Preventing and Treating Conduct Disorders
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Running head: PREVENTING AND TREATING CONDUCT DISORDERS
The Incredible Years Parents, Teachers, and Children Training Series:
A Multifaceted Treatment Approach for Young Children with Conduct Problems
Carolyn Webster-Stratton
M. Jamila Reid
University of Washington
Webster-Stratton, C., & Reid, M. J. (in press). The Incredible Years Parents, Teachers and
Children Training Series: A multifaceted treatment approach for young children with
condut problems. In J. Weisz & A. Kazdin (Eds.), Evidence-based psychotherapies for
children and adolescents, 2nd edition. New York: Guilford Publications.
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The Incredible Years Parents, Teachers, and Children Training Series:
A Multifaceted Treatment Approach for Young Children with Conduct Problems
Overview
The Clinical Problem
The incidence of Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) in
children is alarmingly high, with reported cases of early-onset conduct problems in young
preschool children 4-6% (Egger & Angold, 2006) and as high as 35% for low-income families
(Webster-Stratton & Hammond, 1998). Developmental theorists have suggested that, compared
to typical children, “early starter” delinquents, that is, those who first exhibit ODD symptoms in
the preschool years, have a two- to threefold risk of becoming tomorrow's serious violent and
chronic juvenile offenders (Loeber et al., 1993; Patterson, Capaldi, & Bank, 1991; Snyder, 2001;
Tremblay et al., 2000). These children with early-onset CD also account for a disproportionate
share of delinquent acts in adulthood, including interpersonal violence, substance abuse, and
property crimes. Indeed, the primary developmental pathway for serious conduct disorders in
adolescence and adulthood appears to be established during the preschool period.
Risk factors from a number of different areas contribute to child conduct problems
including: ineffective parenting (Jaffee, Caspi, Moffitt, & Taylor, 2004); family mental health
and criminal risk factors (Knutson, DeGarmo, Koeppl, & Reid, 2005); child biological and
developmental risk factors (e.g., attention deficit disorders, learning disabilities, and language
delays); school risk factors (Hawkins, Catalano, Kosterman, Abbott, & Hill, 1999); and peer and
community risk factors (e.g., poverty and gangs) (Collins, Maccoby, Steinberg, Hetherington, &
Bornstein, 2000; Hawkins et al., 2008). Treatment-outcome studies suggest that interventions for
CD are of limited effect when offered in adolescence, after delinquent and aggressive behaviors
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are entrenched, and secondary risk factors such as academic failure, school absence, and the
formation of deviant peer groups have developed (Dishion & Piehler, 2007; Offord & Bennet,
1994). In fact, group-based interventions targeting adolescents with CD may result in worsening
of symptoms through exposure to delinquent peers (Dishion, McCord, & Poulin, 1999)
This increased treatment resistance in older CD probands results in part from delinquent
behaviors becoming embedded in a broader array of reinforcement systems, including those at the
family, school, peer group, neighborhood, and community levels (Lynam et al., 2000). In contrast,
there is evidence that the younger the child at the time of intervention, the more positive the
behavioral adjustment at home and at school. For these reasons, The Incredible Years treatment
programs were designed to prevent and treat behavior problems when they first begin (infanttoddler through elementary school) and to intervene in multiple areas through parent, teacher, and
child training. It is our belief that early intervention can counteract risk factors and strengthen
protective factors, thereby helping to prevent a developmental trajectory to increasingly
aggressive and violent behaviors.
Characteristics of the Treatment Program
To address the parenting, family, child, and school risk factors, we have developed three
complementary training curricula, known as the Incredible Years Training Series, targeted at
parents, teachers, and children (ages 0–13 years). This chapter reviews these training programs
and their associated research.
Incredible Years Parent Interventions
Goals of the parent programs. Goals of the parent programs are to promote parent
competencies and strengthen families by doing the following:
•
Increasing positive parenting, self-confidence, and parent-child bonding;
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Teaching parents to coach children’s: academic and verbal skills, persistence and
sustained attention, and social and emotional development;
•
Decreasing harsh discipline and increasing positive strategies such as ignoring,
logical consequences, redirecting, monitoring, and problem solving;
•
Improving parents’ problem solving, anger management, and communication;
•
Increasing family support networks and school involvement/bonding;
•
Helping parents and teachers work collaboratively; and
•
Increasing parents’ involvement in children’s academic-related activities at home.
Content of the BASIC parent training treatment program. In 1980, we developed an
interactive, videotape-based parent intervention (BASIC) for parents of children ages 2–7 years.
More recently we revised and updated this program to include four separate age range BASIC
programs: infant (0-1years), toddler (1-3 years), preschool (3-6 years) and school age (6-13
years). Each of these revised programs includes age appropriate examples of more culturally
diverse families, children with varying temperaments, and added emphases on social and
emotional coaching, problem solving, how to set up predictable routines, and support children’s
academic success. The baby program is 8-9 weekly, 2-hour sessions with parents and babies
present. The BASIC toddler parent training program is usually completed in 12 weekly, 2-hour
sessions while the preschool and school age programs are 18-20 weekly sessions. The foundation
of the program is video vignettes of modeled parenting skills (over 300 vignettes, each lasting
approximately 1–3 minutes) shown by a therapist to groups of 8–12 parents. The videos
demonstrate social learning and child development principles and serve as the stimulus for
focused discussions, problem solving, and collaborative learning. The program is also designed
to help parents understand typical child development and temperaments.
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The BASIC program begins with a focus on enhancing positive relationships between
parents and children by teaching parents to use child-directed interactive play, academic and
persistence coaching, social and emotional coaching, praise, and incentive programs. Next,
parents learn how to set up predicable home routines and rules, followed by learning a specific
set of nonviolent discipline techniques including monitoring, ignoring, commands, natural and
logical consequences, and ways to use Time-Out to teach children to calm down. Finally, parents
are taught how they can teach their children problem-solving skills.
