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Incredible Years® - Child Treatment

Blueprints Program Rating: Promising

A child treatment program used by counselors and therapists in a small group setting to treat children ages 3-8 years with conduct problems, ADHD, and internalizing problems by enhancing social competence, positive peer interactions, conflict management strategies, emotional literacy, and anger management. The small group treatment program is delivered in 18-22 weekly 2-hour sessions.

  • Antisocial-aggressive Behavior
  • Conduct Problems
  • Positive Social/Prosocial Behavior
  • Prosocial with Peers

    Program Type

    • Skills Training
    • Social Emotional Learning
    • Teacher Training

    Program Setting

    • Community (e.g., religious, recreation)
    • School

    Continuum of Intervention

    • Selective Prevention (Elevated Risk)
    • Indicated Prevention (Early Symptoms of Problem)

    A child treatment program used by counselors and therapists in a small group setting to treat children ages 3-8 years with conduct problems, ADHD, and internalizing problems by enhancing social competence, positive peer interactions, conflict management strategies, emotional literacy, and anger management. The small group treatment program is delivered in 18-22 weekly 2-hour sessions.

      Population Demographics

      Families with children between the ages of 4 and 8 years who meet the criteria for oppositional defiant disorder and/or ADHD.

      Age

      • Early Childhood (3-4) - Preschool
      • Late Childhood (5-11) - K/Elementary

      Gender

      • Male and Female

      Race/Ethnicity

      • All Race/Ethnicity

      The Incredible Years Series program addresses risk factors in three different areas: parent, child and teacher. Parenting interactions (e.g., inconsistent and harsh discipline; low nurturing; poor parenting), and the resulting escalation of dysregulation on the part of the child, are important risk factors for the development of early-onset conduct problems. A lack of ability to problem solve and limited social skills on the part of the child contributes to problems at home, with teachers and with peers. Risk factors for conduct problems in the classroom include minimal communication between teachers and parents, poor classroom management skills and low rates of praise from the teacher.

      • Individual
      • School
      • Family
      Risk Factors
      • Individual: Antisocial/aggressive behavior*, Early initiation of antisocial behavior, Hyperactivity
      • Family: Neglectful parenting, Poor family management*, Violent discipline
      • School: Low school commitment and attachment
      Protective Factors
      • Individual: Academic self-efficacy, Problem solving skills*, Skills for social interaction*
      • Family: Attachment to parents, Non-violent discipline, Parent social support, Parental involvement in education
      • School: Opportunities for prosocial involvement in education

      *Risk/Protective Factor was significantly impacted by the program.

      See also: Incredible Years® - Child Treatment Logic Model (PDF)

      The Incredible Years is a series of programs that addresses multiple risk factors across settings known to be related to the development of conduct disorders in children. In all three training programs (Parent, Teacher, Child), trained facilitators use videotaped scenes to encourage group discussion, problem-solving, and sharing of ideas. The parent and teacher components of the series are described in separate write-ups.

      Incredible Years Training for Children. The child training component for children aged 3-8 years is comprised of weekly two-hour sessions for 18-19 weeks during which two therapists work with 6-7 children and focus on social skills, conflict resolution, empathy-building, problem solving and cooperation. Teachers and parents receive weekly letters explaining the concepts covered and strategies to reinforce skills taught. Children are assigned homework to complete with their parents and receive weekly good behavior-charts that parents and teachers complete. The child training prevention program is also described in a separate write-up.

      The Incredible Years Series is a comprehensive program for parents, teachers, and children with the goal of preventing, reducing, and treating behavioral and emotional problems in children ages two to eight. The core of the program is the BASIC parent training component which emphasizes parenting skills such as playing with children; helping children learn; using effective praise, incentives, and limit-setting; and handling misbehavior. Additional parent training components include an ADVANCE series which emphasizes parent interpersonal skills such as effective communication, anger management, problem-solving between adults, and ways to give and get support, and a SCHOOL series which focuses on parenting approaches designed to promote children's academic skills.

      To facilitate generalization from home to the school environment, a training series for teachers providing effective classroom management skills was added to the Incredible Years Series. The last addition was the training series for children (Dina Dinosaur Curriculum), a "pull out" treatment program for small groups of children exhibiting conduct problems. This curriculum emphasizes emotional literacy, empathy and perspective taking, friendship development, anger management, interpersonal problem-solving, following school rules, and school success.

      The parent and teacher components of the series and the child prevention component are described in separate write-ups.

      Child Training Program (Dinosaur Curriculum)

      The Children’s Training Series: Dina Dinosaur Social and Emotional Skills and Problem Solving Curriculum emphasizes training children in skills such as emotional literacy, empathy or perspective taking, friendship skills, anger management, interpersonal problem solving, school rules and how to be successful at school. The child program is organized to dovetail with the parent training programs.

      The "pull out" treatment program is for small groups of children (4-6 children per group) exhibiting conduct problems and/or Attention Deficit Hyperactivity Disorder. The small group child training program comprises weekly two-hour sessions for 18-20 weeks facilitated by two therapists. Teachers and parents receive weekly letters explaining the behaviors and concepts taught to children and suggestions for strategies they can use to reinforce skills taught. Children are assigned home activities to complete with their parents and receive weekly good behavior-charts that parents and teachers complete.

      Theoretical Rationale/Conceptual Framework for the Incredible Years Child Training Series

      Children with early-only conduct problems have been reported to be more likely to have certain temperamental characteristics such as inattentiveness, impulsivity, and Hyperactivity Attention Deficit Disorder. Researchers concerned with the biological aspects of the development of conduct problems have investigated variables such as neurotransmitters, autonomic arousal system, skin conductance, hormonal influences and some findings suggest that such children may have low autonomic reactivity (i.e., low physiological response to stimuli). Other child factors have also been implicated in child Oppositional/Defiant Disorder (ODD) and Conduct Disorders. For example, deficits in social-cognitive skills contribute to poor emotional regulation and aggressive peer interactions. Research has shown that children with ODD/CD may define problems in hostile ways, search for fewer cues when determining another’s intentions and focus more on aggressive cues. Children with ODD/CD may also distort social cues during peer interactions, generate fewer alternative solutions to social problems, and anticipate fewer consequences for aggression. The child's perception of hostile intent in others may encourage the child to react aggressively. Research reveals that aggressive behavior in children is correlated with low empathy across a wide age range which may contribute to a lack of social competency and antisocial behavior. Additionally, studies indicate that children with conduct problems have significant delays in their peer play skills; in particular, difficulty with reciprocal play, cooperative skills, turn taking, waiting, and giving suggestions.

