Effects of Parent Management Training and Problem-solving Skills TrainingCombined in the Treatment of Antisocial Child Behavior

ALAN E. KAZDIN, PH.D. , KAREN ESVELDT-DAWSON, M.A., NANCY H. FRENCH, R.N. , AND

ALAN S. UNIS, M.D.

Abstract. This investigation evaluated the combined effects of parent management training (PMT) andcognitive-behavioral problem-solving skills training (PSST) for the treatment of antisocial behavior. Psychiatricinpatient children (N = 40, ages7 to 12) and their parentswereassignedrandomly to either PMT-PSST combinedor to a contact-control condition. In the combined treatment, parents received PMT and the children receivedPSST. In the control condition, parents received contact meetings in which the child's treatment was discussed;children met with a therapist in individual sessions where they discussed activities on the ward. All childrenparticipated in a short-term hospital program before their return to the community. Children in the PMT-PSSTcondition showed significantly less aggression and externalizing behavior at home and at school and greaterprosocial behaviorand overall adjustment than contact-controlchildren. These resultswereevident immediatelyafter treatment and at a l-year follow-up assessment. J, Amer , Acad. Child Adol. Psychiat ., 1987.26,3:416-424.Key Words: training. parent management. problem-solving skills. antisocialbehavior.

Ant isocial behaviors in children and adolescents includeaggressive acts , theft, lying, and a number of other symptomsthat reflect major social rule violations. The clinical signifi­cance of antisocial behaviors is reflected in their relativelyhigh prevalence and clinical referral rates, their stability andpoor prognosis over the course of development. and theircontinu ity within families across multiple generations (Kaz­din . 1987; Rutter and G iller, 1983). The significance of anti­social behavior is heightened by the absence ofclearly effectivetreatments. Several interventions have been implemented,including diverse forms of individual, group, and family ther­apy ; behavior therapy; residential treatment; pharmacother­apy ; psychosurgery; and a variet y of innovative community­based treatments (Kazdin, 1985; McCord, 1982; O'Donnell,1985; Sharnsie, 1981). At present. no treatment has beendemonstrated to ameliorate antisocial behavior and to con­trovert the poor prognosis.

Among the available psychosocial interventions. parentmanagement training (PMT) has proved to be especiallypromising. PMT, as developed by Patterson and colleagues(1982) . has focused on altering coercive parent-child interac­tions in the home that foster aggressive child behavior andthat dist inguish families with antisocial child ren (Patterson,1982). Several controlled outcome studies have attested to theefficacy of treatment with outpatient samples, as reflected on

Received Mar . II . 1986: revised June II , 1986: accepted Sept . 17,1986.

From the Ii 'estern Psychiatric Institute and Clinic, University ofPittsburgh School of Medicine, Reprint requests to Dr. Kazdin, Dept.otPsvchiatrv, Western Psvchiatriclnstltute and Clinic , 3811 O 'Hara.~t .. PiIl.lhu;Xh. PA 1521f

Completion otthis research was supported hy a grant (M H35408)and a Research Sci entist Developm ent Award (M H00353) from theNational lnstuute of Mental Health. Several staff members contrib­uted to the execution and completion ofthis project including: DanielleBailin , Lisa Dec'arolis. Lou ise M oore. St ephan ie Fuderich, AntoinetteRodgers, Debra Colbu s, Todd Seigel, Rosanna Sherick. and SherrvIi 'ilson. Their particination is graufully acknowledged. Also, com·ments were provided on portions of this project by Drs. ThomasAchenba ch and Philip C. Kendall. Their input and evaluations aregreatlyappreciated.

0890-8567/87/2603-0416 $02.00/0 (c) 1987 by the AmericanAcad­emy of Child and Adolescent Psychiatry,

measures of child behavior at home and at school (e.g.•Fleischman, 1981; Patterson et al., 1982).

Another promising treatment approach is cognitive-behav­ioral problem-solving sk ills training (PSST). This treatmentfocuses on the cognitive processes and deficits that are consid­ered to mediate maladaptive interpersonal behavior (see Ken­dall and Braswell. 1985). Research has shown that alteringcognitive processes can alter child behavior at home and atschool (e.g.. Arbuthnot and Gordon, 1986; Kendall andBraswell, 1982; Lochman et al., 1984). Yet , most studies ofPSST have focused on nonclinical populations and haveeval uated outcomes on laboratory measures ofcognitive proc­esses (see Gresham. 1985; Kazdin, 1985).

Although PMT and PSST have been applied separately,the ir combination has potential advantages for clinical use.Aggressive children show serious dysfunction in their inter­actions in and out of the home, PMT may be effective inaltering these interactions. Yet , aggressive behavior is alsoassociated with variety of maladaptive cognitive processes ofthe child (e.g., deficits in problem-solving skills, attributinghostile intent to others) (e.g.. Dodge, 1985; Kendall andBraswell, 1985). PMT is not likely to alter these processeswithin the child. Focusing on these cognitive processes rep­resents a viable strategy to produce change in interpersonalinte ractions involving peers, teachers, and other communitymembers outside the home as well as interactions with par­ents. PMT and PSST. when combined, should equip parentsand child ren to manage a wide range of interpersonal situa­tions in which antisocial behaviors arc likely to emerge.

The present study evaluated the effectiveness of PMT andPSST combined. At this stage of developing empirically basedtreatments for antisocial child behavior , the task is to deter­mine whether reliable and clinically significant changes canbe achieved. The present invest igation is preliminary in thesense of focusing on the effects of a large treatment "package"to maximize the likelihood of producing significant therapeu­tic change among severely disturbed children referred forantisocial behavior. PMT was prov ided to parents and PSSTwas provided to the ir children . A control condition wasincluded to control for any therapeutic effects associated withhospitalization, repeated assessment on the outcome meas­ures. and changes in the clinical course of antisocial behaviorover time.

