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The incredible years parent, teacher, and child intervention: Targeting multiple areas of risk for a young child with pervasive conduct problems using a flexible, manualized treatment program
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The I n c r e d i b l e Years Parent, Teacher, a n d Child Intervention: Targeting Multiple A r e a s o f Risk for a Young Child With Pervasive C o n d u c t P r o b l e m s U s i n g a Flexible, M a n u a l i z e d Treatment Program M. J a m i l a Reid a n d Carolyn Webster-Stratton, University o f W a s h i n g t o n Young children who present for treatment with oppositional-defiant disorder (ODD) and conduct disorder (CD) frequently exhibit these symptoms across settings and often show comorbid symptoms of attention-deficit~hyperactivity disorder (ADHD) and~or internalizing symptoms such as anxiety or depression. Parent training programs to treat these children must beflexible and comprehensive enough to address these issues. This article outlines a case in which the Incredible Years Parent, Teach~ and Child Training programs were used to treat a young boy,John, with ODD. His problems were pervasive and occurred at home, at school, and with peers. In addition to the ODD symptoms, John exhibited symptoms of ADHD as well as significant anxious and depressed behaviors. This case study outlines how a multimodal, manualized treatment can be applied flexibly to attend to individual family needs and address issues of comorbidity.
HE INCIDENCEofoppositional-defiant disorder (ODD) a n d conduct disorder (CD; key predictors of adolescent delinquency, substance abuse, and violent behavior) in children is alarmingly high, with reported rates of early-onset conduct problems in young children as high as 35% for low-income families (Chambless & Hollon, 1998; Webster-Stratton & Hammond, 1998; WebsterStratton, Hollinsworth, & Kolpacoff, 1989). Parent training has been recognized as one of the most effective approaches to preventing and reducing conduct problems (e.g., Brestan & Eyberg, 1998). However, parent training is often perceived as a narrowly focused intervention that focuses exclusively on increasing child compliance and reducing aggressive behavior at home. While many parents of young children with conduct problems seek help because of noncompliant and aggressive behavior at home, our data with well over 600 children (ages 4 to 7) diagnosed with ODD or CD suggest that 50% to 60% of these children also show clinically significant problem behaviors with teachers and peers (Webster-Stratton, 1990). In addition, as many as 50% of children described as aggressive and disruptive are also comorbid for attentiondeficit/hyperactivity disorder (ADHD; Barkley, Guevremont, Anastopoulos, DuPaul, & Shelton, 1993; Lahey & Loeber, 1997). Lastly, children who exhibit high levels of externalizing (aggressive, oppositional) behaviors also tend to show high levels of internalizing (anxious, withdrawn) behaviors (Achenbach, 1991a). In our sample of children presenting with conduct problems, 34% of children who
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Cognitive and Behavioral Practice 8, 377-386, 2001 1077-7229/01/377-38651.00/0 Copyright © 2001 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
scored in the clinical range on the externalizing subscale behaviors of the Child Behavior Checklist (CBCL; Achenbach, 1991a) also scored in the clinical range on internalizing behaviors (the CBCL is a standardized, parent-report Parent training measure of child behavior probmust be broadly lems that has been shown to discriminate between clinicbased and flexible referred and nonreferred chilenough to help dren). Thus, the majority of families cope not children who receive treatment for ODD/CD also exhibit difonly with ficulties in other areas. As a aggressive and consequence, treatment for noncompliance these children must be comprehensive and tailored to spebehavior at home, cific client needs. The parent but also target training component of treatindividual goals for ment must be broadly based and flexible enough to help children who are families cope not only with aganxious, socially gressive and noncompliance isolated, rejected behavior at home, but also target individual goals for chilby peers, or dren who are anxious, socially hyperactive. isolated, rejected by peers, or hyperactive. Comprehensive and broadly based parent training, such as Webster-Stratton's Incredible Years Program, is an important starting place for treating children with conduct problems, and will result in clinically significant improvements for two-thirds of children. However, approximately one-third of children treated with this parent training program (and others) will continue to have diffi-
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cuhies with school and peers (e.g., Funderburk et al., 1998; Webster-Stratton, 1990). The addition of child social skills and problem-solving training to this parent training program (Webster-Stratton & H a m m o n d , 1997) improved long-term child outcome at h o m e and observations showed improved positive conflict m a n a g e m e n t with peers compared to children who received only pro: ent training. The combination of parent and child training, however, did not impact children's noncompliant and aggressive behavior in the classroom, according to Each program teacher reports. ~ t m n teacher training was added to the treatconsists of over ment plan, observations in the 200 videotaped classroom indicated signifivignettes of cant decreases in aggressive behavior with peers at school common situations compared with classrooms with faced b y p a r e n t s , no reacher training (Websterteachers, o r Stratton, Reid, & H a m m o n d , 2001 ). These data indicate that children. V i g n e t t e s for young children whose beshow effective and havior problems are pervasive ineffective ways of (i.e., with parents, teachers, and peers), parent training will be handling these most effective when offered situations. in combination with teacher and child training. This type of comprehensive treatment plan targets muhiple risk and protective factors for children with conduct problems across settings and attempts to effect change in all arenas of the child's experience.
The Incredible Years Programs Each of the three Incredible Years parent, child, and teacher training programs used with the family described in this article have been empirically validated in randomized control-group studies tbr use with children (ages 4 to 7) with c o n d u c t problems (Brestan & Eyberg, 1998; Webster-Stratton, in press). The series consists of groupbased training programs for parents, teachers, and children. Each program consists of over 200 videotaped vignettes of c o m m o n situations faced by parents, teachers, or children. Vignettes show effective and ineffective ways of handling these situations and provide the framework for group discussions on how to handle c o m m o n problems. In addition to the vignettes, each program contains detailed treatment mannals with session-by-session checklists, group-leader scripts, program "principles" to highlight, homework materials, books, and practice activities. Although all three programs are manualized, and strict adherence to treatment protocol is important, leaders are trained in a collaborative and problem-solving pro-
cess that stresses the key therapeutic principle of using the particular goals, issues, and circumstances of each group m e m b e r to fit the curriculum into the particular c o n t e x t o f each family or classroom (for a d e t a i l e d description of the collaborative process, see WebsterStratton & Hancock, 1998).
The Parent Program The parent program is held weekly for 2 hours and last.s 22 to 24 weeks. Groups generally contain 12 to 16 parents. The program consists of topics including childdirected play, encouragement, praise, tangible reintbrcement, monitoring, ignoring, limit setting, natural and logical consequences, and time-out. In addition to learning cognitive behavioral principles, parents are helped to understand and accept individual differences in their child's temperament, attention span, needs for attention, ability to regulate emotions, and how their child's unique "wiring" will determine particular parenting approaches. Material on anger management, m o o d regulation, working with schools and teachers, academic success, communication, problem solving with adults and children, and encouraging children's positive peer relationships is also covered. The videotaped vignettes are used by the group leader to "trigger" parent discussions, problem solving, and role-plays of c o m m o n sitnations in the group. The groups are led in a collaborative tormat whereby the lead* ers present material and provide structure to the discussion, while parents set their own goals and extract parenting "principles" from the material presented. Additionally, parents are given weekly homework consisting of reading and behavioral assignments to practice with their children. Parents self-monitor this h o m e w o r k by committing to particular goals they want to accomplish during the week.
The Teacher Program Similar in format to the parent program, the teacher program is taught in 4 day-long sessions spaced throughout the fall and winter of the school year. Teachers of children involved in our clinic are invited to attend the training (to date, approximately 90% of teachers have agreed to participate). The teacher program consists of topics such as building positive relationships with students, strategies to promote parent-teacher collaboration and parent participation, the importance of teacher praise and positive attention, proactive strategies to prevent problems, using tangible reinfbrcement, decreasing inappropriate behavior with limit-setting and time-out, and classroom-management approaches designed to increase children's prosocial and problem-solving skills. As with the parent program, the teacher program is offered as a collaborative venture between the group leader and the teachers. Role-plays and discussion are used to illustrate
The Incredible Years
new concepts. Teachers are seen as the experts a n d are e n c o u r a g e d to use each o t h e r as resources for solving difficult p r o b l e m s in the classroom. With the g r o u p leader's guidance, teachers h e l p each o t h e r to make changes at the classroom level as well as i m p l e m e n t i n g individual behavior plans for the target child. Outside o f the training days, o u r clinic therapists observe the target child in the classroom, m e e t with the teachers individually to develop behavior plans, a n d facilitate meetings with the parents, teachers, a n d o t h e r school personnel. At the e n d o f the school year, o u r clinic therapist works with the parents a n d teachers to develop a transition plan to d o c u m e n t successful strategies for the child's next teacher.
The Child Program: Dinosaur School T h e Dinosaur Social Skills a n d P r o b l e m Solving curriculum is delivered to the c h i l d r e n in the evenings while their parents are participating in the p a r e n t group. T h e groups consist o f six to seven c h i l d r e n a n d are led by two therapists. T h e p r o g r a m contains topics such as school rules, d o i n g your best in school, feelings, p r o b l e m solving, a n g e r m a n a g e m e n t , m a k i n g friends, a n d teamwork. As with the p a r e n t a n d t e a c h e r programs, the p r o g r a m c o n t e n t is illustrated t h r o u g h v i d e o t a p e d vignettes that c h i l d r e n watch a n d discuss. In addition, the Dinosaur P r o g r a m uses child-size p u p p e t s to discuss a n d role-play c o n t e n t with the children. L e a r n i n g is e n h a n c e d by activities, games, colorful cue cards illustrating key concepts, a n d h o m e w o r k activity books. A token e c o n o m y system is used whereby c h i l d r e n earn chips for g o o d behavior, active participation in discussion, a n d prosocial behavior with the o t h e r c h i l d r e n in the group. C a s e Example Intake Information Sarah a n d Ben were r e f e r r e d to the Parenting Clinic by their school psychologist because of difficulties at h o m e a n d at school with their 6-year-old son, J o h n . Alt h o u g h J o h n was j u s t b e g i n n i n g first grade, he h a d a substantial r e p u t a t i o n at the school for his aggressive a n d oppositional behavior in the classroom a n d on the playground. These behaviors h a d b e e n evident when J o h n was in k i n d e r g a r t e n a n d h a d increased in intensity when he e n t e r e d first grade. At the time that the Smiths came to the clinic, his t e a c h e r h a d a p p r o a c h e d his parents a n d told t h e m that she d i d n o t believe h e r classroom was an a p p r o p r i a t e place for J o h n . J o h n was regularly b e i n g sent to the principal's office a n d h a d also b e e n asked to leave school early on at least two occasions because of his aggressive behavior. In a d d i t i o n to these p r o b l e m s at school, Sarah a n d Ben were c o n c e r n e d a b o u t his behavior at home. Both parents d e s c r i b e d J o h n as extremely volatile. H e would
frequently "lose control o f his behavior" a n d e n g a g e in e x t e n d e d t e m p e r tantrums d u r i n g which he would call his parents names, refuse to comply with any requests, a n d e n g a g e in aggressive o r destructive behavior. Both p a r e n t s d e s c r i b e d feeling helpless to c h a n g e J o h n ' s behavior o n c e it r e a c h e d these p r o p o r t i o n s . T h e y rep o r t e d that t h e i r p a r e n t i n g style was usually to talk a n d r e a s o n with J o h n in p r o b l e m situations, b u t felt that this m e r e l y escalated his behavior. T h e y also h a d t r i e d a n u m b e r o f d i f f e r e n t discipline strategies (e.g., time-out, loss o f privileges), b u t felt that J o h n was u n r e s p o n s i v e to Teachers are seen their efforts. They were often at a loss as to what events h a d as the experts and t r i g g e r e d the t a n t r u m s a n d are encouraged to d e s c r i b e d J o h n as having a use each other as 'Jekyll-and-Hyde" personality. They were quick to describe r e s o u r c e s for J o h n ' s strengths as well as his solving difficult difficulties. D u r i n g his g o o d problems in t h e times, they r e p o r t e d that he was a generous, loving, charmclassroom. ing child with a g o o d sense o f humor. J o h n h a d b e e n assessed by a psychologist p r i o r to c o m i n g to the clinic a n d h a d b e e n d i a g n o s e d as having n u m e r o u s symptoms o f ADHD, b u t was j u s t below the t h r e s h o l d w a r r a n t i n g formal diagnosis. P r i o r to c o m i n g to the P a r e n t i n g Clinic, Sarah a n d Ben h a d e n r o l l e d J o h n in a 10-week social skills p r o g r a m r e c o m m e n d e d by t h e i r school counselor, b u t saw no c h a n g e in his b e h a v i o r as a result of the group. In a d d i t i o n to the difficulties of m a n a g i n g J o h n ' s behavior, Sarah a n d Ben were quite c o n c e r n e d a b o u t the effect that his difficulties were having o n his self-esteem. D u r i n g the year p r i o r to the i n t a k e , J o h n h a d b e g u n saying that no one liked him a n d that he was the d u m b e s t kid in his class. They also perceived him as d e p r e s s e d a n d anxious a b o u t school a n d his lack of friends. T h e Smiths are a middle-class Caucasian family. Both parents are college graduates a n d b o t h work (Ben fulltime a n d Sarah part-time). They h a d b e e n m a r r i e d for 13 years a n d b o t h r e p o r t e d a strong a n d positive marital relationship. They also have a d a u g h t e r who was 8 years old at the time of the intake a n d h a d no significant behavior problems. At the time of the intake, n e i t h e r p a r e n t rep o r t e d any m e n t a l h e a l t h issues, a l t h o u g h S a r a h h a d a history o f depression. T h e Beck Depression Inventory (Beck, Steer, & Garbin, 1988) a n d the Dyadic A d j u s t m e n t Scale (Spanier, 1976) c o n f i r m e d n o r m a l scores for depression a n d g o o d marital satisfaction.John's difficulties, however, were p u t t i n g a significant strain on their family's functioning. Both parents felt that J o h n ' s p r o b l e m s were their m a i n focus, to the exclusion o f o t h e r activities a n d
