Rutter's Child and Adolescent Psychiatry Book 2

Mattessich, P. W., & Monsey, B. R. (1992). Collaboration: What makes it work? A review of research literature on factors influencing successful collaborations. St. Paul, MN: Amherst H. Wilder Foundation. Maughan, B., Pickles, A., Rutter, M., & Ouston, J. (1990). Can schools change? I. Outcomes at six London secondary schools. School Effectiveness and School Improvement, 1, 188–210. McCall, R. B. (submitted). Toward more realistic evidence-based programming and policies. McCall, R. B., & Green, B. L. (2004). Beyond the methodological gold standards of behavioral research: Considerations for practice and policy. Society for Research in Child Development Social Policy Reports, 18, 1–19. McCall, R. B., Green, B. L., Groark, C. J., Strauss, M. S., & Farber, A. E. (1999). An interdisciplinary, university-community, applied developmental science partnership. Journal of Applied Developmental Psychology, 20, 207–226. McCall, R. B., Green, B. L., Strauss, M. S., & Groark, C. J. (1997). Issues in community-based research and program evaluation. In I. E. Sigel, & K. A. Renninger (Eds.), Handbook of child psychology, Vol. 4, 5th edn. (pp. 955–997). New York: Wiley. McCall, R. B., Groark, C. J., & Nelkin, R. (2004). Integrating developmental scholarship and society: From dissemination and accountability to evidence-based programming and policies. Merrill– Palmer Quarterly, 50, 326–340. McCall, R. B., Larsen, L., & Ingram, A. (2003). The science and policy of early childhood education and family services. In A. J. Reynolds, M. C. Wang, & H. J. Walberg (Eds.), Early childhood programs for a new century: Issues in children’s and families’ lives (pp. 255–298). The University of Illinois at Chicago Series on Children and Youth. Washington, DC: CWLA Press. McCall, R. B., Ryan, C. S., & Plemons, B. W. (2003). Some lessons learned on evaluating community-based, two-generation service programs: The case of the Comprehensive Child Development Program (CCDP). Journal of Applied Developmental Psychology, 24, 125–141. Millsap, M. A., Chase, A., Obeidallah, D., Perez-Smith, A., Brigham, N., & Johnston, K. (2000). Evaluation of Detroit’s Comer schools and families initiative. Cambridge, MA: Abt Associates. Morrow, A. L., Townsend, I. T., & Pickering, L. K. (1991). Risk of enteric infection associated with early child day care. Pediatric Annals, 20, 427–433. Mrazek, P. J., & Haggerty, R. J. (Eds.). (1994). Reducing risks for mental disorders: Frontiers for prevention intervention research. Washington, DC: National Academy Press. Muhamedrahimov, R. J., Palmov, O. I., Nikiforova, N. V., Groark, C. J., & McCall, R. B. (2004). Institution-based early intervention program. Infant Mental Health Journal, 25, 488–501. Nation, M., Crusto, C., Wandersman, A., Kumpfer, K. L., Seybolt, D., Morrissey-Kane, E., et al. (2003). What works in prevention: Principles of effective prevention programs. American Psychologist, 58, 449–456. National Evaluation of Sure Start Team. (2005a). Report for team: Variation in Sure Start local programme effectiveness: Early preliminary findings. London, UK: HMSO. National Evaluation of Sure Start Team. (2005b). Report 13: Early impacts of Sure Start local programmes on children and families. London, UK: HMSO. Neufield, B., & LaBue, M. (1994). The implementation of the School Development Program in Hartford: Final evaluation report. Cambridge, MA: Education Matters. Olds, D. L., & Kitzman, H. (1993). Review of research on home visiting for pregnant women and parents of young children. In R. E. Behrman (Ed.), Home visiting: The future of children (Vol. 3, pp. 53–92). Los Angeles, CA: David and Lucile Packard Foundation. Olds, D. L., Henderson, C. R. Jr., Kitzman, H. J., Eckenrode, J. J., Cote, R. E., & Tatelbaum, R. C. (1999). In R. E. Behrman (Ed.), Home visiting: Recent program evaluations. The Future of Children (Vol. 9, pp. 44–65). Los Angeles, CA: David and Lucile Packard Foundation. Ouston, J., Maughan, B., & Rutter, M. (1991). Can schools change? II. Practice in six London secondary schools. School Effectiveness and School Improvement, 2, 3–13. Ringwalt, C. L., Ennett, S., Vincus, A., Thorne, J., Rohrbach, L. A., & Simons-Rudolph, A. (2002). The prevalence of effective substance use prevention curricula in US middle schools. Prevention Science, 3, 257–265. Rosenbam, P. R., & Rubin, D. (1983). The central role of the propensity score in observational studies for causal effects. Biometrika, 70, 41–55. Rossi, P. H., Lipsey, M. W., & Freeman, H. E. (2004). Evaluation: A systematic approach (7th edn.). Thousand Oaks, CA: Sage. Rutter, M. (2006). Is Sure Start an effective preventive intervention? Child and Adolescent Mental Health, 11, 135–141. Schorr, L. B. (2003). Determining “what works” in social programs and social policies: Toward a more inclusive knowledge base. Accessed February 2003 from www.brookings.edu/views/papers/ sawhill/20030226.htm. Scott, K. G., Mason, C. A., & Chapman, D. A. (1999). The use of epidemiological methodology as a means of influencing public policy. Child Development, 70, 1263–1272. Shonkoff, J. P. (2000). Science, policy, and practice: Three cultures in search of a shared mission. Child Development, 71, 181–187. St. Pierre, R. G., Layzer, J. I., Goodson, B. D., & Bernstein. L. S. (1994). National evaluation of the Comprehensive Child Development Program: Interim report. Cambridge, MA: Abt Associates. St. Pierre, R. G., Layzer, J. I., Goodson, B. D. & Bernstein, L. S. (1997a, September). The effectiveness of comprehensive case management interventions: Findings from the national evaluation of the Comprehensive Child Development Program. Cambridge, MA: Abt Associates. St. Pierre, R. G., Layzer, J. I., Goodson, B. D. & Bernstein, L. S. (1997b, June). National impact evaluation of the Comprehensive Child Development Program: Final Report. Cambridge, MA: Abt Associates. Wandersman, A., & Florin, P. (2003). Community interventions and effective prevention. American Psychologist, 58, 441–448. Wandersman, A., & Goodman, R. (1993). Understanding coalitions and how they operate: An “open systems” organizational perspective. W. K. Kellogg Foundation Community-Based Public Health Initiative. Wandersman, A., Imm, P., Chinman, M., & Kaftarian, S. (1999). Getting to outcomes: Methods and tools for planning, evaluation and accountability. Rockville, MD: Center for Substance Abuse Prevention. Wandersman, A., Imm, P., Chinman, M., & Kaftarian, S. (2000). Getting to Outcomes: A results-based approach to accountability. Evaluation and Program Planning, 23, 389–395. Weissberg, R. P., & Kumpfer, K. L. (Eds.). (2003). Prevention that works for children and youth. Special Issue. American Psychologist, 58, 425–490. Weisz, J. R., Jensen-Doss, A., & Hawley, K. M. (2006). Evidencebased youth psychotherapies versus usual clinical care: A metaanalysis of direct comparisons. American Psychologist, 61, 671–689. www.surestart.gov.uk (January 4, 2008). CHAPTER 60 988 9781405145497_4_060.qxd 29/03/2008 02:57 PM Page 988

Objectives and Overview This chapter covers targeted preventive interventions as applied to the psychosocial domain and is divided into three parts. In the first part, we examine who should be the focus of preventive interventions. In doing so, we critically review past and current classification systems of prevention programs in light of the Science of Prevention concepts (Coie, Miller-Johnson, & Bagwell, 2000; Coie, Watt, West et al., 1993) as well as new knowledge accumulated over the last decade in the area of developmental psychopathology (Cicchetti & Cohen, 2006; Masten, Burt, & Coatsworth, 2006). The second part focuses on what should be targeted for change, how such targeting should be accomplished and when such targeting should occur. Finally, we review practical and clinical issues related to recruitment and retention of participants, timing and components of preventive interventions, assessment of results, costeffectiveness and dissemination. Throughout the chapter, we refer to past or ongoing preventive interventions to illustrate our points. We assume that most readers are aware of the theoretical and practical advantages of preventive interventions over treatment. These are well described by Coie, MillerJohnson, & Bagwell (2000) and Offord and Bennett (2002) (see also chapter 60). Who Should be Targeted? Based on the Science of Prevention concept, preventive interventions are a series of organized, theoretically driven efforts to break the developmental pathways linking early risk factors to later adjustment problems. As illustrated in Fig. 61.1, the disruption of this psychopathological process can be achieved by: 1 Eliminating the initial risk factors or their subsequent mediators; 2 Adding beneficial factors to the developmental chain to compensate for risk factors; or 3 Putting in place protective factors (i.e., moderators) that mitigate the links between risk factors and their associated outcomes (for the distinction between risk factors, mediators and moderators see Kraemer, 2003). In this context, developmental psychopathology provides a comprehensive framework for constructing “theories of the emerging problem,” whereas the Science of Prevention can be seen as a comprehensive framework to construct “theories of the appropriate solutions” to prevent problems from emerging. Brief Historical Overview The first conceptualization of prevention into primary, secondary and tertiary interventions was proposed by Caplan (1964). Caplan’s conceptualization emphasized the timing of intervention relative to the problem to be prevented: before onset (i.e., primary prevention), during early or preclinical manifestations (i.e., secondary prevention) or after the full-blown clinical establishment to prevent relapse or further complications (i.e., tertiary prevention). Caplan’s model has been criticized on the basis that it is problematic to assume that the development of a problem follows three easily identifiable and conceptually distinct phases (Kraemer, Stice, Kazdin, Offord, & Kupfer, 2001). Indeed, for most psychopathological problems, frequency and severity of symptoms occur on a continuum, even though specific clusters can be identified (Maughan, 2005; Offord & Bennett, 2002). 989 Clarifying and Maximizing the Usefulness of Targeted Preventive Interventions Frank Vitaro and Richard E. Tremblay 61 Fig. 61.1 Simplified developmental chain illustrating the targets and the functions of a preventive intervention. The signs − or + on the oblique lines indicate that a preventive intervention can either eliminate a risk factor or put in place a resource factor (which is often the opposite of a risk factor) with respect to main effects (i.e., causal risk factors and mediators). Alternatively, the signs + or − on the vertical line indicate that a preventive intervention can, instead or in addition, be designed to put in place protective factors or reduce vulnerability factors with respect to moderators. Causal risk factors Preventive intervention − or + − or + + or − Mediators Outcome 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 989 Rutter’s Child and Adolescent Psychiatry, 5th Edition, Edited by M. Rutter, D. V. M. Bishop D. S. Pine, S. Scott, J. Stevenson, E. Taylor and A. Thapar © 2008 Blackwell Publishing Limited. ISBN: 978-1-405-14549-7

A new classification system was proposed in the 1990s which remains in vogue (Mrazek & Haggerty, 1994; Offord & Bennett, 2002). In the current two-level classification system, prevention initiatives are classified according to who is offered the intervention (Gordon, 1983; Institute of Medicine, 1994; Offord, Kraemer, Kazdin, Jensen, & Harrington, 1998). At the first level are universal preventive interventions (UPI) in which all members of a geographical unit (e.g., a residential area, a school) or a social unit (e.g., kindergarteners, adolescents) are offered new activities or new services aimed at helping them overcome current or future challenges, but without targeting anyone in particular (see chapter 60). According to some authors, UPI encompasses the notion of health promotion (Cowen, 1991), although others do not agree with this view (Institute of Medicine, 1994). In UPI, intervention can occur in the absence of any sign of the problem to be prevented or any visible (i.e., quantifiable) risk, although risk for some individuals is suspected. UPI can also occur in the presence of identified risk factors as long as these factors might affect the entire population (e.g., the availability and acceptability of drugs that seem to be linked to an elevated rate of substance use in the entire adolescent population; Bachman, Johnson, & O’Malley, 1998). The second level includes targeted preventive interventions (TPI). In the case of TPI, only individuals at risk for a problem are targeted. If the individuals are at risk for environmental reasons, as in the case of children born from teenage mothers, then the TPI is called selective. If instead, the children are at risk on the basis of personal dispositions such as early signs of persisting physical aggression, then the TPI is termed indicated. TPI is deployed in the context of risk factors or early precursors of the problem to be prevented. These risk factors or early precursors need to occur at the level of the individual or his or her immediate environment (i.e., family), not at the level of the entire community as in the case of UPI. This distinction may explain in part why TPI-oriented researchers and practitioners usually deploy their efforts at the level of the individual and his or her immediate social environment (i.e., family, teacher, peers). In contrast, UPI-oriented colleagues attempt to establish services and resources at the level of the community. More details about the distinctions between universal, selective and indicated preventive interventions can be found in Mrazek and Brown (2002). Who is At Risk and to What Extent are They At Risk? Traditionally, TPI involves a dichotomous view of those at risk (who should get the full TPI) and those not at risk (who do not need any preventive intervention). In most cases, risk is not a binary category but a continuum of probabilities, although this continuum may not be normally distributed (Meehl, 1992). Hence, it is inaccurate to think of individuals as being either at risk (and thus deserving TPI) or not at risk or not yet at risk. Given the multifactorial and developmental determination of most psychosocial problems, individual variation with respect to risk is most often a variation in CHAPTER 61 990 degree, not in kind. In consequence, we advocate a continuous approach towards risk. This continuous approach also needs to be multivariate. Three strategies can be used to help determine the degree of risk according to a continuous multivariate perspective. The first strategy was proposed by Burgess (1928). It is a cumulative strategy in which the total number of risk factors is calculated after establishing their individual presence (or absence) using a dichotomous approach. This approach is based on the traditional 2 × 2 epidemiology tables that are used to establish risk status based on its relationship with ulterior psychopathology status (Kraemer, Kazdin, Offord et al., 1999; Offord, 1996; Rice & Harris, 1995). A second strategy is to use the results of a multivariate regression, either linear or logistic, to determine the weights of each risk factor before summing them. This method is known as the weighted additive approach. Some authors have claimed that the weighted additive and the cumulative methods are equally effective in determining the degree of risk (Farrington, 1985). However, others report divergent results. For example, Deater-Deckard, Dodge, Bates, and Pettit (1998) showed that a cumulative risk index based on four childhood risk factors (i.e., child characteristics, sociocultural level, parenting and caregiving, and peer victimization/rejection) correlated only modestly with later externalizing problems (i.e., 0.32–0.39 depending on whether parent, teacher or peer reports were used). In contrast, the predictive coefficients between the four risk factors and the outcome varied between 0.60 and 0.67 when using a weighted additive approach. One important advantage of the regression approach on which the weighted additive method rests is that it can be expanded into the interactive approach, which is our favored strategy. Most developmental models include not only risk factors with main effects (either direct or indirect, via mediators), but also moderators that qualify these main effects, sometimes in dramatic ways (Coie, Watt, West et al., 1993; Rutter, Giller, & Hagell, 1998). For example, child maltreatment leads to violent behavior, more so in children with the short allele of a variant in the gene coding for the neurotransmitter metabolizing enzyme monoamine oxidase A (MAOA; Caspi, McClay, Moffitt et al., 2002). These findings correspond to a person × environment interaction model which is now becoming generally accepted in developmental psychopathology research (see chapter 23; Plomin & Crabbe, 2000; Sameroff & Mackenzie, 2003). This interactive model allows for the integration of moderating factors to determine the degree of risk. These moderators can reflect either protection or vulnerability. Contrary to resource (or compensatory) factors that have main effects opposite to risk factors, protection factors mitigate the relationship between risk factors and later outcomes. Conversely, vulnerability factors exacerbate the link between risk factors and later outcome; they can also reduce the link between resource factors and later outcomes (Fergusson, Vitaro, Wanner, & Brendgen, 2007; Luthar, Cicchetti, & Becker, 2000; Rutter, Giller, & Hagell, 1998). 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 990

It follows that the identification of at-risk individuals should result from a combination of environmental and personal factors that can operate additively or interactively, and not only on background factors or on personal vulnerabilities. An important consequence of such a multivariate interactive strategy is to minimize the distinction between selective and indicated TPI because this distinction requires that participants be selected on the basis of either background or personal factors. Already, some prevention programs target at-risk individuals on the basis of both personal and background characteristics. For example, the promoters of Fast Track, one of the major TPIs in the USA (Conduct Problems Prevention Research Group, 1999a,b), selected the participating children on the basis of neighborhood crime and poverty level and parent and teacher-rated disruptiveness scores. To summarize, a risk score can be derived for each individual or each community by combining risk/resource factors and vulnerability/protective factors derived from multivariate analyses. Of course, one should not rely on only one study to establish which risk and protective factors are relevant. Metaanalyses and averaged effect sizes of the r type (i.e., beta weights or odds ratios) can also be used in this context (Lipsey, 1995; McCartney & Rosenthal, 2000). However, the value of the risk score may need to be adjusted depending on cultural or geographical variations (seen here as additional putative moderators). For example, children’s anxiety may not be linked to depressive feelings in China as much as in Canada because anxious Chinese children are not ostracized by their peers as much as their anxious Canadian counterparts, a consequence of the differences in the ways anxiety is perceived in the two cultures (Chen, Rubin, & Sun, 1992). One must also be aware of possible non-linear relationships between risk factors and developmental outcomes. In addition, the risk score should be based on risk factors that are easy to measure, reducing the cost of the screening process and increasing its chance for widespread use. If necessary, the continuous risk score can be split into segments to reflect the degree of risk and possibly the nature of the risk faced by the individuals and the communities from each segment. The cut-off scores used to identify the different segments as well as their respective sets of risk and protective factors can take advantage of traditional or recent clustering techniques (Nagin, 2005; Pickles & Angold, 2003). Note that this segmentation approach is different from the traditional epidemiological approach because: (i) it is based on the full information derived from additive and interactive statistical models; and (ii) in most cases, it generates more than the traditional two segments (i.e., one at risk and one not at risk). Ideally, each segment would receive a program with content and dosage tailored to its specific constellation and level of risk/resource and vulnerability/protective factors. This suggestion is in line with the adaptive preventive intervention approach proposed by Collins, Murphy, and Bierman (2004). According to this approach, different dosages of certain program components, including zero dosages, are assigned across individuals and/or within individuals across time in accordance with the individuals’ needs or response to the program. Clear and well-informed decision rules help link specific levels and types of program components to the characteristics of the individuals in each segment. The latter are called tailored variables. Tailored variables refer essentially to pretest variables that might exert a moderating effect on the impact of a preventive intervention and/or participants’ progress toward a prespecified threshold representing a successful outcome. To illustrate, in the Fast Track multicomponent program (see pp. 993–4), the number of home visits during the first years of the program (i.e., monthly, biweekly, weekly) was determined based upon ratings of parental functioning, which included empirically validated risk factors. A similar approach was used for the reading tutoring component; only the children whose academic performance was below the 33rd percentile received that component. Parental functioning and academic performance were selected because they were hypothesized to moderate the impact of the core elements of the Fast Track program, although they can also be seen as proximal outcomes and putative mediators. Given that the appropriate dosage depends on the tailored variables, these variables should be selected and measured with care. It is also important that they are stringently operationalized according to welldocumented decision rules, which also help in the evaluation of these adaptive preventive interventions. What? When? and How? Now that we have clarified who should be targeted in preventive interventions, we turn to what should be targeted and when, and how preventive interventions should take place. What Should be Targeted and When Should They be Targeted? Not all risk/resource factors and not all vulnerability/protective factors are equally important or relevant for TPI. The risk/ resource factors and the vulnerability/protective factors that should be targeted by TPI are those that are: 1 Theoretically relevant and empirically active; 2 High in predictive power and in causal plausibility; 3 Potent and generative; 4 Chronologically, culturally and geographically relevant; and 5 Modifiable in a cost-effective way. Indeed, only variables and processes that have an active role as main effects or moderators in the developmental pathways leading to the emergence of maladaptation should be targeted by TPI (Felner, Yates Felner, & Silverman, 2000; Rutter, 2003). Hence, risk indicators such as factor B1 in Fig. 61.2 (also called markers, proxies or incidental correlates) need to be distinguished from risk factors with unique main effects such as factors A1 and A2, mediators such as factors B2 and B3, and moderators such as factors B4 and C5. As acknowledged by Rutter (2003), this is not an easy task given that most knowledge about risk factors is derived from correlational studies. However, it is an important task if we want TPI to impact on factors that make an active and possibly causal contribution TARGETED PREVENTIVE INTERVENTIONS 991 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 991

to the complex chain of events leading to maladaptation. Causal plausibility is increased further when the probable mechanisms of these active factors are well documented. Some risk/resource and vulnerability/protective factors may have an active role in a developmental pathway and their operating mode may be well documented, but their effect size may be small in terms of partial correlations and odds ratios resulting from multivariate analyses. These are not potent risk factors and may not be worth targeting through preventive efforts. Instead, priority should be given to risk/resource factors that are more potent in terms of their effect size relative to the outcome to be prevented. Similarly, priority should be given to protective and vulnerability factors that have a high multiplicative power with respect to the link between risk or resource factors and the outcome (Kraemer, Stice, Kazdin et al., 2001). Protective factors with buffering effects should be the primary target of prevention efforts, especially if risk factors are difficult to modify. Generativity of risk/resource factors and of vulnerability/ protective factors is also important in determining which factors deserve to be targeted by TPI. The notion of generativity refers to the number of mediators with potentially additional unique effects of their own that are triggered by a single risk/resource factor according to a cascade model (i.e., such as factor B2 in Fig. 61.2; Masten, Burt, & Coatworth, 2006). It also refers to the number of risk factors that can be moderated by a single protective factor (such as factor B4 in Fig. 61.2) or the number of adjustment problems resulting from a single risk factor according to the principle of multifinality described by developmental psychopathologists (Cicchetti & Hinshaw, 2002; i.e., such as factor C3 in Fig. 61.2). Hence, cost-effective TPI would target generic risk factors in order to “kill several birds with a few stones.” Many, if not most, of these generic risk factors may be found early in life. As a result, early TPI during the prenatal and preschool periods may be the most (cost) effective, as results from preventive interventions during the prenatal and preschool years indicate (Aos, Lieb, Mayfield, Miller, & Pennucci, 2004; Carneiro, & Heckman, 2003; Olds, Henderson, Kitzman, & Eckenrode, 1998; Schweinhart, 2006). Interventions targeting these periods may also receive public and government support more easily because it makes common sense to try to prevent the complex chain of events that leads to later maladjustment in children by targeting the initial elements of the chain (that have a high generic power). Of course, these early risk factors must be ethically modifiable. They should also be easily modifiable. For example, low socioeconomic status (SES) and tobacco exposure during pregnancy are independent risk factors for later disruptive behavior (Maughan, Taylor, Taylor, Butler, & Bynner, 2001; Wakschlag & Hans, 2002). Low SES may be modifiable (Leventhal & Brooks-Gunn, 2004), but not by health professionals, at least not directly. In contrast, prenatal exposure to nicotine is easily modifiable, at least in principle. However, modifying prenatal nicotine exposure requires the right timing; after the first months of pregnancy, it may be too late to effect change. Other risk factors, although modifiable, may not be relevant because of the participants’ characteristics such as age, sex, ethnicity or cultural background. To conclude, trying to change factors that cannot be changed or, when changed, do not affect the incidence of the outcome because the factors are markers and not causal antecedents is a waste of time and valuable resources. Trying to change factors that, although causal, are not potent, not generic, not well-timed or not culturally relevant will also prove to be a waste of resources. In designing preventive interventions, the emphasis should be placed on active, independent, causal, generic, early, modifiable and culturally approved or important risk/resource and vulnerability/protective factors. How do we Achieve the Maximum Impact of TPI? One first step toward answering this question is to identity effective prevention strategies with respect to a specific problem. Narrative (e.g., Greenberg, Domitrovich, & Bumbarger, 2001) and quantitative (LeMarquand, Tremblay, & Vitaro, 2001) reviews of existing prevention programs are a good starting point. Meta-analyses are particularly useful because of the comparative statistics they generate in the form of effect sizes. As illustrated in Table 61.1, several meta-analyses of effective and ineffective prevention programs in different areas of adjustment have become available over the past decade. Above and beyond summary statistics such as the effect size, the usefulness of meta-analyses is to categorize original studies according to their theoretical background, methodological rigor, intervention components or participants’ characteristics. Also useful in the identification of the most effective programs are the hit lists of best preventive programs prepared by different groups of researchers. One such list was prepared by the Center for the Study and Prevention of Violence (http:// www.colorado.edu/cspv/blueprints). The first part of this list CHAPTER 61 992 Fig. 61.2 Different roles of risk factors in developmental pathways. Factor A1 Factor B1 Factor B2 Factor A2 Factor B3 Factor B4 Factor C1 Factor C2 Outcome D1 Factor C3 Factor C4 Outcome D2 Factor C5 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 992

includes 12 prevention programs considered “blueprints” according to a series of well-defined criteria. These programs mainly target substance abuse, aggression and delinquency. The second part of the list contains 16 programs that are considered promising. In addition to narrative and meta-analytic reviews of prevention programs in one problem outcome area, some authors compared the results of several prevention programs across different problem outcome areas in order to identify key characteristics associated with successful programs that might transcend specific content areas. Nation, Crusto, Wandersman et al. (2003) identified nine principles after reviewing 35, mostly narrative, reviews of universal and selective prevention programs that targeted five problem areas: substance use, risky sexual behavior, delinquency, violence and school failure. Nation, Crusto, Wandersman et al. concluded that effective programs are: 1 Theory driven; 2 Appropriately timed; 3 Comprehensive; 4 Oriented towards opportunities for positive relationships; 5 Open to varied teaching methods; 6 Sufficiently potent with respect to dosage and duration; 7 Well integrated in delivery services; 8 Socioculturally relevant; and 9 Effective in triggering strategic mediators. These principles are illustrated and discussed further through the examination of a number of targeted prevention programs. Theory Driven Prevention programs need to rest on clear theoretical grounds and strong empirical evidence. To illustrate, promoters of Fast Track, a multicomponent multitarget TPI for low SES disruptive children and their caregivers, elaborated a clear theoretical rationale for every component of their program and attached each component to specific objectives with regard to risk and protective factors (Conduct Problems Prevention Research Group, 1992, 2004). Hence, each component was first justified by the important part played by that component in the etiology of conduct disorder (the distal outcome in this study). Each component was also justified by its evidence-based effectiveness. The six components were as follows: 1 Group parent training aimed at improving parenting skills and parent–child interactions; TARGETED PREVENTIVE INTERVENTIONS 993 Effect size (range and average) −0.83 to 2.51 (0.62) −0.25 to 0.47 (0.15) None available (0.45) −0.10 to 1.88 (0.22) 0.25 to 1.54 (0.74) −0.62 to 1.151 (0.27 at post-intervention; 0.32 at follow-up) −0.31 to 0.87 (0.14) None available (0.12) −2.39 to 2.79 (0.38 at post-intervention; 0.28 at follow-up) None available (0.86) Participants Disruptive children and adolescents (aged 6–18 years) Adolescents (aged 11–20 years) Hyperactive children (aged 5–15 years) Mixed (from birth through adolescence) Anxious children and adolescents Mixed (children and adolescents) At-risk children Juvenile delinquents (aged 14–18 years) Mixed (children and adolescents) Disruptive children and adolescents Number of primary studies 38 32 63 40 22 30 (18 targeted) 20 200 84 26 Outcome Behavior problems Early pregnancies ADHD Delinquency, violence, criminality Internalized problems (anxiety and depression) Depression Conduct disorder/delinquency Delinquency relapse Antisocial behavior Antisociality Table 61.1 Examples of meta-analyses about targeted preventive programs in regard to the prevention of different outcomes. Only metaanalyses that included primary studies with strong evaluation designs (i.e., either experimental or quasi-experimental) are considered here. Some meta-analyses include both universal and targeted prevention programs. One reason for including them was to compare the effect sizes of the two categories of prevention programs. Author Ang & Hugues (2002) Franklin, Grant, Corcoran, Miller, & Bultman (1997) DuPaul & Eckert (1997) Farrington & Welsh (2003) Grossman & Hugues (1992) Horowitz & Garber (2006) LeMarquand, Tremblay, & Vitaro (2001) Lipsey & Wilson (1998) Lösel & Beelmann (2003) Serketich & Dumas (1996) 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 993

2 Home visits designed to ensure that parenting skills were implemented and to inspire feelings of confidence in parents; 3 Group-based social skills training with the children aimed at improving their social-cognitive skills; 4 Peer-pairing, in which a target child and a no-risk peer participated in guided play sessions designed to capitalize on positive modeling from the no-risk peer and to change the no-risk peer’s likely negative perception of the target child; 5 Academic tutoring designed to prevent academic problems; and 6 Teacher support for effective management designed to help reduce the general level of disruptive behaviors in the classroom. Despite the theoretical and empirical “cutting edge” nature of Fast Track, the evaluation results are at best moderate, with effects sizes varying between 0.2 and 0.5 for the children most at risk (i.e., above the 90th percentile on the disruptiveness screening scores) after the first 3 years. After 5 years (by age 11 or grade 5), 37% of the randomly assigned Fast Track children had no conduct problem dysfunction compared with 27% of control children (Conduct Problems Prevention Research Group, 2002). Interestingly, and importantly, mediation analyses indicated that these results were partially explained by gains in the domains targeted by the program (i.e., parenting, peer relations and social-cognitive skills). The most recent data available show that the children above the 90th percentile were significantly better off with respect to important outcomes such as a DSM diagnosis for conduct disorder, index criminal offenses and interpersonal violence, although the effect sizes remain moderate (Conduct Problems Prevention Research Group, 2005). To illustrate, 72% of the control children had committed an index crime by grade 10 compared to 28% of the intervention children (the percentages for conduct disorder and interpersonal violence were 14 and 43% in the control group versus 6 and 20% in the intervention group, respectively). However, for the lower-risk children (i.e., those between the 70th and the 90th percentiles), the differences between the two groups were non-significant. Appropriately Timed and Developmentally Sensitive Preventive interventions should be initiated early enough to have an impact on the development of the problem behavior to be prevented. There is empirical evidence to suggest that the timing of a preventive intervention may be as important as its content. To illustrate, the Metropolitan Area Child Study Research Group (2002) randomly assigned schools to one of four conditions: a universal 2-year general classroom enhancement program, a universal general enhancement plus small-group peer skills training program, a universal general enhancement plus small-group peer skills plus family intervention, and a care-as-usual control condition. The authors also examined whether the results pertaining to aggressive behaviors and school achievement differed according to the timing of implementation (i.e., grades 2 and 3 only, grades 5 and 6 only, or grades 2, 3, 5 and 6). Globally, the results of this complex factorial study with the high-risk children (defined according to their baseline aggression scores) revealed that the most comprehensive condition produced the best results when aggression scores were examined. Specifically, the improvement in the behavior doubled when the initial 2-year intervention in grades 2 and 3 was followed by a second 2-year intervention in grades 5 and 6. Perhaps even more important, however, were the findings that none of the interventions were effective in preventing aggression when implemented only in grades 5 and 6. In fact, an iatrogenic effect was found whereby children in the control condition decreased in aggression whereas the intervention participants, particularly those in the small-group peer-skills training condition, did not. Comprehensive Because risk is multifactorial, prevention programs must include several components that address as many risk and protective factors in as many systems as possible in order to maximally influence development and the behaviors to be prevented. This rationale guided several of the most recent prevention programs described here (e.g., Fast Track and the Metropolitan Area Child Study) as well as older TPIs (e.g., the Cambridge Somerville Youth Study; McCord, 1978). The evidence in support of this intuitively logical principle, however, is inconsistent. Reid, Webster-Stratton, and Hammond (2003) and Webster-Stratton and Hammond (1997) compared different combinations of their Incredible Years Parent Training Program, their Incredible Years Teacher Program and their Child Training Program within a sample of 159, 4- to 7-year-old children with oppositionaldefiant disorder (in order to prevent later conduct disorder, substance abuse and school dropout, which represent more serious outcomes than ODD) (for further material on parenting programs see chapter 64). More specifically, the authors randomly assigned the children to one of the following conditions: the parent program only, the child program only, the parent and teacher programs, the child and teacher programs, and the child, parent and teacher programs. These five conditions were compared to a waitlist control condition. In the parent program only condition, the parents watched a series of 17 videotapes depicting ways parents can effectively manage problematic behaviors or situations with their children. The rationale, efficacy and content of these weekly 2-h group training sessions at the clinic are described in detail by Webster-Stratton, Mihalic, Fagan et al. (2001a). The child program consisted of 18–19 weekly 2-h sessions with two therapists and 6–7 target children. Through the use of puppets, the therapists illustrated a series of interpersonal skills that are usually absent or in excess in ODD children’s repertoires. These included conflict resolution skills, negative attributions, perspective taking and empathy, complying with teacher or parent requests, and communicating and co-operatively playing with other children. In addition, parents and teachers were asked to reinforce the targeted skills (e.g., sharing, teamwork, friendly talk, listening, compliance with requests, feeling talk and problem-solving) whenever they noticed the child using them in the home or the school. Children were also given weekly homework assignments to complete with their parents. A more complete description of the videotape training curriculum and leader manuals is provided by Webster-Stratton (1990). CHAPTER 61 994 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 994

