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Noncompliance in children having ADHD with varying degrees of oppositional/conduct disordered behaviour Murray, Candice 1999

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NONCOMPLIANCE IN CHILDREN HAVING ADHD WITH VARYING DEGREES OF OPPOSITIONAL/CONDUCT DISORDERED BEHAVIOUR by CANDICE MURRAY B. A., Concordia University, 1995 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES (Department of Psychology) We accept this thesis as conforming • to the required standard THE UNIVERSITY OF BRITISH COLUMBIA May 1999 © Candice Murray, 1999 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. 1 further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of ^Psf-The University of British Columbia Vancouver, Canada Date lrf. ./3. im DE-6 (2/88) 11 Abstract The traditional behavioural model of noncompliance is unidimensional and measures noncompliance according to its frequency. In the past decade, developmental theorists have presented a multidimensional model of noncompliance that underlines the importance of evaluating the quality rather than the quantity of noncompliance. This study examined the type and frequency of noncompliant behaviour in 140 boys having Attention-Deficit/Hyperactivity Disorder (ADHD) with oppositional/conduct disordered behaviour. The data on boys' noncompliant behaviours were coded from videotaped mother-son interactions during a clean up task. A factor analysis indicated that there were three types of noncompliance: Least skilled noncompliance, semi-skilled noncompliance, and most skilled noncompliance. Pearson correlation coefficients examining the relationship between the proportion of the types of noncompliance and maternal ratings of oppositional/conduct disordered behaviour indicated that only semi-skilled noncompliance was related to maternal ratings of oppositional/conduct disordered behaviour. Correlations between maternal ratings of oppositional/conduct disordered behaviour and two measures of the frequency of noncompliance indicated a trend for a positive correlation with one of the measures. It is suggested that a unified measure of noncompliance consisting of both the quantity and quality of child noncompliant behaviour may provide a more meaningful account of ADHD children with oppositional/conduct disordered behaviour. Ill TABLE OF CONTENTS Abstract ii List of Tables iv Introduction 1 Method 16 Results 22 Discussion 30 References 38 iv List of Tables Table 1. Types of Child Noncompliance 20 Table 2. Descriptive Data for Noncompliant Behaviours, Overall Resolution, and Control Episodes 23 Table 3. Oblimin Loadings for Noncompliant Behaviours 24 Table 4. Partial Correlation Coefficients Between Types of Noncompliance and Behavioural Ratings of ODD/CD Behaviour 28 1 In this study the quality, as well as the quantity, of child noncompliance was examined in children having Attention-Deficit Hyperactivity Disorder (ADHD). The necessity of focusing on the quality of noncompliance in this population arises from inconclusive research results concerning the relationship between noncompliance and other disruptive behaviours. That is, although one would expect that children having ADHD with accompanying problems of oppositional or conduct disordered behaviour would display higher levels of noncompliance than ADHD children with fewer oppositional or conduct problems, research findings have been inconsistent. One possible explanation is that studies to date have employed behavioural theory and methodology, which uses the frequency of noncompliance as its primary measure. It may be that what distinguishes children with higher levels of oppositional/conduct problems from those with lower levels is not so much the frequency of noncompliance, but the particular way in which noncompliance is expressed. Thus a developmental approach, which recognizes different types of child noncompliance, may be an important tool in clarifying the research on noncompliance in children with disruptive behaviour. Noncompliance to parental requests is a behaviour that can be observed in all children (Kuczynski & Kochanska, 1990). Patterson and Forgatch (1987) report that in well-functioning families of pre-adolescent boys, a noncompliance rate of 50% is considered to be well within normal limits. Rutter, Tizard, and Whitmore (1970) found that one third of parents of normal, preadolescent children identified noncompliance as a problem in their families. Although most parents do not seek treatment for this child behaviour, noncompliance is recognized as one of the leading problems reported by parents of clinic referred children (Forehand, 1977). Even when children are exhibiting multiple behavioural problems, refusal to follow parent's directives is the behaviour most often targeted for treatment (Charlop, Parrish, Fenton & Cataldo, 1987; Quay, 1986). 2 Children with high levels of attentional/hyperactive and oppositional/conduct problems are even more likely to experience problematic relationships with their parents than children without behaviour problems. Cunningham and Barkley (1979) used videotaped mother-child interactions to observe the behaviour of hyperactive and normal 6 to 12 year old boys. It was found that children who had received high parent ratings of hyperactivity were significantly less compliant than normal children during both free play and task sessions. When children with high levels of hyperactivity did comply, they complied for shorter time periods and were more likely to emit negative behaviours. Similarly, Mash and Johnston (1982) compared mother-child interactions in younger (2-6) and older (7-9) children. Approximately half the children were rated as having high levels of hyperactivity and the other half were rated normal. In both the free play and task sessions, children with high levels of hyperactivity were more negative and noncompliant than normal children. Befera and Barkley (1985) examined mother-child interactions in 6 to 11 year old children with high and low levels of inattention/hyperactivity. Children with high levels of inattention/hyperactivity were less compliant and more negative during a clean-up task than nonproblem children. Given the prevalence of child noncompliant behaviour in nonclinical and clinic-referred families, it appears as though it is a subject which warrants further examination. Fuelling the need for research are studies demonstrating the negative impact that noncompliant child behaviour has on the quality of parent-child relations. Excessive noncompliant behaviour has been associated with parental commands that are accompanied by threats, irritation, sarcasm, anger and physical enforcement (Crockenberg, 1987; Kuczynski, Kochanska, Radke-Yarrow & Girnius-Brown, 1987; Patterson, 1982). Research also suggests that parents of children with high levels of noncompliant behaviour spend less time playing with their children (Cunningham, Benness, & Siegel, 1988), experience more stress in their parental role (Anastopolous, 3 Guevremont, Shelton, & DuPaul, 1992), and report higher levels of depression than parents of normal children (Mash & Johnston, 1983). From the studies reviewed above, it is clear that noncompliance is a widespread familial problem which may present particular challenges to families of children with ADHD and accompanying oppositional/conduct problems. Surprisingly, however, past studies of noncompliance in children with disruptive behaviour rarely distinguish between noncompliance in children diagnosed with ADHD alone and ADHD with accompanying high levels of oppositional/conduct problems (Barkley, Anastopoulos, Guevremont & Fletcher, 1992; Loney & Milich, 1982). This is puzzling, given that descriptions of noncompliant behaviour displayed in children with high levels of oppositional/conduct problems differ from descriptions of noncompliance in children with attentional problems. Children with high levels of oppositional behaviour are described by the American Psychiatric Associations' Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 1994) as actively refusing to comply with adult's rules. Children with high levels of conduct problems are described by the DSM IV as persistently violating norms and rules. Therefore, one would expect children with high levels of oppositional/conduct problems to display high rates of noncompliance. Although the cognitive deficits (e.g., short attention span, distractibility), overactivity (e.g., restlessness), and impulsivity (e.g., impatience, difficulty waiting) that children having ADHD display suggest they will also experience above average levels of difficulty following parental directives, noncompliant behaviour would not be expected to occur in the same frequency or intensity as children with high levels of oppositional/conduct problems. Counter to intuition and descriptive information about these children, the few studies that have examined this issue have generated inconclusive results. Johnston (1996) looked at parent-child interactions in ADHD children with higher and lower levels of oppositional behaviour. One of the measures used in this study was the Home Situations Questionnaire (HSQ), (Barkley 4 & Edelbrock, 1987), a questionnaire which asks