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1. 123
A Family-School Homework Intervention Program for
Children With Attention-Deficit/Hyperactivity Disorder
Dina E Habboushe, Sheeba Daniel-Crotty, James L. Karustis, Stephen S. Left,
Tracy E. Costigan, Suzanne G. Goldstein, Ricardo Eiraldi, and ThomasJ. Power,
Children's Hospital of Philadelphia/University of Pennsylvania School of Medicine
Children with attention-deficit~hyperactivity disorder (ADHD) typically have multiple problems with homework performance that
may contribute to academic skills deficits and underachievement. Specialized interventions to address the homework problems of chil-
dren with ADHD is greatly needed. A brieffamily-school training program to address the homework problems of children with ADHD
is described. The Homework Success Program (HSP) involves group parent training in cognitive and behavioral principles and
strategies that have empirical support in the literature. This program involves increasing parent understanding of their child's be-
havior and training in behavioral techniques to improve academic productivity and behavioralfunctioning. In addition, an empha-
sis is placed on improving goal-setting skills and increasing parent-teacher collaboration to address homework problems. Procedures
for incorporating children into the intervention program are also included. Suggestions are madefor assessing progressand outcomes
in academic and behavioralfunctioning and parent-child interactions. Case illustrations arepresented to demonstrate methods that
may be useful in evaluating program effectiveness and to describethe types of outcomes that may occur when this program is imple-
mented. Future researchdirections and suggestionsfor implementing this program in community and school settings are discussed.
CHILDREN with attention-deficit/hyperactivity disor-
der (ADHD) frequently display problems perform-
ing homework assignments (Barkley, 1998). The Home-
work Success Program (HSP) is a 10-week, seven-session
group behavioral intervention targeting homework prob-
lems that are common in children with ADHD. This in-
tervention program, which is unique in its comprehen-
sive approach, focuses primarily on training parents in
behavioral strategies and developing their skills in work-
ing collaboratively with teachers. Teachers are also in-
volved to set realistic goals for homework and to evaluate
outcomes. Home-school collaboration is emphasized
throughout the implementation of the program. Further,
the HSP includes a structured child group that reinforces
behavioral strategies taught in the parent group. This
paper will present the rationale for the importance of
the HSP, a description of the intervention protocol, pre-
liminary data to demonstrate the process by which the
program is being validated, and future directions for its
development.
A useful working definition for homework is "assign-
ments given by teachers for completion outside of the
normal class period" (Keith & DeGraff, 1997, p. 477).
Most students in both regular and special education are
Cognitive and Behavioral Practice 8, 123-136, 2001
1077-7229/01/123-13651.00/0
Copyright © 2001 by Association for Advancement of Behavior
Therapy. All rights of reproduction in any form reserved.
L~ Continuing Education Quiz located on p. 207.
assigned homework on a regular basis (Polloway, Epstein,
Bursuck, Jayanthi, & Cumblad, 1994), and many of these
students experience significant problems with successful
homework performance (Anesko, Schoiock, Ramirez, &
Levine, 1987). There have been a number of debates
over the years regarding the design, purpose, and actual
effectiveness of homework (Cooper, 1989, 1994; Keith,
1993). Although some studies have concluded that
homework is only weakly correlated with academic
achievement, the majority of the literature indicates that
homework has a positive effect on academic achievement
(Cooper, 1989). Specifically, researchers have found that
the amount of homework completed by the student ap-
pears to be positively correlated with grades and test
scores (Cooper, Lindsay, Nye, & Greathouse, 1998).
Homework is most clearly related to achievement when
teachers provide specific, immediate feedback to stu-
dents (Paschal, Weinstein, & Walberg, 1984). Further, the
majority of parents, teachers, and students appear to
perceive homework to be an important element in aca-
demic programming (Olympia, Sheridan, &Jenson, 1994;
Roderique, Polloway, Cumblad, Epstein, & Bursuck, 1994).
Homework Problems Associated With ADHD
Children with ADHD tend to display impairments in
many functional domains, but the impact of ADHD on
educational performance is particularly profound (Bark-
ley, 1998). Specifically, a majority of students with ADHD
are underachievers and have academic skills deficits, and
many of these youngsters are at high risk for grade reten-

2. 124 Habboushe et al.
tion, dropout from school, and placement in special edu-
cation (Barkley, Fischer, Edelbrock, & Smallish, 1990;
Semsud-Clikeman et al., 1992).
Children with ADHD appear to experience particular
problems with homework, and it has been shown that
children with ADHD are less actively engaged in aca-
demic work than their classmates (Abikoff & Gittelman,
1985). That is, students with ADHD typically display
lower rates of on-task behavior during instruction, and
tend to be less attentive and productive when responding
to in-class and homework assignments (Abikoff & Gittel-
man). A number of studies, including the DSM-1Vfield
Homework
problems
commonly
associated with
ADHD include
failure to
remember
homework
assignments,
off-task or
oppositional
behavior during
homework, and
parent-child
conflict related to
homework.
trials for ADHD, have indi-
cated that the majority of these
children display more frequent
and severe homework prob-
lems than their peers (Daniel &
Karustis, 1998; Karustis, Power,
Rescorla, Eiraldi, & Gallagher,
1998; Lahey et al., 1994). Ex-
amples of homework prob-
lems commonly displayed by
children with ADHD include
(a) failure to remember home-
work assignments, (b) lack of
compliance with directives to
begin homework, (c) off-task
behavior during homework,
(d) difficulty segmenting work
into manageable units, (e)
oppositional behavior around
homework assignments, and
(f) parent-child conflict re-
lated to homework (DuPaul &
Stoner, 1994). Despite the
functional impairments often
associated with homework
problems among children with ADHD, surprisingly little
research has been conducted on the homework needs of
these children and their families.
Homework Interventions
The efficacy of behavioral interventions to improve
homework performance has been supported by a num-
ber of studies. It has been found that home-school notes
that incorporate positive reinforcement techniques are
related to both qualitative and quantitative improve-
ments in homework performance (Goldberg, Merbaum,
Even, Getz, & Safir, 1981). In addition, this behavioral in-
tervention was viewed by parents to have high levels of
treatment acceptability (Goldberg et al.; Landers, 1984).
Other empirically supported homework interventions in-
clude establishing homework ground rules, devising re-
inforcement and punishment systems, and increasing
home-school collaboration (Rhoades & Kratochwill, 1998).