The teacher program comprised 4 full days group training sequenced throughout the school year. Through illustrations and discussion, the teacher program promoted the use of praise and encouragement for positive behaviors, proactive teaching, using of incentives to motivate children, techniques to decrease disruptive behavior and collaborative strategies with parents. The teacher workshops also included topics such as prevention of peer rejection, acknowledgment of individual differences and strategies to prevent playground aggression. Two individual appointments with each teacher were scheduled to develop an individual behavior plan for the targeted child. At the end of the 6-month intervention period, children manifested improvements in comparison to controls that were consistent with the treatment condition. Hence, children in the three conditions with the child program showed more prosocial skills with peers than the children in the control condition. No difference between treatment and control was observed for children in the two conditions without the child program. Similarly, parents in the three parent program conditions manifested less negative and more positive parenting and reported fewer child behavior problems than parents in the control condition and parents in the two conditions without parent training. Children’s behavior problems at school were reduced for those whose teacher participated in the teacher program relative to the control children. Overall, the conditions that included all three programs produced the best results after 6 months. However, at 2-year follow-up the results were less clear-cut. Teachers reported an equal proportion of children with behavior problems across all five treatment conditions (i.e., around 50%). Parents in the parent + teacher programs reported fewer cases of behaviorally disordered children relative to only one other condition – the parent program only condition. Unfortunately, the waitlist control group was not available for comparison at the 2-year follow-up. Results from the Early Risers program (August, Egan, Realmuto, & Hektner, 2003; August, Realmuto, Hektner, & Bloomquist, 2001) further illustrate the lack of evidence in support of the notion that more is necessarily better in the context of a TPI. In their first study, August, Realmuto, Hektner et al. (2001), August, Hektner, Egan et al. (2002) implemented a 2-year program aimed at altering the developmental trajectories of young children with early-onset aggressive behavior. The Early Risers multicomponent program included five CORE components: a child social skills group training that used Webster-Stratton, Mihalic, Fagan et al.s’ (2001a) protocol, a parent education and skills training program that also used the parent training protocol of Webster-Stratton et al., a teacher behavior management program, a student mentoring program focused on academic learning and an annual 6-week summer school program that included non-targeted children. In addition, it also included a FLEX family support component tailored to address the unique needs of families. Intent-to-treat analyses revealed that, compared to controls, program participants showed greater gains in academic functioning. The most severely aggressive children, but not the others, also progressed on measures of self-regulation. In a second study, August, Egan, Realmuto et al. (2003) tested whether the FLEX component increased the impact of their program as expected. The authors randomly assigned a new group of aggressive children and their families to three groups. One group received both the CORE (applied in the same manner to all participants and their families) and the FLEX (tailored to families’ specific needs) components of their Early Risers program. The second group received the CORE component only. The third group received care as usual. Implementation results showed that CORE + FLEX participants attended more program sessions than their CORE-only counterparts. However, the two experimental conditions did not differ from each other in reducing children’s disruptive behaviors and parents’ levels of stress, although both were superior to the care-as-usual condition; these results suggest that the FLEX component, although intuitively appealing, did not seem to improve upon the basic CORE program. Consistent with the idea of creating a synergy between different prevention components, one strategy that might optimize the effects of a TPI is to combine targeted and universal components within the same program. Fast Track illustrates how such a combination of targeted and universal components can be achieved (Conduct Problems Prevention Research Group, 1999b). In addition to the six targeted components already described, a series of socioemotional skills training sessions (i.e., the Promoting Alternative Thinking Strategies or PATHS curriculum; Greenberg, Kusche, Cook, & Quamma, 1995) were implemented in the classrooms of participating children. The PATHS lessons were intended to teach all the classroom children such social and personal skills as self-regulation, emotional awareness and social problem-solving. Combining universal and targeted prevention components in a single program may be more likely to mobilize and prepare the child’s whole social environment, changing the local norms for appropriate behavior. These positive changes in social norms may support the positive changes that the targeted components can achieve with the at-risk children, promoting their maintenance and generalization to other contexts. Combining universal and targeted prevention also ensures that the “false negative” cases (i.e., children not considered at-risk who will nevertheless develop a problem) receive minimal preventive help through the universal component. Similarly, combined programs minimize the “Matthew effect” (Ceci & Papierno, 2005). The term “Matthew effect” refers to the possible outcome of a universal intervention in which children who are not at risk benefit more from the intervention than do those at risk, thus increasing the gap between the two groups. However, these are only speculations because to our knowledge no author has compared the results of a combined program with a TPI only or UPI only program. Sufficient Dosage and Intensity A related issue is the necessary and sufficient dosage and intensity of a TPI. Dosage and intensity refer to aspects of a TPI TARGETED PREVENTIVE INTERVENTIONS 995 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 995

such as length and number of sessions, spacing of sessions and the duration of the total program. Most prevention programs offer all-or-none packages in which some children receive every component of an intervention and other children receive no treatment or treatment-as-usual. However, we believe that dosage of a program should be gauged to the level of risk faced by the targeted individuals or groups and program content should match the nature of the risk factors faced by those individuals or groups. Hence, different groups of at-risk individuals may require different combinations of program components. Ideally, preventionists should develop programs with different modules that address specific risk/protective factors. For example, a child at high risk for a certain problem outcome may receive modules, A, B, C and D whereas another child at a lower risk level may receive only modules A and B. Alternatively, as in the Early Risers program, a basic package can be complemented with supplementary activities tailored to the participants’ needs. Another strategy is to train to criterion (i.e., until a desired threshold is reached). Also of concern are the questions of when to start a TPI and for how long the TPI should last. These are important questions at the clinical, practical and financial levels that have not been addressed adequately until now. As a result, a wide variety of prevention programs of varying lengths have been devised to target the same risky outcomes. Among the prevention programs that start at birth and target children from disadvantaged families, some last for a period of 2 years (e.g., home visiting program; Olds, Eckenrode, Henderson et al., 1997) and some for periods of 4 years (e.g., Sure Start, a largescale preventive program currently deployed in the UK for young children in disadvantaged areas and their families; National Evaluation of the Sure Start Team, 2004). Similarly, among prevention programs that advocate high-quality childcare during the preschool period for at-risk children, some cover a period of 2 years (e.g., from age 3 to age 5 in the Perry Preschool Project; Schweinhart, Barnes, & Weikart, 1993), whereas others cover periods twice as long (e.g., from age 1 to age 5 in the Abecederian Project; Campbell & Ramey, 1995). Finally, programs targeting schoolchildren or early adolescents with behavior problems vary from 12 weeks (Dishion & Andrews, 1995) to 6 months (Webster-Stratton, Reid, & Hammond, 2001b), 1–2 years (e.g., Early Risers; August, Realmuto, Hektner et al., 2001) or a decade (e.g., Fast Track; Conduct Problems Prevention Research Group, 2002). Some programs include booster sessions at transition periods (e.g., Early Alliance; Dumas, Prinz, Smith, & Laughlin, 1999), others do not. More importantly, the reasoning behind the prevention researchers’ choice of program duration and timing is often missing or unsubstantiated. Indeed, the only way to identify the most effective length and timing of a prevention program is through studies that compare different durations and different starting points with similarly at-risk children. Very few studies of this type are currently under way. Meta-analytical reviews that examine intervention dosage or timing as potential moderators of the impact of a prevention program offer a temporary alternative to clarify this question. The results of such reviews are not always in accordance with what one might expect. For example, a meta-analysis of the impact of 70 attachment-based interventions designed to improve maternal sensitivity (a known risk factor for later adjustment problems) concluded that the most effective interventions last between 5 and 16 sessions and are applied during the second half of the first year of life, when problems become visible but problematic child–parent relationships are not yet firmly established (Bakermans-Kranenburg, van IJzendoorn, & Juffer, 2003). Thus, effective interventions need not last many years – but they do need to be intensive and well timed. Until experimental manipulations of timing and duration through factorial designs become available (i.e., experimental conditions × dosage or duration), some interventionists rely on dosage–effect analyses or instrumental variables to extract as much information as possible from their studies (Angrist, Imbens, & Rubin, 1996). It is important to keep in mind that these strategies use quasi-experimental designs and their results should be interpreted with caution. This comment also applies to results from meta-analyses. Modes of Intervention and Teaching Methods The necessary dosage and intensity of a TPI to achieve a goal can depend on the quality, effectiveness and appropriateness of the modalities used to implement the desired changes. Tobler, Roona, Ochshorn et al. (2000) concluded their metaanalysis on school-based drug use prevention programs by stressing that interactive programs were more effective than non-interactive lecture-oriented programs. Actually, noninteractive programs were ineffective, with average effect sizes of about 0.10. This finding suggests that effective prevention programs involve interactive teaching methods, such as roleplaying, corrective feedback, instructions and modeling, and active learning of the desired skills. Such a strategy seems more likely to ensure that actual behaviors are learned – in addition to changes in knowledge and perceptions – by facilitating generalization from the training sessions to the real world. Other researchers have found that teaching methods and modalities for change significantly impact a program’s ability to achieve the desired objectives. For example, in their metaanalytical review of programs designed to prevent delinquency, Farrington and Welsh (2003) noted that the programs that use behavioral parent training (similar to Webster-Stratton’s parent program) are the most effective, with a mean effect size of 0.40. The least effective types – with a mean effect size of 0.07 – are based solely in schools. These authors also found that home visiting, day care/preschool, home/community and multisystemic therapy programs tended to be modestly effective, with mean effect sizes in the mid 0.20s. Ensure Potent Causal Mediators are Set in Motion It is indeed important that by the end of a program, mediating processes have been triggered that will ensure the maintenance, and possibly the progress, of behavior change. The Urban Institute’s Children at Risk program (Harrell, Cavanagh, CHAPTER 61 996 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 996

Harmon, Koper, & Sridharan, 1997; Harrell, Cavanagh, & Sridharan, 1999) serves to illustrate this point. Children at Risk targeted high-risk early adolescents from poor neighborhoods in five cities across the USA in an effort to prevent delinquency. The program included case management and family counseling, family skills training, academic tutoring, adult mentoring, after-school activities and community policing. In addition, the components of the program could be adjusted depending on the specific risk factors in each neighborhood in accordance with the adaptive prevention approach described earlier (Collins, Murphy, & Bierman, 2004). To explain the weak and inconsistent results reported at both post-intervention and at a 1- year follow-up with respect to delinquent behaviors, the authors noted that few individual, family and community factors were changed, although some peer-related factors were (i.e., program youth affiliated with less delinquent peers and had more positive peer support). If affiliation with deviant peers were the only causal risk factor or mediator of risk factors for delinquency (i.e., both necessary and sufficient), then the Urban Institute’s Children at Risk program should have been successful at preventing delinquency even if it failed to influence other important risk factors. As suggested by most prominent theoretical models of delinquency, deviant peer affiliation is not likely to be the only causal risk factor for this outcome (for the possible role of deviant peers in delinquency see Vitaro, Tremblay, & Bukowski, 2001b). Therefore, it may prove important to trigger the necessary (i.e., potent and causal) and sufficient mediators identified in prominent developmental models in order to impact on an outcome at the endpoint of a long developmental chain formed by a series of mediators. Vitaro, Brendgen, and Tremblay (2001a) showed that delinquent behaviors could be prevented in their high-risk sample of low SES, disruptive boys provided that several mediators – each of which corresponded to the proximal objectives of their targeted preventive program – were changed. These mediators included the child’s disruptiveness, parental supervision, academic performance and deviant peer affiliation. The difficulty of triggering the important mediators (which often correspond to the proximal objectives of a TPI) may explain some of the so-called “sleeper effects” that seem to characterize some TPIs. One TPI in which sleeper effects were observed was the Queensland Early Intervention and Prevention of Anxiety Project. This program targeted anxious schoolchildren who did not yet reach the threshold for a clinical disorder (Dadds, Spence, Holland, Barrett, & Laurens, 1997). The program included 10 weekly group training sessions at school. Through modeling and behavioral rehearsal, the children were taught cognitive–behavioral coping strategies to overcome anxiety-arousing situations. They were also taught relaxation techniques to counteract their physiological discomfort. The parents of the anxious children were also taught how to support their child in the use of the coping strategies and how to use similar coping strategies to face their own anxiety. This short-term TPI, which also involved homework for both children and parents, may have required prolonged practice of the new coping skills by both parents and children before producing its optimal effects. Indeed, the experimental children differed from their control counterparts on a series of child- and parent-rated measures not at the immediate posttest but only at later follow-ups. At the 6-month follow-up, only 16% of the experimental group manifested anxiety problems, compared to 54% of the control group. Significant differences were again observed at the 1- and 2-year follow-ups (Dadds, Holland, Laurens et al., 1999). Well-Coordinated and Integrated Prevention Services To ensure effective change on as many potent causal risk or protective factors as possible, comprehensive multimodal prevention programs rely on different categories of prevention agents (e.g., school personnel, childcare workers, physical and mental health professionals, nurses, community leaders, policymakers). As a result, the programs should rest on a wellcoordinated and integrated prevention delivery infrastructure. The Nurse Home Visitation program, first developed for the Elmira project (Olds, Henderson, Tatelbaum et al., 1986; Olds, Henderson, Kitzman et al., 1998), is a good example of a program with such an infrastructure. In this program, a nurse visits primiparous pregnant women who have a high-risk profile. Specifically, the pregnant women are young, unmarried and poor. Nurses visit the women approximately 32 times between 24 weeks’ gestation and the child’s second birthday. Nurses give support to the mothers in three areas of their life: 1 Personal development, including education, workforce integration and family planning; 2 Health-related behavior, including smoking prevention and adequate nutrition for the mother and child; and 3 Competent care of the child. The nurses also link mother and child with community services. This program has been shown to reduce child abuse and neglect (Olds, Henderson, Tatelbaum et al., 1986) as well as maternal and child delinquency. This program has also revealed the importance of a well-trained clinician to the effectiveness of a prevention effort. In a randomized controlled trial, nurses were found to have significantly greater impact on most of the outcomes studied than trained paraprofessionals. The outcomes ranged from reduced smoking in pregnancy and increased workforce integration among the mothers, to improved emotional and cognitive development among the children (Olds, Henderson, Kitzman et al., 1999). Socioculturally Relevant and Engaging Prevention programs need to be tailored to the cultural norms of the participants and the community (for a violence prevention program that specifically addresses cultural diversity see Alkon, Tschann, Ruane, Wolff, & Hittner, 2001). Community representatives should be consulted when planning the objectives and the implementation of a prevention program. The content of the program and the strategies used to ensure implementation may also need to be adjusted to the local norms. Interestingly, models and methods for cultural adaptation of empirically based prevention programs are available (Martinez, 2006). TARGETED PREVENTIVE INTERVENTIONS 997 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 997

Social Acceptability and Cost-Effectiveness Finally, to ensure that prevention programs become part of standard practice and are disseminated, they need to be acceptable to – or even desired by – potential recipients and practitioners. They should also be cost-effective. These last two issues are discussed next. Practical and Sociopolitical Issues Strategies to Mobilize Program Recipients, Program Deliverers and Decision-makers The most effective prevention program is useless if it is not attractive to program recipients or if it is not adopted into everyday practice by program deliverers (for a discussion of these topics in relation to treatment see chapter 18). Indeed, one challenge of preventive interventions, compared to curative interventions, is to engage eligible participants not just during an evaluation trial but also during widespread implementation. Several groups of researchers have noted that, in general, recruitment and retention rates for targeted preventive intervention trials are low, often below 50% (Coie, Underwood, & Lochman, 1991; Fontana, Fleischman, McCarton, Meltzer, & Ruff, 1988; Garvey, Wrenetha, Fogg, Kratovil, & Gross, 2006). Low participation has important consequences for efficacy and effectiveness demonstration trials. First, low participation is a threat to external validity because little or no information is usually available on non-participants. Second, low participation can result in a Matthew effect in which the less at-risk cases benefit more from the program than those at higher risk because the former tend to participate more than the latter (Ceci & Papierno, 2005). Third, low engagement may result in a highly selective sample of participants. This decreased diversity in the sample makes it more difficult to identify participant characteristics that amplify or attenuate the impact of a preventive intervention (i.e., moderators). Fourth, low participation can seriously limit the statistical significance of program effect size in the context of an intention-to-treat analysis. Such an analysis includes all of the assigned participants, regardless of level of participation. Finally, low participation rates (often compounded by low retention rates) may threaten the utility of the program as a tool for social change because sustained funding may not be achieved without a critical mass of participants. Therefore, as stated by Mrazek and Haggerty (1994), “A plan to successfully engage and retain targeted participants is needed.” Because of their key role in most prevention programs targeting child behavior, either as active participants or legal guardians of their children, parents should be at the center of this plan to engage participants. The key role of parents has been acknowledged by many of the successful or promising TPIs reviewed here. Indeed, almost all TPIs that target the prevention of externalized (i.e., violence, delinquency, conduct disorder, school dropout) or internalized (i.e., anxiety) problems include a parent-targeted program component, which is considered the most effective strategy to date (Kazdin, 1985). In contrast, few TPIs that target children and adolescents at risk for major depression (either because of their preclinical levels of depressive symptoms or their experience with divorce or death of a family member) include a parent-targeted component. Most TPIs for major depression adopt a cognitive– behavioral approach to teach youths coping strategies in 10–15 group sessions (e.g., Coping with Depression Course for Adolescents: Clarke, Hawkins, Murphy, & Sheeber, 1995; Penn Prevention/Resiliency program: Cardemil, Reivich, Beevers, Seligman, & James, 2007; Jaycox, Reivich, Gillham, & Seligman, 1994; Cognitive Psychoeducational Intervention program: Beardslee, Salt, Porterfield et al., 1993). The few depression prevention programs that target parents tend to devote only a few sessions to this program component (e.g., three information meetings with the parents in the Clarke, Hornbrook, Lynch et al., 2001, study). Not surprisingly, the effect sizes observed in most depression prevention programs are considered modest by current standards (with values in the low 0.30s at the immediate post-test and in the low 0.20s at follow-up). Similarly, the few TPIs intended to prevent suicide in at-risk individuals also rarely incorporate a parental or family component (Eggert, Thompson, Herting, & Nicholas, 1995; LaFromboise & Howard-Pitney, 1995). The results of these studies are even more mixed and inconclusive than in the case of TPIs to prevent depression. Still, programs that include a parent component are not always successful in actually engaging parents. Hence, given that a parent component seems desirable, knowledge of how to successfully engage parents is needed. This knowledge can be derived from three sources: 1 Studies that examine the factors predicting engagement and perseverance in a prevention program; 2 Narrative or meta-analytical reviews that compare studies that address similar problems but result in different recruitment or retention rates; and 3 Studies that experimentally manipulate factors in order to directly examine the causal impact of those factors on recruitment and retention rates. A combination of efforts in these three areas has revealed a number of factors that predict engagement and retention. These factors can be grouped into five categories. The first category is comprised of sociodemographic factors. The empirical evidence regarding this category is mixed. Some studies report that ethnicity, socioeconomic adversity and child age influence recruitment and retention whereas other studies do not (Holden, Lavigne, & Cameron, 1990; Prinz & Miller, 1994). Still, and although sociodemographic factors cannot be manipulated directly, these factors can have a key role through careful and strategic matching of participants’ and trainers’ characteristics. For example, using nurses to recruit young parents with a history of conduct disorder into a prevention program may be less threatening to the parents than using social care workers. The second category of predictors includes parents’ beliefs about child behavior problems and about the benefits the child will derive from participating in a prevention program. More CHAPTER 61 998 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 998

specifically, the parents’ perception of the benefits the child will receive from a prevention program is influenced by the parents’ perception of the prevalence of the targeted problem and the likelihood that their child might experience that problem. These perceived benefits, in turn, predict the parents’ enrollment in the program (Spoth & Redmond, 1995). Therefore, focusing a prevention program too narrowly on one specific problem may not attract many parents. First, the parents may think that their child is not at risk (even if they acknowledge that prevalence rates are high). Second, parents may think that they can deal with the problem themselves. Without alarming them unnecessarily, parents may need to be informed of their child’s level of risk (if that child is facing many or more severe risk factors) and that the prevention program may help the parents with their own preventive efforts. In order to maximize parents’ motivation to participate in a prevention program, some authors offer a self-screening questionnaire with respect to risk and protective factors. Dishion, Nelson, and Kavanagh (2003) use a “Family Check-up” assessment to enhance parents’ motivation by providing them with feedback about the strengths and the weaknesses of their parent–child relational strategies and their child’s functioning as well as a menu of intervention strategies from which to choose. Once a child and his or her parents are involved in a prevention program, retention is predicted by the extent to which the participants benefit from the program. Improvement in the child’s behavioral repertoire during the first months of a multimodal prevention program for disruptive boys predicted which families would remain involved in a 3-year prevention program and which families would drop out before the end of the first year (Charlebois, Vitaro, Normandeau, & Rondeau, 2001). Another aspect to consider with respect to parents’ beliefs is whether the parents deem the prevention strategies and targeted behaviors to be appropriate. Spoth, Ball, Klose, and Redmond (1996) used “conjoint analysis” (i.e., a marketing data collection strategy designed to tap into consumer choices and needs) to examine parents’ preferences for different intervention strategies (e.g., child-only, family-only or combined child–family skills training) and different practical arrangements (i.e., home visits vs. group meetings, weekdays evening sessions vs. weekend sessions). Interestingly, Spoth, Ball, Klose et al. found that different clusters of parents preferred different arrangements and different strategies. Notably, some parents were open to address personal and sociofamilial issues whereas others were focused mainly on the child’s problems. Using an experimental approach, Miller and Prinz (2003) also found that assignment to a treatment condition that did not match parents’ motivations and expectations was predictive of premature termination. More specifically, premature termination was higher in a parent-only treatment condition than in child-only and combined parent–child conditions. Prinz and Miller (1994) have also shown that adding supportive discussions not directly related to child behavior to a series of parent training sessions targeting children’s disruptiveness resulted in less attrition than focusing exclusively on parenting and parent–child interactions during the sessions. The third category of factors affecting engagement and retention of participants represents practical barriers to participation, including the scheduling of program activities. In general, flexibility in program delivery has been found to be related to retention rates (Prinz & Miller, 1996; Weisz, Weiss, Alicke, & Klotz, 1987). Of special interest is whether home delivery of services produces better engagement and recruitment than flexible out-of-home services. Unfortunately, no study has directly compared the two strategies. However, the relative effectiveness of these two strategies in enhancing participation and retention may vary depending on the child’s age (e.g., newborns vs. early adolescents) and parent characteristics. Facilitating participation by offering transportation, daycare services for the target child and any siblings, or supplementing training sessions for the target child with fun activities may help overcome resistance if the out-of-home delivery service is chosen. Another critical element with respect to participation and retention is the temporal spacing of the prevention activities. If program activities are spaced too far apart, participants may lose interest in the program. Activities spaced too close together may lead participants to feel overloaded. For example, during the Fast Track trial, parents “rebelled” during the third year when session spacing was changed to once every 3 months from once a week during the first year and twice a month during the second year. Based on parents’ reactions, the Fast Track researchers reinstituted more frequent sessions of once a month. In addition, potential recipients who feel that they do not need some program components may refuse participation or become bored and withdraw from the study. In this situation, a differential approach to the spacing and number of sessions – similar to the adaptive approach described above (Collins, Murphy, & Bierman, 2004) – may increase compliance and retention of participants. Parents’ characteristics are another important category of factors that may affect participation in prevention programs. There is empirical evidence showing that fathers are less inclined to participate in prevention programs than mothers (Spoth, Ball, Klose et al., 1996). In consequence, some authors tried to compensate for parents’ low motivation by offering incentives in the form of tangible rewards, such as money and meals (Conduct Problems Prevention Research Group, 2002; St. Pierre, Mark, Kaltreider, & Aikin, 1997; Webster-Stratton, Mihalic, Fagan et al., 2001a), or social rewards, including giving parents a role as co-therapists or co-trainers (Conduct Problems Prevention Research Group, 2002; Cunningham, Bremner, & Boyle, 1995; St. Pierre, Mark, Kaltreider et al., 1997). The final category of factors that might affect participation refers to the manner in which and the moment at which parental participation is requested. Personalized recruitment seems more effective than a generic and impersonal approach (Schlernitzauer, Bierhals, Geary et al., 1998). Even the manner in which the initial invitation to participate is formulated may affect participation. Spoth and Redmond (1994) compared two different letter solicitation strategies for recruiting families TARGETED PREVENTIVE INTERVENTIONS 999 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 999

of early adolescents to participate in a family-based drug prevention program. In one strategy, families were invited first to participate in an assessment session and next to the full program. In the other strategy, the families were offered full participation right away. Not surprisingly, the first strategy produced higher recruitment, but lower retention rates. Linking the program to an official and respected institution may also increase its credibility and, consequently, enhance participation rates of parents as well as of prevention service deliverers (i.e., teachers and mental health professionals). Promotion of the program by esteemed persons or the media may also help increase the participation of key stakeholders. Finally, the description of the program’s objectives is also important. Because most prevention programs, including the targeted ones, focus at least as much on promoting skills and opportunities as on reducing risk factors, the objectives should emphasize health and competence promotion. The timing of the offer to become involved in a prevention program may also affect participation. Transition periods may be particularly good points of entry because of the anxiety and the uncertainty experienced by many parents and children at these times of change. Some transition periods at which interventions are commonly directed include the birth of the child, beginning of preschool, transition to high school and transition to adulthood. Other, less normative experiences may also be considered important transitions (e.g., divorce of parents). Finally, it is essential that the recruiters and trainers possess appropriate skills and knowledge of the targeted families’ cultural and linguistic backgrounds. The recruiters and trainers should also establish a positive bond with the families. Low staff turnover may help ensure such a positive bond (Prinz, Smith, Dumas et al., 2001). In sum, many of the factors reviewed here are controlled or influenced by the individuals responsible for the prevention program. However, although participation rates may be dramatically affected by such factors, the experimental studies that have assessed the impact of these factors on participation remain scarce. Indeed, rates of engagement and retention should be included among the outcomes assessed in any prevention program. How to Optimize Cost-Effectiveness One important argument often used in support of prevention is its cost-effectiveness in comparison to treatment (for a description of cost-effectiveness analysis see chapter 10; Chatterji, Caffray, Jones, Lillie-Blanton, & Werthamer, 2001). However, effective prevention programs addressing psychoemotional problems are not cheap. Indeed, most prevention programs for high-risk individuals or communities need to target several domains of functioning (i.e., different systems) and deploy different intervention strategies over several years to hope for more than modest effect sizes (for an overall consideration of issues of service planning see chapter 71; Greenberg, Domitrovich, & Bumbarger, 2001; Yoshikawa, 1994). One way to reduce the cost of a prevention program is to deliver as many components as possible, such as parent and child training sessions, in a group format. Such a strategy has resulted in at least one cost-effective program – a prevention program for adolescents at risk for major depression (Clarke, Hornbrook, Lynch et al., 2001; Lynch, Hornbrook, Clarke et al., 2005). Notably, the cost-effectiveness of this TPI was comparable to most treatments for adult depression. Still, there is a risk that the economy of scale that results from group sessions may impact adversely on the program’s effectiveness. Ang and Hugues (2002) concluded their metaanalysis by showing that individual social skills-training sessions are more effective in teaching social skills to children than group sessions, probably because of the additional attention a child receives and the additional opportunities to practice the learned skills. Moreover, prevention programs that aggregate at-risk children, such as those with externalizing problems, appear less effective than programs that mix at-risk children with prosocial peers. Group interventions that aggregate only at-risk children may even result in iatrogenic effects through a process known as deviancy training (Boxer, Guerra, Huesmann, & Morales, 2005; Dishion, McCord, & Poulin, 1999; Dodge, Dishion, & Lansford, 2006). However, iatrogenic effects do not invariably result from aggregating at-risk individuals because deviancy training depends on a host of circumstances, including the children’s age and trainer’s competence (Gifford-Smith, Dodge, Dishion, & McCord, 2005). Another strategy to reduce costs during the training and the implementation phases of a prevention program is to manualize the program components as much as possible (van de Wiel, Matthys, Cohen-Kettenis, & van Engeland, 2003). However, it is important that the staff do not lose track of the theoretical principles behind the intervention, as was the case in an unsuccessful dissemination effort of the Prenatal/ Infancy Project (Olds, Henderson, Tatelbaum et al., 1986), which had been found to reduce abuse and promote health in children on many previous occasions. If costs cannot be reduced without negative consequences, then either efficiency or effectiveness – or possibly both – need to be improved. Efficiency refers to the ability to produce optimal effects with the available resources and time. The adaptive approach is one promising strategy to increase efficiency. The resources saved when less at-risk participants receive fewer program components can be transferred to those who have greater need. This increases the potential for optimal impact with the available resources – and may even reduce costs relative to a fixed approach in which all participants receive all components (Collins, Murphy, & Bierman, 2004). There are no studies manipulating dosage or comparing an adaptive approach to a fixed approach. Effectiveness may be increased in at least two ways. First, effectiveness may be enhanced by adding new innovative intervention strategies (such as Fast Track’s peer pairing and academic tutoring components) to more traditional prevention strategies (such as parent training and social-cognitive skills training). Second, combining a universal with a targeted approach may also improve the targeted program’s effectiveness. Adding new prevention components, such as the innovative CHAPTER 61 1000 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 1000

components or a universal component, makes sense only if they target risk or protective factors not already targeted by the more traditional components. In other words, it is important to avoid redundancy and increase coverage of new targets such that enough – and the most potent – risk and protective factors are modified. This, in turn, increases the probability of enhanced effect sizes and notable and durable benefits. Another aspect to consider in cost-effectiveness analysis is whether a prevention program is capable of helping the most at-risk and most costly cases. In the area of disruptive behavior, longitudinal studies have found that 5–10% of the children displaying conduct problems account for at least half of all adolescent and adult crimes (Moffitt, 1990; Nagin & Tremblay, 1999; Stattin & Magnusson, 1991). Each individual persistently involved in crime represents a $2 million lifetime cost (in today’s dollars) to society (Cohen, 1998). This cost does not even include the expenses related to the collateral problems – such as a failure to complete high school and pathological dependence on substances – for which this small group of children is also at higher risk. To develop a full and accurate picture of the cost-effectiveness of a prevention program, investigators should include the cost of all possible problems that the program could prevent. Costly but moderately effective (i.e., effects size of 0.20–0.50 in the short term) prevention programs that impact on the most extreme cases, such as Fast Track, then seem particularly cost-effective (Foster & Jones, 2006). Cost-effectiveness analysis of a number of other targeted prevention programs, such as the Coping Power Program for aggressive children (van de Wiel, Matthys, Cohen-Kettenis et al., 2003) or the Perry Preschool program for disadvantaged children and their families (Barnett, 1985; Schweinhart, Barnes, & Weikart, 1993) shows that these also appear to be cost-effective. Importance of Dissemination, its Challenges, and Some Possible Solutions Large-scale dissemination of evidence-based and cost-effective targeted prevention programs is important. The essential prerequisite before dissemination is a strong test of the program’s validity and efficacy. Lists of model programs that are ready for large-scale implementation are available. However, given the diversity of prevention programs, even among programs targeting the same outcome, direct comparisons between competing prevention programs are needed in order to determine which is most cost-effective. Second, it is essential to replicate the original (effective) prevention programs in different socioeconomic contexts and different cultures in order to identify the program’s limits. Such replications may also explain why the results of evidence-based interventions are often not as strong when disseminated to real-world settings (i.e., the socalled “effect erosion” problem; Lochman, 2001). To address the problem of “effect erosion” when going to scale, preventionists should conduct both efficacy and effectiveness trials for any given program. Contrary to efficacy trials, in which the “maximum” impact of a prevention program is assessed under optimal conditions, an effectiveness trial evaluates the “true” or actual impact of a prevention program under realworld conditions. Both are important preliminary steps that should be taken before large-scale implementation occurs. Only when both efficacy and effectiveness are assessed is it possible to understand the conditions that produce the maximum impact of the program. Performing both efficacy and effectiveness trials may reduce – but not necessarily eliminate – the risk of inadequate dissemination. In order to further reduce or eliminate this risk, researchers need to turn their attention to what Dodge (2001) referred to as the science of dissemination towards practitioners and policy-makers. Elliott and Mihalic (2004) listed a six-step process for achieving successful dissemination of a prevention program: select the sites that are ready, train the practitioners, provide them with technical assistance, monitor and reflect on program fidelity, and assure sustainability through continuous funding and permanent changes in the service delivery system. Other researchers examined the ways to make scientific knowledge more usable and used more frequently by policy-makers and practitioners (Dodge, 2006; Huston, 2005). Among the proposed strategies is the use of the media through press releases or public briefings presenting research findings that are likely to be of interest to the public. Another interesting strategy is to create two-way communication forums in which policy-makers, practitioners and researchers share and debate their research questions, methodologies, cost– benefit analyses and conclusions. Research questions should be framed in such a way that evaluation results will clearly inform about: 1 The chain of factors that lead to change in at-risk individuals or communities; 2 The most cost-effective intervention strategies; and 3 Moderators of program effectiveness. Conversely, preventive intervention evaluation results may also aid researchers in refining the theoretical models that served as the foundation for that intervention. How Preventive Interventions can Inform Theory TPIs can help to clarify the role of the risk and protective factors and processes that were initially selected as proximal outcomes or putative mediators of the intervention effects. They can also help to identify new factors that, although not targeted initially, may have an important role with respect to the program’s impact. Finally, TPIs can help to validate the principles for change that were used to guide the development of the intervention strategies. Hence, a TPI evaluation can illuminate the theory behind the development of the problem to be prevented and the theory behind the process leading to more positive outcomes (Cicchetti & Hinshaw, 2002). To illustrate, Vitaro, Brendgen, & Tremblay (2001a) showed that the Montreal longitudinal prevention program targeting young low SES disruptive boys achieved its impact on later delinquency in two ways. First, the program improved children’s behavioral repertoire and parental supervision (i.e., proximal effects). Second, the program reduced affiliation with deviant peers and school problems (i.e., intermediate effects). TARGETED PREVENTIVE INTERVENTIONS 1001 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 1001

