Improvements in negative parenting mediate changes in children's autonomic responding following a preschool intervention for ADHD

Abstract

Abnormal patterns of sympathetic- and parasympathetic- linked cardiac activity and reactivity are observed among externalizing children, and mark deficiencies in central nervous system regulation of behavior and emotion. Although changes in these biomarkers have been observed following treatment, mechanisms remain unexplored. We used MEMORE—a new approach to analyzing intervening variable effects—to evaluate improvements in parenting as mediators of changes in SNS- and PNS-linked cardiac activity and reactivity among 99 preschoolers with attention-deficit hyperactivity disorder who were treated using an empirically supported intervention. Decreases in negative parenting (criticism, negative commands, physical intrusions) were associated with increases in resting RSA and PEP reactivity to incentives from pre- to post-intervention. Increases in positive parenting were not associated with changes in autonomic function. These findings suggest socially-induced plasticity in peripheral biomarkers of behavior and emotion regulation, and underscore the importance of reducing aversive interactions between parents and children when treating externalizing behavior.

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https://doi.org/10.1177/2167702617727559
Clinical Psychological Science
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DOI: 10.1177/2167702617727559
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Empirical Article
Over the past 40 years, extensive research has eluci-
dated socialization mechanisms through which
emotional lability and emotion dysregulation are shaped
and maintained in families of children with externalizing
behavior disorders (Patterson, DeGarmo, & Knutson,
2000; Snyder, 1977; Snyder, Edwards, McGraw, Kilgore,
& Holton, 1994). In many such families, dyad members
escalate conflict because doing so effectively terminates
aversive interactions. Such coercive exchanges occur
thousands of times across development and negatively
reinforce conflict escalation and associated emotional
liability, since escape from highly aversive interactions
provides relief (Beauchaine & Zalewski, 2016; Snyder,
Schrepferman, & St. Peter, 1997).
Historically, research on family dynamics has been
conducted at the behavioral level of analysis through
painstaking coding of dyadic interactions. This research
demonstrates that operant reinforcement is at play in
the development of coercive relationships (Snyder,
1977; Snyder etal., 1994). More recent findings suggest
that negative reinforcement of emotional lability also
shapes and maintains patterns of physiological activity
and reactivity that often characterize individuals with
impulse control and emotion dysregulation problems
(see Beauchaine, 2015a; Beauchaine, Gatzke-Kopp, &
Mead, 2007; Beauchaine & Zalewski, 2016; Crowell
etal., 2017).
727559CPXXXX10.1177/2167702617727559Bell et al.Effects of Parenting on Children’s Autonomic Function
research-article2017
Corresponding Author:
Theodore P. Beauchaine, Department of Psychology, The Ohio State
University, 1835 Neil Avenue, Columbus, OH 43210
E-mail: beauchaine.1@osu.edu
Improvements in Negative Parenting
Mediate Changes in Children’s Autonomic
Responding Following a Preschool
Intervention for ADHD
Ziv Bell1, Tiffany Shader1, Carolyn Webster-Stratton2,
M. Jamila Reid3, and Theodore P. Beauchaine1
1The Ohio State University; 2University of Washington; and 3Incredible Years, Seattle, Washington
Abstract
Abnormal patterns of sympathetic- and parasympathetic-linked cardiac activity and reactivity are observed among
externalizing children and mark deficiencies in central nervous system regulation of behavior and emotion. Although
changes in these biomarkers have been observed following treatment, mechanisms remain unexplored. We used
MEMORE—a new approach to analyzing intervening variable effects—to evaluate improvements in parenting as
mediators of changes in sympathetic nervous system (SNS)- and parasympathetic nervous system (PNS)-linked cardiac
activity and reactivity among 99 preschoolers with attention-deficit hyperactivity disorder who were treated using
an empirically supported intervention. Decreases in negative parenting (criticism, negative commands, physical
intrusions) were associated with increases in resting respiratory sinus arrhythmia (RSA) and pre-ejection period (PEP)
reactivity to incentives from pre- to postintervention. Increases in positive parenting were not associated with changes
in autonomic function. These findings suggest socially induced plasticity in peripheral biomarkers of behavior and
emotion regulation and underscore the importance of reducing aversive interactions between parents and children
when treating externalizing behavior.
Keywords
RSA, HRV, PEP, ADHD, externalizing, parenting, intervention, mediation
Received 1/27/17; Revision accepted 7/13/17

2 Bell et al.
Family Dynamics and Parasympathetic
Nervous System (PNS) Function
Respiratory sinus arrhythmia (RSA), defined by periodic
increases and decreases in heart rate across successive
respiratory cycles, is both a peripheral index of PNS
efference to the heart and a useful biomarker of emo-
tion regulation capabilities, given appropriate stimulus
conditions (see, e.g., Beauchaine, 2001, 2015a, 2015b;
Beauchaine & Thayer, 2015; Porges, 2007). As reviewed
elsewhere (e.g., Shader et al., in press; Zisner &
Beauchaine, 2016), a large literature demonstrates asso-
ciations between RSA reactivity and emotion regulation
specifically during emotion evocation tasks but not dur-
ing tasks that assess other abilities such as attention
allocation.