Further, using an assignment book regularly signed by
parents (Holmes & Croll, 1989) and designating a consis-
tent place and time for homework (Landers) have also
been found to be effective in improving homework per-
formance. Kahle and Kelley (1994) found that training
parent-child dyads in the use of goal setting and contin-
gency contracting may be a more effective intervention
for treating children's homework problems than training
parents alone in contingency contracting. In addition, as-
signing tasks that are appropriate for the child's level of
academic skills is related to improved homework perfor-
mance (Keith & DeGraff, 1997).
Rationale for Homework Success Program
Students with ADHD who have academic skills deficits
require more instruction and practice to meet classroom
requirements than their non-ADHD peers (Zentall, 1993).
Unfortunately, educational systems often are not pre-
pared to provide these students with the additional in-
struction and practice they need (Landrum, A1-Mateen,
Ellis, Singh, & Ricketts, 1993), and families often are not
equipped to support children who are highly disorga-
nized and who frequently resist assistance with the com-
pletion of homework assignments (Kay,Fitzgerald, Paradee,
& Mellencamp, 1994).
Several parent guides have been developed to address
children's homework problems (e.g., Olympia, Jenson, &
Hepworth-Neville, 1996; Weiner, Sheridan, & Jenson,
1998), but very few have been empirically supported. In
addition, none of these programs has been empirically
validated for, or specifically designed to meet the needs
of, children with ADHD. Further, many programs are de-
signed to be implemented with only one set of parents, al-
though parents of children with ADHD typically report
that assistance from a trained professional through a fam-
ily or group intervention process is related to significant
increases in child compliance (Arnold, Sheridan, &
Estreicher, 1986; Estrada & Pinsof, 1995). Also, even
though empirically validated parent training programs
have been developed to address the behavioral problems
of children with ADHD and related disorders (e.g., Bark-
ley, 1998), these programs do not focus explicitly on the
homework problems experienced by children with this
disorder. As such, specialized homework intervention
programs for children with ADHD are needed for the fol-
lowing reasons: (a) this population is at particularly high
risk for homework problems; (b) parents of children with
ADHD require highly specialized training in behavioral
techniques to manage these youngsters (Barkley); and
(c) many of the interventions used to treat children's

3. Homework Program for ADHD IZ5
homework problems are uniquely related to homework
(e.g., reporting of homework assignment; setting ground
rules; goal setting) and differ from the strategies used to
treat other types of noncompliant behavior. Further, im-
plementing empirically validated manualized treatment
protocols for ADHD can help to ensure the use of cost-
effective treatments, standardized training of therapists
and implementation of interventions, and generalization
of treatment to diverse populations (see the Work Group
on Quality Issues, 1997; Addis & Carpenter, 1997).
Generally, the HSP is designed to be a structured pro-
tocol that provides clear guidelines for treatment imple-
mentation to ensure treatment integrity. Concurrently,
this program incorporates techniques, such as functional
assessment procedures, that provide a means by which to
tailor the intervention to address the individual circum-
stances and needs of each participant. The principles and
procedures included in the HSP have been supported by
studies of children who have problems related to ADHD.
In addition, the HSP incorporates a conjoint behavioral
consultation model (Sheridan, Kratochwill, & Bergan,
1996), an empirically supported intervention that em-
ploys principles of behavioral consultation (Sheridan,
1997; Sheridan, Welch, & Orme, 1996), and promotes
collaborative problem-solving among family members
and school personnel. Thus, parents, teachers, and chil-
dren each play an important role in the HSE
Parent Participation
Parent training is a widely used and accepted interven-
tion approach to address the needs of children with
ADHD (Barkley, 1998; Cantwell, 1996). Typical parent
training programs include education regarding ADHD,
as well as interactive training in the use of frequent feed-
back, effective commands, positive reinforcement, and
negative consequences (e.g., Barldey, 1997). Many parent
training protocols place an emphasis on consequence-
based interventions, such as rewards and punishments.
This approach is limited in terms of its practicality and
cost-effectiveness. It has been suggested that the inclu-
sion of a strong antecedent-based component, such as
structuring environments to increase the likelihood of
on-task behavior and compliance with directions, may be
more effective and may facilitate home-school collabora-
tion (DuPaul, Eckert, & McGoey, 1997; Miller & Kelley,
1991). Based on these ideas, the HSP parent training pro-
tocol involves providing education regarding ADHD and
homework, as well as antecedent and consequent inter-
ventions specifically related to homework. The parent
group also addresses parental self-efficacy and parent-
child relationships, areas that can be problematic in fam-
ilies of children with ADHD (Barldey, Karlsson, & Pol-
lard, 1985; Mash &Johnston, 1992).
Child Participation
Homework intervention protocols and parent train-
ing programs designed to assist children with ADHD typ-
ically do not involve children in the intervention process.
Rather, they are designed to involve children through
parents' implementation of behavioral strategies taught
in the training program. However, a number of factors
point to the importance of in-
cluding children in homework
interventions for ADHD when-
ever possible. First, student in-
volvement in setting goals for
homework completion and ac-
curacy has been linked to in-
creases in performance and
motivation (Olympia, Sheridan,
Jenson, & Andrews, 1994).
Also, including both parents
and children in treatment may
enable group leaders to more
effectively address the high de-
gree of parent-child conflict
that often arises in families
coping with ADHD (Richters,
Arnold,Jenson, &Abikoff, 1995).
Further, introducing children
The HSP is a
comprehensive
group intervention
program that
addresses
homework
performance, an
important domain
of functioning
often overlooked
in children who
have ADHD.
to the principles and strategies that their parents are
being taught through parent training has been shown to
be useful in increasing child understanding, acceptance,
and compliance with such interventions (Frankel, Myatt,
Cantwell, & Feinberg, 1997; Webster-Stratton & Hammond,
1997). In fact, a number of studies with non-ADHD sam-
ples have found that behavioral intervention groups that
include both parent and child training components tend
to be more successful in improving parenting skills and
reducing disruptive behaviors than either component
alone (Frankel et al.; Webster-Stratton & Hammond).
These results have been demonstrated both at the con-
clusion of training and at 1-year follow-up.
Based on these findings, it is recommended that a
child group be conducted concurrent with the parent
training group. Child groups can range from providing
child care to conducting a structured, behavioral pro-
gram with the children. In cases where it is feasible, a
child group that models behavioral strategies, such as the
one that has been created to be an optional component
of this program (see Power, Karustis, & Habboushe,
2001), is recommended in order to complement the
strategies taught in the parent training group.