More specifically, improved social competence and parental supervision and reduced affiliation with deviant friends and school problems mediated, in a two-step sequential process, the impact of the prevention program on later delinquency. These findings enhance the plausibility that these mediators have a causal role in the chain of events leading disruptive boys to become involved in delinquency. They also point to the importance of targeting these mediators through booster sessions if necessary. However, most TPIs cannot clearly establish the causal role of risk factors because more than the putative mediators may have been triggered by the prevention program (Howe, Reiss, & Yuh, 2002). One solution to this problem would be to specify and measure all relevant mediators and control for their effects, a task rarely achieved or even achievable. TPIs can also contribute to developmental models of psychopathology in other ways. Prevention programs can help uncover or verify mechanisms of influence, even when the programs result in iatrogenic effects. Dishion, Spracklen, Andrews, and Patterson (1996) used an experimental design to determine that a group-based social skills prevention program resulted in iatrogenic effects. Dishion, Spracklen, & Andrews et al. were able to confirm the causal role of deviancy training (discovered earlier through the coding of the interactions between the participating at-risk adolescents and their friends in the context of a correlational study). Deviancy training results from positive reinforcement through laughter or positive nonverbal feedback of rule-breaking talk and deviant acts as well as from ignoring or punishing normative behaviors through principles of operant conditioning. Conclusions and Future Directions To conclude, we offer suggestions for the next generation of TPIs. Through narrative or quantitative reviews (i.e., meta-analysis) of prospective longitudinal studies, we need to establish more clearly which risk and protective factors should be used to identify individual levels of risk and categories of at-risk individuals. We favor an interactional approach over a cumulative approach. We also believe that more than two groups exist (i.e., more than simply the at-risk and the low-risk groups), although the number of relevant groups may depend on the type of outcome considered and a host of other factors. Through narrative and quantitative reviews, we need to identify the best prevention practices and program models that match the evolving criteria for efficacy, effectiveness and dissemination. The Society for Prevention Research (2004) proposed a series of clear criteria with respect to each of these three elements that can serve as guidelines, although these criteria are likely to evolve over the coming years. The Institute of Medicine Committee on Prevention of Mental Disorders (Mrazek & Haggerty, 1994) has also issued a seven-level scale to judge the quality of a prevention program from the characteristics of that program’s evaluation protocol. Studies that compare different versions of the same program are needed (i.e., programs that differ with respect to the number of components or duration of the intervention). After experimenting with single or bimodal prevention programs during the 1980s (often social skills and/or family-based programs), prevention scientists started experimenting with multimodal comprehensive programs during the 1990s (e.g., Fast Track). These programs were often compared only with a control condition, a strategy that was well-justified at the time (Coie, Miller-Johnson, & Bagwell, 2000). However, we believe the time has come for factorial designs in which different sets of components, different durations or different programs are compared, taking into account their possible interactions with participants’ characteristics and contextual factors (i.e., moderators). This factorial approach would help refine and possibly increase the power of current and future prevention programs in an optimal cost-effective manner by identifying necessary and sufficient components or important new elements of those programs. Indeed, it would be interesting to see whether targeted prevention programs that are embedded in universal prevention programs bring the multiplicative effects expected in comparison to targeted-only or universal-only programs. It would also be interesting to compare an adaptive approach (Collins, Murphy, & Bierman, 2004) to a fixed approach. Such a comparison could be achieved by comparing two randomly assigned groups of participants: one receiving a fixed dosage of a preventive package and one receiving different combinations and different dosages of the same package. However, costs and resources should be kept equivalent across the two conditions or be taken into account when comparing effect sizes. A randomly assigned no-intervention/care-as-usual control group could also be included. Small-scale experimental studies that compare the efficacy of different modes of intervention or teaching methods to achieve specific desired goals, both with respect to process variables and with respect to outcomes, are also needed. These experimental studies will advance our knowledge about effective strategies for change and their underlying theoretical principles. Programmatic comparative studies are also needed to explore the most effective strategies to engage and retain potential participants, practitioners and decision-makers. The science of prevention took form during the past decade. Currently, a science of dissemination and social policy-making is taking form (Huston, 2005). In order to ensure that the best programs are disseminated and form the basis for social policy, valid and convincing cost-effectiveness studies need to be conducted. Luckily, more and more such studies are available (Foster & Jones, 2006; Lynch, Hornbrook, Clarke et al., 2005; van de Wiel, Matthys, Cohen-Kettenis et al., 2003; see also Cuijpers, 2003; Romeo, Byford, & Knapp, 2005). Business models can also contribute to the promotion and dissemination of the best prevention programs (Rotheram-Borus & Duan, 2003). We need more process-oriented prevention research that documents mediators of change both during and after the prevention trial. This type of prevention research can have both CHAPTER 61 1002 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 1002

theoretical and practical implications. Understanding mediating factors and processes can help to clarify and validate theoretical models. A greater understanding of the role of mediators can also enhance the intervention process by guiding program content and program duration until the potent, pertinent and plausibly causal mediators are sufficiently modified to ensure that the distal outcomes are affected. In the case of an unsuccessful prevention program, being able to pinpoint unchanged important mediators will inform the next wave of prevention programs so that they can target these mediators more effectively. We also need to verify which preventive intervention program works best under which conditions and for which population. Interesting suggestions and examples of contextspecific preventive interventions have been described by a number of researchers (Allen & Philliber, 2001; Beauchaine, Webster-Stratton, & Reid, 2005; Gillham, Shatté, & Reivich, 2001). It is particularly important to document the conditions under which a program previously observed to be effective may fail when applied to new populations (MacMillan, Thomas, Jamieson et al., 2005). The impact of TPIs should be assessed with respect to the distal outcomes they are designed to prevent. Short- and midterm effects on important mediators, although promising, do not always guarantee the final result. In addition to including randomly assigned control participants to guard against spurious results or iatrogenic effects, a group of normative children should also be included to probe the clinical significance of the effects of the TPI (Kendall, Marrs-Garcia, Nath, & Sheldrick, 1999). Despite the statistically significant improvements demonstrated by program children on a number of measures, it is rarely the case that these children function “normally” (i.e., within 0.5 SD of the normative mean or without any clinical symptom) even after the intervention. Only a few TPIs reviewed in this chapter included a normative group (e.g., Early Risers, Fast Track, the Montreal longitudinal prevention program). Short-term results produced by these three high-intensity multicomponent preventive interventions show that none of them was able to move the targeted high-risk children into a normative range on important measures, despite significant overall differences between them and their counterparts in the control condition. In addition, long-term follow-ups show that many targeted children manifest serious adjustment problems, although proportionately less than their control counterparts (Boisjoli, Vitaro, Lacourse, & Tremblay, 2007; Conduct Problems Prevention Research Group, 2002, 2005). This finding alone calls for a renewed strategy with respect to our current prevention efforts. We believe that the diverse and often competing prevention programs targeting different outcomes at different periods in development should become the building blocks of an integrated prevention system. These different programs should be linked to each other at three levels in addition to being delivered in accordance with an adaptive approach at each level. First, at the chronological level, the perinatal programs would be the first to be deployed. If the proximal results are satisfactory, these perinatal programs would be sufficient, as will undoubtedly be the case for some participants and problems. Participants still at risk for problems left unchanged by a perinatal program would be exposed to a second wave of prevention strategies during the preschool years. These may take place in the childcare setting, for example. This cumulative modular strategy would be repeated until the risk factors are dissipated or the protective factors are solid enough to ensure a highly probable positive trajectory. The early prevention programs should target as many potent generic causal factors as possible to achieve an optimal impact. However, because new risk factors may appear with development, booster programs might be needed at later transition periods to address these new and often specific risk factors. These booster programs would also capitalize on the malleability of participants’ behavior during periods of transition. Periods of transition often correspond to the changing phase between two developmental stages which are particularly sensitive to new learning because of the disequilibrium created both at the cognitive and the emotional levels and the new opportunities that become available (Dahlberg & Potter, 2001; Pickles & Angold, 2003). Second, at the service delivery level, different services which often involve different personnel in different contexts need to be integrated into a coherent prevention system. Finally, at the outcome level, it is important to acknowledge that many prevention programs target the same risk factors and use similar strategies to achieve change even though their stated intention is to prevent different adjustment problems (e.g., school dropout vs. delinquency). As a result, programs with different stated goals may also have an important impact on other aspects of development – a probable consequence of their many common risk factors. Hence, most TPIs should assess several types of outcome, independent of their initial goals. This is particularly true for TPIs that adopt a generic perspective. This strategy might help increase the cost-effectiveness of TPIs. In addition, assessing change in different types of problem makes sense given the surprising similarities in the components and strategies used in TPIs targeting children at risk for different types of outcome (e.g., conduct disorder, substance use and depression). Despite our enthusiasm for prevention, we nevertheless wish to conclude by raising concern about several iatrogenic effects that have been reported sporadically in the literature and may represent only the tip of the iceberg (Dishion, McCord, & Poulin, 1999; Dodge, Dishion, & Lansford, 2006; Werch & Owen, 2001). One well-known TPI that produced spectacular iatrogenic effects is the Cambridge Somerville Youth Study (Dishion, McCord, & Poulin, 1999; McCord, 1978). After 30 years, boys who participated in a multimodal program throughout early adolescence which included academic tutoring, family counseling, medical attention, summer camps and contact with community organizations had worse outcomes in several domains of functioning (i.e., criminal behavior, alcoholism, mental and physical problems, death) than matched controls who did not participate in the program. We believe that the planners and the disseminators of prevention programs TARGETED PREVENTIVE INTERVENTIONS 1003 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 1003

should be extremely sensitive and responsive to this issue. We need to learn about the conditions and the processes that are responsible for such iatrogenic effects as much as we need to learn about the conditions and processes responsible for positive and hopefully long-term effects of current and future targeted prevention programs. Complementary References and Websites Because the focus of this chapter is on the underlying principles, the number of prevention programs that were used for illustration purposes is necessarily limited. The reader can find a more complete and detailed list of targeted preventive programs in narrative reviews mentioned below. The reviews by Greenberg, Domitrovich, & Bumbarger (2001) and by Mrazek and Brown (2002) cover most programs targeting children aged 5–18 or 0–6 years, respectively. The reader can also consult the meta-analytical reviews reported in Table 61.1 and several of the other chapters in this volume for a more complete overview of preventive interventions targeting different areas of functioning. Finally, some universal preventive interventions document their results for the most at-risk children in addition to the whole population of children. These findings may be relevant for targeted preventionists even if they are derived from universal programs. One such program is the Good Behavior Game (Kellam, Rebok, Ialongo, & Mayer, 1994), a teambased classroom program that uses group reinforcement and competition to promote appropriate behavior in first grade. At 6-year follow-up, experimental boys who were the most aggressive in first grade manifested less aggression according to teachers than their control counterparts, whereas the other children did not. Further Information and Reading Crill Russell, C. (2002). The state of knowledge about prevention/ early intervention. Toronto, ON: Invest in Kids Foundation. Greenberg, M. T., Domitrovich, C., & Bumbarger, B. (2001). The prevention of mental disorders in school-aged children: Current state of the field. Prevention and Treatment, 4. Mrazek, P. J., & Brown, C. H. (2002). An evidence-based literature review regarding outcomes in psychosocial prevention and early intervention in young children. In C. C. Russell (Ed.), The state of knowledge about prevention/early intervention (pp. 42–165). Toronto, ON: Invest in Kids Foundation. National Institutes of Health State of the Science Conference Statement. (2006). Preventing violence and related health-risking, social behaviors in adolescents, October 13–15, 2004. Journal of Abnormal Child Psychology, 34, 457–470. Society for Prevention Research (SPR). Accessed from http://www. preventionresearch.org University of Colorado Center for the Study and Prevention of Violence. Accessed from http://www.colorado.edu/cspv/blueprints References Alkon, A., Tschann, J. M., Ruane, S. H., Wolff, M., & Hittner, A. (2001). A violence-prevention and evaluation project with ethnically diverse populations. American Journal of Preventive Medicine, 20, 48–55. Allen, J. P., & Philliber, S. (2001). Who benefits most from a broadly targeted prevention program? Differential efficacy across populations in the Teen Outreach program. Journal of Community Psychology, 29, 637–655. Ang, R. P., & Hugues, J. N. (2002). Differential benefits of skills training with antisocial youth based on group composition: A metaanalytic investigation. School Psychology Review, 31, 164–185. Angrist, J. D., Imbens, G. W., & Rubin, D. B. (1996). Identification of causal effects using instrumental variables. Journal of the American Statistical Association, 91, 444–455. Aos, S., Lieb, R., Mayfield, J., Miller, M., & Pennucci, A. (2004). Benefits and costs of prevention and early intervention programs for youth. Seattle, WA: Washington State Public Policy Institute. August, G. J., Egan, E. A., Realmuto, G. M., & Hektner, J. M. (2003). Four years of the early risers early-age-targeted preventive intervention: Effects on aggressive children’s peer relations. Behavior Therapy, 34, 453–470. August, G. J., Hektner, J. M., Egan, E. E., Realmuto, G. M., & Bloomquist, M. L. (2002). The Early Risers longitudinal prevention trial: Examination of three year outcomes in aggressive children with intent-to-treat and as-intended analyses. Psychology of Addictive Behaviors, 16, 27–39. August, G. J., Realmuto, G. M., Hektner, J. M., & Bloomquist, M. L. (2001). An integrated components preventive intervention for aggressive elementary school children: The Early Risers Program. Journal of Consulting and Clinical Psychology, 69, 614–626. Bachman, J. G., Johnston, L. D., & O’Malley, P. M. (1998). Explaining recent increases in students’ marijuana use: Impacts of perceived risks and disapproval, 1976 through 1996. American Journal of Public Health, 88, 887–892. Bakermans-Kranenburg, M. J., van IJzendoorn, M. H., & Juffer, F. (2003). Less is more: Meta-analyses of sensitivity and attachment interventions in early childhood. Psychological Bulletin, 129, 195– 215. Barnett, W. S. (1985). The Perry Preschool Program and its long-term effects: A benefit–cost analysis. Ypsilanti, MI: High/Scope Educational Research Foundation. Beardslee, W. R., Salt, P., Porterfield, K., Rothberg, P. C., van de Velde, P., Swatling, S., et al. (1993). Comparison of preventive interventions for families with parental affective disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 254– 263. Beauchaine, T. P., Webster-Stratton, C., & Reid, M. J. (2005). Mediators, moderators, and predictors of 1-year outcomes among children treated for early-onset conduct problems: A latent growth curve analysis. Journal of Consulting and Clinical Psychology, 73, 371–388. Boisjoli, R., Vitaro, F., Lacourse, E., Barker, E. D., & Tremblay, R. E. (2007). Impact and clinical significance of a preventive intervention for disruptive boys: 15-year follow-up. British Journal of Psychiatry, 191, 415–419. Boxer, P., Guerra, N. G., Huesmann, L. R., & Morales, J. (2005). Proximal peer-level effects of a small-group selected prevention on aggression in elementary school children: An investigation of the peer contagion hypothesis. Journal of Abnormal Child Psychology, 33, 325–338. Burgess, E. W. (1928). Factors determining success or failure on parole. In A. A. Bruce, A. J. Harno, E. W. Burgess, & J. Landesco (Eds.), The workings of the indeterminate-sentence law and the parole systems in Illinois (pp. 221–234). Springfield, IL: Illinois State Board of Parole. Campbell, F. A., & Ramey, C. T. (1995). Cognitive and school outcomes for high-risk African-American students at middle adolescence: Positive effects of early intervention. American Educational Research Journal, 32, 743–772. CHAPTER 61 1004 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 1004

Caplan, G. (1964). Principles of preventive psychology. New York, NY: Basic Books. Cardemil, E. V., Reivich, K. J., Beevers, C. G., Seligman, M. E. P., & James, J. (2007). The prevention of depressive symptoms in low-income, minority children: Two-year follow-up. Behaviour Research and Therapy, 45, 313–327. Carneiro, P., & Heckman, J. (2003). Human capital policy. In J. Heckman, & A. B. Krueger (Eds.), Inequality in America: What role for Human Capital Policies? (pp. 77–240). Boston, MA: MIT Press. Caspi, A., McClay, J., Moffitt, T. E., Mill, J., Martin, J., Craig, I. W., et al. (2002). Role of genotype in the cycle of violence in maltreated children. Science, 297, 851–854. Ceci, S. J., & Papierno, P. B. (2005). The rhetoric and reality of gap closing: When the “Have-nots” gain but the “Haves” gain even more. American Psychologist, 60, 149–160. Charlebois, P., Vitaro, F., Normandeau, S., & Rondeau, N. (2001). Predictors of persistence in a longitudinal preventive intervention program for young disruptive boys. Prevention Science, 2, 133–143. Chatterji, P., Caffray, C. M., Jones, A. S., Lillie-Blanton, M., & Werthamer, L. (2001). Applying cost analysis methods to schoolbased prevention programs. Prevention Science, 2, 45–55. Chen, X. Y., Rubin, K. H., & Sun, Y. R. (1992). Social reputation and peer relationships in Chinese and Canadian children: A crosscultural study. Child Development, 63, 1336–1343. Cicchetti, D., & Cohen, D. J. (2006). Developmental psychopathology, Vol. 1. Theory and methods (2nd edn.). New York, NY: Wiley. Cicchetti, D., & Hinshaw, S. P. (2002). Editorial: Prevention and intervention science: Contributions to developmental theory. Development and Psychopathology, 14, 667–671. Clarke, G. N., Hawkins, W., Murphy, M., & Sheeber, L. B. (1995). Targeted prevention of unipolar depressive disorder in an at-risk sample of high school adolescents: A randomized trial of group cognitive intervention. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 312–321. Clarke, G. N., Hornbrook, M., Lynch, F., Polen, M., Gale, J., Beardslee, W., et al. (2001). A randomized trial of a group cognitive intervention for preventing depression in adolescent offspring of depressed parents. Archives of General Psychiatry, 58, 1127– 1134. Cohen, M. A. (1998). The monetary value of saving a high-risk youth. Journal of Quantitative Criminology, 4, 5–33. Coie, J. D., Miller-Johnson, S., & Bagwell, C. (2000). Prevention science. In A. J. Sameroff, M. Lewis, & S. M. Miller (Eds.), Handbook of developmental psychopathology (2nd edn., pp. 93–112). New York, NY: Kluwer Academic/Plenum. Coie, J. D., Underwood, M., & Lochman, J. E. (1991). Programmatic intervention with aggressive children in the school setting. In D. J. Pepler, & K. H. Rubin (Eds.), The development and treatment of childhood aggression (pp. 389–410). Hillsdale, NJ: Lawrence Erlbaum Associates. Coie, J. D., Watt, N. F., West, S. G., Hawkins, J. D., Asarnow, J. R., Markman, H. J., et al. (1993). The science of prevention: A conceptual framework and some directions for a national research program. American Psychologist, 48, 1013–1022. Collins, L. M., Murphy, S. A., & Bierman, K. L. (2004). A conceptual framework for adaptive preventive interventions. Prevention Science, 5, 185–196. Conduct Problems Prevention Research Group. (1992). A developmental and clinical model for the prevention of conduct disorder: The Fast Track Program. Development and Psychopathology, 4, 509– 527. Conduct Problems Prevention Research Group. (1999a). Initial impact of the Fast Track prevention trial for conduct problems. I. The high-risk sample. Journal of Consulting and Clinical Psychology, 67, 631–647. Conduct Problems Prevention Research Group. (1999b). Initial impact of the Fast Track prevention trial for conduct problems. II. Classroom effects. Journal of Consulting and Clinical Psychology, 67, 648–657. Conduct Problems Prevention Research Group. (2002). Evaluation of the first 3 years of the Fast Track prevention trial with children at high risk for adolescent conduct problems. Journal of Abnormal Child Psychology, 30, 19–35. Conduct Problems Prevention Research Group. (2004). The effects of the Fast Track program on serious problem outcomes at the end of elementary school. Journal of Clinical Child and Adolescent Psychology, 33, 650–661. Conduct Problems Prevention Research Group. (2005). The long-term prevention of serious conduct disorder, interpersonal violence, and violent crime (No. 05–78. Technical Report). University Park, PA: Pennsylvania State University, Methodology Center. Cowen, E. L. (1991). In pursuit of wellness. American Psychologist, 46, 404–408. Cuijpers, P. (2003). Examining the effects of prevention programs on the incidence of new cases of mental disorders: The lack of statistical power. American Journal of Psychiatry, 160, 1385–1391. Cunningham, C. E., Bremner, R., & Boyle, M. (1995). Large group community-based parenting programs for families of preschoolers at risk for disruptive behaviour disorders: Utilization, cost effectiveness, and outcome. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 36, 1141–1159. Dadds, M. R., Holland, D. E., Laurens, K. R., Mullins, M., Barrett, P. M., & Spence, S. H. (1999). Early intervention and prevention of anxiety disorders in children: Results at 2-year follow-up. Journal of Consulting and Clinical Psychology, 67, 145–150. Dadds, M. R., Spence, S. H., Holland, D. E., Barrett, P. M., & Laurens, K. R. (1997). Prevention and early intervention for anxiety disorders: A controlled trial. Journal of Consulting and Clinical Psychology, 65, 627–635. Dahlberg, L. L., & Potter, L. B. (2001). Youth violence: Developmental pathways and prevention challenges. American Journal of Preventive Medicine, 20, 3–14. Deater-Deckard, K., Dodge, K. A., Bates, J. E., & Pettit, G. S. (1998). Multiple risk factors in the development of externalizing behavior problems: Group and individual differences. Development and Psychopathology, 10, 469–493. Dishion, T. J., & Andrews, D. W. (1995). Preventing escalation in problem behaviors with high-risk young adolescents: Immediate and 1-year outcomes. Journal of Consulting and Clinical Psychology, 63, 538–548. Dishion, T. J., McCord, J., & Poulin, F. (1999). When interventions harm: Peer groups and problem behavior. American Psychologist, 54, 755–764. Dishion, T. J., Nelson, S. E., & Kavanagh, K. (2003). The family checkup with high-risk young adolescents: Preventing early-onset substance use by parent monitoring. Behavior Therapy, 34, 553–571. Dishion, T. J., Spracklen, K. M., Andrews, D. W., & Patterson, G. R. (1996). Deviancy training in male adolescent friendships. Behavior Therapy, 27, 373–390. Dodge, K. A. (2001). The science of youth violence prevention: Progressing from developmental epidemiology to efficacy to effectiveness to public policy. American Journal of Preventive Medicine, 20, 63– 70. Dodge, K. A. (2006). Professionalizing the practice of public policy in the prevention of violence. Journal of Abnormal Child Psychology, 34, 475 –479. Dodge, K. A., Dishion, T. J., & Lansford, J. E. (2006). Deviant peer influences in intervention and public policy for youth. New York, NY: Guilford Press. Dumas, J. E., Prinz, R. J., Smith, E. P., & Laughlin, J. (1999). The EARLY ALLIANCE prevention trial: An integrated set of interventions to promote competence and reduce risk for conduct disorder, substance abuse, and school failure. Clinical Child and Family Psychology Review, 2, 37–53. TARGETED PREVENTIVE INTERVENTIONS 1005 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 1005

DuPaul, G., & Eckert, T. L. (1997). The effects of school-based interventions for attention deficit hyperactivity disorder: A meta-analysis. School Psychology Review, 26, 5–27. Eggert, L. L., Thompson, E. A., Herting, J. R., & Nicholas, L. J. (1995). Reducing suicide potential among high-risk youth: Tests of a school-based prevention program. Suicide and Life-Threatening Behavior, 25, 276–296. Elliott, D. S., & Mihalic, S. (2004). Issues in disseminating and replicating effective prevention programs. Prevention Science, 5, 47–53. Farrington, D. P. (1985). Delinquency prevention in the 1980s. Journal of Adolescence, 8, 3–16. Farrington, D. P., & Welsh, B. C. (2003). Family-based prevention of offending: A meta-analysis. The Australian and New Zealand Journal of Criminology, 36, 127–151. Felner, R. D., Yates Felner, T., & Silverman, M. M. (2000). Prevention in mental health and social intervention: Conceptual and methodological issues in the evolution of the science and practice of prevention. In J. Rappaport, & E. Seidman (Eds.), Handbook of community psychology (pp. 9–42). New York, NY: Kluwer Academic/Plenum. Fergusson, D. M., Vitaro, F., Wanner, B., & Brendgen, M. (2007). Protective and compensatory factors mitigating the influence of deviant friends on delinquent behaviors during early adolescence. Journal of Adolescence, 30, 33–50. Fontana, C. A., Fleischman, A. R., McCarton, C., Meltzer, A., & Ruff, H. (1988). A neonatal preventative intervention study: Issues of recruitment and retention. Journal of Primary Prevention, 9, 164–176. Foster, E. M., Jones, D., and the Conduct Problem Prevention Research Group (2006). Can a costly intervention be cost-effective? An analysis of violence prevention. Archives of General Psychiatry 63, 1284–1291. Franklin, C., Grant, D., Corcoran, J., Miller, P., & Bultman, L. (1997). Effectiveness of prevention programs for adolescent pregnancy: A meta-analysis. Journal of Marriage and the Family, 59, 551–567. Garvey, C., Wrenetha, J., Fogg, L., Kratovil, A., & Gross, D. (2006). Measuring participation in a prevention trial with parents of young children. Research in Nursing and Health, 29, 212–222. Gifford-Smith, M., Dodge, K. A., Dishion, T. J., & McCord, J. (2005). Peer influence in children and adolescents: Crossing the bridge from developmental to intervention science. Journal of Abnormal Child Psychology, 33, 255–265. Gillham, J. E., Shatté, A. J., & Reivich, K. (2001). Needed for prevention research: Long-term follow up and the evaluation of mediators, moderators, and lay providers. Commentary on Greenberg, Domitrovich, & Bumbarger (2001). The prevention of mental disorders in school-age children: Current state of the field. Prevention and Treatment, 4, Article 9. Gordon, R. S. (1983). An operational classification of disease prevention. Public Health Reports, 98, 107–109. Greenberg, M. T., Domitrovich, C., & Bumbarger, B. (2001). The prevention of mental disorders in school-aged children: Current state of the field. Prevention and Treatment, 4, Article 9. Greenberg, M. T., Kusche, C. A., Cook, E. T., & Quamma, J. P. (1995). Promoting emotional competence in school-aged children: The effects of the PATHS curriculum. Development and Psychopathology, 7, 117–136. Grossman, P. B., & Hugues, J. N. (1992). Self-control interventions with internalizing disorders: A review and analysis. School Psychology Review, 21, 229–245. Harrell, A. V., Cavanagh, S. E., Harmon, M. A., Koper, C. S., & Sridharan, S. (1997). Impact of the children at risk program: Comprehensive final report. Vol. 1. Washington, DC: The Urban Institute. Harrell, A. V., Cavanagh, S. E., & Sridharan, S. (1999). Evaluation of the children at risk program: Results 1 year after the end of the program. Research in brief (November). Washington, DC: National Institute of Justice, US Department of Justice. Holden, G. W., Lavigne, V. V., & Cameron, A. M. (1990). Probing the continuum of effectiveness in parent training: Characteristics of parents and preschoolers. Journal of Clinical Child Psychology, 19, 2–8. Horowitz, J. L., & Garber, J. (2006). The prevention of depressive symptoms in children and adolescents: A meta-analytic review. Journal of Consulting and Clinical Psychology, 74, 401–415. Howe, G. W., Reiss, D., & Yuh, J. (2002). Can prevention trials test theories of etiology? Development and Psychopathology, 14, 673–694. Huston, A. C. (2005). Connecting the science of child development to public policy. SRCD Social Policy Report, XIX (IV). Institute of Medicine. (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research. Washington, DC: National Academy Press. Jaycox, L. H., Reivich, K. J., Gillham, J., & Seligman, M. E. (1994). Prevention of depressive symptoms in school children. Behaviour Research and Therapy, 32, 801–816. Kazdin, A. (1985). Treatment of antisocial behavior in children and adolescents. Homewood, IL: Dorsey. Kellam, S. G., Rebok, G. W., Ialongo, N., & Mayer, L. S. (1994). The course and malleability of aggressive behavior from early 1st grade into middle school: Results of a developmental epidemiologicallybased preventive trial. Journal of Child Psychology and Psychiatry, 35, 259–281. [Published erratum appears in Journal of Child Psychology and Psychiatry 1994, 35, 983.] Kendall, P. C., Marrs-Garcia, A., Nath, S. R., & Sheldrick, R. C. (1999). Normative comparisons for the evaluation of clinical significance. Journal of Consulting & Clinical Psychology, 67, 285–299. Kraemer, H. C. (2003). Current concepts of risk in psychiatric disorders. Current Opinion in Psychiatry, 16, 421–430. Kraemer, H. C., Kazdin, A. E., Offord, D. R., Kessler, R. C., Jensen, P. S., & Kupfer, D. J. (1999). Measuring the potency of risk factors for clinical or policy significance. Psychological Methods, 4, 257–271. Kraemer, H. C., Stice, E., Kazdin, A., Offord, D., & Kupfer, D. (2001). How do risk factors work together? Mediators, moderators, and independent, overlapping, and proxy risk factors. American Journal of Psychiatry, 158, 848–856. LaFromboise, T., & Howard-Pitney, B. (1995). The Zuni life skills development curriculum: Description and evaluation of a suicide prevention program. Journal of Counseling Psychology, 42, 479–486. LeMarquand, D., Tremblay, R. E., & Vitaro, F. (2001). The prevention of conduct disorder: A review of successful and unsuccessful experiments. In J. Hill, & B. Maughan (Eds.), Conduct disorder in childhood (pp. 449–477). Cambridge: Cambridge University Press. Leventhal, T., & Brooks-Gunn, J. (2004). A randomized study of neighborhood effects on low-income children’s educational outcomes. Developmental Psychology, 40, 488–507. Lipsey, M. W. (1995). What do we learn from 400 research studies on the effectiveness of treatment with juvenile delinquents? In J. McGuire (Ed.), What works: Reducing reoffending. Guidelines from research and practice (pp. 63–78). New York, NY: John Wiley and Sons. Lipsey, M. W., & Wilson, D. B. (1998). Effective intervention for serious juvenile offenders: A synthesis of research. In R. Loeber, & D. P. Farrington (Eds.), Serious and violent juvenile offenders: Risk factors and successful interventions (pp. 313–345). Thousand Oaks, CA: Sage. Lochman, J. E. (2001). Issues in prevention with school-aged children: Ongoing intervention refinement, developmental theory, prediction and moderation, and implementation and dissemination. Prevention and Treatment, 4, Article 4. Lösel, F., & Beelmann, A. (2003). Effects of child skill training in preventing antisocial behavior: A systematic review of randomized evaluations. Annals of the American Academy of Political and Social Science, 587, 84–109. CHAPTER 61 1006 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 1006