Children, adolescents, and adults who experience
problems with emotion dysregulation often exhibit low
resting RSA and/or excessive RSA reactivity (PNS with-
drawal) to emotionally evocative stimuli (see
Beauchaine, 2015a, 2015b; Beauchaine & Thayer, 2015;
Crowell etal., 2005). Perhaps unsurprisingly given that
emotion dysregulation is a hallmark of externalizing
psychopathology, low resting RSA and excessive RSA
reactivity are also observed among children and ado-
lescents with conduct problems, delinquency, and asso-
ciated mental health conditions (e.g., Beauchaine,
Katkin, Strassberg, & Snarr, 2001, Beauchaine etal,
2007, 2013; de Wied, van Boxtel, Matthys, & Meeus,
2012). Such deficiencies in PNS-linked cardiac function
among children with externalizing behavior problems
are observed as early as the preschool years (Crowell
etal., 2006) and predict responses to empirically sup-
ported interventions (Beauchaine etal., 2013). Accord-
ing to contemporary transactional models, emotion
dysregulation and its physiological substrates are
shaped and maintained among children at least in part
through negative reinforcement mechanisms, as out-
lined above (Beauchaine etal., 2007; Beauchaine &
Zalewski, 2016). This assertion is supported empirically
among families of children with multiple adjustment
problems (e.g., Crowell etal., 2013, 2014, 2017; Skowron
etal., 2011).
Externalizing Psychopathology and
Sympathetic Nervous System (SNS)
Function
From preschool to adolescence, children with external-
izing disorders also demonstrate compromised SNS-
linked cardiac activity and reactivity (Beauchaine etal.,
2001, 2013, 2015; Crowell etal., 2006). Cardiac pre-
ejection period (PEP), quantified by the time between
left ventricular depolarization and ejection of blood into
the aorta, marks SNS reactivity via β-adrenergic mecha-
nisms (Sherwood etal., 1990). In a series of papers, we
have argued that PEP nonreactivity to monetary incen-
tives marks central nervous system reward dysfunction,
which confers vulnerability to a range of externalizing
disorders (e.g., Beauchaine etal., 2013). Consistent with
this perspective, lengthened PEP at rest and reduced
PEP reactivity to incentives are observed among
children with ADHD and children with conduct disor-
der and predict early initiation of alcohol and substance
use (Beauchaine et al., 2001, 2013; Brenner &
Beauchaine, 2011; Crowell etal., 2006). Moreover, defi-
ciencies in PEP and RSA interact to predict especially
poor outcomes among children with externalizing
behavior problems (see Beauchaine etal., 2007; Pang
& Beauchaine, 2013).
Transactional models of externalizing behavior sug-
gest that for some, neurobiological vulnerabilities inter-
act with environmental risk to promote increasingly
intractable comportment outcomes across development
(see Beauchaine & McNulty, 2013; Beauchaine, Zisner,
& Sauder, 2017). Impulsive children, many of whom
exhibit the autonomic characteristics described above,
may be particularly vulnerable to developing severe
externalizing behavior when exposed to environmental
adversity, including coercive family processes. In this
article, we evaluate (1) whether deficiencies in SNS-
and PNS-linked cardiac activity/reactivity improve dur-
ing treatment for externalizing behavior and (2) whether
any such improvement is mediated by changes in par-
enting. Such findings would be consistent with research
outlined above suggesting that parenting—specifically
negative reinforcement of emotional lability—shapes
and maintains children’s physiological response pat-
terns (Beauchaine & Zalewski, 2016; Beauchaine etal.,
2007; Crowell etal., 2017). Although the notion that
short-term interventions might alter children’s psycho-
physiological function may seem implausible, such
effects on other psychophysiological measures, includ-
ing electrodermal responding, have been observed
(e.g., Beauchaine etal., 2015; Raine etal., 2001).