Teacher Participation
Home-school collaboration is extremely important
when addressing the homework problems of children who
have ADHD. Teachers have many roles pertaining to

4. 126 Habboushe et al.
homework, including (a) providing effective classroom
instruction to prepare students for homework assign-
ments; (b) designing assignments to support classroom
instruction; (c) assigning a reasonable amount of home-
work; (d) clearly explaining homework instructions and
grading homework; and (e)
The HSP combines
specialized
behavioral
techniques that
have been shown
to be effective for
managing children
with ADHD, as
well as
interventions that
are specifically
focused on
homework.
communicating with parents
when problems arise (Olym-
pia, Sheridan, &Jenson, 1994).
As such, failure to include
the teacher in a homework
intervention program would
most likely limit its effective-
ness. Further, given that home-
work is considered to be a
natural means of home-
school collaboration, inclu-
sion of teachers in the inter-
vention program represents
an excellent opportunity to
increase parental involve-
ment in a child's academic
experience (Olympia, Sheri-
dan, &Jenson). Research has
demonstrated repeatedly that
parental involvement in school is an important contribu-
tor to successful academic performance (Epstein, 1991;
Fantuzzo, Davis, & Ginsberg, 1995).
HSP: Process and Components
Referral and Screening
HSP participants are referred by many professionals,
including pediatricians, school personnel, and behav-
ioral health providers. In our program, prospective child
participants are screened for ADHD with the Diagnos-
tic Interview for Children and Adolescents: DSM-IV
Revision-Parent Form (DICA-IV-R-P; Reich, Shayka, &
Taibleson, 1995) and with the school version of the
ADHD Rating Scale-IV (DuPaul, Power, et al., 1997).
Those in grades 2 through 6 who obtain a diagnosis of
ADHD via the DICA-IV and the ADHD Rating Scale-iv, as
well as demonstrate elevated scores on the Homework
Problems Checklist (HPC; Anesko et al., 1987; i.e., 1.5
standard deviations above the mean), are eligible for par-
ticipation. Exclusionary criteria include a comorbid diag-
nosis of conduct disorder, the presence of high levels of
internalizing problems, or the presence of self-injurious
behavior, which may signal the need for an alternative
treatment before enrolling the family in the HSP. Indica-
tors of cognitive deficits, learning disabilities, or aca-
demic skills deficits may be helpful in addressing the
learning needs of children participating in this program,
but this information generally should not be used to ex-
clude a child from this intervention unless the learning
problems are severe.
Training
The HSP manual (Power et al., 2001) is designed to
provide detailed instruction in the implementation of
this program to facilitate training of clinicians. The man-
ual contains highly specific instructions for implement-
ing each of the seven sessions. Integrity checklists are in-
cluded to assist clinicians in implementing the program
in a standardized manner. In addition, sample recruit-
ment letters, as well as descriptions of suggested screen-
ing, progress monitoring, and outcome measures, are in-
cluded in this manual.
Orientation
In order to maximize the likelihood that the system
will be effective, particular attention is given to orienting
parents to the core components of the program. Specifi-
cally, the use of behavioral principles and the conjoint
model are described to parents. It is explained that re-
solving homework problems will require the collabora-
tion of important adults in the child's life, such as the par-
ents and teachers, in addition to the involvement of the
child. From the outset, group leaders frame problems in
behavioral terms that lead to goal-directed action and
collaborative problem solving. Parents are asked to dis-
cuss the program with teachers after the first session. Be-
cause one of the initial goals is to limit time spent on
homework in order to make it a more manageable and
successful experience for children, teachers are initially
asked to grade children's homework only on what is com-
pleted, and to refrain from penalizing these children for
incomplete work.
Weekly Components
A number of program components occur on a weekly
basis (Table 1). During each session, therapists use an in-
tegrity checklist to ensure that program components are
consistently followed. Several sessions begin with parents
completing forms to measure progress in homework, ac-
Table I
Weekly HSP Components
Group leader use of integrity checklists
Initial 15 minutesincludes both parents and children together
(optional)
Reviewof material from previous session
Discussionof between-sessionassignments
Discussionof experiences with A-B-Clogs
Assistancewith issuespertainingto home-school communication
General troubleshooting

5. Homework Program for ADHD 127
ademic performance, and parent-child relationships (see
below). We recommend that group training in home-
work strategies be provided to children concurrent with
the group for their parents. If a child group is included,
the first 15 minutes of each session involves the parents
and children meeting together with group leaders to im-
prove communications between the parent and child and
to ensure consistency in the training of parents and chil-
dren. During this time, the therapist briefly reviews with
parents and children the material covered in the previ-
ous session, as well as between-session home assignments
and parent-child interactions.
During each session, the parents participate in a brief
discussion of successes and problems with homework that
occurred over the past week. Based on a functional assess-
ment model, homework routines and problems are dis-
cussed in terms of antecedents, behaviors, and conse-
quences. Also, starting after Session 2, parents are
encouraged to log the antecedents and consequences of
daily homework behaviors. This log and the completion
of other homework assignments from the previous week
are discussed at the beginning of each session, prior to
the introduction of new material. Such a review empha-
sizes the importance of between-session assignments in
the behavioral intervention process. In addition, this dis-
cussion provides a forum for reviewing successes and dif-
ficulties with applying techniques, as well as the progress
of homework-related behaviors. On a weekly basis par-
ents also receive assistance with home-school communi-
cation. Specifically, the group leader and participants dis-
cuss negotiating completion and accuracy goals with
teachers, parental efforts regarding homework rules and
interventions, and general troubleshooting as problems
arise.
In general, sessions are spent addressing the weekly
topic (see Table 2 for outline of topics for each session).
These sessions include didactic training in principles and
techniques, group discussion of relevant experiences,
and modeling of interventions. Parents also receive
handouts and worksheets that can be used as guides to
applying the intervention strategies. At the end of each
session, parents are given assignments that are related to
the particular topic covered in that session.