      Finally, reading, learning and language delays are also implicated in children with conduct problems, particularly for “early life course persisters." Low academic achievement often manifests itself in these children during the elementary grades and continues through high school. Academic difficulties may cause disengagement, increased frustration, and lower self-esteem, which contribute to the child’s behavior problems. At the same time, noncompliance, aggression, elevated activity levels, and poor attention limit a child’s ability to be engaged in learning and achieve academically. Thus, a cycle is created in which one problem exacerbates the other. This combination of academic delays and conduct problems appears to contribute to the development of more severe CD and school failure.

      The data concerning the possible biological, socio-cognitive and academic or developmental deficits in children with conduct problems suggest the need for parent and teacher training programs which help them understand children's biological deficits (their unresponsiveness to aversive stimuli and heightened interest in novelty), and support their use of effective parenting and teaching approaches so that they can continue to be positive and provide consistent responses. The data regarding autonomic underarousal theory suggests that these children may require over-teaching (i.e., repeated learning trials) in order to learn to inhibit undesirable behaviors and to manage emotion. Parents and teachers will need consistent, clear, specific limit-setting that utilizes simple language and concrete cues and reminders. Additionally, this information suggests the need to directly intervene with children focusing on social learning needs such as problem-solving, perspective taking, and play skills as well as literacy and special academic needs.

      • Attachment - Bonding
      • Behavioral
      • Cognitive Behavioral
      • Social Learning

      Although the original (BASIC) Incredible Years program has been tested and evaluated numerously for more than 20 years, researchers have only more recently begun to test the effectiveness of the additive components, including the child training series. The main study (Webster-Stratton, Reid, and Hammond, 2004) evaluated child training alone, as well as the additive effects of teacher-training in combination with parent training, child training, or both. Participants were recruited from families requesting treatment for their child's conduct problems at the University of Washington Parenting Clinic. Families of 159 4- to 8-year-old children with oppositional defiant disorder were randomly assigned to one of six conditions: parent training (PT), child training (CT), parent training plus teacher training (PT+TT), child training plus teacher training (CT+TT), parent/child/teacher training (PT+CT+TT), and a waitlist control group. The interventions began each Fall from 1995 to 1997 and ended approximately six months later. Baseline, post-intervention and one-year follow up assessments were conducted and reported in one article and two-year follow up results were reported in a second article. One- and two-year follow-ups do not have a control condition, as they had received the intervention by this point.

      A second study (Webster-Stratton and Hammond, 1997) evaluated the child training alone and compared to the parent training intervention or a combined training group. Several other studies examined child training in combination with parent or teacher training.

      Two randomized controlled trials (RCTs) of the Child Program alone have shown reductions in conduct problems at school and at home reported by parents. Observations demonstrated fewer negative behaviors and more prosocial behaviors. There were clinically significant improvements in child behavior. Child social competence with peers improved, as well as social problem-solving and conflict management skills. There were also improvements in parenting behaviors. Most of these improvements were also demonstrated when the Child Training Program was combined with the Teacher Training program, and also with the combination of child training and parent training. Evaluations of the Incredible Years child training component alone has shown some positive program effects on child conduct behaviors at home and school, conflict management and problem-solving skills. When in combination with the parent program, positive program effects on parenting interactions with children, child social problem-solving skills, and child problem behaviors are enhanced and show greater sustainment (to one-year).

      Significant results shown for child training alone (CT), the CT + teacher training (TT), and the CT + TT + parent training (PT) conditions, relative to controls (Webster-Stratton, Reid, and Hammond, 2004):

      • Conduct problems at school and at home with mothers reduced.
      • Teachers less negative.

      A second study assessing child training alone (CT) and CT+ parent training (PT), relative to controls, resulted in (Webster-Stratton and Hammond, 1997):

      • Improvements in child behavior problems reported by mothers and fathers.
      • Fewer observed negative behaviors and more prosocial behaviors.
      • Clinically significant improvements in child behavior on Parent Daily Report, and additionally on the Child Behavior Checklist for the CT+PT condition.

      Several other studies of child training combined with parent or teacher training also showed benefits on similar sets of outcomes.

      Significant Program Effects on Risk and Protective Factors:

      • Significant improvements in child social competence with peers and reductions in mothers' negative parenting among participants in the child training alone (CT) and the CT + teacher training (TT) conditions (Webster-Stratton, Reid, and Hammond, 2004).
      • Less father negative parenting and more mother positive parenting among participants in the CT + TT + PT condition (Webster-Stratton, Reid, and Hammond, 2004).
      • Improvements in social problem-solving and conflict management skills (Webster-Stratton and Hammond, 2007).
      • One of 4 parenting behaviors improved in CT, and 3 of 4 in CT + PT (Webster-Stratton and Hammond, 2007).

      Inconsistent and negative teacher interactions with parents and children were examined as mediators of conduct problems in children (Webster-Stratton, Reid, and Hammond, 2004). The treatment conditions significantly reduced these types of interactions relative to the control group.

      Another studied focused specifically on mediation (Beauchaine, Webster-Stratton, and Reid, 2005) found that, acccording to mother-report models, both self-reported verbal criticism and harsh parenting predicted and mediated outcomes. Similar findings were revealed for verbal criticism and ineffective parenting as measured by home observations. However, the mediation analysis did not separate the particular mediated impact of child training.

      Calculated in the Webster-Stratton et al. (2004) study, effect sizes across each of the composite scores for the five comparisons between treatment groups and control groups ranged from small for teacher classroom management in the CT-only condition (Cohen's d=.35) to large for father's parenting in the PT+TT condition (Cohen's d=.91).

      The samples from studies of child training alone were comprised of primarily white, two-parent, middle-income families, who were motivated to seek treatment for their child's conduct behavior problems, which limits the generalizability of the study. A study of combined training (Webster-Stratton, Reid, and Beauchaine, 2011) used a sample of disadvantaged children attending Head Start and had a larger representation of minority children.

      • Follow-up assessments at one-year and two-years do not include the control group which makes it difficult to determine sustained effects of the program.
      • Sample is primarily white, two-parent, middle-income families, who were motivated to bring their children to a clinic for treatment, which limits the generalizability of the study.
      • Sample size in each treatment condition is small, thus limiting the statistical power.
      • Attrition is low, but may differ by level of child's behavior problems.
      • Several studies examined the child training only in combination with other training programs.