Luthar, S. S., Cicchetti, D., & Becker, B. (2000). The construct of resilience: A critical evaluation and guidelines for future work. Child Development, 71, 543–562. Lynch, F. L., Hornbrook, M., Clarke, G. N., Perrin, N., Polen, M. R., O’Connor, E., et al. (2005). Cost-effectiveness of an intervention to prevent depression in at-risk teens. Archives of General Psychiatry, 62, 1241–1248. MacMillan, H. L., Thomas, B. H., Jamieson, E., Walsh, C. A., Boyle, M. H., Shannon, H. S., et al. (2005). Effectiveness of home visitation by public-health nurses in prevention of the recurrence of child physical abuse and neglect: A randomised controlled trial. Lancet, 365, 1786–1793. Martinez, C. R. (2006, May). Models and methods for cultural adaptation of prevention programs, Pre-conference at the Annual meeting of the Society for Prevention Research, San Antonio, TX. Masten, A. S., Burt, K. B., & Coatworth, J. D. (2006). Competence and psychopathology in development. In D. Cicchetti, & D. Cohen (Eds.), Developmental psychopathology. Vol 3. Risk, disorder and adaptation (2nd edn., pp. 696–738). New York, NY: Wiley. Maughan, B. (2005). Developmental trajectory modeling: A view from developmental psychopathology. Annals of the American Academy of Political and Social Science, 602, 118–130. Maughan, B., Taylor, C., Taylor, A., Butler, N., & Bynner, J. (2001). Pregnancy smoking and childhood conduct problems: A causal association? Journal of Child Psychology and Psychiatry and Allied Disciplines, 42, 1021–1028. McCartney, K., & Rosenthal, R. (2000). Effect size, practical importance, and social policy for children. Child Development, 71, 173– 180. McCord, J. (1978). A thirty-year follow-up of treatment effects. American Psychologist, 33, 284–289. Meehl, P. E. (1992). Factors and taxa, traits and types, differences of degree and differences in kind. Journal of Personality, 60, 117–174. Metropolitan Area Child Study Research Group. (2002). A cognitive– ecological approach to preventing aggression in urban settings: Initial outcomes for high-risk children. Journal of Consulting and Clinical Psychology, 70, 179–194. Miller, G. E., & Prinz, R. J. (2003). Engagement of families in treatment for childhood conduct problems. Behavior Therapy, 34, 517–534. Moffitt, T. E. (1990). The neuropsychology of juvenile delinquency: A critical review. In M. Tonry, & N. Morris (Eds.), Crime and justice: A review of research (Vol. 112, pp. 99–169). Chicago: University of Chicago Press. Mrazek, P. J., & Brown, C. H. (2002). An evidence-based literature review regarding outcomes in psychosocial prevention and early intervention in young children. In C. C. Russell (Ed.), The state of knowledge about prevention/early intervention (pp. 42–165). Toronto, ON: Invest in Kids Foundation. Mrazek, P. J., & Haggerty, R. J. (1994). Reducing risk for mental disorders: Frontiers for preventive intervention research. Washington, DC: National Academy Press. Nagin, D. S. (2005). Group-based modeling of development. Cambridge, MA: Harvard University Press. Nagin, D. S., & Tremblay, R. E. (1999). Trajectories of boys’ physical aggression, opposition, and hyperactivity on the path to physically violent and non violent juvenile delinquency. Child Development, 70, 1181–1196. Nation, M., Crusto, C., Wandersman, A., Kumpfer, K. L., Seybolt, D., Morrissey-Kane, E., et al. (2003). What works in prevention: Principles of effective prevention programs. American Psychologist, 58, 449–456. National Evaluation of Sure Start Team. (2004). The impact of Sure Start local programs on child development and family functioning: A report on preliminary findings. Report by the Institute for the Study of Children Families and Social Issues, Birbeck University of London. Offord, D. R. (1996). The state of prevention and early intervention. In R. D. Peters, & R. J. McMahon (Eds.), Preventing childhood disorders, substance abuse, and delinquency (pp. 329–344). Thousand Oaks, CA: Sage. Offord, D. R., & Bennett, K. J. (2002). Prevention. In M. Rutter, & E. Taylor (Eds.), Child and adolescent psychiatry (4th edn., pp. 881–899). Oxford, UK: Blackwell Science. Offord, D. R., Kraemer, H. C., Kazdin, A. E., Jensen, P. S., & Harrington, R. (1998). Lowering the burden of suffering from child psychiatric disorder: Trade-offs among clinical, targeted, and universal interventions. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 686–694. Olds, D. L., Eckenrode, J., Henderson, C. R. J., Kitzman, H., Powers, J., Cole, R., et al. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: Fifteenyear follow-up of a randomized trial. Journal of the American Medical Association, 278, 637–643. Olds, D. L., Henderson, C. R., Kitzman, H., & Eckenrode, J. (1998). Prenatal and home visitation by nurses: A program of research. In I. C. Rovee-Collier, P. Lipsitt, & H. Hayne (Eds.), Advances in infancy research (pp. 79–130). Stamford: Ablex. Olds, D. L., Henderson, C. R., Kitzman, H., Eckenrode, J., Cole, R., & Tatelbaum, R. C. (1999). Prenatal and infancy home visitation by nurses: Recent findings. Future of Children, 9, 44–65. Olds, D. L., Henderson, C. R., Tatelbaum, R., & Chamberlin, R. (1986). Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics, 77, 16–28. Pickles, A., & Angold, A. (2003). Natural categories or fundamental dimensions: On carving nature at the joints and the rearticulation of psychopathology. Development and Psychopathology, 15, 529– 551. Plomin, R., & Crabbe, J. (2000). DNA. Psychological Bulletin, 126, 806–828. Prinz, R. J., & Miller, G. E. (1994). Family-based treatment for childhood antisocial behavior: Experimental influences on dropout and engagement. Journal of Consulting and Clinical Psychology, 62, 645–650. Prinz, R. J., & Miller, G. E. (1996). Parental engagement in interventions for children at risk for conduct disorder. In R. D. Peters, & R. J. McMahon (Eds.), Preventing childhood disorders, substance abuse, and delinquency (pp. 161–183). Thousand Oaks, CA: Sage. Prinz, R. J., Smith, E. P., Dumas, J. E., Laughlin, J. E., White, D. W., & Barron, R. (2001). Recruitment and retention of participants in prevention trials involving family-based interventions. American Journal of Preventive Medicine, 20, 31–37. Reid, M. J., Webster-Stratton, C., & Hammond, M. (2003). Followup of children who received the Incredible Years intervention for oppositional-defiant disorder: Maintenance and prediction of 2-year outcome. Behavior Therapy, 34, 471–491. Rice, M. E., & Harris, G. T. (1995). Psychopathy, schizophrenia, alcohol abuse, and violent recidivism. International Journal of Law and Psychiatry, 18, 333–342. Romeo, R., Byford, S., & Knapp, M. (2005). Annotation: Economic evaluations of child and adolescent mental health interventions: A systematic review. Journal of Child Psychology and Psychiatry, 46, 919–930. Rotheram-Borus, M. J., & Duan, N. (2003). Next generation of preventive interventions. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 518–526. Rutter, M. (2003). Crucial paths from risk indicator to causal mechanism. In B. B. Lahey, T. E. Moffitt, & A. Caspi (Eds.), Causes of conduct disorder and juvenile delinquency (pp. 3–24). New York, NY: Guilford Press. Rutter, M., Giller, H., & Hagell, A. (1998). Antisocial behavior by young people. New York: Cambridge University Press. TARGETED PREVENTIVE INTERVENTIONS 1007 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 1007

Sameroff, A. J., & Mackenzie, M. J. (2003). Research strategies for capturing transactional models of development: The limits of the possible. Development and Psychopathology, 15, 613–640. Schlernitzauer, M., Bierhals, A. J., Geary, M. D., Prigerson, H. G., Stack, J. A., Miller, M. D., et al. (1998). Recruitment methods for intervention research in bereavement-related depression: Five years’ experience. American Journal of Geriatric Psychiatry, 6, 67–74. Schweinhart, L. J. (2006). The High/Scope approach: Evidence that participatory learning in early childhood contributes to human development. In N. F. Watt, C. Ayoub, R. H. Bradley, J. E. Puma, & W. LeBoeuf (Eds.), The crisis in youth mental health: Critical issues and effective programs, Vol. 4. Early intervention programs and policies (pp. 207–227). Westport, CT: Praeger Publishers/Greenwood Publishing Group. Schweinhart, L. L., Barnes, H. V., & Weikart, D. P. (1993). Significant benefits: The High/Scope Perry School Study through age 27. Ypsilanti, MI: High/Scope Press. Serketich, W. J., & Dumas, J. E. (1996). The effectiveness of behavioral parent training to modify antisocial behavior in children: A meta-analysis. Behavior Therapy, 27, 171–186. Society for Prevention Research. (2004). Standards of evidence: Criteria for efficacy, effectiveness, and dissemination. Falls Church, VA: Society for Prevention Research. Society for Prevention Research. http://www.preventionresearch.org. Spoth, R., Ball, A. D., Klose, A., & Redmond, C. (1996). Illustration of a market segmentation technique using family-focused prevention program preference data. Health Education Research, 11, 259–267. Spoth, R., & Redmond, C. (1994). Effective recruitment of parents into family-focused prevention research: A comparison of strategies. Psychology and Health, 9, 353–370. Spoth, R., & Redmond, C. (1995). Parent motivation to enroll in parenting skills programs: A model of family context and health belief predictors. Journal of Family Psychology, 9, 294–310. St. Pierre, T. L., Mark, M. M., Kaltreider, D. L., & Aikin, K. J. (1997). Involving parents of high-risk youth in drug prevention: A threeyear longitudinal study in boys and girls clubs. Journal of Early Adolescence, 17, 21–50. Stattin, H., & Magnusson, D. (1991). Stability and change in criminal behaviour up to age 30. British Journal of Criminology, 31, 327– 346. Tobler, N. S., Roona, M. R., Ochshorn, P., Marshall, D. G., Streke, A. V., & Stackpole, K. M. (2000). School-based adolescent drug prevention programs: 1998 Meta-analysis. Journal of Primary Prevention, 20, 275–336. University of Colorado Center for the Study and Prevention of Violence. http://www.colorado.edu/cspv/blueprints. van de Wiel, N. M. H., Matthys, W., Cohen-Kettenis, P., & van Engeland, H. (2003). Application of the Utrecht Coping Power Program and care as usual to children with disruptive behavior disorders in outpatient clinics: A comparative study of cost and course of treatment. Behavior Therapy, 34, 421–436. Vitaro, F., Brendgen, M., & Tremblay, R. E. (2001a). Preventive intervention: Assessing its effects on the trajectories of delinquency and testing for mediational processes. Applied Developmental Science, 5, 201–213. Vitaro, F., Tremblay, R. E., & Bukowski, W. M. (2001b). Friends, friendships, and conduct disorders. In J. Hill, & B. Maughan (Eds.), Conduct disorder in childhood (pp. 346–378). Cambridge: Cambridge University Press. Wakschlag, L. S., & Hans, S. L. (2002). Maternal smoking during pregnancy and conduct problems in high-risk youth: A developmental framework. Development and Psychopathology, 14, 351–369. Webster-Stratton, C. (1990). Long-term follow-up of families with young conduct-problem children: From preschool to grade school. Journal of Consulting and Clinical Psychology, 19, 1344–1349. Webster-Stratton, C., & Hammond, M. (1997). Treating children with early-onset conduct problems: A comparison of child and parent training interventions. Journal of Consulting and Clinical Psychology, 65, 93–109. Webster-Stratton, C., Mihalic, S., Fagan, A., Arnold, D., Taylor, T., & Tingley, C. (2001a). Blueprints for violence prevention, book eleven: the incredible years: Parent, teacher, and child training series. Boulder, CO: Center for the Study and Prevention of Violence. Webster-Stratton, C., Reid, M. J., & Hammond, M. (2001b). Preventing conduct problems, promoting social competence: A parent and teacher training partnership in Head Start. Journal of Clinical Child Psychology, 30, 283–302. Weisz, J. R., Weiss, B., Alicke, M. D., & Klotz, M. L. (1987). Effectiveness of psychotherapy with children and adolescents: A metaanalysis for clinicians. Journal of Consulting and Clinical Psychology, 55, 542–549. Werch, C. E., & Owen, D. M. (2001). Iatrogenic effects of alcohol and drug prevention programs. Journal of Studies on Alcohol, 63, 581–590. Yoshikawa, H. (1994). Prevention as cumulative protection: Effects of early family support and education on chronic delinquency and its risks. Psychological Bulletin, 115, 28–54. CHAPTER 61 1008 9781405145497_4_061.qxd 29/03/2008 02:57 PM Page 1008

Background Origins Behaviorism began to take hold as a major influence in psychology in the early 20th century. John B. Watson finished his doctoral thesis on the behavior of the white rat in 1903, in which he acknowledged the powerful effects of innate capabilities, but showed that early experience, in a way that could be carefully measured, had a clear strong effect on current behavior. In 1913, in his article “Psychology as the behaviorist sees it,” he drew attention to the limitations of psychological theories current at the time and proposed behaviorism as an objective natural science with a progressive pragmatic agenda that could be applied to humans as well as animals. The article has a lengthy footnote on the nature of thinking, and Watson believed that complex emotional reactions in humans were derived from the newborn’s unlearned reactions of fear, rage and love. Thus, contrary to some current concerns, from the outset, major mainstream behaviorists recognized the importance of innate inherited traits, accepted the existence of complex emotional states and had theories about the role of cognitions. However, while recognizing these influences, behaviorists showed that for a given individual, many particular behaviors could be substantially altered by changing the immediately preceding events, and those that immediately followed. Watson’s ideas were developed by Skinner, who gave more emphasis to the influence of events subsequent to a given behavior than to antecedent stimuli. Skinner was especially skeptical of psychological explanations for behavior based on introspections, which he called “mental fictions.” Skinner expanded his approach beyond the individual level to suggest a model society based on behavioral principles for returning US war veterans in Walden Two (Skinner, 1948), and applied behaviorist principles to language, in his classic Verbal Behavior (Skinner, 1957). However, the limitations of a behaviorist approach to language were set out by the young Chomsky (1959), who was scathing of Skinner’s approach, pointing out that language learning occurs independently of external rewards. Soon there were clinical applications, and in 1952 Eysenck coined the term “behavior therapy” to capture the application of behavioral principles to treatment of patients, and Wolpe began developing treatments based on classic conditioning theory. The 1960s saw the heyday of pure behaviorism, with the founding of several journals such as the Journal for the Experimental Analysis of Behavior, Journal of Applied Behavioral Analysis, Behavior Therapy and Behavior Research and Therapy, in which a plethora of articles explored the application of behavioral principles to a wide range of situations, from animal behavior to business management. Many clinical applications were developed for adults. In the 1970s, many treatments were developed for children and adolescents. These covered all the main disorder groupings, with, for example, exposure treatments with relaxation for fears and anxiety, contingency management through parent training for disruptive disorders and functional analysis for challenging behaviors in children with intellectual disability. In this era, evaluations showed that the new treatments were generally notably effective; typically, they used relatively small numbers (4–10 cases) in single-case designs, plus some group trials, typically with 15–40 participants. In the last 25 years behavioral therapies have continued to be refined, and large-scale randomized controlled trials comparing behavioral therapy with controls or in combination with medications with 100–800 participants have generally attested to their effectiveness (Conduct Problems Research Group, 1999; MTA Cooperative Group, 1999). In addition to modifications along purely behavioral lines, other therapies have grafted different approaches onto a behavioral base. Cognitive–behavioral therapies (CBT; see chapter 63) address thoughts as well as actions, but not in a loose introspective way, instead applying to cognitions the same concepts espoused by behaviorists of precise measurement, pragmatic individual formulation of phenomena in the present time and experimental trying out of what works with each patient and modifying it according to its effectiveness. A number of family systems approaches have taken up behavioral ideas and methods; for example, Functional Family Therapy (Alexander, Pugh, Parsons, & Sexton, 2000) and Multisystemic Therapy (Henggeler, Schoenwald, Liao, Letourneau, & Edwards, 2002). Problemsolving and social skills therapies use behavioral methods within the context of impaired relationships (see chapter 63). Therapies for those with post-traumatic stress disorder (PTSD) in the context of wider personal violations such as war or sexual abuse 1009 Behavioral Therapies 62 Stephen Scott and William Yule 9781405145497_4_062.qxd 29/03/2008 02:58 PM Page 1009 Rutter’s Child and Adolescent Psychiatry, 5th Edition, Edited by M. Rutter, D. V. M. Bishop D. S. Pine, S. Scott, J. Stevenson, E. Taylor and A. Thapar © 2008 Blackwell Publishing Limited. ISBN: 978-1-405-14549-7

have broadened behavioral therapies to include addressing the profound impact on the patient’s sense of self and identity (e.g., using narrative approaches; Schauer, Neuner, Elbert et al., 2004). In the last 10 years, a “third generation” of behaviorallybased cognitive therapies has emerged following traditional behavior therapy and CBT. Examples include Acceptance and Commitment Therapy (ACT; Hayes, Luomaa, Bond, Masudaa, & Lillisa, 2006), Dialectical Behavior Therapy (DBT; Linehan, 1993) and Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2001). Although based on behavioral principles, these therapies take cognitive issues further, by acknowledging that sometimes unpleasant thoughts and feelings cannot be changed, but can be accepted as less concerning; to date child and adolescent versions are only just emerging. Basic Tenets Classic Conditioning Pavlov described classic conditioning, whereby unconditioned stimuli (e.g., food) that led to unconditioned responses (salivation) could be presented at the same time with other (conditioned) stimuli (e.g., a bell), which then led to similar, but not identical, conditioned responses. Watson showed that classic conditioning had wide applicability. Understanding this mechanism has led to several applications; for example, dogs given food as they smell explosives learn to associate the smell of explosives with a reward, and can be trained to sniff airline luggage. A clinical application was developed by Wolpe (1958) when he suggested that in phobias the unconditioned response of overwhelming fear to a stimulus could be replaced by a competing conditioned response of relaxation through sufficient exposure, so that habituation occurred, a process he named systematic desensitization. This mechanism continues to underpin many current treatments for anxiety, phobias and PTSD. Operant Conditioning Skinner was concerned that most everyday behaviors were not related to simple unconditioned responses such as fear or hunger, but rather were often emitted spontaneously, and if they were followed by rewards or punishment then their form and frequency were adapted. Thus, children starting school soon learn that speaking to their friends in class may be punished by disapproval and a consequence such as detention, but that putting their hands up to answer a teacher’s question is likely to be rewarded by approval. Skinner termed behaviors that led to rewards or punishments operants because they operated to change the environment for the individual. Others have argued that this description of events is the wrong way round, because it is the events subsequent to the original behavior that control its future emission. Both classic and operant approaches do not concern themselves with the inner motives of the individual, but instead address the antecedent stimuli and consequent responses. This is in contrast to psychotherapies that primarily aim to change the inner world. Some of the differences between behavioral therapies and traditional psychotherapies are outlined in Table 62.1. Private thoughts and feelings are not ignored by behavior therapists, but they take a very different approach to them from traditional therapists, because they believe the same principles can be applied to them as to behavior (e.g., precise operational definition, quantifiable measurement, modification through learning principles). In short, thoughts and feelings are not seen as belonging to a different world (Phillips, 1981). Methods Behavioral Assessment A core tool is behavioral assessment. This can vary in intensity, from a behaviorally-based interview, supplemented with a chart or diary if necessary, using a reliable and valid rating scale, to adding direct observation, additionally carrying out a full functional analysis which includes experimental manipulation of key variables, where possible. Interview In the interview, a thorough and detailed description of the behavior in question is elicited, including its frequency, duration and severity. Usually, the account is from the parents or the teacher, who may need help in moving from a generalized concern such as “He’s a rude boy” to specifics such as “He shouts at me in a loud voice for 3–4 minutes every day.” The general setting should be explored, such as “He’s only started doing it since his Dad left me 3 months ago,” moving on to clarify the antecedents, “It’s when I’m on the telephone,” and the consequences, “I have to stop chatting to my friend and tell him off.” Diary Where the picture is unclear, parents can be asked to keep a diary and note each day what happens over, say, a 2-week period. This may reveal exceptions, when the problem behavior is not shown; then the clinician will work closely with the parents to elucidate what else differed on those days. Rating Scales A standardized rating scale is helpful in ensuring that a systematic approach is taken to measuring the extent and severity of the problem domain. It can provide a useful talking point when an item has been checked, and can act as a baseline measurement of severity, to be given at different points of treatment to monitor progress. It is preferable to have at least two informants (e.g., parent and teacher for attention deficit/ hyperactivity disorder [ADHD] symptoms, or parent and child for obsessive-compulsive disorder [OCD]). Some useful examples include the Conner’s rating scales for ADHD symptoms, the Eyberg Inventory for conduct problems, the Mood and Feelings Questionnaire for depression, the Child Impact of Traumatic Events Scale Revised for PTSD, and the Yale– Brown Obsessive-Compulsive Scale for OCD (more details of rating scales are given in chapter 20). CHAPTER 62 1010 9781405145497_4_062.qxd 29/03/2008 02:58 PM Page 1010

Direct Observation Direct observation, preferably “live” in the context where the behavior occurs, is often revealing. For example, the same complaint “hits other children in school” might in one child be observed only to occur when other children speak to him while he is engrossed in schoolwork, and in another when she is taunted about her weight and told by her peers to go away. The first case might be triggered by too close proximity of others, in a child who is fairly solitary and wants to be left alone; the second by anger at being belittled and excluded by “friends.” BEHAVIORAL THERAPIES 1011 Traditional psychotherapy May be general concern about feelings (e.g., inner disquiet) General review of patient’s view of world and meanings attributed Not undertaken formally Formal reassessment may not be carried out; treatment may need to last months until improvement expected Inner turmoil arises because of conflict between incompatible beliefs and desires Making covert desires and beliefs explicit leads to resolution of conflicts; it may or may not lead to changed behavior Working through of conflicts occurs unconsciously between sessions Wide range of theories and case studies; relatively few systematic studies of mechanisms or outcomes Necessary for patient to want to change and be ready for this; therapy helps uncover true drives and passions Personal meanings and the patient’s understanding of events core to therapy May do little beyond referring or bringing the child Follows what patient reveals; no manual Months to years Core to therapy. Therapist may use self as measuring instrument for feelings evoked by patient, and reflect these back Therapist waits to see what patient brings up; interpretations offered; patient not directed, judged or praised: neutrality preserved Behavior therapy Precisely measurable externally observable events Careful recording (e.g., by diary) of problem frequency and severity, with explicit noting of setting context, immediately preceding external events, and real-world consequences of the behavior Formal, often with diaries, charts and numbered rating scales Often repeated at each treatment session, so failure to progress picked up early and addressed by reappraisal and change of strategy How problem arises not especially central; more important are the external contingencies that maintain it Modification of current external contingencies leads to the learning of new, more adaptive behavior External context has to change and/or new behavior be learned; action is required, new responses have to be practiced; homework between sessions may be set to enable this to happen Wide range of studies testing and experimentally altering variables including contingencies, form and duration of treatment, mechanisms Not necessary to know patient’s motives in order to treat (e.g., challenging behavior) Therapy can successfully be given with no knowledge of child’s personal meanings and understanding of events (e.g., by changing external contingencies) or with children with intellectual disability Central figures for changing the environment around the child, crucial allies in delivering the therapy Often programmatic, stepwise application of principles to the problem; manual often available Weeks to months Therapist is vehicle for delivery, which may also be selfadministered by book or computer After assessment, therapist sets agenda; may suggest courses of action, may praise patient Table 62.1 Behavior therapy contrasted with traditional psychotherapy. Problem definition Assessment Measurement type Measurement frequency Theory of problem causation Treatment principle Postulated mechanism of change Empirical research base Role of motivation Role of meanings Role of parent and teacher in therapy Treatment content Treatment duration Relationship with therapist Transactions with therapist 9781405145497_4_062.qxd 29/03/2008 02:58 PM Page 1011