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Table I
Baseline, Posttreatment, and 1- and 2-Year Follow-Up Assessments
Mother Report Eyberg Prob.i' Eyberg Intensity CBCL Ext.b CBCL Int. CBCL Attention Father Report Eyberg Prob. Eyberg Intensity CBCL Ext. CBCL Int. CBCL Attention Teacher Report TRF Ext.c TRF Int. TRF Attention Classroom Observation Ratio of Teacher Praise to Criticals Satisfactiond Mother Father Teacher
Baseline
Immediate Posttreatment
1-Year Follow-up
2-Year Follow-up
18 139 71 (98%) 61 (86%) 63 (90%)
11 118 66 (95%) 57 (76%) 60 (84%)
9 112 63 (90%) 46 (34%) 60 (84%)
4 116 58 (79%) 43 (24%) 57 (76%)
21 155 72 (99%) 71 (98%) 60 (84%)
14 126 70 (98%) 49 (46%) 57 (76%)
7 117 71 (98%) 53 (62%) 63 (90%)
9 107 66 (95%) 53 (62%) 51 (54%)
62 (88%) 51 (54%) 62 (88%)
68 (96%) 57 (76%) 67 (96%)
71 (98%) 56 (73%) 75 (99%)
78 (100%) 60 (84%) 68 (96%)
1.5 ----
7.75 6.5 6 5.7
6 5.3
-__ _
--
Eyberg Child Behavior InventorT (Robinson et al., 1980). bChild Behavior Check List (Achenbach, 1991a): T scores and percentiles. ~Teacher Report Form (Achenbach, 1991b). dTreatment Satist~tctionmeasure: 7-point scale (7 = ve U satisfied). a
interests. They felt that they n o longer had control over their family and were worried that J o h n ' s behavior was on an irreversible trajectory. They were perplexed by their inability to help J o h n , since they both felt they had strong p a r e n t i n g skills a n d they had little difficulty with their daughteL See Table 1 for a summary of key i n f o r m a t i o n on J o h n ' s behavior. Note that in addition to J o h n ' s externalizing behaviors, his internalizing a n d attention scores on the p a r e n t a n d teacher CBCL were elevated at intake. J o h n ' s scores on the Eyberg Child Behavior Inventory (ECBI) were also in the clinical range (Robinson, Eyberg, & Ross, 1980). The ECBI is a 36-item behavioral inventory that provides a total p r o b l e m score ( n u m b e r of behaviors parents endorse as problematic) as well as an intensity score for those behaviors (how frequently they occur o n a 7-point scale). Problem scores of 16 a n d intensity scores of 142 correspond to the 90th percentile for this measure. O u r school observer visited J o h n ' s classroom on four occasions a n d coded him in two structured and two unstructured periods using the MOOSES coding system (Tapp, Wehby, & Ellis; see Figure 1 for observational
data). The observer n o t e d that J o h n had great difficulty concentrating. D u r i n g both structured observations, J o h n was disengaged for the majority of the time (crawling u n d e r desks, w a n d e r i n g a r o u n d the room). During the u n s t r u c t u r e d observations (on the playground or in the lunch room), J o h n was aggressive with other children o n multiple occasions. The observer's impression was that in the classroom the teacher had given u p o n J o h n . She ignored all his off-task behavior unless he was overtly disruptive or aggressive, at which p o i n t she r e p r i m a n d e d him or asked him to leave the room. She seemed to have stopped requiring anything of him academically. The Smith family was observed in their h o m e for an h o u r on two occasions using the DPICS-R coding system (Robinson & Eyberg, 1981; Webster-Stratton, 1989; see Figure 1 for child data a n d Figure 2 for p a r e n t data). During both observations our observer rated J o h n ' s behavior as very challenging. He was n o n c o m p l i a n t to 79% of his parent's commands, a n d was engaged in o n g o i n g smart talk, namecalling, a n d whining. The coder summary report n o t e d the following:
Sarah a n d Ben are intelligent, thoughtful, considerate parents, b u t n o t h i n g they do is working. They e n c o u r a g e conversation a n d o p i n i o n s from the children, b u t J o h n consistently responds by saying they are d u m b or stupid. They a t t e m p t to discuss his feelings a n d are completely b a m b o o zled when his response is defiance a n d n o n c o m pliance. It is an awful situation that the parents keep f e e d i n g into. He cries over real or i m a g i n e d hurts a n d the parents are all over him with comfort a n d questions. The m i n u t e they leave, he stops. His sister gets very little of their time b e c a u s e J o h n is the c e n t e r of t h e i r universe. He is c o n t r o l l i n g the h o u s e h o l d with his negative behavior. T h e r e are n o negative c o n s e q u e n c e s for J o h n ' s behavior.
Treatment
T r e a t m e n t b e g a n in October, following the assessment p e r i o d . J o h n and his parents came to the clinic each week for 2 hours in the evening. During that time J o h n att e n d e d the child group with five other children (three boys and two girls, ages 4 to 7) a n d his parents a t t e n d e d the p a r e n t i n g group with the parents of those children.
The Incredible Years
8O
50 e
60 5
"~ - % Child
4O
Noncomply
40
•
- # Child Negative
o. 2 0
--
j
.L
% Disengaged
..
30 o
# School Aggression
0
/
381
D.
20
Parent group. D u r i n g the initial group, parents described their child a n d their reasons for c o m i n g to the clinic. T h e parents in this g r o u p s e e m e d to form an imm e d i a t e b o n d with o t h e r parents a r o u n d the c o m m o n issues of aggression, n o n c o m p l i a n c e , a n d school problems. Many of the parents, Sarah, in particular, d e s c r i b e d how isolated she felt as a p a r e n t o f a " p r o b l e m child." She felt that they could no l o n g e r socialize with their friends because J o h n was n o t able to behave appropriately. She felt j u d g e d by o t h e r parents a n d was b e g i n n i n g to feel that she was a "bad parent" because n o t h i n g she d i d worked with J o h n . After the group, Ben privately expressed relief a b o u t the o t h e r parents in the group. H e said, "I can see that this is a g r o u p o f good, c o m m i t t e d parents. They are a lot like we are a n d are dealing with similar problems." H e h a d b e e n afraid that a p a r e n t i n g g r o u p would consist o f parents who were clearly parenting badly a n d that he a n d Sarah would feel out o f place. Sarah a n d Ben expressed their goals for J o h n primarily in terms of his happiness a n d self-esteem. A l t h o u g h they clearly wanted h o m e life to be smoother, they wanted most for him to be successful in school, to learn to regulate his emotions, a n d make friends with o t h e r children. Sarah a n d Ben were active participants in the parenting group. They a d d e d thoughtful reflections to the g r o u p discussions a n d were able to generalize new material to their own situation. They consistently c o m p l e t e d h o m e w o r k assignments. They were also able to r e s p o n d to o t h e r parents in an u n d e r s t a n d i n g a n d helpful way. They came to the g r o u p with many strengths, a n d the o t h e r m e m b e r s of tile g r o u p trusted their f e e d b a c k a n d opinions. T h e y were also able to see the h u m o r in some of the difficult situations that they f o u n d themselves in with J o h n a n d shared that perspective with o t h e r parents.
] I I I
10
Baseline
Figure 1. Child behaviors o b s e r v e d at h o m e (dashed) and at school (solid) at baseline, posttreatment, and 1-year follow-up. Percent n o n c o m p l y = p e r c e n t a g e n o n c o m p l i a n c e to p a r e n t c o m m a n d s at home. Number child negatives = frequency of child whining, crying, s m a r t talk, and a g g r e s s i o n at h o m e . Number school aggression = frequency of aggressive behaviors to peers or teachers. Percent disengaged = percentage of time that child was disengaged at school.
: Mom Indirect 4 = M o m Direct ~ & - Dad Indirect --" Dad Direct
Post
1-Year
Figure 2. Number of direct (e.g., "Pick up your toys") and indirect ("Wouldn't it be nice if your toys were picked up") parent commands observed at baseline, posttreatment, and 1-year follow up.
Since b o t h parents already h a d many positive interactions with J o h n , the initial topics on play a n d praise were n o t difficult for them. They did note that they enjoyed having the structure a n d the goal of s p e n d i n g focused time with J o h n each day a n d noticed that he s e e m e d to b e c o m e m o r e r e l a x e d with t h e m d u r i n g the regularly structured play times. They struggled somewhat with how to r e s p o n d to him when he b e c a m e negative d u r i n g play sessions, b u t were able to i n c o r p o r a t e differential attention, distraction, a n d i g n o r i n g to redirect his play. T h e topics a n d limit-setting units were m o r e challenging for the Smiths. Both were a c c u s t o m e d to r e a s o n i n g with J o h n when he was misbehaving. As n o t e d by o u r observer d u r i n g the h o m e visit, this p r o v i d e d J o h n with considerable attention for his misbehavior. Observations indicated that Sarah gave a high n u m b e r o f vague, i n d i r e c t c o m m a n d s ( m o r e than 1 p e r minute) a n d few clear, direct c o m m a n d s . She s e e m e d u n c e r t a i n a n d tentative a b o u t limit setting. Both Sarah a n d Ben intellectually und e r s t o o d the principle of using i g n o r i n g when J o h n was a n n o y i n g o r v e r b a l l y abusive a n d t i m e - o u t w h e n he was aggressive. However, they h a d some initial difficulty i m p l e m e n t i n g these strategies. They h a d tried using time-out b u t h a d always given u p partway t h r o u g h the process because o f J o h n ' s aggressive a n d destructive behavior. J o h n was very persistent with his whining a n d tantrums, a n d b o t h parents n e e d e d s u p p o r t a n d e n c o u r a g e m e n t to stick to their discipline plans. F o r Sarah, this involved teaching h e r to use calming self-talk (e.g., "I can stay calm, I can h a n d l e this") a n d r e f r a m i n g strategies (e.g., "He will feel safer when he learns there are predictable limits"). With Sarah, in particular, J o h n frequently swore a n d called h e r names, which she f o u n d difficult to ignore. W h e n she d i d ignore, he would also cry a n d yell that she d i d n ' t love him a n d would b e c o m e so upset that she worried a b o u t w h e t h e r he would be okay. She was inclined to catastrophize the situation a n d worry that
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.John's behavior was irreversible a n d that he was on the path to b e c o m i n g a delinquent. Sarah practiced changing these negative thoughts by substituting c o p i n g thoughts such as, "He knows that I love him, h e ' s j u s t saying that to get my attention"; "IfI keep i g n o r i n g this time, n e x t time he'll know that I m e a n business"; "We can c h a n g e this behavior"; ' J o h n is only 6 a n d if we help him now, he won't b e c o m e a delinquent." Ben issued fewer comm a n d s a n d was less affected With encourageby J o h n ' s name-calling a n d tantrums, but he had diffim e n t from the culty i g n o r i n g J o h n ' s destrucgroup, the tive behavior d u r i n g the tantherapists, and trums a n d d u r i n g time-out. The g r o u p discussed with him several role-plays the long-term benefits of conthey m a n a g e d to tinuing to follow t h r o u g h with successfully a time-out even if it m e a n t n e e d i n g to repair d a m a g e c o m p l e t e several that J o h n caused d u r i n g timelengthy time-out out. They also h e l p e d him to s e q u e n c e s with problem-solve ways to make sure that J o h n was safe even John. There was a when he was b e i n g destrucmarked shift in tive d u r i n g the time-outs. their selfWith e n c o u r a g e m e n t from the group, the therapists, a n d confidence after several role-plays where Sarah this point. a n d Ben took turns b e i n g J o h n a n d themselves, they m a n a g e d to successfully c o m p l e t e several lengthy timeout sequences with J o h n . T h e r e was a m a r k e d shift in their self-confidence after this point. A l t h o u g h J o h n c o n t i n u e d to have very difficult days, they felt m o r e e q u i p p e d to h a n d l e his b e h a v i o r at h o m e . T h e y also noticed that the f r e q u e n c y o f these vmT intense t a n t r u m s d e c r e a s e d markedly. T h e topics on c o m m u n i c a t i o n a n d p r o b l e m solving with each o t h e r were, for the most part, review for Sarah a n d Ben. They d i d remark, howevel, that since most o f their energy h a d b e e n focused on .John, they had not taken as m u c h time to talk t o g e t h e r a b o u t o t h e r issues. They used this time to catch up with each o t h e r on o t h e r life issues. As with the play units, they c o m m e n t e d that they a p p r e c i a t e d the assignment to s p e n d focused time with each o t h e r on specific problem-solving exercises. Both noticed that as their lives b e c a m e too busy, they t e n d e d to let the play sessions with the c h i l d r e n as well as their time with each o t h e r slip. W h e n they did this, they f o u n d that they were in "reaction m o d e " with each o t h e r a n d with J o h n . W h e n they were able to turn this a r o u n d a n d plan the time to play with the children a n d talk to each other, they felt m o r e proactive and in control o f
