Parenting Hyperactive Preschoolers Clinician Guide

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Library of Congress Cataloging-in-Publication Data

Harvey, Elizabeth A. (Psychologist)
Parenting hyperactive preschoolers : clinician guide / Elizabeth A. Harvey, Sharonne D. Herbert, Rebecca M. Stowe.
pages cm.—(Programs that work)
Includes bibliographical references.
ISBN 978–0–19–020463–1 (alk. paper)
1. Hyperactive children—Behavior modification. 2. Parents of attention-deficit-disordered children.
3. Preschool children. I. Title.
RJ506.H9H3856 2015
371.94—dc23
2014044318

9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
About PROGRAMS T H AT W O R K

Stunning developments in healthcare have taken place over the last sev-
eral years, but many of our widely accepted interventions and strategies
in mental health and behavioral medicine have been brought into ques-
tion by research evidence as not only lacking benefit but also, perhaps,
inducing harm (Barlow, 2010). Other strategies have been proven effec-
tive using the best current standards of evidence, resulting in broad-based
recommendations to make these practices more available to the public
(McHugh & Barlow, 2010). Several recent developments are behind
this revolution. First, we have arrived at a much deeper understand-
ing of pathology, both psychological and physical, which has led to the
development of new, more precisely targeted interventions. Second, our
research methodologies have improved substantially, such that we have
reduced threats to internal and external validity, making the outcomes
more directly applicable to clinical situations. Third, governments around
the world and healthcare systems and policymakers have decided that the
quality of care should improve, that it should be evidence based, and that
it is in the public’s interest to ensure that this happens (Barlow, 2004;
Institute of Medicine, 2001; McHugh & Barlow, 2010).

Of course, the major stumbling block for clinicians everywhere is the

accessibility of newly developed evidence-based psychological interven-
tions. Workshops and books can go only so far in acquainting respon-
sible and conscientious practitioners with the latest behavioral healthcare
practices and their applicability to individual patients. This new series,
ProgramsThatWork, is devoted to communicating these exciting new
interventions to clinicians on the frontlines of practice.

The manuals and workbooks in this series contain step-by-step detailed

procedures for assessing and treating specific problems and diagnoses. But
this series also goes beyond the books and manuals by providing ancil-
lary materials that will approximate the supervisory process in assisting
practitioners in the implementation of these procedures in their practice.

In our emerging healthcare system, the growing consensus is that

evidence-based practice offers the most responsible course of action for

v
 the mental health professional. All behavioral healthcare clinicians deeply
desire to provide the best possible care for their patients. In this series,
our aim is to close the dissemination and information gap and make that
possible.

This therapist guide addresses the challenge of parenting hyperactive pre-

schoolers. Parenting a young child who exhibits extreme hyperactivity and
impulsivity can prove to be very difficult, requiring extra patience, effort,
and skill. Additionally, children with symptoms of attention deficit hyperac-
tivity disorder (ADHD) can have substantial difficulties with emotion regu-
lation and are at risk for developing emotional or behavioral disorders, so the
problem is one of great importance and common concern among families.

The program presented in this therapist guide outlines a 14-week par-

ent training and emotion socialization program designed to be delivered
in 90-minute sessions, in either a group or individual setting. It guides
clinicians in providing parents with needed tools to help their hyperac-
tive children to behave in adaptive, socially appropriate ways that will
also help prevent their children from developing further difficulties. The
treatment focuses on behavior management strategies tailored for chil-
dren with hyperactive symptoms and teaches parents emotion socializa-
tion skills that are linked to better emotion regulation in children. The
manual also includes homework forms and handouts for parents and chil-
dren to help guide them in applying their newly learned skills at home.

David H. Barlow, Editor-in-Chief,

Programs ThatWork
Boston, MA

References

Barlow, D.H. (2004). Psychological treatments. American Psychologist, 59, 869–878.