Content of the ADVANCE parent training treatment program. In addition to parenting
behavior per se, other aspects of parents' behavior and personal lives constitute risk factors for
child conduct problems. Researchers have demonstrated that personal and interpersonal risk
factors such as parental depression, marital discord, lack of social support, poor problem-solving
ability, and environmental stressors disrupt parenting behavior and contribute to coercive parent–
child interactions and relapses subsequent to parent training. This evidence led us to expand our
theoretical and causal model concerning conduct problems, and in 1989 we developed the
ADVANCE treatment program, updated in 2008. We theorized that a broader-based training
model (i.e., one involving helping parents with conflict management issues) would help mediate
the negative influences of these personal and interpersonal factors on parenting skills and
promote increased maintenance and generalizability of treatment effects.
The content of this 10-12-session video program (over 90 vignettes), which is offered
after the completion of the BASIC training program, involves five components:
1. Personal self-control. Parents learn to substitute positive self-talk for depressive,
angry, and blaming self-talk. Parents learn specific anger management techniques.
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2. Communication skills. Parents are taught to identify blocks to communication and to
learn effective communication skills for dealing with conflict.
3. Problem-solving skills for adults. Parents are taught effective strategies for coping
with conflict with spouses, employers, extended family members, and teachers.
4. Teaching children problem solving. Parents learn to use problem-solving strategies
with their children. Parents of older children learn to conduct family meetings.
5. Strengthening social support and self-care. Group members learn to ask for support
when necessary and to give support to others.
The content of both the BASIC and ADVANCE programs is also provided in the text that
parents use for the program, titled The Incredible Years: A Troubleshooting Guide for Parents
(Webster-Stratton, 2006).
Content of the SCHOOL parent training treatment. In follow-up interviews with parents
who completed our parent training programs, 58% requested guidance on school related issues
such as homework, communication with teachers, school behavior problems, and school work.
These data suggested a need for teaching parents to access schools, collaborate with teachers,
and supervise children's peer relationships. In addition, 40% of teachers reported problems with
children's compliance and aggression in the classroom. Clearly, integrating interventions across
home and school settings to target school and family risk factors fosters greater betweenenvironment consistency and offers the best chance for long-term reduction of antisocial
behavior.
In 1990 we developed an interactive video modeling academic skills training intervention
(SCHOOL) as an adjunct to our school age BASIC program and a school readiness intervention
as an adjunct to our preschool BASIC program. These two interventions consist of four to six
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additional sessions that are offered to parents after the BASIC program. For parents of schoolage children, these sessions focus on collaboration with teachers, ways to foster children's
academic readiness and school success through parental involvement in school activities and
homework, and the importance of after-school and peer monitoring. For the parents of preschool
children, the sessions focus on interactive reading skills and ways to promote children’s social,
emotional, self-regulation, and cognitive skills.
Program components include:
1. Promoting children's self-confidence. Parents lay the foundation for school success by
helping children feel confident about their own ideas and ability to learn.
2. Promoting children’s school readiness, academic success. Parents of young children
prepare their children for school by facilitating language and reading skills. Parents of
school-age children establish a predictable homework routine and learn strategies to
support homework success.
3. Dealing with children's discouragement and learning difficulties. Parents think about
realistic goals for children, help children persist with difficult tasks, tailor learning
tasks to children’s abilities, and use praise, tangible rewards, and academic coaching to
motivate and reinforce learning progress at home.
4. Using teacher–parent conferences to advocate for children. Parents learn to
collaborate with teachers to develop behavior plans that address school difficulties,
such as inattention, impulsiveness, noncompliance, social problems, and aggression.
Incredible Years Teacher Training Intervention
Once children with behavior problems enter school, negative academic and social
experiences escalate the development of conduct problems. Aggressive, disruptive children
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quickly become socially excluded, which leads to fewer opportunities to interact socially and to
learn appropriate friendship skills. Evidence suggests that peer rejection eventually leads to
association with deviant peers. Once children have formed deviant peer groups, the risk for drug
abuse and antisocial behavior is even higher.
Furthermore, teacher behaviors and school characteristics, such as low emphasis on
teaching social and emotional competence, low rates of praise, and high student–teacher ratio are
associated with classroom aggression, delinquency, and poor academic performance. Aggressive
children frequently develop poor relationships with teachers and are often expelled from
classrooms. In our own studies with conduct problem children, ages 3–7 years, over 50% of the
children had been asked to leave three or more classrooms by second grade. Lack of teacher
support and exclusion from the classroom exacerbates these children’s social problems and
academic difficulties, contributing to the likelihood of school dropout.
Goals of the teacher training programs. The goals are to promote teacher competencies
and strengthen home–school connections by doing the following:
•
Strengthening teachers’ effective classroom management skills;
•
Strengthening teachers’ use of academic, persistence, social, and emotional
coaching with students;
•
Strengthening positive relationships between teachers and students;
•
Increasing teachers’ use of effective discipline strategies;
•
Increasing teachers’ collaborative efforts with parents;
•
Increasing teachers’ ability to teach social skills, anger management, and
problem-solving skills in the classroom; and
•
Decreasing levels of classroom aggression.
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Content of teacher training intervention. The teacher training program is a 6-day (or 42hour) group format program for teachers, school counselors, and psychologists. Training targets
teachers' use of effective classroom management strategies for dealing with misbehavior;
promoting positive relationships with difficult students; strengthening social skills and emotional
regulation in the classroom, the playground, bus, and lunchroom; and strengthening teachers’
collaborative process and positive communication with parents (e.g., the importance of positive
home communication, home visits, and successful parent conferences). Teachers, parents, and
group facilitators jointly develop "transition plans" that detail successful classroom strategies for
the child with conduct problems; characteristics, interests, and motivators for the child; and ways
parents would like to be contacted by teachers. This information is passed on to the following
year’s teachers. In addition, teachers learn to prevent peer rejection by helping the aggressive
child learn appropriate problem-solving strategies and helping his or her peers to respond
appropriately to aggression. Teachers are encouraged to be sensitive to individual developmental
differences and biological deficits in children and the relevance of these differences for enhanced
teaching efforts that are positive, accepting, and consistent. Physical aggression is targeted for
close monitoring, teaching, and incentive programs. A complete description of the content
included in this curriculum is described in the book that teachers use for the course, titled How to
Promote Children’s Social and Emotional Competence (Webster-Stratton, 2000).