their family time. With the e n c o u r a g e m e n t o f the group, Sarah a n d Ben also s c h e d u l e d some evenings t o g e t h e r away from the children. They also d e c i d e d that when the p a r e n t g r o u p was over, they would c o n t i n u e to go o u t tog e t h e r on the night that the g r o u p h a d b e e n held. Working with the school and teacher training. A l t h o u g h Sarah a n d Ben progressed relatively easily t h r o u g h the p a r e n t i n g p r o g r a m in terms o f their skills at h o m e a n d their interactions with J o h n , they were e x p e r i e n c i n g significant conflict with the school. Even after J o h n ' s behavior b e g a n to improve at h o m e , it c o n t i n u e d to worsen at school. His teacher was r e p e a t e d l y requesting that he be removed from h e r classroom, a n d J o h n was so u n h a p p y at school that it b e c a m e a battle j u s t to get him o n t o the bus in the mornings. Sarah a n d Ben h a d b e e n called into the school on n u m e r o u s occasions because o f J o h n ' s behavior. In one instance at r e c e s s , J o h n was digging in the dirt with an o p e n p a p e r clip. W h e n the p l a y g r o u n d assistant requested that J o h n give h e r the p a p e r clip, he refused a n d waved it at her. The i n c i d e n t was written up describing the p a p e r clip as a weapon. Since the school h a d a no-tolerance policy, the school p l a n n e d to s u s p e n d J o h n for 3 days. A l t h o u g h Sarah a n d Ben h a d excellent interpersonal skills, their relationship with J o h n ' s t e a c h e r a n d with the school principal had b e c o m e quite adversarial. T h e Smiths r e p o r t e d that whenever they m e t with the principal a n d the teachers, they felt personally attacked, a n d felt responsible for d e f e n d i n g J o h n , even t h o u g h they a g r e e d that his behavior h a d b e e n unacceptable. Particularly in the p a p e r clip incident, they felt that if a similar event had o c c u r r e d with a n o t h e r child, it would have not b e e n h a n d l e d so severely. In o u r conversations with the school, it was clear that the teacher a n d principal were fl-ustrated with the Smiths, with.John, a n d with the difficulty o f d e a l i n g with .John's aggressive a n d n o n c o m pliant behavior on a day-to-day basis. In addition, parents of o t h e r children were reluctant to allow J o h n to associate with their children because o f his aggressive behavior. T h e typical sequence of o u r t r e a t m e n t p r o g r a m is for the p a r e n t a n d child groups to m e e t for the first m o n t h a n d then to begin the t e a c h e r training after we have established relationships with the families a n d have worked with the child. In a d d i t i o n to the four s c h e d u l e d days o f teacher training, o u r therapists m e e t with parents a n d teachers to develop behavior plans a n d deal with school issues. Two to three meetings o f this type are built into the t r e a t m e n t protocol, but, if necessa~T, m o r e meetings are a d d e d in special circumstances such as this (all extra meetings are d o c m n e n t e d in o u r therapy records). It quickly b e c a m e clear that earlier intervention with the school a n d teacher would be necessm T with J o h n . After the i n c i d e n t with the p a p e r clip, a school m e e t i n g was set up with the therapist, the teacher, the principal, a n d Sarah and Ben. The therapist rehearsed with Sarah mad Ben
The Incredible Years
the i m p o r t a n c e of b e g i n n i n g the m e e t i n g with an ack n o w l e d g m e n t of the work that the teacher a n d school had d o n e o n J o h n ' s behalf. They also agreed to share some of the difficulties they were having with J o h n at home. Lastly, they rehearsed a n o n c o n f r o n t a t i v e way to request that the school consider an alternative to suspension. With the therapist at the m e e t i n g to support them, they felt comfortable acknowledging that they knew that J o h n was a difficult child to manage. This helped to establish a b o n d with the teacher, who had b e e n feeling as if J o h n ' s parents blamed her for all the difficulties that J o h n was having. The therapist also helped discuss with the principal that s e n d i n g J o h n h o m e for misbehavior could actually backfire a n d be reinforcing for J o h n since he felt so negatively about b e i n g at school. Together, the teacher, principal, a n d parents agreed that for aggressive behaviors, J o h n would be given a brief time-out in the classroom or the office or would lose the privilege of using the classroom computer. The therapist e n c o u r a g e d everyone to think of the process of making J o h n successful in this classroom as a long-term goal with many small steps. At that m e e t i n g the teacher a n d the Smiths b e g a n to set u p a behavior plan to increase home-school c o m m u n i c a t i o n a n d to focus o n small, positive goals for J o h n ' s behavior in the classroom. J o h n ' s teacher a t t e n d e d teacher training when it began in November. Although she participated actively in the training sessions, she a n d the Smiths c o n t i n u e d to report that the situation at school had n o t improved. It began to seem that J o h n had established such a negative reputation in that classroom in the first few m o n t h s of school that it was hard for his teacher a n d his peers to view him in a positive light. A n o t h e r school m e e t i n g was set up to discuss the c o n t i n u e d difficulty, a n d it was decided that J o h n might be more successful in the other k i n d e r g a r t e n classroom in the school. Moving a child to a new classroom is quite u n u s u a l in o u r program, b u t seemed to be the best option in this particular situation. Prior to moving J o h n to the second classroom, a m e e t i n g was set up with the old a n d new teacher, J o h n ' s parents, a n d the therapist from the clinic. A transition plan was discussed so that J o h n would begin in the new classroom with a behavior plan in place. This plan focused on a few positive behavioral goals with f r e q u e n t reinforcement, a "wiggle space" for times when J o h n was having difficulty sitting still, a n d a back-up time-out plan for severe negative behavior. J o h n had b e e n participating very successfully in the child Dinosaur groups at the P a r e n t i n g Clinic, so feedback from the clinic child therapist was incorporated into the plan. J o h n was able to earn breaks for successfully completing manageable parts of his seatwork. Because it was difficult for him to sit still for long periods of time, he was also given sanctioned reasons to move a r o u n d the classroom. The therapist also worked individ-
ually with the new teacher to make u p the c o n t e n t that she had missed d u r i n g the first teacher training meetings. The new teacher agreed to attend the s u b s e q u e n t teacher training sessions. This classroom switch worked extremely well for J o h n . His new teacher was able to begin on a more positive note with J o h n . His behavior c o n t i n u e d to be difficult, b u t she had the support of the principal, the therapist at the clinic, a n d Sarah a n d Ben, so problems were addressed as they occurred. Peer issues were also addressed immediately, a n d his new teacher made a concerted effort to introduce J o h n to the class in a positive The therapist light. As part of his behavior encouraged plan he was able to earn everyone to think chances to assist other child r e n (an activity that had of the process of proven to be very reinforcing making John to him in our child Dinosaur successful in this group at the clinic). O n the playground, J o h n was initially classroom as a limited to activities in a long-term goal smaller, well-supervised area, with many small a n d t h r o u g h appropriate behavior was able to earn the steps. privilege of expanded recess. D u r i n g the r e m a i n d e r of the year, there were several additional incidents that required Sarah a n d Ben to meet with the teacher a n d the principal. For those meetings, the therapist met with Sarah a n d Ben at the clinic prior to the school m e e t i n g a n d discussed a strategy with them. T h e n they a t t e n d e d the school meetings themselves a n d worked with the school to set up a plan to deal with the problems. This increased their confidence in their ability to deal successfully o n their own with the school issues. By the e n d of the year, the principal, teacher, a n d Sarah a n d Ben had an effective, collaborative relationship. W h e n o u r therapist att e n d e d the last m e e t i n g to discuss a transition plan for the next year, Sarah a n d Ben n e e d e d little help to negotiate the best p l a c e m e n t for J o h n ' s second-grade year. Altogether, the therapist a t t e n d e d two initial meetings at the school a n d the transition m e e t i n g at the e n d of the year. Therapists from the P a r e n t i n g Clinic also called J o h n ' s teacher d u r i n g the year to check o n his behavior plan a n d update her o n the c u r r i c u l u m presented to J o h n in the Dinosaur group. Although the timing of these meetings was earlier than o u r usual protocol, the n u m b e r of meetings was well within the usual range for our o t h e r families. The therapist spent slightly more time o n p h o n e consultations than for families where school issues were n o t the m a i n concern. Child Dinosaur social skills and problem-solving group. J o h n was initially resistant to the idea of c o m i n g to the child
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groups. His negative experience with school made him extremely reluctant to participate in any activity that seemed remotely like school. He reported that he hated the children at his daytime school a n d did n o t want to meet any new children at night. In addition, because of his attentional difficulties, participating in a 2-hour group after a long day in the classroom was a challenge. D u r i n g the first several sessions, the child group leaders allowed children to discuss their feelings about coming to the groups. The leaders had the puppets model that they, too, had b e e n scared or mad when they first came to Dinosaur school, b u t that they soon started to like the group, a n d that they made good friends. After this initial processing, the therapists ignored J o h n ' s cornplaints a b o u t b e i n g in the group. Rather, they focused on praising a n d giving tokens While he was for any appropriate behavior reluctant to that he exhibited. They quickly volunteer answers noticed that while he was reluctant to volunteer answers or p a r t i c i p a t e o n or participate on his own, if he his o w n , if h e w a s was asked m help another child a s k e d to help with an answer or a project, he quickly became involved. a n o t h e r c h i l d with Initially, J o h n sought attenan a n s w e r or a tion from the other children project, he quickly in the group by being disruptive and inappropriate. The became involved. other children were taught to ignore this inappropriate behavior.John was also put in charge of h e l p i n g to m o n i t o r other children's friendly and positive behavior. This provided him with an opportunity to receive attention a n d positive approval from the other children. Children were taught to c o m p l i m e n t things that they liked about the other children, a n d therapists repeatedly p o i n t e d out a n d reinforced every instance of friendly behavior they observed. After four sessions, .John began to report to his parents that he liked Dinosaur school. Two of the other boys in the group became friends with J o h n , a n d they began to have some play dates alter school. From this p o i n t on, J o h n was consistently positive about coming to the group a n d his parents reported that he seemed happy a b o u t a group peer activity for the first time in his life. A second issue for.John d u r i n g the child groups was difficulty sitting a n d a t t e n d i n g for more than a few minutes at a time. (In this particular group, three children had b e e n diagnosed with ADHD, a n d . J o h n had borderline symptoms, so modifications made for J o h n were also used tbr the other children.) The therapists arranged the format of the group such that children had f r e q u e n t opportunities to change activities and move around. After watching each videotaped vignette, therapists would lead
a brief discussion with the p u p p e t a n d then would have children get up a n d role-play the situation. They continually interspersed sedentary activities with more active rehearsal a n d hands-on l e a r n i n g to engage the children. J o h n was reinforced for attentive behavior, b u t the therapist also ignored considerable wiggling a n d movement, if he was engaged in the lesson. J o h n was also allowed to leave the group a n d go to a "wiggle space" if he was unable to sit still. Unlike time-out, this was n o t a punishment, a n d J o h n could participate in the group discussions from the wiggle space as long as he appropriately raised his hand. At first therapists p r o m p t e d him to use the wiggle space, a n d eventually he began to learn to recognize when he n e e d e d a break from sitting still. As long as the activities c h a n g e d frequently a n d the therapists m o n i t o r e d J o h n ' s attention level a n d n e e d to move around, they were able to keep him engaged a n d on-task. W h e n reviewing tapes of the sessions,John's p r o b l e m behavior frequently occurred if he had b e e n sitting for longer periods of time without a break. If a therapist m a n a g e d to redirect a n d re-engage him when he first became restless or off-task, the sequence of misbehavior could be diverted fairly easily. Summary of treatment. John's behavior improved at home first as Sarah a n d Ben began to use more effective limit setting, c o m b i n e d with f r e q u e n t positive interactions. There c o n t i n u e d to be explosive incidents t h r o u g h o u t the t r e a t m e n t period, b u t they became less frequent, a n d Sarah a n d Ben were confident in their abilit)" to h a n d l e the problems. The Dinosaur child group quickly became a reinforcing activity for J o h n , a n d he made some of his first friends in the group. His parents reported that he was p r o u d of these friends a n d p r o u d of his ability to help them. This was in sharp contrast to his negative feelings a b o u t peers a n d school at the b e g i n n i n g of the year. The school situation was most difficult for this family. The change in the classroom p l a c e m e n t along with some initial work in h e l p i n g the parents a n d school to work together f b r J o h n (instead of b l a m i n g each other for the difficulties) led to a m u c h smoother school experience for J o h n . As at h o m e , J o h n ' s difficult behavior a n d explosive episodes at school c o n t i n u e d , b u t were reported to be less f r e q u e n t a n d less intense. In addition, the school and the teacher felt capable in their ability to handle the behaviors a n d work collaboratively with J o h n ' s parents to set goals a n d modify his behavior plan as needed. It is worth n o t i n g that a classroom change, such as this one, is rare in the families who participate in our treatment. O u r first goal is almost always to make a c u r r e n t classroom situation work for the child a n d the teacher. However, in cases where a classroom switch is det e r m i n e d to be most beneficial to the child, the goal of the t r e a t m e n t then becomes to make the transition as smooth as possible.
