mothers and fathers reports of teen tactics. Thus, teens with ADHD/ODD may be underreporting severity of conict more than CC teens. Once more, the teens in the ADHD/ODD group were observed to use more negative and less positive forms of interaction with their fathers, and fathers used more negative interactions toward their teens than was the case with the CC group. Furthermore, although the presence of the father during conict discussions appeared to reduce the level of teen negative behavior in CC teens, this was not the case in ADHD/ODD teens. There, negativity actually increased, albeit not signicantly, during father presence. A similar, though marginally signicant, pattern between the groups was evident in the effect of father presence on mothers negative behavior as well during these conict discussions. Buhrmester et al. (1992) found similar suppressing effects of father presence on motherchild conict

Edwards, Barkley, Laneri, Fletcher, and Metevia in ADHD children and speculated that it may stem from paternal rescuing of mothers from their childrens coercive behavior by the fathers involvement in the interaction. Just as in some earlier research on fatherchild interactions in hyperactive children (Johnston, 1996; Tallmadge & Barkley, 1983), this study did not nd differences in parentteen interactions as a function of sex of the parent on most of the measures. Mothers and fathers both reported comparable numbers of conicts and comparable degrees of aggressiveness and extent of parentteen positive communication in their interactions, even though mothers and fathers of ADHD/ODD teens reported signicantly more such problems than was the case in the CC group. However, this study did nd that mothers, regardless of group, reported higher levels of anger in their conict discussions with their teen than was reported by fathers during their own interactions with the teens. The teens, again regardless of group, also reported having used a more aggressive or hostile tactic toward their mothers than was the case with fathers. This is reminiscent of earlier ndings by Burhmester et al. (1992) on parentchild interactions where boys were found to direct more negative behavior toward their mothers than fathers. Apart from these few differences, the conicts that mothers have with their teens are largely comparable to those of fathers within each of these groups. The patterns of interaction conict for both parents in families of ADHD/ODD teens are in keeping with family coercion theory (Patterson et al., 1992) where greater family conict would be most evident in that subset of ADHD teens having comorbid social aggression (ODD). One purpose of this study was to examine the worst level of violence that occurred in the parentteen relations of ADHD/ODD teens. According to family coercion theory, family members ought to demonstrate more extreme aggressive tactics toward each other over time as the use of coercive tactics escalates via a process of negative reinforcement for progressively more aggressive behavior toward each other. Consistent with this theory, mothers in the ADHD/ODD group reported that, on average, the worst tactics they used involved throwing, hitting, smashing, or kicking something or actually throwing something at their teenager during conict discussions. Mothers of CC teens, in contrast, reported that their worst tactics averaged between stomped out of the room or house or yard or cried. Mothers in the ADHD/ODD group further reported that their teens worst tactics averaged between throwing something at them and pushed, grabbed, or shoved them, whereas mothers in the CC group reported their teens worst tactics, on average, ranged between crying and doing something to spite the other person. Interestingly, the groups did not differ in the teens reports of

Family Conict and ADHD/ODD the worst tactics they used toward their mothers or that the mothers used toward them. This was largely owing to the ADHD/ODD group reporting a lower level of aggressive tactic relative to their mothers reports than was the case with the teens in the CC group, whose reports were similar to those of their mothers. Similar ndings held true with respect to severity of fatherteen violence during conicts. Fathers of the ADHD/ODD group reported their worst tactics and that of their teens as being at levels similar to that reported by the mothers of these teens (threw, smashed, hit or kicked something, or threw something at the other person) whereas fathers of the CC teens reported lower levels of aggression that were again comparable to those reported by the mothers. Higher levels of violence, then, may be more typical of parentteen conict interactions in families with an ADHD/ODD teen than is the case in families of CC teens. The former families are locked into coercive spirals of ever-escalating aggressive behavior toward each other whereas the latter families are less prone to such interaction spirals (Fletcher et al., 1996). It is conceivable that the worst levels of violence during conicts in the ADHD/ODD group may be even higher, on average, than those reported here due to the intentional truncation of the parents version of the Conict Tactics Scale to levels just short of physical violence. This was done so as to preclude triggering state mandated reports of potential abuse. In keeping with past studies of ADHD children and teens (Barkley, Anastopoulos, et al., 1992; Befera & Barkley, 1985; Cunningham et al., 1988; Johnston, 1996), particularly those having comorbid ODD, this study documented signicantly greater levels of depression and hostility in the mothers of teens with ADHD/ODD relative to mothers in the CC group. However, this study did not nd lower levels of marital satisfaction in the mothers of teens with ADHD/ODD as previous studies had reported. Nor did mothers of the ADHD/ODD group report having more symptoms of ADHD, either currently or in childhood, than did mothers of the CC group. Such a nding seems inconsistent with the substantial evidence for the high heritability of ADHD (average h2 = .80+; Faraone, 2000; Thapar et al., 1999) and with the increased risk of the disorder among the biological relatives of child probands having ADHD (Biederman et al., 1992). However, fathers of the ADHD/ODD group did report having had a higher level of ADHD symptoms, at least as children, than did CC group fathers. The disparity between this study and prior research on the familial aggregation of ADHD may be due to at least two factors. This study used only rating scales of ADHD symptoms rather than direct personal interviews to assess DSM criteria for parental ADHD. And up to 10% of the parents participating in this study were