Functional Analysis Functional analysis goes a step further so that after generating hypotheses, they are tested experimentally. Thus, in the first example above, children might be asked to approach the boy and see whether indeed he then lashes out; it might emerge that he does so when boys approach and not girls. The hypothesis might be refined to state that the behavior has the function of keeping boys at a distance. In this way of thinking, causation in the pure sense is eschewed for practical functions, so that the hypothesized “cause”: 1 Covaries with the behavior; 2 Is in principle changeable; and 3 When changed, leads to an alteration in behavior. In many cases, interview and diary keeping are sufficient to formulate an effective plan. However, in secondary referrals for complex cases, observation is invaluable. Functional analysis is especially useful when children have intellectual disabilities with challenging behavior that is hard to make sense of, such as head banging. Case Formulation This should go considerably further than behavioral assessment to incorporate all relevant psychiatric factors. As well as determining triggering and maintaining factors, defining positive behaviors to train up is usually more important than simply eliminating negative behaviors in one context (Herbert, 1987). Intervention Techniques to Increase Behavior What follows is a broad account of techniques. Readers seeking a detailed manual are referred to Herbert (1987) and to Hersen (2005). Positive Reinforcement This should be used when a new behavior is to be incorporated into the child’s repertoire, or when an existing behavior is desired more frequently or across more situations. It can also be used to increase the strength of an existing behavior so that an undesirable incompatible response diminishes. The method is to identify what is desired, and arrange matters so an immediate reward follows the performance of the behavior; in the words of one adage “Catch them being good” (and then reward them). Social Rewards Reinforcers may be social or tangible. In the social domain, attention is most powerful with younger children, but it is often also very effective for adolescents. It is often enough to say a few words showing that the behavior has been appreciated (e.g., describing what they did). To add power, it may be combined with words of praise or physical expressions of affection such as a hug. Positive attention is a two-way process in that children’s positive behavior reinforces adults; a happy relationship results from many mutually reinforcing interactions. As the child grows up, attention from peers, when present, may be far more influential than attention from parents. Attention that is associated with criticism or punishment will usually not be reinforcing; however, there is an exception. For children raised with very little attention, negative attention (such as being told off in a disapproving tone of voice) may be more reinforcing than being ignored completely. In this way, a parent who mainly ignores their child and then only scolds them may unwittingly be reinforcing bad behavior. Tangible Rewards These include items such as food (from single sweets to a trip to a restaurant), leisure activities (time on the computer or the telephone, going swimming) and privileges (staying up late, having a friend over). For more frequently occurring behaviors, tokens such as stars on a chart, or points can be given and later exchanged for a tangible reward; money can be given too. Application of Rewards Reinforcers can be provided by adults such as parents and teachers, other children such as siblings or peers, or the child themselves. The person doing the reinforcing will need coaching in each case – one cannot automatically assume that a parent or teacher has a large repertoire of praising comments that they use freely and warmly; and a child may need to rehearse congratulating themselves for, say, doing their homework or not losing their temper. Praise in front of others (e.g., peers and siblings) can have a particularly strong effect. Reinforcers should be given for trying and for steps in the right direction – not withheld until a perfect performance is given. Praise is given for the behavior, and so needs to be labeled – it is not for the child in general. Rewards should be given often, and not mixed with criticism. “Well done for getting two A grades – if you hadn’t been lazy, you’d have got three” is going to completely undo the effect of the praise element. In practice, rules for rewards must be clear and simple; the therapist must check with the child that they understand them, and check that the parent implements them fairly and consistently. Rewards need to be changed every week or so to avoid satiation. Non-contingent general praise will not improve specific behaviors and can lead the child to be “spoiled” (i.e., believe they are approved of whatever they do). Reinforcers need to be carefully selected for the individual – they need to be something that the child wants. Differential attention is where appropriate behavior is attended to, whereas inappropriate behavior is ignored (e.g., minor irritations, whining; hitting and destruction cannot be ignored). In practice, the difficulty here is to get the parent to switch back to attending to the desirable behavior after ignoring the undesirable behavior, because by now the parent is often irritated. Application of differential attention takes practice, and often some reattributions may need to be rehearsed with the parent (e.g., “He’s only doing it for attention, I shan’t give in!”). If assessment fails to show any relationship between attention and the behavior in question, it may not be appropriate to use this technique. Schedules of Reinforcement These may be continuous (i.e., after each behavior) or variable, CHAPTER 62 1012 9781405145497_4_062.qxd 29/03/2008 02:58 PM Page 1012

either by time (interval) or after a certain number of behaviors (ratio). Rewards set up expectancies within the individual, and help them predict their world. Their effects will depend on what the child is previously used to; if they already receive a great deal of praise then adding more may not be a powerful reinforcer and a tangible reward may be more effective. Conversely, where there has previously been little or no praising, some children may take a while to accept it – parents may need to persist for a few weeks to be believed. Variable schedules establish behaviors that are hard to extinguish (the individual’s experience is that reward may still come, even after a long time without). Negative Reinforcement This refers to the removal of something unpleasant, with the consequence that the procedure is reinforcing (the term is sometimes mistakenly used to refer to receiving reinforcement for negative behavior; e.g., through attention). Negative reinforcement can be used to increase wanted behavior through removing a mildly aversive situation after the child behaves as desired (e.g., a parent may threaten to turn off the TV unless the child takes his feet off the table, and remove the threat after he does). Inappropriate negative reinforcement may unwittingly lead parents to encourage antisocial behavior (e.g., by giving in). Thus, if a parent tells a child to go to bed (when the child wants to continue playing a video game), the child responds by whining and being defiant and the parent then backs off for 5 min, the child is learning that if they are defiant the aversive stimulus is removed. Positive and negative reinforcement can be further divided into: 1 Reward training: “If you make the response, you will get a reward”; 2 Privation training: “If you don’t make the response, I will withdraw a reward”; 3 Escape training: “If you make the response I will withdraw a punishment”; 4 Avoidance training: “If you don’t make the response you will be punished.” All serve to increase the frequency of a desired behavior. In practice, parents need to be very clear about which behavior is to be rewarded and to ensure the child is also clear. This can be achieved by the parent devising a chart with the child, and placing it in a prominent position such as above the child’s bed or on the refrigerator door. Token Systems These allow instant rewards to be given, and so maintain performance over a time when reward cannot be given without delay. Later, they can be exchanged for substantive rewards such as a special meal, going to the park or having a friend round. Useful applications apply in classrooms and in foster homes. Token systems can be helpful where adult social rewards such as attention or praise are for some reason less effective. An example would be in classrooms where peer pressures compete with adult attention. The Good Behavior Game is an evidence-based token system that makes use of peer influences, rather than fighting against them. Groups of children in a classroom earn points for good behavior, and the winning group gets rewarded; children monitor and control their peer group’s behavior to ensure their group wins. This has proven effective in trials (Kellam, Rebok, Ialongo, & Mayer, 1994). A second example would be promoting peer friendship behaviors, for example by giving tokens for good gamesmanship such as praising a team-mate’s efforts, which has also been proven effective in randomized controlled trials (RCTs; Frankel & Myatt, 2003). Some children are not responsive to social rewards because they have been abused and so do not trust adults. The Multidimensional Treatment Foster Care program uses token systems to improve behavior in the home and at school; it too is supported by RCT evidence (Chamberlain & Reid, 1998). Like other behavioral techniques, token systems are not a magical solution to be applied in a mechanical way, but require thought and skill. Shaping Here one reinforces small steps in the right direction of a behavior the individual has not done before. It is a popular technique with animal trainers, who can train two naïve pigeons to play ping-pong in half an hour! Shaping is especially helpful for children if they cannot imagine what is required, the behavior cannot be modeled for them or they will not understand it. Shaping is especially useful with children with intellectual disability. The Premack Principle Premack (1965) was concerned to identify effective reinforcers where obvious ones did not appear to work. He suggested that observing what an individual liked to do with high frequency when left to their own devices would be a good reinforcer for a targeted low-frequency behavior – thus, actually it is a response that is rewarding. This can be especially helpful for children with severe learning disability (e.g., one might let them suck a favorite toy for 2 min after they have learned a step towards a new behavior). Modeling This technique is useful for learning new complex behaviors or for learning more appropriate responses (e.g., a fearless response to a dog). It assumes the child can observe the model and internalize it, and that externally (or through internal motivation) one can reward it. If the model has characteristics the child respects or desires, this will aid effectiveness. One can use filmed modeling for children (e.g., of other children being brave when confronted by feared situations) or to show parents other ways of responding to their children (WebsterStratton, Hibbs, & Jenson, 2005). Prompting A prompt is a stimulus that may help a behavior pattern be initiated, and is especially useful at the beginning of a program. When giving a command it may help to hold up the reward BEHAVIORAL THERAPIES 1013 9781405145497_4_062.qxd 29/03/2008 02:58 PM Page 1013

(say, a token) to the child to prompt him or her. For prompting to work, it is crucial to have rewarding consequences in place – parents and teachers often use multiple prompts ineffectively (nagging) without setting up the consequences likely to ensure that the desired behavior occurs. Written prompts are prevalent in everyday life (“Drive slowly!” “Now wash your hands”). Intervention Techniques to Decrease Behavior Extinction This refers to the withholding of reinforcements for behavior so that it is eliminated from the child’s repertoire. It requires careful analysis of all possible reinforcers (e.g., attention from parents, siblings and peers) and then ensuring no source of reinforcement is available – in this example, asking all parties not to respond to the behavior in question. As ever, to succeed one has to be very clear and specific about the behavior to target, and rehearse with parents and teachers how to avoid responding. This may be hard; if the behavior in question is rude remarks from the child, the adult has to learn to withhold responding. Initially, the child may “strive” even harder to elicit the reinforcer and so behave more badly than ever, the so-called “extinction burst”; one needs to persevere to overcome this. For extinction to work, the behavior in question has actually to occur and the link with reward be weakened, so the procedure is not suitable for behaviors that are dangerous or seriously disruptive of others. In these cases, other strategies such as punishment may be necessary. The cutting out of reinforcers needs to be almost total, because if intermittent reinforcement is available, the behavior may be maintained indefinitely. Extinction can work well in the classroom, although teachers may find it hard to ignore or only attend briefly to poor behavior. Thus, Walker and Buckley (1974) found that 18% of teachers’ attention to non-problem children was for inappropriate behavior, whereas 89% of that paid to children with behavioral difficulties was for undesirable classroom behavior. Overall, 77% of all teachers’ individual attention was directed at children with problem behavior. This state of affairs is likely to maintain difficult behavior. To extinguish it, teachers can be taught to give very brief, quiet warnings that are rapidly followed by a consequence if the behavior is repeated (Webster-Stratton, 2005). Extinction works especially well when combined with differential reinforcement of other behavior (DRO), so the teacher ignores the child looking out of the window but praises her when she is doing her bookwork. Stimulus Control Here the aim is to remove a stimulus that leads to a difficult behavior, rather than changing the consequences. Turning off the TV may help a child get to bed by removing the competing stimulus of the program; removing a boy from a place in class beside his chatty neighbor may stop him talking in class; halting access visits of a maltreated child to her abusive father may prevent the episodes of self-harm that used to follow. Older children can learn to self-regulate stimuli (e.g., avoiding going to parts of town where they are likely to be tempted by the offer of drugs). Punishment This can be the withdrawal of something reinforcing (i.e., extinction), or the contingent application of something aversive; at times one may shade into the other. Hitting and hurting are types of punishment that have been associated with more traditional cultures and families. Apart from the inhumanity and potential for abuse of such methods of discipline, they tend to suppress or inhibit behavior through fear, pain or humiliation, without necessarily extinguishing it or teaching a mutually incompatible constructive alternative. Punishment alone reduces the chance of the child learning prosocial alternatives. Excessive painful punishment may have undesirable side effects such as inducing general fearfulness of the parent or teacher, the promotion of aggressive responding to frustrating situations through modeling by the adult and the induction of resentment in the child, thus leading to cycles of retaliation, withdrawal and non-cooperation. Punishment can be popular with parents and teachers because of its reinforcing characteristics for them – prompt cessation of the unwanted behavior by the child, even though it may recur relatively soon – and, for some, the feeling of having given the child their just desserts and “taught them a lesson.” Even if it is not effective in the long term, these shortterm reinforcers for the adult may help make it a frequentlyused strategy unless other alternatives are taught. Studies suggest that punishing children is especially harmful when given in a painful, humiliating way that is ill-timed, irregular, inconsistent and retaliatory, with no accompanying choices for the child, or encouragement of more positive behaviors (Kazdin & Benjet, 2003). To be effective, punishment does not need to be intense or physical, but it does need to be applied quickly and consistently when the inappropriate behavior is displayed (Kazdin & Benjet, 2003). Time out is a good example of an appropriate way to administer punishment. Time Out The full term is time out from positive reinforcement. To be effective, before the punishment is given, the child has to be in a context that is positively reinforcing. Typically, the child is sent to a boring place such as the end of the corridor, a toilet or the bottom of the stairs. In time out there is general removal from a wide range of stimuli, as well as the reinforcing ones and removal from the context where undesirable behavior took place, so preventing further harm or damage to the surroundings or other people. In both these characteristics it differs from extinction, which is removal from specific, previously identified reinforcers. If the context around the child is not reinforcing – say, a boring lesson or a harsh parent – then being sent to time out will not be a punishment but may be a relief, and so will not be effective in reducing inappropriate behavior. As for other techniques, time out is less likely to work on its own than if combined with reinforcement of desired behaviors and extinction procedures. CHAPTER 62 1014 9781405145497_4_062.qxd 29/03/2008 02:58 PM Page 1014

The technique provides a useful alternative to smacking or spanking. It also has an advantage in terms of emotional control, because it provides a time for both the young person and the parent to cool down. It is especially useful for teachers as it removes the child from being an aggravating stimulus to other pupils, and to teachers and parents too. Adults need to be taught how to implement time out effectively; the time should not be longer than a maximum of around 5 min, with the proviso that the child has to be quiet for the last minute of the time (so a complaining child may need to be in time out for 40 min on the first occasion if it takes him that long to quieten down). The space used must be cleared of breakable objects as far as possible (e.g., perfume bottles in toilets) as the child may continue an angry tantrum and try escalating behavior before calming down. It is suitable for children aged around 3–10 years; older children may be too strong to be made to go, in which case a back-up strategy should be used, such as response cost strategies (e.g., “Because you have refused to go to time out, you will not be going to the football game tomorrow”). Response Cost This refers to the withdrawal of specified amounts of reinforcement (e.g., points, tokens, money, privileges) immediately following a previously defined unwanted behavior. Thus, for responding in a way that violates rules, the child promptly loses out. Response cost tends to be used with tangible, rather than social rewards, and consequently is especially helpful when social rewards are not likely to work: for example, in the context of a relationship that the child does not particularly care about, say a disliked teacher whose disapproval would not matter; for children for whom social rewards are generally less effective (e.g., abused children); looked after children who have had several sets of carers and become mistrustful; or children with psychopathic traits. There are a number of practice points to bear in mind when setting up a response cost regime: 1 By definition, there has to be some level of positive rewards (e.g., points or money) or else there is nothing to withdraw. 2 The value of points or tokens has to be agreed in advance and be individually tailored to the child. 3 As for any consequence, the cost has to be applied immediately and consistently; giving feedback to child so they learn to make the connection helps. 4 It is important to avoid making the costs too high (the child may give up out of frustration). 5 Wherever possible, after removal of points, it helps to arrange for the child to be able to earn them back soon through a reparative positive behavior. In contrast to time out, immediately after losing points, the child can gain positive reinforcement. He also remains in the presence of the stimulus that triggered the unwanted behavior, which can help learning towards self-control, or provoke the inappropriate behavior again, depending on the circumstances. Response cost is easier to implement than time out, as there is no need to take the child physically to another place; in school, the child continues to be exposed to class learning material. Because there are set rules, response cost is helpful in situations where it is important to avoid lengthy emotional interchanges and nagging, for example with oppositional teenagers in a foster home (Chamberlain & Reid, 1998). Overcorrection Here the child is subjected not only to a response cost, but also to an additional penalty to “overcorrect” for their misbehavior; the idea being to make the child especially aware of the punishment that will follow the unwanted behavior. Thus, a child who throws down litter may be made not only to tidy up his or her own rubbish, but to clear up a whole field. Differential Reinforcement of Other Behavior or Incompatible Behavior DRO refers to reinforcement of any other behavior; incompatible behavior takes the principle further by selecting a behavior that is specifically impossible to perform at the same time as the undesirable behavior. Both strategies are enormously helpful in reducing undesirable behavior. A noisy child can be given tokens for keeping quiet, an obsessive child rewarded for not enacting rituals, and so on. Graded Exposure/Systematic Desensitization This procedure is typically used where there is avoidance (e.g., because of phobias or anxiety states, or events experienced as traumatic). It can be combined with other techniques such as participant modeling (see p. 1013; e.g., the child watches the therapist stroke a frightening dog). The method is to make a hierarchy of the feared stimuli, starting with imagined ones, moving up systematically to reproductions such as pictures, to being at a distance from the real stimulus and finally to being close to the frightening object. The child defines the hierarchy, with help from the therapist. The child is trained in incompatible responses – typically relatively pleasant ones, for example imagining a favorite place, or training the child in relaxation techniques, or simply reassuring the child, or another pleasant activity such as eating or playing. When the child is comfortable, he is exposed to the stimuli, for long enough to overcome an anxious or fearful response so that this is replaced with a relaxed one. Over a number of sessions, the stimulus strength is increased by ascending the hierarchy, and supports are withdrawn. Encouraging active participation by the child enhances the procedure. During exposure, the child can rank their fear response on, say, a 1–100 scale; as the level of fear goes up, they practice the techniques. In this way the procedure effectively includes a coping element, with the child achieving mastery. It is crucial not to stop too soon during the procedure, because adequate exposure for long enough is key to getting anxiety levels eventually to subside. A variation of exposure is response prevention, whereby steps are taken to stop the child responding to the feared stimulus by acting inappropriately, as occurs in obsessive-compulsive disorder. Flooding This is an extreme form of exposure, whereby the child is BEHAVIORAL THERAPIES 1015 9781405145497_4_062.qxd 29/03/2008 02:58 PM Page 1015

brought into contact with the most feared item on the inventory, and kept in contact with it until the fear is extinguished. Because it is initially very frightening, this procedure is seldom used with children; it could be seen as abusive, especially in maltreated children, and adds little to graded exposure. Modeling Here a model is exposed to the feared stimuli while the child watches – thus it is a form of exposure whereby the child can identify and learn from the model that the stimuli are in fact safe and can be coped with. For example, a child can be shown a film of medical procedures, or a teddy bear can be given a blood test. Such procedures have been shown to reduce fear and anxiety (Melamed & Siegal, 1975). Live modeling is generally more effective than symbolic modeling. If anxiety is severe, it can be combined with relaxation, and repeated several times in a graded way. Modeling can be used to develop a whole range of prosocial skills, and is especially effective if combined with other techniques such as role play. It is more effective if the model gets rewarded for the new (e.g., prosocial) behavior. Complex behaviors may need to be broken down into component steps, as in problem-solving (see chapter 63). Role Playing By enacting behaviors rather than just talking about them, the child gets to practice the new responses in a favorable environment with fewer distracting stimuli than in real life. This is particularly helpful when emotional reactions may supervene (e.g., when a child with anger management problems is trying to stay calm while being provoked). For parents who cannot imagine the impact of their harsh practices on a child, it can be helpful to set up a role play with the parent playing the child, and another person behaving the way the parent usually does. Fading and Generalization After setting up a relatively intense reinforcement program, assuming it works, then the issues of generalization and withdrawal arise. Too abrupt a withdrawal of the reinforcement schedule is equivalent to introducing an extinction program for the new desired behavior. Fading procedures gradually change the environmental stimuli so they approximate, as far as possible, the natural conditions that will prevail following treatment. Methods include reducing reinforcement to an intermittent schedule, arranging for the artificial rewards such as tokens to be replaced by social ones such as praise from close adults – in real life these rewards are likely to be given only intermittently. If during fading the desired behavior diminishes or the undesired one recurs, then one should go back to the preceding reinforcement schedule for longer. Another approach is to widen the rewards and the people giving them, thus increasing generalization. Overlearning is a useful approach for more chaotic, conduct problem families where parents find it difficult to maintain consistency. Promoting the child to selfdirect is a powerful way to promote generalization, whereby the child evaluates and directs their own behavior. Application and Effectiveness in Specific Conditions Emotional disorders Anxiety Disorders Anxiety disorders respond well to behavioral approaches, which are a mainstay of treatment, although medication can be effective too, at least in the short term (see chapter 39). The underlying principle is to expose the child to the feared stimulus and teach an alternative conditioned response characterized by calm and relaxation. Graded exposure and systematic desensitization are used as described above. Nowadays, the children’s cognitions will be worked on as well, with an element teaching them to monitor their thoughts and challenge their erroneous beliefs (“Maybe I’m dying,” “Everyone can see I’m going to faint”). These interventions would therefore be classified as cognitive–behavioral, but there is a strong behavioral element and cognitions are addressed using behavioral principles. The treatments work well, but then the question arises as to what is the active ingredient. Three studies have addressed this, using control groups that received various forms of non-specific supportive counseling or psychoeducation (Beidel, Turner, & Morris, 2000; Last, Hansen, & Franco, 1998; Silverman, Kurtines, Ginsburg et al., 1999). Only the last of these showed CBT was more effective than active control. Further studies are needed to determine what mediated a good treatment response – for example, it may be that in the control conditions educating children about fears and supporting them about their anxieties gave sufficient mental exposure to allow them to learn more adaptive behavioral, cognitive and emotional responses. Additionally, trials are needed with long-term follow-up that directly compare medication with behavioral treatments. Earlier trials of behavioral therapy for anxiety took an adult model of treatment, with the therapist seeing the child only. However, there are several reasons for involving parents in treatment. First, from the earliest months, infants look to their mothers to “read” whether situation are dangerous and anxiety provoking, as shown in Gibson’s experiment where infants looked to their mothers to see if it was safe to walk across a glass plate with a drop beneath it (the “visual cliff”; Gibson & Walk, 1960). Therefore, helping parents to show a calm response rather than colluding with anxious responses should help to reduce child anxiety. Second, parents can support the therapeutic endeavor by ensuring that the child gets exposed to feared situations, and by helping with coping responses. The effectiveness of adding family involvement was tested by Barrett, Dadds, and Rapee (1996), who found it gave a significant advantage in reducing child anxiety, which was maintained at 1-year follow-up. Obsessive-Compulsive Disorder In childhood OCD, anxiety is a major feature, and the behavioral treatment is based on similar graded exposure to the feared object or context (say, dirt). During exposure (E) to the phobic stimulus, it is important to prevent the child from CHAPTER 62 1016 9781405145497_4_062.qxd 29/03/2008 02:58 PM Page 1016

carrying out the obsessive response, which acts as a negative reinforcer for the child by reducing anxiety. Response prevention (RP) involves stopping the child carrying out rituals; for example, they must touch “germy things” but refrain from washing until their anxiety is reduced. A third element in addition to E and RP is stopping parental reassurance, to ensure full exposure effects (March, Franklin, & Foa, 2005). The efficacy of E and RP has been demonstrated in multiple open studies and two RCTs (Barrett, Healey-Farrell, & March, 2004; POTS, 2004). Cognitive components may be added if there are substantial obsessive thoughts, but these are absent in up to half of cases (Swedo, Rapoport, Leonard, Lenane, & Cheslow, 1989), and to date there have been no studies comparing the effectiveness of adding cognitive components with none. As for other anxiety therapies, studies are now beginning to examine different parameters of delivery of E and RP. Involving families is now standard practice, but an RCT demonstrated that it is equally efficacious when conducted in a group setting as with individual families, an important consideration for cost-effective service delivery (Barrett, Healy-Farrell, & March, 2004). Futhermore, in adults, computer-based E and RP delivery with minimal therapist contact time is effective (Kenwright, Marks, Graham, Franses, & Mataix-Cols, 2005); a similar study with children is now needed. The necessary “dose” of behavior therapy for children has been studied by Franklin, Kozak, Cashman et al. (1998), who compared once weekly with daily therapy; no significant difference in outcome was found, although the study was not randomized, so conclusions now need confirmation in an RCT. The metaanalysis by the UK National Institute of Clinical Excellence (NICE, 2005) suggested that while more therapist-intensive approaches were more efficacious, even those involving relatively little therapist contact time (less than 10 h) were also effective (NICE, 2005). Behavioral and pharmacological treatments were directly compared in the Pediatric OCD Treatment (POTS) multicenter study that randomized children to sertraline, CBT, both treatments combined, or pill placebo for 12 weeks (POTS, 2004). All active treatments were superior to pill placebo, and CBT alone was as efficacious as sertraline, but combined treatment was more effective than either alone. This finding of the superiority of combined psychological treatment and medication was also found in a small study (Neziroglu, Yaryhura-Tobias, Walz, & McKay, 2000); a direct comparison of behavior therapy with clomipramine found a non-significant advantage for psychotherapy (de Haan, Hoogduin, Buitelaar, & Keijsers, 1998), suggesting the POTS study findings broadly agreed with others. Post-Traumatic Stress Disorder As for other anxiety-related conditions, the core of behavioral treatment for PTSD is exposure, in this case to vivid recollection of the traumatic event. In a non-randomized design, Goenjian, Karayan, Pynoos et al. (1997) reported that a sevensession school-based CBT intervention for young people with PTSD over a year after an earthquake resulted in symptom reduction, whereas an untreated control group showed no such improvement. March, Biederman, Wolkow et al. (1998) used a single-case design and several measures to evaluate an 18- session group CBT intervention for 17 young people who had developed PTSD following a variety of trauma (road traffic accidents, accidental injury, gunshot injury and fires). After treatment, there were significant reductions in PTSD symptoms and associated psychopathology (anxiety, depression and anger). Three RCTs of psychological interventions with children who developed PTSD symptoms as a result of single-event traumas have been reported. Chemtob, Nakashima, and Hamada (2002) randomly assigned 248 children at high risk of PTSD after a hurricane hit Hawaii to four sessions of CBT delivered individually, or in groups; or to a control group. Both individual and group treatment had equally good results compared to controls by an effect size of 0.76; more children dropped out of individual than group treatment. Stein, Jaycox, Kataoka et al. (2003) randomized 126 children who had been exposed to violence to 10 sessions of group CBT or a waitlist control. Three months post-treatment, the treated group had significantly lower scores on PTSD, depression and psychosocial dysfunction measures, although teacher-rated behavioral difficulties did not reflect improvement. Using Ehlers and Clark’s (2000) more cognitive model of PTSD, Smith, Yule, Perrin et al. (2007) randomized 24 clinically referred children with a diagnosis of PTSD (rather than a population-based sample screened for symptoms) following assault or a road traffic accident to trauma-focused CBT or waitlist control. After treatment, 92% of the CBT group no longer met criteria for PTSD, compared to 42% on the waitlist; treated children also showed significant reductions in symptoms of depression and anxiety. The effect size was 2.2 on the self-report measure and 1.6 on the clinician-rated instrument. The differences remained at 6-month follow-up. This study was innovative because it measured a potential mediator, maladaptive cognitions, which did indeed turn out to mediate treatment effectiveness. Finally, the question arises whether a cognitive element adds anything to imaginal exposure. Tarrier and Sommerfield (2004) found no difference at 1-year follow-up in a trial comparing the two approaches in adults, but at 5-year follow-up 29% of the imaginal exposure group still had PTSD whereas none of the cognitive group did. Similar trials for children are now called for. PTSD and Child Sexual Abuse In recent years, some of the reactions some children develop after sexual abuse have been recognized as fulfilling some or all criteria for PTSD. This has resulted in a number of therapeutic trials of CBT to treat these reactions, including full PTSD. There are many other sequelae of abuse, and only PTSDtype outcomes in trials of CBT are reviewed here. Generally speaking, studies favor CBT. Thus, Deblinger, Stauffer, and Steer (2001) randomized 67 children aged 2–8 years to group BEHAVIORAL THERAPIES 1017 9781405145497_4_062.qxd 29/03/2008 02:58 PM Page 1017

CBT or a support group; the CBT group had better outcomes. Cohen, Deblinger, Mannarino, and Steer’s (2004) multi-site RCT also favored CBT, but Celano, Hazzard, Webb, and McCall (1996) compared 15 girls in an abuse-specific program with 17 given a parallel set of eight non-directive supportive sessions and found no differences in outcomes. To investigate different approaches to delivery, King, Tonge, Mullen et al. (2000) allocated 36 sexually abused children aged 5–17 years who met criteria for PTSD to CBT with child and family, CBT with child alone, or waitlist control. Both ways of delivering CBT (which lasted 20 sessions) were equally effective in reducing PTSD and anxiety more than in controls. Disruptive Disorders Conduct Disorders Behavioral methods and the social learning approach revolutionized the treatment of conduct problems. In the late 1960s and through the 1970s, clinical researchers such as Patterson at the Oregon Social Learning Center, Wahler in Tennessee, Forehand in Georgia and Eyberg in Washington State tested and refined methods for parents to apply to disruptive children. By reducing attention for inappropriate behavior, giving it for desired responses and combining this with calm consistent discipline, antisocial behavior was considerably reduced. Over 100 trials attest to their effectiveness (Kazdin, 2005), and meta-analyses show mean effect sizes of around 0.4–1.0 standard deviations (SD; Barlow, 1999). More recent developments include similar programs for teachers to apply at school, because generalization of parenting programs to that setting is unreliable (Scott, 2002). Anger management programs working directly with children and adolescents are also based on behavioral theory, to which a self-control cognitive element has been added (see chapters 35 and 63). They are a useful adjunct to parent and teacher programs, helping temper control not only at home and in school, but also out in the community with peers (see chapters 35 and 63). The question arises whether parent, teacher and child interventions should ideally all be given. Kazdin, Siegel, and Bass (1992) compared parent training alone with child social skills training alone, and both combined. All groups improved substantially, with improvements seen not only by parents at home, but also by teachers at school and self-reported offending by the young people. However, the combined treatment had greater effectiveness on nearly all measures, notably 0.5–1.1 SD greater effect than parent training alone on antisocial behavior. Webster-Stratton and Hammond (1997) used a group format with videotapes to compare parent training only with child training only, both parent training plus child training, and a waitlist control group. A total of 97 children aged 4–8 years specifically referred to a parenting clinic were studied with a thorough set of measures including direct observation at home and observation of interaction with a friend. The intervention was relatively long (22 weekly sessions of 2 h) and attendance was excellent, with all cases attending at least half of the sessions and most attending nearly all. There were no dropouts. There were several important findings. On parent questionnaire, children in all three intervention conditions did considerably better than waitlist controls, who did not improve significantly. The fact that child training alone led to improvements in child behavior is important practically because there will always be some parents who are unable or unwilling to attend for intervention. All interventions had an effect in reducing observed directive parenting behavior. From a theoretical standpoint, it is interesting that child training led to less coercive parenting behavior, confirming the hypothesis that for children with clinically significant antisocial behavior (as for non-clinical children) child as well as parent factors are involved in driving parenting style; it shows that the coercive cycle of negative parenting and child defiance can be interrupted from either end. Parent training led to greater changes in parent-reported child behavior problems than child training, whereas child training led to better improvements in the ratio of positive to negative strategies used by children when interacting with a friend on direct observation, and on laboratory tests of social problemsolving. The combined parent–child intervention led to similar effect sizes as one would predict from either intervention alone in the domain in which they were most effective, but did not act synergistically. Thus, parent-rated child behavior was no more improved in the combined condition than for child training alone, and observed child–peer behavior was no more improved in the combined condition than with parent training alone. The exception was observed antisocial behavior in the home at 1-year follow-up, where the combined condition had a greater effect than either alone. Unfortunately, although in all intervention conditions there was a good effect compared to controls for observed reduction in child behavior at home (ES 0.7–0.8), total deviant behavior reduced to half original levels whereas controls did not change, the variance was large (standard deviations greater than means in all cases), so none was statistically significant. All gains were maintained at 1-year follow-up, suggesting that the reduction in antisocial behavior is lasting. Unfortunately, further follow-up to test longer-term persistence of benefits will not be possible from this study as the control group were treated after the waiting period for ethical reasons. No intervention made any difference to teacher-rated child behavior in either the short or longer term. This was partly because some of the children had no significant problems at school, but nonetheless it suggests that child behavior may be fairly context specific, and supports adding a teacher element. Attention Deficit/Hyperactivity Disorder Behavior therapy for ADHD has tended to be similar to that for conduct disorders, with parents and teachers giving rewards for prosocial behavior and punishments for rule infringements and antisocial behavior. This is not unreasonable, given that it is often the comorbid conduct problems that are more troublesome than inattention and hyperactivity per se. Laboratory studies indicate that children with ADHD respond better to immediate rewards – delays beyond a few seconds lead to diminished responses; but, like other children, they will work CHAPTER 62 1018 9781405145497_4_062.qxd 29/03/2008 02:58 PM Page 1018

to maximize the total reward on offer (Scheres, Dijkstra, Ainslie et al., 2006). Modifications to standard behavioral programs should include giving rewards more rapidly and frequently, changing them more often to avoid boredom, and giving directions more clearly. Generally speaking, core symptoms of ADHD change less in behavioral programs than do conduct symptoms. Generalization outside the immediate situation where the reward system is being operated may be limited (e.g., in the playground when there is a teacher-administered reward system only in class); nonetheless, even after regimes are faded, there are some enduring effects (Arnold, Chuang, Davies et al., 2004). The presence of ADHD does not prevent specific methods being effective. For example, Fabiano, Pelham, Manos et al. (2004) compared the effectiveness of short (5 min) and long (15 min) time out sessions versus none in a crossover design with 71 6- to 12-year-olds with ADHD. Both time out regimes were more effective than none in reducing aggression, destructiveness and repeated non-compliance, with an effect size of 0.32 SD; longer time out was no more effective, confirming other findings that 5 min is sufficient. In the MTA Cooperative Group trial (1999), behavioral therapy was compared to medication and both in combination; there was also a treatment-as-usual arm (which was mainly lower doses of medication). In the behavioral-treatment-only arm, ADHD symptoms improved only modestly but conduct symptoms more so; the mechanism here appears to be child insensitivity to the changed contingencies, because direct observation of the parents showed that they did indeed change their responses to the children (Wells, Chi, Hinshaw et al., 2006). Behavioral treatment worked equally well irrespective of potential moderators, whereas in the medication arm, parental depression and more severe child ADHD symptoms moderated a poorer response (Owens, Hinshaw, Kraemer et al., 2003). The question arises whether medication potentiates the effects of behavior therapy – it might be expected that because there is a central nervous system deficit in ADHD, correcting this through medication would then enable the behavior therapy to work much better. However, this was not found to be a large tendency in the MTA trial, where once medication had been given, adding behavior therapy did not improve outcomes much further – the main improvements in core ADHD symptoms came from the drug. However, adding behavior therapy increased the proportion of children brought into the normal range, and improved aggression at home (MTA Cooperaive Group, 1999). Also, in the arm with both behavior therapy and medication, substantially lower doses of medication were used while getting similar overall results – thus, behavior therapy allowed less medication to be used. A final point to remember is that reasonably well-conducted intervention studies from 20–30 years ago that used relaxation training procedures alone or in combination with other treatments generated larger effect sizes than did CBT interventions (Benson, Beary, & Carol, 1974; Budzynski & Stovay, 1969; Kratter, 1983). More studies are needed that directly compare different treatments while measuring potential mediators. Developmental Disorders Nocturnal Enuresis This is a good example of the great success behavioral methods can bring. Mowrer (1980) recounts how, despite being a professor at Yale, during the great depression in the 1930s to supplement his salary he and his wife took a job in a residential home for misfit boys, most of whom wet the bed every night. Based on classic conditioning, they devised an aversive conditioned response triggered by the stimulus of wetness in pads worn in underpants. Initially, the aversive response was provided by a spring-loaded metal bed that catapulted the child across the room, but soon a loud bell was used instead (Mowrer & Mowrer, 1938). This has repeatedly been shown to be effective in simple nocturnal enuresis (von Gontard, 2005). The Cochrane review of alarm interventions for nocturnal enuresis (Glazener, Evans, & Peto, 2005) found 55 trials involving 3152 children. Immediately after treatment, two-thirds were dry at night, with half remaining so in the long term (compared to no untreated controls ever becoming dry). Adding overlearning (e.g., by increasing fluid intake at night – for details see Houts’ 2003 account) reduced the long-term relapse rate further to around 20%, but adding penalties for wet beds was positively counterproductive. Alarms were better than tricyclics during treatment, and while desmopressin achieved dryness in most cases while it was taken, a meta-analysis of studies has shown that almost all cases relapsed after it was stopped (Glazener & Evans, 2007). The mechanism of action of alarms has been debated. Mowrer was clear that classic conditioning was involved as outlined above. Subsequent physiological studies (Norgaard, 1989) suggest that bladder detrusor muscle contractions that lead to urination are inhibited by pelvic floor muscle contractions. The alarm promotes these, and then the child does not wake up. However, nocturnal enuretics have learned to habituate to the aversive stimulus of a wet bed, and have relaxed pelvic floors during nocturnal micturition. The classic aversion account was challenged by Azrin, Sneed, and Foxx (1973), who claimed that the mechanism of effective treatment was that the child was operantly rewarded by dryness. He developed so-called “dry-bed” procedures with the parents waking up the child at regular intervals in the night and taking them to the toilet so they remained dry; no alarm was used. This procedure is demanding on parents, but results showed it was indeed as effective as simple alarm training (61% vs. 59% success at 2 years in the trial by Bollard, 1982). It seems therefore that both accounts of the mechanism of action of each treatment may hold true; at times it is a fine line between “classic” learning of conditioned responses to clearly identifiable stimuli, and “operant” learning whereby the individual responds because certain apparently spontaneous actions are rewarding. Pervasive Developmental Disorders Behavioral methods can help some specific problems in autistic spectrum disorders (ASD), but should only be part of an overall package. This should aim to stimulate, as far as possible, normal development of language and socialization, and to BEHAVIORAL THERAPIES 1019 9781405145497_4_062.qxd 29/03/2008 02:58 PM Page 1019