416

APPROACHES TO TREATING ANTISOCIAL BEHAVIOR 417

Method

Participants

Child characteristics. The subjects consisted of 40 children(9 girls and 31 boys) and their parent(s). The children wereall inpatients of a psychiatric facility where children are hos­pitalized for 2 to 3 months. The facility houses 22 children(ages 5 to 13) at anyone time. The children are admitted foracute disorders including highly aggressive and destructivebehavior. suicidal or homicidal ideation or behavior, anddeteriorating family conditions.

For inclusion, children needed: (I) to be referred for treat­ment for their antisocial behavior including aggressive acts,fighting, unmanageability at home or at school, stealing,running away, truancy, or related antisocial behaviors, asidentified at intake assessment; (2) to be rated by their parentat or above the 98th percentile on either the aggression ordelinquency scale of the Child Behavior Checklist; (3) to fallbetween 7 to 13 years of age; (4) to receive a full-scale WISC­R IQ of 70 or above; (5) to show no evidence of neurologicalor organic impairment, seizures, psychoses, or pervasive de­velopmental disorder; and (6) to not be receiving psychotropicmedication.

Children were considered for the program only if there wasa parent or guardian who could participate, as determined byan evaluation of the family at intake. Diagnosable psychopa­thology of the parent(s) was not used as an exclusion criterionunless there was reason to believe that the implementation oftreatment would not be possible (e.g., current psychosis) orthe parent was likely to be hospitalized and therefore un­available. Consent to participate was obtained from bothparent and child.

The children ranged in age from 7 to 12 years (X = 10.1)and in full-scale WISC-R IQ from 70 to 126 (X = 98.5).Thirty (75%) children were white; 10 (25%) were black.Diagnoses of the children, based on DSM-III criteria, wereobtained from direct interviews with the children and theirparent(s) immediately before admission and psychiatric eval­uation after the child had been admitted. Two staff independ­ently completed diagnoses for each child using the abovesources of information. Agreement on principal axis I diag­nosis was relatively high (K = 0.76). Disagreements werediscussed to reach a consensus on the appropriate diagnosis.Principal axis I diagnoses included: Conduct Disorder (N =23), Attention Deficit Disorder (N = 3), Major Depression (N= 4), Anxiety Disorder (N = 2), and other mental disorders(N = 8). Considering principal or secondary axis I diagnosis,31 (78%) of the children met criteria for conduct disorder.

Parent characteristics. In all families, the primary caretakerof the child was the mother or maternal guardian. Theyincluded biological mothers (N = 34) and step, foster, oradoptive mothers (N = 6). They ranged in age from 25 to 50years (X = 33.0). Eighteen children (45.0%) came from two­parent families; 22 (55.0%) came from single-parent families.Head of household social class, calculated by the Hollingsheadand Redlich (1958) two-factor index, yielded the followingbreakdown: classes V (8.8%), IV (38.2%), III (41.2%), II(8.8%), and I (2.9%). Estimated monthly income for familiesranged from 0 to $500 to more than $2,500 (median range,

$500 to $1000). Forty-one percent of the families were onsocial assistance.

Parent psychiatric diagnoses were obtained by administer­ing the Schedule for Affective Disorders and Schizophrenia(SADS-L) (Endicott and Spitzer, 1978) individually to eachparent within 2 to 3 weeks of the child's admission. Twelveof 40 (30.0%) of the mothers met criteria for current mentaldisorder; 28 (70.0%) for past mental disorder. For the 19fathers available for assessment, 3 (15.8%) met criteria forcurrent mental disorder and 10 (52.6%) for past mentaldisorder. Among the mothers and fathers with a disorder,major depression and substance abuse, respectively, were themost frequent diagnoses.

Assessment

Treatment outcome was assessed by parent and teacherevaluations of child behavior at home and at school. Pretreat­ment measures were completed when the child was admittedto the hospital. Posttreatment measures were completed Imonth after the final treatment session to permit parents andteachers to base their evaluations on a sufficient sample ofthe child's functioning. These assessments were also con­ducted 4, 8, and 12 months after treatment had been com­pleted.

Parent checklist ratings. Parents completed the Child Be­havior Checklist (CBCL) (Achenbach and Edelbrock, 1983).The measure includes 118 items each rated on a 0- to 2-pointscale. The items comprise multiple behavior problem scales(first-order factors) derived from factor analyses completedseparately for boys and girls in different age groups (e.g., ages6 to II and 12 to 16). The broad-band and summary scaleswere used for the present study because they apply to boysand girls of all age groups.

Two broad-band behavior problem scales (second-orderfactors) are internalizing and externalizing, which reflect in­ward directed (e.g., schizophrenia, depression) versus outwarddirected (e.g., aggression, delinquency) problems. A total be­havior problem score includes items loading on the first-orderscales plus other items that do not load on specific scales. Ofcentral interest was the effect of treatment on the externalizingscale, which includes a wide range ofantisocial behaviors (e.g.,fighting, destroying objects). In addition to measures of be­havioral problems, the CBCL includes three a priori socialcompetence scales: activities (child participation in activities),social scale (child interactions with others), and school scale(child's academic performance at school), which together yielda total social competence score.

Teacher checklist ratings. To evaluate performance atschool, the children's teachers completed the School BehaviorChecklist (SBCL-Form A2) (Miller, 1977). The measure in­cludes 96 items that assess deviant behavior among children7 to 13 years old. Behavioral characteristics are rated by thechild's teacher as true or false. Of the six factor-analyticallyderived scales (low need achievement, aggression, anxiety,academic disability, hostile isolation, and extraversion), theaggression scale was selected to reflect the area of centralclinical focus. In addition to this scale, the overall summaryscale, total disability, was of interest. This scale reflects asummary score of the degree of behavioral symptoms anddysfunction across the six scales. The SBCL also includes five

418 KAZDIN ET AL.

items in which the teacher rates. on 9-point Likert scales. thechild's intellectual ability. academic skills and performance.emotional adjustment. and personal appeal. These ratingswere summed and used for evaluation as the teachers' globalratings ofschool adjustment.