569 not the biological parents of these teens. There may also exist a referral bias among these families in that higher functioning families having less parental ADHD may be more likely to seek treatment services for their teens. The nal aim of this study was to determine the extent to which parental hostility, depression, anxiety, and ADHD contributed to parentteen conicts beyond the contribution made by the teens level of disruptive behavior problems (ADHD/ODD). Once more, in keeping with family coercion theory and past research, this study found severity of teen ODD symptoms made the greatest contribution to severity of parentteen conict, with symptoms of ADHD contributing less so. The parents level of selfrated hostility also contributed signicantly to the level of parentteen conict in both sexes of parent. Moreover, for motherteen conict, not only did the mothers level of hostility contribute to such conict, so did that reported by their male partners (mostly husbands). The reverse was not true for fatherteen conict. Prior research on disruptive males suggests that this effect of father hostility on motherson interactions may stem from an indirect pathway of inuence, in this case modeling (Lavigueur, Tremblay, & Saucier, 1995). Fathers hostility toward mothers is signicantly correlated with motherson conict perhaps because sons are imitating the fathers interaction style toward the mother. Unexpectedly, fathers self-rated level of anxiety contributed inversely to the level of fatherteen conict beyond the contribution made by the teens ADHD/ODD symptoms and fathers self-rated hostility. This implies that higher levels of anxiety may serve to diminish fathers propensities for engaging in coercive, conictual exchanges with more disruptive teens. The results of this study must be viewed in the context of its limitations. One was that the vast majority of ADHD/ODD teens and their parents volunteered because of their desire to participate in the subsequent study of family therapies for parentteen conict associated with this project (Barkley et al., in press-b). It is possible that these families may not be representative of all clinic referred ADHD/ODD teens but only those with conicts that are sufciently extreme to compel them to seek these treatments. Also noteworthy was the limitation introduced by the high percentage of teens in the ADHD/ODD group that were on medication at the time of their evaluation. Although the screening measures used to select participants were collected based on parental reports of the teens adjustment off-medication, the dependent measures were based upon current functioning regardless of medication status. Fortunately, the medicated ADHD/ODD participants did not differ signicantly from the nonmedicated ADHD/ODD ones on any of the dependent measures. It is still possible that the presence of so many medicated teens

570 in the ADHD/ODD group may have reduced the representativeness of that group relative to the larger population of teens with ADHD/ODD. Nevertheless, any such bias would have acted conservatively to reduce ADHD/ODD versus CC group differences given that those medications (mainly stimulants) have been shown to have a benecial impact on parentchild interactions in studies of children with ADHD (Danforth et al., 1991). A further limitation was the relatively small sample of control teens and their parents, particularly for the number of fathers participating in that group. This may have limited the statistical power of this study to detect additional group differences beyond those reported here. Even so, group differences for father ratings of parentteen conict were signicant despite this limitation in sample size, suggesting that such elevated conict in fatherteen relations in the ADHD/ODD group is probably reliable and rather robust. In summary, this study found that parents and teens in families having adolescents clinically diagnosed with comorbid ADHD and ODD reported having substantially more issues of conict, expressing higher levels of anger intensity during such conicts, and using more aggressive conict tactics toward each other than did a community control group of teens and parents. Greater levels of negative interactive behavior and lower levels of positive interactive behavior were also documented through direct observations of parents and teens during conict discussions in a clinical setting, though not during a neutral discussion period. The results also indicated that parental self-reports of hostility made additional contributions to the level of parentteen conict beyond that contributed by teen ADHD and ODD. Such ndings are quite consistent with coercion theory and past research on aggressive children where increased intrafamilial conict serves as a training ground for social aggression. These ndings have implications for interventions for reducing parentteen conict. Although treatment may need to focus on parentteen problem-solving and communication skills, as was done in the subsequent treatment study with these teens (Barkley et al., in press-a, in press-b), this may not be sufcient, as was also evident in the outcome of that treatment study. The substantial contribution of both ODD and ADHD symptoms to family conict suggest that other therapies, such as stimulant medication, must be added that directly reduce both symptom domains if greater therapeutic efcacy is to be attained. The contribution of parental hostility to parent teen conict generally and the possible indirect modeling effects of paternal hostility in particular further suggests that both anger control training and marital therapy with parents may also be necessary to further increase treatment success beyond the relatively mixed results obtained

Edwards, Barkley, Laneri, Fletcher, and Metevia by teen-focused family therapies to date for this clinical population (Barkley et al., in press-a, in press-b; Barkley, Guevremont, Anastopoulos, & Fletcher, 1992). ACKNOWLEDGMENTS Appreciation is expressed to Trisha Chaplin for assistance with data entry, to Denise Kwasnik and Susan Barrett for assistance with the viewing and coding of the videotapes of family interactions, and to Laura Montville for administrative assistance. REFERENCES
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