HSP Parent Training Curriculum
Session 1: Introduction and Orientation
The goals of Session 1 are to (a) describe the aims of
the HSP, including increasing homework productivity, re-
ducing homework time, improving academic achieve-
ment, developing a sense of parental efficacy, and im-
proving the parent-child relationship; (b) discuss the
relationship between ADHD and homework problems;
(c) discuss parents' previous experiences during home-
work time; (d) explain the rationale and learn tech-
niques for limiting time spent on homework; and (e)
provide instruction in basic techniques for improving
home-school collaboration (e.g., preparing questions for
the teacher, supporting classroom interventions). During
the week between Session 1 and 2, parents are asked to
monitor their child's homework assignment sheet that is
to be signed by the teacher on a daily basis. Parents are
also provided with their own assignment sheet to record
their weekly HSP assignments.
Between Sessions 1 and 2
In between the first two sessions, the therapist makes
brief contact with the children's teachers to introduce
the program, review the homework assignment sheet,
and to support the process of parent-teacher collabora-
tion by answering teachers' questions pertaining to com-
pletion and accuracy goals, as well as to specific content
areas of the treatment group program. The clinician ex-
plains the importance of putting time limits on home-
work and requests that temporarily the teacher grade stu-
dents primarily on work accuracy, as opposed to work
completion.
Table 2
Outline of HSP Curriculum
Session Topic
1 Introduction and Orientation
Describe aims of HSP
Educate about ADHD and homework problems
Share experiences
Present limiting time spent on homework
Initiate home/school collaboration
Establishing Ground Rules and GivingEffectiveCommands
Introduce A-B-Cmodel
Describe the Homework Ritual
Advise about giving effective commands
Providing Positive Reinforcement
Train in principlesand techniques
Present types of reinforcers and core components
Managing Time and Setting Goals
Discuss manageable goals
Describe Goal Setting Tool (Power et al., 2001)
Emphasize reinforcement for meeting goals
Using Negative Consequences
Teach strategic use of negative consequences
Describe types of negative reinforcements
Integrating Skillsand AnticipatingFuture Problems
Reviewmaterial presented in previous sessions
Problem solve difficulties in applyingapproaches
Reinforce successes
Booster Session
Reviewsuccesses and difficulties
Problem solve difficulties
Reinforce successes and program completion

6. 128 Habboushe et al.
Session 2: Establishing Ground Rules
and Giving Effective Commands
Session 2 begins with introducing the Antecedents-
Behavior-Consequences (A-B-C) model that enables parents
to functionally assess their child's behavior. The use of
this model provides a framework with which to under-
stand children's behaviors by examining the influence of
antecedents and consequences on these behaviors. Par-
ents are instructed to use A-B-C logs to record a specific
problematic behavior that their child exhibits during home-
work time, as well as the antecedents and parent's subse-
quent responses to this behavior.
This introduction to the A-B-C model provides the
background for designing strategies to address the ante-
cedents of homework behaviors. "The Homework Ritual"
involves setting ground rules regarding a consistent
Student
involvement in
setting goals for
homework
completion and
accuracy has been
linked to increases
in performance
and motivation.
time for doing homework, a
distraction-minimized location
in which parents are able to
provide supervision, parental
review of the homework as-
signment sheet, and consis-
tent availability of the neces-
sary materials. Inherent in
this structure are explicit ex-
pectations, the modeling of
organizational skills, and de-
creased opportunities for con-
flicts during homework time.
Another focus of this ses-
sion is to provide training in
giving effective commands. Based on the work of Patter-
son (1982) and Forehand and McMahon (1981), parents
are taught to minimize distractions, use eye contact, and
make requests that are simple and achievable. During the
session, parents are encouraged to role-play giving com-
mands, and feedback is provided. During the week, par-
ents are instructed to work with their children in estab-
lishing homework ground rules.
Session 3: Positive Reinforcement
The primary goal of Session 3 is to train parents in the
principles and techniques of using positive reinforce-
ment. After reviewing progress in establishing the home-
work ritual and giving effective commands, which were
introduced in Session 2, the principle of utilizing conse-
quences to increase desired behaviors is presented within
the A-B-C model. The technique of positive reinforce-
ment is discussed relatively early in the program so as to
emphasize the importance of using a positive approach
to address children's behavior problems and to allow
time throughout the group for parents to practice these
critical skills.
During this session, the difficulties parents have expe-
rienced in attempting to identify and reinforce positive
behaviors in a child with ADHD are elicited and acknowl-
edged. Specific types of reinforcers are described, includ-
ing parental attention, verbal feedback, privileges, and
concrete rewards. In addition, the core components of
reinforcement are described through the acronym
C.I.S.S.-4, which refers to Consistency, Immediacy, Speci-
ficity, Saliency, and a 4-to-1 ratio of positive-to-negative re-
sponses to children's behaviors. The rationale and means
of implementing each of these elements of an effective
system of positive reinforcement is described. Finally, par-
ents are given homework assignments to devise a rein-
forcement program with their child, including specifying
target behaviors and reinforcers.
Session 4: Managing Time and Setting Goals
Session 4 focuses on educating and training parents in
the concepts of managing time and setting goals, inter-
ventions that have clear empirical support for improving
homework productivity (Kahle & Kelley, 1994; Miller &
Kelley, 1991; Olympia, Sheridan, Jenson, & Andrews,
1994). Specifically, a rationale and strategy for establish-
ing manageable goals for completion and accuracy are
presented. Clinicians describe and model a series of steps
that include dividing homework into subunits, setting
time limits, and establishing goals for completion and ac-
curacy of each subunit, The goal-setting intervention
(Power et al., 2001) includes an evaluation of homework
performance by the child and parents to determine
whether the goals are met. The child receives reinforcers
for meeting goals. Parents are instructed to practice
using this Goal-Setting Tool (GST) on a daily basis.
Session 5: Using Negative Consequences
The use of negative consequences is intentionally not
introduced until Session 5, thus underscoring the impor-
tance of a primarily positive approach to behavior
change. Another reason for delaying the introduction of
strategies for negative consequences until the fifth ses-
sion is that at the outset of the program parents typically
report excessive use of punishment and infrequent use of
positive reinforcement. The main goal of Session 5 is to
teach parents to use negative consequences strategically in
order to reduce intolerable behaviors. Throughout the
discussion of negative consequences, there is a clear em-
phasis on the C.I.S.S.-4 principles, particularly the main-
tenance of a 4-to-1 ratio of positive-to-negative parent re-
sponses. In addition to these general guidelines, various
forms of negative consequences, including verbal cor-
rection, response-cost, and time-out, as well as specific
steps regarding when and how to use negative conse-
quences, are presented to participants. It is emphasized
that time-out be used sparingly, given the potential for

7. Homework Program for ADHD 129
this technique to serve as a means for children to avoid
homework demands.