      Several of the studies did not include a condition that isolated IY child training from other types of IY training (Webster-Stratton, Reid, and Beauchaine, 2011; Drugli et al., 2006; Drugli et al., 2010; Larsson et al., 2009). Although they cannot show the specific impact of child training, these studies are described because the child training can contribute in part to the outcomes.

      A last study (Beauchaine, Webster-Stratton, and Reid, 2005) examined child training both separately and in combination with other training but focused on mediation and moderation across all types of interventions.

      • Blueprints: Promising
      • Crime Solutions: Effective
      • OJJDP Model Programs: Effective
      • SAMHSA: 3.6-3.7

      Contact Person: Dean Coffey
      Organization Name: Children’s Hospital Los Angeles
      Address: 4650 Sunset Blvd, Los Angeles, CA 90027
      Phone: (323) 660-2450
      Email: dcoffey@chla.usc.edu
      Organization URL: chla.org

      Contact Person: Judy Ohm or Angie Clair
      Organization Name: Wilder Foundation, Parent Education Center
      Address: 451 Lexington Pkwy. North, St. Paul, MN 55104
      Phone: 651-280-2606
      Email: Judy.Ohm@wilder.org
      Organization URL: Wilder.org

      Beauchaine, T. P., Webster-Stratton, C., & Reid, M. J. (2005). Mediators, moderators, and predictors of one-year outcomes among children treated for early-onset conduct problems: A latent growth curve analysis. Journal of Consulting and Clinical Psychology, 73(3), 371-388.

      Drugli, M. B., & Larsson, B. (2006). Children aged 4-8 years treated with parent training and child therapy because of conduct problems: Generalizing effects to day-care and school settings. European Child and Adolescent Psychiatry, 15(7), 392-399.

      Drugli, M. B., Larsson, B., Fossum, S., & Morch, W. T. (2010). Five- to six-year outcome and its prediction for children with ODD/CD treated with parent training. The Journal of Child Psychology and Psychiatry, 51(5), 559-566.

      Larsson, B., Fossum, S., Clifford, G., Drugli, M., Handegard, B., & Morch, W. (2009). Treatment of oppositional defiant and conduct problems in young Norwegian children. European Child Adolescent Psychiatry, 18, 42-52.

      Reid, M. J., Webster-Stratton, C., & Hammond, M. (2003). Follow-up of children who received the Incredible Years intervention for oppositional defiant disorder: Maintenance and prediction of 2-year outcome. Behavior Therapy, 34, 471-491.

      Webster-Stratton, C., & Hammond, M. (1997). Treating children with early-onset conduct problems: A comparison of child and parent training interventions. Journal of Consulting and Clinical Psychology, 65, 93-109.

      Webster-Stratton, C. H., Reid, M. J., & Beauchaine, T. (2011). Combining parent and child training for young children with ADHD. Journal of Clinical Child and Adolescent Psychology, 40(2), 191-203.

      Webster-Stratton, C., Reid, M. J., & Hammond, M. (2004). Treating children with early-onset conduct problems: intervention outcomes for parent, child, and teacher training. Journal of Clinical Child and Adolescent Psychology, 33(1), 105-124.

      Webster-Stratton, C., Reid, M.J., & Stoolmiller, M. (2008). Preventing conduct problems and improving school readiness: An evaluation of the Incredible Years Teacher and Child Training Program in high risk schools. Journal of Child Psychology and Psychiatry, 49(5), 471-488.

      Jamila Reid, Director of Operations
      Incredible Years, Inc.
      1411 8th Avenue West
      Seattle, WA 98119 USA
      phone: 206-285-7565
      incredibleyears@incredibleyears.com
      www.incredibleyears.com

      Study 1

      Reid, M. J., Webster-Stratton, C., & Hammond, M. (2003). Follow-up of children who received the Incredible Years intervention for oppositional defiant disorder: Maintenance and prediction of 2-year outcome. Behavior Therapy, 34, 471-491.

      Webster-Stratton, C., Reid, M. J., & Hammond, M. (2004). Treating children with early-onset conduct problems: intervention outcomes for parent, child, and teacher training. Journal of Clinical Child and Adolescent Psychology, 33(1), 105-124.

      Study 2

      Webster-Stratton, C., & Hammond, M. (1997). Treating children with early-onset conduct problems: A comparison of child and parent training interventions. Journal of Consulting and Clinical Psychology, 65, 93-109.

      Webster-Stratton, C., Reid, M. J., & Hammond, M. (2004). Treating children with early-onset conduct problems: intervention outcomes for parent, child, and teacher training. Journal of Clinical Child and Adolescent Psychology, 33(1), 105-124.

      Reid, M. J., Webster-Stratton, C., & Hammond, M. (2003). Follow-up of children who received the Incredible Years intervention for oppositional defiant disorder: Maintenance and prediction of 2-year outcome. Behavior Therapy, 34, 471-491.

      This study evaluated the additive effects of teacher-training in combination with parent training, child training, or both.

      Evaluation Methodology

      Design: Participants were recruited from families requesting treatment for their child's conduct problems at the University of Washington Parenting Clinic. One-third of the families were self-referred, the others were referred by professional (teachers, physicians) in the community. Families entered the study in three 50-55 family cohorts in the fall of 1995, 1996 and 1997. Families of 159 4- to 8-year-old children with oppositional defiant disorder were randomly assigned to one of six conditions: parent training (PT; n=31), child training (CT; n=30), parent training plus teacher training (PT+TT; n=24), child training plus teacher training (CT+TT; n=23), parent/child/teacher training (PT+CT+TT; n=25), and a waitlist control group (n=26). The waitlist control group received no treatment and had no contact with the research team or the team's therapists during the 8-9 month waitlist period. After the post-intervention assessment, control group families were offered the parent training program. Baseline assessments were conducted in early Fall, post-intervention assessments were conducted approximately six months later in the Spring, for all six conditions in each of the three cohorts. Follow-up assessments were conducted one year later in the Spring for five of the six conditions, because the control group was treated after post-intervention assessments.

      Of the entire sample that completed baseline assessments, four families dropped out before beginning treatment and refused to participate in post-assessments. The rest of the sample completed post-assessments regardless of how many sessions attended. There was no significant difference in drop-out rate by treatment condition. No teachers dropped out of the TT condition.

      Interventions: In the Child Training intervention, children were offered weekly two-hour sessions for 18 to 19 weeks for about six months with two therapists and six to seven children (Dinosaur School). The Parent Training intervention involved 10 to 12 parents meeting with 2 therapists for 2-hour sessions over the course of 22 to 24 weeks. Teacher Training involved 4 full days (32 hours) of group training sequenced throughout the school year.