The CBCL and SBCL were selected because they sample abroad range of childhood dysfunction . including aggressiveand other antisocial behaviors that served as the basis forclinical referral. Also. each measure includes facets of proso­cial behavior (e.g.• social competence scales. overall ratings ofschool adjustment). Finally, both the CBCL and SBCL havebeen studied extensively with clinic and nonclinic popula­tions . Transformed scores are available to facilitate interpre­tation of the measures in relation to normal (nonclinical)same-age peers.

Treatment Conditions

Because all children were inpatients, the treatment condi­tions were superimposed upon the general ward milieu pro­gram ." This program included a variety of routine ward andgroup activities and day-to-day contact with direct care work­ers and other staff. Time out from reinforcement and seclu­sion were included as routine procedures for handling uncon­trollable behavior. Apart from the ward program. other spe­cific treatments were not provided beyond those reportedbelow. On the other hand. treatments with known effects werenot withheld from the patients. If it was felt during thepretreatment diagnostic period (3 to 4 weeks) that anotherspecific treatment was clearly indicated (e.g.. medication fora child with Major Depression and Conduct Disorder), thechild was not included in the project . Children in the projectdid not receive treatments other than those described belowor included as part of routine ward care . In addition to thegeneral ward program for all children, the hospital programincluded biweekly contact with the parents rout inely for allchildren . This contact was provided to convey how the childwas doing generally in the hospital and to discuss issues relatedto discharge.

Two groups or conditions were included in the study; (I)the combination of PMT-PSST: and (2) a contact-controlcondition, described below. Cases were assigned randomly toone of two conditions and to one of four therapists. Therapistssaw children in each condition.

Parent management training-s-problem solving sk ills train­ing combined (N = 24). In this condition, separate interven­tions were provided to parents and their child . PMT consistedof meeting with the parent(s) of the hospitalized child. Thetreatment program was modeled after Patterson et al., (1975)and Fleischman and Conger (1978). Thirteen sessions wereprovided individually to each family. Each session lastedapproximately 2 hours and was provided once per week. Thesessions covered several specific content areas including ob­serving and defining behavior. positive reinforcement, timeout, negotiating and contracting. and so on.

With in the sessions. several different procedures were used

" The term milieu here is used to denote a general ward manage­men/ program rather than milieu therapy. Such programs reflectgenera! organization ot' the ward routines and self-care behaviors.classroom activities. ofinpatient services (see Kazdin, 1985).

to train the parents including didactic instruction. role play.and modeling. Audiotapes of problematical parent-child in­teractions were presented and used as a basis for discussionand designing behavioral programs. Treatment of the parentsbegan while the child was in the hospital. Parents practicedthe initial skills (e.g.. observing and recording behavior) onother children or someone else in the home because the childpatient remained in the hospital at this time. After 5 or 6weeks. the child went home for a weekend trial visit. In thenext week or two. the child was discharged and returnedhome . Training was continued on an outpatient basis for theremaining sessions. Sessions at this point focused on imple­mentation of procedures designed to manage the child's prob­lems at home and at school.

Children of parents who received PMT received PSST.Treatment was administered individually in 20 sessions. Eachsession lasted approximately 50 minutes. Therapy wasmodeled after the treatment procedures developed by Spivacket al. (1976) and Kendall and Braswell (1985). The treatmentfocused on teaching problem-solvingsteps the child could useto manage interpersonal situations and to train requisite skillsfor generating alternative solutions, developing means-endsand consequential thinking. and taking the perspecti ve andrecognizing the feelings of others.

Tra ining began initiall y by teaching the child to use thesteps on academic tasks (selected at grade level) and games(e.g.. checkers) . The tasks became increasingly complex overthe course of sessions and were devoted primarily to enactinginterpersonal situations where the child could apply the steps.In each session, practice. modeling, role-playing. correctivefeedback. and social reinforcement were used to developproblem-solving skills. Response cost (loss of chips) was alsoused for errors in carrying out the problem-solving approach(e.g., skipping a step). Chips. provided at the beginning ofeach session. could he exchanged for toys and prizes at theend of the sessions. As part of treatment, children wereassigned homework in which they at first identified situationsin their daily lives in which the problem-solving approachcould be applied. and eventually they actually used the ap­proach in real-life situations.

Approximately 15 of the 20 sessions were completed whilethe child was in the hospital. The remaining sessions werecont inued on an outpatient basis to provide opportunities toappl y the approach to everyday situations. When the childreturned for his or her weekly session, the parents were alsoseen for their session of PMT. Separate therapists saw theparents and child. The sessions completed by the child orparent were coordinated within a family so that parents andchild returned approximately an equal number of times foroutpatient sessions."

Information was conveyed to parents and children so thateach knew what the other person(s) was learning. Parentslearned about the problem-solving steps and the purposestoward which they were directed and encouraged. after dis-

" Because (!I" scheduling and discharge ex igencies, the child andparents did not always complete theirfinal sessions at the same week.For assessment purposes. the end oftreatment was defined as the lasttreatment contact, whether it was with the parent or child. ifthese did/101both occur on the same day.

APPROACHES TO TREATING ANTISOCIAL BEHAVIOR 419

charge, to praise the child's use of the approach. Similarly,the child was informed about what the parents were learningand was involved, in part of one session ofPMT in negotiationand contracting, to help develop a behavioral program thatcould be continued after discharge. There was no attempt toteach parents how to train problem-solving skills nor to teachchildren how to apply alternative social-learning principles.

Treatment-contact control (N = 16). Several features of thePMT-PSST condition might contribute to or account fortherapeutic change including hospitalization, separation ofchildren from stressful home and school situations, repeatedtreatment contact of therapists with parents and children,repeated assessment contacts spanning over I year, identifi­cation of children for a "special" treatment program on theward, and so on. Ideally, it would be valuable to contrastPMT-PSST with another viable treatment with known effectsto control for many of the influences that could contribute totherapeutic change. The absence of a routine procedure withclearly demonstrated efficacy among the large array of avail­able treatments (see Kazdin, 1985) not only raises a dilemmafor selection of a comparison group but also serves as theimpetus for the present study.

