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Treating Childhood

and Developmental
Treating Childhood
and Developmental
Edited by

Johnny L. Matson
Louisiana State University, Baton Rouge, LA

Frank Andrasik
University of West Florida, Pensacola, FL

Michael L. Matson
Louisiana State University, Baton Rouge, LA
Johnny L. Matson Frank Andrasik
Department of Psychology Department of Psychology
Louisiana State University University of West Florida
Baton Rouge, LA 70803 Pensacola, FL 32514-5751
225-752-5924 fandrasik@uwf.edu

Michael L.Matson
Department of Psychology
Louisiana State University
Baton Rouge, LA 70803

ISBN: 978-0-387-09529-5 e-ISBN: 978-0-387-09530-1

DOI: 10.1007/978-0-387-09530-1

Library of Congress Control Number: 2008931350

© Springer Science + Business Media, LLC 2009

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Chapter 1. History of Treatment in Children

with Developmental Disabilities and Psychopathology ..................... 3
Jonathan Wilkins and Johnny L. Matson

Chapter 2. Applied Behavior Analysis and the Treatment

of Childhood Psychopathology and Developmental Disabilities ........ 29
Joel E. Ringdahl and Terry S. Falcomata

Chapter 3. Cognitive Behavior Therapy .......................................... 55

Ellen Flannery-Schroeder and Alexis N. Lamb

Chapter 4. Parent-training Interventions ........................................ 79

Nicholas Long, Mark C. Edwards, and Jayne Bellando



Chapter 5. Conduct Disorders ....................................................... 107

Christopher T. Barry, Lisa L. Ansel, Jessica D. Pickard,
and Heather L. Harrison

Chapter 6. Treatment of Attention-Deficit/

Hyperactivity Disorder (ADHD) ........................................................ 139
Ditza Zachor, Bart Hodgens, and Cryshelle Patterson

Chapter 7. PTSD, Anxiety, and Phobia ............................................ 183

Thompson E. Davis III

Chapter 8. Treatment Strategies for Depression in Youth................ 221

Martha C. Tompson and Kathryn Dingman Boger


Chapter 9. Medication Treatment of Bipolar

Disorder in Developmentally Disabled Children
and Adolescents.............................................................................. 253
Zinoviy A. Gutkovich and Gabrielle A. Carlson

Chapter 10. Treatment of Autism Spectrum Disorders ................... 287

Mary Jane Weiss, Kate Fiske, and Suzannah Ferraioli

Chapter 11. Treatment of Self-Injurious Behaviour

in Children with Intellectual Disabilities.......................................... 333
Frederick Furniss and Asit B. Biswas

Chapter 12. Communication, Language, and Literacy

Learning in Children with Developmental Disabilities...................... 373
Erna Alant, Kitty Uys, and Kerstin Tönsing


Chapter 13. Eating Disorders ......................................................... 403

David H. Gleaves, Janet D. Latner, and Suman Ambwani

Chapter 14. Treatment of Pediatric Feeding Disorders ................... 435

Cathleen C. Piazza, Henry S. Roane, and Heather J. Kadey

Index .............................................................................................. 445

List of Contributors
Erna Alant
Center for Augmentative and Alternative Communication,
University of Pretoria, Pretoria 0002 South Africa, erna.alant@up.ac.za

Suman Ambwani
Department of Psychology, Dickinson College, P.O. Box 1773, Carlisle,
PA 17013, ambwanis@dickinson.edu

Lisa L. Ansel
Department of Psychology, The University of Southern Mississippi,
118 College Dr., Box 5025, Hattiesburg, MS 39406, lisaansel@gmail.com

Christopher T. Barry
Department of Psychology, University of Southern Mississippi,
Hattiesburg, MS 39406, Christopher.Barry@usm.edu

Jayne Bellando
Department of Pediatrics, University of Arkansas for Medical Sciences,
Arkansas Children’s Hospital, Little Rock, AR 72202

Asit B. Biswas
Leicestershire Partnership NHS Trust and University of Leicester,
Leicester Frith Hospital, Leicester LE3 9QF, UK, asitbiswas@yahoo.co.uk

Kathryn Dingman Boger

Department of Psychology, Boston University, Boston, MA 02215,

Gabrielle A. Carlson
Stony Brook University School of Medicine, Stony Brook, NY 11794,

Thompson E. Davis III

Department of Psychology, Louisiana State University, Baton Rouge,
LA 70803, ted@lsu.edu


Mark C. Edwards
Department of Pediatrics, University of Arkansas for Medical Sciences,
Arkansas Children’s Hospital, Little Rock, AR 72202

Terry S. Falcomata
Center for Disabilities and Development, Division of Pediatric
Psychology, Department of Pediatrics, Children’s Hospital of Iowa,
Iowa City, IA 52242

Suzannah Ferraioli
Douglass Developmental Disabilities Center, 151 Ryders Lane,
New Brunswick, NJ 08901, sferraioloi@gmail.com

Kate Fiske
Douglass Developmental Disabilities Center, 151 Ryders Lane,
New Brunswick, NJ 08901, katefiske@gmail.com

Ellen Flannery-Schroeder
Department of Psychology, University of Rhode Island, Kingston,
RI 02881, efschroeder@mail.uri.edu

Frederick Furniss
The Hesley Group, School of Psychology, University of Leicester,
Doncaster DN4 5NU, UK, fred.furniss@hesleygroup.co.uk

David H. Gleaves
Department of Psychology, University of Canterbury, Christchurch,
New Zealand, david.gleaves@canterbury.ac.nz

Zinoviy A. Gutkovich
Division of Child and Adolescent Psychiatry, Department of Psychiatry,
The Zucker Hillside Hospital, Glen Oaks, NY 11004, ZGutkovi@lij.edu

Heather L. Harrison
Department of Psychology, The University of Southern Mississippi,
118 College Dr., Box 5025, Hattiesburg, MS 39406,

Bart Hodgens
Civitan International Research Center, University of Alabama
at Birmingham

Alexis N. Lamb
Psychology Department, University of Rhode Island, 10 Chafee Rd.,
Kingston, RI 0288, anlamb@mail.uri.edu

Janet D. Latner
Department of Psychology, University of Hawaii at Manoa,
2430 Campus Road, Honolulu, HI 96822, jlatner@hawaii.edu

Nicholas Long
UAMS Department of Pediatrics, College of Medicine,
University of Arkansas for Medical Sciences, Little Rock,
AR 72202, longnicholas@uams.edu

Heather J. Kadey
Munroe-Meyer Institute for Genetics and Rehabilitation,
University of Nebraska Medical Center, Omaha 68198, NE

Johnny L. Matson
Department of Psychology, Louisiana State University,
Baton Rouge, LA 70803, johnmatson@aol.com

Cryshelle Patterson
Sparks Clinics, University of Alabama at Birmingham

Cathleen C. Piazza
Munroe-Meyer Institute for Genetics and Rehabilitation,
University of Nebraska Medical Center, Omaha 68198, NE

Jessica D. Pickard
Department of Psychology, The University of Southern Mississippi,
118 College Dr., Box 5025, Hattiesburg, MS 39406, pickard_jd@yahoo.com

Joel E. Ringdahl
Center for Disabilities and Development, Division of Pediatric
Psychology, Department of Pediatrics, Children’s Hospital of Iowa,
Iowa City, IA 52242, joel-ringdahl@uiowa.edu

Henry S. Roane
Munroe-Meyer Institute for Genetics and Rehabilitation, University
of Nebraska Medical Center, Omaha 68198, NE

Martha C. Tompson
Department of Psychology, Boston University, Boston, MA 02215,

Kerstin Tönsing
Center for Augmentative and Alternative Communication,
University of Pretoria, Pretoria 0002, South Africa, kerstin.tonsing@up.ac.za

Kitty Uys
Center for Augmentative and Alternative Communication,
University of Pretoria, Pretoria 0002, South Africa, kitty.uys@up.ac.za

Mary Jane Weiss

Douglas Developmental Disabilities Center Rutgers, The State University
of New Jersey, New Brunswick, NJ 08901, weissnj@rci.rutgers.edu

Jonathan Wilkins
Department of Psychology, Louisiana State University, Baton Rouge,
LA 70803, Johnmatson@aol.com

Ditza Zachor
Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
History of Treatment
In Children With
Developmental Disabilities
And Psychopathology


The history of modern child psychopathology and developmental dis-

abilities is of fairly recent origins. However, of the two topics, intellectual
disability (ID) is the area which has received the most attention as a mod-
ern science and profession for the longest period of time.
In December of 1896 in an address to the American Psychological
Association, Lightner Witmer outlined what he descried as a scheme
for practical work in psychology. The plan had four components: 1) the
investigation of mental and moral development; 2) a psychological clinic
supplemented by a training school/hospital to treat retardation or physical
defects interfering with school progress; 3) practical work in the observation
and training of normal and retarded children; and 4) training of students for
a new profession, the psychological expert, who would examine and treat
mentally and morally retarded children, or in connection with the practice
of medicine (Witmer, 1907). Witmer discusses pedagogical treatment for
stammering and other speech defects, bad spelling, slow mental develop-
ment, and motor defects. As such, these early efforts were primarily geared
toward remediation of what we would now call developmental or learning

JONATHAN WILKINS and JOHNNY L. MATSON • Louisiana State University

J.L. Matson et al. (eds.), Treating Childhood Psychopathology 3

and Developmental Disabilities, DOI: 10.1007/978-0-387-09530-1,
© Springer Science + Business Media, LLC 2009

This topic is followed by autism and more recently the autism spec-
trum disorders (ASD), followed by child psychopathology such as depres-
sion, hyperactivity, and anxiety. The area that has the briefest history is
behavioral medicine with children. There are of course various reasons for
the time when various areas of study began to emerge with children. The
purpose of this chapter is to provide an overview of these areas and major
developments that have led to the establishment of each topic as an evi-
dence-based area of research and practice.