Session 6: Integrating Skills and Anticipating
Future Problems
The purpose of Session 6 is to provide a review of the
principles and techniques presented in the previous five
sessions, as well as to assist parents in troubleshooting
potential difficulties in applying these strategies. Parents
are encouraged to acknowledge their successes, as well
as to develop a plan to address potential barriers to ef-
fective homework performance in the future. A review
sheet is provided that includes the major principles of
the program.
Session 7: Booster Session
Session 7 serves as the follow-up, or booster session,
and thus should occur 4 to 6 weeks after Session 6. Dur-
ing this session, parents are encouraged to discuss their
successes and problems in implementing the techniques
introduced in the previous six sessions. Also, parents re-
ceive assistance in troubleshooting partic-
ular problems that have arisen. Further,
therapists focus on parents' successes with
implementing the program's techniques,
as well as on children's homework perfor-
Content:
mance gains. Such support encourages pa-
rental efforts and models the importance
of positive reinforcement. Parents are pro-
vided with a handout of additional re-
sources, such as reading materials and sup-
port/educational organizations, as well as
information to obtain further assistance
with issues that are not the primary focus
of the HSP, such as evaluation and inter-
vention for specific learning problems. In
addition, each participant receives a certif-
icate that acknowledges their completion
of the group. Finally, parents are asked to
complete an evaluation form, which pro-
vides valuable feedback to group leaders
regarding the efficacy and acceptability of
the HSP.
Monitoring Treatment Integrity
The success of the HSP is contingent
upon a clinician's adherence to interven-
tion procedures. Thus, it is important to
ensure that major components of this pro-
gram are followed. Integrity checklists for
each session have been developed to assist
with the monitoring of treatment integrity.
Each checklist includes items pertaining
Process:
to the content and process of sessions, as well as items re-
ferring to activities that are to occur between sessions,
such as telephone contact with teachers or parents (see
Table 3 for an example).
The content sections of the integrity checklists specifi-
cally outline each step of the session to ensure that all of the
necessary material is covered. The process section of
these checklists is designed to ensure inclusion of the
empirically supported core elements of group therapy
process (Schoenholts-Read, 1994), such as enlisting par-
ticipation- of all group members and therapists' respon-
siveness to participants' concerns.
Evaluating Intervention Outcome
Parent-, child-, and teacher-completed questionnaires
are used to examine the effectiveness of the HSP in meet-
ing targeted goals. It is expected that the HSP will have
positive effects on various elements of parent, child, and
family functioning, including (a) parent and child knowl-
edge of the concepts and skills taught in the HSP; (b)
Table 3
Sample Integrity Checklist (Session 1)
Distribute name tags and folder with handouts for session
Participants complete baseline measures
Group leader(s) and participants introduce themselves
Participants state major concerns and group leader writes these concerns on board
ReviewHandout #1: "Welcome to the HSP"
_ _ Discuss goals of group
Provide outline of format for sessions
_ _ Discuss confidentiality issues
_ _ Provide overview of basic requirements of group
_ _ Describe modified conjoint consultation model
_ _ Emphasize importance of completion of between-session homework
assignments
Distribute and discuss Handout #2: "Weekly Family Assignments Sheet"
Discuss issues pertaining to promoting hope and optimism
Distribute and discuss Handout #3: "ADHD: Basic Facts"
Distribute and discuss Handout #4: "Some WaysADHD Is Related to Homework
Problems" (refer to parents' concerns that are written on the board)
Discuss rationale and techniques for limiting time spent on homework
Distribute Handout #5 and discuss introducing time limits on homework with
teachers
Elicit parental feedback regarding material introduced thus far
Assign homework
Reviewand distribute Handout #6: Homework Assignment Sheet, which is
to be completed and signed daily by teacher
Meet with teacher
_ _ Talk with child about feelings around homework
Did each family participate in group discussion?
Did each parent within a family participate in group discussion?
Did each family discuss homework assigned for the previous week?
Was group leader responsive to each family's needs this week?

8. 130 Habboushe et al.
children's homework accuracy, productivity, and effi-
ciency; (c) children's academic functioning; (d) symp-
toms related to ADHD; (e) the parent-child relationship
and interactions; (f) parent functioning; and (g) parent
and child self-efficacy and well-being. In addition, it is im-
portant to evaluate the social validity of the program and
to solicit feedback about ways to improve the program
(Kazdin, 1980; Riemers, Wacker, & Koeppl, 1987). The
following sections describe the dimensions of function-
ing that are important to evaluate, the rationale for mon-
itoring and evaluating each dimension, and the expected
outcomes for each of these variables. Table 4 includes
suggested measures with which to evaluate progress and
outcomes in these areas of functioning. The current im-
plementation of the HSP entails conducting evaluations
before Session 1 (pretreatment), after Session 3 (mid-
treatment), after Session 6 (posttreatment), and at Ses-
sion 7 (follow-up).
Academic Functioning
The primary outcome variable for the HSP is home-
work performance. Based on the research noted above
Table 4
Suggested Progress Monitoringand Outcome Measures
1. Ratings of academic performance
a. Academic Performance Rating Scale (DuPaul et al., 1991)
b. Homework Problems Checklist (Aneskoet al., 1987)
c. Homework Performance Questionnaire (Power,Karustis,
Mercugliano, &Blum, 1998)
d. Dailyhomework logs of percentages of completed and
accurate work
e. Goal-SettingTool (GST;Power,Karustis,& Habboushe,
200l)
2. ADHDsymptomsand other behavior variables
a. ADHDRating Scale-lN
~(DuPaul et al., 1998)
b. Conners Parent Rating Scale- Revised (Conners, 1997)
c. Child Behavior Checklist (Achenbach, 1991)
d. BehavioralAssessmentSystemfor Children (Reynolds&
Kamphaus, 1994)
e. Antecedent-behavior-consequence (A-B-C)logs
3. Parentingstress and familyfunctioning
a. The IssuesChecklist (Robin &Foster, 1989)
b. Home Situations Questionnaire (Barkley&Edelbrock,
1987)
c. Conflict Behavior Questionnaire (Robin &Foster, 1989)
d. The ParentingStressIndex (Abidin, 1995)
f. ParentingSense of Self-Competence Scale (Johnston &
Ma.sh, 1989)
4. Treatment acceptabilityand knowledge
a. Treatment Evaluation Inventory,- Short Form (Kellyet al.,
1989)
b. Children's InterventionRating Profile (Witt&Elliott,
1985)
c. Treatment Evaluation Inventor), (Kazdin, 1980)
d. ADHDKnowledgeand Opinion Scale (Bennett et al.,
1996)
supporting many aspects of the HSP, it is anticipated that
the HSP will lead to significant improvements in home-
work performance. Specifically, the core components of
this program, including developing a homework ritual,
limiting time spent on homework, structuring homework
time, goal setting, and modifying the consequences for
productive and unproductive homework, are all expected
to have a significant impact on homework accuracy, com-
pletion, and efficiency. In addition to the effects of the
HSP on homework performance, it is hypothesized that
the HSP will have positive effects on academic perfor-
mance in the school setting.