The Incredible Years
Posttreatment All observations a n d reports were collected again immediately p o s t t r e a t m e n t (6 m o n t h s after the initial assessment, a n d I m o n t h p r i o r to school ending) a n d I a n d 2 years later when J o h n was in grades 2 a n d 3 (see Tables 1 a n d Figures 1 a n d 2). Overall, J o h n showed fewer behavior p r o b l e m s following treatment, a n d these changes m a i n t a i n e d at the follow-up assessments. O n the ECBI, J o h n ' s behavior was in the clinical range at pretest a n d in the n o r m a l range at posttest a n d follow-up. O n the CBCL, a c c o r d i n g to p a r e n t report, J o h n ' s scores d e c r e a s e d across time points. It is clear from the scores, however, that he c o n t i n u e d to have h i g h e r rates o f externalizing p r o b l e m s (particularly at school) than o t h e r c h i l d r e n his age. It is notable that his internalizing CBCL scores d r o p p e d to within the n o r m a l range following treatment. J o h n ' s scores on the Attention subscale of the CBCL d r o p p e d a c c o r d i n g to p a r e n t report, b u t r e m a i n e d high on the t e a c h e r report. It is also notable that Sarah a n d Ben's stress scores related to p a r e n t i n g issues d r o p p e d substantially following treatment, reflecting their reports that a l t h o u g h J o h n c o n t i n u e d to be a challenging child, they now felt they h a d the skills to m a n a g e his behavior. T h e h o m e observations reflected a m u c h different picture than those at pretest. T h e average n u m b e r o f negative behaviors (whining, crying, yelling, n a m e calling) that J o h n displayed d r o p p e d from 43 at pretest to a r o u n d 3 at posttest a n d follow-up. In addition, the observer's r e p o r t reflected a different atmosphere. Overall, Sarah a n d Ben issued fewer c o m m a n d s , a n d Sarah, in particular, drastically r e d u c e d h e r use o f indirect o r vague c o m m a n d s . J o h n was still n o n c o m p l i a n t approximately 60% o f the time, b u t this was a r e d u c t i o n from baseline, a n d Sarah a n d Ben followed t h r o u g h when J o h n was n o n c o m p l i a n t . D u r i n g one visit, J o h n was given a time-out for n o n c o m p l i a n c e . J o h n c o m p l a i n e d a n d called his m o t h e r names, b u t she i g n o r e d a n d calmly followed t h r o u g h with the time-out. W h e n J o h n r e t u r n e d from time-out, he initially p o u t e d , b u t received little attention for the p o u t i n g a n d quickly r e j o i n e d the conversation in a positive manner. This time the coder's impressions o f the visit were, "These parents enjoy s p e n d i n g time as a family a n d are very involved in their kid's activities. Sarah a n d Ben a p p e a r to have the art o f i g n o r i n g down. J o h n m a d e negative c o m m e n t s at the start o f each visit, b u t these c o m m e n t s d i s a p p e a r e d when he received no attention for them. These parents a p p e a r to have g o o d control over b o t h children." T h e p o s t t r e a t m e n t school observation also showed a different situation than the p r e t r e a t m e n t observation. T h e observer r e p o r t e d that J o h n was somewhat restless a n d inattentive d u r i n g the two circle times, but that the t e a c h e r i g n o r e d the inisbehaviors a n d re-engaged him in the discussion. D u r i n g seatwork, J o h n finished his work
a n d went to the t e a c h e r to receive a sticker. D u r i n g recess,John was actively e n g a g e d in playing with o t h e r children. At one point, the playing b e c a m e r o u g h as J o h n a n d three o t h e r c h i l d r e n b e g a n tossing rocks into the air (although n o t at a n o t h e r child). A recess assistant interv e n e d a n d J o h n a n d a friend were sent to a different p a r t of the playground, where they b e g a n to dig a hole. At ano t h e r recess, he played kickball with friends. Follow-up Contact With the Family A l t h o u g h their t r e a t m e n t e n d e d 3 years ago, Sarah a n d Ben have c o n t i n u e d to stay in touch with their therapists at the P a r e n t i n g Clinic. Over the past 3 years, J o h n has c o n t i n u e d to be challenging at h o m e a n d at school, b u t his behavior in both settings is m o r e manageable. Sarah a n d Ben r e p o r t that J o h n ' s difficult times frequently coincide with times when their schedules are busier than usual a n d / o r they have stopped being as consistent with positive discipline a n d limit setting. At these times, they make an effort to sit down together a n d problem-solve the situation. They almost always feel capable of making the changes they n e e d to in o r d e r to turn Sarah and Ben's the negative cycle around. Ocstress s c o r e s casionally they consult with related t o their therapist a b o u t a difficult situation, but in these inparenting issues stances they have usually already dropped come up with a reasonable plan of action. T h e r e have substantially b e e n two to three major incifollowing dents at school in the past 3 treatment. years. Each time, Sarah and Ben have arranged a meeting with the school a n d have felt capable of h a n d l i n g the situation on their own. They are on very g o o d terms with J o h n ' s teacher a n d the school principal and are comfortable working together with them to plan J o h n ' s education. At the 1-year follow-up, when J o h n was in s e c o n d grade, his parents r e p o r t e d that he h a d b e e n evaluated for special education because o f his c o n t i n u i n g school difficulties. H e h a d an Individualized Education Plan with behavioral goals a n d received resource r o o m instruction for two 40-minute periods a week. H e was also occasionally sent to the resource r o o m if his behavior was u n m a n a g e a b l e in the regular classroom. His parents also r e p o r t e d that he h a d b e g u n taking I m i p r a m i n e for a diagnosis o f Sensory Integration Disorder. At the 2-year follow-up, J o h n was still receiving resource r o o m assistance a n d was c o n t i n u i n g to take the medication. J o h n is involved in g r o u p activities for the first time a n d is enthusiastic a b o u t Boy Scouts a n d baseball. H e has friends at school a n d in the n e i g h b o r h o o d . H e reports that he likes school a n d likes his teacher.
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Reid & Webster-Stratton 82 studies, and 5,272 kids. Journal of Clinical Child Pw:hology, 2Z 180-189. Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical I4sycholog% 66, 7-18. Ftmderburk, B. W., Eyberg, S. M., Newcomb, K., McNeil, C. C., Hembree-Kigin, T., & Capage, L. (1998). Parent-child interaction therapy with behavior problem children: Maintenance of treatment effects in the school setting. ChiM l+lmi(~ Behavicrr Therapy, 21,
Summary Y o u n g c h i l d r e n p r e s e n t i n g with O D D / C D f r e q u e n t l y e x h i b i t t h e s e p r o b l e m s across s e t t i n g s ( h o m e , s c h o o l , p e e r s ) . In a d d i t i o n to o p p o s i t i o n a l a n d aggressive b e h a v iors, t h e y f r e q u e n t l y display s y m p t o m s o f A D H D a n d h i g h e r t h a n n o r m a l levels o f a n x i e t y a n d / o r d e p r e s s i o n . M a n u a l i z e d t r e a t m e n t s t h a t h a v e t h e flexibility" to a d d r e s s
17-38. Lahey, B. B., & Loehm; R. (1997). Attention-deficit/hperactivitydiso~: del; and aduh antisocial behavior: A life span perspective. In D. M. Stoff.J. Breiling, &J. D. Maser (Eds.), Handbook oJanlisocial behav ior (pp. 51-60). NewYork: John Wiley & Sons. Robinson, E. A., & Eyberg, S. M. (1981 ). The dyadic parent-child inter: action coding system: Standardization and validation. Jou*val of Consulting and Clinical Psycholo©; 49, 245 - 250. Robinson, E. A., Eyberg, S. M., & Ross, A. W. (1980). "]7hestandardization of an inventoI y of child conduct problem behaviors. Journal of Clinical Child Ps~cholog3', 9, 22-28. Spanier. G. B. (1976). Measuring dyadic actjustment: New scales for assessing the quality of marriage and similar dyads.Jou~vml of Ma*~ flake and the Fam@, 3& 15-28. "Iapp, J. T., Wehb~;J. H., & Ellis, D. N. (1993). MOOSES: A multiple option obsel~'ation system fi)r experimental studies. Behavioral Research Methods, Instruments, & Compute~:~, 25, 53-56. Webster-Stratton, C. (1989). Dyadic Parent-Child Interaction Coding System-Revised, Seattle. Webster-Stratton, C. (1990). Long-term [ollow-up of tiamilies with young conduct-problem children: From preschool to grade school. Journal o/Consulting and Clinical P~),cholog3; 19, 1344-1349. Wet)stm=Stratton, C. (in press). The Incredible Years Parents, Teachers, and Child Training Series: Early inteccention and prevention programs tor young children. In R S. Jensen & E. D. ttibbs (Eds.), Ps3'chosocialtreaments for child and adolescent disordeT:~: Empirically based approaches. Washington, DC: American Psychological Association. Webster-Stratton, C., & t lammond, M. (1997). Treating children with early-onset conduct problems: A comparison of child and parent training interventions.Journal oJ Consulting and Clinical Psychology, 65, 93-11)9. Webstet=Stratton, C., & Hammond, M. (1998). Conduct problems and level of social competence in Head Start children: Prevalence, pervasiveness, and associated risk thctors. Clinical ChiM andFamily Psychology Rr~iew, 1(2). Webste>Stratton, C., & Hancock, L. (1998). Training tot parents of young children with conduct problems: Content, methods, mad therapeutic processes. In C. E. Schaetin" & J. M. Beriesmeister (Eds.), Handbook of parenting traini,g (pp. 98-152), New York: John Wiley & Sons. Webstm~Stratton, C., Hollinsworth, "I:, & Kotpacott, M. (t989). The long-term eftiectiveness and clinical significance of three costetfective training programs tor tmnilies with condnct-problem children.Journal of Consulti,g and Clinical Ps3"cholog);57, 550-553. Webste~Stratton, C., Reid, M. J., & Hammond, M. (2001). Treating early-onset conduct problems: The benefits (~ combining teacher training with parent and child inte~wention. Manuscript in preparation.
issues in all t h e p r o b l e m a r e a s c a n b e e x t r e m e l y effective f o r t h e s e c h i l d r e n . T h e a b o v e e x a m p l e is a case w h e r e t h e I n c r e d i b l e Years P a r e n t , T e a c h e l , a n d C h i l d p r o g r a m s w e r e u s e d with a c h i l d p r e s e n t i n g with pervasive e x t e r n a l i z i n g b e h a v i o r p r o b l e m s as well as s o m e s y m p t o m s o f A D H D a n d e l e v a t e d i n t e r n a l i z i n g s y m p t o m s . T h i s child, family, a n d s c h o o l r e c e i v e d t h e s a m e c o n t e n t as o t h e r p a r e n t s p a r t i c i p a t i n g in o u r g r o u p s . In e a c h area, however, t h e t h e r a p i s t t o c u s e d t h e t r e a t m e n t o n t h e issues t h a t w e r e m o s t s a l i e n t f o r this case. In this way, t h e t h e r a pist was a b l e to tailor t h e m a n u a l i z e d t r e a t m e n t to t h e ind i v i d u a l s i t u a t i o n , with a successful r e s u l t f o r t h e family. In a d d i t i o n to t h e i n d i v i d u a l s u p p o r t p r o v i d e d by t h e t h e r a p i s t s , t h e g r o u p a s p e c t o f t h e t r e a t m e n t was also h e l p f l f l f o r this family. B e i n g p a r t o f a g r o u p o f o t h e r pare n t s a n d c h i l d r e n with similar issues p r o v i d e d s u p p o r t a n d c o n f i d e n c e . T h e s e p e r s o n a l c o n n e c t i o n s with t h e o t h e r f a m i l i e s h e l p e d to r e m o v e s o m e o f t h e s t i g m a a n d guilt t h a t S a r a h a n d B e n felt b e c a u s e o f t h e i r difficulties with J o h n . G r o u p t r a i n i n g c a n also h e l p p a r e n t s to become
more
independent
in
their
problem
solving
( r a t h e r t h a n d e p e n d i n g solely o n t h e t h e r a p i s t ) . S a r a h a n d B e n actively p a r t i c i p a t e d in t h e buddy-calls d u r i n g t h e g r o u p a n d f r e q u e n t l y c a l l e d o t h e r p a r e n t s f o r supp o r t w h e n t h e y w e r e first i m p l e m e n t i n g t i m e - o u t . Even a f t e r t h e g r o u p e n d e d , t h e y c o n t i n u e d to socialize with o t h e r p a r e n t s a n d also u s e d t h e m as r e s o u r c e s w h e n p r o b l e m s c a m e up. F o r J o h n , t h e o t h e r c h i l d r e n in t h e D i n o s a u r g r o u p p r o v i d e d s o m e o f his first positive p e e r relationships.
References Achenbach, T. M. ( 1991 a). Manual/br the Child Behavior Checklist~4-18 and 1991 Profile. Burlington, \q': University of Vermont Department of PsychiatD'. Achenbach, T. M. (1991b). Manual fi)r the Teacho 3 Report Form and 1991 Profile. Burlington, VF: UniversiD' of Vermont Department of PsychiattT. Barkley, R. A., Guevremont, D. C., Anastopoulos, A. D., DuPanl, G.J., & Shelton, 7-. L. 11993). Driving-related risks and outcomes of attention deficit hyperactivity disorder in adolescents and young adtflts: A 3- to 5-year tbllow-up study. Pediatrics, 92, 212-218. Beck, A. T., Steer, R. A., & Garbin, M. G. (1988). Psychometric propm: ties of the Beck Depression lnventolT: Twenty-fiveyears of evaluation. Clinical Psychology Reoiew, 8, 77-100. Brestan, E. V., & Eyberg, S. M. (1998). Efti~ctive psychosocial treatment,s of conduct-disordered children and adolescents: 29 years, "l~
This research was supported by the NIH National (;enter tot Nursing Research Grant #5 R01 NR01075-11. Address correspondence to Jamila Reid, Parenting Clinic, University of Washington, 1107 N.E. 45th St., Suite 305, Seattle, %~_ 98105; e-mail: [email protected].