parents to identify the number of common home situations in which the child's behaviour is problematic and to identify the severity of the problematic behaviour. It was found that both mothers and fathers of children with ADHD reported a greater number of problems on the HSQ than parents of nonproblem children but that there was no difference in the number of problems reported by parents of children with higher and lower levels of oppositional behaviour. Mothers, however, rated ADHD children with higher levels of oppositional behaviour as having more severe problems than ADHD children with lower levels of oppositional behaviour, whereas fathers did not make this distinction. When child noncompliant behaviours were observed in parent-child interactions, it was found that in a task situation, children with ADHD having higher levels of oppositional behaviour were more noncompliant than either nonproblem children or children with ADHD having lower levels of oppositional behaviour. Children classified as having ADHD with low levels of oppositional behaviour displayed no more noncompliant behaviours than nonproblem children. This effect was found for both mothers and fathers. Barkley et al. (1992) used diagnosis of disruptive behaviour disorders as an indicator of oppositional behaviour. In this study, adolescents diagnosed with ADHD were compared to those diagnosed with both ADHD and ODD. It was found that mothers of adolescents with ADHD alone and those with comorbid ODD reported the same number of parent-adolescent conflicts, and both reported significantly more conflicts than mothers of control children. The results were the same for the intensity of the conflicts. Adolescents with ADHD/ODD reported more conflicts of greater intensity with their mothers than control adolescents, but there was no difference in either the amount or intensity of conflicts reported by adolescents with ADHD/ODD and adolescents with ADHD alone. Another study which used diagnosis as an indicator of oppositional behaviour examined children with ADHD, CD, ADHD/CD, and normal children (Schachar & Wachsmuth, 1991). Briefly, the results 5 revealed that families of children with CD and ADHD/CD reported higher levels family dysfunction than families of children with ADHD alone. Clearly, these results are not conclusive. In terms of the amount of conflict or behavioural problems reported by parents of children with ADHD, both Johnston (1996) and Barkley et al. (1992) found no difference between children with ADHD alone and children with high levels of oppositional/conduct problems. Conversely, Schachar and Wachsmuth (1991) found there to be more conflict in families of children with both ADHD and CD problems than ADHD alone. In contrast to the amount of conflict, Johnston (1996) found the severity of problems to be reported as more extreme in ADHD children with higher levels of oppositional behaviour than lower levels, whereas Barkley et al. (1992) found no difference in reported conflict severity between the children with ADHD alone and the children with conduct problems. Finally, using observational measures, Johnston (1996) found noncompliance to be higher than controls only among children having ADHD with higher levels of oppositional behaviour. Reasons are unclear for the discrepancies across studies comparing the amount and severity of noncompliant behaviour in children with ADHD alone and with comorbid oppositional/conduct problems. Methodological variations among the studies (e.g. self-report versus observational measures, methods of classifying the level of oppositional /conduct problems) and differences in operational definitions of noncompliance are possible explanations. An additional explanation for why a consensus has not been reached on whether noncompliance occurs more frequently or more severely in children having ADHD with higher levels of oppositional/conduct problems compared to children with lower levels, may be that frequency and severity (as currently measured) of noncompliance are not the variables that distinguish these children. Specifically, the operational definitions and consequent measurement of noncompliance in these studies have focused on behavioural formulations of noncompliance, which may fall short of providing us with an accurate portrayal of child noncompliance. 6 In the behavioural model, noncompliance has been conceptualized as a unidimensional construct that is undesirable and dysfunctional. Patterson (1982) characterizes noncompliance as an aversive child behaviour and Forehand (1977) identifies child noncompliance as a primary behaviour problem requiring treatment. Behaviourists define noncompliance as a child's failure to respond to a parental command within a specified time period, which can vary with the child's age. For adolescents, Patterson and Forgatch (1987) define noncompliance as a failure to follow a parental command within 12 seconds of the request. Forehand and MacMahon (1981) allow only a 5 second delay with 3 to 8 year olds. Forehand (1977) reported substantial variability in the time criterion, citing studies that ranged from a 5 to a 30 second delay following a parental command. Although some researchers consider a child's behaviour to be compliant only if the instructed behaviour has been successfully completed in the predetermined time period, Forehand (1977) allows the behaviour to be classified as compliant as long as it was initiated before the end of the coding interval. Therefore, the latency and initiation of the child's behaviour are of primary interest in defining noncompliance. An important implication of this formulation of child noncompliance is that behavioural methodology focuses on measuring the frequency of noncompliance; no distinctions are made among the types of noncompliance. In the behavioural model, the origin of noncompliant child behaviour is postulated to occur through the mechanism of reinforcement (Patterson, 1982). When a parent delivers a command, a child can either adhere to, or disobey the parent's request. If the child complies with the parental command, the parent may reinforce the compliant behaviour and thus increase the likelihood of future compliance. If the child does not comply with the parental command, the parent could punish the child immediately or become more insistent that the child comply. In the former case, it is theorized that the punishment for noncompliance will decrease the frequency of this behaviour. In the latter scenario, the parent becomes increasingly insistent that the child comply. If the child continues to noncomply, the parent-child conflict will escalate and 7 intensify. If the child eventually complies, the parent's most insistent or negative command behaviour will be negatively reinforced; the aversive stimulus (e.g. child noncompliance) has been removed thereby increasing the likelihood that the parent will use threats or coercion the next time the child is noncompliant. Alternatively, if the parent eventually gives in when the child refuses to comply, the child is likely to calm down. The child calming down reinforces the parent for giving in, and the parent giving in reinforces the child's most extreme form of noncompliance. The next time the child is noncompliant, the situation will escalate more quickly due to the reinforcement in previous episodes. Negative reinforcement therefore fuels and intensifies parent-child conflicts surrounding child noncompliance. Considerable research exists to support the role that reinforcement is believed to play in the development of noncompliance. Loeber (1981) found that parents of children with behaviour disorders do not consistently reinforce prosocial behaviour, and are not consistent with their punishment of noncompliant behaviour. These parents tend to lecture and threaten their children without following through on punishments. When they do implement the punishments, they are often unrealistic (e.g. the child must stay in the house for a month) and they are not enforced. Dumas and Lechowicz (1989) studied parenting techniques in families of noncompliant children and found that parental commands oscillated between being power-assertive and overly vague. Parents responded to their child's noncompliance with a mixture of positive and negative attention and exhibited a tendency to relinquish the commands when the child disobeyed. Dumas and Wahler (1985) examined maternal control strategies in families of aggressive and oppositional children and found that these mothers used a mixture of power-assertive and lax strategies when disciplining their children. Acker and O'Leary (1996) instructed mothers to respond to their children's demands for attention using a variety of strategies. A pattern of inconsistent parent behaviours (using both reprimands and positive attention) resulted in more problematic child behaviours than parental use of consistent strategies. 