The effects of this program on homework problems
and overall academic performance are evaluated through
measures such as the Homework Problems Checklist
(HPC; Anesko et al., 1987), the Academic Performance
Rating Scale (APRS; DuPaul, Rapport, & Perriello, 1991),
homework logs (Kahle and Kelley, 1994; Miller & Kelley,
1991), and the Goal Setting Tool (GST; Power et al.,
2001). The HPC is a measure that assesses parent percep-
tions of their child's problems with the organization, ini-
tiation, completion, and accuracy of homework. The
APRS is a teacher-completed scale that assesses the accu-
racy and completion of classwork for major academic
subjects. Homework logs provide daily parent ratings of
homework accuracy and completion for each assigned
subject. Rates of hoxnework completion can have a ceil-
ing effect with some children in that it is not uncommon
for students to have high rates of work completion at the
outset of treatment. Nonetheless, for some children,
rates of work completion are relatively low and need to
be improved, and for other children it is important to en-
sure that rates of work completion are being maintained
during the course of the intervention and follow-up
phases. Additionally, the use of the GST, which allows par-
ents and children to evaluate the child's homework per-
formance based on completion and accuracy rates for
each assigned subject, is also a means of obtaining valu-
able outcome assessment data.
ADHD Symptoms and Other Behavioral Variables
It is expected that the HSP will have a significant im-
pact on ADHD-related behaviors, as has been found with
other behaviorally oriented parent-training programs
(Barkley, 1998; Erhardt & Baker, 1990). Specifically, the
emphasis on organization, appropriate goal-setting, and
positive reinforcement principles is directly relevant to
these expected outcomes. Because the diagnosis of ADHD
involves functional impairment in multiple settings, in or-
der to evaluate progress and outcome, it is important to
obtain repeated measures from multiple sources, such as
teachers and parents.
Table 4 includes a number of measures of ADHD
symptoms (e.g., ADHD Rating Scale-IV; DuPaul, Power,

9. Homework Program for ADHD 131
Anastopoulos, & Reid, 1998), as well as broad-band be-
havioral measures (e.g., Child Behavior Checklist; Achen-
bach, 1991) that can be used to assess changes in symp-
toms over time.
Familyfunctioning. The HSP is designed to improve
family functioning by decreasing parent-child conflict,
reducing parenting stress, and elevating perceptions of
parenting competence. Research has found that parents
of children with ADHD tend to experience more family
conflict (Barkley, Fischer, Edelbrock, & Smallish, 1991)
and negative interactions with their child (Johnston,
1996) than do families that do not include children with
ADHD. ADHD is also related to family strain, increased
parenting stress (Anastopoulos, Guevremont, Shelton, &
DuPaul, 1992), and a lowered perception of parenting
competence (Mash & Johnston, 1983). In addition, re-
search in the general population has identified a connec-
tion between homework problems and increased parent-
child conflict (Anesko & O'Leary, 1982; Anesko et al.,
1987; Kuhlman, 1973).
Several rating forms and questionnaires are available to
assess parent-child conflict, parenting stress, and parenting
competence (see Table 4). In an effort to empirically val-
idate the program, clinicians are currently using The
Conflict Behavior Questionnaire-Parent and Adolescent
Version (CBQ; Robin & Foster, 1989) and the Parenting
Stress Index (PSI; Abidin, 1995). The parent and child
forms of the CBQ assess perceived communication and
conflict between parents and their children. The PSI as-
sesses stress related to the parent-child relationship as ex-
perienced by parents. Separate subscale scores may be
calculated in order to assess stress related to child charac-
teristics, parent characteristics, and overall life stress. Fur-
ther, the A-B-C logs that are introduced during the pro-
gram, which are to be used regularly as an intervention
tool, are also useful to assess both behaviors and the envi-
ronmental factors that can influence the initiation and
maintenance of ADHD symptoms, problematic behav-
iors, and conflictual parent-child interactions during
homework time.
Intervention Acceptability
Another important aspect of program evaluation is
the assessment of program acceptability. It is important
that the clinician be aware of the degree of participants'
acceptability and satisfaction with the HSP principles and
procedures introduced during the program in order to
better attend to each family's progress and needs in
learning and implementing these methods. Reimers and
colleagues (1987) noted that assessing acceptability may
be useful in designing interventions that will be imple-
mented with high levels of integrity.
The current implementation of the HSP includes as-
sessing treatment acceptability using the parent-rated
Treatment Evaluation Inventory-Short Form (TEI-SF;
Kelly, Heffer, Gresham, & Elliott, 1989) and a modified
version of the Children's Intervention Rating Profile
(CIRP; Witt & Elliot, 1985) that is completed by children.
Both of these measures are administered after the third,
sixth, and seventh sessions. As mentioned above, prelimi-
nary analyses have found that the majority of the partici-
pating families have endorsed the acceptability of the HSE
Case Illustrations
The remainder of this paper will present case illustra-
tions from one group of children that has participated in
the HSE This group was selected as a case example from
numerous others that exhibited similar outcomes within
a larger treatment outcome study that is being conducted
to assess the effectiveness of this
program. This case will help to
illustrate the means by which
this program is currently being
validated and the range of out-
comes that have been observed.