Received: Jane 1 o, 2001 Accepted: June 20, 2001 t
•
The I n c r e d i b l e Years Parent, Teacher, a n d Child Intervention: Targeting Multiple A r e a s o f Risk for a Young Child With Pervasive C o n d u c t P r o b l e m s U s i n g a Flexible, M a n u a l i z e d Treatment Program M. J a m i l a Reid a n d Carolyn Webster-Stratton, University o f W a s h i n g t o n Young children who present for treatment with oppositional-defiant disorder (ODD) and conduct disorder (CD) frequently exhibit these symptoms across settings and often show comorbid symptoms of attention-deficit~hyperactivity disorder (ADHD) and~or internalizing symptoms such as anxiety or depression. Parent training programs to treat these children must beflexible and comprehensive enough to address these issues. This article outlines a case in which the Incredible Years Parent, Teach~ and Child Training programs were used to treat a young boy,John, with ODD. His problems were pervasive and occurred at home, at school, and with peers. In addition to the ODD symptoms, John exhibited symptoms of ADHD as well as significant anxious and depressed behaviors. This case study outlines how a multimodal, manualized treatment can be applied flexibly to attend to individual family needs and address issues of comorbidity.
HE INCIDENCEofoppositional-defiant disorder (ODD) a n d conduct disorder (CD; key predictors of adolescent delinquency, substance abuse, and violent behavior) in children is alarmingly high, with reported rates of early-onset conduct problems in young children as high as 35% for low-income families (Chambless & Hollon, 1998; Webster-Stratton & Hammond, 1998; WebsterStratton, Hollinsworth, & Kolpacoff, 1989). Parent training has been recognized as one of the most effective approaches to preventing and reducing conduct problems (e.g., Brestan & Eyberg, 1998). However, parent training is often perceived as a narrowly focused intervention that focuses exclusively on increasing child compliance and reducing aggressive behavior at home. While many parents of young children with conduct problems seek help because of noncompliant and aggressive behavior at home, our data with well over 600 children (ages 4 to 7) diagnosed with ODD or CD suggest that 50% to 60% of these children also show clinically significant problem behaviors with teachers and peers (Webster-Stratton, 1990). In addition, as many as 50% of children described as aggressive and disruptive are also comorbid for attentiondeficit/hyperactivity disorder (ADHD; Barkley, Guevremont, Anastopoulos, DuPaul, & Shelton, 1993; Lahey & Loeber, 1997). Lastly, children who exhibit high levels of externalizing (aggressive, oppositional) behaviors also tend to show high levels of internalizing (anxious, withdrawn) behaviors (Achenbach, 1991a). In our sample of children presenting with conduct problems, 34% of children who
T
Cognitive and Behavioral Practice 8, 377-386, 2001 1077-7229/01/377-38651.00/0 Copyright © 2001 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
scored in the clinical range on the externalizing subscale behaviors of the Child Behavior Checklist (CBCL; Achenbach, 1991a) also scored in the clinical range on internalizing behaviors (the CBCL is a standardized, parent-report Parent training measure of child behavior probmust be broadly lems that has been shown to discriminate between clinicbased and flexible referred and nonreferred chilenough to help dren). Thus, the majority of families cope not children who receive treatment for ODD/CD also exhibit difonly with ficulties in other areas. As a aggressive and consequence, treatment for noncompliance these children must be comprehensive and tailored to spebehavior at home, cific client needs. The parent but also target training component of treatindividual goals for ment must be broadly based and flexible enough to help children who are families cope not only with aganxious, socially gressive and noncompliance isolated, rejected behavior at home, but also target individual goals for chilby peers, or dren who are anxious, socially hyperactive. isolated, rejected by peers, or hyperactive. Comprehensive and broadly based parent training, such as Webster-Stratton's Incredible Years Program, is an important starting place for treating children with conduct problems, and will result in clinically significant improvements for two-thirds of children. However, approximately one-third of children treated with this parent training program (and others) will continue to have diffi-
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cuhies with school and peers (e.g., Funderburk et al., 1998; Webster-Stratton, 1990). The addition of child social skills and problem-solving training to this parent training program (Webster-Stratton & H a m m o n d , 1997) improved long-term child outcome at h o m e and observations showed improved positive conflict m a n a g e m e n t with peers compared to children who received only pro: ent training. The combination of parent and child training, however, did not impact children's noncompliant and aggressive behavior in the classroom, according to Each program teacher reports. ~ t m n teacher training was added to the treatconsists of over ment plan, observations in the 200 videotaped classroom indicated signifivignettes of cant decreases in aggressive behavior with peers at school common situations compared with classrooms with faced b y p a r e n t s , no reacher training (Websterteachers, o r Stratton, Reid, & H a m m o n d , 2001 ). These data indicate that children. V i g n e t t e s for young children whose beshow effective and havior problems are pervasive ineffective ways of (i.e., with parents, teachers, and peers), parent training will be handling these most effective when offered situations. in combination with teacher and child training. This type of comprehensive treatment plan targets muhiple risk and protective factors for children with conduct problems across settings and attempts to effect change in all arenas of the child's experience.
The Incredible Years Programs Each of the three Incredible Years parent, child, and teacher training programs used with the family described in this article have been empirically validated in randomized control-group studies tbr use with children (ages 4 to 7) with c o n d u c t problems (Brestan & Eyberg, 1998; Webster-Stratton, in press). The series consists of groupbased training programs for parents, teachers, and children. Each program consists of over 200 videotaped vignettes of c o m m o n situations faced by parents, teachers, or children. Vignettes show effective and ineffective ways of handling these situations and provide the framework for group discussions on how to handle c o m m o n problems. In addition to the vignettes, each program contains detailed treatment mannals with session-by-session checklists, group-leader scripts, program "principles" to highlight, homework materials, books, and practice activities. Although all three programs are manualized, and strict adherence to treatment protocol is important, leaders are trained in a collaborative and problem-solving pro-
cess that stresses the key therapeutic principle of using the particular goals, issues, and circumstances of each group m e m b e r to fit the curriculum into the particular c o n t e x t o f each family or classroom (for a d e t a i l e d description of the collaborative process, see WebsterStratton & Hancock, 1998).
The Parent Program The parent program is held weekly for 2 hours and last.s 22 to 24 weeks. Groups generally contain 12 to 16 parents. The program consists of topics including childdirected play, encouragement, praise, tangible reintbrcement, monitoring, ignoring, limit setting, natural and logical consequences, and time-out. In addition to learning cognitive behavioral principles, parents are helped to understand and accept individual differences in their child's temperament, attention span, needs for attention, ability to regulate emotions, and how their child's unique "wiring" will determine particular parenting approaches. Material on anger management, m o o d regulation, working with schools and teachers, academic success, communication, problem solving with adults and children, and encouraging children's positive peer relationships is also covered. The videotaped vignettes are used by the group leader to "trigger" parent discussions, problem solving, and role-plays of c o m m o n sitnations in the group. The groups are led in a collaborative tormat whereby the lead* ers present material and provide structure to the discussion, while parents set their own goals and extract parenting "principles" from the material presented. Additionally, parents are given weekly homework consisting of reading and behavioral assignments to practice with their children. Parents self-monitor this h o m e w o r k by committing to particular goals they want to accomplish during the week.
The Teacher Program Similar in format to the parent program, the teacher program is taught in 4 day-long sessions spaced throughout the fall and winter of the school year. Teachers of children involved in our clinic are invited to attend the training (to date, approximately 90% of teachers have agreed to participate). The teacher program consists of topics such as building positive relationships with students, strategies to promote parent-teacher collaboration and parent participation, the importance of teacher praise and positive attention, proactive strategies to prevent problems, using tangible reinfbrcement, decreasing inappropriate behavior with limit-setting and time-out, and classroom-management approaches designed to increase children's prosocial and problem-solving skills. As with the parent program, the teacher program is offered as a collaborative venture between the group leader and the teachers. Role-plays and discussion are used to illustrate
The Incredible Years
new concepts. Teachers are seen as the experts a n d are e n c o u r a g e d to use each o t h e r as resources for solving difficult p r o b l e m s in the classroom. With the g r o u p leader's guidance, teachers h e l p each o t h e r to make changes at the classroom level as well as i m p l e m e n t i n g individual behavior plans for the target child. Outside o f the training days, o u r clinic therapists observe the target child in the classroom, m e e t with the teachers individually to develop behavior plans, a n d facilitate meetings with the parents, teachers, a n d o t h e r school personnel. At the e n d o f the school year, o u r clinic therapist works with the parents a n d teachers to develop a transition plan to d o c u m e n t successful strategies for the child's next teacher.
The Child Program: Dinosaur School T h e Dinosaur Social Skills a n d P r o b l e m Solving curriculum is delivered to the c h i l d r e n in the evenings while their parents are participating in the p a r e n t group. T h e groups consist o f six to seven c h i l d r e n a n d are led by two therapists. T h e p r o g r a m contains topics such as school rules, d o i n g your best in school, feelings, p r o b l e m solving, a n g e r m a n a g e m e n t , m a k i n g friends, a n d teamwork. As with the p a r e n t a n d t e a c h e r programs, the p r o g r a m c o n t e n t is illustrated t h r o u g h v i d e o t a p e d vignettes that c h i l d r e n watch a n d discuss. In addition, the Dinosaur P r o g r a m uses child-size p u p p e t s to discuss a n d role-play c o n t e n t with the children. L e a r n i n g is e n h a n c e d by activities, games, colorful cue cards illustrating key concepts, a n d h o m e w o r k activity books. A token e c o n o m y system is used whereby c h i l d r e n earn chips for g o o d behavior, active participation in discussion, a n d prosocial behavior with the o t h e r c h i l d r e n in the group. C a s e Example Intake Information Sarah a n d Ben were r e f e r r e d to the Parenting Clinic by their school psychologist because of difficulties at h o m e a n d at school with their 6-year-old son, J o h n . Alt h o u g h J o h n was j u s t b e g i n n i n g first grade, he h a d a substantial r e p u t a t i o n at the school for his aggressive a n d oppositional behavior in the classroom a n d on the playground. These behaviors h a d b e e n evident when J o h n was in k i n d e r g a r t e n a n d h a d increased in intensity when he e n t e r e d first grade. At the time that the Smiths came to the clinic, his t e a c h e r h a d a p p r o a c h e d his parents a n d told t h e m that she d i d n o t believe h e r classroom was an a p p r o p r i a t e place for J o h n . J o h n was regularly b e i n g sent to the principal's office a n d h a d also b e e n asked to leave school early on at least two occasions because of his aggressive behavior. In a d d i t i o n to these p r o b l e m s at school, Sarah a n d Ben were c o n c e r n e d a b o u t his behavior at home. Both parents d e s c r i b e d J o h n as extremely volatile. H e would
frequently "lose control o f his behavior" a n d e n g a g e in e x t e n d e d t e m p e r tantrums d u r i n g which he would call his parents names, refuse to comply with any requests, a n d e n g a g e in aggressive o r destructive behavior. Both p a r e n t s d e s c r i b e d feeling helpless to c h a n g e J o h n ' s behavior o n c e it r e a c h e d these p r o p o r t i o n s . T h e y rep o r t e d that t h e i r p a r e n t i n g style was usually to talk a n d r e a s o n with J o h n in p r o b l e m situations, b u t felt that this m e r e l y escalated his behavior. T h e y also h a d t r i e d a n u m b e r o f d i f f e r e n t discipline strategies (e.g., time-out, loss o f privileges), b u t felt that J o h n was u n r e s p o n s i v e to Teachers are seen their efforts. They were often at a loss as to what events h a d as the experts and t r i g g e r e d the t a n t r u m s a n d are encouraged to d e s c r i b e d J o h n as having a use each other as 'Jekyll-and-Hyde" personality. They were quick to describe r e s o u r c e s for J o h n ' s strengths as well as his solving difficult difficulties. D u r i n g his g o o d problems in t h e times, they r e p o r t e d that he was a generous, loving, charmclassroom. ing child with a g o o d sense o f humor. J o h n h a d b e e n assessed by a psychologist p r i o r to c o m i n g to the clinic a n d h a d b e e n d i a g n o s e d as having n u m e r o u s symptoms o f ADHD, b u t was j u s t below the t h r e s h o l d w a r r a n t i n g formal diagnosis. P r i o r to c o m i n g to the P a r e n t i n g Clinic, Sarah a n d Ben h a d e n r o l l e d J o h n in a 10-week social skills p r o g r a m r e c o m m e n d e d by t h e i r school counselor, b u t saw no c h a n g e in his b e h a v i o r as a result of the group. In a d d i t i o n to the difficulties of m a n a g i n g J o h n ' s behavior, Sarah a n d Ben were quite c o n c e r n e d a b o u t the effect that his difficulties were having o n his self-esteem. D u r i n g the year p r i o r to the i n t a k e , J o h n h a d b e g u n saying that no one liked him a n d that he was the d u m b e s t kid in his class. They also perceived him as d e p r e s s e d a n d anxious a b o u t school a n d his lack of friends. T h e Smiths are a middle-class Caucasian family. Both parents are college graduates a n d b o t h work (Ben fulltime a n d Sarah part-time). They h a d b e e n m a r r i e d for 13 years a n d b o t h r e p o r t e d a strong a n d positive marital relationship. They also have a d a u g h t e r who was 8 years old at the time of the intake a n d h a d no significant behavior problems. At the time of the intake, n e i t h e r p a r e n t rep o r t e d any m e n t a l h e a l t h issues, a l t h o u g h S a r a h h a d a history o f depression. T h e Beck Depression Inventory (Beck, Steer, & Garbin, 1988) a n d the Dyadic A d j u s t m e n t Scale (Spanier, 1976) c o n f i r m e d n o r m a l scores for depression a n d g o o d marital satisfaction.John's difficulties, however, were p u t t i n g a significant strain on their family's functioning. Both parents felt that J o h n ' s p r o b l e m s were their m a i n focus, to the exclusion o f o t h e r activities a n d