From a methodological standpoint, it would also be desir­able to compare PMT-PSST against a no-treatment or mini­mal treatment control group. The reason for considering sucha group is the absence of information from clinical treatmenttrials on the short- or long-term course of severe antisocialchild behavior. A no-treatment group would provide thebaseline information regarding clinical course of antisocialbehavior against which the effects of a treatment conditionwould be compared.

Patients in the present project of necessity participated intreatment (hospitalization and the associated milieu). Al­though there is no apparent standardized treatment for anti­social children, a variety of treatments are often appliedincluding diverse variations of individual, group, and familytherapies. To date, there is no firm evidence that variationsof these techniques produce therapeutic change in antisocialyouths seen in outpatient or inpatient settings (see Kazdin,1985). The present program did not include individual, group,or family therapies as part of the standard treatment beforethe inception of the present project. All children in the projectparticipated in the hospital milieu program that includedwidely practiced features of residential care such as individu­alized academic activities in the classrooms on the treatmentservice, close personal contact among children and staff,structured routines and activities, discussions designed topromote socialization, and so on. Rather than withhold anyof these. the control group as well as the treatment groupparticipated fully in the hospital program. Control childrendid not receive PMT-PSST sessions. Several practices wereadded to control for some of the influences in the PMT-PSSTcondition that might contribute to therapeutic change.

The control group consisted of children who received thehospital program and repeated assessment over the course ofpretreatment through follow-up. Also, given the structure ofthe ward experience, it was important that children in thecontrol condition were identified on the ward as receiving aspecial treatment and individual sessions with a therapist aswere the children in the PSST condition.

To partially control for attendance in special sessions,individual contact with a therapist, and treatment beyond theusual ward routines, a treatment-contact control group wasdevised. As the PSST children, control children received 20individual treatment sessions. The number of sessions andtheir schedule were similar to those ofPSST. However, controlsubjects completed their sessions while in the hospital to avoidbringing them back for a condition that was designed as acontrol procedure. This did not require any difference induration of hospitalization between children who receivedPSST or control conditions. Spacing of the sessions beforedischarge was used to coordinate the treatment schedules.

An important feature of this condition was to provide thetherapist and child with time to be together. The therapist'stask in the sessions was to engage the child in discussionrelated to routine activities on the ward. Although the primarymedium of exchange was conversation, there was no attemptto probe the child's feelings or clinical problems or to developinsight, self-acceptance, or to address related processes. Thetherapist played games (e.g., checkers) if the child wished, aslong as the child and therapist were together. To keep thefocus on daily activities and games, the treatment sessionswere relatively brief (20 to 25 minutes) and hence less thanone half the duration of PSST sessions.

Parents of the control children did not receive specialindividual treatment sessions to control for the contacts as­sociated with PMT. A major reason for this decision was thefact that repeated contacts were made with each family aspart of hospital care. Parents in the treatment and controlcondition received scheduled contacts on a biweekly basis(with a social worker and a resident or intern) over the courseof hospitalization. These contacts, provided individually toparents of all families, discussed how the child was doing,diagnostic and assessment information, and any issues rele­vant to the child's discharge.

Treatment Administration

Therapists. Four female clinicians (ages 25 to 31) served astherapists. Each had completed postgraduate course work inchild development or other mental health related fields. Thetherapists had I to 2 years of direct care experience withchildren and families on the clinical service. The therapistsparticipated in an intensive training program for approxi­mately 6 months to learn the techniques. During this period,they received didactic instruction on the techniques and un­derlying rationale. The treatments were prepared in manualform in which the content of each session, the materials, theirorder of presentation, and sample dialogues were detailed.Therapists saw training cases that were closely supervised bydirect observation of each session, review of tapes with indi­vidual therapists on a session-by-session basis, discussion ofthe case, and group meetings to review cases. Once the inves­tigation began, supervision continued throughout the courseof treatment with individual meetings with clinicians, groupmeetings, and weekly case review. Treatment sessions werevideo- or audiotaped and/or observed directly through a one­way mirror for supervision purposes.

Treatment integrity. Several practices were invoked tomaintain the integrity of treatment (Yeaton and Sechrest,1981): (I) therapists followed a manual for each treatment

420 KAZDIN ET AL.

that prescribed specific practices and procedures for eachsession; (2) before seeing cases for the study, each therapistsaw 2 to 3 training cases in each condition; (3) several mate­rials were provided to foster the correct execution of eachsession such as checklists that prescribed the necessary mate­rials; (4) documentation of the session summarized whattranspired, any unique features, child progress, and so on;and, (5) ongoing clinical supervision, feedback, and trainingwere provided throughout the project.

Attrition

Forty subjects were assigned randomly to either the PMT­PSST or control conditions. Four (10.0%) of the 40 subjectsdid not complete treatment, 3 were from the combined treat­ment, and I was from the control condition. -The reasonsincluded early termination of hospitalization against medicaladvice (N = 2) and parent failure to complete sessions afterdischarge of the child (N = 2). One additional child from eachcondition was lost because of parent refusal to provide orconsent to posttreatment assessment. Twenty of 24 (83.3%)subjects from the PMT-PSST group and 14 of 16 (87.5%)from the control condition completed treatment, providedassessment data, and were used for the data analyses. At thel-year follow-up assessment, data were available from parentsand teachers for 28 (82.4%) and 27 (79.4%) of the children,respectively.

Results

Preliminary Analyses

To evaluate the influence of subject and demograhic vari­ables on performance across the different measures, factorialmultivariate analyses of variance (MANOVAs) were com­pleted for child age, gender, race, IQ, mother age, current orpast mental disorder, welfare status, and family Hollingsheadclass. For continuous variables (e.g., age, IQ), median splitswere used for these data analyses. No reliable differences wereobtained as a function of subject and demographic variablesat pretreatment, posttreatment, or follow-up assessments.MANOVAsalso were completed to evaluate whether childrenin the combined treatment or control groups differed atpretreatment either in subject and demograhic variables or inperformance on the CBCL or SBCL. No significant effectsemerged.