Treating Externalizing Behaviors
Empirically supported psychosocial treatments for
externalizing behaviors almost invariably include com-
ponents that target coercive parenting (see, e.g., Eyberg,
Nelson, & Boggs, 2008; Pelham & Fabiano, 2008). The
Incredible Years® (IY) intervention is a well-established
treatment for conduct problems among children ages
4 to 12 years (see Beauchaine, Webster-Stratton, & Reid,
2005; Webster-Stratton, 2015). The program includes
parent, child, and teacher components. Parents meet in
small-group sessions, during which trained therapists

Effects of Parenting on Children’s Autonomic Function 3
discuss adaptive responses to children’s impulsive and
dysregulated behaviors. Parents also watch vignettes of
behaviors that are typical of children with externalizing
psychopathology and learn to issue clear, age-
appropriate commands, avoid conflict escalation, and
positively reinforce socially competent behaviors and
emotion regulation. Child components include struc-
tured and unstructured group activities with trained
therapists who teach anger management, emotional
awareness, emotion regulation, and appropriate social
behaviors. Together, parent and child components
decrease coercion within families, teach prosocial
skills to children, reduce conduct problems, and
improve emotion regulation (Webster-Stratton, Reid, &
Beauchaine, 2011). A randomized, waitlist control trial
of IY conducted by our research group among pre-
school children produced pre-post treatment improve-
ments in child externalizing behavior, child emotion
regulation, self-report parenting behaviors, and
observed positive parenting (Beauchaine etal., 2013;
Webster-Stratton etal., 2011; Webster-Stratton, Reid, &
Beauchaine, 2013). Reductions in negative parenting
during both home visits and lab sessions were also
observed. Moreover, treated children exhibited pre–
post improvements in electrodermal responding
(Beauchaine etal., 2015).
In this study, we evaluate changes in positive and
negative parenting as mediators of changes in SNS- and
PNS-linked cardiac activity and reactivity following
treatment for ADHD. Although few studies have
addressed such questions, Graziano, Bagner, Sheinkopf,
Vohr, and Lester (2012) found that improvements in
parenting following treatment for behavior problems
predicted changes in RSA reactivity among children
born prematurely. However, children in their study
were younger and had fewer behavior problems. More-
over, they did not assess changes in SNS-linked cardiac
reactivity.
Toward evaluating changes in parenting as mediators
of changes in children’s autonomic function, we apply
the well-established Kraemer, Wilson, Fairburn, and
Agras (2002) conceptual criteria for evaluating interven-
ing variable effects. We test these effects statistically
using MEMORE (Montoya & Hayes, 2016), a new
method that uses bootstrap confidence intervals to test
direct and indirect effects of mediation, as described in
further detail below.
Method
Participants
Data were collected as part of a randomized controlled
trial of the IY intervention (Webster-Stratton etal., 2011,
2013). Preschool-aged children (n = 99), ages 4 to 6
years (mean age = 5.36, SD = 0.92), with the hyperac-
tive/impulsive or combined subtypes of ADHD, based
on Diagnostic and Statistical Manual for Mental Disor-
ders (4th ed., text rev.; DSM-IV-TR; American Psychiatric
Association, 2000) criteria, were recruited. Participant
children were 76% male, and 22% identified as ethnic
minority, consistent with the Seattle population. The
inattentive subtype was excluded, since it is distinct
etiologically from the hyperactive/impulsive and com-
bined subtypes (Adams, Derefinko, Milich, & Fillmore,
2008; Fair etal., 2013) and does not portend progres-
sion to more severe externalizing behaviors in later
childhood and adulthood (e.g., Beauchaine, Ben-David,
& Sela, 2017; Diamond, 2005; Lee, Burns, Becker, &
Beauchaine, 2016).
Families were recruited through print advertisements
placed in local publications and posted at schools and
pediatricians’ offices. Parents were invited to complete
an initial phone interview if their child was ever diag-
nosed with ADHD. Trained research assistants com-
pleted phone interviews with 204 families and explained
study procedures and inclusion criteria. Parents of chil-
dren who still appeared to be eligible then completed
the attention problems subscale of the Child Behavior
Checklist (Achenbach & Edelbrock, 1991) and the
hyperactive/impulsive and combined ADHD scales of
the Child Symptom Inventory (CSI; Gadow & Sprafkin,
1997). Those who appeared to meet DSM-IV criteria for
ADHD on the CSI and scored at or above the 95th
percentile on the attention problems subscale of the
CBCL were invited to the lab for an interview using the
Diagnostic Interview Schedule for Children (DISC;
Shaffer, Fisher, Lucas, Mina, & Schwab-Stone, 2000).
Among 103 families who visited the lab, 99 had a child
with ADHD and were enrolled in the study.
Intervention
All study procedures were approved by the local insti-
tutional review board. Families were randomized to
immediate (n = 49) and delayed (waitlist control) inter-
vention (n = 50) groups. Children in the immediate
intervention participated with one or both parents in
twenty 2-hr weekly sessions beginning after pretreat-
ment assessment of behavioral and psychophysiological
measures in which parents and children met in separate
groups (see Webster-Stratton etal., 2011). As outlined
above, parents learned effective problem-solving, adap-
tive emotion regulation, positive parenting techniques,
and effective parenting responses to impulsive/
disruptive child behaviors, among other topics. Children
participated in the IY Dinosaur training program, in
which trained therapists taught and coached emotion

4 Bell et al.
regulation skills during structured and unstructured
activities. Therapists reinforced topics related to emo-
tional awareness, anger management, teamwork, and
problem-solving.