reduce the particular maladaptive behaviors such as rigidity, stereotypies and inflexibility as well as general ones such as hyperactivity and tantrums. Behavior therapy needs to be adapted to this client group in a number of ways. First, changes need to be introduced gradually, within a framework that is predictable and structured in terms of daily routines – otherwise anxiety, social isolation and rigidities may emerge rapidly. Second, instructions need to be concrete, specific and calmly delivered, because metaphorical expressions and using tone of voice to convey meanings may lead to misunderstandings. Third, the intensity of social stimulation will need to be titrated to the level that can be handled, which may be quite low in some cases. Fourth, training and interventions should be performed as much as possible in daily-life situations, to overcome the problems in the transfer of skills mastered in one setting to another. There is a modest amount of research suggesting intensive early interventions for children with ASD are more likely to be successful than low-intensity treatment later on. A wellknown approach is that taken by Lovaas and Smith (2003) in the Young Autism Project at the University of California in Los Angeles. This is a comprehensive teaching and rearing program, rather than just treatment for particular problems. There is an introductory phase of establishing a teaching relationship where basic directions such as “sit” or “come here” are established and interfering behaviors such as tantrums reduced. This is followed by several months of developing communication and social skills, culminating in peer relationship training; depending on the rate of progress, the program may take 1–3 years or longer, terminating when the child goes to elementary school. Lovaas (1987) and McEachin, Smith, and Lovaas (1993) published a comparison of 59 children nonrandomly allocated to intensive treatment, minimal treatment or special education. By age 7 the mean IQ of the intensivetreatment group was 83 while those of the two comparison groups were 52 and 59; by age 12 the percent with an IQ over 85 who were in a normal school was 42% in the intensivetreatment group and 0% in the minimal-treatment group. An independent replication (Smith, Groen, & Wynn, 2000) that was less intensive (25 h per week rather than 40) but fully randomized found at follow-up that the intensive-intervention group had an IQ 16 points higher than controls. Other replications have yielded comparable results (Smith, 1999); thus, Eikeseth, Smith, Jahr, and Eldevik (2002) tried the method with older children (4 years and above) but still obtained good results, including an IQ gain of 13 points. Since then, reviews of more recent evaluations indicate that although this approach is certainly effective, the overall results are neither as marked nor as universal as initially claimed (Shea, 2004). Is such intensive intervention by fully qualified professionals necessary, or can parents be taught to deliver it as effectively? Bibby, Eikeseth, Martin, Mudford, and Reeves (2001) studied 66 children treated through their parents using consultants, but the results were disappointing – although there were gains of 9 points on an adaptive behavior scale, there were no intelligence or language gains. Kabot, Masi, and Segal (2003) have suggested that for maximal gains, both intensive professional daycare and high-quality parent training are needed. Such a model is incorporated in the school-based Treatment and Education of Autistic and Communication Handicapped Children program (TEACCH; Mesibov, Shea, & Schopeler, 2005). This uses parents as co-therapists to ensure that the same principles are enacted at home; to date there has not been an RCT evaluation, although a small-scale study (Panerai, Ferrante, & Zingale, 2002) reported significant gains in educational and adaptive behaviors compared to progress in an integrated classroom. More specific interventions are available (e.g., social skills training programs, delivered on an individual or on a group basis), and are increasingly being offered to children and adolescents with ASD (Bauminger, 2002). However, the merits on a long-term basis are often disappointing because of a lack of generalization of skills. Intellectual Disability (Mental Retardation) Behavioral methods are a major part of treatment regimes in children with intellectual disability. While children with IQs above 60 or so may be able to participate to some extent in using cognitive techniques (Turk, 2005), this is seldom the case for those with lower IQs, for whom behavioral approaches are key. Challenging behaviors such as tantrums and self-injury are especially common in this group, and a thorough functional analysis should be carried out. Depending on what this shows, a range of techniques may be applied (Ball, Bush, & Emerson, 2004). Stimulus control and manipulation of antecedent variables are often especially helpful. These can include changing routines so the child is in a better biological state (e.g., less hungry, tired, or constipated); changing activities that precede the challenging behavior (e.g., by providing more varied activities and curricula to avert boredom and frustration); and changing triggers that in the functional analysis appear to lead immediately to the behavior (e.g., transition points in the daily routine, too close facial contact). Teaching alternative responses can also be very effective. Functional communication training is a form of functional displacement, whereby a child is taught a more appropriate alternative. For example, if a child’s aggression in class serves the function of enabling them to escape disliked activities, they can be taught to request an alternative activity instead. This will work so long as the child finds it is effective in getting the result, and is easy for the child to implement (Carr, Levin, McConnachie et al., 1994). More generally, DRO, which is often a very effective technique in typically developing children, is often less effective in children with intellectual disability, who may find it hard to learn relatively complex alternatives (Didden, Duker, & Korzilius, 1997). Punishments such as time out can be effective, but should not be used frequently in this group as they could become abusive. CHAPTER 62 1020 9781405145497_4_062.qxd 29/03/2008 02:58 PM Page 1020

General Issues Indications and Limitations As the above review has shown, behavioral therapies have offered mainstream interventions for many conditions. However, they may not be especially helpful where the primary problem is an inner mood or belief state without pressing behavioral manifestations. Thus, there is no purely behavioral method for the treatment of the core symptoms of depression, although the approach can be used to tackle some of the manifestations (e.g., lack of physical activity), and some of the postulated maintaining factors (e.g., low self-esteem because of a lack of friends arising from poor social skills). In contrast, behavioral approaches offer unique strengths for conditions where the child’s problems cannot easily be changed effectively by a cognitive approach, for example in babies and young infants (e.g., feeding and sleeping problems), in children with severe learning disabilities (e.g., challenging behavior) and more generally where the behavior is not very amenable to conscious control (e.g., hyperactivity and aggression). More widely, behavioral techniques are helpful for any condition where changes in the external environment can make a difference, and behavioral analysis can reveal where this is the case. Even where little can be done to change externally the main features of the environment such as a hostile family or a dangerous neighborhood, often children can be instructed in techniques that will enable them to mitigate its worst aspects or select better contexts (e.g., by learning what leads parents to become hostile, or learning to avoid bullies). The absence of any theory about what is happening in the child’s inner world and the failure to address it directly inevitably bring with them some limitations. While learning is expected to occur in an unconscious way, in certain conditions this does not always hold. Thus, there is the issue of generalization, which requires the individual to be able to extract the rules regarding both the context when they behave a certain way and the rewards. Many children learn new habits from the rewards, and these will persist after the rewards are withdrawn. If no lasting connection is made, then extinction will occur as the rewards are withdrawn. This can occur if material rewards such as sweets are given and then withdrawn, and particularly for children who may be poor at generalizing and so need ongoing rewards, such as those with autism. Rewards that can always be easily given such as social rewards (smiles, praise) may lead to better control in these cases. Likewise, newly learned behaviors may not persist in antisocial children once the context is changed – thus, delinquents may behave very well while in controlled settings such as “boot camps” but the rate of relapse is over 80% after they are released back into the community (Stinchcomb, 2005). The issue here is to change the contingencies in the child’s natural environment (e.g., praise at home and close supervision in the community). A further criticism of behavioral approaches arises from the apparent failure to take the individual’s past or personal vulnerabilities and liabilities to a condition into account. While it is true that certain individuals may be more at risk than others, there is abundant evidence that for many problems and disorders, the dynamic interplay between the context and the individual is crucial in determining the expression of the difficulty in any particular case (e.g., life events in depression, or coercive parenting in antisocial behavior). A good therapist will take a very detailed history of the predicament of the child and check carefully what the triggers are for them – so that the resulting program will be entirely individualized and will not fit another child. Arguably, this is a much more personalized approach than, say, prescribing medication. Has Adding Cognitive Elements to Behavior Therapy Improved Outcomes? More trials are needed to explore this issue, in addition to the few reviewed above. Certainly, clinically there are often scenarios where the beliefs seem to prevent behavior change; for example, the parent who thinks it is militaristic to set limits, or who cannot bear to ignore a child crying at night. Adding cognitive components would be worth evaluating in these contexts. In the adult literature, CBT techniques have produced impressive outcomes in many areas but it is not clear how much of this is brought about by what was added to traditional behavior therapy. Component analysis studies have often failed to find support for the importance of direct cognitive change strategies, which was the common sense lynchpin of CBT (Jacobson, Dobson, Truax et al., 1996). The response to traditional cognitive therapy often occurs before cognitive change techniques have been implemented (Ilardi & Craighead, 1994), and support for the hypothesized mediators of change in CBT is often weak (Burns & Spangler, 2001; Morgenstern & Longabaugh, 2000). Well-known cognitive therapists have been forced to conclude that in some important areas there is “no additive benefit to providing cognitive interventions in cognitive therapy” (Dobson & Khatri, 2000, p. 913). This overall picture presents an anomaly. On the one hand, most empirical clinicians agree that traditional behavior therapy was simply not adequate and that better methods of dealing with thoughts and feelings were needed. CBT is widely understood to have been a step forward in freeing up the behavior therapy tradition to work directly with cognition, and the outcomes for CBT protocols are generally quite good compared to work outside of behavior therapy writ large. On the other hand, the core concept of traditional cognitive and CBT – that direct cognitive change is necessary for clinical improvement – is still only partially supported. Therapist variables Does it matter how well behavioral therapies are delivered? Therapist variables can be divided into: 1 The alliance which, put simply, refers to how well therapist and client get on together, including sharing of goals of treatment; 2 Fidelity or adherence, which refers to whether the therapist carried out specific procedures; and BEHAVIORAL THERAPIES 1021 9781405145497_4_062.qxd 29/03/2008 02:58 PM Page 1021

3 The skill or competence with which the therapy was carried out. The Alliance A meta-analysis of studies of the alliance over a range of treatment modalities with children found an effect size of 0.21 for the effect of the alliance, and found it was important across treatment types (including giving medication), and across child, parent or family treatment approaches (Shirk & Karver, 2003). Kazdin, Whitley, and Marciano (2006) found about 7% of the variance in outcome of treatment for antisocial children was related to the alliance, although findings varied by informant. Fidelity or Adherence Fidelity or adherence concerns the extent to which the therapist follows the actions prescribed in the manual. Studies of child therapies have found equivocal effects. In a study of multisystemic therapy for delinquency, Henggeler, Melton, Brondino, Scherer, and Hanley (1997) compared a total of 15 parent, therapist and youth-rated fidelity scales with 7 youth outcomes, and found significant effects for only 7 out of 42 parent-rated associations, 4 out of 35 therapist-rated and 1 out of 28 adolescent-rated; moreover, some effects went the “wrong” way, with better fidelity leading to worse outcomes. The same group (Huey, Henggeler, Brondino, & Pickrel, 2000) found that when they used a latent variable approach, therapistrated fidelity improved family functioning and parent monitoring, both of which in turn reduced youth delinquency, but that parent- and youth-rated fidelity had no effect. These somewhat modest findings for the role of adherence or fidelity raise the question of whether applying the treatment according to the manual is necessary or sufficient to bring about change. Skill or Competence It is possible that a more important and relevant influence on effectiveness is the skill or competence with which tasks are carried out; put simply, skill concerns how well the therapist performs the actions. Thus, two behavior therapists might each carry out a functional assessment, set up a behavioral program, choose targets and rewards, and issue homework. However, the more skilled one might do this in a more sensitive way with greater complexity, and so characterize the child’s problems more accurately and be more proficient in overcoming barriers to doing homework, thus leading to more change. Researchers from the Treatment of Depression Collaborative Research Program (TDCRP) reported that therapist variables had substantial effects on a clinician-rated outcome of depression (Shaw, Elkin, Yamaguchi et al., 1999). The quality of the alliance accounted for 5% of outcome variability, but therapist adherence had no effect. Competence added a further 15%, although when this was decomposed into how well the sessions were structured and how skillfully the sessions were run, skill had no effect if structure was entered first in a multiple regression. Amongst childhood studies, Forgatch, Patterson, and DeGarmo (2005) developed an observer-based instrument to assess therapist variables that included skill in a parenting program for recently divorced parents. They measured knowledge, structure, teaching skill, clinical skill and overall effectiveness. The outcome they assessed was the proximal one of observed parenting practices, rather than child behavior; greater therapist skill led to more change in parenting. Finally, Scott, Carby, and Rendu (unpublished data) examined the effect of therapist skill in a multi-site trial of parent training for children with severe conduct problems. Skill correlated 0.7 with improvement in child antisocial behavior. The practitioners in the top third level of skill achieved twice the change of the bottom third, and the lowest level of skill actually made the children slightly worse. If further research supports these findings, then it will provide evidence for the need for more high-quality training. Service Issues In some countries and in some professions, behavioral approaches are poorly understood and poorly taught. They may be seen as mechanical and not addressing feelings and relationships, which some practitioners feel is core to their work. Further, there are still many practitioners in education, social work and mental health professions who pay scant attention to the evidence of what treatments work. In fact, the effectiveness of behavioral therapies means they often have a powerful effect on children’s happiness, and the children have more fulfilling relationships with their families, friends and teachers. Behavioral methods can be combined well with other therapeutic modalities (e.g., with family therapy in disruptive disorders, with medication as reviewed above, or with life story and other work in war-affected refugees who have PTSD). Delivery may need to be commissioned at different levels of skill, with self-administered behavioral therapy being tried first for less severe cases with families judged to be able to handle this, ranging up to deployment of highly skilled therapists for complex cases. Conclusions In the last 40 years or so, behavioral therapies have revolutionized the treatment of emotional and behavioral disorders in children, and have offered effective interventions to improve social and intellectual functioning. Purely behavioral treatments have continued to be refined and expanded, in content, mode of application and large-scale evaluations. Behavioral approaches based on the same method of empirical scientific enquiry and experimental testing have strongly influenced the development of cognitive elements in CBT, in a manner that is entirely consistent with the thinking of the founders of behaviorism. Future research needs to clarify mechanisms of action and modes of delivery, and to compare behavioral therapies with plausible alternatives. Wider training is required in what behavioral techniques have to offer, and how to deliver them. References Alexander, J., Pugh, C., Parsons, B., & Sexton, T. (2000). Blueprints for violence prevention: Functional family therapy. University of Colorado: Institute of Behavioral Science. CHAPTER 62 1022 9781405145497_4_062.qxd 29/03/2008 02:58 PM Page 1022

Arnold, L. E., Chuang, S., Davies, M., Abikoff, H. B., Conners, C. K., Elliott, G. R., et al. (2004). Nine months of multicomponent behavioral treatment for ADHD and effectiveness of MTA fading procedures. Journal of Abnormal Child Psychology, 32, 39–51. Azrin, N. H., Sneed, T. J., & Foxx, R. M. (1973). Dry bed: A rapid method of eliminating bedwetting (enuresis) of the retarded. Behavioral Research and Therapy, 11, 427–434. Ball, T., Bush, A., & Emerson, F. (2004). Psychological interventions for severely challenging behaviours shown by people with learning disabilities. Leicester: British Psychological Society. Barlow, J. (1999). Systematic review of the effectiveness of parenttraining programmes in improving behaviour problems in children aged 3–10 years (2nd edn.). A review of the literature on parenttraining programmes and child behaviour outcome measures. University of Oxford: Health Services Research Unit. Barrett, P., Healy-Farrell, L., & March, J. S. (2004). Cognitive– behavioral family treatment of childhood obsessive-compulsive disorder: A controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 46–62. Barrett, P. M., Dadds, M. R., & Rapee, R. M. (1996). Family treatment of childhood anxiety: A controlled trial. Journal of Consulting and Clinical Psychology, 64, 333–342. Bauminger, N. (2002). The facilitation of social-emotional understanding and social interaction in high-functioning children with autism: Intervention outcomes. Journal of Autism and Developmental Disorders, 32, 283–298. Beidel, D. C., Turner, S. M., & Morris, T. L. (2000). Behavioral treatment of childhood social phobia. Journal of Consulting and Clinical Psychology, 68, 1072–1080. Benson, H., Beary, J. F., & Carol, M. P. (1974). The relaxation response. Psychiatry: Journal for the Study of Interpersonal Processes, 37, 37–46. Bibby, P., Eikeseth, S., Martin, N. T., Mudford, O. C., & Reeves, D. (2001). Progress and out comes for children with autism receiving parent-managed intensive interventions. Research in Developmental Disabilities, 22, 425–447. Bollard, J. (1982). A two year follow up of bedwetters treated with dry bed training and standard conditioning. Behavioral Research and Therapy, 20, 571–580. Budzynski, T. H., & Stoyva, J. M. (1969). An instrument for producing deep muscle relaxation by means of analog information feedback. Journal of Applied Behavior Analysis, 2, 231–237. Burns, D. D., & Spangler, D. L. (2001). Do changes in dysfunctional attitudes mediate changes in depression and anxiety in cognitive behavioral therapy? Behavior Therapy, 32, 337–369. Carr, E. G., Levin, L., McConnachie, G., Carlson, J. I., Kemp, D. C., & Smith, C. E. (1994). Communication-based interventions for problem behavior: A user’s guide for producing positive change. Baltimore: Brookes. Celano, M., Hazzard, A., Webb, C., & McCall, C. (1996). Treatment of traumagenic beliefs among sexually abused girls and their mothers: An evaluation study. Journal of Abnormal Child Psychology, 24, 1–17. Chamberlain, P., & Reid, J. B. (1998). Comparison of two community alternatives to incarceration for chronic juvenile offenders. Journal of Consulting and Clinical Psychology, 66, 624–633. Chemtob, C. M., Nakashima, J. P., & Hamada, R. S. (2002). Psychosocial intervention for postdisaster trauma symptoms in elementary school children: A controlled community field study. Archives of Pediatrics and Adolescent Medicine, 156, 211–216. Chomsky, N. (1959). Review of Skinner, 1957. Language, 35, 26–58. Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 393–402. Conduct Problems Prevention Research Group. (1999). Initial impact of the Fast Track prevention trial for conduct problems. 1. The high-risk sample. Journal of Consulting and Clinical Psychology, 67, 631–647. de Haan, E., Hoogduin, K. A., Buitelaar, J. K., & Keijsers, G. P. (1998). Behavior therapy versus clomipramine for the treatment of obsessivecompulsive disorder in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 1022– 1029. Deblinger, E., Stauffer, L. B., & Steer, R. A. (2001). Comparative efficacies of supportive and cognitive–behavioral group therapies for young children who have been sexually abused and their nonoffending mothers. Child Maltreatment: Journal of the American Professional Society on the Abuse of Children, 6, 332–343. Didden, R., Duker, P. C., & Korzilius, H. (1997). Meta-analytic study on treatment effectiveness for problem behaviors with individuals who have mental retardation. American Journal of Mental Retardation, 101, 387–399. Dobson, K. S., & Khatri, N. (2000). Cognitive therapy: Looking backward, looking forward. Journal of Clinical Psychology, 56, 907–923. Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319–345. Eikeseth, S., Smith, T., Jahr, E., & Eldevik, S. (2002). Intensive behavioral treatment at school for 4- to 7-year-old children with autism: A 1-year comparison controlled study. Behavior Modification, 26, 49–68. Fabiano, G. A., Pelham, W. E., Manos, M. J., Gnagy, E. M., Chronis, A. M., Onyango, A. N., et al. (2004). An evaluation of three timeout procedures for children with attention deficit/hyperactivity disorder. Behavior Therapy, 35, 449–469. Forgatch, M. S., Patterson, G. R., & DeGarmo, D. S. (2005). Evaluating fidelity: Predictive validity for a measure of competent adherence to the Oregon model of parent management training. Behavior Therapy, 36, 3–13. Frankel, F., & Myatt, R. (2003). Children’s friendship training. Brunner-Routledge. New York. Franklin, M. E., Kozak, M. J., Cashman, L. A., Coles, M. E., Rheingold, A. A., & Foa, E. B. (1998). Cognitive–behavioral treatment of pediatric obsessive-compulsive disorder: An open clinical trial. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 412–419. Gibson, E. J., & Walk, R. D. (1960). The visual cliff. Scientific American, 202, 64–71. Glazener, C. M. A., Evans, J. H. C., & Peto, R. E. (2005). Alarm interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews, CD01567, 1. Glazener, C. M. A., & Evans, J. H. C. (2007). Desmopressin for nocturnal enuresis in children. Cochrane Database of Systematic Reviews, CD002911, 2. Goenjian, A. K., Karayan, I., Pynoos, R. S., Minassian, D., Najarian, L. M., Steinberg, A. M., et al. (1997). Outcome of psychotherapy among early adolescents after trauma. American Journal of Psychiatry, 154, 536–542. Hayes, S. C., Luomaa, J. B., Bond, F. W., Masudaa, A., & Lillisa, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44, 1–25. Henggeler, S. W., Melton, G. B., Brondino, M. J., Scherer, D. G., & Hanley, J. H. (1997). Multisystemic therapy with violent and chronic juvenile offenders and their families: The role of treatment fidelity in successful dissemination. Journal of Consulting and Clinical Psychology, 65, 821–833. Henggeler, S. W., Schoenwald, S. K., Liao, J. G., Letourneau, E. J., & Edwards, D. L. (2002). Transporting efficacious treatments to field settings: The link between supervisory practices and therapist fidelity in MST programs. Journal of Clinical Child and Adolescent Psychology, 31, 155–167. Herbert, M. (1987). Behavioural treatment of children with problems: A practical manual (2nd edn.). London: Academic Press. BEHAVIORAL THERAPIES 1023 9781405145497_4_062.qxd 29/03/2008 02:58 PM Page 1023

Hersen, M. (2005). Encyclopedia of behavior modification and cognitive behavior therapy. Vol. 2. Clinical child applications. Thousand Oaks, CA: Sage. Houts, A. C. (2003). Behavioral treatments for enuresis. In A. Kazdin, & J. Weisz (Eds.), Evidence-based psychotherapies for children and adolescents (pp. 389–406). New York: Guilford Press. Huey, S. J., Henggeler, S. W., Brondino, M. J., & Pickrel, S. G. (2000). Mechanisms of change in multisystemic therapy: Reducing delinquent behavior through therapist adherence and improved family and peer functioning. Journal of Consulting and Clinical Psychology, 68, 451–467. Ilardi, S. S., & Craighead, W. E. (1994). The role of nonspecific factors in cognitive-behavior therapy for depression. Clinical Psychology: Science and Practice, 1, 138–156. Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., et al. (1996). A component analysis of cognitive behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64, 295–304. Kabot, S., Masi, W., & Segal, M. (2003). Advances in the diagnosis and treatment of autism spectrum disorders. Professional Psychology: Research and Practice, 34, 26–33. Kazdin, A. E. (2005). Parent management training. Oxford: Oxford University Press. Kazdin, A. E., & Benjet, C. (2003). Spanking children: Evidence and issues. Current Directions in Psychological Science, 12, 99–103. Kazdin, A. E., Siegel, T. C., & Bass, D. (1992). Cognitive problemsolving skills training and parent management training in the treatment of antisocial behavior in children. Journal of Consulting and Clinical Psychology, 60, 733–747. Kazdin, A. E., Whitley, M., & Marciano, P. L. (2006). Child– therapist and parent–therapist alliance and therapeutic change in the treatment of children referred for oppositional, aggressive, and antisocial behavior. Journal of Child Psychology and Psychiatry, 47, 436–445. Kellam, S. G., Rebok, G. W., Ialongo, N., & Mayer, L. S. (1994). The course and malleability of aggressive behavior from early first grade into middle school: Results of a developmental epidemiologybased preventive trial. Journal of Child Psychology and Psychiatry, 35, 259–281. Kenwright, M., Marks, I., Graham, C., Franses, A., & Mataix-Cols, D. (2005). Brief scheduled phone support from a clinician to enhance computer-aided self-help for obsessive-compulsive disorder: Randomized controlled trial. Journal of Clinical Psychology, 61, 1499–1508. King, N. J., Tonge, B. J., Mullen, P., Myerson, N., Heyne, D., Rollings, S., et al. (2000). Treating sexually abused children with posttraumatic stress symptoms: A randomized clinical trial. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1347–1355. Kratter, J. (1983). The use of meditation in the treatment of attention deficit disorder with hyperactivity. Dissertation Abstracts International, 44, 1965. Last, C. G., Hansen, C., & Franco, N. (1998). Cognitive–behavioral treatment of school phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 404–411. Linehan, M. M. (1993). Cognitive–behavioral treatment of borderline personality disorder. New York: Guilford Press. Lovaas, O. I. (1987). Behavioural treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3–9. Lovaas, O. I., & Smith, T. (2003). Early and intensive behavioral intervention in autism. In: A. E. Kazdin and J. Weisz (Eds.), Evidencebased psychotherapies for children and adolescents. New York: Guilford Press, pp. 325–340. March, J. S., Biederman, J., Wolkow, R., Safferman, A., Mardekian, J., Cook, E. H., et al. (1998). Sertraline in children and adolescents with obsessive-compulsive disorder: A multicenter randomized controlled trial [see comment]. Journal of the American Medical Association, 280, 1752–1756. [Erratum appears in Journal of the American Medical Association (2000) 283, 1293.] March, J. S., Franklin, M., & Foa, E. (2005). Cognitive behavioural psychotherapy for obsessive-compulsive disorders. In P. Graham (Ed.), Cognitive–behaviour therapy for children and families (pp. 281– 300). Cambridge, UK: Cambridge University Press. McEachin, J. J., Smith, T., & Lovaas, O. I. (1993). Long-term outcome for children with autism who received early intensive behavioral treatment. American Journal of Mental Retardation, 97, 359–372. Melamed, B. G., & Siegel, L. J. (1975). Reduction of anxiety in children facing surgery by modeling. Journal of Consulting and Clinical Psychology, 43, 511–521. Mesibov, G. B., Shea, V., & Schopler, E. (2005). The TEACCH approach to autism spectrum disorders. New York: Springer Science & Business Media. Morgenstern, J., & Longabaugh, R. (2000). Cognitive–behavioral treatment for alcohol dependence: A review of evidence for its hypothesized mechanisms of action. Addiction, 95, 1475–1490. Mowrer, O. H. (1980). Enuresis: The beginning work: What really happened. Journal of the History of the Behavioral Sciences, 16, 25–30. Mowrer, O. H., & Mowrer, W. M. (1938). Enuresis: A method for its study and treatment. American Journal of Orthopsychiatry, 8, 436–459. MTA Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Multimodal Treatment Study of Children with ADHD. Archives of General Psychiatry, 56, 1073–1086. National Institute of Clinical Excellence (NICE). (2005). Obsessivecompulsive disorder: Clinical guidelines 31. London: National Institute for Health and Clinical Excellence. Neziroglu, F., Yaryura-Tobias, J. A., Walz, J., & McKay, D. (2000). The effect of fluvoxamine and behavior therapy on children and adolescents with obsessive-compulsive disorder. Journal of Child and Adolescent Psychopharmacology, 10, 295–306. Norgaard, J. P. (1989). Urodynamics in enuretics. I. Reservoir function. Neurology and Urodynamics, 8, 199–211. Owens, E. B., Hinshaw, S. P., Kraemer, H. C., Arnold, L. E., Abikoff, H. B., Cantwell, D. P., et al. (2003). Which treatment for whom for ADHD? Moderators of treatment response in the MTA. Journal of Consulting and Clinical Psychology, 71, 540–552. Panerai, S., Ferrante, L., & Zingale, M. (2002). Benefits of the Treatment and Education of Autistic and Communication Handicapped Children (TEACCH) programme as compared with a non-specific approach. Journal of Intellectual Disability Research, 46, 318– 327. Pediatric OCD Treatment Study (POTS). (2004). Cognitive–behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: The Pediatric OCD Treatment Study (POTS) randomized controlled trial. Journal of the American Medical Association, 292, 1969–1976. Phillips, L.W. (1981). Roots and branches of behavioral and cognitive practice. Journal of Behavior Therapy and Experimental Psychiatry, 12, 5–17. Premack, D. (1965). Reinforcement theory. In D. Levine (Ed.), Nebraska symposium on motivation (pp. 123–180). Lincoln, NE: University of Nebraska Press. Schauer, E., Neuner, F., Elbert, T., Ertl, V., Onyut, L. P., Odenwald, M., et al. (2004). Narrative exposure therapy in children: A case study. Intervention: International Journal of Mental Health, Psychosocial Work and Counselling in Areas of Armed Conflict, 2, 18–32. Scheres, A., Dijkstra, M., Ainslie, E., Balkan, J., Reynolds, B., SonugaBarke, E., et al. (2006). Temporal and probabilistic discounting of rewards in children and adolescents: Effects of age and ADHD symptoms. Neuropsychologia, 44, 2092–2103. CHAPTER 62 1024 9781405145497_4_062.qxd 29/03/2008 02:58 PM Page 1024