Intelligence testing is one of the first and best established areas of

study with children. These developments initially grew from pragmatic
considerations about how to differentiate slow learners and high achievers in
the school system. Alfred Binet of the Sorbonne pioneered a series of tests
to identify “at risk” school children. With his assistant Theodore Simon,
they published their new IQ test in 1905, the Binet–Simon scale. In 1908,
they revised the scale, dropping, modifying, and adding tests by age level
for ages 3–13. The test was later renormed in the United States at Stanford
University and became the Stanford-Binet Intelligence Test which is in
wide use today.
Herbert H. Goddard translated Binet’s writings from French to Eng-
lish. He was an early proponent of IQ testing and served as Director of
Research at the Vineland Training School for Feeble-Minded Girls and
Boys. Goddard also developed the notion of subcategories of ID and used
the terms moron and imbecile for those with lower IQ, and idiot for those
with the lowest scores (Goddard, 1920). Although the terminology has
changed from these labels to mild, moderate, severe, and profound, the
recognition that marked performance differences exist in ID and that sub-
categories are advisable has persisted.
Lewis H. Terman, a professor at Stanford University, went beyond
Goddard in that he actually revised the test itself. Most important in
his changes were more standardized responses. He also revised the test
so that it could be used to identify gifted children as well as those with
ID. Published in 1916, the Stanford Revision of the Binet-Simon Scale
of Intelligence became the standard in the United States for assessing
One of the unforeseen developments from the widespread acceptance
of IQ testing was the creation of a multimillion dollar testing industry
with hundreds of millions of standardized tests being given to children
yearly. A second development was the recognition that objective stand-
ardized measures could be developed using the IQ test model for a range
of developmental disabilities and forms of child psychopathology. There
was a rather long germination period relative to this later trend with most
of the innovations coming in the latter half of the 20th century. A third
related development involved treatment. Once disorders and disabilities
had been defined and identified, there was an obvious need for training
and treatment strategies.


The establishment of the first juvenile court in the United States in

1899 is often considered the beginning of the child mental health movement
(Schowalter, 2000). The thrust was the treatment of juvenile delinquency
and was spearheaded by women civic leaders who established the Juvenile
Psychopathic Institute. A neurologist named William Healy headed the
institute. One of his primary accomplishments was the development of
a triad of professionals including a psychiatrist, psychologist, and social
worker. The psychiatrist typically provided treatment, the psychologist did
testing, and the social worker coordinated services and assisted parents.
As reported in many books and articles, this approach became the serv-
ice model for treating children. Typically these services were provided via
community mental health clinics.
Great momentum occurred in 1963 when President John F. Kennedy
signed the Community Mental Health Centers Act mandating the con-
struction of community outpatient facilities. The dominant treatment
paradigm during this time was psychodynamic. In many ways this
approach retarded the growth of treatments for child psychopathol-
ogy and developmental disabilities. For example, children and people
with ID were described as lacking sufficient “ego strength” to develop
many forms of psychopathology. As recently as 1978, researchers were
debating if children could evince depression (Lefkowitz & Burton, 1978).
Similarly, major diagnostic systems such as DSM have only recently
begun to present and refine various forms of psychopathology in chil-
dren (Matson, 1989).


The primary means of intervention for children have involved learning-

based models. More recently medications for some problems have also
begun to be used, typically in combination with learning-based treatments.
For example, Tofranil was approved to treat depression in 1951, and
Thorazine was used to treat psychotic behaviors in Paris in 1952 and was
approved for use in America in 1954.
Although psychodynamic formulations have not been supported by
the research, evidence-based practice does go back to the very found-
ing of the area. Witmer (1907) described his work as clinical psychol-
ogy, a term he says he “borrowed” from medicine. He suggested the
term “clinical” implied a method and noted that the clinical psycholo-
gist was primarily interested in the individual child. He stressed the
relationship between science and practice as well as the notion that
the clinical psychologist was a contributor to science who must dis-
cover the relationship between cause and effect in his applications of
There have been a number of general movements from a historical
point of view. These include classical conditioning, operant conditioning/

applied behavior analysis, behavior therapy/cognitive behavior therapy,

medication, and combined therapies. The evaluation of each of these
methods follows.

Classical Conditioning
John Broadus Watson is credited with applying the principles of clas-
sical conditioning (first demonstrated by Pavlov) to human beings. His
research and charismatic personality led to the establishment of behavior-
ism (Maultsby & Wirga, 1998). Watson championed Pavlovian conditioning
as the basis for behavioral psychology, and he maintained an inflexible
adherence to its tenets in his work. Behaviorism was a response to struc-
turalism, a movement spearheaded by E. B. Titchenor in America and
based on the ideas of Wilhelm Wundt, which focused on the passive intro-
spection of one’s mind.
Watson completely rejected the notion of consciousness and intro-
spection, and publicly attacked them in 1913 at Columbia University
with his famous lecture, which was published under the title, “Psychol-
ogy as the Behaviorist Views It” and later became known as the “behav-
iorist manifesto”. However, behaviorism as a movement did not become
popular in the United States until the 1920s. It was during this time,
and as a result of the involvement of American psychologists in World
War I and the publishing of Watson’s Psychology from the Standpoint
of a Behaviorist in 1919, that behaviorism began to spread throughout
American psychology. Watson’s text was the first to analyze human
psychological functioning in terms of behavior (Wozniak, 1997). In
the book, he conceptualized psychopathology as a failure to adjust to
change; it develops when a person holds onto old habits and associated
emotions that no longer work in the context of new situations. Watson
also pointed out that proof for his ideas was evident in the possibility of
retraining as a cure.
Watson first applied classical conditioning to a human subject in
1920 with the case study of Little Albert. In this classic study, Watson
and one of his students, Rosalie Rayner, conditioned the 11-month-old
child to have an irrational fear of a white rat by pairing the presenta-
tion of the animal with an unexpected loud noise. Watson and Rayner
(1920) also demonstrated the generalization of the conditioned fear
response as Albert had spontaneously become afraid of other furry
objects. Although they made some suggestions as to how the fear might
be unlearned, no attempt was made to then reduce Albert’s fear of the
furry objects.
It wasn’t until Mary Cover Jones, another one of Watson’s stu-
dents, that the elimination of irrational fears by induced extinction was
demonstrated. In her research, children who were already overly fearful
were treated with a combination of social imitation and countercondition-
ing. The feared objects were gradually presented while the children enjoyed
a preferred food. Her research was notably documented in with the case
of Peter (Jones, 1924). In this study, Jones eliminated the boy’s fear of a
white rabbit using counterconditioning (i.e., preferred food was presented

simultaneously with the rabbit). During treatment, the rabbit was gradu-
ally brought closer to Peter and he became more tolerant of its presence,
eventually touching the animal without fear. As a result of her work with
conditioning and fears, Jones is often cited as pioneering behavior therapy
(Goodwin, 2005).
However, Watson’s ideas and the doctrine of behaviorism did not
make a large impact in the realm of psychotherapy until after World War
II (Pichot, 1989). This was largely due to the dominant forms of therapy
at the time, hypnosis and suggestion initially and later psychoanalysis;
in addition, the practitioners and proponents of behaviorism were experi-
mental psychologists and outside the field of medicine, which handled the
treatment of neuroses at the time.
The basic principles of classical conditioning have had a far-reaching
influence on treatment strategies for children. Most of the treatments
described below are based on these principles or contain elements of clas-
sical conditioning. Classical conditioning has also been used to treat fear
and phobias of children with developmental disabilities and other learning
disorders but these studies have been sporadic (Labrador, 2004). Usu-
ally elements of classical conditioning are paired with other closely related
techniques such as exposure. A further discussion of these studies is pre-
sented in the section on behavior therapy.

Operant Conditioning/Applied Behavior Analysis

B. F. Skinner’s research and theories have had a profound effect on
the development of behavioral and learning-based therapies. His concept
of reinforcement schedules and how controlling the delivery of reinforce-
ment can influence the speed of learning new habits and their resistance
to extinction was especially important to the development of behavior
therapy (Maultsby & Wirga, 1998). Behavior modification represented an
alternative to psychotherapy, which was lengthy, costly, and ultimately
ineffective, and it was in Science and Human Behavior that Skinner (1953)
outlined his alternative to current theories of psychopathology and psy-
chotherapy (Labrador, 2004).
The goal of therapy in Skinner’s mind was not to eliminate the
impulse that caused the occurrence of a problem behavior but to intro-
duce a replacement behavior that could overcome the circumstances that
had produced the problematic behavior. The way to correct these cir-
cumstances, then, is to first systematically analyze them (i.e., perform a
functional analysis).
Skinner’s goal was to use the experimental analysis of behavior to
modify and reduce abnormal behavior. He believed that abnormal behav-
ior, as any behavior, has been learned in an attempt to adapt to some
environment. However, when a learned behavior is disapproved by society,
it becomes abnormal or maladaptive, and the goal of treatment, then,
is to modify the behavior by replacing it with a more appropriate one.
The effectiveness of treatments for maladaptive behaviors is evaluated by
comparing end results to baseline data. These ideas formed the basis for
applied behavior analysis (ABA) and behavior therapy.