Barlow, D.H. (2010). Negative effects from psychological treatments: A perspective. American
Psychologist, 65(2), 13–20.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century.
Washington, DC: National Academy Press.
McHugh, R.K., & Barlow, D.H. (2010). Dissemination and implementation of evidence-based
psychological interventions: A review of current efforts. American Psychologist, 65(2), 73–84.

vi
Contents

Acknowledgments ix

Chapter 1 Introductory Information for Clinicians 1

Chapter 2 Group Logistics 13

Chapter 3 Session 1: Introduction and Managing Hyperactive

Behavior 21

Chapter 4 Session 2: Using Praise Effectively 33

Chapter 5 Session 3: Increasing Positive Interactions and Using

Attention to Shape Children’s Behavior 47

Chapter 6 Session 4: Setting Up an Effective Reward System 57

Chapter 7 Session 5: Using Commands to Guide Children’s

Behavior 69

Chapter 8 Session 6: Using Logical and Natural Consequences and

Rewards 77

Chapter 9 Session 7: Using Time Out 87

Chapter 10 Session 8: Teaching Children Problem-Solving and

Negotiating Skills 97

Chapter 11 Session 9: Learning About Emotion Development 107

Chapter 12 Session 10: Teaching Children to Identify and Label

Emotions 117

Chapter 13 Sessions 11 and 12: Handling Children’s Negative

Emotion 127

vii
 Chapter 14 Session 13: Giving Children Opportunities to
Experience Positive Emotion 143

Chapter 15 Session 14: Modeling Emotion Regulation and

Expression 153

Appendix Parent Handouts and Worksheets 161

References 225
About the Authors 233

viii
Acknowledgments

We would like to acknowledge the many people who have influenced

our thinking about this program, including our mentors and colleagues,
many influential experts in the field of parenting and ADHD, and our
own parents and children. We would also like to thank the clinicians and
families who were involved in the first parenting groups using an earlier
draft of this program and who helped us in refining it. Finally, we would
like to thank the UMass Psychological Services Center, which provided
support during the development of this program.

ix
Parenting Hyperactive
Preschoolers
 Introductory Information
CHAPTER 1
for Clinicians

Background Information and Purpose of This Program

The goal of this program is to provide parents1 with a set of tools to better
manage preschoolers who are extremely active and impulsive. Parenting
any preschooler can be challenging, but when hyperactivity and impulsiv-
ity are extreme, parenting requires extraordinary effort and skill. Parents
need tools not only for helping their children to behave in ways that are
adaptive and socially appropriate, but also for preventing their children
from developing additional difficulties. Children who are hyperactive are
at risk for developing emotional or behavioral disorders (Barkley, 2006),
and family interactions during the preschool years may play a key role
in this process. Because parenting hyperactive preschoolers can be very
stressful, it can be easy to fall into interaction patterns that make a difficult
situation even worse. For example, a coercive cycle (Patterson, 2002) can
develop, in which difficult child behaviors elicit harsh parenting prac-
tices, which in turn not only exacerbate the difficult child behaviors but
also may sow the seeds for additional emotional and behavior problems.
By intervening early, we hope to interrupt this cycle, reduce the difficult
child behaviors, and prevent the development of additional difficulties.

This program consists of 14 sessions, which focus on teaching parent-

ing strategies for managing hyperactive and oppositional behavior and

1
We use the term parents for convenience, but include any adult who provides a signifi-
cant caregiving role for the child. This may include guardians, grandparents, aunts and
uncles, or parents’ partners.

1
 for helping children develop better emotion regulation. Sessions last
approximately 1½ hours and are designed to be conducted in a group set-
ting, which allows parents to receive support and input from each other.
However, the program can be easily adapted to individual sessions, which
can be shorter because there is less discussion than in a group. This pro-
gram is designed to be used by clinicians who have had graduate train-
ing in child mental health, including education on parenting and child
development.