8 Because noncontingent or inconsistent consequences and negative reinforcement are believed to maintain, if not generate, chronic child noncompliance, Patterson (1976) has suggested that parents consistently punish noncompliant behaviours to prevent their onset or terminate their perpetuation. Therefore, three main goals of behavioural parent training programs are to teach parents a power assertive approach to child rearing (e.g., delivering clear and forceful commands), to instruct parents how to deliver effective punishment (e.g., time out) contingent on noncompliance, and to teach parents to positively reinforce compliance. The desired result of this training is to increase child compliance and extinguish noncompliance. Studies that have examined the effectiveness of behaviourally-based parent training programs have been encouraging. In a meta-analysis of 117 outcome studies on behavioural parent training, Serketich and Dumas (1996) found these programs were effective in improving the behaviour of antisocial children both at home and at school. Kazdin (1997) also reviewed outcome studies on behavioural parent training for children: with antisocial, oppositional and aggressive behaviour and concluded that parent training results in improved child behaviour according to parent and teacher reports, direct observations at home and at school, and institutional records. The treatment gains were reported to be long-term and clinically significant. Although the behavioural model of noncompliance has played an integral role in the conceptualization and treatment of disruptive behaviour disorders, there are a growing number of concerns with this view. A major critique of the behavioural view of noncompliance is that, although the reciprocal nature of parent-child interactions is appreciated in theoretical formulations (Darling & Steinberg, 1993; Patterson, 1982), behavioural research and treatment continue to focus on the child as the passive recipient in the dyad (Kuczynski et al., 1987). For example, behavioural studies typically examine parental control strategies and children's reaction to parents' commands. Behavioural parent training programs presuppose that modifying parental 9 behaviour will cause children's behaviour to change. Critics suggest that behavioural research and therapy underplay children's ability to influence their parents' behaviour (Kuczynski et al., 1987). Another criticism is that behaviourists' formulation of noncompliance places too much emphasis on immediate compliance as a parental goal (Kuczynski, 1991). Critics point out that parenting goals in childrearing have changed dramatically over the last few decades (Kuczynski, 1991). It is argued that the value of child obedience has declined as our society increasingly emphasizes assertiveness and autonomy as desirable traits in both adults and children. Immediate compliance to persons of authority, as seen in Milgram's (1974) studies, has been forwarded as an example of unhealthy compliance (Kuczynski, 1992). Other research has demonstrated that abused and neglected children engage in high levels of compliant behaviours that has been termed "compulsive compliance" (Crittenden & DiLalla, 1988). It is postulated that compulsive compliance is motivated by the children's fear of what will happen to them if they refuse. It has been demonstrated that children who engage in compulsive compliance have a distorted perception of and response to reality. Therefore, these extreme levels of compliance are considered to be unhealthy (Crittenden & DiLalla, 1988). Kuczynski and Kochanska (1990) examined compliant behaviours in a sample of nonproblem children during toddlerhood and again when the children were 5 years old. It was found that children who were frequently compliant during toddlerhood displayed fewer behaviour problems at age 5 than children who were less compliant as toddlers. However, 5 year-old boys who were more compliant than other boys the same age were more likely to experience internalizing behaviour problems. Despite such evidence of maladaptive forms of compliance, the behavioural model fails to address how excessive compliance can be maladaptive or interfere with a child's development, or how noncompliance may be an adaptive response. Thus, by ignoring the context and goals of the noncompliant child, it is believed that behaviourists may not have the full picture. 10 A final critique of the behavioural theory of noncompliance is that, in general, it presents an overly narrow view of noncompliance. This critique is of central importance to the present study. As stated earlier, noncompliance is typically defined as the frequency of a child's failure to comply within a given time period following a parental request. The lack of theoretical and empirical distinction among the different ways that a child can express noncompliance is viewed as a serious shortcoming of the theory (Kuczynski, 1992). Also, the high rate of noncompliant behaviour observed in nonproblem children is difficult to reconcile with the behavioural view of all noncompliant behaviour as maladaptive. Finally, although research has supported the behavioural perspective by demonstrating that parent training programs are effective in decreasing child noncompliance in children with high levels of ADHD and oppositional/conduct problems, ratings of post-treatment behaviour indicate that these children are still encountering more problematic relationships with their parents than normal children (e.g., Pisterman, McGrath, Firestone, Goodman, Webster & Mallory, 1989). Over the last decade, these concerns with the behavioural model have been addressed by the emergence of a developmental model of child noncompliance. Developmental psychologists distinguish among different types of noncompliance and suggest that some forms are less negative than others (Kuczynski & Kochanska, 1990). In this perspective, noncompliance can be generally divided into two categories: skilled and unskilled (Crockenberg & Litman, 1990; Kuczynski & Kochanska, 1990; Kuczynski et al., 1987). Generally, developmental theorists view a child's ability to say "no" to a parent as an indication that the child views him/herself as a separate being and has achieved a certain level of autonomy (Crockenberg & Litman, 1990). Because assertive verbal refusals are associated with the development of the child's sense of autonomy within the parent-child relationship, they are believed to reflect competence in children and thus are considered to be skilled forms of noncompliance (Kuczynski et al., 1987). Defiance is viewed as a more intense mode of noncompliance that is aversive to parents 11 (Kuczynski et al., 1987). Although defiance is also a way in which children can assert their autonomy, its use is less effective because it may contribute an escalation of parent-child conflict (Patterson, 1982). Defiance is therefore considered to. be an unskilled form of noncompliance (Crockenberg & Litman,1990; Kuczynski et.al., 1987). Kuczynski et al. (1987) have elaborated on the two broad categories of noncompliance and identified subtypes for skilled and unskilled noncompliance: direct defiance, passive noncompliance, simple refusal, and negotiation. Direct defiance and passive noncompliance are considered to be unskilled forms of noncompliance. A child who is directly defiant will express verbal or non-verbal opposition to the parent's directive that is accompanied by poorly controlled anger or aggression (Kuczynski & Kochanska, 1990). For example, a child may throw an object when told to do something. A child who simply ignores a parental command without any behavioural response is engaging in passive noncompliance. Direct defiance and passive noncompliance are considered to be unskilled because they are aversive to the parent and therefore are likely to arouse parental resistance and contribute to coercive interactions (Patterson. 1982). More skilled forms of noncompliance are simple refusal and negotiation (Kuczynski & Kochanska, 1990). Simple refusals are considered intermediary between unskilled and skilled strategies for noncompliance. A simple refusal is a straightforward refusal to follow a parental directive. If the child offers any explanation, it refers only to the child's will (e.g., "I don't want to"). Simple refusals are viewed as more skilled than passive noncompliance because they are direct without being aversive. Finally, negotiation is identified as the most skilled form of noncompliance. A child engaging in negotiation may offer explanations, bargaining, if-then statements or excuses (Kuczynski & Kochanska, 1990). In contrast to behavioural theory, noncompliant behaviour in the developmental perspective is presented as part of the normal repertoire of child behaviours which serves a positive function in the development of children's autonomy and assertiveness (Kuczynski, 12 1991). When a child says no to a parental command, this may provide a context in which the child learns socially sanctioned interpersonal influence strategies (Kuczynski et al., 1987). Thus, noncompliant behaviour may reflect the child's developmentally appropriate attempts to influence their parents' commands. Whether a child uses skilled or unskilled noncompliance is seen to depend on the child's age and motivation (Kuczynski et al., 1987). Evidence in support of the differentiation between skilled and unskilled forms of noncompliance was found in a longitudinal study that followed children from age 1 Vi to 5 years (Kuczynski & Kochanska, 1990). It was found that at age 5, children