Incredible Years Child Training Intervention (Dinosaur School)
Research has indicated that some abnormal aspects of the child's internal organization at
the physiological, neurological, and/or neuropsychological level are linked to the development of
conduct disorders, particularly for children with a chronic history of early behavioral problems.
Children with conduct problems are more likely to have certain temperamental characteristics
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such as inattentiveness, impulsivity, and attention-deficit/hyperactivity disorder (ADHD). Other
child factors have also been implicated in early-onset conduct disorder. For example, deficits in
social-cognitive skills and negative attributions contribute to poor emotional regulation and
aggressive peer interactions. In addition, studies indicate that children with conduct problems
have significant delays in their peer-play skills—in particular, difficulty with reciprocal play,
cooperative skills, taking turns, waiting, and giving suggestions. Finally, reading, learning, and
language delays are also associated with conduct problems, particularly for “early life course
persisters. The relationship between academic performance and ODD/CD is bidirectional.
Academic difficulties may cause disengagement, increased frustration, and lower self-esteem,
which contribute to the child’s behavior problems. At the same time, noncompliance, aggression,
elevated activity levels, and poor attention limit a child’s ability to be engaged in learning and
achieve academically. Thus, a cycle is created in which one problem exacerbates the other. This
combination of academic delays and conduct problems appears to contribute to the development
of more severe CD and school failure.
These data suggest that children with conduct problems and ADHD require added
structure, monitoring, and over teaching (i.e., repeated learning trials) to learn to inhibit
undesirable behaviors and to manage emotion. Parents and teachers need to use predictable
routines; consistent, clear, specific limit setting; simple language; concrete cues; and frequent
reminders and redirections. In addition, this information suggests the need for direct intervention
with children, focusing on their particular social learning needs, such as problem solving,
perspective taking, and play skills, as well as literacy and special academic needs.
Goals of the child training programs. The goals are to promote children’s competencies
and reduce aggressive and noncompliant behaviors by doing the following:
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Strengthening children’s social skills and appropriate play skills;
•
Promoting children’s use of self-control and self-regulation strategies;
•
Increasing emotional awareness by labeling feelings, recognizing the differing
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views of oneself and others, and enhancing perspective taking;
•
Promoting children’s ability to persist with and attend to difficult tasks;
•
Boosting academic success, reading, and school readiness;
•
Reducing defiance, aggression, noncompliance, peer rejection, bullying, stealing,
and lying and promoting compliance with teachers and peers;
•
Decreasing negative attributions and conflict management approaches; and
•
Increasing self-esteem and self-confidence.
Content of child training treatment. In 1990 we developed a video modeling child
treatment program for children with conduct problems (ages 3–8). This 22-week program
consists of a series of DVD programs (over 180 vignettes) that teach children problem-solving
and social skills. Organized to dovetail with the content of the parent training program, the
program consists of seven main components: (1) Introduction and Rules; (2) Empathy and
Emotion; (3) Problem-Solving; (4) Anger Control; (5) Friendship Skills; (6) Communication
Skills; and (7) School Skills. The children meet weekly in small groups of six children for 2
hours.
Group Process and Methods Used in Parent, Teacher, and Child Training Programs
All three treatment approaches rely on performance training methods including videotape
modeling, role play, practice activities, and live feedback from the therapist and other group
members. In accordance with modeling and self-efficacy theories of learning, parents, teachers
and children using the program develop their skills by watching (and modeling) video examples
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of key management and interpersonal skills. We theorized that video examples provide a more
flexible method of training than didactic verbal instruction or sole reliance on role play; that is,
we could portray a wide variety of models and situations. We hypothesized that this flexible
modeling approach would result in better generalization of the training content and, therefore,
better long-term maintenance. Further, it would be a better method of learning for less verbally
oriented learners. Finally, such a method has the advantage not only of low individual training
cost when used in groups but also of possible mass dissemination. Heavily guided by the
modeling literature, each of the programs aims to promote modeling effects for participants by
creating positive feelings about the video models. For example, the video vignettes show parents,
teachers, and children of differing ages, cultures, socioeconomic backgrounds, and
temperaments, so that participants will perceive at least some of the models as similar to
themselves and will therefore accept the vignettes as relevant. Whenever possible, vignettes
show models (unrehearsed) in natural situations "doing it effectively" and "doing it less
effectively" in order to demystify the notion there is "perfect parenting or teaching" and to
illustrate how one can learn from one's mistakes. This approach also emphasizes our belief in a
coping and interactive model of learning (Webster-Stratton & Herbert, 1994); that is, participants
view a video vignette of a situation and then discuss and role-play how the individual might have
handled the interaction more effectively. Thus participants improve upon the interactions they
see in the vignettes. This approach enhances participants' confidence in their own ideas and
develops their ability to analyze interpersonal situations and select an appropriate response. In
this respect, our training differs from some training programs where the therapist provides the
analysis and recommends a particular strategy.
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The video vignettes demonstrate behavioral principles and serve as the stimulus for
discussions, problem solving, and collaborative learning. After each vignette, the therapist
solicits ideas from the group and involves them in the process of problem solving, sharing, and
discussing ideas and reactions. The therapist’s role is to support group members by teaching,
leading, reframing, predicting, and role playing, always within a collaborative context. The
collaborative context is designed to ensure that the intervention is sensitive to individual cultural
differences and personal values. The program is "tailored" to each teacher, parent, or child's
individual needs and personal goals as well as to each child's personality and behavior problems.
This program also implies a commitment to group members’ self-management. We
believe that this approach empowers participants in that it gives back dignity, respect, and selfcontrol to parents, teachers, and children who are often seeking help at time of low selfconfidence and feelings of self-blame. The group format is more cost-effective than individual
intervention and also addresses an important risk factor for children with conduct problems; the
family's isolation and stigmatization. The parent groups provide that support and become a
model for parent support networks. (For details of therapeutic processes, please see WebsterStratton & Herbert, 1994.) The child groups provide children who have conduct problems some
of their first positive social experiences with other children. Moreover, it was theorized that the
group approach would provide more social and emotional support and decrease feelings of
isolation for teachers as well as parents and children.