Disorder or Problem Focus

This program is designed for hyperactive preschoolers, many of

whom have or are at risk for developing attention deficit hyperactiv-
ity disorder (ADHD). (See DSM-5 for criteria for ADHD; American
Psychiatric Association, 2013.) Preschoolers are typically active and
high in energy. This is part of normal development and not a cause
for concern. Why then do we need to provide guidance for parents
of hyperactive preschoolers? It turns out that there is an important
difference between preschoolers who are extremely active—whose
activity level and impulsivity is much higher than that of most other
preschoolers—and preschoolers who show levels of hyperactivity that
are average or even somewhat above average for their age. Unlike typi-
cally active preschoolers who are likely to outgrow these behaviors,
preschoolers who are extremely active—for example, more active than
95% of their peers—are likely to continue to have difficulties with
hyperactivity as they grow older. It is estimated that between 75% and
90% of preschoolers with clinically significant levels of hyperactivity
will meet criteria for ADHD during their school-age years (Harvey,
Youngwirth, Thakar, & Errazuriz, 2009; Lahey, Pelham, Loney, Lee, &
Willcutt, 2005; Riddle et al., 2013). Moreover, ADHD is common
among preschoolers, with an estimated 4.2% of them meeting cri-
teria for ADHD (Egger, Kondo, & Angold, 2006). Thus, although
in the past it has been common for healthcare professionals to take
a wait-and-see approach with hyperactive preschoolers (Fanton,
MacDonald, & Harvey, 2008), there is growing evidence that early
intervention may be appropriate. Early intervention may be particu-
larly effective for young children whose brains are rapidly developing
and are therefore potentially more receptive to being rewired based on
experiences (Nelson & Bloom, 1997).

2
 There has been a growing recognition over the past decade that ADHD
often begins during the preschool years. In 2011, guidelines for diag-
nosing ADHD were expanded by the American Academy of Pediatrics
(AAP) to include children as young as 4 years of age (Subcommittee on
Attention-Deficit/Hyperactivity Disorder Committee on Quality, 2011).
However, a relatively small proportion of children are diagnosed with
ADHD during the preschool years. In 2012, The Centers for Disease
Control reported that 1.7% of 3- to 4-year-old children had been diag-
nosed with ADHD, compared to 9.5% of 5- to 11-year-old children
(Bloom, Cohen, & Freeman, 2012). Thus, it is important to provide
interventions not only for preschoolers who have been diagnosed with
ADHD, but also for preschoolers exhibiting early signs of ADHD who
may not yet have been diagnosed. Parents may ask whether they should
have their children evaluated for ADHD, and appropriate referral infor-
mation should be provided to parents who inquire. However, it should
be emphasized to parents that a diagnosis of ADHD is not required for
children to benefit from this program.

Development of This Treatment Program and Evidence Base

With mounting evidence that ADHD often begins during the preschool
years, there has been a growing recognition of the need to develop and
evaluate interventions for preschoolers with or at risk for ADHD. This
led to the launching of a large randomized controlled trial to exam-
ine the efficacy of psychopharmacological interventions for preschool-
ers, the Preschoolers with Attention-Deficit/Hyperactivity Disorder
Treatment Study (PATS; Kollins et al., 2006). Although the PATS
found some evidence that stimulant medication is efficacious in this age
group, effect sizes appear to be lower for preschool-aged children than
for school-aged children (Greenhill et al., 2006). Moreover, psycho-
pharmacological treatment in preschool-aged children has been associ-
ated with declines in growth rates (Swanson et al., 2007), moderate to
severe adverse events (e.g., emotional outbursts, difficulty falling asleep,
repetitive behavior/thoughts, decreased appetite) in almost one-third of
preschoolers (Wigal et al., 2006), and much higher rates of children
discontinuing medication (11% in PATS) compared to school-aged
children (less than 1% in the Multimodal Treatment of ADHD study;
Wigal et al., 2006). These results, coupled with the fact that little is
known about the long-term effects of medication on brain development

3
 in young children, highlight the need to develop alternatives to drug
therapy.