who used unskilled forms of noncompliance in their interactions (passive noncompliance, defiance) did so consistently and interchangeably. In contrast, children who negotiated did not tend to engage in unskilled types of noncompliance. Simple refusals were positively associated with both types of noncompliance, supporting the idea that this is an intermediary strategy (Kuczynski & Kochanska, 1990). Research has also supported the notion that the noncompliant strategies used by children shift with age (Kuczynski et al., 1987). In a sample of 70 mother-child dyads, it was found that unskilled noncompliance decreased between the ages of 154 and 3 Yi, while skilled noncompliance (i.e. negotiation) increased within this age range. These age-related changes in noncompliant strategies are believed to reflect the development of the child's sense of independence. Therefore, whereas behavioural theory conceptualizes noncompliance as a homogeneous and aversive behaviour that develops through a process of negative reinforcement and inconsistent parenting, the developmental perspective presents noncompliance as an intricate construct with different levels of sophistication reflecting skilled and unskilled child behaviour. The different types of noncompliance proposed by developmental theorists may explain the discrepancy between the high prevalence of noncompliant behaviour among normal children and the finding that noncompliance is also the defining feature of many clinic referred families. That 13 is, the salient and aversive types of noncompliance (e.g., direct defiance and passive noncompliance) may be the ones associated with clinic-referred disruptive disorders, whereas the noncompliance of normal children may be of a more skilled variety. In other words, the quality of the noncompliant behaviour may be the important characteristic discriminating between nonproblem and clinic referred children. In summary, developmental research suggests that there are different types of noncompliance and that only unskilled noncompliance is positively associated with externalizing problems. Of all child externalizing problems, behaviours associated with ADHD and the oppositional/conduct disorders are the most common. Despite the extensive volume of research that has been conducted on children exhibiting high levels of ADHD, oppositional, and conduct problems, few studies have examined the relative frequency of noncompliant behaviour among children with ADHD and children with lower and higher levels of oppositional/conduct behaviours. Those studies which have examined noncompliance in these children have generated inconsistent results. One possible explanation for the lack of research supporting higher levels of noncompliance in children having ADHD with higher levels of oppositional/conduct problems is that research to date has used behavioural theory and methodology to examine noncompliance, which examines the quantity rather than the quality of child noncompliance. Preliminary research by developmental theorists suggest that children's noncompliance techniques can reflect different levels of skilfulness and can signal the development of autonomy. Therefore, the developmentalists' view of noncompliance may shed some light on our understanding of noncompliance in children with high levels of oppositional/conduct problems. As noted earlier, children with high levels of oppositional and conduct problems are described as being deliberately oppositional (DSM-IV, 1994). There is a distinct quality of intent or unwillingness in their refusals to conform to the demands of others that is often 14 accompanied by hostility, anger, and aggression. In contrast, children with ADHD are described as primarily inattentive, impulsive and overactive. Noncompliance in children having ADHD is viewed as a behaviour that develops as a result of their difficulty in performing tasks that require skills such as sustained attention (DSM-IV, 1994). Given this distinction between intentional defiance in children with oppositional and conduct problems and unintentional noncompliance in children with ADHD, one would expect that noncompliance in children with more severe oppositional and conduct problems would be of a different quality than that of children with milder problems. Preliminary data suggests that this may be the case. Kochanska and Kuczynski (1990) report on a study of depressed and nondepressed mothers whose reports of internalizing and externalizing behaviour problems in their children were collected via the Child Behaviour Checklist (CBCL; Achenbach & Edelbrock, 1983). The data was first collected when the children were toddlers and gathered a second time when the children were 5 years old. It was predicted that the type of noncompliance (skilled or unskilled) that a child displayed would be related to the presence of behavioural problems. Specifically, it was hypothesized that unskilled forms of noncompliance would be positively associated with externalizing behaviour problems (e.g., oppositional behaviour), and skilled forms of noncompliance would be negatively associated with externalizing behaviour problems. The results of the study confirmed this hypothesis. Externalizing problems in 5 year old children were positively correlated with the child's use of direct defiance when they were younger and their use of passive noncompliance at age 5 (unskilled noncompliance). Conversely, simple refusal during toddlerhood and negotiation at age 5 (skilled types of noncompliance) were negatively correlated with externalizing problems at age 5. This research suggests that child behaviour problems may be related to the type of noncompliance in place of, or in addition to, the frequency of the noncompliance. This study examined noncompliant behaviours in children having ADHD with varying levels of oppositional and conduct problems. The noncompliant behaviour in children having ADHD with lower levels of oppositional/conduct problems is thought to be due to inattention rather than defiance whereas the noncompliant behaviour in children having ADHD with higher levels of oppositional/conduct problems is more likely to be defiant and aversive to the parent. Therefore, it was expected that children with ADHD who have higher levels of oppositional/conduct behaviours would exhibit higher levels of unskilled noncompliance than children with lower levels of oppositional/conduct behaviours. 16 Method Participants The sample consists of 140 boys with ADHD and their mothers. Videotaped interactions of the mother-son dyads were made available to the author by the University of California (Berkeley) and the University of Pittsburgh, two of six sites involved in the Multimodal Treatment Study of Children with ADHD (MTA) funded by the National Institute of Mental Health. Families of children having ADHD were referred to the MTA study by primary care physicians, mental health clinics, schools, and parent support groups. Recruitment and assessment procedures involved a four stage process. Initially, families engaged in a telephone screening interview where basic information about the study was provided. Second, families who were eligible and interested in participating were mailed a package which included a release of information form for the school, a demographics form, and a variety of questionnaires. Children had to be off stimulant medication for 5 days before the materials from the mailed package could be completed. Based on the results of these questionnaires, families who qualified for the project visited the site clinic. At this third stage, informed consent for assessment and treatment was collected and the Diagnostic Interview Schedule for Children (DISC 3.0; Shaffer et al.,1996), a structured interview used to derive DSM-IV diagnoses for child disorders was conducted with the child's parent. Diagnoses of ADHD were made based on the results of the DISC 3.0 interview and all interviews were audiotaped for reliability verification. Children diagnosed with ADHD participated in the fourth and final stage of the recruitment and assessment procedure, the baseline assessment battery. Exclusion criteria for the MTA study criteria is described in detail by Hinshaw et al. (1997). It included factors such as insufficient fluency in English, comorbid diagnoses for Tourette's Syndrome or Motor Tic Disorder, and children with a low Estimated Learning Potential. 