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Table I
Baseline, Posttreatment, and 1- and 2-Year Follow-Up Assessments
Mother Report Eyberg Prob.i' Eyberg Intensity CBCL Ext.b CBCL Int. CBCL Attention Father Report Eyberg Prob. Eyberg Intensity CBCL Ext. CBCL Int. CBCL Attention Teacher Report TRF Ext.c TRF Int. TRF Attention Classroom Observation Ratio of Teacher Praise to Criticals Satisfactiond Mother Father Teacher
Baseline
Immediate Posttreatment
1-Year Follow-up
2-Year Follow-up
18 139 71 (98%) 61 (86%) 63 (90%)
11 118 66 (95%) 57 (76%) 60 (84%)
9 112 63 (90%) 46 (34%) 60 (84%)
4 116 58 (79%) 43 (24%) 57 (76%)
21 155 72 (99%) 71 (98%) 60 (84%)
14 126 70 (98%) 49 (46%) 57 (76%)
7 117 71 (98%) 53 (62%) 63 (90%)
9 107 66 (95%) 53 (62%) 51 (54%)
62 (88%) 51 (54%) 62 (88%)
68 (96%) 57 (76%) 67 (96%)
71 (98%) 56 (73%) 75 (99%)
78 (100%) 60 (84%) 68 (96%)
1.5 ----
7.75 6.5 6 5.7
6 5.3
-__ _
--
Eyberg Child Behavior InventorT (Robinson et al., 1980). bChild Behavior Check List (Achenbach, 1991a): T scores and percentiles. ~Teacher Report Form (Achenbach, 1991b). dTreatment Satist~tctionmeasure: 7-point scale (7 = ve U satisfied). a
interests. They felt that they n o longer had control over their family and were worried that J o h n ' s behavior was on an irreversible trajectory. They were perplexed by their inability to help J o h n , since they both felt they had strong p a r e n t i n g skills a n d they had little difficulty with their daughteL See Table 1 for a summary of key i n f o r m a t i o n on J o h n ' s behavior. Note that in addition to J o h n ' s externalizing behaviors, his internalizing a n d attention scores on the p a r e n t a n d teacher CBCL were elevated at intake. J o h n ' s scores on the Eyberg Child Behavior Inventory (ECBI) were also in the clinical range (Robinson, Eyberg, & Ross, 1980). The ECBI is a 36-item behavioral inventory that provides a total p r o b l e m score ( n u m b e r of behaviors parents endorse as problematic) as well as an intensity score for those behaviors (how frequently they occur o n a 7-point scale). Problem scores of 16 a n d intensity scores of 142 correspond to the 90th percentile for this measure. O u r school observer visited J o h n ' s classroom on four occasions a n d coded him in two structured and two unstructured periods using the MOOSES coding system (Tapp, Wehby, & Ellis; see Figure 1 for observational
data). The observer n o t e d that J o h n had great difficulty concentrating. D u r i n g both structured observations, J o h n was disengaged for the majority of the time (crawling u n d e r desks, w a n d e r i n g a r o u n d the room). During the u n s t r u c t u r e d observations (on the playground or in the lunch room), J o h n was aggressive with other children o n multiple occasions. The observer's impression was that in the classroom the teacher had given u p o n J o h n . She ignored all his off-task behavior unless he was overtly disruptive or aggressive, at which p o i n t she r e p r i m a n d e d him or asked him to leave the room. She seemed to have stopped requiring anything of him academically. The Smith family was observed in their h o m e for an h o u r on two occasions using the DPICS-R coding system (Robinson & Eyberg, 1981; Webster-Stratton, 1989; see Figure 1 for child data a n d Figure 2 for p a r e n t data). During both observations our observer rated J o h n ' s behavior as very challenging. He was n o n c o m p l i a n t to 79% of his parent's commands, a n d was engaged in o n g o i n g smart talk, namecalling, a n d whining. The coder summary report n o t e d the following:
Sarah a n d Ben are intelligent, thoughtful, considerate parents, b u t n o t h i n g they do is working. They e n c o u r a g e conversation a n d o p i n i o n s from the children, b u t J o h n consistently responds by saying they are d u m b or stupid. They a t t e m p t to discuss his feelings a n d are completely b a m b o o zled when his response is defiance a n d n o n c o m pliance. It is an awful situation that the parents keep f e e d i n g into. He cries over real or i m a g i n e d hurts a n d the parents are all over him with comfort a n d questions. The m i n u t e they leave, he stops. His sister gets very little of their time b e c a u s e J o h n is the c e n t e r of t h e i r universe. He is c o n t r o l l i n g the h o u s e h o l d with his negative behavior. T h e r e are n o negative c o n s e q u e n c e s for J o h n ' s behavior.
Treatment
T r e a t m e n t b e g a n in October, following the assessment p e r i o d . J o h n and his parents came to the clinic each week for 2 hours in the evening. During that time J o h n att e n d e d the child group with five other children (three boys and two girls, ages 4 to 7) a n d his parents a t t e n d e d the p a r e n t i n g group with the parents of those children.
The Incredible Years
8O
50 e
60 5
"~ - % Child
4O
Noncomply
40
•
- # Child Negative
o. 2 0
--
j
.L
% Disengaged
..
30 o
# School Aggression
0
/
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D.
20
Parent group. D u r i n g the initial group, parents described their child a n d their reasons for c o m i n g to the clinic. T h e parents in this g r o u p s e e m e d to form an imm e d i a t e b o n d with o t h e r parents a r o u n d the c o m m o n issues of aggression, n o n c o m p l i a n c e , a n d school problems. Many of the parents, Sarah, in particular, d e s c r i b e d how isolated she felt as a p a r e n t o f a " p r o b l e m child." She felt that they could no l o n g e r socialize with their friends because J o h n was n o t able to behave appropriately. She felt j u d g e d by o t h e r parents a n d was b e g i n n i n g to feel that she was a "bad parent" because n o t h i n g she d i d worked with J o h n . After the group, Ben privately expressed relief a b o u t the o t h e r parents in the group. H e said, "I can see that this is a g r o u p o f good, c o m m i t t e d parents. They are a lot like we are a n d are dealing with similar problems." H e h a d b e e n afraid that a p a r e n t i n g g r o u p would consist o f parents who were clearly parenting badly a n d that he a n d Sarah would feel out o f place. Sarah a n d Ben expressed their goals for J o h n primarily in terms of his happiness a n d self-esteem. A l t h o u g h they clearly wanted h o m e life to be smoother, they wanted most for him to be successful in school, to learn to regulate his emotions, a n d make friends with o t h e r children. Sarah a n d Ben were active participants in the parenting group. They a d d e d thoughtful reflections to the g r o u p discussions a n d were able to generalize new material to their own situation. They consistently c o m p l e t e d h o m e w o r k assignments. They were also able to r e s p o n d to o t h e r parents in an u n d e r s t a n d i n g a n d helpful way. They came to the g r o u p with many strengths, a n d the o t h e r m e m b e r s of tile g r o u p trusted their f e e d b a c k a n d opinions. T h e y were also able to see the h u m o r in some of the difficult situations that they f o u n d themselves in with J o h n a n d shared that perspective with o t h e r parents.
] I I I
10
Baseline
Figure 1. Child behaviors o b s e r v e d at h o m e (dashed) and at school (solid) at baseline, posttreatment, and 1-year follow-up. Percent n o n c o m p l y = p e r c e n t a g e n o n c o m p l i a n c e to p a r e n t c o m m a n d s at home. Number child negatives = frequency of child whining, crying, s m a r t talk, and a g g r e s s i o n at h o m e . Number school aggression = frequency of aggressive behaviors to peers or teachers. Percent disengaged = percentage of time that child was disengaged at school.
: Mom Indirect 4 = M o m Direct ~ & - Dad Indirect --" Dad Direct
Post
1-Year
Figure 2. Number of direct (e.g., "Pick up your toys") and indirect ("Wouldn't it be nice if your toys were picked up") parent commands observed at baseline, posttreatment, and 1-year follow up.
Since b o t h parents already h a d many positive interactions with J o h n , the initial topics on play a n d praise were n o t difficult for them. They did note that they enjoyed having the structure a n d the goal of s p e n d i n g focused time with J o h n each day a n d noticed that he s e e m e d to b e c o m e m o r e r e l a x e d with t h e m d u r i n g the regularly structured play times. They struggled somewhat with how to r e s p o n d to him when he b e c a m e negative d u r i n g play sessions, b u t were able to i n c o r p o r a t e differential attention, distraction, a n d i g n o r i n g to redirect his play. T h e topics a n d limit-setting units were m o r e challenging for the Smiths. Both were a c c u s t o m e d to r e a s o n i n g with J o h n when he was misbehaving. As n o t e d by o u r observer d u r i n g the h o m e visit, this p r o v i d e d J o h n with considerable attention for his misbehavior. Observations indicated that Sarah gave a high n u m b e r o f vague, i n d i r e c t c o m m a n d s ( m o r e than 1 p e r minute) a n d few clear, direct c o m m a n d s . She s e e m e d u n c e r t a i n a n d tentative a b o u t limit setting. Both Sarah a n d Ben intellectually und e r s t o o d the principle of using i g n o r i n g when J o h n was a n n o y i n g o r v e r b a l l y abusive a n d t i m e - o u t w h e n he was aggressive. However, they h a d some initial difficulty i m p l e m e n t i n g these strategies. They h a d tried using time-out b u t h a d always given u p partway t h r o u g h the process because o f J o h n ' s aggressive a n d destructive behavior. J o h n was very persistent with his whining a n d tantrums, a n d b o t h parents n e e d e d s u p p o r t a n d e n c o u r a g e m e n t to stick to their discipline plans. F o r Sarah, this involved teaching h e r to use calming self-talk (e.g., "I can stay calm, I can h a n d l e this") a n d r e f r a m i n g strategies (e.g., "He will feel safer when he learns there are predictable limits"). With Sarah, in particular, J o h n frequently swore a n d called h e r names, which she f o u n d difficult to ignore. W h e n she d i d ignore, he would also cry a n d yell that she d i d n ' t love him a n d would b e c o m e so upset that she worried a b o u t w h e t h e r he would be okay. She was inclined to catastrophize the situation a n d worry that
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.John's behavior was irreversible a n d that he was on the path to b e c o m i n g a delinquent. Sarah practiced changing these negative thoughts by substituting c o p i n g thoughts such as, "He knows that I love him, h e ' s j u s t saying that to get my attention"; "IfI keep i g n o r i n g this time, n e x t time he'll know that I m e a n business"; "We can c h a n g e this behavior"; ' J o h n is only 6 a n d if we help him now, he won't b e c o m e a delinquent." Ben issued fewer comm a n d s a n d was less affected With encourageby J o h n ' s name-calling a n d tantrums, but he had diffim e n t from the culty i g n o r i n g J o h n ' s destrucgroup, the tive behavior d u r i n g the tantherapists, and trums a n d d u r i n g time-out. The g r o u p discussed with him several role-plays the long-term benefits of conthey m a n a g e d to tinuing to follow t h r o u g h with successfully a time-out even if it m e a n t n e e d i n g to repair d a m a g e c o m p l e t e several that J o h n caused d u r i n g timelengthy time-out out. They also h e l p e d him to s e q u e n c e s with problem-solve ways to make sure that J o h n was safe even John. There was a when he was b e i n g destrucmarked shift in tive d u r i n g the time-outs. their selfWith e n c o u r a g e m e n t from the group, the therapists, a n d confidence after several role-plays where Sarah this point. a n d Ben took turns b e i n g J o h n a n d themselves, they m a n a g e d to successfully c o m p l e t e several lengthy timeout sequences with J o h n . T h e r e was a m a r k e d shift in their self-confidence after this point. A l t h o u g h J o h n c o n t i n u e d to have very difficult days, they felt m o r e e q u i p p e d to h a n d l e his b e h a v i o r at h o m e . T h e y also noticed that the f r e q u e n c y o f these vmT intense t a n t r u m s d e c r e a s e d markedly. T h e topics on c o m m u n i c a t i o n a n d p r o b l e m solving with each o t h e r were, for the most part, review for Sarah a n d Ben. They d i d remark, howevel, that since most o f their energy h a d b e e n focused on .John, they had not taken as m u c h time to talk t o g e t h e r a b o u t o t h e r issues. They used this time to catch up with each o t h e r on o t h e r life issues. As with the play units, they c o m m e n t e d that they a p p r e c i a t e d the assignment to s p e n d focused time with each o t h e r on specific problem-solving exercises. Both noticed that as their lives b e c a m e too busy, they t e n d e d to let the play sessions with the c h i l d r e n as well as their time with each o t h e r slip. W h e n they did this, they f o u n d that they were in "reaction m o d e " with each o t h e r a n d with J o h n . W h e n they were able to turn this a r o u n d a n d plan the time to play with the children a n d talk to each other, they felt m o r e proactive and in control o f