The child program video vignettes show children of differing ages, sexes, and cultures
interacting with adults (parents or teachers) or with other children. After viewing the vignettes,
children discuss feelings, generate ideas for more effective responses, and role-play alternative
scenarios. In addition to the interactive video vignettes, the therapists use life-size puppets to
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model appropriate behavior and thinking processes for the children. The use of puppets appeals
to children on the fantasy level so predominant in this preoperational age group. Because young
children are more vulnerable to distraction, are less able to organize their thoughts, and have
poorer memories, we use a number of strategies for reviewing and organizing the material, such
as: (1) playing "copy cat" to review skills learned; (2) using many video examples of the same
concept in different situations and settings; (3) using cartoon pictures and specially designed
stickers as "cues" to remind children of key concepts; (4) role-playing with puppets and other
children to provide practice opportunities; (5) reenacting video scenes; (6) rehearsing skills with
play, art, and game activities; (7) homework, so children can practice key skills with parents; and
(8) letters to parents and teachers that explain the key concepts children are learning and asking
them to reinforce these behaviors.
Evidence for the Effects of Treatment
Effects of Parent Training Program
The efficacy of the Incredible Years BASIC parent treatment program for children (ages
3–8 years) diagnosed with ODD/CD has been demonstrated in seven published randomized
control group trials by the program developer and colleagues at the University of Washington
Parenting Clinic (Reid, Webster-Stratton, & Hammond, 2007; Webster-Stratton, 1981; WebsterStratton, 1982, 1984, 1990a, 1992, 1994, 1998; Webster-Stratton & Hammond, 1997; WebsterStratton, Hollinsworth, & Kolpacoff, 1989; Webster-Stratton, Kolpacoff, & Hollinsworth, 1988;
Webster-Stratton, Reid, & Hammond, 2004). In all of these studies, the BASIC program has
been shown to improve parental attitudes and parent–child interactions and reduce harsh
discipline and child conduct problems compared to both wait-list control groups. In the third of
these studies, treatment component analyses indicated that the combination of group discussion,
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a trained therapist, and video modeling produced the most lasting results in comparison to
treatment that involved only one training component (Webster-Stratton, Hollinsworth, &
Kolpacoff, 1989; Webster-Stratton, Kolpacoff, & Hollinsworth, 1988). In addition, the BASIC
program has been replicated in five projects by independent investigators in mental health clinics
with families of children diagnosed with conduct problems (Drugli & Larsson, 2006; Lavigne et
al., 2008; Larsson et al., 2008; Scott, Spender, Doolan, Jacobs, & Aspland, 2001; Spaccarelli,
Cotler, & Penman, 1992; Taylor, Schmidt, Pepler, & Hodgins, 1998) as well as with indicated
populations (children with symptoms) and high risk populations (families in poverty) (Gardner,
Burton, & Klimes, 2006) (Gross et al., 2003; Hutchings et al., 2007; Miller Brotman et al.,
2003). These replications were “effectiveness” trials done in applied mental health settings, not a
university research clinic, and the therapists were typical therapists at the centers. Three of the
above replications were conducted in the United States, two in United Kingdom, and one in
Norway. This illustrates the transportability of the BASIC parenting program to other cultures.
See Table 1 for summary of all studies with Incredible Years.
In our fourth study, we examined the effects of adding the ADVANCE intervention
component to the BASIC intervention (Webster-Stratton, 1994) by randomly assigning families
to either BASIC parent training or BASIC + ADVANCE training. Both treatment groups showed
improvements in child adjustment and parent–child interactions and a decrease in parent distress
and child behavior problems. These changes were maintained at follow-up. ADVANCE children
showed increases in the number of prosocial solutions generated during problem solving, in
comparison to children whose parents received only the BASIC program. Observations of
parents' marital interactions indicated improvements in ADVANCE parents' communication,
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problem solving, and collaboration skills when compared with parents who did not receive
ADVANCE.
Overall, these results suggest that focusing on helping families to manage personal
distress and interpersonal issues through a video modeling group discussion treatment
(ADVANCE) added to treatment outcomes for our BASIC program. Consequently a 20-24 week
program that combines BASIC plus ADVANCE has become our core treatment for parents with
children with conduct problems.
In our sixth and seventh studies respectively, we examined the additive effects of
combining our child training intervention (Dinosaur School) and teacher training with the parent
training program (BASIC + ADVANCE). Both studies replicated our results from the prior
ADVANCE study and provided data on the advantages of training children and teachers as well
as parents. (See description of these study results below, in the section on child training results.)
Parent training treatment: Who benefits and who does not? We have followed families
longitudinally (1, 2, and 3 years post treatment), and for study three we have completed a 10–15year follow-up. We have assessed both "statistical significance" of treatment effects, and also
their "clinical significance." In assessing the clinical significance, we looked at the extent to
which parent and teacher reports indicated that the children were within the normal or the
nonclinical range of functioning or showed a 30% improvement if there were no established
normative data; and whether families requested further therapy for their children's behavior
problems at the follow-up assessments. In our 3-year follow-up of 83 families treated with the
BASIC program, we found that while approximately two-thirds of children showed behavior
improvements, 25% to 46% of parents and 26% of teachers still reported child behavior
problems (Webster-Stratton, 1990b). We also found that the families whose children had
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continuing externalizing problems (according to teacher and parent reports) at our 3-year followup assessments were more likely to be characterized by maritally distressed or single-parent
status, increased maternal depression, lower social class, high levels of negative life stressors,
and family histories of alcoholism, drug abuse, and spouse abuse (Webster-Stratton, 1990b;
Webster-Stratton & Hammond, 1990).
Hartman (Hartman, Stage, & Webster-Stratton, 2003) examined whether child ADHD
symptoms (i.e., inattention, impulsivity, and hyperactivity) predicted poorer treatment results
from the parent training intervention (BASIC). Contrary to Hartman’s hypothesis, analyses
suggested that the children with ODD/CD who had higher levels of attention problems showed
greater reductions in conduct problems than children with no attention problems. Similar
findings for children with ADHD were reported in the UK study (Scott, Spender, Doolan,
Jacobs, & Aspland, 2001). Currently a study is underway to evaluate the parent and child
treatments with young children whose primary diagnosis is ADHD.