Evidence Supporting the Use of Parent Training

The AAP recommends that behavioral treatments such as parent train-

ing should be the first line of treatment for preschoolers with ADHD
(Subcommittee on Attention-Deficit/Hyperactivity Disorder Committee
on Quality, 2011). Parent training programs have long been shown to be
effective treatments for preschool-aged children with conduct and oppo-
sitional problems (e.g., Reid, Webster-Stratton, & Baydar, 2004) and
have also been used to treat school-aged children with ADHD (Barkley,
2013; Danforth, Harvey, Ulaszek, & McKee, 2006). A smaller but grow-
ing body of research has evaluated the effectiveness of parent training
for preschool-aged children with significant ADHD symptoms. Several
randomized controlled trials of preschoolers with symptoms of ADHD
have found significant reductions in ADHD symptoms (Jones, Daley,
Hutchings, Bywater, & Eames, 2008; Matos, Bauermeister, & Bernal,
2009; Sonuga-Barke, Daley, Thompson, Laver-Bradbury, & Weeks, 2001;
Strayhorn & Weidman, 1989; Thompson et al., 2009; Webster-Stratton,
Reid, & Beauchaine, 2011) or associated behavior problems (Bor, Sanders, &
Markie-Dadds, 2002; Pisterman et al., 1992; Pisterman, McGrath,
Firestone, & Goodman, 1989) following parent training compared to a
control group. Follow-up studies have also documented improvement as
much as 18 months post-treatment (Bor et al., 2002; Jones et al., 2008;
Pisterman et al., 1992, 1989; Strayhorn & Weidman, 1991). Additional
studies without a no-treatment control group have reported significant
changes in ADHD symptoms from pre-treatment to post-treatment
(DuPaul & Kern, 2013; Huang, Chao, Tu, & Yang, 2003; Kern
et al., 2007).

Parent training programs that have been used for hyperactive preschoolers
are grounded in a large base of theory and research that point to parenting
practices that are most effective in fostering healthy child development.
These programs are guided by a number of theoretical frameworks. Many
programs are largely based on social learning theory, which holds that
behavior is learned and changed through social interactions (Bandura,
1978). Some programs (e.g., Parent-Child Interaction Therapy; Eyberg &
Bussing, 2010) are also grounded in attachment theory (Bowlby, 1983).
Guided by these theories, strategies are designed to increase positive
parent–child interactions and reinforce positive behavior and typically

4
teach parents to use effective commands, tangible rewards, and appropri-
ate consequences (e.g., Bor et al., 2002; Huang et al., 2003; Kern et al.,
2007; Pisterman et al., 1992; Strayhorn & Weidman, 1989). The use of
these strategies is supported not only by existing theory but also by a large
base of empirical support, which we review in the introductory sections
for each session.

Development of the Parenting Hyperactive Preschoolers Program

Parenting Hyperactive Preschoolers was developed specifically for hyperac-

tive preschoolers and therefore places special emphasis on adapting these
parenting tools for this population. In addition, because there is growing
evidence that children with ADHD tend to have difficulties controlling
their emotions (Martel, 2009), this program also has a special emphasis on
emotion socialization tools that theory and research suggest are critical for
the development of children’s emotion regulation (Denham, Bassett, &
Wyatt, 2008). In particular, emotion socialization theory (Eisenberg,
Cumberland, & Spinrad, 1998) suggests that parents’ expression of emo-
tion, discussion of emotion, and reactions to children’s emotion are key in
shaping the development of children’s emotion competence. The focus of
this program on emotion socialization is particularly important because
the preschool years are thought to be a critical time for emotional devel-
opment (Supplee, Skuban, Trentacosta, Shaw, & Stoltz, 2011).