Five families with children
who were diagnosed with ADHD
(four diagnosed with ADHD,
Combined Type; one diag-
nosed with ADHD, Inattentive
Type) and had significant home-
work difficulties were recruited
from the ADHD/School Prob-
lems Program of a pediatric
hospital located in a large met-
ropolitan area. Of these chil-
dren, one child was also diag-
The HSP parent
training protocol
involves providing
education
regarding ADHD
and homework, as
well as antecedent
and consequent
interventions
specifically related
to homework.
nosed with a comorbid depressive disorder, and two
other children were diagnosed with both oppositional-
defiant disorder (ODD) and an anxiety disorder. These
diagnoses were being addressed through other means of
intervention. The clinical team determined that the pres-
ence of these additional problems did not serve as an im-
pediment to the family's ability to benefit from this pro-
gram. M1 children were enrolled in grades 2 through 6
(M age = 10 years, 3 months) and were of average or
above average intelligence (M IQ = 110.4, SD = 14.5;
range -- 91 to 126), as assessed by the Wechsler Intelli-
gence Scale for Children-Third Edition (WISC-III;
Wechsler, 1991). Two of the five children were taking psy-
chostimulant medication prior to and throughout the
program. Four families were Caucasian and one family
was African American. All families were of middle- to
upper-middle socioeconomic status (SES) as determined
by the Hollingshead Four-Factor Index of Social Status
(Hollingshead, 1975).
After the families were enrolled in the program and l

10. ! 3Z Habboushe et al.
week prior to Session 1, parents were sent a packet of
questionnaires consisting of the PSI, the CBQ, the HPC,
and homework logs. If two parents lived at home, the par-
ent who reported spending the most time with the child
during homework was asked to complete the question-
naires. The mother completed the questionnaires in four
cases, and the father completed questionnaires in one
case. M1 parents signed statements of informed consent.
In addition, the APRS was sent to the teacher to complete
prior to the first session. During Session 1, these ques-
tionnaires were collected from each family. Assent was
obtained from the children and the CBQwas also admin-
istered to the children during this session. Question-
naires (CBQ, HPC, PSI, APRS) were again completed at
Session 3 (midtreatment), Session 6 (posttreatment),
and Session 7 (4-week follow-up). During each session,
the previous week's homework logs were collected and
new logs were distributed.
The treatment acceptability measure, the TEI-SE was
completed by the parents at Session 3, Session 6, and Ses-
sion 7. During each session, the group leader followed an
integrity checklist that indicated the important compo-
nents of content and process of the intervention. In addi-
tion, each session was videotaped in order to evaluate
treatment integrity.
Each of the five families attended all seven sessions of
the HSP and demonstrated posttreatment gains in one or
more areas of academic and family functioning. Table 5
displays raw scores on measures of treatment effective-
ness. Specifically, there were clearly evident reductions in
homework-related problems as measured by the HPC.
The HPC total score ranges from 0 to 60 (M = 10.5, SD =
8.04), and higher scores are associated with a greater
number and severity of homework problems. Prior to
treatment, the mean total score on the HPC for the
group was 31.2 (two standard deviations above the mean
for children of this age). At posttreatment, the group's
mean total score on the HPC decreased to 15.6 (less than
one standard deviation above the general population
mean), indicating that parents perceived fewer home-
work-related problems. The improvement in homework
completion rates was relatively small, primarily due to the
fact that pretreatment levels of completion were gener-
ally high. Homework completion rates at the outset of
treatment are often quite high, perhaps because it is so
important for parents to make sure that the work is being
completed. Thus, it is often more interesting and impor-
tant to examine changes in rates of work accuracy and
time spent doing homework. In terms of accuracy levels
for this group, the mean percentage of homework that
Table 5
Pretreatment and Posttreatment Raw Scores on Measures of Academic
and Family Functioning
CBQ
HPCa Parentb
APRS-
PSI-Total Academic Average % Average % Treatment
Stress Productivity Homework Homework Evaluation
Scorec Subscalea Completed Accurate Inventory~
Child A
pre 38 8 273
post 8 2 245
Child B
pre 27 5 195
post 19 1 206
Child C
pre 19 9 263
post 15 11 281
Child D
pre 35 9 244
post 18 10 231
Child E
pre 37 14 245
post 18 13 265
27 100 85.5 35
31 100 97.2 32
23 81 86 37
25 100 82.3 33
* 94 37.5 33
* 94 84.5 33
24 100 78.6 35
27 100 86.7 35
27 ** ** 33
29 ** ** 34
* Child was home-schooled, and therefore teacher data were not available.
** Missing data.
Scores range from 0 to 60; M = 10.5; SD = 8.04.
b Scores range from 0 to 20; M = 2.4; SD = 2.8.
c Scores range from 101 to 505; means vary by child's age.
d Scores range from 9 to 45; means vary by grade level.
e Scores range from 9 to 45, moderate acceptability = 27.

11. Homework Program for ADHD 133
was done correctly increased from pretreatment (M =
71.9%) to posttreatment (M = 87.67%). Teacher-reported
academic performance as measured by the APRS also im-
proved slightly for the group. On the APRS, subscale
scores range from 9 to 45, with higher scores indicating
greater academic performance. Prior to treatment the
mean academic performance subscale score for the group
was 25.3 and at posttreatment the mean score was 28.
There were no overall group reductions in negative
communication between parent and child and stress re-
lated to parenting as measured by the CBQ-P and the PSI,
respectively. Treatment acceptability was assessed using
the TEI-SE Total scores range from 9 to 45, with higher
scores associated with greater acceptability (a score of 27
indicates moderate acceptability). The group mean at
midtreatment (M = 34.6) and posttreatment (M = 33.4)
demonstrated that throughout the course of the treat-
ment, parents found the HSP to be highly acceptable. To
further illustrate the methods being used to validate the
HPC and the findings that are emerging, two case examples,
which appear to be representative of the larger group of
subjects who have similar outcomes, are presented.
Case of Alison
Alison, a female enrolled in the 3rd grade (8 years, 7
months) attended all seven sessions with her parents.
Alison was diagnosed with ADHD, Combined Type, ODD
and mood disorder NOS, and was taking stimulant medi-
cation prior to, as well as throughout, the program. Ali-
son was a child who had difficulty completing work at
home and at school, frequently made careless mistakes,
and was very argumentative.
At pretreatment, Alison demonstrated significant
homework problems, resulting in a total score of 38 on
the HPC as reported by her mother (3.5 standard devia-
tions above the general population mean). At posttreat-
ment, she displayed a normalization of homework prob-
lems (i.e., a total score less than one standard deviation
above the mean of the HPC). Alison demonstrated slight
improvement in academic performance while participat-
ing in the program. At pretreatment, she obtained an ac-
ademic performance score one standard deviation below
the mean for girls in third grade (M = 35.9, SD = 7.3);
and at posttreatment, teacher-rated academic perfor-
mance mildly improved as indicated by a score that was
less than one standard deviation below the grade and
gender mean. Alison displayed an improvement in the
percentage of homework completed accurately, from 86%
to 97%.