Families in the delayed intervention group started
treatment following postassessments of immediate
intervention participants, approximately 20 weeks after
pretreatment assessments. Parents in the delayed condi-
tion received 10 sessions of IY parenting groups—half
the dose of the immediate intervention condition. Chil-
dren in the delayed condition received an equivalent
dose of the IY Dinosaur program as those in the imme-
diate intervention (approximately 40 hr). In this study,
we combine participants into a single group for all
analyses. This was necessary to attain an adequate
sample size to address our main hypotheses, which
required tests of statistical interactions (see below).
Combining groups is justified in part given nonsignifi-
cant group differences on all but 10 of 136 parent and
child behavioral outcome measures (about the number
expected by chance; see Beauchaine etal., 2015). More
importantly, the average effect size of these 136 group
comparisons was quite small (d = 0.04).
Interventions were delivered by master’s- and doc-
toral-level therapists who were certified to lead IY
groups. Details about adherence and fidelity are
reported elsewhere (Webster-Stratton etal., 2011, 2013).
Pretreatment assessments for all participants (both the
immediate and delayed conditions) were completed
approximately 1 week after the diagnostic interviews,
prior to the start of IY for the immediate condition.
Posttreatment assessments were completed separately
at the end of treatment for each condition.
Laboratory tasks
Psychophysiological measures were collected during the
pretreatment assessment in 30-min laboratory sessions.
Children participated in a protocol that began with a
resting 5-min baseline in a noise-attenuated, distraction-
free room. To evaluate incentive responding, children
played a matching game to earn toy rewards, similar to
tasks previously used to assess responses to reward in
preschool children (Crowell etal., 2006). In this game,
they are presented with shapes (e.g., circles, squares,
triangles) on a computer screen and select matching
shapes on an age-appropriate keyboard. Correct
responses are paired with an image of a smiley face and
a tone, whereas incorrect responses are paired with a
blank screen and a different tone. Children are told that
if they collect enough smiley faces, they can choose
from a container of toys, all worth about $10. Following
the task, children are allowed to keep a toy for “trying
hard,” regardless of their performance.
Next, children and their parent (mothers in all but
one case) engaged in 7 min of free play, followed by
a 2-min rest period, then a frustrating block building
task. During the task, children were tethered to psy-
chophysiological recording equipment and sat within
a small marked area on the floor to reduce movement-
related artifacts. Parents were instructed to retrieve and
dump a container of large foam blocks on the floor.
Without touching the blocks, parents coached their
children to build progressively complex structures
based on figures given to the parent. The task is difficult
for 4 to 6-year-olds and is frustrating for both parents
and children, as assessed by observations of dyadic
conflict and expressions of negative affect (Beauchaine,
Strassberg, Kees, & Drabick, 2002).
Psychophysiological measures
RSA. High-frequency spectral densities were calculated
via fast Fourier transformation of R-R time series in
Kubios 2.2 (Tarvainen, Niskanen, Lipponen, Ranta-Aho,
& Karjalainen, 2014). Electrocardiographic (ECG) signals
were sampled at 1 kHz by an HIC 2004 impedance car-
diograph, using a spot electrode configuration (Qu,
Zhang, Webster, & Tompkins, 1986). Accurate assess-
ment of RSA requires appropriate specification of respira-
tory frequencies (Ritz, 2009; Shader etal., 2017), which
vary considerably by age (see Zisner & Beauchaine,
2016). We therefore used FFT windows that were adjusted
for ages of participants, based on published population
values (Fleming et al., 2011; Wallis, Healy, Undy, &
Maconochie, 2005). FFT windows were set to 0.33 to 0.50
Hz for 4-year-olds, 0.32 to 0.50 Hz for 5-year-olds, and
0.30 to 0.50 Hz for 6-year-olds. Of note, negligible
respiratory-linked spectral power is observed above 0.50
Hz, regardless of age (see Shader etal., 2017). Resting
RSA was calculated across the final 1 minute of the initial
5-minute baseline, whereas RSA reactivity to emotion
evocation was calculated by subtracting resting RSA col-
lected during the 2-minute baseline immediately before
the block task from RSA collected during block building.
Thus, as is customary in psychophysiological research,
negative scores indicate RSA withdrawal (reduced PNS
activity).
PEP. The HIC 2004 impedance cardiograph was used to
collect both ECG and impedancecardiographic (ICG)
waveforms. Cardiac data were segmented into 30-second
epochs using Bio-Impedance Technology CopWin soft-
ware, version 5.06 (Bio-Impedance Technology, Inc., 2001).