17 Of the families recruited to the Berkeley and Pittsburgh MTA sites, only male children with ADHD were used in the present study to increase the homogeneity of the sample. For the same reason, only parent-child interactions involving mothers were analyzed. A few videotaped interactions could not be used due to damaged or lost videotapes or because of missing diagnostic information. Therefore, from the original MTA sample of 165 families of both boys and girls from the Berkeley and Pittsburgh sites, 140 families of boys with ADHD were used in this study. The boys' ages ranged from 7 years 0 months to 10 years 3 months with a mean age of 8 years and 3 months. Sixty-four percent of the boys were white, 26% were black, 2% were Hispanic and 8% were identified as "other" or a mixed ethnicity. Thirty-one percent of the boys were from single-parent families. Maternal education was assessed using a 6-point rating scale (1= less than grade 8 education; 6= graduate degree). The mean level of maternal education was 4.20 (i.e., college). Procedure Mother-Child Interactions. The videotaped mother-child interaction was a component of the baseline assessment battery in the MTA study. It was always the first measure taken in the battery and all children were unmedicated. Mother-child interactions were conducted in laboratory rooms furnished with a large table and four chairs, a small table, a wastebasket, magazines, and a plastic bin containing toys (e.g., plastic bowling pins and a ball, a foam bat and ball, a plastic drum set). The interactions were videotaped using a camera that was either behind a one-way observation mirror or mounted on the wall in the upper corner of the observation room. Video cameras were equipped with a date and time generator that allowed time in seconds to be superimposed each tape. A research assistant entered the room to deliver instructions to the mother when appropriate. Each mother-child interaction lasted approximately 17 minutes and consisted of four periods that were carried out in the following order: Free play, parent busy, paper-pencil, and 18 clean-up. Although both the paper-pencil and clean-up tasks comprised the command portion of the interaction and one would expect both to elicit noncompliant behaviours in the children, preliminary observations indicated that noncompliance was infrequent in the paper and pencil task. Therefore, for the purpose of the present study, only the clean up task was examined. The clean up task began when a research assistant tapped on the one-way observation window, signalling that the mother should tell her child to stop working on the paper-pencil task and clean up the room. Mothers had been instructed both verbally and in writing to issue three distinct commands to their children: To pick up tiny, round, coloured dots of paper from the floor and put them in the trash can, to collect all of the toys in the room and place them in a plastic bin, and to place the work booklet, pencil, and eraser on the small table. Mothers were instructed not to assist their children in cleaning the room, not to tell their children that clean up was part of the research protocol, and to act as natural as possible. The clean up task lasted approximately 5 minutes. Measures Oppositional/conduct problem behaviour. The level of oppositional and conduct behaviour in the boys was assessed using the SNAP-IV (Swanson, 1992) and the DSM-IV Conduct Disorder Checklist (DSM-IV, 1994) which were completed during the second phase of the MTA assessment process prior to the videotaped parent-child interaction. The SNAP-IV and DSM-IV Conduct Disorder Checklist are rating scales with items reflecting DSM-IV symptoms of the disruptive disorders and provide a dimensional measurement of ODD and CD symptomatology. The SNAP-IV consists of 8 items measuring oppositional behaviour and the DSM-IV Conduct Disorder Checklist has 15 items measuring conduct problem behaviour. Both rating scales ask participants to describe the extent to which each item is descriptive of the child on a 4-point scale ranging from 0 to 3. The level of oppositional/conduct problem behaviour for each child was determined by summing all of the item scores for both checklists with a possible 19 range of 0 to 69. The SNAP-IV and the DSM-IV Conduct Disorder Checklist were completed by both the child's mother and teacher and information from each of the two sources was used in the analysis to include more than one perspective of the child's behaviour. Although the psychometric properties of the SNAP-IV are not available at this time, the SNAP-IV is similar to the Disruptive Behavior Disorders (DBD) Rating Scale which uses the same format but includes DSM-III-R symptoms rather than those of DSM-IV. The DBD has an internal consistency of .95 on the oppositional subscale when completed by children's teachers (Pelham et al., 1998). Likewise, the psychometric properties for the DSM-IV Conduct Disorder Checklist have not been established, but Pelham et al. (1998) reported an internal consistency of .75 for the conduct scale on the teacher completed DBD. Psychometric properties for checklists measuring oppositional/conduct behaviour problems that are similar to the SNAP-IV and completed by the child's parent are unavailable. However, DuPaul (1991) has reported test-retest reliability and internal consistency scores of .94 when parents rate their child's ADHD symptoms on a checklist with the same format as the SNAP-IV and the DBD (i.e., a 4-point rating scale ranging from 0 to 3). Child noncompliance. Child noncompliance was assessed by observational coding of the videotaped mother-son interactions. The coding system used in the present study was a modified version of the system described by Kuczynski et al. (1987) and Kuczynski and Kochanska (1990). To capture the overall goal and final resolution of mother-child conflicts in addition to the quality of child noncompliance, an episodic approach was adopted. Control episodes began with clear maternal commands aimed at promoting or prohibiting child behaviour. For example, a mother may have asked her child to remove toys from the floor and put them in a plastic bin. The episode ended when the mother issued a new command or when the research assistant entered the room at the end of clean up. If neither of these events occurred, the episode ended when the child was clearly finished the task. 20 Within each control episode the child's behaviour in response to maternal commands (i.e., type of noncompliance) and the final resolution (in terms of child compliance or noncompliance) was coded. The child behaviours described in the coding system used by Kuczynski and Kochanska (1990) were designed for children between the ages ofVA and 5 years old. Using their system as a basis, a coding system was developed with noncompliant behaviours that were more appropriate for children between the ages of 7 to 10 years old. The addition of new categories was based on observations of tapes not used in this study (see Table 1). Several types of child behaviours could be identified within a single control episode, and each type of child behaviour (e.g., bargaining) could be coded more than once. The overall resolution of the episode was coded as either compliance or noncompliance at the end of the episode. Table 1. Types of Child Noncompliance Child Noncompliance Description Crying Cries in response to maternal command Counter-commanding Responds by issuing a directive to his mother (e.g., "You do it!") External explanation Refers to task difficulty, justice, etc. (e.g., "But I didn't do it") Ignoring Ignores mother's command for at least 5 seconds Internal explanation Refers to wants, needs, desires, abilities (e.g., "I'm too tired") Lying Lies about the task at hand (e.g., "I did it already!") Nonverbal refusal Expresses desire to noncomply physically (e.g., shakes head) Nonverbal defiance Nonverbal refusal with anger/aggression (e.g., throws toy) Negotiating Trying to change terms of task (e.g., "I'll do half) Stalling Verbally agrees but behaviourally noncompliant Request for information Asks why task must be done Request for help Asks for help in doing the task Token compliance Begins to comply behaviourally but verbally resists Verbal defiance Displays anger/aggression while verbally refusing (e.g., yells "no!") Verbal refusal Refuses in a neutral, non-angry manner (e.g., "no") Two undergraduate students and one graduate student (the author) were trained to use the coding system over a two month period. The training involved weekly meetings in which pilot tapes were observed and coded. The coding manual was modified for clarity when necessary 21 and training continued until 80% agreement was reached among the three coders. Weekly meetings ensued to monitor the interrater reliability of coded tapes, to discuss any discrepancies between reliability coded tapes, and to address any relevant issues that may have arisen. Al l three coders were blind to the child's level of oppositional/conduct problem behaviour and 30% of the videotapes were reliability coded. Observer agreement for the control episodes and the overall resolution was calculated as the number of agreements between coders divided by the number of episodes identified by coders. Observer agreement for child noncompliance was calculated as the number of agreements between coders (across all types of noncompliance) divided by the total amount of noncompliance identified. The percentage agreement was 90% for identifying control episodes, 95% for the overall resolution, and 82% for child noncompliance. 