(Rinaldi, 2001) conducted an 8- to 12-year follow-up of families who were in the
ADVANCE study. She interviewed 83.5% of the original study parents and adolescents (ages
12–19 years). Results indicated that 75% of the teenagers were typically adjusted with minimal
behavioral and emotional problems. Furthermore, parenting skills taught in the intervention had
lasting effects. Predictors of long-term outcome were mothers’ post-treatment level of critical
statements and fathers’ use of praise. In addition, the level of coercion between the children and
mothers immediately post-treatment was a predictor of later teen involvement in the criminal
justice system (Webster-Stratton, Rinaldi, & Reid, 2009).
In the past decade, we have also evaluated the parent programs as a selective prevention
program with multiethnic, socioeconomically disadvantaged families in two randomized studies
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with Head Start families. Results of these studies suggest the program’s effectiveness as method
of preventing the development of conduct problems and strengthening social competence in
preschool children (Webster-Stratton, 1998; Webster-Stratton, Reid, & Hammond, 2001). A
recent study with elementary school children evaluated the effects of the parent intervention with
an indicated, culturally diverse population. Children who received the intervention showed fewer
externalizing problems, better emotion regulation, and stronger parent-child bonding than control
children. Mothers in the intervention group showed more supportive and less coercive parenting
than control mothers (Reid, Webster-Stratton, & Hammond, 2007). Similar results were reported
by independent investigators with selective and indicated populations (Gardner, Burton, &
Klimes, 2006; Gross et al., 2003; Hutchings & Gardner, 2006; Linares, Montalto, Li, & Oza,
2006; Miller Brotman et al., 2003).
Effects of Child and Teacher Training Programs
To date, the developer has conducted two randomized studies evaluating the effectiveness
of the child training program for reducing conduct problems and promoting social competence in
children diagnosed with ODD/CD. In the first study, children with ODD and their parents were
randomly assigned to one of four groups: parent training treatment (PT), child training treatment
(CT), child and parent treatment (CT + PT), or a waiting-list control group (CON). Posttreatment assessments indicated that all three treatment conditions resulted in improvements in
parent and child behaviors in comparison to controls. Comparisons of the three treatment
conditions indicated that children who received CT showed improvements in problem solving,
and conflict management skills compared to those in the PT condition. On measures of parent
and child behavior at home, PT and CT + PT parents and children had more positive interactions
in comparison to CT parents and children.
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One-year follow-up assessments indicated that all the changes noted immediately posttreatment were maintained over time. Moreover, child conduct problems at home had decreased
over time. Analyses of the clinical significance of the results suggested that the combined CT +
PT condition produced the most improvements in child behavior at 1-year follow-up. However,
children from all three treatment conditions showed increases in behavior problems at school 1
year later, as measured by teacher reports (Webster-Stratton & Hammond, 1997).
A second study tested the effects of different combinations of parent, child, and teacher
training. Families with a child diagnosed with ODD were randomly assigned to one of six
groups: (1) Parent training only (BASIC + ADVANCE); (2) Child training only (Dina Dinosaur
Curriculum); (3) Parent training, academic skills training, and teacher training (BASIC +
ADVANCE + SCHOOL + TEACHER); (4) Parent training, academic skills training, teacher
training and child training (BASIC + ADVANCE + SCHOOL + TEACHER + CHILD); (5)
Child training and teacher training (CHILD + TEACHER); and (6) Waiting-list control group.
Results indicated that, as expected, trained teachers were rated as less critical, harsh, and
inconsistent, and more nurturing than control teachers. Parents in all three conditions that
received parent training were less negative and more positive than parents who did not receive
training. Children in all five treatment conditions showed reductions in aggressive behaviors
with mothers at home and at school with peers and teachers compared with controls (WebsterStratton & Reid, 1999). Treatment effects for children’s positive social skills with peers were
found in the three conditions with child training compared with controls. Most treatment effects
were maintained at 1-year follow-up. In summary, short-term results replicate our previous
findings on the effectiveness of the parent and child training programs and indicate that teacher
training improves teachers’ classroom management skills and improves children’s classroom
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aggressive behavior. In addition, treatment combinations that added either child training or
teacher training to the parent training were most effective.
One randomized control group study by the developer (Webster-Stratton, Reid, &
Hammond, 2001) and one study by an independent evaluator evaluated the teacher training
curriculum in prevention settings with Head Start teachers (Raver et al., 2008). In the first study
parent–teacher bonding was higher for experimental conditions than for controls. Experimental
children showed fewer conduct problems at school than controls, and trained teachers showed
better classroom management than control teachers. In the second study Head Start classrooms in
the treatment condition had higher levels of positive classroom climate, teacher sensitivity and
behavior management than classrooms in the control condition.
Lastly a recent study evaluated the teacher training and classroom Dinosaur curriculum in
Head Start and with schools who serve high numbers of economically disadvantaged children.
Results showed improvements in conduct problems, self-regulation, and social competence
compared with control students who participated in regular Head Start or elementary school
education. Effect size comparing treatment versus control groups at post assessment showed the
intervention had small to moderate effects on children whose baseline behavior was in the
average range, but had large effects on children with high initial levels of conduct problems.
(Webster-Stratton, Reid, & Stoolmiller, 2008).
Who Benefits From Dinosaur Child Training? Families of 99 children with ODD/CD,
aged 4–8 years who were randomly assigned to either the child training treatment group or a
control group, were assessed on multiple risk factors (child hyperactivity, parenting style, and
family stress). These risk factors were examined in relation to children’s responses to the child
treatment. The hyperactivity or family stress risk factors did not have an impact on children's
Preventing and Treating Conduct Disorders
21
ability to benefit from the treatment program. Negative parenting, on the other hand, did have a
negative impact on children’s treatment outcome. Fewer children who had parents with one of
the negative parenting risk factors (high levels of criticism or physical spanking) showed
improvements compared to children who did not have a negative parenting risk factor. This
finding suggests that for children whose parents exhibit harsh and coercive parenting styles, it
may be necessary to offer a parenting intervention in addition to a child intervention (WebsterStratton, Reid, & Hammond, 2001). Our studies also suggest that child training enhances the
effectiveness of parent training treatment for children with pervasive conduct problems (home
and school settings).
Who Benefits From Treatment and How?