Treatment Effects

MANOVAs indicated no significant differences for thefunction of therapist as a main effect or interaction withtreatment condition on the CBCL or SBCL at posttreatmentor follow-up. Consequently, the therapist was not used as aclassification variable to evaluate treatment effects.The effectsof treatment condition were evaluated with analyses of covar­iance for CBCL and SBCL scales. For the covariance analyses,pretreatment performance was the covariate for the specificmeasure. Changes over the course of treatment were evaluatedby within-group t tests.

Posttreatment. Posttreatment assessment was conducted Imonth after the final treatment session. Means and S. D. forthe parent and teacher measures appear in Table I. Analysesof covariance are presented in Table 2. The results at post­treatment indicated significant group differences for internal-

izing, externalizing, and total behavioral problem scales ofthe CBCL. For each measure, the children who received PMT­PSST combined were significantly less deviant than the con­tact-control group. For the social competence scales of theCBCL at posttreatment, parents of PMT-PSST youths ratedtheir children as participating in more social activities, inter­acting socially more with others, and progressing better atschool than did parents of children in the control condition.On the SBCL, PMT-PSST children were rated by their teach­ers as less aggressive and deviant overall on these scales andmore well adjusted at school (Table 2). Within-group t (Table3) indicated significant improvements from pre- to posttreat­ment for CBCL and SBCL scales for the children in thecombined treatment group. Children in the control groupimproved on total behavioral problems (CBCL) and aggres­sion scale (SBCL) but did not show a broad range of improve­ments from pre- to posttreatment across the different scales.

One-year follow-up. The CBCL and SBCL were readmin­istered to parents and teachers 4, 8, and 12 months aftertreatment. The results were similar for the different follow-upperiods and did not lead to different conclusions about theimpact of treatment or relative standing of the treatment andcontrol conditions." For summary purposes and to evaluatethe impact of treatment at the final assessment point, onlythe results for the I-year follow-up are discussed.

At the 12-month follow-up, significant between-group dif­ferences remained for parent evaluations of internalizing,externalizing, and total behavioral problem scales (see Table2). Social competence scales indicated that PMT-PSST chil­dren participated more in activities, interacted socially morewith others, and progressed in their school performance sig­nificantly better than contact-control subjects. For behavioralproblem and social competence scales, the magnitude of thedifferences at follow-up tended to be greater than those evi­dent at posttreatment. The SBCL aggression, total disability,and global ratings of school adjustment also showed groupdifferences at the 12-month follow-up in favor of the PMT­PSST children.

Within-group t tests indicated that from pretreatment tothe I-year follow-up, the improvements for PMT-PSST groupwere significant across almost all of the measures (Table 3).For contact-control subjects, there was statistically significantdeterioration of performance from pretreatment to the I-yearfollow-up, as reflected in decreased participation in activitiesand academic progress at school (see Table 3).

The within-group changes from pretreatment to I-yearfollow-updo not convey the extent to which behavior changedafter treatment. Within-group t tests from posttreatment tothe I-year follow-up indicated that combined treatment sub­jects did not change (i.e., improve or deteriorate) significantlyduring the year after treatment. In contast, for the posttreat­ment to l-year follow-up period, contact controls tended todeteriorate, as reflected by increases in externalizing (1(12) =- 3.16, p < 0.0 I) and total behavior problem scores (1(12) =-3.37, p < 0.01) and by decreases in participation in socialactivities (1(12) = -2.74, p < 0.05) and school performance(I( 12) = -4.63, p < 0.00 I). Within-group tests suggest that

<' Tables and data anlyses that include the 4- and 8-month follow­up assessments are available on request.

APPROACHES TO TREATING ANTISOCIAL BEHAVIOR 421

TABLE 1. Means and S.D. for Child Behavior Checklist and School Behavior Checklist from Pre- to Posttreatment Through Follow-up

Pre Post l-yr Follow-upGroup

X X XS.D. S.D. S.D.

PMT-PSSTcombined treatmentCBCL: Internalizing 72.7 (10.3) 64.2 (6.9) 64.9 (8.7)

Externalizing 77.6 (5.8) 66.7 (6.1) 67.3 (5.8)Total behavior problems 78.9 (8.9) 66.4 (7.4) 68.4 (8.7)Activities 42.7 (10.7) 49.5 (6.2) 46.2 (11.4)Social 29.0 (12.1 ) 38.1 (11.1) 37.8 (12.4)School performance 29.8 (8.7) 36.3 (8.7) 36.4 (9.8)

SBCL: Aggression 80.5 (9.8) 65.8 (13.8) 65.1 (13.1)Total disability 75.5 (8.2) 62.1 (10.7) 63.2 (10.0)Global school adjustment 19.2 (5.7) 26.1 (6.6) 25.1 (4.9)

Treatment-contact controlCBCL: Internalizing 70.9 ( 10.4) 67.2 (7.0) 69.6 (5.9)

Externalizing 77.6 (5.0) 75.8 (6.6) 80.2 (5.0)Total behavior problems 78.4 (7.7) 73.1 (7.0) 78.8 (6.4)Activities 44.3 (9.8) 41.3 (7.9) 36.3 (10.6)Social 29.6 (10.2) 27.4 (7.5) 25.4 (9.8)School performance 41.2 (10.8) 34.1 (11.1 ) 28.7 (12.8)

SBCL: Aggression 78.7 (8.0) 73.9 (9.7) 76.9 (8.7)Total disability 70.2 (6.5) 67.8 (6.5) 68.3 (6.1)Global School Adjustment 19.4 (4.0) 17.7 (6.1) 18.1 (5.6)

Note: Scoresare normalized T scoresderived from the Child BehaviorProfile.

Assessment Period

TABI.E 2. Analyses ofCovariance (F Values) After Treatment and atFollow-up

in development of the rating scales (Achenbach and Edel­brock, 1983; Miller, 1977).