their family time. With the e n c o u r a g e m e n t o f the group, Sarah a n d Ben also s c h e d u l e d some evenings t o g e t h e r away from the children. They also d e c i d e d that when the p a r e n t g r o u p was over, they would c o n t i n u e to go o u t tog e t h e r on the night that the g r o u p h a d b e e n held. Working with the school and teacher training. A l t h o u g h Sarah a n d Ben progressed relatively easily t h r o u g h the p a r e n t i n g p r o g r a m in terms o f their skills at h o m e a n d their interactions with J o h n , they were e x p e r i e n c i n g significant conflict with the school. Even after J o h n ' s behavior b e g a n to improve at h o m e , it c o n t i n u e d to worsen at school. His teacher was r e p e a t e d l y requesting that he be removed from h e r classroom, a n d J o h n was so u n h a p p y at school that it b e c a m e a battle j u s t to get him o n t o the bus in the mornings. Sarah a n d Ben h a d b e e n called into the school on n u m e r o u s occasions because o f J o h n ' s behavior. In one instance at r e c e s s , J o h n was digging in the dirt with an o p e n p a p e r clip. W h e n the p l a y g r o u n d assistant requested that J o h n give h e r the p a p e r clip, he refused a n d waved it at her. The i n c i d e n t was written up describing the p a p e r clip as a weapon. Since the school h a d a no-tolerance policy, the school p l a n n e d to s u s p e n d J o h n for 3 days. A l t h o u g h Sarah a n d Ben h a d excellent interpersonal skills, their relationship with J o h n ' s t e a c h e r a n d with the school principal had b e c o m e quite adversarial. T h e Smiths r e p o r t e d that whenever they m e t with the principal a n d the teachers, they felt personally attacked, a n d felt responsible for d e f e n d i n g J o h n , even t h o u g h they a g r e e d that his behavior h a d b e e n unacceptable. Particularly in the p a p e r clip incident, they felt that if a similar event had o c c u r r e d with a n o t h e r child, it would have not b e e n h a n d l e d so severely. In o u r conversations with the school, it was clear that the teacher a n d principal were fl-ustrated with the Smiths, with.John, a n d with the difficulty o f d e a l i n g with .John's aggressive a n d n o n c o m pliant behavior on a day-to-day basis. In addition, parents of o t h e r children were reluctant to allow J o h n to associate with their children because o f his aggressive behavior. T h e typical sequence of o u r t r e a t m e n t p r o g r a m is for the p a r e n t a n d child groups to m e e t for the first m o n t h a n d then to begin the t e a c h e r training after we have established relationships with the families a n d have worked with the child. In a d d i t i o n to the four s c h e d u l e d days o f teacher training, o u r therapists m e e t with parents a n d teachers to develop behavior plans a n d deal with school issues. Two to three meetings o f this type are built into the t r e a t m e n t protocol, but, if necessa~T, m o r e meetings are a d d e d in special circumstances such as this (all extra meetings are d o c m n e n t e d in o u r therapy records). It quickly b e c a m e clear that earlier intervention with the school a n d teacher would be necessm T with J o h n . After the i n c i d e n t with the p a p e r clip, a school m e e t i n g was set up with the therapist, the teacher, the principal, a n d Sarah and Ben. The therapist rehearsed with Sarah mad Ben
The Incredible Years
the i m p o r t a n c e of b e g i n n i n g the m e e t i n g with an ack n o w l e d g m e n t of the work that the teacher a n d school had d o n e o n J o h n ' s behalf. They also agreed to share some of the difficulties they were having with J o h n at home. Lastly, they rehearsed a n o n c o n f r o n t a t i v e way to request that the school consider an alternative to suspension. With the therapist at the m e e t i n g to support them, they felt comfortable acknowledging that they knew that J o h n was a difficult child to manage. This helped to establish a b o n d with the teacher, who had b e e n feeling as if J o h n ' s parents blamed her for all the difficulties that J o h n was having. The therapist also helped discuss with the principal that s e n d i n g J o h n h o m e for misbehavior could actually backfire a n d be reinforcing for J o h n since he felt so negatively about b e i n g at school. Together, the teacher, principal, a n d parents agreed that for aggressive behaviors, J o h n would be given a brief time-out in the classroom or the office or would lose the privilege of using the classroom computer. The therapist e n c o u r a g e d everyone to think of the process of making J o h n successful in this classroom as a long-term goal with many small steps. At that m e e t i n g the teacher a n d the Smiths b e g a n to set u p a behavior plan to increase home-school c o m m u n i c a t i o n a n d to focus o n small, positive goals for J o h n ' s behavior in the classroom. J o h n ' s teacher a t t e n d e d teacher training when it began in November. Although she participated actively in the training sessions, she a n d the Smiths c o n t i n u e d to report that the situation at school had n o t improved. It began to seem that J o h n had established such a negative reputation in that classroom in the first few m o n t h s of school that it was hard for his teacher a n d his peers to view him in a positive light. A n o t h e r school m e e t i n g was set up to discuss the c o n t i n u e d difficulty, a n d it was decided that J o h n might be more successful in the other k i n d e r g a r t e n classroom in the school. Moving a child to a new classroom is quite u n u s u a l in o u r program, b u t seemed to be the best option in this particular situation. Prior to moving J o h n to the second classroom, a m e e t i n g was set up with the old a n d new teacher, J o h n ' s parents, a n d the therapist from the clinic. A transition plan was discussed so that J o h n would begin in the new classroom with a behavior plan in place. This plan focused on a few positive behavioral goals with f r e q u e n t reinforcement, a "wiggle space" for times when J o h n was having difficulty sitting still, a n d a back-up time-out plan for severe negative behavior. J o h n had b e e n participating very successfully in the child Dinosaur groups at the P a r e n t i n g Clinic, so feedback from the clinic child therapist was incorporated into the plan. J o h n was able to earn breaks for successfully completing manageable parts of his seatwork. Because it was difficult for him to sit still for long periods of time, he was also given sanctioned reasons to move a r o u n d the classroom. The therapist also worked individ-
ually with the new teacher to make u p the c o n t e n t that she had missed d u r i n g the first teacher training meetings. The new teacher agreed to attend the s u b s e q u e n t teacher training sessions. This classroom switch worked extremely well for J o h n . His new teacher was able to begin on a more positive note with J o h n . His behavior c o n t i n u e d to be difficult, b u t she had the support of the principal, the therapist at the clinic, a n d Sarah a n d Ben, so problems were addressed as they occurred. Peer issues were also addressed immediately, a n d his new teacher made a concerted effort to introduce J o h n to the class in a positive The therapist light. As part of his behavior encouraged plan he was able to earn everyone to think chances to assist other child r e n (an activity that had of the process of proven to be very reinforcing making John to him in our child Dinosaur successful in this group at the clinic). O n the playground, J o h n was initially classroom as a limited to activities in a long-term goal smaller, well-supervised area, with many small a n d t h r o u g h appropriate behavior was able to earn the steps. privilege of expanded recess. D u r i n g the r e m a i n d e r of the year, there were several additional incidents that required Sarah a n d Ben to meet with the teacher a n d the principal. For those meetings, the therapist met with Sarah a n d Ben at the clinic prior to the school m e e t i n g a n d discussed a strategy with them. T h e n they a t t e n d e d the school meetings themselves a n d worked with the school to set up a plan to deal with the problems. This increased their confidence in their ability to deal successfully o n their own with the school issues. By the e n d of the year, the principal, teacher, a n d Sarah a n d Ben had an effective, collaborative relationship. W h e n o u r therapist att e n d e d the last m e e t i n g to discuss a transition plan for the next year, Sarah a n d Ben n e e d e d little help to negotiate the best p l a c e m e n t for J o h n ' s second-grade year. Altogether, the therapist a t t e n d e d two initial meetings at the school a n d the transition m e e t i n g at the e n d of the year. Therapists from the P a r e n t i n g Clinic also called J o h n ' s teacher d u r i n g the year to check o n his behavior plan a n d update her o n the c u r r i c u l u m presented to J o h n in the Dinosaur group. Although the timing of these meetings was earlier than o u r usual protocol, the n u m b e r of meetings was well within the usual range for our o t h e r families. The therapist spent slightly more time o n p h o n e consultations than for families where school issues were n o t the m a i n concern. Child Dinosaur social skills and problem-solving group. J o h n was initially resistant to the idea of c o m i n g to the child
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groups. His negative experience with school made him extremely reluctant to participate in any activity that seemed remotely like school. He reported that he hated the children at his daytime school a n d did n o t want to meet any new children at night. In addition, because of his attentional difficulties, participating in a 2-hour group after a long day in the classroom was a challenge. D u r i n g the first several sessions, the child group leaders allowed children to discuss their feelings about coming to the groups. The leaders had the puppets model that they, too, had b e e n scared or mad when they first came to Dinosaur school, b u t that they soon started to like the group, a n d that they made good friends. After this initial processing, the therapists ignored J o h n ' s cornplaints a b o u t b e i n g in the group. Rather, they focused on praising a n d giving tokens While he was for any appropriate behavior reluctant to that he exhibited. They quickly volunteer answers noticed that while he was reluctant to volunteer answers or p a r t i c i p a t e o n or participate on his own, if he his o w n , if h e w a s was asked m help another child a s k e d to help with an answer or a project, he quickly became involved. a n o t h e r c h i l d with Initially, J o h n sought attenan a n s w e r or a tion from the other children project, he quickly in the group by being disruptive and inappropriate. The became involved. other children were taught to ignore this inappropriate behavior.John was also put in charge of h e l p i n g to m o n i t o r other children's friendly and positive behavior. This provided him with an opportunity to receive attention a n d positive approval from the other children. Children were taught to c o m p l i m e n t things that they liked about the other children, a n d therapists repeatedly p o i n t e d out a n d reinforced every instance of friendly behavior they observed. After four sessions, .John began to report to his parents that he liked Dinosaur school. Two of the other boys in the group became friends with J o h n , a n d they began to have some play dates alter school. From this p o i n t on, J o h n was consistently positive about coming to the group a n d his parents reported that he seemed happy a b o u t a group peer activity for the first time in his life. A second issue for.John d u r i n g the child groups was difficulty sitting a n d a t t e n d i n g for more than a few minutes at a time. (In this particular group, three children had b e e n diagnosed with ADHD, a n d . J o h n had borderline symptoms, so modifications made for J o h n were also used tbr the other children.) The therapists arranged the format of the group such that children had f r e q u e n t opportunities to change activities and move around. After watching each videotaped vignette, therapists would lead
a brief discussion with the p u p p e t a n d then would have children get up a n d role-play the situation. They continually interspersed sedentary activities with more active rehearsal a n d hands-on l e a r n i n g to engage the children. J o h n was reinforced for attentive behavior, b u t the therapist also ignored considerable wiggling a n d movement, if he was engaged in the lesson. J o h n was also allowed to leave the group a n d go to a "wiggle space" if he was unable to sit still. Unlike time-out, this was n o t a punishment, a n d J o h n could participate in the group discussions from the wiggle space as long as he appropriately raised his hand. At first therapists p r o m p t e d him to use the wiggle space, a n d eventually he began to learn to recognize when he n e e d e d a break from sitting still. As long as the activities c h a n g e d frequently a n d the therapists m o n i t o r e d J o h n ' s attention level a n d n e e d to move around, they were able to keep him engaged a n d on-task. W h e n reviewing tapes of the sessions,John's p r o b l e m behavior frequently occurred if he had b e e n sitting for longer periods of time without a break. If a therapist m a n a g e d to redirect a n d re-engage him when he first became restless or off-task, the sequence of misbehavior could be diverted fairly easily. Summary of treatment. John's behavior improved at home first as Sarah a n d Ben began to use more effective limit setting, c o m b i n e d with f r e q u e n t positive interactions. There c o n t i n u e d to be explosive incidents t h r o u g h o u t the t r e a t m e n t period, b u t they became less frequent, a n d Sarah a n d Ben were confident in their abilit)" to h a n d l e the problems. The Dinosaur child group quickly became a reinforcing activity for J o h n , a n d he made some of his first friends in the group. His parents reported that he was p r o u d of these friends a n d p r o u d of his ability to help them. This was in sharp contrast to his negative feelings a b o u t peers a n d school at the b e g i n n i n g of the year. The school situation was most difficult for this family. The change in the classroom p l a c e m e n t along with some initial work in h e l p i n g the parents a n d school to work together f b r J o h n (instead of b l a m i n g each other for the difficulties) led to a m u c h smoother school experience for J o h n . As at h o m e , J o h n ' s difficult behavior a n d explosive episodes at school c o n t i n u e d , b u t were reported to be less f r e q u e n t a n d less intense. In addition, the school and the teacher felt capable in their ability to handle the behaviors a n d work collaboratively with J o h n ' s parents to set goals a n d modify his behavior plan as needed. It is worth n o t i n g that a classroom change, such as this one, is rare in the families who participate in our treatment. O u r first goal is almost always to make a c u r r e n t classroom situation work for the child a n d the teacher. However, in cases where a classroom switch is det e r m i n e d to be most beneficial to the child, the goal of the t r e a t m e n t then becomes to make the transition as smooth as possible.