22 Results Data Reduction for Child Noncompliance Measures Descriptive statistics were performed on each of the 28 noncompliant behaviours that were coded (Table 2). Ten behaviours that had mean frequencies equal to or less than .01 and one behaviour that did not correlate with any other behaviour (i.e., lying) were eliminated from the analyses. A factor analysis was performed with the remaining 17 behaviours to determine whether the noncompliant behaviours could be summarized by categories suggested by past research: unskilled and skilled noncompliance (Kuczynski & Kochanska, 1990). To examine the factor structure of the noncompliant behaviours, a principle-axis factor analysis with oblique rotation was conducted. The results of this analysis are presented in Table 3. Initially the standard practice of retaining factors with eigenvalues of at least 1 was used (Kaiser, 1960). This technique produced a four-factor solution which contained many cross-loaded items and which was difficult to interpret theoretically. Therefore, the number of factors extracted was guided by the simplicity of the solution and apriori conceptualizations that were based on developmental theory and previous research findings (Kuczynski & Kochanska, 1990). Using these guidelines three factors were extracted with eigenvalues greater than 1.8 and which together accounted for 53% of the variance in the noncompliant behaviours. Items with factor loadings >.30 on one factor were retained. Three items (request for information, nonverbal defiance with token compliance, and requests for help with token compliance) were dropped because they had factor loadings of less than .30 on all three factors. Verbal refusal loaded above .30 on both Factors I and II. This variable was retained in Factor I based on apriori conceptualizations about the behaviour and supplemented by its higher loading on Factor I Table 2. Descriptive Data for Noncompliant Behaviours, Overall Resolution, and Control Episodes N Minimum Maximum Mean SD Measures Noncompliant Behaviours: information with TC 140 0.00 11.00 2.01 2.16 ignoring 140 0.00 15.00 1.69 2.80 request for information 140 0.00 11.00 1.56 1.78 external explanation 140 0.00 12.00 1.00 1.89 internal explanation 140 0.00 9.00 0.76 1.66 negotiation 140 0.00 6.00 0.61 1.13 verbal refusal 140 0.00 9.00 0.61 1.39 external explanation with TC 140 0.00 5.00 0.59 1.07 nonverbal defiance 140 0.00 20.00 0.58 2.20 negotiation with TC 140 0.00 5.00 0.54 1.05 internal explanation with TC 140 0.00 10.00 0.49 1.23 nonverbal refusal 140 0.00 6.00 0.36 0.93 help with TC 140 0.00 6.00 0.33 0.88 nonverbal defiance with TC 140 0.00 6.00 0.33 0.94 verbal defiance 140 0.00 4.00 0.19 0.70 request for help 140 0.00 5.00 0.15 0.61 crying 140 0.00 8.00 0.14 0.82 lying 140 0.00 2.00 0.11 0.36 counter-command 140 0.00 2.00 0.01 0.21 crying with TC 140 0.00 2.00 0.01 0.19 ignoring with TC 140 0.00 1.00 0.01 0.22 lying with TC 140 0.00 2.00 0.01 0.19 nonverbal refusal with TC 140 0.00 2.00 0.01 0.17 stalling 140 0.00 1.00 0.01 0.15 verbal defiance with TC 140 0.00 1.00, 0.01 0.12 verbal refusal with TC 140 0.00 2.00 0.01 0.17 counter-command with TC 140 0.00 0.00 0.00 0.00 staling with TC 140 0.00 0.00 0.00 0.00 Overall Resolution: 140 0.00 5.00 0.45 1.00 Control Episodes: 140 1.00 8.00 3.49 1.54 Note: Noncompliant behaviours retained for the factor analysis have boldfaced means. TC = token compliance Table 3. Oblimin Loadings for Noncompliant Behaviours 24 Factor Noncompliant behaviours 1 2 3 crying -0.97 -0.14 -0.10 nonverbal defiance -0.96 -0.15 -0.01 verbal refusal -0.53 0.39 -0.11 verbal defiance -0.51 0.01 0.19 external explanation -0.12 0.66 -0.01 negotiation 0.01 0.58 0.19 nonverbal refusal -0.01 0.54 -0.14 request for help -0.01 0.49 0.01 ignoring 0.01 0.47 -0.01 internal explanation -0.27 0.44 -0.01 information with TC 0.01 -0.26 0.68 internal explanation with TC -0.01 -0.01 0.66 external explanation with TC -0.01 -0.01 0.46 negotiation with TC 0.01 -0.01 0.32 nonverbal defiance with TC -0.16 0.11 0.01 request help with TC -0.01 0.26 0.17 request for information 0.01 0.26 0.01 Note: Oblimin rotation is used. Rotated factor loadings greater than .30 which are included in the creation of factor scores are presented in boldface. TC = token compliance. than Factor II. Following the content of items loading on each factor and the conceptual model of noncompliance presented in this study, Factor I will be referred to as "least skilled" noncompliance, Factor II as "semi-skilled" noncompliance, and Factor III as "most skilled" noncompliance. Cronbach's coefficient alpha indicated that the internal consistency of these factors was .76, .63, and .57 respectively. Following these analyses, the frequency of the behaviours on each factor was summed for each child. The next phase involved calculating proportion scores for each factor for each child. Proportions were computed by dividing the summed frequency of the behaviours on each factor by the total frequency of behaviours (regardless of type) for each participant. The resulting .25 ratios represented the proportion of least skilled, semi-skilled, and most skilled noncompliance for each participant. The overall resolution of the episode was calculated by summing the episodes that ended in noncompliance for each participant, and the number of control episodes was computed by adding the total number of episodes for each participant (for descriptive information see Table 2). In summary, the measures available for analysis were the frequency and proportion of each type of noncompliance, the frequency of noncompliance as an overall resolution, and the frequency of control episodes. Potential Confounding Variables Proportion Scores One-way analyses of variance (ANOVA) were performed to test whether participants' ethnicity or family marital status were related to the proportion of types of noncompliance. Ethnicity and marital status were each between-subject factors and the proportion of type of noncompliance was the within-subject factor. No significant effect of ethnicity (least skilled, p_ = .66; semi-skilled, p_ = .42; most skilled, p_ = .21) or marital status (least skilled, p_ = .80; semi-skilled, rj = .17; most skilled, p_ = .07) was found. Pearson correlation coefficients were used to determine if there was any association between the child's age or maternal education and the proportion of each type of noncompliance. Child age was significantly associated with the proportion of the least skilled noncompliance, r(139) = -.14, p_ = .05, and consequently was controlled in subsequent analyses. Maternal education was not significantly associated with the proportion of the types of noncompliance (least skilled, p_ = .14; semi-skilled, p = .07; most skilled, E = -37). 26 Frequency Scores One-way analyses of variance (ANOVA) were also performed to test whether participants' ethnicity or family marital status were related to the frequency of noncompliance types. Ethnicity was significantly related to the frequency of semi-skilled noncompliance, F (3, 139) = 4.78, p < .01. This association between ethnicity and the frequency of semi-skilled noncompliance indicated that collapsing across ethnic groups in the analyses of frequency scores would not be justified. Due to the small sample size (i.e., low power) of the non-white groups, separate analyses on these children could not be performed. Therefore, subsequent analyses on the frequency of noncompliance types were performed using data from the white sample only. Family marital status was also significantly related to the frequency of semi-skilled noncompliance, F (5, 135) = 2.59, p = .03. Perusal of the data suggested that ethnicity and marital status were related to each other. A Chi-Square statistic performed on ethnicity and family marital status confirmed this hypothesis, X ( l , 136) = 51.55, p < .01. A further confirmation of this hypothesis was that a one-way ANOVA indicated that marital status and the frequency of semi-skilled noncompliance were no longer significantly related when the analysis was limited to white participants' data (p = .32). Therefore, analyses on the frequency of types of noncompliance were confined to white participants and partialing marital status in addition to age was not considered necessary. Pearson correlation coefficients were used to test whether there was an association between child age or maternal education and the frequency of noncompliance types. Age was significantly associated with the frequency of the least skilled (r (139) = -.16, p_ = .03), semi-skilled (r (139) = -.22, p = .01), and most skilled (r (139) = -.14, p = .05) types of noncompliance and was controlled in analyses of the frequency of noncompliant types. Maternal education was not associated with the frequency of the types of noncompliance (least skilled, p = .13; semi-skilled, p = .09; most skilled, p = .19). 