PEP values were ensemble-averaged in 30-second epochs
by trained research assistants, who inspected all data visu-
ally to ensure proper placement of the dZ/dt B-wave. Reac-
tivity was calculated by subtracting ensemble-averaged PEP

Effects of Parenting on Children’s Autonomic Function 5
values during the final 1 min of the initial 5-min resting
baseline from those collected during the incentive task. As
is customary, negative values therefore indicate PEP short-
ening (increased SNS activity).
Complete psychophysiological data were available
for 81% of children, and complete behavioral observa-
tion data (see below) were available for 85% of parents.
Nine participant children did not return for the post-
treatment clinic visit, and data from 11 participants were
affected by excessive movement or problems with
physiological recording. In addition, 15 participant
families did not complete the posttreatment home visit.
Missing data were replaced by averaging across 30
imputations following recommendations set forth by
Graham (2009).
Behavior observations
Behavior observations were conducted during 30-min
free play sessions in participants’ homes. Parents and
children were instructed to stay in one room with famil-
iar toys and not to use electronics such as televisions
or handheld gaming devices. Trained research assistants
who were blind to condition and study hypotheses
coded child and parent behaviors from videotapes of
these sessions, using the Dyadic Parent-Child Interac-
tion Coding System (DPICS; Robinson & Eyberg, 1981).
The DPICS is a well-researched microanalytic coding
system that assesses parenting behaviors including
positive affect, critical statements, encouragement, and
negative physicality. For purposes of this study, two
parenting composites were formed, including positive/
supportive parenting and negative/critical parenting.
Scores on these behaviors were summed across the
entire 30 min. Following from Reid, Webster-Stratton,
and Hammond (2007), positive parenting included
positive affect, positive physicality, praise, descriptive
commenting, encouragement, and problem-solving.
Negative parenting included critical statements, nega-
tive commands, commands with no opportunity for
compliance, physical intrusions, and negative physical-
ity. We have used these composite variables in several
previous studies (e.g., Reid etal., 2007). Mothers who
participate in the IY program use more positive parent-
ing and less negative parenting than untreated controls.
Although these changes are associated with improve-
ments in child behavior and dyadic relationship quality
(e.g., Webster-Stratton etal., 2011, 2013), no previous
research has evaluated relations between treatment-
induced changes in parenting in the home and chil-
dren’s physiological reactivity.
Pre-post changes in
parenting, externalizing, and
psychophysiological responding
Postintervention child outcomes, including mother,
father, and teacher reports, are presented elsewhere
(Beauchaine etal., 2013, 2015; Webster-Stratton etal.,
2011, 2013) and are summarized in Table 1. In brief,
mothers, fathers, and teachers all reported significant
reductions in children’s externalizing behaviors, includ-
ing impulsivity, hyperactivity, and oppositionality. In
addition, behavior observations indicated improve-
ments in social competence. From pre- to postinterven-
tion, children’s resting RSA increased, as did their RSA
reactivity. Changes in PEP activity and reactivity were
not found. Since sample-wide changes in dependent
variables are not prerequisites for mediation, analyses
were conducted as planned (see below).
As noted above, differences in children’s behavioral
outcomes between the immediate and delayed condi-
tions were negligible. Furthermore, changes in their
physiological responding did not differ across condi-
tions, all ts(97) ≤ 1.48, all ps ≥ .142, all ds ≤ 0.30. In
contrast, greater improvements in both positive and
Table 1. Descriptive Statistics for Child Outcomes
Variable Pre mean (SD) Post mean (SD)t(98) p d
CBCL externalizing (T) 64.6 (8.8) 58.3 (1.3) 6.53 < .001 1.32
CPRS-R hyperactivity (T) 74.5 (8.7) 63.8 (15.4) 6.63 < .001 1.34
CPRS-R oppositionality (T) 67.7 (12.0) 59.0 (14.7) 5.03 < .001 1.02
Resting RSA (ln[ms2]) 5.49 (1.15) 5.87 (1.16) 2.75 .007 0.56
RSA reactivity (ln[ms2]) −0.38 (0.95) −0.75 (1.24) −2.37 .020 −0.48
Resting PEP (ms) 80.55 (12.49) 79.35 (11.87) −0.90 .373 −0.10
PEP reactivity (ms) 1.05 (3.76) 1.05 (3.71) < 0.01 .999 0.00
Note: CBCL = Child Behavior Checklist (Achenbach & Edelbrock, 1991); CPRS-R = Conners’ Parent Rating
Scale Revised (Conners etal., 1998); PEP = pre-ejection period; RSA = respiratory sinus arrhythmia. All
externalizing outcomes reported in this table are mother-reports. Data are collapsed across groups given
nonsignificant differences of very small effect size on all outcomes (see text).