      Sample Characteristics: The children in the study were 90% boys, 79% white, with an average age of 5 years and 11 months. 74% of the parents were married.

      Measures: Composite measures were calculated by adding multiple instruments in five areas:

      Positive and Negative Parenting: Two parent-report measures (Parenting Practices Interview and Dyadic Parent–Child Interactive Coding System-Revised) and two observational measures (Coder Impressions Inventory and Parent Daily Discipline Inventory) were used to assess parenting styles and skills. The Parenting Practices Interview (PPI) has internal consistency alpha coefficients of .71 for harsh discipline and .66 for supportive parenting. The Dyadic Parent–Child Interactive Coding System-Revised (DPICS-R), which looks at positive parenting and critical statements, has a Cronbach's alpha of .78. The Coder Impressions Inventory-Parent (CII-P) is completed following a half-hour parent-child observation where parents are measured on 12 harsh-critical items (Cronbach's alpha = .89; interclass consistency coefficient = .54), 13 nurturing-supportive items (Cronbach's alpha = .88; interclass consistency coefficient = .67) and a rating on a 5-point scale of the observers perception of the degree to which a family needs help (interclass consistency coefficient = .64.

      Child Conduct Problems at Home: Composite scores were calculated using one parent-report variable (the Eyberg Child Behavior Inventory - ECBI; Cronbach's alpha = .92) and four in-home observations including the DPICS-R coding system and the Coder Impressions Inventory for Children (CII-C).

      Child Conduct Problems at School: The composite scores included two teacher report variables (scales from Teacher Assessment of School Behavior - TASB - Cronbach's alpha ranges between .62 to .91 ; and pertinent scales from the Teacher Rating of Perceived Competence Scale for Young Children - PCSC - reliability ranges between .70-.90 for the subscales) and two summary scores from independent observations of classrooms.

      Child Social Competence with Peers: The composite score includes two teacher-report variables (relevant scales from TASB and PCSC), one classroom observation (30-minute observations calculating conduct problems; Cronbach's alpha = .71) and one laboratory observation of the child with a peer (observation focused on Inappropriate Play scale from DPIS; internal consistency = .88).

      Negative Classroom Management: A composite score of negative classroom management and atmosphere was computed via direct observation for each teacher using five variables: total teacher criticism; observation of classroom atmosphere (CAM, Cronbach's alpha ranging from .94 to .95) measured on a 10-item questionnaire; and three items from the Coder Impression Inventory - Teacher, which rates harsh techniques, nurturing techniques and percentage of time teacher is inappropriate.

      Analysis: The procedures were consistent with an intent-to-treat analysis. The four families who dropped out before treatment began were followed up with, but they refused to complete postassessments. Treatment effects for each measure were analyzed using six-group analysis of covariance with pretest scores as covariates for corresponding posttest scores. Planned comparisons contrasting each treatment condition with the control condition were conducted and then the addition of TT to CT and to PT was tested against CT alone and PT alone. Lastly, PT+CT+TT condition was tested against two factor conditions (CT+TT and PT+TT). Missing data were handled at two levels: an individual summary score was only computed if at least 60% of the items that made up the scale were present. Composite scores were also only computed if at least 60% of the summary scores in the composite were present. Cases were excluded from analysis on that composite if the composite score was missing at one of the time points. This resulted in sample sizes that fluctuated differently for different composite scores and treatment groups. The CT only condition had the most fluctuation at follow up for the father's positive parenting (n dropped from 30 to 22 at follow up).

      Outcomes

      Implementation Fidelity: Therapists conducting the parent or child group co-led their first group with a supervisor, followed a treatment manual for each session and documented fidelity to the program through a weekly protocol checklist of standards to be covered in each session. Group sessions were videotaped for feedback and analysis at weekly supervision meetings. Therapists received ongoing supervision, feedback and training throughout the study. Supervisors also randomly selected videotapes for integrity checks and the study reports that the analysis of checklists indicates high treatment integrity. Teacher training sessions were manualized, videotaped and the tapes were reviewed to ensure that training procedures did not vary across cohorts of teachers.

      Attendance at the children and parent groups ranged between 90% and 100% for at least 15 sessions among the CT, CT+TT, PT, PT+TT and CT+PT+TT groups. All teachers attended the four days of training and all attended at least two meetings to work on individualized behavior plans for the child.

      Baseline Equivalence: The study used ANOVA and chi-square analyses to compare baseline equivalence across all six conditions. No significant differences were found at baseline among all groups on demographic or family background variables. Further, there were no significant differences between conditions at baseline on any composite scores.

      Differential Attrition: From the entire sample that completed baseline assessments, only four families dropped out prior to the beginning of the study and refused to participate in postassessments. No information was provided about how these four families differed at baseline from those that continued in the study. At the two-year follow up, 9% of the families in the treatment groups (n=12 families) dropped out. Significantly more families in the CT condition dropped out. The children in these families who dropped out at two-year follow-up had fewer behavior problems at postassessment.

      Post-test (Webster-Stratton, 2004): Following the six-month intervention, all treatment conditions resulted in significantly fewer conduct problems, both at home and school, for children compared to controls. However, when compared with each other, there was little significant difference between treatment groups.

      The following results were found in the five areas measured:

      Negative and Positive Parenting: The six-group ANCOVA revealed significant effects for all four composite scores: mother negative parenting (F=7.26, p<.001); father negative parenting (F=6.65, p<.001); mother positive parenting (F=3.29, p<.01); and, father positive parenting (F=2.37, p<.05). Based on pre-planned comparisons across groups, when parent training was involved, most groups had significant differences between treatment group and control groups, but for CT or CT+TT, only a measure of mother's negative parenting was significantly different between treatment group and control group.

      Child conduct problems at home: The six-group ANCOVA revealed significant differences among the groups. However, there were no significant differences between the different treatments for child behavior with mother or father.

      Child conduct problems at school: The six-group ANCOVA was non-significant for the child negative problems at school composite score, however, preplanned comparisons indicated that all five of the treatment conditions showed significant treatment effects when compared with the control, though there were no differential effects of treatment conditions.

      Child social competence with peers: The six-group ANCOVA was non-significant for the child social competence composite score, however, preplanned comparisons indicated that three of the treatment conditions that included CT showed significant treatment effects when compared with the control, though there were no differential effects of treatment conditions.

      Teacher Classroom Management: The ANCOVA revealed significant group effects for the teacher classroom management composite score (F=5.39, p<.001). The three conditions that received TT, as well as the CT-only condition, showed significant treatment effects when compared to the control. There were no significant effects for other between-treatment comparisons.