27 Overall Noncompliant Resolution of Control Episodes One-way ANOVAs were performed to test whether participants' ethnicity and family marital status were related to the overall noncompliant resolution of control episodes. Neither ethnicity (p_ = .08) nor family marital status (p_ = .30) were related to the frequency of control episodes ending in noncompliance. The child's age was significantly associated with the overall noncompliant resolution of control episodes, r(139) = -.17, p_=.03 and was controlled in the analyses of the overall noncompliant resolution of control episodes. There was no correlation between maternal education and the overall resolution of episodes, p_ = .45. Number of Control Episodes One-way ANOVAs were used to test whether the number of control episodes were related to family marital status or the child's ethnicity. No relationship was found for either marital status (p_ = .53) or ethnicity (p_ = .35). The number of control episodes was not significantly correlated with the child's age (p_ = .23) or maternal education (p_ = .09). Correlations between Types of Noncompliance and Oppositional/Conduct Disordered Behaviour Proportion Scores As predicted, a partial correlation controlling for child age revealed that ADHD boys whose mothers reported them as having higher levels of oppositional/conduct disordered behaviours exhibited higher proportions of semi-skilled noncompliance than boys whose mothers reported lower levels of oppositional/conduct disordered behaviours (Table 4). Maternal ratings of oppositional/conduct disordered behaviour were not associated with least skilled or most skilled noncompliance. Teacher ratings of boys' oppositional/conduct disordered behaviour were not associated with any of the three types of noncompliance. Frequency Scores Confining the analyses to white participants and controlling for child age, the relationship between the frequency of the types of noncompliance and oppositional/conduct disordered 28 behaviour was assessed. Partial correlation coefficients indicated that boys with higher maternal ratings of oppositional/conduct disordered behaviour engaged in significantly more frequent semi-skilled noncompliance, and maternal ratings were not related to the frequency of the least skilled noncompliance. These findings are consistent with the proportion score data. Unlike the proportion score data, maternal ratings of oppositional/conduct disordered behaviour showed a trend towards a significant negative correlation with the frequency of the most skilled noncompliance (Table 4). Consistent with proportion score data, teacher ratings of boys' oppositional/conduct disordered behaviour were not associated with the frequency of noncompliance types. Table 4. Partial Correlation Coefficients between Types of Noncompliance and Behavioural Ratings of ODD/CD Behaviour Types of Noncompliance Ratings N Least Skilled Semi-Skilled Most Skilled Proportion Scores: Parent ODD/CD Rating 131 .04 .14 -.01 p = .33 p = .05 p = .49 Teacher ODD Rating 130 .08 -.02 .04 p = .17 p = .41 p = .34 Frequency Scores: Parent ODD/CD Rating 83 -.03 .20 -.15 p = .40 p = .04 p = .08 Teacher ODD Rating 84 -.01 .02 -.09 p = A9 p = .42 P = -20 Note: p = probability value. Partial correlations control for child age. Frequency scor performed on white sample only. Proportion scores performed on complete sample. 29 Correlations between the Overall Noncompliant Resolution of Episodes and Oppositional/Conduct Disordered Behaviour A partial correlation (controlling for child age) indicated a trend for a positive correlation between maternal ratings of oppositional/conduct disordered behaviour and the frequency of control episodes ending in any type of child noncompliance, r ( 130) = .14, p_ = .06. There was no association between teachers' behavioural ratings and the overall noncompliant resolution of episodes. Correlations between the Frequency of Control Episodes and Oppositional/Conduct Disordered Behaviour There were no associations between the number of control episodes and behaviour problems as reported by the parent (p_ = .23) or teacher (p_ = .24). 30 Discussion The purpose of the present study was to clarify a body of research that attempted to distinguish between children having ADHD with higher and lower levels of oppositional/conduct disordered behaviour on the basis of the frequency of noncompliant behaviours (Barkley et al., 1992; Johnston, 1996; Schachar & Wachsmuth, 1991). The results suggest that the type of noncompliance exhibited by children is an important dimension of resistance that may enhance our understanding of children with behavioural problems. The factor analysis performed in this study replicated previous distinctions among types of child noncompliance. Consistent with Kuczynski and Kochanska's (1990) longitudinal research on noncompliance, defiant behaviours and simple refusals were found to be the least skilled forms of noncompliance. A new category, crying, was an addition to the least skilled category. In contrast to Kuczynski and Kochanska's (1990) findings, ignoring did not cluster with the least skilled forms of noncompliance. Conceptually, this difference makes sense. The cluster of least skilled noncompliant behaviours, defiance (e.g., yelling, throwing toys), simple refusals (e.g. "no") and crying, are direct, straightforward, and often characterized by aggression. These behaviours are aversive and would be unlikely to result in a mutually satisfying outcome for the parent and child. Ignoring is indirect and is open to diverse interpretations from the parent. For example, the child may not have heard the command, be stalling, or be taking his/her time in responding to the parental command. Clearly, this behaviour is less aversive than direct confrontations characteristic of least skilled noncompliance. Also consistent with Kuczynski and Kochanska's (1990) research, negotiation and explanations were found to be relatively more skilled noncompliant behaviours. Different kinds of explanations, reflecting internal orientations (e.g., "I don't feel like picking up the toys") and external orientations (e.g., "It's not fair~I didn't put the toys there") loaded on the same factor. The addition of new behaviours developed to reflect the behaviour of older children (e.g., token 31 compliance) resulted in a category of noncompliance representing a higher level of skilfulness than the ones identified by Kuczynski and Kochanska (1990). Specifically, the possibility of behaviourally compliant behaviour (i.e., token compliance) accompanying any of the noncompliant strategies permitted the detection of behaviours being used by children who intended to noncomply, but who combined conciliatory behaviour with protestations. The behaviours in this most skilled noncompliance category consisted of explanations (internal and external), negotiation, and requesting information. Other than the accompaniment of token compliance, three of the four behaviours in this category were identical to the behaviours that loaded on the factor reflecting semi-skilled noncompliance. A possible interpretation of the semi- and most skilled noncompliance categories is that what differentiates them is not skill level, but the fact that the former represents noncompliant behaviours whereas the latter is actually compliance. Practical and empirical information challenge this interpretation. Practically, a child may participate in behavioural compliance, and use strategies of noncompliance at the same time. The goal of the child is still to make the parent drop or modify the command. Children who are more skilled at resistance strategies may have learned that showing a preliminary willingness to cooperate may increase their chances of successfully negotiating their way out of performing a given task. Empirically, if the most skilled form of noncompliance (i.e., verbal noncompliance accompanied by behavioural compliance) was identical to compliance, one would expect it to correlate highly with the frequency of children's compliance. Preliminary findings suggest that this is not the case. As part of another study being conducted in our laboratory (Jones & Johnston, 1999), the videotaped mother-son interactions used in this study were coded to record the absolute frequency of maternal commands and the boys' compliance to each command. A Pearson correlation coefficient conducted between each boys' most skilled noncompliance frequency score and the absolute frequency of his compliance indicated only a trend towards significance, r (135) = .12, p_ 32 = .09. This suggests that although there may be some association between most skilled noncompliance and compliance, most skilled noncompliance is not merely a duplicate measure of compliance. Additional evidence in support of the developmental model of noncompliance was the finding of a negative correlation between the proportion of least skilled noncompliance and child age. Higher proportions of least skilled noncompliance in younger children are consistent with Kuczynski and Kochanska's (1990) results which suggest that noncompliance strategies shift with age, with younger children using the least skilled forms noncompliance more than older children. Further support for the developmental model of noncompliance would have been accomplished by finding a positive correlation between the proportion of most skilled noncompliance and child age. The results of this study did not support such an association. In summary, the results of the factor analysis partially support the developmental model of child noncompliance as a multidimensional construct that varies in skilfulness (Kuczynski & Kochanska, 1990). Given this, what relation (if any) do these different dimensions have to oppositional/conduct disordered behaviour? According to maternal reports, children with ADHD who have higher levels of oppositional/conduct disordered behaviours engaged in proportionally more semi-skilled noncompliance than children with lower levels of oppositional/conduct disordered behaviours. Despite the fact that there was no