6 Bell et al.
negative parenting were observed for those in the imme-
diate intervention condition. Thus, parents who received
a larger dose of treatment improved more. As shown in
Table 2, parents in the immediate intervention demon-
strated improved positive and negative parenting,
whereas parents in the delayed intervention condition
showed increases in positive parenting, t(49) = 2.37,
p = .02, d = 0.38, but nonsignificant reductions of
small−medium effect size in negative parenting, t(49) =
−1.73, p = .09, d = −0.31. Furthermore, compared to
the delayed condition, parents in the immediate condi-
tion exhibited greater increases in positive parenting,
t(97) = 2.28, p = .03, d = 0.46, and greater reductions
in negative parenting, t(97) = −1.88, p = .06, d = −0.38.
It is important to note that such findings do not
threaten the validity of mediation analyses using the
combined sample. In fact, more variance in parenting
outcomes could help in detecting mediated effects.
Nevertheless, we chose to run tests of mediation within
the combined sample first, then run separate follow-up
tests in both the immediate and delayed intervention
subsamples. These latter analyses were considered
exploratory given low power to detect effects with
smaller ns (see Whisman & McClelland, 2005).
Correlations among psychophysiological and parent-
ing variables are presented in Table 3. PEP reactivity was
correlated negatively with resting PEP, r = −.28, p = .004,
and RSA reactivity, r = −.29, p = .004. No other variables
were correlated significantly, all rs ≤ .16, all ps ≥ .05.
According to Kraemer etal. (2002), “to show that M
is a mediator of treatment, [1] M would have to measure
an event or change occurring during treatment, and [2]
then it must correlate with treatment choice, hence
possibly be a result of treatment, and [3] have either a
main or interactive effect on the outcome” (p. 879). As
Table 1 indicates, the first criterion is met by virtue of
improvements in positive and negative parenting—our
putative mediators. Since everyone received an inter-
vention, the second criterion requires that changes in
parenting among the immediate intervention group
following their treatment exceed any de novo changes
in parenting among the waitlist intervention group dur-
ing the waitlist period. These effects are carried in
Treatment × Condition interactions, which were sig-
nificant for both positive and negative parenting. Thus,
changes in parenting among those in the immediate
intervention condition exceeded changes in parenting
during the waitlist period among those in the delayed
intervention condition. Finally, the third criterion is met
by testing the mediational effect statistically, as
described below.
Mediation analyses
Historically, mediation analyses in intervention research
have been tested using path analytic approaches, fol-
lowing steps set forth by Judd, Kenny, and McClelland
(2001). In large samples, the Kraemer etal. (2002) cri-
teria have been evaluated using structural equation
modeling (e.g., Beauchaine etal., 2005). A new pro-
gram, MEMORE, tests mediational effects in repeated-
measures designs using path analytic regression
(Montoya & Hayes, 2016). The advantage of MEMORE
over traditional approaches is that it estimates bootstrap
confidence intervals for direct and indirect effects, with-
out relying on multiple tests to infer mediation. In simu-
lations, the percentile bootstrap confidence interval
provides a desirable balance between Type I error and
power. In contrast, the causal steps approach is often
Table 2. Pre- to Postintervention Changes in Parenting for Participants in the Immediate and Delayed Conditions
Immediate Intervention Delayed Intervention
Variable Pre (SD) Post (SD)t(48) p d Pre (SD) Post (SD)t(49) p d
Positive parenting 23.39
(18.45)
39.76
(24.74)
4.06 < .001 0.75 22.03
(13.12)
27.75
(16.94)
2.37 .022 0.38
Negative parenting 35.04
(23.42)
21.67
(12.44)
−4.48 < .001 −0.71 28.42
(20.39)
23.10
(12.57)
−1.73 .089 −0.31
Note: PEP = pre-ejection period; RSA = respiratory sinus arrhythmia.
Table 3. Correlations Among Pretreatment
Psychophysiological and Parenting Variables for Combined
Immediate and Delayed Intervention Participants
Variable 1 2 3 4 5
1. Resting RSA —
2. RSA reactivity .07 —
3. Resting PEP −.09 .04 —
4. PEP reactivity −.10 −.29* −.28* —
5. Positive parenting .16 −.02 −.02 .11 —
6. Negative parenting .07 −.07 −.04 .16 .15
Note: PEP = pre-ejection period; RSA = respiratory sinus arrhythmia.
*p ≤ .01.

Effects of Parenting on Children’s Autonomic Function 7
too conservative (see Hayes, 2013; Montoya & Hayes,
2016).
Results
The test of mediation of changes in resting RSA through
changes in negative parenting is shown in Figure 1.
Sample-wide increases in resting RSA from pre–post
intervention were mediated in part by reductions in
negative parenting. The indirect effect of parenting on
resting RSA was different from zero, with a 95% bias-
corrected bootstrap confidence interval of [−0.290,
−0.015] (a × b = −0.124).1 Reductions in negative par-
enting also mediated changes in PEP reactivity (b =
0.060), with a 95% bias-corrected bootstrap confidence
interval of [−1.369, −0.070] (a × b = −0.560). Thus,
reductions in negative parenting were associated with
greater PEP reactivity to incentives. Mediational effects
of changes in parenting on changes in RSA reactivity
and resting PEP were not significant (i.e., their confi-
dence intervals included zero).