Skinner’s research and ideas have even become an international move-

ment, spreading to places such as Latin America in the 1960s (McCrea,
1976). Fuller (1949) was the first to demonstrate that operant principles
could be applied in a clinical setting. The sole participant in this study
was an 18-year-old male described as a “vegetative idiot”. Using sweetened
milk as a reinforcer, a significant increase of the target behavior (raising
his right arm to a vertical position) was demonstrated in four sessions.
Fuller was also able to show that the behavior could be extinguished by
removing the reinforcing stimulus.
A few years later in 1953, Skinner and Lindsley began applying the
principles of operant conditioning to psychiatric inpatients at a state hos-
pital. They created what was essentially a Skinner box for humans, a
room that allowed tangible reinforcers to be dispensed depending on the
behavior performed by the inhabitant of the room (Skinner, 1954). The
psychiatric patients, who were described as “catatonics, mental defectives
with delusions, paranoids, and in one case, a manic,” were left alone in
the room for one hour each day. The experimenters studied the effects of
different reinforcement schedules and noted that response patterns were
similar to those of animals that had been studied previously in a similar
setting. Skinner believed that applying operant techniques in such a way
would have great motivational value and ultimately lead to positive behav-
ior change.
From this early research with adults, Bjou and colleagues (Bjou, 1959,
1963; Bjou, Birnbrauer, Kidder, & Tague, 1966) and Barrett and Linds-
ley (1962) applied operant conditioning to children with ID. Ferster and
DeMyer (1961) did the same with autistic children by employing a simi-
lar apparatus to the one used by Skinner that dispensed tangible objects
when a key was pressed.
Children with developmental disabilities (especially severe ID and
autism) represent one population that has benefited greatly from the
development of operant-based treatment techniques. The efficacy of
behavioral treatments has been well documented in the literature with
this group, especially with regard to reducing the frequency and severity
of symptoms and challenging behaviors and facilitating the acquisition of
adaptive skills (Rogers, 1998). Such children are likely to evince challeng-
ing behaviors, such as aggression or self-injury, that are severe in inten-
sity and pose a threat to self and others, and it is currently recognized
that the most effective method for treating these high-intensity behaviors
is based on the principles of operant conditioning: either via reinforce-
ment, punishment, or a combination of the two (Pelios, Morren, Tesch, &
Axelrod, 1999).
Challenging behavior is a term that is used interchangeably with mala-
daptive or problem behavior and was introduced to American psychology
in the 1980s to describe problematic behaviors commonly evinced by
individuals with ID (Xeniditis, Russell, & Murphy, 2001). Over the years
these behaviors have been treated with aversive stimuli such as electric
shock (Lovaas & Simmons, 1969), water misting, exposure to aromatic
ammonia, or physical restraint. One problem, however, is that the treat-
ment must be able to be applied consistently across settings.

Although these procedures were usually highly successful at eliminat-

ing the behaviors, there are obvious ethical implications. However, in some
cases the behavior is so severe that there is no other alternative. This is
usually the case when no consistent maintaining functions for the behav-
ior can be identified. Azrin and Holz (1966) noted that the reason that pun-
ishment-based procedures are so effective at eliminating self-injury, for
example, is that the aversive nature of the treatment is able to overcome
whatever source of reinforcement is sustaining the behavior. Less aver-
sive punishment techniques are still frequently employed (e.g., extinction,
time-out, response cost).
Because behaviors such as self-injury or aggression can have differ-
ent functions across individuals and settings and may even vary across
situations for the same individual, selecting a potentially effective treat-
ment can only be accomplished once the maintaining events or factors
for that behavior are understood (Iwata, Dorsey, Slifer, Bauman, & Rich-
man, 1982). Therefore, an important development in the use of operant
techniques in modifying maladaptive behavior in children with ID was the
increasingly pronounced role of functional assessment.
Functional assessment or analysis involves a thorough assessment
of the events preceding (antecedents) and following (consequences) the
behavior. Understanding the antecedents and consequences of a behavior
provides essential information about the reasons why a problem behav-
ior is occurring or why a desired behavior is not occurring. Therefore,
treatments that are constructed on the basis of a careful consideration
of a target behavior’s maintaining factors are more likely to be effective in
reducing or eliminating the behavior and can be just as effective as pun-
ishment (Iwata et al., 1994). A comprehensive approach for conducting a
functional analysis was first delineated by Iwata and colleagues in 1982.
In this study, the authors described four experimental conditions related
to different maintaining factors: social disapproval, academic demand,
unstructured play, and alone.
For example, the self-injurious behavior (SIB) of many children is
maintained by social reinforcement; children exhibiting this behavior have
not learned a socially appropriate way of gaining attention from adults
and have discovered that the behavior gets them the attention they desire
(e.g., parent telling them to stop). In this case, after the function of the
behavior has been identified (i.e., attention), the intervention or treat-
ment will focus on replacing the maladaptive behavior with another, more
appropriate behavior that serves the same function (e.g., saying “Come
play with me.”; Iwata et al., 1994). This procedure is known as functional
communication training (FCT). The desired response is then reinforced
by providing social attention whenever the child asks appropriately and
ignoring instances where the child is engaging in the problem behavior.
In general, this procedure is referred to as differential reinforcement of
alternate behavior (DRA). Alternately, the child could be provided with
social attention anytime he or she is not engaging in the behavior, which is
known as differential reinforcement of other behavior (DRO).
More specifically, functional communication training teaches the child
to emit some type of communicative behavior that results in the same

outcome as the challenging behavior and ultimately reduces the frequency

of that behavior. This procedure is especially appropriate for children with
severe ID and/or ASD, who are often limited in their abilities to communi-
cate. This procedure was first described by Carr and Durand (1985), and in
that paper, the authors stated that the goal of FCT is replacing challenging
behaviors with socially appropriate behaviors, one of which is functional
communication. In order for the communicative replacement behavior to
effectively reduce or replace the maladaptive behavior, it needs to be func-
tionally related to the controlling stimuli (Carr & Durand, 1985). This is
because the socially inappropriate behavior was previously serving as a form
of nonverbal communication for the child. Common replacement behaviors
include asking for help or for a break for escape-motivated behaviors or
an appropriate way to request attention for socially motivated behaviors.
Appropriate responses can be spoken, or in the case of nonverbal individu-
als, involve gestures as in pointing to a picture board. When FCT does not
produce a significant reduction in the problem behavior, adding a punish-
ment component can increase its effectiveness (Fisher et al., 1993).
An early emphasis on functional assessment was evident in the work
of Wolpe (1969). However, the technique fell to subsequent neglect in the
1980s as punishment-based procedures began to gain popularity. During
this time it was believed that punishment alone was sufficient to control
behavior, and the number of these studies increased greatly throughout
the 1970s and mid-80s (Matson & Taras, 1989).
It was believed that punishment could not only reduce challenging
behavior but oftentimes eliminate the behavior completely (Iwata et al.,
1982). However, after reviews by Carr (1977) and Johnson and Baumeister
(1978), functional analysis began to regain favor with clinicians. In these
reviews, it was suggested that some of the failings in the treatment of SIB
reported in the literature were likely due to a lack of information regard-
ing setting and maintaining factors. It was recognized that failing to con-
duct an adequate functional assessment prior to treatment would mean
that the treatment chosen would be implemented without an understand-
ing of the underlying causes of the behavior and would therefore be less
effective. And, when a clinician conducts a functional assessment before
selecting a treatment, he or she is more likely to choose a reinforcement-
based procedure, which is a trend that has become increasingly evident
since the late 1980s/early 1990s (Pelios et al., 1999). Such reinforcement-
based treatment programs would be tailored toward targeting the motivat-
ing factors behind the behavior and should be able to effectively reduce the
problem behavior without the use of punishment. However, behaviors that
have nonsocial functions can be very difficult to treat with reinforcement-
based procedures alone (Iwata et al., 1994). Treatment based on func-
tional analysis, therefore is most effective when the behavior is maintained
by positive (e.g., attention or tangible function) or negative reinforcement
(e.g., escape function; Fisher et al., 1993).
ABA has been the treatment of choice not only for severe problem
behaviors such as aggression and SIB but also in treating sleep problems
(Didden, Curfs, Sikkema, & de Moor, 1998), and star charts and rewards
have been found to be effective in the treatment of enuresis (Järvelin,

2000). Sleep problems in particular are prevalent and usually persist into
later childhood for developmentally disabled children; additionally such
difficulties can contribute to the manifestation of other challenging behav-
iors during the day (Didden et al., 1998). In many cases, sleep problems
have been determined by functional assessment to be maintained and
shaped by parental attention and have thus been successfully treated with
extinction (Didden et al., 1998).

Behavior Therapy
From these operant-based techniques, behavior therapy diversified
and progressed in a rapid manner. In 1952 with his article, “The Effects of
Psychotherapy: An Evaluation,” Hans Eyesnick convincingly brought the
ineffectiveness of psychoanalysis to light. It was at this time that psychoa-
nalysis began to lose its grip as a dominate therapy in the United States
and new treatments based on the principles of classical and operant con-
ditioning began to gain popularity. One of the most influential of the new
therapies that emerged was created by Joseph Wolpe and called systematic
desensitization or reciprocal inhibition.