Beauchaine and colleagues (Beauchaine, Webster-Stratton, & Reid, 2005) examined
mediators, moderators, and predictors of treatment effects by combining data from six
randomized controlled trials of the Incredible Years (including 514 children between the ages of
3 and 9). Families in these trials had received parent training, child training, teacher training, or a
combination of treatments. Marital adjustment, maternal depression, paternal substance abuse,
and child comorbid anxiety and attention problems were treatment moderators. In most cases
analyses of these treatment moderators showed that interventions combinations that included
parent training were generally more effective than interventions without parent training. For
example, children of mothers who were martially distressed fared better if their treatment
included parent training. Indeed, parent training exerted the most consistent effects across
different moderating variables, and there were no instances in which interventions without parent
training were more effective than interventions with parent training. However, the addition of
teacher training seemed to be important for impulsive children. Finally, despite these moderating
Preventing and Treating Conduct Disorders
22
effects, more treatment components (parent, child, plus teacher training) were associated with
steeper reductions in mother reported externalizing slopes. This suggests that all things being
equal, more treatment is better than less. Harsh parenting practices both mediated and predicted
treatment success; in other words, the best treatment responses, were observed among children of
parents who scored relatively low on verbal criticism and harsh parenting at baseline, but
nevertheless improved during treatment.
In a prevention study which included socioeconomically disadvantaged children with and
without conduct problems (Reid, Webster-Stratton, & Baydar, 2004) we found that child change
was related to maternal engagement in the parenting program and to whether mothers reduced
their critical parenting. In this study, maternal engagement was highest for highly critical
mothers and for mothers of children who had the highest levels of conduct problems. A second
study analyzing these same prevention data (Baydar, Reid, & Webster-Stratton, 2003) showed
that while mothers with mental health risk factors (i.e., depression, anger, history of abuse as a
child, and substance abuse) exhibited poorer parenting at baseline than mothers without these
risk factors, they were engaged in and benefited from the parenting training program at levels
that were comparable to mothers without these risk factors. Recent research with children with
ADHD and ODD showed that dosage of intervention was related to treatment outcome with
mothers who attended 18-20 sessions showing more significant change in parenting and child
outcomes than those who attended 10 sessions. A similar independent finding regarding dose
effects, with greater improvement for those receiving more treatment sessions, was also found in
a study treating children with ODD in a primary care setting (Lavigne, LeBailly, Gouze,
Cicchetti, Pochyly, Arendl, et. al., 2008). This argues for the importance of not abbreviating
intervention.
Preventing and Treating Conduct Disorders
23
Directions for Future Research
In recent years the Incredible Years parent programs have been extended to include older
children (8-13 years) as well as infants and toddlers (0-3 years). Current studies are in progress
to evaluate the effectiveness of these programs. A recent study using the 8-12 year old version
of the updated school age program has shown significantly improved parent reports of child
behavior problems as well as significant improvements in parental depression and parenting
skills (Hutchings, Bywater, Williams, Shakespeare, & Whitaker, 2009). Other research is
evaluating the Incredible Years programs with new populations including neglectful and abusive
families referred by Child Protective Services, children with ADHD, and families from many
different countries around the world including Russia, Turkey, Australia, and Scandinavia.
Although our programs were first designed and evaluated to be used as clinic-based
treatments for diagnosed children, our recent work has extended our clinic-based treatment
model to school settings and has targeted high-risk populations. As more is known about the
type, timing, and dosage of interventions needed to prevent and treat children’s conduct
problems, we can further target children and families to offer treatment and support at strategic
points. By providing a continuum of prevention and treatment services, we believe we will be
able to prevent the further development of conduct disorders, delinquency, and violence.
Preventing and Treating Conduct Disorders
24
References
Baydar, N., Reid, M. J., & Webster-Stratton, C. (2003). The role of mental health factors and
program engagement in the effectiveness of a preventive parenting program for Head
Start mothers. Child Development, 74(5), 1433-1453.
Beauchaine, T. P., Webster-Stratton, C., & Reid, M. J. (2005). Mediators, moderators, and
predictors of one-year outcomes among children treated for early-onset conduct
problems: A latent growth curve analysis. Journal of Consulting and Clinical
Psychology, 73(3), 371-388.
Collins, W. A., Maccoby, E. E., Steinberg, L., Hetherington, E. M., & Bornstein, M. H. (2000).
Contemporary research on parenting: The case for nurture and nature. American
Psychologist, 55, 218-232.
Dishion, T. J., McCord, J., & Poulin, F. (1999). When interventions harm: Peer groups and
problem behavior. American Psychologist, 54, 755-764.
Dishion, T. J., & Piehler, T. F. (2007). Peer dynamics in the development and change of child
and adolescent problem behavior. In A. S. Masten (Ed.), Multilevel dynamics in
development psychopathology: Pathways to the future (pp. 151-180). Mahwah,NJ:
Erlbaum
Drugli, M. B., & Larsson, B. (2006). Children aged 4-8 years treated with parent training and
child therapy because of conduct problems: Generalisation effects to day-care and school
settings European Child and Adolescent Psychiatry, 15, 392-399.
Egger, H. L., & Angold, A. (2006). Common emotional and behavioral disorders in preschool
children: Presentation, nosology, and epidemiology. Journal of Child Psychology and
Psychiatry, 47, 313-337.
Preventing and Treating Conduct Disorders
25
Gardner, F., Burton, J., & Klimes, I. (2006). Randomized controlled trial of a parenting
intervention in the voluntary sector for reducing conduct problems in children: Outcomes
and mechanisms of change. Journal of Child Psychology and Psychiatry, 47, 1123-1132.
Gross, D., Fogg, L., Webster-Stratton, C., Garvey, C., W., J., & Grady, J. (2003). Parent training
with families of toddlers in day care in low-income urban communities. Journal of
Consulting and Clinical Psychology, 71(2), 261-278.
Hartman, R. R., Stage, S., & Webster-Stratton, C. (2003). A growth curve analysis of parent
training outcomes: Examining the influence of child factors (inattention, impulsivity, and
hyperactivity problems), parental and family risk factors. The Child Psychology and
Psychiatry Journal, 44(3), 388-398.