Based on their analyses of clinical and nonclinical samples,Achenbach and Edelbrock (1983) suggested that the 90thpercentile is a cutoff score for the upper limit of the normalrange for the total behavior problem score. Scores below thispercentile fall within the nonclinical ("normal") range. Forpresent purposes, the 90th percentile criterion was used todefine the upper limit of the normal range on total behaviorproblem scores on the CBCL and total disability score on theSBCL. Achenbach and Edelbrock (1983) also suggested the10th percentile as a lower limit of the nonclinical range onthe total social competence score (sum of three social scales).Children below this percentile are more deviant in theirprosocial behavior than 90% of children in nonreferred nor­mative samples.

Group means. The initial question of interest for the presentanalysis is the extent to which changes achieved among chil­dren in treatment and contact-control groups fell within thenonclinical range. To address this question, T scores thatdefined the upper limit of the normal range were used as acriterion to evaluate performance over the course of theproject for treatment and control subjects for total behaviorproblem and total disability scales. Mean Tscores for childrenin the two groups as well as the T-score cutoffs based on dataobtained from nonclinical samples are presented in Figure I.The figure shows that clear changes were evident on bothCBCL and SBCL behavior problem scales (upper and lowerpanels, respectively) for the combined treatment group. Forthe CBCL, it is also clear that the mean level of performancedid not fall within the normative range. For the SBCL, themean level of the combined treatment cases fell within thisrange after treatment and remained close to this level atfollow-up. Even so. it must be remembered that this is theupper limit of the normative range rather than a necessarily

I-yrFollow-up

(df= 1.25)4.71·

47.84···13.88···8.14··8.96··

12.63···(d/= 1.24)

9.05··5.35·9.83··

Dependent Measure

deterioration of control children over the follow-up periodrather than further improvements among the PMT-PSSTchildren accounted for the larger between-group differencesat follow-up than at posttreatment.

Clinical Impact otTreatment

A major question is the extent to which the combinedtreatment produced clinically important changes. One meansto examine the clinical significance is to evaluate the extentto which treatments brought child behavior within the non­clinical range offunctioning (Kazdin, 1977). Normative dataare available for both the CBCL and SBCL that permitdelineation ofa range of behavior for nonclinical samples. Toreflect an overall level of dysfunction, total behavior problem(CBCL) and total disability (SBCL) scales were examined forchildren who participated in the study relative to nonclinicalsamples within the same age range as derived from data used

AfterTreatment

Child BehaviorChecklist (d/= I. 30)Internalizing 6.57·Externalizing 19.51···Total behavior problems 7.89··Activities 15.20···Social 11.22··School performance 16.96···

School BehaviorChecklist tdf= I. 31)Aggression 6.75·Total disability 5.58·Global-school Adjustment 14.51···

-------• P s 0.05; •• P s 0.01; ••• P -s 0.00 I.

422 KAZDIN ET AL.

TABLE 3. Within-Group t Tests From Pre- to Post/reatment and from Pre- to /- Year Follow-up

PMT-PSST Control

Dependent Measures Pre toPost

Pre toFollow-up

Pre toPost

Pre toFollow-up

Child Behavior Checklist (df= 18) (df= 14) (df= 13) (df= 12)Internalizing 5.82··· 4.02··· 1.95 <IExternalizing 6.80··· 7.70··· 1.22 -1.90Total behavior problems 5.83··· 5.01··· 2.45· <IActivities 3.04·· 1.54 -1.34 - 3.03··Social 2.85· 2.69· 1.00 -1.84School performance 3.67·· 2.64· <I -5.96···

School Behavior Checklist (df= 19) (df= 16) (df= 13) (df= 9)Aggression 5.61··· 4.92··· 2.23· <ITotal disability 5.15··· 5.43··· 1.38 < IGlobal-school adjustment 4.25··· 3.00·· < I < I

Note: PMT-PSST. parent management training and problem-solving skills training combined; control, treatment-contact control. Minus tvalues indicate that change is in the direction of deterioration (increased deviance. decreased prosocial behavior).

• p -s 0.05. •• p ~ 0.01, ••• p s 0.001.

60

75

CBCLTOTAL 70BEH

adaptive level of functioning. As for social competence total(Figure 2), performance of both groups was close to the lowerboundary (10th percentile) for nonclinical range. Social com­petence fell within this range after treatment and at the l-yearfollow-up only for the PMT-PSST children. Control subjectsdecreased in their social competence scores, i.e., becameworse, over the course of treatment and follow-up.

Individual cases. The group means fail to reflect the per­formance of individual children. Chi-square tests were com­pleted to evaluate the proportion of children within each ofthe two conditions that fell within the nonclinical range." Forthese analyses, children were excluded if their pretreatmentscores for the specific measure already fell'within this range.The proportion of subjects who fell within the nonclinicalrange at posttreatment and at the I-year follow-up is presentedin Table 4. Although a larger proportion of subjects from thePMT-PSST group fell within the nonclinical range than theproportion from the contact-control group on the behaviorproblem scales of the CBCL and SBCL at posttreatment andat the I-year follow-up, these differences only attained signif­icance (p < 0.05) for the CBCL at follow-up (see Table 4).For the social competence measure, a higher proportion ofchildren in the PMT-PSST condition than the control groupfell within the normative range at posttreatment (p < 0.05)and at follow-up (p < 0.0 I). Although the results indicatedthat more combined treatment than control subjects fellwithin the normal range at posttreatment and follow-up, mostof the treatment subjects remained outside of the normativerange on the behavior problem measures.

SBCLTOTAL

DIS

• PMT/PSST

o CONTROL

_.- NORMALRANGE

PRE POST FU 12ASSESSMENT

PRE POST FU 12ASSESS~ENT

FIG. I. Mean T scores for the PMT-PSST and contact-controlgroups for the total behavior problem scale of the CBCL (upper panel)and total disability scale of the SBCL (lower panel). The horizontalline represents the upper limit of the nonclinical (normal) range ofchildren of the same gender and age. T scores below this level (line)fall within the normal range.