Systematic Desensitization
In the early 1950s, Wolpe was dissatisfied with the poor outcome
he was getting treating patients with psychoanalysis. He combined his
medical training with learning theory to create a medically credible,
non-Freudian hypothesis with regard to the origin of neurotic fears and
how to effectively treat those fears in a behaviorally informed manner
(Maultsby & Wirga, 1998). The result was a combination of deep muscle
relaxation and emotive imagery that Wolpe termed systematic desensiti-
zation. He described his theories in a landmark text published in 1958
entitled Psychotherapy by Reciprocal Inhibition. Wolpe (1958) conceptual-
ized fears or phobias as responses that have been learned through classical
conditioning and can therefore be eliminated by applying specific coun-
In a typical session, which usually lasts one hour, the client first self-
induces a state of deep muscle relaxation. This is followed by the therapist
verbally leading him or her through a predetermined list of feared objects
or events that the client imagines starting with the least fear-inducing and
gradually moving up to the most feared object or situation. If the client
becomes noticeably anxious, he or she is told to stop imagining the object
or situation and return to establishing the state of relaxation. Exposure
to the actual feared objects is often incorporated as well. The rapid effec-
tiveness of systematic desensitization and the large number of successful
cases surprised the field. Some of the earliest studies were conducted by
Lang and colleagues and involved using the technique to reduce fear of
snakes in college students (Lang & Lazovik, 1963; Lang, Lazovik, & Rey-
nolds, 1965; Lazovik & Lang, 1960).
Although the effectiveness of systematic desensitization for treating
phobias and anxiety was well documented throughout the 1960s, interest

began to wane as the number of published studies dropped dramatically

starting in the early 1970s (McGlynn, Smitherman, & Gothard, 2004).
This decline was evident both in research and clinical practice. The reason
for the decline has been attributed to the emergence of other therapies
that competed directly (e.g., flooding, participant modeling) and indirectly
(cognitive behavior therapy; McGlynn et al., 2004).
There are two main variants of systematic desensitization that have
been used to treat fears and anxiety in children: in vivo desensitization
(i.e., exposure), which has confrontation with the actual feared stimuli as
the principal feature, and in vitro, also known as standard or vicarious,
desensitization, which uses symbolic representations (e.g., imagination or
modeling) in place of the actual feared stimuli (Ultee, Griffioen, & Schelle-
kens, 1982). Early applications of these techniques with children yielded
positive results in reducing fear of animals with the former technique
(Kuroda, 1969; Murphy & Bootzin, 1973; Ritter, 1968) but mixed results
with the latter (Lazarus & Abramowitz, 1962; Miller, Barrett, Hampe, &
Noble, 1972). Ultee et al. (1982) compared the two procedures directly in a
sample of children with water phobia; in vivo was found to be more effec-
tive than in vitro desensitization, and the response to the latter treatment
was not significantly different from a wait-list control condition. It was also
determined that the combination of the two was no more effective than in
vivo desensitization alone.
Similar results were found in a later study by Menzies and Clarke
(1993), who not only demonstrated that in vivo exposure was significantly
more effective in reducing fear of water in children, but that those treat-
ment gains generalized to other situations involving water and were main-
tained after three months. Based on the results of these studies and others,
real-life exposure to the feared object appears to be the most important
component of systematic desensitization (Ollendick & King, 1998).
Anxiety and phobia frequently co-occur with ASD and are present
in higher rates than in normally developing children (Love, Matson, &
West, 1990; Luscre & Center, 1996; Reaven & Hepburn, 2006; Woodard,
Groden, Goodwin, Shanower & Bianco, 2005), and children with ID have
more fears than children of normal intelligence with and without learning
disability (Deverensky, 1979). In addition, individuals with Williams syn-
drome evince higher levels of anxiety and phobias than normally develop-
ing children as well as children with ID (Dykens, 2003). Common phobias
reported in the literature for children and adolescents with developmental
disabilities include animals (particularly dogs; Obler & Terwilliger, 1970),
the toilet (Jackson & King, 1982; Luiselli, 1977), medical and dental pro-
cedures (Freeman, Roy, & Hemmick, 1976; Kohlenberg, Greenberg, Rey-
more, & Hass, 1972; Luscre & Center, 1996), riding the bus (Luiselli,
1978; Obler & Terwilliger, 1970), strangers (Matson, 1981), loud noises
(e.g., thunder; Guarnaccia & Weiss, 1974), and water (Guarnaccia &
Weiss, 1974).
Systematic desensitization can be difficult to apply with children
because relaxation training can be fairly demanding and tedious for the aver-
age child, as can the controlled recall of feared images (King, Cranstoun, &
Josephs, 1989). Given the difficulty of applying the procedure to normally

developing children, this renders the application of traditional systematic

desensitization even more problematic for developmentally disabled chil-
dren. As a result, treatment of phobias and anxiety in children with ASD
and ID has focused on related techniques such as emotive imagery, gradu-
ated exposure, counterconditioning, and modeling, and usually includes
operant components such as providing tangible rewards for tolerating the
feared object. Counterconditioning in such treatment with developmen-
tally disabled children usually includes the presence of a comforting per-
son (e.g., child’s mother) whose involvement is gradually faded as the child
becomes more comfortable around the fear-inducing stimulus (Sovner &
Hurley, 1982)
Emotive imagery involves the therapist evoking positive emotions in
the child, usually by including characters from television or fiction that
the child enjoys, and then gradually introducing the feared stimuli in the
context of a fun or exciting narrative involving the child and the charac-
ters (Lazarus & Abramovitz, 1962). These authors used the technique to
successfully treat fear of dogs, darkness, and school. More recently, Corn-
wall, Spence, and Schotte (1997) demonstrated that the procedure was
superior on a variety of outcome measures in treating fear of darkness in
24 children when compared to wait-list control. The active mechanism of
the procedure is believed to be reciprocal inhibition, in that instead of the
child inducing a state of ease or relaxation himself or herself, this positive
state is induced by engaging in an activity the child enjoys (e.g., pretend-
ing to be a superhero; King et al., 1989).
In a study by Freeman et al. (1976), a hierarchal series of real-life
exposures was created to treat an intellectually disabled boy’s fear of
physical examinations with a preferred nurse from the ward being used
as the counterconditioning agent. In another similar study, an autis-
tic child’s fear of the sound of toilet flushing was successfully treated
using laughter to reduce anxiety (Jackson & King, 1982). Laughter was
induced by tickling and this was gradually introduced while the child
used and then flushed the toilet. However, these were uncontrolled
case studies so the results should be interpreted with some degree of
On this note, Obler and Terwilliger (1970) employed a modified version
of systematic desensitization with 15 “neurologically impaired” children
who presented with excessive fear of dogs or riding the bus. Significant
reduction in phobic symptoms was reported for the treatment group but
not for a group of matched controls. The treatment procedure in this study
involved first presenting a picture of the feared stimulus and then once
this was tolerated, presenting the actual object and rewarding the child for
moving closer and closer to it. Rewards were chosen by the participants
prior to treatment and included toys, books, and candy.
Modeling involves a peer or adult demonstrating nonfearful behavior
in the fear-producing situation and can be either live or filmed. Bandura
and colleagues conducted some of the earliest research with this technique
and demonstrated that modeling, both live and filmed, was able to effec-
tively reduce fear of dogs (Bandura, Grusec, & Menlove, 1967; Bandura &
Menlove, 1968). In addition, Lewis (1974) found a combination of modeling

(video of peers) and participation to be more effective than either modeling

or participation alone in reducing water phobia. However, each condition
alone also significantly reduced avoidance behavior when compared to a
control condition.
Modeling has also been used to treat phobias in developmentally
disabled children. This usually consists of the therapist demonstrating
an appropriate nonfearful response to the presence of the fear-inducing
object or situation (King, Ollendick, Gullone, Cummins, & Josephs, 1990).
For example, Matson (1981) used modeling in a multiple baseline study
across subjects to treat three children with moderate ID who refused to
interact with or be around people other than a few close family members.
Modeling was performed by a parent in the clinic and then generalized to
home with treatment gains being maintained after six months.
In contrast to emotive imagery and modeling, operant-based treatment of
anxiety and phobias does not assume that the anxiety must first be reduced
or eliminated before exposure to the feared object or situation will be toler-
ated (King et al., 1990). Such techniques are typically used in combination
with the procedures described above. Luiselli (1977, 1978) demonstrated
successful implementation of operant-based treatments with an intellectu-
ally disabled adolescent who was afraid of the toilet and an autistic child who
was afraid of riding the bus. In the latter study, the autistic boy’s mother
initially sat on the bus with him and provided tangible reinforcement. Even-
tually, she moved farther away from him until he was able to ride the bus to
school by himself, which was achieved in seven days. In addition, Kohlen-
berg et al. (1972) successfully treated fear of dental procedures in a sample
of children and adolescents with ID ages 8–20 using shaping with social and
tangible reinforcement. The outcome measure for this study was the number
of physical restraints required for the procedure, of which, after treatment,
the experimental group received significantly less than a control group.