Hawkins, J. D., Brown, E. C., Oesterle, S., Arthur, M. W., Abbott, R. D., & Catalano, R. F.
(2008). Early effects of Communities That Care on targeted risks and initiation of
delinquent behavior and substance abuse. Journal of Adolescent Health, 43(1), 15-22.
Hawkins, J. D., Catalano, R. F., Kosterman, R., Abbott, R., & Hill, K. G. (1999). Preventing
adolescent health-risk behaviors by strengthening protection during childhood. Archives
of Pediatrics and Adolescent Medicine, 153, 226-234.
Hutchings, J., Bywater, T., Williams, M. E., Shakespeare, M. K., & Whitaker, C. (2009).
Evidence for the extended School Age Incredible Years parent programme with parents
of high-risk 8 to 16-year olds. Bangor: Bangor University.
Hutchings, J., Gardner, F., Bywater, T., Daley, D., Whitaker, C., Jones, K., et al. (2007).
Parenting intervention in Sure Start services for children at risk of developing conduct
disorder: Pragmatic randomized controlled trial. British Medical Journal, 334(7595), 1-7.
Preventing and Treating Conduct Disorders
26
Jaffee, S. R., Caspi, A., Moffitt, T. E., & Taylor, A. (2004). Physical maltreatment victim to
antisocial child: Evidence of environmentally mediated process. Journal of Abnormal
Psychology, 113, 44-55.
Knutson, J. F., DeGarmo, D., Koeppl, G., & Reid, J. B. (2005). Can neglect, supervisory neglect
and harsh parenting in the development of children's aggression: A replication and
extension. Child Maltreatment, 10, 92-107.
Larsson, B., Fossum, B., Clifford, G., Drugli, M., Handegard, B., & Morch, W. (2008). Treatment of
oppositional defiant and conduct problems in young Norwegian children: Results of a
randomized trial. European Child Adolescent Psychiatry.
Lavigne, J. V., LeBailly, S. A., Gouze, K. R., Cicchetti, C., Pochyly, J., Arend, R., et al. (2008).
Treating Oppositional Defiant Disorder in primary care: A comparison of three models.
Journal of Pediatric Psychology, 33(5), 449-461.
Linares, L. O., Montalto, D., MinMin, L., & S., V. (2006). A Promising Parent Intervention in Foster
Care. Journal of Consulting and Clinical Psychology, 74(1), 32-41.
Loeber, R., Wung, P., Keenan, K., Giroux, B., Stouthamer-Loeber, M., Van Kammen, W. B., et
al. (1993). Developmental pathways in disruptive child behavior. Development
Psychopathology, 5, 103-133.
Lynam, D. R., Caspi, A., Moffitt, T. E., Wikstrom, P. H., Loeber, R., & Novak, S. (2000). The
interaction between impulsivity and neighborhood context on offending: The effects of
impulsivity are stronger in poorer neighborhoods. Journal of Abnormal Child
Psychology, 109, 563-574.
Miller Brotman, L., Klein, R. G., Kamboukos, D., Brown, E. J., Coard, S., & L., S.-S. (2003).
Preventive intervention for urban, low-income preschoolers at familial risk for conduct
Preventing and Treating Conduct Disorders
27
problems: A randomized pilot study. Journal of Child Psychology and Psychiatry, 32(2),
246-257.
Offord, D. R., & Bennet, K. J. (1994). Conduct disorder: Long term outcomes and intervention
effectiveness. Journal of the American Academy of Child and Adolescent Psychiatry, 33,
1069-1078.
Patterson, G. R., Capaldi, D., & Bank, L. (1991). An early starter model for predicting
delinquency. In D. J. Pepler & K. H. Rubin (Eds.), The development and treatment of
childhood aggression (pp. 139-168). Hillsdale, NJ: Erlbaum.
Raver, C. C., Jones, S. M., Li-Grining, C. P., Metzger, M., Champion, K. M., & Sardin, L.
(2008). Improving preschool classroom processes:Preliminary findings from a
randomized trial implemented in Head Start settings. Early Childhood Research
Quarterly, 23, 10-26.
Reid, M. J., Webster-Stratton, C., & Baydar, N. (2004). Halting the development of externalizing
behaviors in Head Start children: The effects of parenting training. Journal of Clinical
Child and Adolescent Psychology, 33(2), 279-291.
Reid, M. J., Webster-Stratton, C., & Hammond, M. (2007). Enhancing a classroom social
competence and problem-solving curriculum by offering parent training to families of
moderate-to-high-risk elementary school children. Journal of Clinical Child and
Adolescent Psychology, 36(5), 605-620.
Rinaldi, J. (2001). Long-term outcomes of parent training and predictors of adolescent
adjustment. Dissertation Abstracts International, 62(05), 2498 (UMI No. 3014016).
Preventing and Treating Conduct Disorders
28
Scott, S., Spender, Q., Doolan, M., Jacobs, B., & Aspland, H. (2001). Multicentre controlled trial
of parenting groups for child antisocial behaviour in clinical practice. British Medical
Journal, 323(28), 1-5.
Snyder, H. (2001). Epidemiology of official offending. In R. Loeber & D. Farrington (Eds.),
Child delinquents: Development, intervention and service needs (pp. 25-46). Thousand
Oaks, CA: Sage.
Spaccarelli, S., Cotler, S., & Penman, D. (1992). Problem-solving skills training as a supplement
to behavioral parent training. Cognitive Therapy and Research, 16, 1-18.
Taylor, T. K., Schmidt, F., Pepler, D., & Hodgins, H. (1998). A comparison of eclectic treatment
with Webster-Stratton's Parents and Children Series in a children's mental health center:
A randomized controlled trial. Behavior Therapy, 29, 221-240.
Tremblay, R. E., Japel, C., Perusse, D., Boivin, M., Zoccolillo, M., Montplaisir, J., et al. (2000).
The search for the age of "onset" of physical aggression: Rousseau and Bandura revisited.
Criminal Behavior and Mental Health, 24(2), 129-141.
Webster-Stratton, C. (1981). Modification of mothers' behaviors and attitudes through videotape
modeling group discussion program. Behavior Therapy, 12, 634-642.
Webster-Stratton, C. (1982). Teaching mothers through videotape modeling to change their
children's behaviors. Journal of Pediatric Psychology, 7(3), 279-294.