The Incredible Years
Posttreatment All observations a n d reports were collected again immediately p o s t t r e a t m e n t (6 m o n t h s after the initial assessment, a n d I m o n t h p r i o r to school ending) a n d I a n d 2 years later when J o h n was in grades 2 a n d 3 (see Tables 1 a n d Figures 1 a n d 2). Overall, J o h n showed fewer behavior p r o b l e m s following treatment, a n d these changes m a i n t a i n e d at the follow-up assessments. O n the ECBI, J o h n ' s behavior was in the clinical range at pretest a n d in the n o r m a l range at posttest a n d follow-up. O n the CBCL, a c c o r d i n g to p a r e n t report, J o h n ' s scores d e c r e a s e d across time points. It is clear from the scores, however, that he c o n t i n u e d to have h i g h e r rates o f externalizing p r o b l e m s (particularly at school) than o t h e r c h i l d r e n his age. It is notable that his internalizing CBCL scores d r o p p e d to within the n o r m a l range following treatment. J o h n ' s scores on the Attention subscale of the CBCL d r o p p e d a c c o r d i n g to p a r e n t report, b u t r e m a i n e d high on the t e a c h e r report. It is also notable that Sarah a n d Ben's stress scores related to p a r e n t i n g issues d r o p p e d substantially following treatment, reflecting their reports that a l t h o u g h J o h n c o n t i n u e d to be a challenging child, they now felt they h a d the skills to m a n a g e his behavior. T h e h o m e observations reflected a m u c h different picture than those at pretest. T h e average n u m b e r o f negative behaviors (whining, crying, yelling, n a m e calling) that J o h n displayed d r o p p e d from 43 at pretest to a r o u n d 3 at posttest a n d follow-up. In addition, the observer's r e p o r t reflected a different atmosphere. Overall, Sarah a n d Ben issued fewer c o m m a n d s , a n d Sarah, in particular, drastically r e d u c e d h e r use o f indirect o r vague c o m m a n d s . J o h n was still n o n c o m p l i a n t approximately 60% o f the time, b u t this was a r e d u c t i o n from baseline, a n d Sarah a n d Ben followed t h r o u g h when J o h n was n o n c o m p l i a n t . D u r i n g one visit, J o h n was given a time-out for n o n c o m p l i a n c e . J o h n c o m p l a i n e d a n d called his m o t h e r names, b u t she i g n o r e d a n d calmly followed t h r o u g h with the time-out. W h e n J o h n r e t u r n e d from time-out, he initially p o u t e d , b u t received little attention for the p o u t i n g a n d quickly r e j o i n e d the conversation in a positive manner. This time the coder's impressions o f the visit were, "These parents enjoy s p e n d i n g time as a family a n d are very involved in their kid's activities. Sarah a n d Ben a p p e a r to have the art o f i g n o r i n g down. J o h n m a d e negative c o m m e n t s at the start o f each visit, b u t these c o m m e n t s d i s a p p e a r e d when he received no attention for them. These parents a p p e a r to have g o o d control over b o t h children." T h e p o s t t r e a t m e n t school observation also showed a different situation than the p r e t r e a t m e n t observation. T h e observer r e p o r t e d that J o h n was somewhat restless a n d inattentive d u r i n g the two circle times, but that the t e a c h e r i g n o r e d the inisbehaviors a n d re-engaged him in the discussion. D u r i n g seatwork, J o h n finished his work
a n d went to the t e a c h e r to receive a sticker. D u r i n g recess,John was actively e n g a g e d in playing with o t h e r children. At one point, the playing b e c a m e r o u g h as J o h n a n d three o t h e r c h i l d r e n b e g a n tossing rocks into the air (although n o t at a n o t h e r child). A recess assistant interv e n e d a n d J o h n a n d a friend were sent to a different p a r t of the playground, where they b e g a n to dig a hole. At ano t h e r recess, he played kickball with friends. Follow-up Contact With the Family A l t h o u g h their t r e a t m e n t e n d e d 3 years ago, Sarah a n d Ben have c o n t i n u e d to stay in touch with their therapists at the P a r e n t i n g Clinic. Over the past 3 years, J o h n has c o n t i n u e d to be challenging at h o m e a n d at school, b u t his behavior in both settings is m o r e manageable. Sarah a n d Ben r e p o r t that J o h n ' s difficult times frequently coincide with times when their schedules are busier than usual a n d / o r they have stopped being as consistent with positive discipline a n d limit setting. At these times, they make an effort to sit down together a n d problem-solve the situation. They almost always feel capable of making the changes they n e e d to in o r d e r to turn Sarah and Ben's the negative cycle around. Ocstress s c o r e s casionally they consult with related t o their therapist a b o u t a difficult situation, but in these inparenting issues stances they have usually already dropped come up with a reasonable plan of action. T h e r e have substantially b e e n two to three major incifollowing dents at school in the past 3 treatment. years. Each time, Sarah and Ben have arranged a meeting with the school a n d have felt capable of h a n d l i n g the situation on their own. They are on very g o o d terms with J o h n ' s teacher a n d the school principal and are comfortable working together with them to plan J o h n ' s education. At the 1-year follow-up, when J o h n was in s e c o n d grade, his parents r e p o r t e d that he h a d b e e n evaluated for special education because o f his c o n t i n u i n g school difficulties. H e h a d an Individualized Education Plan with behavioral goals a n d received resource r o o m instruction for two 40-minute periods a week. H e was also occasionally sent to the resource r o o m if his behavior was u n m a n a g e a b l e in the regular classroom. His parents also r e p o r t e d that he h a d b e g u n taking I m i p r a m i n e for a diagnosis o f Sensory Integration Disorder. At the 2-year follow-up, J o h n was still receiving resource r o o m assistance a n d was c o n t i n u i n g to take the medication. J o h n is involved in g r o u p activities for the first time a n d is enthusiastic a b o u t Boy Scouts a n d baseball. H e has friends at school a n d in the n e i g h b o r h o o d . H e reports that he likes school a n d likes his teacher.
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Reid & Webster-Stratton 82 studies, and 5,272 kids. Journal of Clinical Child Pw:hology, 2Z 180-189. Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical I4sycholog% 66, 7-18. Ftmderburk, B. W., Eyberg, S. M., Newcomb, K., McNeil, C. C., Hembree-Kigin, T., & Capage, L. (1998). Parent-child interaction therapy with behavior problem children: Maintenance of treatment effects in the school setting. ChiM l+lmi(~ Behavicrr Therapy, 21,
Summary Y o u n g c h i l d r e n p r e s e n t i n g with O D D / C D f r e q u e n t l y e x h i b i t t h e s e p r o b l e m s across s e t t i n g s ( h o m e , s c h o o l , p e e r s ) . In a d d i t i o n to o p p o s i t i o n a l a n d aggressive b e h a v iors, t h e y f r e q u e n t l y display s y m p t o m s o f A D H D a n d h i g h e r t h a n n o r m a l levels o f a n x i e t y a n d / o r d e p r e s s i o n . M a n u a l i z e d t r e a t m e n t s t h a t h a v e t h e flexibility" to a d d r e s s
17-38. Lahey, B. B., & Loehm; R. (1997). Attention-deficit/hperactivitydiso~: del; and aduh antisocial behavior: A life span perspective. In D. M. Stoff.J. Breiling, &J. D. Maser (Eds.), Handbook oJanlisocial behav ior (pp. 51-60). NewYork: John Wiley & Sons. Robinson, E. A., & Eyberg, S. M. (1981 ). The dyadic parent-child inter: action coding system: Standardization and validation. Jou*val of Consulting and Clinical Psycholo©; 49, 245 - 250. Robinson, E. A., Eyberg, S. M., & Ross, A. W. (1980). "]7hestandardization of an inventoI y of child conduct problem behaviors. Journal of Clinical Child Ps~cholog3', 9, 22-28. Spanier. G. B. (1976). Measuring dyadic actjustment: New scales for assessing the quality of marriage and similar dyads.Jou~vml of Ma*~ flake and the Fam@, 3& 15-28. "Iapp, J. T., Wehb~;J. H., & Ellis, D. N. (1993). MOOSES: A multiple option obsel~'ation system fi)r experimental studies. Behavioral Research Methods, Instruments, & Compute~:~, 25, 53-56. Webster-Stratton, C. (1989). Dyadic Parent-Child Interaction Coding System-Revised, Seattle. Webster-Stratton, C. (1990). Long-term [ollow-up of tiamilies with young conduct-problem children: From preschool to grade school. Journal o/Consulting and Clinical P~),cholog3; 19, 1344-1349. Wet)stm=Stratton, C. (in press). The Incredible Years Parents, Teachers, and Child Training Series: Early inteccention and prevention programs tor young children. In R S. Jensen & E. D. ttibbs (Eds.), Ps3'chosocialtreaments for child and adolescent disordeT:~: Empirically based approaches. Washington, DC: American Psychological Association. Webster-Stratton, C., & t lammond, M. (1997). Treating children with early-onset conduct problems: A comparison of child and parent training interventions.Journal oJ Consulting and Clinical Psychology, 65, 93-11)9. Webstet=Stratton, C., & Hammond, M. (1998). Conduct problems and level of social competence in Head Start children: Prevalence, pervasiveness, and associated risk thctors. Clinical ChiM andFamily Psychology Rr~iew, 1(2). Webste>Stratton, C., & Hancock, L. (1998). Training tot parents of young children with conduct problems: Content, methods, mad therapeutic processes. In C. E. Schaetin" & J. M. Beriesmeister (Eds.), Handbook of parenting traini,g (pp. 98-152), New York: John Wiley & Sons. Webstm~Stratton, C., Hollinsworth, "I:, & Kotpacott, M. (t989). The long-term eftiectiveness and clinical significance of three costetfective training programs tor tmnilies with condnct-problem children.Journal of Consulti,g and Clinical Ps3"cholog);57, 550-553. Webste~Stratton, C., Reid, M. J., & Hammond, M. (2001). Treating early-onset conduct problems: The benefits (~ combining teacher training with parent and child inte~wention. Manuscript in preparation.
issues in all t h e p r o b l e m a r e a s c a n b e e x t r e m e l y effective f o r t h e s e c h i l d r e n . T h e a b o v e e x a m p l e is a case w h e r e t h e I n c r e d i b l e Years P a r e n t , T e a c h e l , a n d C h i l d p r o g r a m s w e r e u s e d with a c h i l d p r e s e n t i n g with pervasive e x t e r n a l i z i n g b e h a v i o r p r o b l e m s as well as s o m e s y m p t o m s o f A D H D a n d e l e v a t e d i n t e r n a l i z i n g s y m p t o m s . T h i s child, family, a n d s c h o o l r e c e i v e d t h e s a m e c o n t e n t as o t h e r p a r e n t s p a r t i c i p a t i n g in o u r g r o u p s . In e a c h area, however, t h e t h e r a p i s t t o c u s e d t h e t r e a t m e n t o n t h e issues t h a t w e r e m o s t s a l i e n t f o r this case. In this way, t h e t h e r a pist was a b l e to tailor t h e m a n u a l i z e d t r e a t m e n t to t h e ind i v i d u a l s i t u a t i o n , with a successful r e s u l t f o r t h e family. In a d d i t i o n to t h e i n d i v i d u a l s u p p o r t p r o v i d e d by t h e t h e r a p i s t s , t h e g r o u p a s p e c t o f t h e t r e a t m e n t was also h e l p f l f l f o r this family. B e i n g p a r t o f a g r o u p o f o t h e r pare n t s a n d c h i l d r e n with similar issues p r o v i d e d s u p p o r t a n d c o n f i d e n c e . T h e s e p e r s o n a l c o n n e c t i o n s with t h e o t h e r f a m i l i e s h e l p e d to r e m o v e s o m e o f t h e s t i g m a a n d guilt t h a t S a r a h a n d B e n felt b e c a u s e o f t h e i r difficulties with J o h n . G r o u p t r a i n i n g c a n also h e l p p a r e n t s to become
more
independent
in
their
problem
solving
( r a t h e r t h a n d e p e n d i n g solely o n t h e t h e r a p i s t ) . S a r a h a n d B e n actively p a r t i c i p a t e d in t h e buddy-calls d u r i n g t h e g r o u p a n d f r e q u e n t l y c a l l e d o t h e r p a r e n t s f o r supp o r t w h e n t h e y w e r e first i m p l e m e n t i n g t i m e - o u t . Even a f t e r t h e g r o u p e n d e d , t h e y c o n t i n u e d to socialize with o t h e r p a r e n t s a n d also u s e d t h e m as r e s o u r c e s w h e n p r o b l e m s c a m e up. F o r J o h n , t h e o t h e r c h i l d r e n in t h e D i n o s a u r g r o u p p r o v i d e d s o m e o f his first positive p e e r relationships.
References Achenbach, T. M. ( 1991 a). Manual/br the Child Behavior Checklist~4-18 and 1991 Profile. Burlington, \q': University of Vermont Department of PsychiatD'. Achenbach, T. M. (1991b). Manual fi)r the Teacho 3 Report Form and 1991 Profile. Burlington, VF: UniversiD' of Vermont Department of PsychiattT. Barkley, R. A., Guevremont, D. C., Anastopoulos, A. D., DuPanl, G.J., & Shelton, 7-. L. 11993). Driving-related risks and outcomes of attention deficit hyperactivity disorder in adolescents and young adtflts: A 3- to 5-year tbllow-up study. Pediatrics, 92, 212-218. Beck, A. T., Steer, R. A., & Garbin, M. G. (1988). Psychometric propm: ties of the Beck Depression lnventolT: Twenty-fiveyears of evaluation. Clinical Psychology Reoiew, 8, 77-100. Brestan, E. V., & Eyberg, S. M. (1998). Efti~ctive psychosocial treatment,s of conduct-disordered children and adolescents: 29 years, "l~
This research was supported by the NIH National (;enter tot Nursing Research Grant #5 R01 NR01075-11. Address correspondence to Jamila Reid, Parenting Clinic, University of Washington, 1107 N.E. 45th St., Suite 305, Seattle, %~_ 98105; e-mail: [email protected].
Received: Jane 1 o, 2001 Accepted: June 20, 2001 t
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