Cognitive Behavior Therapy

Around the same time as Wolpe’s formulations regarding his ideas
for systematic desensitization and for principally the same reason (i.e., a
lack of success treating patients with psychoanalysis), Albert Ellis devel-
oped his brand of highly effective, therapist-led psychotherapy that he
termed rational emotive therapy (Maultsby & Wirga, 1998). This treatment
model later became known as rational emotive behavior therapy or cogni-
tive behavior therapy (CBT). From this viewpoint, maladaptive behavior
is the result of maladaptive cognitions, and therefore cognitive changes
can produce a change in behavior. The therapy focuses on the ABC model
of human emotions: Activating event, Beliefs about the event, and Con-
sequence of or emotional response to the event. Its goal is to get people
to recognize and then eliminate their irrational beliefs. CBT encourages
therapists to be active, objective, and firmly directive while combining talk
therapy with elements of classical conditioning.
Variants of Ellis’s original therapy have been applied to children with
fear and anxiety. In an early study of this type, Kanfer, Karoly, and Newman
(1975) found that having children repeat verbal self-instructions related to

competence in dealing with their fear of the dark (e.g., “I am a brave boy/
girl. I can take care of myself in the dark.”) while in a dark room was more
effective than stimulus control (e.g., repeating “The dark is a fun place to
be.”) and control (repeating nursery rhymes) conditions. Kane and Kendall
(1989) treated four children diagnosed with Overanxious Disorder with a
cognitive-behavioral based treatment. The cognitive component included
teaching the children to recognize their anxious feelings and bodily reac-
tions to those emotions, clarifying their cognitions in anxiety-provoking
situations, developing strategies to cope with those situations, and evalu-
ating the success of those strategies. The behavioral portion of the treat-
ment included elements of modeling, in vivo exposure, relaxation training,
role play, and contingent reinforcement. Homework was also included.
The treatment was effective at reducing anxiety to within normal limits
and was maintained at three- to six-month follow-up.
Meichenbaum and Goodman (1971) were among the first to advo-
cate the application of cognitive-behavioral techniques in the treatment of
ADHD. Since that time, a great deal of research has been directed toward
this topic (Pelham, Wheeler, & Chronis, 1998). CBT for ADHD typically
consists of weekly sessions in which the therapist works with the child on
developing cognitive techniques to help control inattention and impulsive
behavior that the child will hopefully generalize to other situations (Pelham
et al., 1998). However, the results of multiple controlled studies have not
supported the effectiveness of this approach (Abikoff & Gittelman, 1985;
Bloomquist, August, & Ostrander, 1991; Brown, Borden, Wynne, Spunt,
& Clingerman, 1987).
Cognitive-behavioral approaches have also been utilized for children
and adolescents with depression and are commonly done in group settings
(Kaslow & Thompson, 1998). Because of the initial debate on the exist-
ence of childhood depression and the fact that depression is an internal-
izing disorder and thus may go unnoticed, controlled studies evaluating
the effectiveness of CBT and related therapies are scarce. For the most
part, interventions for children have been modified from those available for
adults and lack a developmental framework (Kaslow & Thompson, 1998).
Stark and colleagues (Stark, Reynolds, & Kaslow, 1987; Stark, Rouse, &
Livingston, 1991) conducted some of the first controlled studies of psycho-
social treatment of childhood depression.
In the first study, Stark et al. (1987) compared 12 sessions of group
therapy with a wait-list control condition in a sample of fourth- through
sixth-graders. Group therapy consisted of either a self-control intervention
that taught self-management skills or a behavior-problem solving inter-
vention that included education and group problem solving. Compared
to the control condition, the children in the two experimental conditions
reported fewer symptoms of depression with the majority no longer meeting
criteria for depression at eight-week follow-up. However, caretaker ratings
of depression, anxiety, and self-esteem did not significantly differ among
the three conditions.
Stark et al. (1991) then expanded this procedure to 24 to 26 sessions
and included monthly family meetings that added a parent training com-
ponent to help their children generalize the skills to the home. This method

was found to be superior to a traditional counseling approach at reduc-

ing depressive symptomatology. The efficacy of manualized approaches to
CBT with young persons suffering from depression has also been demon-
strated (Lewinsohn, Clarke, Hops, & Andrews, 1990; Lewinsohn, Clarke,
Rhode, Hops, & Seeley, 1996).
Dykens (2003) suggests that specific cognitive-behavioral interven-
tions for phobia and anxiety may be applicable for people with Williams
syndrome given the circumscribed goals and relatively short duration of
such treatments as well as the well-developed expressive language and
interpersonal skills in many individuals with the condition. However, the
application of cognitive-behavioral interventions for children with devel-
opmental disabilities awaits further investigation. Reaven and Hepburn
(2006) suggest that cognitive-behavioral treatment strategies for children
with high-functioning ASD and anxiety should include a high level of
parental involvement.

The prescription of psychotropic medication for adolescents increased
by 2.5% from 1994-2001 (Thomas, Conrad, Casler, & Goodman, 2006). In
1997, the Food and Drug Administration passed the Modernization Act,
which made it easier for off-label medications to be promoted to physi-
cians (Buck, 2000). This, taken with the increased presence of managed
care incentives limiting the number of therapy visits, has contributed
significantly to increased reliance on psychotropic medication in treating
childhood psychopathology (Thomas et al., 2006). However, there remains
a paucity of empirical research concerning the utility of using psycho-
tropic medication to treat developmentally disabled children with comorbid
mental health conditions.
This puts the clinician in the position of having to extrapolate
from the existing data regarding adults with ID and children of normal
development (Aman, Collier-Crespin, & Lindsay, 2000). As mentioned
above, because response to psychotropic medication may depend on
the child’s developmental level, extrapolating from research on adults
can be problematic (Aman, Collier-Crespin, et al., 2000). There is no
medication for intellectual disability or ASD and medical profession-
als should proceed with caution before prescribing psychotropics for
children with these conditions. When such a child is being prescribed
medication for the suppression of challenging behaviors and not for
an underlying comorbid condition, the treatment may serve primarily
as chemical restraint. A summary of research on the major classes of
psychotropic medication used in the treatment of childhood psychopa-
thology follows.

For some mental health conditions, pharmacological interventions
have been the most widely used and recommended. Since the 1970s this
has been the case with stimulant medication and ADHD (Pelham et al.,

2000). However, stimulant medication does not work for everyone with
ADHD (70–80% of cases respond) and the long-term efficacy is questionable
(Pelham et al., 2000).
From 1980 to 2000, there were at least ten group studies examining
the effects of stimulant medication (methylphenidate and dextroampheta-
mine) in intellectually disabled children and adults with ADHD (Aman,
Collier-Crespin, et al., 2000). The cumulative results of this research indi-
cate that psychostimulant medication is effective in treating symptoms
of ADHD in individuals with ID. With the exception of one instance, all of
the studies yielded statistically significant, positive results with improve-
ments noted in the areas of managing motor overflow, attention span,
and impulsiveness along with cognitive performance, social behavior, and
independent play (Aman, Collier-Crespin, et al., 2000). However, the over-
all response rate in children and adolescents with ID at 54% is less than
that for those of typical development (Aman, 1996). Later research with
methylphenidate in intellectually disabled children has yielded similar
results (Pearson, Lane, et al., 2004; Pearson, Santos, et al., 2004).
Although current DSM-IV-TR diagnostic criteria preclude a comorbid
diagnosis of ADHD in children with ASD, core symptoms of ADHD such
as impulsivity, hyperactivity, and inattention are common in children with
ASD (American Psychological Association [APA], 2000; Lecavalier, 2006).
The effects of stimulant medication on symptoms of ADHD in ASD children
are mixed. For example, Stigler, Desmond, Posey, Wiegand, and McDougle
(2004) found a low rate of treatment success with a high rate of side-effects
in a retrospective review of 195 ASD children. On the other hand, Posey et
al. (2007) demonstrated that methylphenidate was superior to placebo in
66 children with ASD in alleviating primary symptoms of ADHD.

Since the early 1990s, antidepressants, especially the selective serotonin
reuptake inhibitors (SSRIs), have increasingly become the treatment of
choice in treating childhood depression (Jureidini et al., 2004). Prescription
of SSRIs increased dramatically from 1998–2002 among adolescents aged
15–18 (Delate, Gelenberg, Simmons, & Motheral, 2004). One major concern
with this trend is the efficacy and safety of these drugs with children. Of
particular concern is the risk of suicide among adolescents taking SSRIs
(Jureidini et al., 2004; Whittington et al., 2004). Treatment with tricyclics in
children has largely been abandoned due to the high frequency of adverse
side-effects and a lack of efficacy (Whittington et al., 2004). In a review of six
clinical trials comprising 477 children treated with paroxetine, fluoxetine,
sertraline, or venlafaxine, and 464 children treated with placebo, Jureidini
and colleagues (2004) found the children treated with antidepressant medi-
cation only significantly improved on 14 of 42 reported outcome measures.
In addition, a larger number of children treated with antidepressant medi-
cation experienced adverse side-effects (paroxetine) and some had to withdraw
from one of the studies as a result (sertraline).
Whittington et al. (2004) also reviewed the risk–benefit profiles of
these drugs by examining published and unpublished studies. Fluoxetine