      One-year post intervention (Maintenance effects, no control group): Because the control group was treated after postassessments, these follow up results were only focused on whether children and parents in the treatment conditions improved or maintained effects in the following eight areas: mother negative parenting; father negative parenting; mother positive parenting; father positive parenting; child conduct at home per father; child conduct at home per mother; child conduct at school; and, child social competence. Mixed design (Time x Condition) ANOVAs were computed for each composite score from postassessment to follow up. Seven of the eight areas were not significant at one-year follow up. Only child conduct at school was significant at one-year follow up (F=3.45; p<.01). However, seven of the eight measures maintained to the 1-year follow-up. School behavior of children in the PT+CT+TT deteriorated from postassessment to follow-up.

      Two-years post intervention (Reid et al., 2003): At two-year follow-up, parents were asked if their children received additional services or treatment after completing the program, and what changes in medications their children received. Results indicated no significant differences for any of these variables among treatment conditions. On ratings of conduct problems at home, comparison among treatment groups showed that children in the PT+TT group had significantly better outcomes that in the PT alone condition (chi-sq=5.27; p<.02). On ratings of conduct at school, the number of children showing significant improvement according to teacher reports maintained or improved for all five treatment groups. However, there were no significant differences between treatment groups.

      Brief Bullets

      Significant results shown for Child Training alone (CT) and CT + Teacher Training (TT), relative to controls:

      • Child social competence improved; marginal effect in CT+TT.
      • Mothers' negative parenting reduced, but no change in positive parenting, and ns effects for fathers.
      • Fewer conduct problems at home shown with mothers, but not fathers, and fewer conduct problems at school.
      • Teachers less negative.

      Child Training (CT) + Teacher Training (TT) + Parent Training (PT):

      • Similar improvements shown in the combination of CT + TT + Parent Training (PT), with the addition of less father negative parenting and more mother positive parenting.
      • Teacher negativity was in the wrong direction.

      BASIC + ADVANCE Program + the Incredible Years Child Training Component (Dina Dinosaur Curriculum) (Indicated Intervention)

      Webster-Stratton, C., & Hammond, M. (1997). Treating children with early-onset conduct problems: A comparison of child and parent training interventions. Journal of Consulting and Clinical Psychology, 65, 93-109.

      Long-term evaluations of parenting interventions for children with Oppositional Defiant Disorder (ODD) and/or Conduct Disorder (CD) often reveal that improvements do not generalize from home to school, and that teacher reports do not always indicate marked reductions in children’s behavioral problems at school. Based on this evidence, the Child Training (Dina Dinosaur curriculum) component of the Incredible Years program was developed, targeting children aged four to eight. This intervention identifies the child as the agent of change and combats child risk factors such as poor problem-solving, empathy, communication, and social skills; negative attributions; limited emotional language; loneliness; and peer rejection.

      Evaluation Methodology

      Design: The Dina Dinosaur curriculum was evaluated in a randomized trial with 97 clinic-referred children (72 boys and 25 girls) ages four to seven. Children and their parents (95 mothers and 71 fathers) were randomly assigned to one of four groups:

      • Child training only (Dina Dinosaur Curriculum) (n=27)
      • Parent training only (BASIC + ADVANCE) (n=26)
      • Combined parent and child training intervention (n=22)
      • Waiting-list control group (n=22)

      The Dina Dinosaur curriculum consisted of 18 weeks of two-hour sessions focusing on empathy training, problem-solving training, anger control, friendship skills, communication skills and overcoming difficulties at school. Children met in small groups (six children) which allowed participants to collaborate, share ideas, and develop bonds to each other. As in the parenting programs, videotapes were used to foster discussion, teach problem-solving skills, and model prosocial behaviors. Because young children are vulnerable to distraction, the intervention incorporated group practice, role plays, stories, puppet plays, home assignments, and clubs and incentives to strengthen motivation, hold children’s attention, and reinforce key concepts. Facilitators used life-size puppets to model appropriate behavior and thinking processes. Parents and teachers were involved by helping with homework assignments and receiving regular letters outlining key concepts being taught and suggesting home or classroom reinforcement of particular behaviors.

      Those assigned to the parent training condition received the BASIC and ADVANCE programs, including 22 weekly sessions that reviewed the concepts described in the earlier evaluations. Parents in the combined intervention received the BASIC and ADVANCE programs while their children participated in the Dina Dinosaur curriculum. Families in the waiting list control condition were randomly assigned to one of the three intervention conditions after eight or nine months.

      Sample Characteristics: Families were primarily Caucasian (85%), 68% were two-parent, and the majority were low- to middle-income. Children were selected for inclusion based on meeting the DSM-IV criteria for ODD and/or CD.

      Measures: Families were assessed at baseline, two months after intervention and one year after treatment. Assessments included parent reports of children’s negative and positive behaviors at home (CBCL, ECBI, PDR), teacher reports of child behavior at school (PBQ), and child problem-solving testing (PPS-I CARE). Blinded observations were also conducted, including observations of parent-child interactions at home (assessing parent commands and criticisms, praise, positive affect, and negative valence, as well as children’s deviance, positive affect/warmth), laboratory observations of children playing with a friend (using the PPS-I CARE to note problem-solving and conflict resolution skills), and laboratory observations of parents discussing their child’s behavior (assessing parent’s problem-solving and collaboration skills on the PPS-I CARE). There were no significant differences between groups in demographic or family background characteristics at baseline, nor in parents or teacher reports of child misbehavior.

      Analysis: A four-group analysis of covariance (ANCOVA) was used to evaluate treatment effects for each dependent variable, using pretreatment performance as the covariate. Significant effects were followed by preplanned contrasts (t statistics), comparing each treatment group.

      Outcomes

      Baseline Equivalence: There were no significant differences among the four groups on demographic or family background variables, nor were there any significant differences for parent reports of child behavior (CBCL, ECBI, PSI), teacher reports of child behavior, or observations of child behavior in the home or laboratory.

      Posttest: At post treatment, all treatment groups improved on many of the parent and child behavioral variables, relative to the control group. More specifically, the treatment groups were superior to the control group according to parent reports of child adjustment (CBCL, ECBI), mother observations of children’s positive and negative behaviors (according to the PDR), observations of children’s conflict management skills during peer interactions, and parent stress. In contrast, there were no significant differences between treatment and control groups according to teacher reports of problem behavior or in observer reports of child deviance or positive affect displayed during parent-child interactions.