Alison's mother reported a moderate level of negative
communication and parent-child conflict at pretreat-
ment (two standard deviations above the mean of nondis-
tressed families; M = 2.4, SD = 2.8). By posttreatment,
Alison's mother reported essentially no parent-child con-
flict. Stress related to parenting also decreased over the
course of treatment. The Total Stress Score of Alison's
mother decreased from the 85th percentile to the 75th
percentile from pretreatment to posttreatment.
Case of Bernard
Bernard, a male enrolled in 5th grade (11 years, 3
months), attended all seven sessions with his parents.
Bernard was diagnosed with
ADHD, Inattentive Type, and
was not taking stimulant medi-
cation throughout the pro-
gram. Bernard was a child who
had particular difficulty in ac-
curately completing language
arts assignments and was fre-
quently argumentative around
doing his work.
At pretreatment, Bernard
demonstrated a score of 27 on
the HPC as reported by his
mother (two standard devia-
tions above the general popu-
lation mean). At posttreatment
he displayed a normalization of
homework problems (i.e., a to-
tal score less than one standard
The HSP is
designed to
improve family
functioning by
decreasing parent-
child conflict,
reducing
parenting stress,
and elevating
perceptions of
parenting
competence.
deviation above the mean of the HPC). Bernard also
demonstrated slightly improved academic performance
while participating in the program. At pretreatment, he
obtained an academic performance score one standard
deviation below the mean for boys in 5th grade (M =
32.1, SD = 9.8); and at posttreatment, teacher-rated aca-
demic performance slightly improved as indicated by a
score that is less than one standard deviation below the
grade and gender mean. Although accuracy of Bernard's
work did not improve, he displayed an improvement in
the percentage of homework completed.
Bernard's mother reported a moderate level of par-
ent-child conflict at pretreatment (one standard devia-
tion above the mean for nondistressed families; M = 2.4,
SD = 2.8). By posttreatment, Bernard's mother reported
essentially no parent-child conflict. Stress related to
parenting did not decrease over the course of treatment.
Conclusions and Future Directions
The HSP is a comprehensive group intervention pro-
gram that addresses homework performance, an impor-
tant domain of functioning that is often overlooked in
children who have ADHD. The HSP includes behavioral
interventions that have been demonstrated to be the
most effective with children who have homework prob-

12. 134 Habboushe et al.
The next step is to
conduct the HSP
in schools with
community
partners as
co-facilitators.
lems. Thus, it is expected that the HSP will provide bene-
fits to children with ADHD, as well as to their parents and
teachers. Benefits of this program may include a reduc-
tion in parent-reported homework problems, an im-
provement in homework completion and accuracy rates,
and, in some cases, a reduction in parent-child conflict.
As indicated above, the efficacy of comprehensive
homework intervention programs for children with
ADHD have not been empirically validated (Rhoades &
Kratochwill, 1998; Weiner et al., 1998). Case examples to
illustrate the implementation and typical outcomes of
the HSP have been included in this article, but carefully
designed single-subject and group design research is
needed to evaluate the effectiveness of this program for
children with ADHD and their
families. Currently, we are con-
ducting a group design study
to comprehensively evaluate
the effects of this program on
homework performance and
family flmctioning. In investi-
gating the effectiveness of the
HSP, it is suggested that target
variables should include mea-
sures of homework comple-
tion and accuracy, parent and teacher perceptions of ac-
ademic progress, and child and parent self-efficacy, as
well as family and home-school relationships. It is sug-
gested that multiple outcome measures be included and
that information from multiple sources be obtained,
given the limitations inherent in each measure and
source of data. For example, the use of parent-reported
homework accuracy rates may not be precise due to in-
consistencies in submitting this data and inaccuracy of
the parents' reports. Thus, it is important to ensure reli-
ability by using other measures of this variable, such as
teacher-reported levels of accuracy. In addition, accept-
ability of treatment and cost-effectiveness of the program
are important to assess to provide further support for the
utility of this program. Further, it is important to examine
the effects of such a program on individuals who present
with various stressors, such as low SES, single parent-
hood, or parental psychopathology.
As noted, to date, the HSP has been conducted in
clinic settings. The next step in the development of the
program is to expand the range of settings in which it is
used, with particular emphasis on implementation in
school settings. Conducting the HSP in schools is consis-
tent with a national trend toward full-service schools, de-
signed to make health and mental health services more
accessible to families and to reduce treatment costs
(Crump & Eltis, 1996; Nastasi, Varjas, Bernstein, &
Pluymert, 1998; Power, DuPaul, Shapiro, & Parrish,
1995). This trend is largely based on findings that the ma-
jority of children with behavioral problems do not
present for treatment at clinical settings (Nastasi, Varjas,
& Bernstein, 1997). In addition, using a school-based
program would facilitate parent-teacher collaboration by
having parents on-site and in a position to readily com-
municate directly with teachers.
Psychologists, counselors, and social workers are in a
particularly advantageous position to coordinate and
lead the program, given their training in behavior
change strategies and group process. A treatment man-
ual, parent handouts, and integrity checklists have been
designed to facilitate the training of such personnel
(Power et al., 2001). In many cases clinicians may be lim-
ited in their ability to provide this service to families in a
community-responsive and culturally sensitive manner,
particularly when therapists do not know the community
well or do not have the credibility that comes with being
parents themselves. Thus, we recommend that clinicians
partner with community residents to cofacilitate the HSE
Community partners can be very helpful in eliciting par-
ent participation, supporting parents, and providing
practical models with which parents can easily identify.
One of the areas in which the HSP is continuing to
evolve is in the development of a structured child group.
Given our clinical impressions of the utility of this child
group and recent research demonstrating superior ef-
fects of behavioral interventions that combined parent
and child training components (Frankel et al., 1997;
Webster-Stratten & Hammond, 1997), it will be impor-
tant that future research on the HSP directly evaluate the
efficacy of the combined parent and child training
groups versus the parent training group alone.
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Address correspondence to ThomasJ. Powm; Department of Pediatric
Psychology, Children's Seashore House of the Children's Hospital of
Philadelphia, 3405 Civic Center Blvd., Philadelphia, PA 19104-4388;
e-mail: power@email.chop.edu.
Received: August 28, 1999
Accepted: I,?bruary5, 2000