J Normative data and percentile equivalents are available from theassessment manuals/or the CBCL (Achenbach and Edelbrock, /983)and SBCL (Miller, /977). To compute whether a child's score fallswithin the normal range. raw scores need to be examined. The reasonis that different raw scores may yield the same T'scores (see Achenbachand Edelbrock, /983). For the present analyses. the raw scores wereused bill converted to T scores/or presentation ofresults.

APPROACHES TO TREATING ANTISOCIAL BEHAVIOR 423

40

In the absence of including other treatments, several pre­liminary conclusions still seem warranted. Given the contact­control condition, it is unlikely that group differences wereattributed to the passage of time, the impact of hospitalizationor repeated testing, and participation in treatment sessions orcontact with a therapist. On the other hand, the controlcondition did not encompass several other features associatedwith PMT-PSST such as extra contact with the parents beyondthose associated with hospital care, duration of individualtreatment sessions with the children, and treatment contactafter hospitalization. Whether these and related influences areplausible explanations for the differences in outcome of treat­ment and control conditions for severely aggressive childrenimmediately after treatment and up to I year later is a matterof conjecture. Yet, these alternative influences cannot be ruledout based on the present design.

To date, there are too few tests of treatment with controlconditions of any sort that have shown reliable changes im­mediately after treatment and up to I year later in clinicallyreferred antisocial youths (see Kazdin, 1985). Although thechanges associated with the combined treatment in the presentstudy were statistically significant, the clinical impact waslimited. More children within PMT-PSST condition than thecontrol condition fell within the nonclinical range. However,at the l-year follow-up the majority of treated and controlchildren remained outside of this range on parent and teachermeasures of behavioral problems. The magnitude of changeneeds to be much greater to bring the children within morenormative levels of functioning.

There are several limitations of the present study stemmingin part from the nature of the question that was asked, thesetting in which the evaluation was conducted, and the design.First, the combination of PMT and PSST raises the questionof whether both were necessary and, if so, their relativecontributions. The two techniques were combined to addressa very preliminary question; namely, can a "package" of twopromising treatments produce therapeutic change? Only aftersuch changes have been demonstrated is it meaningful toexamine the necessary and sufficient conditions for suchchanges (see Kazdin, 1986). In relation to the present study,the highest priority remains to bolster the impact of treatment.

Second, treatments were administered to hospitalized chil­dren, all of whom participated in a general ward program.The hospital program might be therapeutic and hence help to

35• PMT/PSST

CBCL 30 o CONTROLSOC CaMP

_.- NORMAL

25 RANGE

20PRE POST FU 12

ASSESSMENT

FIG. 2. Mean T scores for the PMT-PSST and contact-controlgroups for the total social competence scales of the CBCL. Thehorizontal li.ne represents the lower limit of the nonclinical (normal)range .of children of the same gender and age for these prosocialbehaviors, T scores above this level (line) fall within the normal range.

Discussion

The major results are that: ( I) parent management trainingcombined with problem-solving skills training producedgreater changes at posttreatment and at l-year follow-up thandid the contact-control condition; (2) changes for the com­bined treatment group were sustained for up to a l-yearfollow-up assessment; (3) changes were not only evident inthe symptom areas that served as the basis of subject selectionand the focus of treatment (e.g., externalizing behavior) butin other areas as well (e.g., internalizing symptoms, prosocialbehavior, school adjustment); and (4) changes for combinedtreatment cases were evident both at home and at school.

In previous research, PMT and PSST have been studiedseparately given their different conceptual underpinnings andpresumed therapeutic processes. They were combined in thepresent study in an attempt to maximize therapeutic changegiven the absence of clearly effective or standardized treat­ments for antisocial behavior. The findings suggest that reli­able improvements could be achieved with severely aggressivechildren. It might be that PMT-PSST appeared effective be­cause of the weak control condition with which it was con­trasted. Possibly a stronger alternative treatment such as in­tensive individual or family therapy would have effectedsimilar changes as the PMT-PSST group. Evidence in supportof this possibility is difficult to cull from the literature. Nev­ertheless, further tests with alternative other treatments areneeded.

_____T_A_"_LE 4. Proportion o(Children Who Fall Within Ran!?eofNonclinical Samples at Posllreatment and at Follow-up

Groups

PMT-PSST Control

3.294.74·

<I

1/14(7.1%)1/11 (9.1%)4/10 (40.0%)

6/17 (35.3%)8/15 (53.3%)

11/18 (61.1%)

PosttreatmentCBCL: Total behavior problems

Social competence totalSBCL: Total disability

One-year follow-upCBCL: Total behavior problems 4/15 (26.7%) 0/13 (0.0%) 4.06·

Social competence total 8/13 (61.5%) 0/10 (0.0%) 9.45··SBCL: Total disability 7/15 (46.7%) 3/7 (42.9%) <I

Note: Children with a raw score at or below the 90th percentile on the total behavior problem scale (CBCL) or total disability scale (SBCL)~r;.~~e the 10th percentile on the social competence total (CBCL) at pretreatment were excluded from these proportions. • p s0.05; •• = p

424 KAZDlN ET AL.

confound the results. Firm empirical evidence that hospitalprograms can reliably alter antisocial behavior among childor adolescent patients in the short- or long-run is currentlyunavailable (see Kazdin, 1985; Shamsie, 1981). Nevertheless,'the impact of hospitalization cannot be discounted. It ispossible that the effects of the PMT-PSST interacted with andwould not be evident without hospitalization of the child.Strictly speaking, the conclusions of the present study need tobe qualified by noting that all children were initially removedfrom their home, a condition that might very much facilitatetreatment implementation and contribute to therapeuticchange.