      When the individual groups were compared to the control group and to each other, the child training program was found to have some unique beneficial effects on children’s behavior. Children receiving the Dina Dinosaur curriculum only demonstrated significant improvements in observed conflict management skills when interacting with peers compared to those receiving parent training only, and those receiving child training (either alone or with parent training) demonstrated better problem-solving skills than the parent training only group. Those receiving parent training (either alone or with child training) demonstrated significantly more positive parenting behaviors and parent collaboration compared to control families and those receiving child training only. For example, those receiving parent training only improved on all four observed mother behaviors (including commands/criticisms, positive affect, praise, and negative valence), while those in the combined condition improved on three of four behaviors and those in the child training only condition improved on only one variable. Similarly, fathers in the parent training only condition improved on 3 of 4 variables compared to the control group, while those in the combined and child training only conditions had no improvements. Those receiving the combined parent and child training interventions demonstrated more mother praise compared to those in the control group and the child training only intervention.

      All three conditions, relative to the control group, demonstrated improvements in child behavior problems according to both mother and father reports. When the three treatment groups were compared with each other, those receiving parent training only had better mother reports of children’s problem behavior (according to the CBCL) and reduced stress compared to those receiving only child training. Mothers in all three conditions observed significantly fewer targeted negative behaviors and more prosocial behaviors at home than control mothers, but there were no significant differences among the three treatment conditions.

      Results obtained after one year demonstrate continued improvements in parent and child behaviors since post assessment, as well as the emergence of several additional significant findings. Comparing one-year measures to baseline scores, all three treatment groups had significantly fewer child behavior problems (CBCL, ECBI and PDR), better child problem-solving skills, less spanking, improved parent behavior during parent-child interactions (including fewer criticisms and commands, less negative valence, and more positive affect), and lower parenting stress levels. In addition, observers rated intervention children as demonstrating less deviance and more positive affect and physical warmth at home, compared to their baseline scores, a finding not found at post treatment. While teacher reports at the one-year follow-up show intervention children having increased behavior problems since the post assessment, those in the abnormal range of the ECBI at baseline demonstrated significantly improved behavior at the one-year follow-up, for all three treatment groups.

      Overall, the combined parent and child training group appeared to have the most positive effects in the broadest array of behaviors. It was superior to the child training only intervention in improving parent behaviors in their interactions with children (particularly in mother praise and parent collaboration) and in reducing children’s problem behaviors. In addition, it produced better results than the parent training only program in children’s social problem-solving skills.

      Moreover, analyses of clinically significant improvements (measured by a reduction in total child deviant behaviors at home) revealed that the combined parent and child intervention showed the most sustained effects in child behavior at the one-year follow-up. Children in the combined intervention group showed a 95 percent decrease in deviant behaviors since baseline, compared to reduction of 74 percent for those in the child only condition and 60 percent for those in the parent only condition.

      Brief Bulleted Outcomes

      In Child Training alone (CT) and in CT+ Parent Training (PT), relative to controls, significant effects found as follows:

      • Improvements in child behavior problems reported by mothers and fathers.
      • Fewer observed negative behaviors and more prosocial behaviors.
      • Improvements in social problem-solving and conflict management skills.
      • One of 4 parenting behaviors improved in CT, and 3 of 4 in CT + PT.
      • Clinically significant improvements in child behavior on Parent Daily Report, and additionally on the CBCL for the CT+PT condition.
      • Effects maintained at one year, compared to their baseline scores.

      Webster-Stratton, C. H., Reid, M. J., & Beauchaine, T. (2011). Combining parent and child training for young children with ADHD. Journal of Clinical Child and Adolescent Psychology, 40 (2), 191-203.

      This randomized control study sought to determine the effect of combining Incredible Years parent and child training on preschool children with a primary diagnosis of ADHD. Researchers also intended to demonstrate that the Incredible Years program prevents and/or reduces the development of oppositional defiant disorder in this population. However, assessments were conducted pre and post-intervention, and no follow-up data were gathered, thereby limiting any sustainability claims.

      Evaluation Methodology

      Design: Participants for the study were recruited through teachers and counselors at local schools, doctor’s offices, mental health professionals and community parent publications. A total of 204 parents called to inquire about the study because their child either had symptoms of, or was diagnosed with, ADHD. After an initial phone conversation with a researcher, 156 parents completed a structured interview with a clinician to assess for ADHD and ODD (oppositional defiant disorder). Of the 103 children who met the inclusion criteria, 99 (96%) attended an intake and were randomly assigned to a treatment condition (n=49) or a waitlist control condition (n=50). A total of five families (3 from control and 2 from treatment) dropped out during the study (5% attrition rate). Data were gathered at baseline and immediately follow the intervention. Post-test data were gathered on 96 of the 99 families.

      Intervention: The IY program has been described previously in detail and comprises 20 weekly, 2-hour parent training sessions and separate child training sessions. During this study, the newest version of the curriculum (revised in 2008) was used. New material focusing on coaching, predictable schedules, emotional regulation strategies and problem-solving strategies were included. New vignettes demonstrating effective parental responses to child behavior were used with parents.

      Sample Characteristics: A majority of the children were male (75%) with an average age of 64 months. 73% were White; mothers in the sample had an average of 15.6 years of education; fathers had an average of 15 years of education.

      Measures: Assessments consisted of previously used measures including 27 scales completed by parents and teachers and 13 scales completed by blinded observers:

      Parent reports of child behavior problems were collected using the CBCL, ECBI Intensity and Total Problems scales; Conners’ Parent Rating Scale – Revised (a 57-item instrument that assesses ADHD; alpha=.91-.93); and Social Competence Scale.

      Parent reports of parenting behavior were collected using the Parenting Practices Inventory which measures appropriate discipline, praise and incentives, monitoring, harsh and inconsistent discipline, and physical punishment.

      Teacher reports of child behavior were collected using the Teacher Report Form and Conners’ Teacher Rating Scale – Revised.

      Independent observations of parent-child behavior were conducted in a lab and measured using the Dyadic Parent-Child Interactive Coding System – Revised.

      Independent observations of child behavior in the classroom were conducted by blinded observers using the Coder Observation of Child Adaptation – Revised.

      Child problem-solving and feelings assessment was conducted using Wally Problem Solving Test and Wally Feelings Test, though it was unclear who conducted these assessments with the children.

      Analysis: Data were analyzed using repeated measures analyses of variance. Results for condition-by-time interactions were presented, as were differences in posttest means.

      Intention-to-treat: The study used data on all families who provided valid assessments, regardless of dose of intervention received.