As outlined above, exploratory follow-up media-
tional analyses were conducted separately for the
immediate and delayed treatment conditions to test
whether significant effects from the pooled analyses
were specific to either group. For resting RSA, media-
tional effects of parenting were not significant in either
condition: immediate treatment 95% bias-corrected con-
fidence interval of [−0.636, 0.040] (a × b = −0.253) and
delayed treatment 95% bias-corrected confidence inter-
val of [−0.201, −0.029] (a × b = −0.06). In contrast, the
mediational effect of parenting on PEP reactivity was
significant for the immediate treatment condition, 95%
bias-corrected confidence interval of [−3.085, −0.033]
(a × b = −0.124), but not for the delayed treatment
condition, 95% bias-corrected confidence interval of
[−3.082, 0.039] (a × b = −0.124).
Discussion
For the combined sample, reductions in negative par-
enting mediated pre- to posttreatment improvements
in both PNS- and SNS-linked cardiac function, as
indexed by resting RSA and PEP reactivity to incentives
following an empirically supported intervention for
ADHD. The IY series and similar interventions consis-
tently yield improvements in parenting, children’s exter-
nalizing behaviors, and children’s emotion regulation
(Beauchaine et al., 2005, 2013; Eyberg etal., 2008;
Pelham & Fabiano, 2008). However, despite empirical
findings linking physiological reactivity specifically to
coercive relationship dynamics in cross-sectional stud-
ies (e.g., Crowell etal., 2014, 2017), almost no studies
have evaluated effects of parenting on children’s auto-
nomic activity/reactivity in treatment–outcome con-
texts. In fact, this is the first study that we are aware of
to evaluate mediating effects of parenting on changes
on children’s SNS- and PNS-linked cardiac activity and
reactivity. According to Kraemer etal. (2002), effects
that accrue during the course of an intervention and
account for variance in outcomes are mediators of treat-
ment response. Following transactional models, which
suggest that coercive family processes reinforce emo-
tional lability and emotion dysregulation (see
Beauchaine & Zalewski, 2016; Snyder etal., 1997), we
hypothesized that changes in parenting following the
1
Change in
resting RSA
Change in
negative parenting
a = –9.305 b = 0.013
c′ = 0.496
Fig. 1. Mediation of changes in resting RSA during treatment by changes in negative
parenting. In the figure, 1 represents treatment, a represents the link between treatment
and changes in parenting (the mediator), b represents the association between change in
RSA (the dependent variable) as a function of changes in parenting (the mediator), and c′
represents the association between treatment and change in RSA. The a × b product quanti-
fies the indirect effect of changes in parenting on changes in RSA.

8 Bell et al.
IY series, which targets coercive, negative parenting
behaviors, would mediate changes in children’s auto-
nomic function.
In support of this hypothesis, improvements in chil-
dren’s resting RSA and PEP reactivity were mediated by
reductions in negative parenting in the combined sam-
ple. However, when analyses were conducted in the
immediate and delayed treatment conditions separately,
most of these effects were nonsignificant, which is
likely a result of reduced statistical power (see above)
given the relatively small number of children in each
group (n = 49–50). It is well documented that tests of
higher order interactions require larger samples than
we had available for these subgroup analyses (e.g.,
Whisman, & McClelland, 2005). Given that failure to
find mediational effects of parenting in three of the four
subsample tests was likely attributable to low power,
we discuss findings from the overall sample throughout
the remainder of this discussion.
Although it may seem unlikely that changes in chil-
dren’s psychophysiological function would be observed
following a brief intervention, preschool-aged children
demonstrate considerable neuroplasticity (e.g., Anderson
& Reidy, 2012; Tau & Peterson, 2010), and previous
research with this sample revealed improvements in
electrodermal responding, a different SNS measure (see
Beauchaine etal., 2015). Findings reported by Raine
etal. (2001) indicate that preschool interventions confer
improvements in electrodermal responding into middle
childhood.
Previous research implicates coercive, harsh, and
invalidating parenting in shaping and maintaining emo-
tional lability and emotion dysregulation and in confer-
ring risk for progression to increasingly severe
externalizing behaviors across development (Beauchaine
& Zalewski, 2016; Patterson, Capaldi, & Bank, 1991;
Snyder etal., 1994, 1997). These family dynamics may
be especially potent mediators of such progression
among children who are physiologically reactive (e.g.,
Beauchaine etal., 2017; Crowell etal., 2017). Thus, evi-
dence that a parenting intervention mediated improve-
ments not only in children’s behavior but also in their
physiological responding may have important clinical
implications—especially given the wide range of adverse
outcomes associated with excessive autonomic reactivity
(e.g., Beauchaine & Thayer, 2015; Shader etal., 2017).