association between the proportion of least skilled noncompliance and maternal ratings of child behaviour, ADHD children with higher levels of oppositional/conduct disordered behaviour were displaying higher proportions of a type of noncompliance that would be considered less skilled than their potential (i.e., most skilled). Thus, these results lend support, albeit limited, to the hypothesis of this study. An examination of the data using measures more compatible with the behavioural model of noncompliance were also performed. For example, the measure of the number of times 33 control episodes terminated in noncompliance and the total number of control episodes were aggregated for each participant. Correlations using these measures of the frequency of noncompliance indicated only a trend for boys with higher maternal ratings of oppositional/conduct disordered behaviour to display higher frequencies of overall noncompliant resolutions. Control episodes were not associated with oppositional/conduct disordered behaviour reported by mothers. As mentioned earlier, child noncompliance was also coded in a separate study being conducted in our laboratory (Jones & Johnston, 1999). More in line with traditional behavioural measures of noncompliance, the absolute frequency of boys' noncompliance to maternal commands was recorded in this study. Results indicated that there was no association between this measure of the frequency of all types of noncompliance and maternal ratings of oppositional/conduct disordered behaviour, r (129) = -.26, p = .19, controlling for child age. In summary, maternal ratings of oppositional/conduct disordered behaviour were correlated only with the proportion of semi-skilled noncompliance and not with the proportion of least or most skilled forms of noncompliance. When more traditional behavioural measures of noncompliance (e.g., the frequency of noncompliance regardless of the type) were correlated with maternal ratings of oppositional/conduct disordered behaviour, there was a trend towards significance in only one of the three analyses. Clearly, neither the analyses using the proportion of types of noncompliance (as proposed in this study) nor the absolute frequency of noncompliance (as proposed by the behavioural model) provided a satisfying account of resistance strategies in ADHD children with oppositional/conduct disordered behaviour. Combining these measures may provide more information: When the frequencies of the different types of child noncompliance were examined, there was still no association between maternal ratings of oppositional/conduct disordered behaviour and least skilled noncompliance. However, in addition to a positive correlation 34 between maternal ratings of oppositional/conduct disordered behaviour and the frequency of semi-skilled noncompliance, there was a trend in the direction of a negative correlation between maternal ratings and most skilled noncompliance. Not only were children with higher levels of oppositional/conduct disordered behaviour engaging in more semi-skilled noncompliance, they were engaging in less of the skilled noncompliant behaviour. Due to the observed correlation between ethnicity and the frequency of types of noncompliance, these analyses were conducted only with the white children, therefore caution must be exercised in generalizing these results beyond a white population. It appears that a consideration of both the frequency and the type of noncompliance may tell a more complete story of the behaviour ADHD children with oppositional/conduct disordered behaviour than either frequency or type on its own. The findings of this study may have implications for conceptualizations of behaviour disorders (such as Oppositional Defiant Disorder) in children with ADHD. The results presented suggest that children with these behavioural problems may engage in resistant behaviours that are maladaptive both because they occur frequently and are unskilled. With this in mind, parent training programs that focus exclusively on reducing the frequency of noncompliance without consideration of the type may be misguided. The effectiveness of parenting programs could be enhanced by teaching parents which types of noncompliant behaviours should be discouraged, and conversely, which types of noncompliant behaviours are normal and acceptable. Future research needs first to examine noncompliance in nonproblem children and children with behavioural problems and secondly, to determine whether parent training programs can benefit from targeting problematic types of noncompliance that occur frequently. In this study there was no association between teacher ratings of oppositional behaviour and the types of noncompliance even though there was some association found for maternal ratings. This was true for both proportion and frequency scores. One reason for this discrepancy could be the generally low interrater reliability between teachers' and parents' ratings of child 35 behaviour (Achenbach, McConaughy, & Howell, 1987). Consistent with the research, the correlation between mother and teacher ratings of oppositional behaviour on the SNAP IV in this study was .38. This rater variance may reflect differences in the perceptions of the raters, raters' exposure different situations and thus different child behaviours, or differences in the way the child acts with their parents versus their teachers. The latter point is particularly important to consider. It is possible that maternal behaviour elicits different types of noncompliance from children. Trickett and Kuczynski (1986) found that maternal use of coercive disciplinary techniques (e.g., power assertion) was related to aversive forms of opposition in children. Kuczynski et al. (1987) found that maternal use of "direct commands" (e.g., unclear commands, reprimands, enforcement) was positively correlated with children's use of defiance and negatively correlated with children's use of negotiation. Beyond correlational research where causal processes are unclear, further support for parental influences on children's oppositional/conduct disordered behaviour comes from outcome studies of parent training programs. The effectiveness of these programs in improving child behaviour and parent-child interactions was discussed in the introduction of this paper (e.g., Serketich & Dumas, 1996). It should be noted that the direction of influence in the association between parent and child behaviour must be interpreted with great caution. There is a substantial body of evidence indicating that changing oppositional/conduct disordered behaviour in children with the use of stimulant medication improves both child and parent behaviour (Barkley, 1985). In short, the causal direction in problematic parent-child interactions remains unknown. Research to date points to a reciprocal relationship: parents have the ability to elicit aversive child behaviours, and children may elicit aversive parental behaviours. Despite the corroborative value and knowledge gained in this study, several limitations exist. Although the level of oppositional/conduct disordered behaviour was correlated with the proportion and frequency of semi-skilled noncompliance, there was no association between 36 ratings of child behaviour and least skilled noncompliance. The lack of correlation is most likely attributable to the low frequency of the least skilled behaviours. The modal value for these behaviours was zero, causing the distribution to be extremely negatively skewed and prohibiting the use of transformation techniques (Games, 1983). There are at least two explanations for why boys did not use these strategies. It may be that defiance, verbal refusal, and crying are behaviours that are too immature for 7-10 year old boys. These are behaviours that were originally identified in nonproblem VA - 5 year old children (Kuczynski et al., 1987). Until normative data is collected on noncompliance in children above the age of 5 years, this question will remain unanswered. Related to this issue is the possibility that semi-skilled noncompliant behaviours are as aversive to parents of older children as the least skilled behaviours are to parents of younger children. Thus, in addition to collecting normative data, it may be worthwhile to assess the aversiveness of various noncompliant behaviours to parents of older children, especially since developmental theorists use this criteria to define skill level. A second explanation for the low frequency of the least skilled noncompliance is that the situation used in this study did not elicit noncompliant behaviours that would occur in more naturalistic settings. Using more challenging laboratory tasks for boys in the 7-10 year old age range or more naturalistic observations in future studies may rectify this problem. A second limitation of this study was a general problem of low frequencies of noncompliant behaviours and thus low variance. Possible explanations for the low level of noncompliance have already been discussed above. The effects of the limited variance were that the factor analysis explained only 53% of the variance and the internal consistency of the noncompliance scales were low. 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