The efficacy of this program has recently been evaluated using a ran-
domized controlled trial (Herbert, Harvey, Roberts, Wichowski, &
Lugo-Candelas, 2013) with preschool children who demonstrated clini-
cally significant levels of hyperactivity based on a diagnostic interview
and/or behavior rating scale. The parenting program was delivered to 17
families in small groups (between 3 and 6 families per group) by clini-
cians (clinical psychology doctoral students, a school psychologist, and a
licensed clinical psychologist) in an outpatient training clinic. Significant
and large-sized decreases were found in preschool children’s ADHD
symptoms (inattention Cohen’s d = .87; hyperactivity/impulsivity Cohen’s
d = .71), and moderate-sized decreases were reported in children’s oppo-
sitional defiance (Cohen’s d = .44) at the end of the parenting program
compared to waitlist children. Moderate improvement was also found
on one of two subscales measuring emotion regulation (emotional labil-
ity; Cohen’s d = .45) but was not observed on another subscale assessing
empathy, emotional self-awareness, and responding positively to others,
nor on an observational measure of child misbehavior and negative affect.

5
 Larger scale studies will be needed to replicate these findings, examine
whether improvement can be observed outside of the home setting, evalu-
ate the effectiveness of this program outside of a research setting, and
examine whether these effects are maintained over time.

What Is Social Learning Theory and Emotion Socialization Theory?

Although ADHD is thought to be caused by biological factors, socializa-

tion plays an important role in the way ADHD symptoms manifest them-
selves and in the development of co-occurring emotional and behavioral
problems (Johnston & Mash, 2001). Social learning theory and emotion
socialization theory articulate the ways in which parenting may shape
children’s behavioral and emotional development.

Social learning theory (see Figure 1.1) argues that behavior, internal pro-
cesses (e.g., thoughts), and the environment influence one another in
a dynamic and reciprocal manner (Bandura, 1978). Principles of rein-
forcement and punishment (Skinner, 1974) are integrated in this theory,
and are important mechanisms through which these domains affect one
another. Thus, social learning theory argues that behavior is shaped by
its consequences, and these consequences may be external (e.g., a par-
ent rewarding or punishing a child), internal (e.g., positive emotions or
thoughts), or both. Moreover, behavior, in turn, influences both internal
experiences and the environment. Thus, social learning theory empha-
sizes the importance of parenting in young children’s development but
recognizes the complex ways in which parents and children influence one
another and highlights the important role that children’s internal pro-
cesses play in guiding and motivating their behavior.

Internal
Processes

Behavior Environment

Figure 1.1
Social Learning Theory Model
Adapted from Bandura, A. (1978). The self system in reciprocal determinism.
American Psychologist, 33(4), 344–358.

6
 Parent Parent Parent
Reactions to Discussion of Expressivity of
Child Emotions Emotions Emotions

Child Emotion
Competence

Figure 1.2
Emotion Socialization Model
Figure created based on text from Eisenberg, N., Cumberland, A., & Spinrad, T. L.
(1998). Parental socialization of emotion. Psychological Inquiry, 9(4), 241–273.

Emotion socialization theory (Eisenberg et al., 1998) suggests that parents

play a critical role in the development of children’s emotion competence,
including children’s understanding of emotion, expression of emotion,
and ability to regulate emotions. In particular, parents’ reactions to emo-
tions, discussion of emotions, and expressivity of emotions all contribute
to the development of children’s emotion competence, which in turn lays
an important foundation for their social and emotional functioning (see
Figure 1.2). Parents who are sensitive to and supportive of children’s emo-
tional experience, model appropriate expression of emotion, and talk with
and educate their children about emotion tend to have children who are
more emotionally competent (Eisenberg et al., 1998).

Risks and Benefits of This Treatment Program

When successfully implemented, this program has the potential to foster

positive parent–child relationships and to support children’s behavioral
and emotional functioning. It is, however, important for leaders to be
aware of potential pitfalls.

First, parents come to treatment with a variety of different beliefs about

parenting. It is critical to be respectful of parents and their views and to
avoid judging them. The parenthood status of group leaders can further
complicate this issue. Group leaders who are not parents themselves may
have difficulty fully understanding the experiences of parents. At the same
time, group leaders who are parents may have their own well-established