      Outcomes

      Implementation Fidelity: Parent satisfaction questionnaires were completed by parents at the end of the program. Both mother (92%) and father (85%) attendance at sessions was high. Fidelity was also monitored by videotaping groups and reviewing them during weekly supervision. Protocol checklists were completed after each session by group leaders.

      Baseline Equivalence: No statistically significant differences between conditions were observed for any demographic variables, however no test for significance was conducted for between-group differences on outcome variables at baseline.

      Differential Attrition: Attrition was minimal in the study, though no information about differential attrition was provided.

      Posttest: Tests of significance are presented in two forms. First, the authors test for mean differences across groups at posttest (with no baseline controls). Second, using repeated measures ANOVA, baseline controls, and condition-by-time interactions, they test group differences in the change in outcomes from pretest to posttest. Since the two tests often give different results, both are summarized.

      Mean differences across posttest (between group differences):

      Of the 27 measures assessing child behavior from the perspectives of mother, father and teacher, 6 mother-report measures and 2 father report measures revealed significant posttreatment between group differences. The six mother-report measures were CBCL aggression, CPRS hyperactive, ECBI intensity, ECBI problems, emotional regulation and social competence. The two father-report measures were emotional regulation and social competence.

      Of the 13 measures conducted by observers in lab and school settings, 4 measures revealed significant posttreatment between group differences. The four measures were praise and coaching during free play and praise and coaching during task-driven observations. None of the school peer observations or observations of child behaviors was significant for between group differences at posttreatment.

      Of the 10 measures completed by parents rating their own behavior, none of the measures was significant for between group differences at posttreatment.

      Of the two measures that assessed child problem solving and feeling language, one (problem solving) was significant for between group differences at posttreatment.

      Condition x Time differences

      Of the 27 measures assessing child behavior from the perspectives of mother, father and teacher, 19 measures revealed significant condition x time effects.

      Of the 13 measures conducted by observers in lab and school settings, 5 measures revealed significant condition x time effects.

      Of the 10 measures completed by parents rating their own behavior, 4 measures revealed significant condition x time effects. All four were mother-report measures. None of the father-report measures were significant.

      Of the two measures that assessed child problem solving and feeling language, both were significant for condition x time effects.

      Limitations

      • No test for baseline equivalence of outcome measures was conducted.
      • No follow-up assessment was conducted and therefore sustained effects were not demonstrated. According to the author, follow up data were gathered and presented in a different article (currently in press). However, given the waitlist design, the control group received treatment before follow-up data were gathered. The follow-up results thereby can demonstrate only maintenance effects and not sustained effects.

      Independent Replication of Parent Training Program in Norway

      Drugli, M. B., & Larsson, B. (2006). Children aged 4-8 years treated with parent training and child therapy because of conduct problems: Generalizing effects to day-care and school settings. European Child and Adolescent Psychiatry, 15 (7), 392-399.

      Drugli, M. B., Larsson, B., Fossum, S., & Morch, W. T. (2010). Five- to six-year outcome and its prediction for children with ODD/CD treated with parent training. The Journal of Child Psychology and Psychiatry, 51 (5), 559-566.

      Larsson, B., Fossum, S., Clifford, G., Drugli, M., Handegard, B., & Morch, W. (2009). Treatment of oppositional defiant and conduct problems in young Norwegian children. European Child Adolescent Psychiatry, 18, 42-52.

      Drugli and Larsson (2006) and Larsson et al. (2009) examined outcomes at posttest and, for intervention subjects only, at 6-month follow-up. Drugli et al. (2010) examined outcomes after 5 to 6 years for intervention subjects only. All three studies examined the child training in combination with the parent training.

      Evaluation Methodology

      Design: Children ages 4-8 referred to two child psychiatric outpatient clinics for treatment of oppositional or conduct problems were studied. Children were screened using the ECBI 90th percentile as a cut-off score. Exclusionary criteria included gross physical impairment, sensory deprivation, intellectual deficit, or autism, and children receiving other psycho-therapeutic interventions, as well as children on ADHD medication more than six months prior to study entry.

      In all, 136 children were randomized to the BASIC parent program (PT; n = 51), PT combined with child therapy (PT + CT; n = 55), and a waiting list control group (n = 30) who were offered the intervention after six months. Child therapy was based upon the Incredible Years Dinosaur School Program, which sought to provide child social skills, conflict resolutions skills, playing and cooperation with peers.

      Sample Characteristics: All children had a diagnosis of ODD (n=111) or threshold ODD (n=16), and 18.9% received a subthreshold (n=14) or definite CD diagnosis (n=10). Also, 35.4% (n=45) met diagnostic criteria for ADHD.

      Measures: Drugli and Larsson (2006) examine a diverse set of outcomes reported by parents, children, and teachers.

      Parents were the sole informants for the other studies, although there are both mother and father reports. The parent-reported Eyberg Child Behavior Inventory (total intensity and problem subscales), was the prime outcome measure. The parent-reported CBCL (internalizing, aggression and attention subscales) was also used. The Parent Practices Interview, modified from the Oregon Social Learning Center's discipline questionnaire to apply to young children was used to measure inconsistent discipline, harsh discipline, and positive parenting. The Parent Stress Index consisted of 101 items to assess parents' perceived stress related to both child behaviors and parenting.

      Analysis: Associations between categorical variables were analyzed with chi-square tests. Differences in group means between treatment conditions posttreatment and at 1-year follow-up (no control group, maintenance effects only) were analyzed with ANCOVAs using pretreatment scores as covariates. Imputation was used for subjects with one missing value on any of the three assessment points, baseline, posttest, and 1-year follow-up. Findings are reported for completers only, but authors state that intent-to-treat analysis found identical results for the primary ECBI measure.

      Outcomes

      Baseline Equivalence and Differential Attrition: There were no significant differences among the groups on any of the demographic variables, diagnostic status, the primary outcome measure (ECBI), or use of medication because of ADHD. At posttest, the sample included 127 (of the original 136) children (2 dropped and 4 failed to complete PT; 3 failed to complete the combined treatment, and 2 controls did not complete a posttest assessment). At the one-year follow-up, the wait list control group was no longer available as they had received treatment; however, the PT condition included 40 and the combined condition 48 that completed the assessment. Because intent-to-treat analysis showed identical results for the primary measure, the ECBI, outcomes were reported only for completers.

      Posttest:

      Drugli and Larsson (2006)

      At posttest, children in the combined parent and child training had significantly lower aggression scores, significantly lower clinical levels of aggression, and significantly higher problem-solving skills. At follow-up, most gains were not maintained. These outcomes did not improve significantly from parent training alone.