Scott, S. (2002). Parent training programmes. In M. Rutter, & E. Taylor (Eds.), Child and adolescent psychiatry (4th edn., pp. 949–967). Oxford: Blackwell. Segal, Z. V., Williams, J. M. G., & Teasdale, J. T. (2001). Mindfulnessbased cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford Press. Shaw, B. F., Elkin, I., Yamaguchi, J., Olmsted, M., Vallis, T. M., Dobson, K. S., et al. (1999). Therapist competence ratings in relation to clinical outcome in cognitive therapy of depression. Journal of Consulting and Clinical Psychology, 67, 837–846. Shea, V. (2004). A perspective on the research literature related to early intensive behavioral intervention (Lovaas) for young children with autism. Autism, 8, 349–367. Shirk, S. R., & Karver, M. (2003). Prediction of treatment outcome from relationship variables in child and adolescent therapy: A meta-analytic review. Journal of Consulting and Clinical Psychology, 71, 452–464. Silverman, W. K., Kurtines, W. M., Ginsburg, G. S., Weems, C. F., Rabian, B., & Serafini, L.T. (1999). Contingency management, selfcontrol, and education support in the treatment of childhood phobic disorders: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 67, 675–687. Skinner, B. F. (1948). Walden Two. New York: Macmillan. Skinner, B. F. (1957). Verbal behavior. New York: Appleton-CenturyCroft. Smith, T. (1999). Outcome of early intervention for children with autism. Clinical Psychology: Science and Practice, 6, 33–49. Smith, P., Yule, W., Perrin, S., Tranah, T., Dalgleish, T., & Clark, D. M. (2007). Cognitive–behavior therapy for PTSD in children and adolescents: A preliminary randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 1051–1061. Smith, T., Groen A., & Wynn, J. W. (2000). Randomized trial of intensive early intervention for children with pervasive developmental disorder. American Journal of Mental Retardation, 105, 269–285. Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., Tu, W., Elliott, M. N., et al. (2003). A mental health intervention for schoolchildren exposed to violence: A randomized controlled trial. Journal of the American Medical Association, 290, 603–611. Stinchcomb, J. B. (2005). From optimistic policies to pessimistic outcomes: Why won’t boot camps either succeed pragmatically or succumb politically? In B. B. Benda, & N. J. Pallone (Eds.), Rehabilitation issues, problems, and prospects in boot camp (pp. 27–52). New York, NY: Haworth Press. Swedo, S., Rapoport, J., Leonard, H., Lenane, M., & Cheslow, D. (1989). Obsessive compulsive disorder in children and adolescents. Clinical phenomenology of 70 consecutive cases. Archives of General Psychiatry, 46, 335–341. Tarrier, N., & Sommerfield, C. (2004). Treatment of chronic PTSD by cognitive therapy and exposure: 5-year follow-up. Behavior Therapy, 35, 231–246. Turk, J. (2005). Children with developmental disabilities and their parents. In P. Graham (Ed.), Cognitive behaviour therapy for children and families (pp. 244–262). Cambridge, UK: Cambridge University Press. von Gontard, A. (2005). Elimination disorders: enuresis and encopresis. In C. Gillberg, R. Harrington, & H. C. Steinhausen (Eds.), A clinician’s handbook of child and adolescent psychiatry (pp. 625–654). Cambridge, UK: Cambridge University Press. Walker, H. M., & Buckley, N. K. (1974). Token reinforcement techniques. Eugene, OR: Engelmann-Becker. Webster-Stratton, C., & Hammond, M. (1997). Treating children with early-onset conduct problems: A comparison of child and parent training interventions. Journal of Consulting and Clinical Psychology, 65, 93–109. Webster-Stratton, C. (2005). The Incredible Years: A training program for the prevention and treatment of conduct problems in young children. In E. D. Hibbs and P. S. Jensen (Eds.), Psychological Treatments for Child and Adolescent Disorders: Empirically-based Strategies for Clinical Practice (2nd edn). pp. 507–555. Washington DC: American Psychological Association. Wells, K. C., Chi, T. C., Hinshaw, S. P., Epstein, J. N., Pfiffner, L., Nebel-Schwalm, M., et al. (2006). Treatment-related changes in objectively measured parenting behaviors in the multimodal treatment study of children with attention deficit/hyperactivity disorder. Journal of Consulting and Clinical Psychology, 74, 649–657. Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press. BEHAVIORAL THERAPIES 1025 9781405145497_4_062.qxd 29/03/2008 02:58 PM Page 1025

1026 Cognitive–behavioral therapies represent a large portion of empirically supported treatments for child and adolescent psychiatric disorders (Kazdin & Weisz, 1998). Cognitive–behavioral therapy (CBT) is based on the premise that cognitions or thoughts can influence emotions and behaviors across a variety of situations, and thus altering maladaptive, distorted or deficient cognitions can be effective in treating various forms of psychopathology. While the widespread application of CBT to emotional and behavioral problems in youth began in the mid 1980s (Graham, 2005), often using problem-solving interventions, the theoretical and empirical underpinnings of these treatments began as early as the 1950s. In this chapter we provide an overview of the development of cognitive–behavioral interventions, as well as their current application in treating various disorders in childhood and adolescence. Historical Cognitive Processing Models Social Learning Theory The application of CBT to the treatment of child and adolescent disorders is based upon social and cognitive learning theories proposed over 40 years ago. Rotter (1954) developed one of the first social learning models of early child development and psychological disorders, drawing on studies of animal learning (Hull, 1943) and conceptualizations of personality development as a dynamic process (Jones & Burks, 1936). Rotter noted that behavioral theories that focused on innate drives and reinforcement contingencies were insufficient for understanding individual differences in human behavior. He stressed that behavior was also influenced by cognitive processes, such as the subjective value individuals placed on reinforcers and their expectations that specific behaviors would result in rewards. Whereas these expectancy contingencies were influenced by previous experiences, they were not necessarily equivalent to objective probabilities (Rotter, Seeman, & Liverant, 1962), and were believed to impact on behavior across a wide variety of social situations (Jessor, 1954). As a result, this model expanded upon existing behavioral theories by introducing cognitive representations of social information and reinforcement contingencies as mediating processes. Observational Learning Early observation learning theories also stressed the importance of cognitions by recognizing that a child’s observations of reallife and symbolic models could influence subjective reward contingencies and decision-making processes. The processes initially proposed for acquiring a behavioral pattern through observational learning included attending to a model, cognitively retaining relevant aspects of the model’s behavior, enacting the observed behavior and then being reinforced for the reproduced behavior (Miller & Dollard, 1941). Early studies in this area found that children tended to imitate aggressive behavior when they observed a model being reinforced for aggression, and were less likely to imitate aggressive behavior when they observed a model being punished for aggression (Bandura, Ross, & Ross, 1963). Subsequent studies demonstrated that observational learning could be used to promote morality development (Bandura & McDonald, 1963) and delayed gratification (Bandura & Mischel, 1965). In addition, several factors were found to impact on the extent to which observational learning occurred in children, including characteristics of the model, the observer and the social context (Bandura, 1973). These early studies provided evidence that modeling could be used to influence children’s cognitions and promote positive behavioral change. Cognitive Social Learning Mischel (1973) proposed a cognitive social learning model of human behavior that combined developments in social learning theory (Bandura, 1969) with research on cognitive processing and symbolic mental representations (Neisser, 1967) in an attempt to explain the complex and dynamic interactions between children and their environment. He posited that the relation between environmental stimuli and behavior was mediated by individual difference characteristics such as construction competencies, encoding strategies, outcome expectancies and values, behavioral regulation systems and planning abilities. Environmental characteristics were believed to influence future behavior in so far as they changed an individual’s cognitive perceptions at these various stages or levels. In addition, Mischel (1973) theorized that children’s overt behavior could modify the amount and type of situations they experienced. As a result, children were viewed as active participants in their social environment, with the ability to influence social exchanges and reinforcement contingencies, as well as be influenced by them. Cognitive–Behavioral Therapies 63 John E. Lochman and Dustin A. Pardini 9781405145497_4_063.qxd 29/03/2008 02:58 PM Page 1026 Rutter’s Child and Adolescent Psychiatry, 5th Edition, Edited by M. Rutter, D. V. M. Bishop D. S. Pine, S. Scott, J. Stevenson, E. Taylor and A. Thapar © 2008 Blackwell Publishing Limited. ISBN: 978-1-405-14549-7

Cognitive Problem-Solving Models In conjunction with the development of cognitive social learning models, researchers also began stressing the importance of deficient cognitive problem-solving in the development of emotional and behavioral problems in children. These early models suggested that ineffective interpersonal problem-solving in daily life could produce a wide variety of social and emotional adjustment difficulties (Jahoda, 1953, 1958). Along these lines, Shure, Spivack, and Jaeger (1971, p. 1792) noted that a well-adjusted person “is one who thinks through ways of solving real-life problems and has an appreciation of the potential consequences which could ensue from an act.” Early theoretical models of effective problem-solving often described five basic steps: 1 Recognizing there is a problem that requires a novel solution; 2 Defining the nature of the problem; 3 Generating possible solutions to the problem; 4 Evaluating the proposed solutions to determine which has the greatest chance of a favorable outcome; and 5 Evaluating the outcome that results from the chosen solution (D’Zurilla & Goldfried, 1971). The last stage allows the individual to make self-corrections in future problem-solving scenarios in the event that the chosen solution was less than optimal. While outlined as distinct and sequential stages, researchers acknowledged that in real-life problem-solving situations these stages likely overlap and influence one another in a bidirectional manner (D’Zurilla & Goldfried, 1971). However, these stages have proven to be a useful heuristic for understanding the components of effective problem-solving and facilitating the teaching of these components to others. Early research supported the notion that deficits in problemsolving may be driving conduct problems in youths. For example, elementary school children with disruptive behavior problems developed fewer logical strategies to solve problems and were less likely to foresee obstacles associated with implementing solutions in comparison with their non-externalizing peers (Shure & Spivack, 1972). In preschool children, poorer school adjustment was also associated with the generation of fewer solutions to problems and a narrower range of possible solutions (Shure & Spivack, 1970). Importantly, early research suggested that the link between poor problem-solving and disruptive behavior problems could not be accounted for by differences in intellectual functioning (Shure & Spivack, 1972; Shure, Spivack, & Jaeger, 1971). However, later studies have found mixed support for the notion that children with disruptive behavior generate fewer possible solutions to social problems (Quiggle, Garber, Panak, & Dodge, 1992; Youngstrom, Wolpaw, Kogos et al., 2000). Instead, finergrained analysis suggests that disruptive behavior is more consistently associated with the generation of specific types of solutions (Lochman & Dodge, 1994; Lochman & Lampron, 1986). For example, children exhibiting disruptive behavior tend to generate a greater proportion of forceful solutions (Youngstrom, Wolpaw, Kogos et al., 2000), are more likely to choose an aggressive solution to solve the problem and indicate that an aggressive solution would be easy to implement (Quiggle, Garber, Panak et al., 1992) than children without these problems. Research on problem-solving skills in children and adolescents exhibiting emotional problems also revealed relatively circumscribed deficits. Several studies indicate that children with emotional problems do not seem to have significant difficulties generating alternative solutions to hypothetical problems involving social interactions (Mullins, Siegal, & Hodgens, 1985; Quiggle, Garber, Panak et al., 1992; Youngstrom, Wolpaw, Kogos et al., 2000). However, depressed adolescents tend to be less confident in their ability to solve problems (Sacco & Graves, 1984), and are more likely to report making snap judgments in problem situations than non-depressed adolescents (Marcotte, Alain, & Gosselin, 1999). Depressed children were also more likely to evaluate withdrawal positively as a solution to conflict situations (Spence, Sheffield, & Donovan, 2003), and were more likely to expect that with-drawal would lead to positive outcomes than non-depressed youth (Quiggle, Garber, Panak et al., 1992). Taken together, this suggests that children with emotional problems tend to “cope by withdrawing from other children and from problems they cannot solve” (Shure, 1993, p. 50). One of the earliest and best researched programs designed to teach children and adolescents problem-solving skills was Interpersonal Cognitive Problem Solving (ICPS) developed by Spivack and Shure (for a review of early studies see Urbain & Kendall, 1980). An early study on the preschool version of the training program was conducted with 219 African-American children (113 intervention, 106 no intervention) attending a federally funded daycare program (Spivack & Shure, 1974; Shure & Spivack, 1980). This version of the ICPS intervention consisted of 46 daily lessons implemented by the teacher, with each daily session lasting 20 minutes. The initial sessions focused on teaching children the basic word concepts necessary for consequential and causal thinking. The remaining sessions focused on developing three problem-solving abilities: alternative thinking, consequential thinking and causal thinking. Using both hypothetical and real-life interpersonal conflict situations, alternative thinking sessions focused on teaching children how to generate multiple possible solutions to a problem. Sessions on consequential thinking had children consider both the immediate and long-range consequences of the multitude of possible solutions to a problem. The final sessions of the intervention involved teaching children causal thinking, such as linking specific solutions with their consequences to identify the solution that would best help them reach a desired outcome or goal. All sessions were taught using techniques such as role plays, games and puppet demonstrations. Findings from this early study suggested that children who received the intervention showed improvements in alternative, consequential and causal thinking, as well as behavioral improvements, in comparison to a no-treatment control group at post-treatment (Shure & Spivack, 1980). Consistent with the theoretical underpinnings of the program, children who showed improvements in problem-solving skills were more likely to exhibit sustained behavioral improvements 1 year later. Over the years, Shure (1992a,b) has further developed the program COGNITIVE–BEHAVIORAL THERAPIES 1027 9781405145497_4_063.qxd 29/03/2008 02:58 PM Page 1027

(now called “I Can Problem Solve”) for use as either a primary prevention or preventative–intervention program during the preschool and elementary school years. While problem-solving therapies can be included under the broad umbrella of cognitive–behavioral interventions, a defining feature of these therapies is that they focus on teaching the process of successful problem-solving, rather than targeting specific behavioral responses or distorted cognitive processes (D’Zurilla & Goldfried, 1971). The primary goal of problem-solving skills interventions is to teach children how to think, rather than telling them what to think (Youngstrom, Wolpaw, Kogos et al., 2000). For example, solutions to problems are not evaluated as being good or bad, even if the solution involves engaging in aggressive behavior (Shure, 1993). However, many problem-solving therapies do include sessions devoted to teaching children social skills such as emotion recognition (Shure, 1992a,b) and some include sessions devoted to challenging negative or irrational beliefs (Spence, Sheffield, & Donovan, 2003). Similarly, nearly all cognitive–behavioral interventions targeting disruptive and emotional problems in children and adolescents include a problem-solving component. Early Cognitive–Behavioral Treatments Whereas Beck (1963) began publishing on the use of cognitive therapy to treat adult depression in the 1960s, the earliest cognitive–behavioral treatments for children focused on problems of self-control. The downward extension of adult cognitive therapies to children was largely influenced by early models of cognitive development in healthy children. Specifically, Piaget described children as developing an increasingly sophisticated set of mental representations and logical structures in order to master their own behavior and the environment (for review see Thomas, 1996). According to Piaget, children initially perceived the world through simple cause and effect relationships driven by their own overt actions. However, children quickly learned to represent objects and events using symbols (e.g., words, mental imagery) and then began performing logical operations on these symbols to represent cause and effect relationships in the real world, helping to facilitate behavioral planning and effortful self-control. In concert with Piaget, developmental theorists Vygotsky and Luria also proposed that children learned to master their behavior in a predictable pattern contingent upon early cognitive development (for review see Akhutina, 1997). Their model of self-mastery asserted that the behavior of preverbal children was initially directed and controlled by the verbalizations of adults, but as children developed the ability to speak, they began using overt self-verbalizations, and later internalized self-talk, to master their own behavior. Based on these early theories, impulsive children were believed to have difficulties using mental operations (e.g., internalized verbalizations) to guide and regulate their behavior (Meichenbaum & Goodman, 1969). Inspired by the use of cognitive therapies to treat adult depression and guided by studies of child cognitive development, Meichenbaum developed the first cognitive self-guidance treatment program for impulsive children (Meichenbaum & Goodman, 1971). The program taught children to control their own behavior by modeling self-control verbalizations and instructing children on how to engage in private self-speech while performing sustained attention tasks. Findings suggested that impulsive children who underwent this treatment improved their ability to use private self-speech to orient attention and think carefully when making important decisions. Kendall and Braswell (1982) developed a more comprehensive cognitive therapy that taught impulsive children the general steps to problem-solving and how to use internalized coping statements to deal with frustration and failures when engaged in goal-directed behaviors. Children who received this intervention were shown to have better school compliance at a 10-week follow-up than children who received behavioral training alone. While relatively simplistic, these studies demonstrated that children could be taught cognitive strategies to help improve their behavioral functioning. Uniqueness of Cognitive–Behavioral Therapy A core feature underlying all cognitive–behavioral therapies is the idea that altering dysfunctional or deficient thoughts that accompany or precede problematic emotions or behaviors can be effective in treating various disorders (Graham, 2005). Whereas this concept may seem mundane given the widespread adoption of cognitive–behavioral approaches, it is important to recognize that cognitive therapies received substantial criticism from pure behaviorists as late as the 1970s. During this period, some behavioral journals were refusing to publish the word “cognition” in articles, and presentations on cognitive factors were banned from the American Association of Behavior Therapy (Meichenbaum, 2003). However, in contrast to purely cognitive therapies, interventions that are cognitive– behavioral in nature are more likely to incorporate techniques based on basic behavioral principles when appropriate (see chapter 62). For example, cognitive–behavioral interventions for very young children with conduct problems often teach parents how to use the behavioral principals of reinforcement, extinction and shaping to change their child’s behavior (Brestan & Eyberg, 1998). It is also important to note that contemporary cognitive–behavioral interventions often include elements of problem-solving therapy and parent-training interventions (Graham, 2005), which are described in greater detail within other chapters in this text. However, all cognitive–behavioral interventions seek to integrate these strategies into an overarching treatment model that emphasizes the influence of both cognitive factors and behavioral contingencies in the development of problematic emotions and behaviors. Contemporary Cognitive Processing Models Because various forms of social maladjustment are often the focus of cognitive–behavioral interventions with children and CHAPTER 63 1028 9781405145497_4_063.qxd 29/03/2008 02:58 PM Page 1028

adolescents, social information processing models have been developed as a framework for understanding and treating both externalizing and internalizing problems in youth. Contemporary models have attempted to delineate the primary cognitive processing steps associated with encoding and interpreting social information, as well as generating and enacting solutions during social conflicts, as a mean of understanding the drivers of social maladjustment. In addition, research on the relative influence that cognitive schemas and emotional arousal have on social information processing guides contemporary cognitive–behavioral therapies for youth. The importance of distinguishing automatic from deliberate cognitive processing and distorted cognitions from cognitive deficits is also implicit in many cognitive–behavioral therapies. Social Information Processing Model Arguably the most influential and comprehensive social information processing model relevant for cognitive–behavioral interventions with children and adolescents was developed by Dodge (1993; Crick & Dodge, 1994). The model explicitly describes the “online” cognitive process steps that occur when children are engaged in social interactions and social problemsolving. In the most recent version of this model, a series of six sequential steps are outlined: 1 Encoding of external and internal cues; 2 Interpretation of these cues; 3 Determining goals or desired outcomes for the situation; 4 Generating possible responses; 5 Evaluating and selecting a response; and 6 Enacting and evaluating the chosen response. Social adjustment problems in youth are believed to arise because of difficulties at one or more of these information processing steps. Whereas certain problem behaviors (e.g., aggression, depression) have been associated with specific social information processing problems, this framework is also useful for understanding heterogeneity among children exhibiting the same problem behavior. For example, the aggressive behavior of one child may be driven by a propensity to misinterpret others’ benign behaviors as hostile (stage 2), whereas a second aggressive child may be able to accurately interpret others’ intentions, but have particular difficulties generating non-aggressive solutions to social conflicts (stage 4). Understanding this heterogeneity in the context of CBT is important because the most efficient and effective treatment plans for these two children would focus on ameliorating fundamentally different social information processing problems. Although it is important to recognize that there are individual differences within groups of children exhibiting the same problem behavior, there is considerable research indicating that children with disruptive behavior problems (e.g., aggression, conduct problems) tend to exhibit a general pattern of social information processing difficulties. At encoding, disruptive children recall fewer relevant cues about events (Lochman & Dodge, 1994) and overattend to hostile cues (Gouze, 1987; Milich & Dodge, 1984) than non-disruptive controls. In the interpretation stage, they are also more likely to infer that others are acting in an aggressive or hostile manner (Burgess, Wojsalawowicz, Rubin, Rose-Krasnor, & Booth-LaForce, 2006; Dodge, Petit, McClaskey, & Brown, 1986). When clarifying goals in conflict situations, disruptive and seriously antisocial youth tend to focus on dominance and self-centered rewards, and are less concerned with avoiding punishment and the suffering of others (Lochman, Wayland, & White, 1993; Pardini, Lochman, & Frick, 2003). In conflict situations, aggressive and disruptive children also tend to generate fewer verbal assertions (Asarnow & Callan, 1985; Lochman & Lampron, 1986) and compromise solutions (Lochman & Dodge, 1994), and generate more physically aggressive solutions (Pepler, Craig, & Roberts, 1998; Waas & French, 1989). When evaluating possible responses to social conflicts, children with disruptive behavior problems rate aggressive solutions more positively than children without these difficulties (Crick & Werner, 1998). Even when they choose prosocial responses, children with disruptive behavior problems tend to be less adept at enacting them (Dodge, Petit, McClaskey et al., 1986). There is also emerging evidence suggesting that children with emotional problems (e.g., depression, anxiety) tend to exhibit a unique pattern of social information processing problems. At the encoding stage, depressed children tend to recall more negative cues in the environment (Hammen & Zupan, 1984), whereas anxious children seem to have an attentional bias associated with processing environmental cues of potential threat (Ehrenreich & Gross, 2002). During the interpretation phase, both depressed and anxious children are more likely to attribute negative events to internal, stable and global characteristics (Jacobs & Joseph, 1997; Quiggle, Garber, Panak et al., 1992). There is also evidence suggesting that children with emotional problems may be less likely to generate assertive solutions to social conflicts (Quiggle, Garber, Panak et al., 1992) and tend to understate their own social competence (Rudolph & Clark, 2001). When choosing solutions to social problems, both depressed and shy or withdrawn children tend to adopt avoidant strategies and depressed children tend to view assertive social solutions as resulting in fewer positive and more negative outcomes (Burgess, Wojslawowicz, Rubin et al., 2006; Quiggle, Garber, Panak et al., 1992). Role of Schemas Recent revisions of social cognitive models have more explicitly introduced the role that children’s cognitive schemas have on information processing (Crick & Dodge, 1994; Lochman, Wayland, & White, 1993). Schemas are commonly regarded as patterns of thinking or beliefs that remain relatively consistent across social situations (Lochman & Lenhart, 1995). These latent cognitive structures are believed to promote the filtering of incoming information and can distort self and other perceptions (Fiske & Taylor, 1984). While schemas allow people to operate efficiently in their social worlds by providing prototypes for how to interpret social cues and manage social conflicts, dysfunctional schemas can perpetuate emotional and behavioral problems by negatively influencing several social information processing steps (Lochman & Dodge, 1998). COGNITIVE–BEHAVIORAL THERAPIES 1029 9781405145497_4_063.qxd 29/03/2008 02:58 PM Page 1029

When encoding social cues, schemas can narrow children’s attention to specific facets of the social environment at the expense of other social cues (Lochman, Nelson, & Sims, 1981). For example, a child with a general expectancy that others will try to dominate him, may be hypervigilant to verbal and non-verbal signals about a peer’s control efforts, while missing signs of the peer’s friend-liness or attempts to negotiate. Children’s schemas can also influence the interpretation of encoded social cues, such as the tendency for a depressed or anxious child to attribute negative social events to internal, stable and global characteristics (Jacobs & Joseph, 1997; Quiggle, Garber, Panak et al., 1992). Schemas can also play a significant part at the end stages of information processing, as the child anticipates consequences for different problem solutions, and decides which strategy will be enacted. In this regard, social goals and outcome expectations that are consistently endorsed in social situations of a particular theme (e.g., social conflicts with peers) are often conceptualized as schemas (Mischel, 1990; Rotter, Chance, & Phares, 1972). Emotional Arousal and Social Information Processing It is important to recognize that social information processing might both influence, and be adversely impacted by, heightened levels of negative affect and emotional arousal. Emotions have been hypothesized to mediate the relationship between attributions and behavior (Weiner, 1990) and serve as an adaptive system that motivates individuals to solve their perceived problems (Smith & Lazarus, 1990). For example, when a child attributes blame for a social conflict to another person’s hostility, the child will tend to experience frustration or anger, but when the child attributes a social conflict to personal flaws or imperfections, the child will tend to experience sadness or depression (Weiner, 1990). These attribution–emotion linkages can then result in different decisions about social goals (e.g., revenge vs. conflict avoidance) and appropriate behavioral responses in interpersonal situations (e.g., aggression vs. withdrawal). In addition, emotional reactions in the early stages of interactions often persist across time, which can negatively influence social attributions and response styles throughout an extended social exchange (Dodge & Somberg, 1987; Lochman, 1987). Along these lines, a recent laboratory investigation found that young boys who experience increased heart rate as the result of provocation also experience increases in hostile attributional biases (Williams, Lochman, Phillips, & Barry, 2003). Whereas the temporal ordering of these relations (increased heart rate influences attributions or vice versa) could not be determined based on the design of the study, this study provides convincing evidence that changes in negative emotional arousal and dysfunctional cognitions are closely linked. Distinguishing Automatic and Controlled Information Processing When evaluating the social information processing of children and adolescents, it is often useful to differentiate between more automatic and more controlled processing problems (Lazarus, 1991). Automatic processing is commonly described as occurring outside of conscious awareness and is fast, effortless and unintentional. Effortful processing, on the other hand, occurs within conscious awareness and is depicted as slow, effortful and deliberate. At each stage of social information processing, the difficulties exhibited by children and adolescents with various emotional and behavioral problems can be conceptualized as being on a continuum from relatively automatic to more controlled (Daleiden & Vasey, 1997). Although a vast majority of research with children and adolescents has focused on effortful social information processing, studies have begun to examine the association between emotional problems and more automatic processing of social stimuli. For example, trait anxiety in adults has been associated with increased skin conductance responses to threatening pictures in comparison with neutral pictures, even when these stimuli are presented outside of conscious awareness (Najström & Jansson, 2006). Whereas this suggests that relatively automatic attentional biases to fear and threat cues may be associated with anxiety problems in adults, studies examining how automatic processes are related to children’s and adolescents’ anxiety, as well as other forms of psychopathology, are needed. Differentiating Cognitive Distortions from Cognitive Skills Deficits Cognitive–behavioral therapies with youth often make distinctions between cognitive distortions and cognitive skills deficits when treating social information processing problems. Cognitive distortions are self-defeating interpretations of people or events that do not accurately represent reality (Daleiden & Vasey, 1997). These thinking errors are believed to help maintain negative emotions and often result in dysfunctional social interactions and poor social problem-solving. A common cognitive distortion is an overgeneralization, in which an individual assumes that a specific negative event is part of a continual or pervasive pattern. For example, a depressed child may think “All people I care about will leave me” when a friend moves out of town, or an aggressive child my think “Everyone is out to get me” after being ridiculed by a single peer. Other common forms of cognitive distortion include jumping to conclusions about the intentions of others, catastrophizing relative minor setbacks, personalizing negative events and discounting positive events (Dodge, 1993). Within the context of cognitive–behavioral therapies, children and adolescents are often taught to recognize and refute these distortions, which is a process commonly referred to as cognitive restructuring. Replacing these distorted cognitions with more realistic and adaptive thinking patterns is designed to reduce negative emotional reactions to adverse social events and promote more competent social problem-solving. Although negative appraisals of the self and social environment may be caused by cognitive distortions, it is also possible that these perceptions are actually accurate representations of reality that may arise from cognitive skills deficits. For example, a depressed child may accurately endorse having no friends at school because of an inability to start appropriate conversations with others. In this instance, the child is describing a deficiency CHAPTER 63 1030 9781405145497_4_063.qxd 29/03/2008 02:58 PM Page 1030

in the cognitive skills necessary to develop peer friendships, rather than engaging in cognitive distortions by exaggerating a complete absence of friends or lack of social skills. CBT with a child or adolescent exhibiting cognitive deficits focuses primarily on skill building, such as practicing how to start and maintain conversations. Often, it may be difficult to determine from the youth’s self-report alone whether social difficulties are the result of cognitive distortions, cognitive skills deficits or some other factor. As a result, it is often necessary to gather information from collateral informants (e.g., parents, teachers, peers) to garner an accurate depiction of the problem (Pardini, Barry, Barth, Lochman, & Wells, 2006). It is also important to keep in mind that cognitive distortions and deficits are not mutually exclusive categories. For example, Ruldolph and Clark (2001) found that depressed children not only have greater difficulties engaging in skillful social interactions with peers than non-depressed children (cognitive deficit), but also tend to exaggerate the extent of their social problems (cognitive distortion). In addition, there are cases in which children’s emotional difficulties are brought about by life circumstances beyond their control (e.g., death in the family, victimization, physical deformity) rather than a cognitive deficit or distortion, in which case it may be more appropriate to focus on teaching children skills for coping with stressful life events. Areas of Application Conduct Problems The largest application of CBT to child and adolescent psychopathology has focused on the treatment of conduct problems (e.g., aggression, defiance, oppositional behaviors, rule-breaking). Whereas cognitive–behavioral therapies for conduct problems differ based on the developmental level of the target population (e.g., preschool children vs. adolescents) and the severity of the behavior problems being targeted (e.g., treatment for conduct disorder vs. preventative–intervention for minor aggressive behavior), common elements pervade most empirically supported cognitive–behavioral approaches (for descriptions see Lochman, Phillips, McElroy, & Pardini, 2005; Pardini & Lochman, 2003). Nearly all of these treatments involve a child–parent intervention component, and there are several topic areas that are commonly addressed in these interventions. As a result, a prototypical cognitive–behavioral intervention for treating conduct problems in youth is described, followed by empirical evidence supporting the efficacy of these interventions with various populations. Prototypical Youth Intervention for Conduct Problems Most youth interventions for conduct problems are performed with small groups of 4–6 individuals over the course of several weeks to a year. There is typically an emphasis on anger management, social problem-solving and social skills development, and prosocial goal-setting. Anger management sessions involve assisting children in recognizing the level of arousal and anger they experience in difficult interpersonal situations and identifying the triggers that lead to these high arousal reactions. Perspective-taking sessions are commonly used to help participants understand how others can have a range of intentions in a given situation that are often unclear. This is done in an attempt to prevent children from assuming that other people are always trying to be cruel or mean in conflict situations, which often triggers increased anger. Coping techniques to manage anger arousal and to avoid impulsive rage-filled responses are often the focus of several sessions, including the use of distraction, relaxation and self-talk techniques. Children often practise using coping self-instructions and distraction techniques within the group, sometimes while being teased directly by other group members or by using puppets. Children are reinforced for creating a repertoire of coping self-statements that are relevant and useful for them, and are encouraged to use these strategies in real-life social situations. Parents and teachers are often taught to cue and assist the youth in using anger management strategies at home and school, and are instructed to reinforce the successful implementation of these skills. Cognitive–behavioral interventions for conduct problems also focus on teaching youth appropriate social problem-solving strategies and social skills. Consistent with Dodge’s (1993; Crick & Dodge, 1994) social information processing model, participants are commonly taught to engage in a series of cognitive processing steps when solving social problems. In most interventions, youth learn to: 1 Identify the problem and their emotional reaction to it; 2 Analyze the possible intentions of the other party; 3 Come up with potential solutions to the conflict; 4 Analyze the short- and long-term consequences of each solution; 5 Choose and enact a final plan; and 6 Evaluate the effectiveness of the plan after it is implemented. In addition, children are often taught basic social skills that are important for making friends: empathizing and co-operating with others, and successfully resolving interpersonal conflicts. These skills are often taught through a combination of verbal instructions, modeling and in-session role plays. The in-session role plays frequently focus on dealing with interpersonal conflicts experienced by youth (e.g., being teased by a peer), as well as other social situations that are difficult for youth with conduct problems, such as making new friends. As therapy progresses, children are often given homework assignments in which they are asked to apply their newly learned problemsolving and social skills to real-life interpersonal situations of increasing complexity. Parents and teachers are often taught to cue and assist the youth in using these problem-solving strategies and social skills, as well as to reinforce their successful implementation. Another facet of cognitive–behavioral treatments for conduct problems involves having the youth identify and work on goals designed to improve their behavior. In order to help facilitate this process, teachers or parents are often asked to identify four or five behavioral goals designed to reduce problematic behaviors. Because initial successes are important in motivating children to work on challenging issues, children are COGNITIVE–BEHAVIORAL THERAPIES 1031 9781405145497_4_063.qxd 29/03/2008 02:58 PM Page 1031