was cited as having a favorable risk–benefit profile in children with noted

efficacy in reducing depressive symptoms with no increased risk of side-
effects. The risk–benefit profiles of sertraline and paroxetine were mixed,
whereas both citalopam and venlafaxine were found to have unfavorable
risk–benefit profiles. In addition, Emslie and colleagues (1997) conducted
a double-blind, randomized, placebo-controlled study of fluoxetine in 96 chil-
dren and adolescents and reported a 60% response rate.
Pary (2004) notes that, as with children of normal development, the
first-line treatment for major depression in Down syndrome is SSRI treat-
ment (with the exception of paroxetine). In one study, however, paroxetine
was found to be effective in reducing symptoms of depression in seven
mildly intellectually disabled adolescents (Masi, Marchesci, & Pfanner,
1997). However, SSRIs (i.e., fluoxetine, paroxetine, and sertraline) may be
less effective in children with ASD. In an open label study, Awad (1996)
treated a small sample of children with ASD with these medications and
found a reduction in symptoms of obsessional, repetitive, and anxiety symp-
toms in half the children but that treatment had to be discontinued for the
other half because of side-effects and worsening of symptoms. SSRIs may
also have some benefit in reducing self-injury in developmentally disabled
children (Aman, Arnold, & Armstrong, 1999). However, at this point, this
data are preliminary, based on case reports, and more research is needed.
When medication fails to alleviate symptoms of depression, alternative
treatments such as electroconvulsive therapy (ECT) may be effective. One
case report documents successful remediation of depressive symptoms in a
15-year-old adolescent with Down syndrome and treatment-refractory major
depressive disorder (Gensheimer, Meighen, & McDougle, 2002). For this indi-
vidual, ECT was found to be safe and effective after four administrations.

Mood Stabilizers
Adolescents diagnosed with bipolar disorder are treated with the same
medications as adults with the condition; however, mixed or rapid cycling,
which adolescents tend to experience more than adults, has been associ-
ated with a poor response to lithium (Cogan, 1996). Although the expres-
sion of bipolar disorder in preadolescent children is rare and even rarer in
children with ID, a few case studies have found positive results for treat-
ment with valproic acid (Kastner, Friedman, & Plummer, 1990; Whittier,
West, Galli, & Raute, 1995) and lithium in young people with ID (Dostal &
Zvolsky, 1970; Goetzl, Grunberg, & Berkowitz, 1977; Linter, 1987). How-
ever, lithium has also been associated with limited clinical efficacy and
adverse side-effects in this population (Kastner et al., 1990). In addition,
Komoto and Usui (1984) reported a case study in which a 13-year-old
autistic female with moderate ID and depression was effectively treated
with valproic acid.

Because the symptoms of schizophrenia do not usually manifest
themselves until late adolescence, there is very little research concerning

treatment of young persons with antipsychotic medication specifically

for schizophrenia. Based on a review of this small body of literature,
Campbell and Gonzalez (1996) summarize research indicating that
thiothixene was superior to thioridazine in adolescents with chronic
schizophrenia, whereas haloperidol and clozapine may also be effective
for young people with schizophrenia, However, much more research is
An early study by Cunningham, Pillai, and Blanchford-Rogers (1968)
found that haloperidol was effective in treating children with aggressive
and destructive behaviors. Although, Conduct Disorder can be difficult
to diagnose in children with ID because of determining the intent of the
behavior, risperidone significantly reduced clinician and parent ratings on
conduct problems in 118 intellectually disabled children with comorbid
Conduct Disorder or Oppositional Defiant Disorder compared to placebo
(Aman, Findling, Derivan, & Merriman, 2000). There has been a notable
increase in recent years of using atypical antipsychotic medication to treat
self-injurious behavior in developmentally disabled children with risperi-
done and olanzapine being the most common (Aman, Collier-Crespin, et
al., 2000). However, these studies were not controlled and more research
is needed.

Little is known about the effects of treating childhood anxiety with
benzodiazepines with only a few controlled studies available (Simeon,
1993). The paucity of such research is likely due to SSRIs being commonly
prescribed to treat anxiety conditions among young persons (Reinblatt &
Riddle, 2007). Among those with ID, this class of drugs has been com-
monly used to manage challenging behaviors and treat generalized anxiety
disorders (Aman, Collier-Crespin, et al., 2000). A handful of studies has
examined the effects of benzodiazepines in treating children with ID to
mixed results (LaVeck & Buckley, 1961; Krakowski, 1963; Bond, Man-
dos, & Kurtz, 1989). The children in these studies were not only small in
numbers but were being treated more for behavioral problems than any
underlying anxiety disorder.
As mentioned above, anxiety conditions seem to be more prevalent
in children with ASD and have been successfully treated with behavioral
approaches. One study did find that buspirone was effective at reduc-
ing symptoms of anxiety and irritability in children and adolescents with
ASD (Buitelaar, van der Gaag, & van der Hoeven, 1998). Side-effects were
reported to be minimal except for one child who developed abnormal
involuntary movements. Werry (1999) suggests that the anxiety associated
with ASD may respond better to antipsychotic drugs than to anxiolytics.

Other Drugs
There is currently only one recommended medication for enuresis,
which is desmopressin (Jarvelin, 2000). Desmopressin is typically administered
as a nasal spray. In the past, imipramine has also been used, but research

indicates that children with ID have responded unfavorably (Aman et al.,

2000). Studies of imipramine with children of normal development have
also been mixed with response rates of 10–60%; however relapse was high
(90%; Schmitt, 1997).

Combined Therapies
For ADHD, limitations of both pharmacological and behavioral inter-
ventions have led to the development of combination therapies consisting
of behavior modification and stimulant medication (Pelham et al., 2000).
Such treatment packages are most successful when the behavioral com-
ponent includes outpatient parent training and school training or occurs
in the context of a summer treatment program (Pelham et al., 2000). In
the case of parent and school training, this helps to increase the generaliz-
ability of the treatment across settings and people.

Comprehensive early intervention treatment packages with the aims
of reducing level of impairment and improving outcome are available for chil-
dren with ASD (Rogers, 1998). Better outcomes have been reported for
children enrolling in such programs before the age of five years (Fenske,
Zalenski, Krantz, & McClannahan, 1985). Other than behavioral interven-
tions aimed at remediation of specific deficit areas, this is the only other
empirically supported treatment available for children with ASD (Rogers,
1998). However, these comprehensive programs are expensive and time-
consuming, involving a team of professionals across different settings
(home, classroom, and clinic), and in some cases, thousands of hours of
treatment over many years. According to Kabot, Masi, and Segal (2003),
for an early intervention program to be appropriate and effective it should:
begin at the earliest possible age, be intensive, include parent training,
focus on social and communication domains, contain individualized goals
and objectives, and emphasize generalization.
One example of this type of approach is the Treatment and Education
of Autistic and related Communication handicapped CHildren (TEACCH)
program established in 1966 at the University of North Carolina in Chapel
Hill. At a time when the prevailing psychodynamic model of the time was
spreading the notion that autism was the result of a lack of parental
emotional support or “refrigerator mothers”, TEACCH recognized paren-
tal involvement as a critical factor and incorporated parent training into
the program so that treatment strategies could be implemented in the
home. The program was demonstrated to be effective early after its incep-
tion (Schopler, Brehm, Kinsbourne, & Reichler, 1971). Ozonoff and Cath-
cart (1998) demonstrated that a TEACCH-based home program resulted in
three to four times greater improvement than a control group on tests of
imitation, fine and gross motor, and nonverbal conceptual skills in autistic

Another notable comprehensive treatment package for autism was

developed by Lovaas and colleagues (1981). This manualized protocol
utilizes reinforcement-based operant techniques along with some pun-
ishment-based procedures to increase a variety of social, language, cogni-
tive, and self-care skills while reducing maladaptive behaviors in children
with autism. The effectiveness of Lovaas’s program was documented in
two published studies (Lovaas, 1987; McEachlin, Smith, & Lovaas, 1993).
The research was conducted over a two-year span and involved a group
receiving the treatment compared with two control groups: one group who
received a few elements of the program delivered by the same staff in the
treatment group in limited duration and intensity and a second group
matched on chronological and mental age that was obtained through
chart review. They found a large and statistically significant difference in
IQ scores and educational placement, with the treatment group scoring
25–30 points higher in IQ and a larger percentage of placements in typical
classrooms for this group (47% to 2% for the control groups). However, one
critique of this research is that group assignment was nonrandom (Rog-
ers, 1998). Regardless of this methodological flaw, the effectiveness of this
treatment package has been replicated by two other sets of independent
researchers, albeit at a lower rate of success (Birnbrauer & Leach, 1993;
Sheinkopf & Siegel, 1998).


Psychopathology is a common problem for children and adolescents,

with one prevalence study finding a rate of 36.7% of 9- to 13-year-olds meet-
ing criteria for at least one psychiatric disorder (Costello, Mustillo, Erkanli,
Keeler, & Angold, 2003). Because the way child psychopathology is concep-
tualized and classified has changed from various editions of the DSM and is
still changing (Ollendick & Vasey, 1999), it is important that future trends
in treatment strive to empirically validate various treatments and not simply
assume that therapies for adult disorders will apply to children. Treatments
utilizing operant principles and elements of systematic desensitization for
reducing phobias are among the best studied and have proven thus far to be
the most effective. On the other hand, the efficacy and effectiveness of cog-
nitive behavioral and pharmacological treatments warrants further study.
However, the trend toward establishing empirically supported treatments
for children is encouraging (Lonigan, Elbert, & Johnson, 1998).
These issues become even more critical with developmentally and
intellectually disabled populations. Taken with the finding that chil-
dren with ID are at a greater risk for developing psychopathology than
the general population (Menolascino & Swanson, 1982) and present
with higher rates of depression (Matson, Barrett, & Helsel, 1988), it
is of great importance that the treatments outlined in this chapter be
validated and proven efficacious for this group. Further complicating
the issue is that major mental health problems are often undiagnosed
and untreated in individuals with developmental disabilities (Deb &
Weston, 2000).