      No significant benefits of either intervention emerged for several other measures: attention problems, internalizing problems, social competence, peer interactions, student-teacher relationships, and parent-teacher involvement.

      Larsson et al. (2009)

      ECBI Scales: Mothers and fathers in PT reported lower intensity scores for the children, and fathers reported significantly fewer problems than wait-list controls. There were no differences between the combined condition and wait-list controls. There were also no significant differences between the two interventions.

      CBCL Scales: Mothers in the PT condition reported less aggression, better attention, and less internalizing problems than controls. There were no significant differences reported by fathers in the PT condition vs control. In the combined condition vs. controls, only mother-reported aggression was significant, with the intervention lessening aggression.

      Parenting Practices and Stress: Parental use of positive strategies increased after treatment in both conditions (reported by both mothers and fathers). The use of harsh and inconsistent discipline decreased in both conditions as reported by mothers, and fathers reported less inconsistent discipline in the combined condition only. Mothers' experience of stress was less in both conditions, although fathers reported less stress in the PT condition only.

      One-Year Followup (maintenance effects only, no control group): No differences between PT and the combined condition were found on any parenting measures, other than fathers in the combined condition reported a significant reduction in harsh disciplining of the child as opposed to those in PT.

      About 80% of the children no longer received an ODD diagnosis at the one-year follow-up. From posttreatment to one-year follow-up, mothers reported an improvement in clinical significance, with children in PT improving from 57.1% to 63.2%, and in the combined condition 54.9% to 65.6%.

      Overall, it is questionable that the child therapy combined with parent training added much.

      Long-term Follow-up

      Drugli et al. (2010)

      A telephone assessment was completed with 54 of the 99 treated families (54.5%) 5-6 years after treatment ended, to determine diagnostic status of the children. The mean age of the children was 12.1 years. There were no significant differences between the original sample and the long-term follow-up sample on demographic variables, however, there were significantly more participants from the combined PT+CT condition (63% of sample) than the PT only group (37% of sample). Analyses were conducted on combined treatment conditions and only data returned from mother reports were used for all time points due to low father response rate.

      Independent t-tests indicate that 33% of the children (n=18) had ODD and/or CD diagnoses at the 5-6-year follow-up. The majority of these children also had a diagnosis of ADHD or anxiety/depression. Of those who did not have an ODD/CD diagnosis (n=36), more than half (n=20) had diagnoses of ADHD, anxiety/depression, or both. About a third (35.2%) of the sample did not have any psychiatric diagnosis at the long-term follow-up. Five (9.3%) of the children received an ODD/CD diagnosis at both long-term follow-up time points, while half of the children (51.9%) changed diagnostic status between long-term follow-up periods (24.1% deteriorating and 27.8% improving), and 38.9% of children maintained a non-diagnostic status at both time periods.

      Variables that significantly predicted (at pre-treatment) a diagnostic status of ODD/CD at 5-6-year follow-up included female child, single parent mother, a diagnosis of CD, and higher levels of child internalizing problems. Variables at post-treatment that significantly predicted ODD/CD diagnostic status at the 5-6-year follow-up were high levels of child internalizing and externalizing problems, high levels of mother's depressive symptoms and maternal stress in parenting.

      Beauchaine, T. P., Webster-Stratton, C., & Reid, M. J. (2005). Mediators, moderators, and predictors of one-year outcomes among children treated for early-onset conduct problems: A latent growth curve analysis. Journal of Consulting and Clinical Psychology, 73 (3), 371-388.

      This study combines data from six randomized clinical trials to determine mediators, moderators and predictors of outcomes.

      Evaluation Methodology

      Design: The study combined data from six randomized clinical trials conducted with 21 separate cohorts of 3- to 8-year-old children over the previous 20 years. The resulting sample included 514 families who participated in IY treatment-outcome research on oppositional defiant disorder and conduct disorder. A total of 317 families received parent training only (PT), 60 received child training only (CT), 38 received PT+CT, 24 received PT+Teacher training (TT), 23 received CT+TT, and 25 received PT+TT+CT. Twenty seven families were assigned to a waitlist control condition and received PT after their post-assessment.

      Sample Characteristics: Children were on average 5.4 years old and 78% were male, 88.5% were White, 4.8% were African American and 3.9% were Hispanic.

      Measures: Assessments consisted of previously used measures and were gathered through home observations (DPICS-R) and mother- report (ECBI, CBCL and PSI).

      The purpose of this study was to evaluate predictors/moderators of outcome and therefore the following additional measures were examined: Parenting Stress Index, Dyadic Adjustment Scale, Beck Depression Inventory, parental substance abuse, comorbid child psychopathology, additional familial predictors (maternal education level, maternal age, maternal relationship status, social class, family size) and additional child predictors (children’s age, sex, conduct problems).

      The secondary purpose of this study was to evaluate mediators of outcome and therefore the following additional measures were examined: parenting style (as measured through home observations using DPICS-R and self-reported Daily Discipline Inventory), and treatment dose.

      Analysis: Data were analyzed using latent growth curve models.

      Intention-to-treat: Data were gathered on all families regardless of dose of intervention received. Full information maximum likelihood estimation was used when data were missing. However, analyses were also conducted in which families with missing data were dropped and the pattern of results from the latent growth curve models remained unchanged.

      Outcomes

      Implementation Fidelity: No information provided in this study; however details can be found in other studies from which this study uses data.

      Baseline Equivalence: No information provided in this study.

      Differential Attrition: No information provided in this study.

      Results:

      The following significant predictive relationships were found:

      • According to mother-report models, better child outcomes were observed when more treatment components (i.e., PT, CT, TT) were delivered to families. However, this relationship was not found in behavior observation models.

      The following significant moderational relationships were found:

      • According to mother-report models, when marital satisfaction is low, children of mothers who received PT improved more at one-year follow-up than children who received an intervention without PT. According to mother-report of child behavior, more positive treatment responses were observed in children with comorbid symptoms of anxiety/depression.
      • According to home observation models, maternal depression, social class, paternal substance abuse, marital status and comorbid attention problems moderated treatment response. In most cases, including PT and/or CT was more effective, except in the case of comorbid attention problems, where including TT was more effective than not including TT.

      The following significant mediators of outcome were found:

      • According to mother-report models, both self-reported verbal criticism and harsh parenting predicted and mediated outcomes. This means that children of mothers who scored low on harsh parenting and verbal criticism at baseline and still improved during treatment had best treatment responses. Similar findings were revealed for verbal criticism and ineffective parenting as measured by home observations.