often encouraged to select goals initially that are of low to moderate difficulty. Progress in meeting these goals is monitored regularly, and children receive rewards or privileges for reaching agreed-upon levels of goal completion. Prototypical Parent Intervention for Conduct Problems Most efficacious cognitive–behavioral programs for child and adolescent conduct problems involve a parent-training component. Cognitive–behavioral parenting interventions have received the most consistent empirical support for the successful treatment of conduct problems in youth, both in isolation and when combined with child interventions (Brestan & Eyberg, 1998). As a result, it is strongly recommended that cognitive– behavioral interventions for child and adolescent conduct problems involve a parenting component whenever possible. Typically, these sessions are conducted during several group sessions lasting approximately 2 h, with periodic individual contacts through home visits and telephone contacts to promote generalization of skills learned in group sessions. In order to lay a foundation for positive parent–child interactions, parents are initially encouraged to initiate non-threatening play sessions with their child in a manner that shows a genuine interest in and appreciation of their ideas. This typically includes using skills such as reflecting the child’s statements, describing and praising the child’s behavior, ignoring undesirable behaviors and avoiding the tendency to direct the play or criticize the child. Parents are coached on ways in which they can verbally and non-verbally express acceptance, warmth and caring toward their child. The purpose of this component is to strengthen a positive parent–child relationship and extinguish maladaptive behaviors that are reinforced by parental attention. Most interventions have parents practice these skills in session as the therapist provides feedback and suggestions for improvement. Another common component of parenting interventions involves learning to analyze child behavior problems from a cognitive–behavioral mindset, and implement discipline strategies that target the drivers of conduct problems from a cognitive– behavioral perspective. Along these lines, parents are taught to use positive reinforcement to increase the frequency of their child’s prosocial behaviors, while using non-abusive, yet consistent, methods of discipline to deal with disruptive behaviors. The appropriate use of time out, verbal reprimands, negotiation and behavioral contracting is often discussed, as well as using a naturally occurring consequence for inappropriate behavior, such as giving children an earlier bedtime when they refuse to get up on time for school in the morning. Sessions also focus on teaching parents to use problem-solving strategies similar to those taught to their children to manage crises within the family. After a home behavioral program is started, parents are encouraged to begin a school-based reinforcement program to help improve their child’s academic and behavioral compliance. The school program consists of negotiating certain school goals and monitoring the child’s progress in meeting these goals through the use of a home–school behavioral report card. Children are typically given reinforcement for achieving specific goals (e.g., special activities, privileges) and are frequently given feedback regarding their behavioral progress. Outcome Research Reviews of Efficacy of Cognitive–Behavioral Therapy for Conduct Problems Several reviews have examined the efficacy of psychosocial treatments for conduct problems in children and adolescents in comparison to no treatment or waitlist control conditions. These reviews indicate that a vast majority of the empirically supported treatments for conduct problems in youth are based upon a CBT framework (Brestan & Eyberg, 1998; Farmer, Compton, Burns, & Robertson, 2002; Kazdin & Weisz, 1998; Nock, 2003). Meta-analytic studies suggest that the effect sizes for cognitive–behavioral interventions targeting conduct problems range from medium to large, i.e., 0.47–0.90 (for review see Nock, 2003). In addition, research suggests that cognitive– behavioral interventions that include a child component focusing on social problem-solving and social skills development together with a parent-training component produce broader positive effects and better maintenance of behavioral improvements over time than interventions with either component in isolation (Kazdin, Siegel & Bass, 1992; Nock, 2003; Webster-Stratton & Hammond, 1997). However, the parenting component of these interventions has been shown to produce particularly robust reductions in conduct problems and delinquent behaviors (Beauchaine, Webster-Stratton, & Reid, 2005; Lochman & Wells, 2004). Two exemplars: The Incredible Years and Coping Power Programs Two examples of intervention programs that have received empirical support for the treatment of conduct problems are the Incredible Years program and the Coping Power program. The Incredible Years program primarily consists of a parent and child intervention designed for children aged 4–7 who have conduct problems significant enough to warrant a diagnosis of either oppositional defiant disorder or conduct disorder (Webster-Stratton, Reid, & Hammond, 2004). Research findings regarding the effectiveness of the child and parent training interventions alone and in combination are impressive. The parent-training component has repeatedly been show to produce significant reductions in child conduct problems at home and school, decreases in negative parenting and increases in positive parenting in comparison with waitlist control conditions (Webster-Stratton, 1984; Webster-Stratton & Hammond, 1997; Webster-Stratton, Kolpacoff, & Hollinsworth, 1988; Webster-Stratton, Reid, & Hammond, 2004). In addition, evidence suggests that overall improvements in children’s behavior problems as the result of the parenting intervention can still be seen at 3-year follow-up (Webster-Stratton, 1990). The Incredible Years child intervention has also been shown to produce significant reductions in the amount of conduct problems children exhibit at home and school, as well as produce increases in social problem-solving skills in comparison CHAPTER 63 1032 9781405145497_4_063.qxd 29/03/2008 02:58 PM Page 1032

with wait-list controls (Webster-Stratton & Hammond, 1997; Webster-Stratton, Reid, & Hammond, 2004). There is also evidence indicating that at 1-year follow-up approximately two-thirds of children who participated in the intervention have parent ratings of behavioral problems in the normal rather than clinically significant range (Webster-Stratton & Hammond, 1997). In contrast to the Incredible Years program, the Coping Power program was developed as a preventative intervention to assist aggressive elementary schoolchildren in making a successful transition to middle school. The efficacy of the Coping Power program in comparison with no treatment has also been demonstrated in several studies. For example, aggressive boys randomly assigned to an early version of the program (i.e., anger coping) displayed less parent-reported aggressive behavior, fewer behavior problems in the classroom and higher levels of self-esteem at post-treatment than aggressive boys who did not receive treatment (Lochman, Burch, Curry, & Lampoon, 1984). At a 3-year follow-up, the intervention boys exhibited lower substance use involvement and increased self-esteem and social problem-solving skills than controls (Lochman, 1992). Aggressive children who have participated in the expanded Coping Power program have been shown to exhibit post-treatment reductions in self-reported substance use, proactive aggression, as well as improved social competence and teacher-rated behavioral improvements in comparison with non-treated controls (Lochman & Wells, 2004). The intervention has also been found to reduce several maladaptive cognitions related to aggressive behavior by post-treatment, such as hostile attributions, expectations that aggression will result in positive outcomes and an external locus of control regarding positive outcomes (Lochman & Wells, 2002a). At 1-year follow-up, findings indicate that aggressive boys who have participated in the Coping Power program exhibit lower levels of self-reported delinquency and parent-reported substance use, as well as higher levels of teacher-rated behavioral improvements than non-treated controls (Lochman & Wells, 2002a). The Coping Power effects on children’s self-reported delinquency and substance use, and teacher-reported aggressive behavior at the time of a 1-year follow-up, compared with a randomly assigned control condition, were replicated in a second sample (Lochman & Wells, 2003). Moderators and Mediators of Treatment Efficacy Whereas cognitive–behavioral treatments are generally effective for treating conduct problems in youth, it is also clear that some children’s behavior problems do not improve as the result of treatment. Along these lines, research has been increasingly focused on answering the question: “What child, parent, family, and contextual features influence (moderate) outcome?” (Kazdin, 2003). Although there has been some historical speculation that preschool children and youth with learning problems may not benefit from CBT for disruptive behavior, recent evidence suggests that this may not be the case. For example, children as young as 4 years old (Beauchaine, Webster-Stratton, & Reid, 2005; Webster-Stratton, Reid, & Hammond, 2004), and youth with mild cognitive impairments (e.g., learning problems, mild intellectual disability) have shown significant behavioral improvements as the result of developmentally appropriate cognitive–behavioral interventions (Kam, Greenberg, & Kusché, 2004; Kazdin & Crowley, 1997). More recently, researchers have suggested that conduct problem youth with a callous and unemotional (CU) interpersonal style may exhibit a particularly severe and recalcitrant form of antisocial behavior that is resistant to traditional treatments (see chapter 51; Frick, Cornell, Barry, Bodin, & Dane, 2003; Pardini, 2006). Along these lines, one study found that increased CU traits were associated with lower levels of behavioral improvements following a cognitive–behavioral parenting intervention for youth with conduct problems (Hawes & Dadds, 2005). However, this effect was relatively small in magnitude, suggesting that youth with CU traits may benefit from empirically supported CBT. Many studies examining moderators of CBT for youth with disruptive behavior have produced contradictory or counterintuitive findings. Whereas early studies suggested that children with more global psychiatric impairment were less likely to benefit from CBT for disruptive behavior (Kazdin & Wassell, 1999), more recent evidence suggests that comorbidity and case complexity may not significantly influence therapeutic change (Kazdin & Whitely, 2006a). Similarly, lower socioeconomic status and increased parental psychopathology and stress have been found to predict poorer treatment outcomes in some studies (Dumas & Wahler, 1983; Kazdin & Wassell, 1999; Reyno & McGrath, 2006; Webster-Stratton & Hammond, 1990), but not in others (Beauchaine, Webster-Stratton, & Reid, 2005; Hartman, Stage, & Webster-Stratton, 2003). Recently, a large and comprehensive examination of treatment moderators was conducted with 514 children who participated in six randomized trials of the empirically supported Incredible Years program (Beauchaine, Webster-Stratton, & Reid, 2005). Findings indicated that children whose parents had a history of substance abuse and those with co-occurring emotional disturbance showed greater improvements in disruptive behaviors by 1-year follow-up. Children of parents who exhibited lower levels of critical, harsh and ineffective discipline at baseline also exhibited greater behavioral improvements. In addition, the parent-training component of the program (in comparison with the other components) produced greater improvements in children’s disruptive behavior at 1-year follow-up for single mothers, mothers who reported low levels of marital satisfaction and children low on emotional disturbance. In contrast to theoretical conjecture (Lynam, 1996), the intervention was equally effective in reducing conduct problems among children with elevated levels of attention deficit/hyperactivity disorder (ADHD) symptoms as in those without these problems (Beauchaine, Webster-Stratton, & Reid, 2005; Hartman, Stage, & Webster-Stratton, 2003). However, evidence does suggest that CBT may not be effective for reducing core ADHD symptoms in youth (MTA Cooperative Group, 1999). Although these studies have begun providing insights into possible moderators of treatment efficacy, there remains a lack of understanding about why these factors lead to differential responses COGNITIVE–BEHAVIORAL THERAPIES 1033 9781405145497_4_063.qxd 29/03/2008 02:58 PM Page 1033

to treatment (Nock, 2003). This issue seems particularly important given that research in this area has produced counterintuitive (e.g., parental substance use history positively influences treatment outcome) and contradictory findings. An under-studied area involves examining the mechanisms through which CBT influences reductions in child and adolescent conduct problems (i.e., mediators). Evidence suggests that reductions in critical, harsh and ineffective parenting practices tend to co-occur with improvements in disruptive behavior problems at post-treatment and 1-year follow-up (Beauchaine, Webster-Stratton, & Reid, 2005). In addition, Lochman and Wells (2002b) found evidence indicating that intervention-related reductions in delinquency at 1-year followup were at least partially mediated by reductions in inconsistent parenting from pre- to post-treatment. However, evidence supporting the assertion that modifying maladaptive or deficient cognitions in children leads to subsequent changes in their problem behavior was limited. Depression Depressed youth have certain common social–cognitive characteristics. Depressed youth display both cognitive distortions and cognitive deficits, evident in their core symptoms of feelings of worthlessness, associated negative beliefs about themselves and their future, attributions of failures, and having an external locus of control (Gladstone & Kaslow, 1995). The onset of youth depression is often preceded by family conflict, physical illness, the break-up of romantic relationships or the loss of a friendship (Weersing & Brent, 2003). Depressed pre-adolescent children have similar causal attributions for the positive and negative events that they experience, which is quite different from non-depressed children, who perceive the causes of negative events to be external to themselves (Kaslow, Rehm, Pollack, & Siegel, 1988). These attribution distortions become even more apparent with adolescent in-patient samples, where the depressed adolescents attribute the cause of positive events to external, unstable and specific causes, consistent with findings that adolescents experience more anhedonia than younger depressed children (Curry & Craighead, 1990). Depressed children’s distorted schemas and internal working models have been found to be linked to insecure attachment to parent figures (Cowan, Cohn, Cowan, & Peterson, 1996; Stark, Sander, Hauser et al., 2006b). In addition to these problems in their habits of thought, they often show problems in their low rates of social acceptance and high rates of isolation from their peers, caused by poor social skills and poor problem-solving skills. Garber, Braafladt, and Zeman (1991) found that depressed children had certain specific social information processing difficulties, evident in their patterns of generating avoidant and aggressive strategies to handle social difficulties, rather than using more adaptive strategies involving active problem-solving and distraction. Contents of a Typical Cognitive–Behavioral Therapy Approach Common treatment components across different CBT programs include: 1 Self-control skills, self-consequation (reinforcing themselves more, punishing themselves less), self-monitoring (paying attention to positive things they do), self-evaluation (setting less perfectionistic standards for their performance) and assertiveness training; 2 Social skills, including methods of initiating interactions, maintaining interactions, handling conflict, and using relaxation and imagery; and 3 Cognitive restructuring, involving confronting children about the lack of evidence for their distorted perceptions (Stark, Hargrave, Sander et al., 2006a). An example of how the cognitive skills are separated from the behavioral skills is evident in the CBT program for adolescents developed by Weersing and Brent (2003). This program consisted of 15 sessions, 10 of which were manualized and structured, and 5 of which were highly individualized for the particular client’s strengths and abilities. In addition to the work in the session with the adolescent, there was take home work from a practice book, and there was some parent involvement. The skills were separated into two sets for the ACT behavioral skills (activities that solve problems, activities that the youth enjoys, being calm and confident, using one’s talents) and the THINK cognitive skills (think positive, get help from a friend, identify the silver lining, don’t replay bad thoughts, keep thinking and don’t give up). The youth develops a coping plan with sequential steps, and the skills are actively practiced in role plays and in vivo activities. CBT with depressed children can also be given in a group format, where the CBT sessions are typically carefully structured, going through a regular sequence of activities, each session including: rapport building, set agenda, goal attainment check-in, review of previous meeting and homework, coping skills activity, skill building, review, positive behavior review and assignment of therapeutic homework (Stark, Hargrave, Sander et al., 2006a). Outcome Research Reviews of Evidence-based Cognitive–Behavioral Therapy Approaches Meta-analytic reviews indicate that children and adolescents benefit from CBT interventions regardless of severity of depressive symptoms, and that adolescents have larger effect-size improvements from CBT intervention than do younger children (Michael & Crowley, 2002; Stark, Hargrave, Sander et al., 2006a). Overall, CBT interventions have had similar effects for mildly to severely depressed adolescents in these reviews, but recent research has suggested that the beneficial effects of CBT may be most apparent with mild to moderate depression in youth (Melvin, Tonge, King et al., 2006). Treated youths’ reductions in depressive symptoms are maintained over time, and effect sizes at the end of treatment are in the moderate to large range across studies (Reinecke, Ryan, & DuBois, 1998). Two Exemplars: CBT for Adolescents and the TADS Study Typical of the positive results that have been reported from CBT programs for depressed youth, Weersing and Brent (2003) CHAPTER 63 1034 9781405145497_4_063.qxd 29/03/2008 02:58 PM Page 1034

described the results from the series of CBT studies conducted at the Western Psychiatric Institute Mood and Anxiety Disorders Clinic. In the 1997 clinical trial (Brent, Holder, Kolko et al., 1997), 107 youth were screened for major depressive disorder, were required to have at least borderline Beck Depression Inventory scores, and did not have psychosis, bipolar disorder, obsessive-compulsive disorder, eating disorders or substance abuse. The youth were randomly assigned to CBT, systemic behavioral family therapy (SBFT) or nonspecific therapy (NST). SBFT was based on models of the effects of negative life events and family conflict on youth depression, and included a problem definition stage, in which adolescents’ problems were redefined as being problems for the entire family system and in which dysfunctional interactions and alliances were identified, and a problem-solving stage. NST controlled for the non-specific aspects of therapy by having adolescents express feelings with warm and non-directive therapists. At post-treatment, CBT had significantly higher rates of youth being diagnosis-free (CBT 83%, SBFT 38%, NST 39%), but these treatment group differences had become non-significant by the time of a 2-year follow-up (Birmaher, Brent, Kolko et al., 2000). However, the utility of the CBT as a stand-alone treatment for depression has become less clear with the results of the large multi-site TADS study (March, Silva, Petrycki et al., 2004). A total of 351 adolescents who had received primary diagnoses of moderate to severe major depressive disorder were randomly assigned to fluoxetine, CBT, the combination of fluoxetine and CBT, or placebo. The CBT intervention included six structured skill-building sessions and six modular or optional sessions, to permit more careful tailoring of interventions to specific adolescents’ needs with regard to social engagement, communication, negotiation, compromise or assertion. The CBT intervention used in TADS did not have as many intensive cognitive elements as was evident in the Brent, Holder, Kolko et al. (1979) study (Stark, Sander, Hanser et al., 2006b). The greatest decreases in symptoms in the TADS study were evident in the condition that included both CBT and fluoxetine, followed by the fluoxetine-only condition. Both of these conditions were more effective than CBT only or placebo. Thus, CBT used in the TADS study was found to be useful in accompaniment to medication, and was found to produce greater reduction in the likelihood of suicidal ideation and behavior than the fluoxetine-only condition. However, CBT alone was less effective than fluoxetine in reducing depression symptoms among those adolescents with major depressive disorder. The findings of the lack of intervention effects for CBT alone may have been because of the inclusion of fewer cognitive treatment elements in the TADS CBT intervention, or to the use of less-experienced therapists. Mediation and Moderation Kolko, Brent, Baugher, Bridge, and Birmaher (2000) examined whether the CBT and SBFT conditions in the Brent, Holder, Kolko et al. (1997) study produced differential improvements in cognitive distortions. As anticipated, CBT was uniquely able to change adolescents’ cognitive distortions, unlike the SBFT condition, and was able to produce changes in general family functioning to a similar degree as the SBFT condition, suggesting that a mechanism of action in CBT is the ability to alter cognitive distortions. In terms of predictors of outcomes, youth with more severe and chronic depression, evident in the presence of double depression and more severe cognitive distortions, have poorer outcomes after any form of treatment in the Brent, Holder, Kolko et al. (1997) study of CBT. Youth with serious suicidality were more responsive to CBT than to non-CBT treatment, with equal levels of CBT effectiveness for suicidal and non-suicidal youth (Barbe, Bridge, Birmaher, Kolke, & Brent, 2004). Youth with greater numbers of depressive episodes and younger age at first onset had the best outcomes in the Adolescents Coping With Depression program (Clarke, DeBar, & Lewinsohn, 2003). Thus, there is mixed evidence at this time about whether CBT would have its best effects with less severe or chronic depressive children. Anxiety CBT for anxiety disorders integrates cognitive and behavioral perspectives on the origin and maintenance of anxiety symptoms (Stark, Sander, Hauser et al., 2006b). There is a focus on the children’s internal and external environments, addressing behavioral, cognitive, affective and social factors. Children with anxiety disorders have been found to have certain information processing and emotional experiencing styles. The children’s interpersonal contexts within their family and peer groups have also been linked to their experience of anxiety, and have implications for treatment. There is considerable correspondence between serious levels of child and maternal anxiety (Frick, Silverthorn, & Evans, 1994). Family factors that are linked to child anxiety include parental overcontrol, parental reinforcement of avoidant strategies, the presence of parental anxiety and the presence of anxiety in siblings. Interestingly, some parental anxiety has been found to decrease when mothers have been included as coaches to assist their children’s use of comforting self-talk, cue controlled relaxation and pleasant imagery in the management of their anxiety symptoms (Peterson & Shigetomi, 1981). Parents have benefitted by using the same skills themselves, and their anxiety may decline as children have reduced levels of symptoms. Contents of a Typical Cognitive–Behavioral Therapy Approach The Coping Model underlying Kendall’s Coping Cat program (Kendall & Suveg, 2006) emphasizes that the goal is not to alleviate anxiety entirely, but to assist the child to learn skills to better manage or cope with anxiety in the future. Three of the primary treatment targets are: 1 To identify physiological cues related to anxiety and to use relaxation skills to manage this arousal, because anxiety is associated with manifest physiological arousal; 2 To identify automatic thoughts and to learn countervailing coping thoughts, because children have cognitive distortions COGNITIVE–BEHAVIORAL THERAPIES 1035 9781405145497_4_063.qxd 29/03/2008 02:58 PM Page 1035

that lead them to overestimate the chance of negative events occurring and the impact of those events; and 3 To be exposed to the feared situations as the child learns and actively practices problem-solving skills. The Coping Cat program consists of 16–18 sessions, with the first eight sessions focusing on teaching the components of the FEAR plan. In the FEAR plan, “F” refers to assisting children to becoming better aware of their feelings of being frightened, emphasizing greater awareness of physical symptoms as a cue to respond, and using deep breaths and muscle relaxation to teach the child that he or she has control over physical reactions. “E” refers to children’s identification of their incorrect expectations and self-statements that bad things will happen. Through modeling and role play, the child identifies his or her thoughts in anxiety-provoking situations, and learns to test out the negative expectations. “A” is a problem-solving step in which the child develops his or her confidence and ability to clearly define the problem situation and goals, and to generate alternative solutions to the anxiety-provoking situation. The idea of needing to deal with problems is normalized as part of everyday life, and the importance of not relying on initial reactions in problem situations is stressed. Finally, “R” reminds children to reward themselves and to take credit for the results they achieve. The critical aspect of self-evaluation for these children is to help them perceive that perfection is not the goal, because many of these children have unrealistically high achievement standards. Exposure to the feared situation is an important part of the treatment process, and children move through exposure experiences in structured stepwise ways, starting with imaginal inoffice exercises with low levels of anxiety, then moving to in vivo situations that have low levels of anxiety, and then moving to increasingly anxiety-provoking situations in imaginal and in vivo practice. In addition to the direct work with children, periodic meetings are held with parents to maintain their support and to collaborate on treatment plans. The Coping Cat program has led to several other similar evidence-based programs such as Coping Koala and the FRIENDS program (Barrett & Shortt, 2003). Some of these more recent programs, such as FRIENDS, have a more substantial focus on working with parents. In group meetings, parents learn to deal with their own anxiety and to use behavioral reward skills with their children. Outcome Research Reviews of Evidence-based Cognitive–Behavioral Approaches Reviews of empirically supported treatments for children with anxiety disorders conclude that behavioral and cognitive– behavioral procedures have more empirical support than do other approaches (Chorpita & Southam-Gerow, 2006; Kazdin & Weisz, 1998). Behavioral techniques (including imaginal and in vivo desensitization) are especially efficacious for phobias, and cognitive–behavioral procedures have been determined to be well-established and probably efficacious for other anxiety disorders (Kendall & Suveg, 2006). Two Exemplars: Coping Cat and FRIENDS Programs The Coping Cat program has been evaluated in a series of studies, beginning with Kendall’s (1994) study of 47 9- to 13-year-old youth diagnosed as having separation anxiety disorder, overanxious disorder or avoidant disorder. At posttreatment, 64% of those who had received Coping Cat no longer met diagnostic criteria for one of these disorders, in comparison to a 5% diagnosis-free rate for waitlist controls, and these gains were maintained at a 1-year follow-up. A longer-term follow-up of this sample, at a point over 3 years after the end of intervention, indicated that these intervention gains were long-lasting (Kendall & Southam-Gerow, 1996). In a second sample, Kendall, Flannery-Schroeder, PanichelliMindel et al. (1997) followed 94 9- to 13-year-old children who were randomly assigned to Coping Cat or to waitlist control, and found that 50% of Coping Cat children were diagnosis-free at post-treatment, and for those who still had diagnoses there was a significant decrease in the severity of their conditions. These significant intervention effects were maintained at 1-year and 7.4-year follow-ups, and the intervention children had reduced risk for other related sequelae of the anxiety disorder, such as substance abuse. In an effort to compare the different forms for delivering the intervention, Flannery-Schroeder and Kendall (2000) randomly assigned 37 8- to 14-year-old children to group CBT, individually delivered CBT or a waitlist control. At postintervention, both intervention conditions demonstrated significant improvement, but the rate of improvement was stronger in children who had been seen individually (73% diagnosisfree in individual CBT, 50% in group CBT and 8% in the control condition). The Coping Cat program was adapted in Australia as the Coping Koala program, and a first evaluation study randomly assigned 79 7- to 14-year-olds to child CBT, child + family CBT or to a waitlist control (Barrett, Dadds, & Rapes, 1996). Children had been diagnosed with separation anxiety disorder, overanxious disorder or social phobia. The combined intervention was somewhat more effective at post-intervention than the child-only intervention (88% diagnosis-free for child + family intervention, 61% diagnosis-free for child-only intervention), but both were more effective than the waitlist control condition (less than 30% diagnosis-free), and both had a similar rate of continued effectiveness at a follow-up that occurred 5–7 years after intervention ended (87% diagnosis-free for child CBT only and 86% for the combined intervention). In a study of the FRIENDS program, Barrett (1998) randomly assigned 60 7- to 14-year-old children to either group CBT, group CBT plus family intervention or to waitlist control. The results favored the combined intervention at post-intervention (56% diagnosis-free for child group CBT, 71% for group CBT + family, 25% for control) and at a 1-year follow-up (65% diagnosis-free for group CBT, 85% for group CBT + family), indicating the added value of also working with parents in these CBT approaches for anxious children. CHAPTER 63 1036 9781405145497_4_063.qxd 29/03/2008 02:58 PM Page 1036

Mediation and Moderation Variables that have been found to be predictive of poorer responses to the Coping Cat intervention are: 1 Higher levels of children’s internalizing problems, using teacher or maternal reports; 2 Higher rates of maternal self-reported depressive symptoms; and 3 Older ages (Southam-Gerow, Kendall, & Weersing, 2001). In contrast, variables that have not been found to moderate CBT intervention outcomes for children with anxiety problems are ethnicity, gender, family income, family composition, maternal-rated externalizing problems or child-reported internalizing problems. The family component of the Barrett, Dadds, & Rapee (1996) program is most effective with younger children, consistent with prior findings of moderators of childoriented CBT programs, and with girls and with families that have parents with anxiety problems. Thus, child-focused CBT appears to be more appropriate for older and more seriously anxious children, and for children with depressed mothers. In contrast, parent-focused CBT is more effective with younger children. Examining mediation effects, Treadwell and Kendall (1996) examined longitudinal changes in 8- to 13-year-olds who had received CBT intervention. Children’s reductions in negative cognitions and state-of-mind ratio were found to mediate the effects of intervention on children’s subsequent improvement in anxiety after treatment. Factors that Influence Outcomes Treatment Fidelity and Adaptation Psychotherapy with children and adolescents has traditionally been a field in which many empirically unsupported approaches have been used (Roberts, Lazicki-Puddy, Puddy, & Johnson, 2003), and typical community-based care had consistently poor outcomes (Bickman, 2002). There was a scarcity of evidence-based research on child interventions until recent years (Rubenstein, 2003). However, in the past decade there has been a tremendous increase in efforts to identify and disseminate evidence-based treatments, many of them based on cognitive–behavioral models (Bickman, 2002; Hawley & Weisz, 2002). Efforts to study systematically the dissemination process of evidence-based interventions for children has only recently begun (Schoenwald & Hoagwood, 2001; Silverman & Kurtines, 2004). Although intervention developers may often insist on complete adherence to protocols, innovations inevitably change as development proceeds (Berwick, 2003), including adjustments made to program materials to address participants’ educational developmental and motivational levels. Arguments can be made for both sides of debates about whether adaptations to evidence-based prevention protocols promote effective use of the programs or not. On the one hand, careful use of the intervention protocol, with high intervention integrity, would be expected to produce outcomes similar to those obtained in rigorous efficacy trials with that intervention. On the other hand, innovative interventions often need to be adapted to the realities of intervening with children in applied settings (Stirman, Crits-Christoph, & DeRubeis, 2004). When exporting interventions from research laboratories to clinical practice settings, refinements can be made to fit clinic conditions (Weisz, Donenberg, Han, & Kauneckis, 1995a), and to make strategies appropriate for the target audiences. As long as rigid adherence to manuals is avoided (Henry, 1998) then clinicians may not regard a manual as a “required cookie cutter approach” (Kendall, 2002). The creative flexible use of CBT manual-based interventions can permit individualization of intervention and increases the likely transportability of the intervention to new settings (Kendall, Chu, Gifford, Hayes, & Nauta, 1998). Thus, manuals derived from intervention research may not be expected to be followed word-for-word in applied practice, but could instead provide a guide for core skills and concepts to be covered (Connor-Smith & Weisz, 2003). Despite the likelihood of adaptation of programs over time, and the possibility that rigid inflexible use of manuals may lead to less effective outcomes when interventions are disseminated to applied settings, little research has examined the effects of program adaptations. Research on the overall usefulness of manuals in treatments with adults have had mixed results (Herschell, McNeil, & McNeil, 2004). Although some studies with adults have found the use of a manual to be related to better outcomes (DeRubeis & Feeley, 1990), other studies of the use of intervention manuals with adult clients have had negative outcomes (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996). Only two studies have directly addressed this issue with child interventions (Harnett & Dadds, 2004; Kendall & Chu, 2000). Harnett and Dadds (2004) asked facilitators in a schoolbased dissemination of a universal prevention program for depression to complete checklists on intervention integrity and on their degree of deviation from the manual’s instructions for specific activities. Prior analyses had found that facilitators’ ratings on this checklist were generally, although not completely, correlated with the ratings of independent observers (r = 0.65 for changes on activities; r = 0.73 for the percentage of core concepts presented). The program was not found to have an influence on outcomes in this dissemination study, and facilitators’ degree of deviation from session activities was not found to be significantly associated with program outcomes. Kendall and Chu (2000) asked therapists who had used a structured evidence-based cognitive–behavioral intervention manual with 148 children (aged 9–13) who had primary anxiety disorders, what kinds of intervention adaptations they made. Therapists made retrospective ratings using the Flexibility Questionnaire. This measure had 7-point rating scales, and assessed the therapists’ degree of flexibility in using seven techniques and activities, and their flexibility in the scope of material discussed. The Flexibility Questionnaire had strong internal consistency (alpha = 0.83). Prior research with these samples had found very high treatment integrity, with 100% adherence to session goals. The study found that the therapists’ COGNITIVE–BEHAVIORAL THERAPIES 1037 9781405145497_4_063.qxd 29/03/2008 02:58 PM Page 1037