Recognizing these disorders in such individuals is difficult because

of cognitive and communication difficulties. In addition, the role of early
intervention has been increasingly emphasized in treatment programs
for ASD children, and this represents the best chance these children
have at functioning independently as adults. Along the same lines,
because these treatment packages are so intensive and costly, parents
of children with ASD have become increasingly susceptible to buying
into new treatments or “miracle cures” offering little to no empirical
support (e.g., glutein-free diet, chelation therapy). These issues rep-
resent some of the major challenges currently facing the treatment of
childhood psychopathology and developmental disabilities.


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Applied Behavior Analysis
And The Treatment of
Childhood Psychopathology
And Developmental


This chapter provides a description and examples of the use of applied

behavior analysis (ABA) in the treatment of childhood psychopathology and
developmental disabilities. This task is a daunting one given that many of
the single topics that are discussed in the following pages can, and have,
served as topics for entire chapters and texts. This limitation means we
are not able to delve into each topic in a comprehensive manner. However,
we do provide an overview of the important topics related to ABA and its
use in the treatment of childhood psychopathology and developmental dis-
abilities. In addition, we provide a discussion of literature-based examples
for these ABA-based treatments, brief examples of generalization of treat-
ment effects, and discussion of effectiveness.
It is important to note that ABA is not a single treatment. It is more
accurate to say that ABA represents an approach to treatment as opposed
to a specific type of treatment. This approach includes a number of treat-
ment strategies that can be used to address the behavioral symptoms
associated with childhood psychopathology and the behavioral challenges

JOEL E. RINGDAHL and TERRY S. FALCOMATA ● The University of lowa.

J.L. Matson et al. (eds.), Treating Childhood Psychopathology 29

and Developmental Disabilities, DOI: 10.1007/978-0-387-09530-1,
© Springer Science + Business Media, LLC 2009

associated with developmental disabilities. As an approach to treatment,

ABA relies on arranging response–consequence relationships (including
positive and negative reinforcement and punishment), schedule of rein-
forcement effects, and antecedent manipulations (including stimulus-con-
trol procedures and altering establishing operations) to reduce problem
behavior and increase appropriate behavior.
In the paragraphs that follow, we provide an overview of ABA, includ-
ing how it is defined, a description of ABA-based treatment strategies,
including both consequence and antecedent-based interventions, and
a brief summary of recent effectiveness research related to ABA-based
treatments and behavior problems common to individuals with childhood
psychopathology and/or developmental disabilities.


Baer, Wolf, and Risley (1968) outlined seven dimensions of applied

behavior analysis. It is upon these dimensions that the clinical applica-
tions are based. According to Baer et al., ABA is applied, behavioral, and
analytic. In addition, ABA should be technological, conceptually system-
atic, effective, and generalizable. The term applied indicates that the target
behavior is of social significance. It is the emphasis on social significance
that sets ABA apart from laboratory analysis. Examples of applied are wide-
ranging and can include any behavior that society deems important. The
term behavioral indicates the focus of ABA should be on actions exhib-
ited by the individual as opposed to what the individual says about those
actions. Pragmatically, the implication is that what should be measured are
observable actions exhibited by an individual. The term analytic indicates
that a “believable demonstration of events … responsible for the occurrence
or non-occurrence of that behavior” (p. 93–94). Thus, ABA approaches to
treatment are often implemented and demonstrated within a single-subject
research design (e.g., reversal, multielement, or multiple baseline designs).
Along with establishing what constituted applied, behavior, and ana-
lytic, Baer et al. delineated four other dimensions for ABA. Applied behavior
analysis should be technological, meaning that the “techniques making up
a particular behavior application are completely identified” (p. 95). Thus,
it is incumbent upon the behavior analyst implementing an ABA-based
treatment to provide a complete description of its components. Baer et al.
also asserted that ABA be conceptually relevant explanation. Additionally,
Baer et al. stressed practical significance, as opposed to theoretical sig-
nificance, as a hallmark of ABA. In essence, if a behavioral technique does
not produce effects that are of practical value, that application has failed.
Finally, behavior change produced by ABA should be durable over time
(i.e., effects should be generalizable).
Since the publication of Bear et al.’s dimensions of applied behavior
analysis, other behavior analysts have described additional characteristics
of ABA. Heward (2005) described ABA as accountable, public, doable,
empowering, and optimistic. Cooper, Heron, and Heward (2007) described
these characteristics in the following manner.

Accountable: “The commitment of applied behavior analysis to effec-

tiveness, their focus on accessible environmental variables that reliably
influence behavior, and their reliance on direct and frequent measurement
to detect changes in behavior yield an inescapable and socially valuable
form or accountability” (p. 18).
Public: “… ABA is visible and public, explicit and straightforward”
(p.18) Applied behavior analysis is transparent and there are no hidden or
unexplained treatments.
Doable: the interventions found to be effective in ABA studies are
able to be implemented by “teachers, caregivers, coaches, supervisors, and
sometimes even the individuals themselves” (p.19). Cooper et al. suggest
that the procedures are not “prohibitively complicated or arduous” (p. 19).
Empowering: “ABA gives practitioners real tools that work” (p. 19)
thus improving their confidence.
Optimistic: the result of practitioners having effective strategies and
the ability to detect improvements, along with literature-based examples
of success gives cause for optimism regarding the future success of behav-
ior change programs.
Collectively, Cooper et al. (2007) summarized these dimensions and
characteristics of applied behavior analysis as “… the science in which
tactics derived from the principles of behavior are applied systematically
to improve socially significant behavior and experimentation is used to
identify the variables responsible for behavior change” (p. 20). This reli-
ance on systematic evaluation of the variables responsible for behav-
ior change results in an approach to the assessment and treatment of
behavior problems that is functional, as opposed to structural. Thus, the
selected treatment, or treatment package, is based on the relationship
demonstrated between the presenting behavior of interest (i.e., out of seat
behavior) and the environment. This approach can be contrasted to an
approach that prescribes or selects treatment based on the diagnosis (e.g.,
ADHD) that is of concern. Using this functional approach, it is conceiva-
ble that the same treatment(s) could be used to address different present-
ing concerns and different treatment(s) might be used to address similar
presenting concerns.


In this section, an overview of many of the frequently used ABA-based

treatments is provided. The section has been subdivided into conse-
quence-based treatments (reinforcement and punishment based), ante-
cedent-based treatments (noncontingent reinforcement and prompting
strategies), and treatments in combination (i.e., including two or more
consequence or antecedent components or at least one antecedent and
one consequence-based component).
Also included in this section are examples in application of each of the
treatment strategies described. At least two examples from the literature are

provided for each treatment. When possible, an example is provided for both
childhood psychopathology (or disorders not associated with developmental
disabilities) and developmental disabilities. Given that the ABA approach
has been most widely used to treat the psychopathologies of children in two
broad categories (early childhood disorders such as conduct disorder, disrup-
tive behavior disorder, and attention-deficit/hyperactivity disorder and anxi-
ety and phobias), childhood psychopathology examples will likely fit into one
of these two categories. The developmental disabilities examples focus on the
treatment of behavioral challenges presented by individuals with develop-
mental disabilities and autism. These challenges include, but are not limited
to (1) problems of behavioral excess such as stereotypic movement disorder,
self-injurious behavior, aggression, destruction, tantrums, and so on, and
(2) problems of behavioral deficit such as delays in language development,
difficulty with skill acquisition, and problems with academic performance.

Consequence-Based Procedures: Punishment

Punishment is a response-dependent (i.e., contingent) operation
resulting in the decreased likelihood of a particular response. Two types of
punishment have been described in the behavior analysis literature: posi-
tive and negative. Positive punishment involves the response-dependent
delivery of a stimulus that results in a subsequent decrease in respond-
ing. Alternatively, negative punishment involves the response-dependent
removal of a stimulus that results in a subsequent decrease in respond-
ing. The effect on behavior is the same; the difference stems from the
action given to the stimulus (i.e., presented or removed).

Positive Punishment
As indicated, positive punishment involves the contingent presenta-
tion of an aversive stimulus following the target response. In application,
this approach to treatment has included any number of aversive stimuli
including, but not limited to, aversive outcomes such as electric shock
(Linscheid, Iwata, Ricketts, Williams, & Griffin, 1990), water mist (Singh,
Watson, & Winton, 1986), facial screen (Rush, Crockett, & Hagopian,
2001), aversive activities such as exercise (Kahng, Abt, Wilder, 2001), and
overcorrection (Foxx & Azrin, 1973).
Linscheid et al. (1990) described the treatment of self-injurious behavior
(SIB) exhibited by five individuals, including three individuals under the age
of 18, with developmental disabilities. It is important to note that each of the
five cases had a long-standing history of SIB that had proven unmanageable
and was severe in nature (i.e., caused significant tissue damage or put the
individual at risk of tissue damage or death). As well, the authors address
issues related to generalization, maintenance, and potential for abuse for this
particular treatment. Treatment included the contingent application of elec-
tric shock following occurrences of severe SIB. Immediate and pronounced
effects were observed for each of the five participants. Anecdotal follow-up
data suggested that no habituation had occurred for four of the five partici-
pants months after treatment was initiated.