Webster-Stratton, C. (1984). Randomized trial of two parent-training programs for families with
conduct-disordered children. Journal of Consulting and Clinical Psychology, 52(4), 666678.
Preventing and Treating Conduct Disorders
29
Webster-Stratton, C. (1990a). Enhancing the effectiveness of self-administered videotape parent
training for families with conduct-problem children. Journal of Abnormal Child
Psychology, 18, 479-492.
Webster-Stratton, C. (1990b). Long-term follow-up of families with young conduct problem
children: From preschool to grade school. Journal of Clinical Child Psychology, 19(2),
144-149.
Webster-Stratton, C. (1992). Individually administered videotape parent training: "Who
benefits?" Cognitive Therapy and Research, 16(1), 31-35.
Webster-Stratton, C. (1994). Advancing videotape parent training: A comparison study. Journal
of Consulting and Clinical Psychology, 62(3), 583-593.
Webster-Stratton, C. (1998). Preventing conduct problems in Head Start children: Strengthening
parenting competencies. Journal of Consulting and Clinical Psychology, 66(5), 715-730.
Webster-Stratton, C. (2000). How to children's promote social and emotional competence.
London, England: Sage Publications.
Webster-Stratton, C. (2006). The Incredible Years: A trouble-shooting guide for parents of
children ages 3-8 years. Seattle: Incredible Years Press.
Webster-Stratton, C., & Hammond, M. (1990). Predictors of treatment outcome in parent
training for families with conduct problem children. Behavior Therapy, 21, 319-337.
Webster-Stratton, C., & Hammond, M. (1997). Treating children with early-onset conduct
problems: A comparison of child and parent training interventions. Journal of Consulting
and Clinical Psychology, 65(1), 93-109.
Preventing and Treating Conduct Disorders
30
Webster-Stratton, C., & Hammond, M. (1998). Conduct problems and level of social competence
in Head Start children: Prevalence, pervasiveness and associated risk factors. Clinical
Child Psychology and Family Psychology Review, 1(2), 101-124.
Webster-Stratton, C., & Herbert, M. (1994). Troubled families—problem children: Working with
parents: A collaborative process. Chichester: Wiley & Sons.
Webster-Stratton, C., Hollinsworth, T., & Kolpacoff, M. (1989). The long-term effectiveness and
clinical significance of three cost-effective training programs for families with conductproblem children. Journal of Consulting and Clinical Psychology, 57(4), 550-553.
Webster-Stratton, C., Kolpacoff, M., & Hollinsworth, T. (1988). Self-administered videotape
therapy for families with conduct-problem children: Comparison with two cost-effective
treatments and a control group. Journal of Consulting and Clinical Psychology, 56(4),
558-566.
Webster-Stratton, C., & Reid, M. J. (1999, November, 1999). Treating children with early-onset
conduct problems: The importance of teacher training. Paper presented at the
Association for the Advancement of Behavior Therapy, Toronto, Canada.
Webster-Stratton, C., Reid, M. J., & Hammond, M. (2001). Preventing conduct problems,
promoting social competence: A parent and teacher training partnership in Head Start.
Journal of Clinical Child Psychology, 30(3), 283-302.
Webster-Stratton, C., Reid, M. J., & Hammond, M. (2004). Treating children with early-onset
conduct problems: Intervention outcomes for parent, child, and teacher training. Journal
of Clinical Child and Adolescent Psychology, 33(1), 105-124.
Webster-Stratton, C., & Herman, K. (2008). The impact of parent behavior-management training on
child depressive symptoms. Journal of Counseling Psychology, 55(4), 473-484.
Preventing and Treating Conduct Disorders
31
Webster-Stratton, C., Reid, M. J., & Stoolmiller, M. (2008). Preventing conduct problems and
improving school readiness: Evaluation of the Incredible Years Teacher and Child
Training Programs in high-risk schools. Journal of Child Psychology and Psychiatry
49(5), 471-488.
Webster-Stratton, C., Rinaldi, J., & Reid, J. M. (2009). Long-Term outcomes of Incredible Years
Parenting Program: Predictors of Adolescent Adjustment. Unpublished manuscript, Seattle.
Preventing and Treating Conduct Disorders
32
Author Note
This research was supported by the NIH National Center for Nursing Research Grant 5
R01 NR01075 and NIMH Research Scientist Development Award MH00988. Correspondence
concerning this chapter should be addressed to Carolyn Webster-Stratton, University of
Washington, School of Nursing, Parenting Clinic, 1107 NE 45th St. Suite #305, Seattle, WA
98105.
Preventing and Treating Conduct Disorders
Table 1
Summary of Treatment Results for Studies Evaluating the Incredible Years Programs
Study Information
Number
Investigator: Program
Program
of
Developer or Independent
Population:
Evaluated
Studies1
Replication
Prevention or Treatment
Parent
6
Developer
Treatment
Parent
4
Developer
Prevention
Child
2
Developer
Treatment
Child
1
Developer
Prevention
Teacher
1
Developer
Treatment
Teacher
2
Developer
Prevention
Parent
5
Replication
Treatment
Parent
5
Replication
Prevention
Child
1
Replication
Treatment
Child
1
Replication
Prevention
Teacher
2
Replication
Prevention
Outcomes
Variable Measured
Effect Size2
(Observation and Report)
Cohen’s d
Positive Parenting Increased
d=.46-.51
Parent
Harsh Parenting Decreased
d=.74-.81
Parent
Child Home Behavior Problems Decreased
d=.41-.67
Parent
Child Social Competence
d=.69-.79
Child
School Readiness and Engagement
d=82-2.87
Child and Teacher
Child School Behavior Problems
d=.71-1.23
Child and Teacher
Parent-School Bonding
d=.57
Teacher
Teacher Positive Management
d=1.24
Teacher
Teacher Critical Teaching
d=.32-1.37
Teacher
Most Effective Program
1
All studies used randomized control group design and are cited in the reference list.
2
Effect sizes include both treatment and prevention studies conducted by the program developer.
The range of effect sizes represents the range for a particular outcome across all studies that
included that outcome measure. The information to calculate effect sizes for independent
replications was not available.
33