Third, the results relied upon parent and teacher ratings.Although the measures have been shown to correlate withovert behavior (see Achenbach and Edelbrock, 1983; Miller,1977), the absence of direct observations in the home and atschool delimits interpretation of the results. There may bebiases in the assessment procedures that would foster theconclusion that combined treatment was therapeutic. Possi­bly, parents who participated in treatment were more likelyto rate behavior more positively because of the attention theyreceived. Such a bias cannot be entirely ruled out. Yet teacherevaluations were much less subject to this influence becauseteachers knew only that children had been in the hospital.Nevertheless, future studies need to expand the assessmentbeyond parent and teacher ratings.

Fourth, the study may not have provided a strong test oftreatments. The sample size was relatively small and thestrength of treatment (e.g., duration of the regimen) could beincreased. Indeed, the statistically reliable but clinically smallimpact of the PMT-PSST suggests that a much more intensivetreatment regimen warrants testing. The present results indi­cate reliable changes in performance at home and at schooland hence provide promising basis for continued evaluation.

Finally, the study might be faulted for suffering from apatient "uniformity myth" (Kiesler, 1971). By focusing ontreatment techniques only, the study may inadvertently sug­gest that all antisocial youths are similar and perhaps shouldrespond similarly. Actually, the screening criteria attemptedto select a relatively homogeneous set of patients in terms oftheir presenting problems. Nevertheless, it will be importantto delineate child, parent, and family variables that mayinteract with treatment effects.

In view of the above, the present results must be regardedas preliminary. An initial priority is to work further to aug­ment the effects of treatment so that the clinical impact isclear. To date, few controlled studies of antisocial behavior inchildren have been reported (Kazdin, 1985). The presentresults do not begin to satisfy the urgent need for empiricallybased and demonstrably effective treatments for antisocialyouths. The findings do suggest that current treatments holdpromise and warrant further study.

ReferencesAchenbach, T. M. & Edelbrock, C. S. (1983), Manual for the Child

Behavior Checklist and Revised Child Behavior Profile. Burlington,Vt.: University Associates in Psychiatry.

Arbuthnot, J. & Gordon, D. A. (1986), Behavioral and cognitiveeffectsof a moral reasoningdevelopment intervention for high-riskbehavior-disordered adolescents.J. Consult. Clin. Psychol., 54:208­216.

Dodge, K. A. (1985), Attributional bias in aggressive children. In: ed.P. C. Kendall. Advances in Cognitive-Behavioral Research andTherapy, Vol. 4, pp. 73-110. Orlando, Florida: Academic Press.

Endicott, J. & Spitzer, R. L. (1978), A diagnostic interview: TheSchedule of Affective Disorders and Schizophrenia. Arch. Gen.Psychiat., 35:837-844.

Fleischman, M. J. (1981), A replication of Patterson's "Interventionfor boys with conduct problems." J. Consult. Clin. Psychol.,49:343-351.

-- & Conger, R. E. (1978), An approach to families of aggressivechildren: procedures for didactic parent training groups. Unpub­lished manuscript. Family Research Associates.

Gresham, F.M. (1985), Utility of cognitive-behavioral procedures forsocial skills training with children: a critical review. J. Abnorm.Child Psvchol., 13:411-423.

Hollingshead, A. B.& Redlich, F. C. (1958), Social Class and MentalIllness. New York: Wiley.

Kazdin, A. E. (1977), Assessing the clinical or applied significanceofbehavior change through social validation. Behav. Modification,1:427-452.

-- (1985), Treatment ofAntisocial Behavior in Children and Ado­lescents. Homewood, III.: Dorsey Press.

-- (1986), The evaluation of psychotherapy: research design andmethodology. In: ed. S. L. Garfield & A. E. Bergin, Handbook ofPsychotherapy and Behavior Change, Ed. 3, pp. 23-68. New York:Wiley.

-- (1987), Conduct Disorder in Childhood and Adolescence. New­bury Park, Calif.:Sage.

Kendall, P.C. & Braswell, L. (1982), Cognitive-behavioral self-controltherapy for children: a components analysis. J. Consult. Clin.Psvchol., 50:672-689.

--'-- (1985), Cognitive-Behavioral Therapy for Impulsive Chil­dren. New York: Guilford Press.

Kiesler, D. J. (1971), Experimentaldesignsin psychotherapyresearch.In: ed. A. E. Bergin & S. L. Garfield, Handbook ofPsychotherapyand Behavior Change: An Empirical Analysis, pp. 36-74. NewYork: Wiley.

Lochman, J. E.. Burch. P. R.. Curry, J. F. & Lampron, L. B. (1984),Treatment and generalization effects of cognitive-behavioral andgoal-setting interventions with aggressive boys. J. Consult. Clin.Psvchol., 52:915-916.

McCord. W. (1982). The Psychopath and Milieu Therapy: A Longi­tudinal Studv. New York: Academic Press.

Miller.L. C. (1'977), School Behavior Checklist Manual. Los Angeles,Calif.:Western Psychological Services.

O'Donnell, D. J. (1985), Conduct disorders. In: ed. J. M. Weiner,Diagnosis and Psychopharmacology of Childhood and AdolescentDisorders, pp. 249-287. New York: Wiley.

Patterson, G. R. (1982), Coercive Family Process. Eugene. Ore.:Castalia.

--Chamberlain. P. & Reid, J. B.(1982), A comparative evaluationof a parent-training program. Behav. Ther., 13:638-650.

- Reid. J. B., Jones, R. R. & Conger. R. W. (1975). A SocialLearning Approach to Family Intervention, Vol. I. Eugene. Ore.:Castalia.

Rutter. M. & Giller, H. (1983), Juvenile Delinquency: Trends andPerspectives. New York: Penguin Books.

Shamsie, S. J. (1981), Antisocial adolescents: our treatments do notwork-where do we go from here? Canad. J. Psychiat., 26:357­364.

Spivack.G., Platt. J. J. & Shure. M. B. (1976), The Problem-SolvingApproach to Adjustment. San Francisco, Calif.: Jossey-Bass.

Yeaton. W. H. & Sechrest, L. (1981), Critical dimensions in thechoice and maintenance of successful treatments: strength, integ­rity, and effectiveness. J. Consult. Clin. Psychol., 49:156-167.