Incredible Years – Child Treatment

Study 1

Evaluation Methodology

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

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

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

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

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

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

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

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

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

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

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

Outcomes

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

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

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

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

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

The following results were found in the five areas measured:

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

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

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

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

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

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

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

Study 2

Evaluation Methodology

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

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

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

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

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

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

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

Outcomes

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

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

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

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

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

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

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

Study 3

Evaluation Methodology

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

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

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

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

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

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

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

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

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

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

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

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

Outcomes

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

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

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

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

Mean differences across posttest (between group differences):

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

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

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

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

Condition x Time differences

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

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

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

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

Study 4

Evaluation Methodology

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

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

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

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

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

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

Outcomes

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

Posttest:

Drugli and Larsson (2006)

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

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

Larsson et al. (2009)

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

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

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

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

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

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

Long-term Follow-up

Drugli et al. (2010)

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

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

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

Study 5

Evaluation Methodology

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

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

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

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

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

Analysis: Data were analyzed using latent growth curve models.

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

Outcomes

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

Baseline Equivalence: No information provided in this study.

Differential Attrition: No information provided in this study.

Results:

The following significant predictive relationships were found:

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

The following significant moderational relationships were found:

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

The following significant mediators of outcome were found:

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