Future research should continue to evaluate effects
of psychosocial interventions on emotional lability and
associated autonomic function among children, over
longer follow-ups. Such research should continue to
specify dose effects to ensure that mechanisms of emo-
tional lability and emotion dysregulation are altered in
the most cost-effective manner. Analyses with larger
samples could evaluate incremental changes in physiol-
ogy associated with additional hours of parent manage-
ment training.
One limitation concerns the small number of female
participants, which precluded analyses of sex effects. In
addition, mothers accompanied their children to the lab
in all but one case. Future research on sex differences
in children’s reactions to specific parenting behaviors
may increase precision of models predicting coercive
behaviors between mothers and sons versus fathers and
daughters, for example. A second limitation concerns
diagnosing based solely on parent-reports. Given the
young age of child participants (mean age = 5.36 years,
SD = 0.92 years) and the location of the study (Seattle,
Washington), many children did not have teachers or
daycare workers to report on symptoms in a second
setting. Thus, we relied in part on nationally normed
scores on parent-reports that placed children at or above
the 95th percentile on attention problems, in addition to
meeting parent-report criteria for the hyperactive/impul-
sive or combined subtypes of ADHD using the DISC.
A third limitation is that we did not include an
untreated control group in our analyses. One could
therefore argue that changes in RSA and RSA reactivity
represent normative developmental shifts in autonomic
responding. However, observed changes in resting RSA
(0.38 Hz) were 20 or more times larger than expected
across ages 4 to 5 (0.01 Hz) and ages 5 to 6 (0.02 Hz;
see Shader etal., 2017). Thus, maturation is an unlikely
alternative explanation for our findings.
Although sample-wide pre to post changes in PEP
reactivity were not observed, individual-level changes
in PEP responding were nevertheless mediated by
reductions in negative parenting. It bears repeating that
mediation does not require significant direct effects
(Hayes, 2013), nor does it preclude potential effects of
unmeasured third variables on outcomes. The IY series
is a multifaceted intervention with numerous mecha-
nisms of action, some of which may also account for
changes in children’s autonomic function. We chose,
based on strong theoretical considerations, to test medi-
ational effects of parenting. This choice follows from
four decades of research linking negative parenting—
including coercion, aggression, and invalidation—to
children’s behavior problems, emotional lability, emo-
tion dysregulation, and autonomic reactivity (e.g.,
Beauchaine, 2015a; Beauchaine & Zalewski, 2016;
Crowell etal., 2014, 2017; Snyder, 1977; Snyder etal.,
1994, 1997). That being said, tests of other mediating
effects should be evaluated in future research.
Conclusion
Considerable evidence links intervention-related
changes in parenting to improvements in child behavior
(Eyberg etal., 2008; Webster-Stratton etal., 2011). How-
ever, almost no studies have evaluated changes in psy-
chophysiological function as treatment outcomes (for
an exception, see Graziano etal., 2012). Our findings

Effects of Parenting on Children’s Autonomic Function 9
therefore make a unique contribution to the literature.
Our study is also the first to use MEMORE to estimate
indirect effects of behavioral management on changes
in children’s psychophysiological function. Understand-
ing potential neurobiological mechanisms of interven-
tions can aid in (a) identifying children who are resistant
to treatment and (b) evaluating efficacy of treatments
across multiple levels of analysis.
Changes in PNS- and SNS-linked cardiac function
occurred during a relatively brief intervention for
ADHD, and changes in parenting behaviors were
observed. This study contributes to decades of research
on the role of parenting in shaping children’s behavior
and emotion regulation and underscores the impor-
tance of reducing aversive interactions among family
members. These interaction patterns appear to have
implications for children’s peripheral nervous system
responding as well as their behavior.
Author Contributions
Z.B. drafted the paper and performed statistical analyses with
T.S. Data collection was performed by C.W.-S., M.J.R., and
T.P.B. T.P.B edited the paper. All authors approved the final
version for submission.
Declaration of Conflicting Interests
C.W.-S. has disclosed a potential conflict of interest because
she disseminates these treatments and stands to gain from
favorable reports. She has voluntarily agreed to distance her-
self from certain critical research activities, including recruit-
ment, consenting, primary data handling, and data analysis.
The University of Washington has approved these arrange-
ments. M.J.R. performs Incredible Years interventions as an
independent contractor.
Funding
Research was supported by National Institute of Mental
Health Grants MH67192 and MH63699.
Note
1. MEMORE yields unstandardized coefficients given that esti-
mation of a-paths relies on the mean of the pre-post interven-
tion difference. Standardizing variables in regression equations
changes intercepts, which are required for proper interpretation
of effects. We therefore report unstandardized coefficients.
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