Kahng et al. (2001) described the implementation of a positive pun-

ishment procedure to reduce the SIB exhibited by a 16-year-old girl. One
topography of SIB was reduced by the implementation of a noncontingent
reinforcement procedure. However, other topographies of SIB continued
to be exhibited when this treatment procedure was in place. As a second
treatment component, an aversive activity (i.e., exercise; touching toes)
was made contingent on each occurrence of all topographies of SIB. This
procedure was added to the ongoing noncontingent reinforcement pro-
gram as well as a restraint fading program. Immediate reductions in SIB
were observed when this punisher was in place.

Negative Punishment
Negative punishment involves the contingent removal of a reinforcer
following occurrences of the target response. Applied examples of the pro-
cedure include response cost and timeout from reinforcement. Response
cost is the loss of a specific amount of a reinforcer following each occur-
rence of the target response, resulting in a decreased probability of the
response (Cooper et al., 2007).
Conyers et al. (2004) used a response cost procedure to reduce the
disruptive behavior exhibited by 25 children in a classroom setting. Spe-
cifically, the authors compared a reinforcement-based procedure (differ-
ential reinforcement of other behavior; DRO) with response cost. During
RC, each child’s name was displayed on a board and 15 stars (tokens)
were placed next to each name. Disruptive behavior resulted in the loss of
a token. The remaining tokens could be traded for preferred items at the
conclusion of each session. Results of the study suggested that, although
both RC and DRO behavior were effective in reducing disruptive behavior,
the classroomwide RC procedure was more effective.
Long, Miltenberger, and Rapp (1999) incorporated response cost
into a treatment package to reduce the thumb sucking and hair pull-
ing exhibited by a typically developing six-year-old girl. Reinforce-
ment-based procedures were ineffective in reducing the behavior to
sufficiently low levels. Thus, a response cost contingency was added to
the reinforcement package. Specifically, the participant was able to earn
an M&M at specific time intervals for engaging in behavior other than
thumb sucking or hair pulling. When the RC component was added,
the participant was told she would lose one M&M for engaging in either
thumb sucking or hair pulling. Immediate reductions of both these tar-
get responses were observed. According to the authors, the participant
only lost access to one M&M during the first session of treatment with
the RC contingency in place. Treatment gains were maintained for 23
weeks. Corresponding decreases in problem behavior were reported by
the participant’s parents in the home setting.
Time out from reinforcement (TO) includes the “withdrawal of the
opportunity to earn positive reinforcers or the loss of access to positive
reinforcers for a specified time, contingent on the occurrence of a behav-
ior” (p. 357). Again, the effect on behavior is decreased probability of future
occurrence (Cooper et al., 2007).

Kodak, Grow, and Northup (2004) used time out from reinforcement
as a component of treatment to reduce the elopement exhibited by a young
child diagnosed with ADHD. A functional analysis of the child’s elope-
ment behavior indicated it was maintained by adult attention. During
treatment, this consequence (adult attention) was provided on a sched-
uled basis (every 15 s). However, if the child engaged in the target response
(elopement), she was removed from the activity for 30 s and adult attention
was withheld. This combination of components resulted in a decrease in
elopement to near-zero levels.
Falcomata, Roane, Hovanetz, Kettering, and Keeney (2004) imple-
mented a time out from reinforcement procedure to reduce the inappropri-
ate vocalizations exhibited by an 18-year-old individual with developmental
disabilities. The researchers were able to identify a highly preferred activ-
ity (i.e., a positive reinforcer, listening to the radio), and access to this
activity was interrupted for a specified time following occurrences of the
target behavior. The timeout contingency resulted in almost immediate
reductions in problem behavior. Any number of studies could have been
included here to illustrate the effects of timeout from reinforcement in
application. The Falcomata et al. study was included because it illus-
trates the close relationship between RC and time out from reinforcement.
Many researchers in applied behavior analysis do not draw a distinction
between the two treatments (in fact, the title of the Falcomata et al. article
is “Response cost in the treatment of …”). The take-home point is that both
RC and TO involve contingent removal of positive reinforcers.
There are several concerns that go along with the use of punish-
ment. Vollmer (2002) discussed four potential concerns regarding the use
of punishment that are often raised. First, punishment procedures can
sometimes produce negative emotional side-effects. Second, the effects of
punishment are often short-lived. Third, punishment procedures have the
potential to be abused. This risk of abuse, to some, outweighs the benefits
of some procedures. Finally, the treatment does not teach the individual
an appropriate behavior that can be used to recruit reinforcers from their
environment. Additional concerns regarding the use of punishment include
the development of escape and avoidance behavior, behavioral contrast
(i.e., an increase in the behavior targeted for punishment in the absence of
the punisher), and undesirable modeling (Cooper et al., 2007).
It is important to note that neither Vollmer (2002) nor Cooper et al.
(2007) advocate against the use of punishment procedures. Instead,
they provide discussions of some of the considerations that need to be
taken into consideration before developing and implementing a punish-
ment-based procedure. However, for the above stated reasons, and, often
because of administrative and legal reasons, reinforcement-based strate-
gies are typically implemented as a first step in the treatment of behavior

Consequence-Based Intervention Strategies: Reinforcement

Reinforcement involves the response-dependent delivery (positive rein-
forcement) or removal (negative reinforcement) of a stimulus, resulting in
an increased future likelihood of the target response. Reinforcement-based

procedures often serve as the cornerstone for both simple and complex
behavior-change programs. In application, reinforcement-based proce-
dures include such strategies as token economies, contingency contract-
ing, and differential reinforcement. In each approach, a consequence is
identified using some sort of selection process including preference assess-
ments, reinforcer assestsments, or functional analyses of target behavior.
The stimulus or stimuli identified via these procedures are then scheduled
for delivery contingent on the behavior targeted for increase. Delivery can
take place after each occurrence of the behavior, after a specified number of
occurrences, following the first response after a specified time interval (i.e.,
the stimuli are delivered on ratio or interval schedules), or in a deferred
manner once some behavioral criteria are met (i.e., the stimuli are delivered
as part of a token economy). In addition, a single response can be targeted
for increase, or a sequence of responses can be targeted.

Positive Reinforcement
Positive reinforcement procedures involve the contingent delivery of a
known preferred item or reinforcer contingent on a behavior targeted for
increase. When delivered on a ratio or interval schedule, the individual
must meet a particular response requirement (e.g., two responses or one
response after 10 s has elapsed) to gain access to the positive reinforcer.
This strategy is most often used when the clinical goal is the establishment
of an appropriate behavior, such as communication or task completion, or
a repertoire of appropriate behavior such as social skills or toileting.
Graff, Gibson, and Galiatsatos (2006) used a positive-reinforcement
procedure to increase the vocational and academic work completed by
four adolescents with developmental disabilities. In this study, high and
low preferred stimuli were identified via a series of preference assessments.
High preferred and low preferred stimuli were then made contingent on
completion of various vocational tasks. The results of the study demon-
strated that the contingent presentation of both high and low preferred
stimuli increased the rate of vocational responses. However, contingent
presentation of the high preferred stimuli was correlated with higher, sus-
tained response rates for each participant.
Luiselli (1991) described the use of a positive reinforcement procedure
to increase the independent feeding behavior of a boy with Lowe’s syn-
drome. Specifically, praise and access to sensory-based reinforcers (i.e.,
light and music stimulation) was provided contingent on independently
completing components of the self-feeding response. As each component
was mastered, the reinforcer was provided for the next response in the
task analysis. Results indicated that the participant exhibited acquisition
of each of the steps of the task analysis, eventually exhibiting independent

Negative Reinforcement
Negative reinforcement procedures involve the contingent removal
(escape) of an aversive event, or allow the individual to postpone an aver-
sive event (avoidance). When delivered on a ratio or interval schedule,

the individual must meet a particular response requirement (e.g., two

responses or one response after 10 s has elapsed) before the negative rein-
forcer is removed or postponed. This strategy is most often used when an
individual exhibits problem behavior maintained by escape or avoidance of
instructional, self-care, or other aversive situations.
Kelley, Piazza, Fisher, and Oberdorff (2003) increased the number of
cup sips exhibited by a child with a feeding disorder through the applica-
tion of a negative reinforcement procedure. Prior to treatment, nonpre-
ferred foods were identified via a stimulus preference assessment. During
treatment, spoonfuls of the nonpreferred food were presented along with
prompts to take sips from a cup. Sips from the cup allowed the child to
escape the bite of nonpreferred food that was otherwise presented if inap-
propriate behavior or sip refusal was exhibited. Increases in sips were
observed as a function of this negative-reinforcement procedure.
Rolider and Van Houten (1985) applied negative reinforcement to the
treatment of encopresis associated with constipation exhibited by a 12-
year-old with no other stated diagnoses. During the negative reinforce-
ment-based treatment, the participant was required to sit on the toilet for
20 min or until a bowel movement occurred. If the child had a bowel move-
ment, she was not required to sit on the toilet again that day. If no bowel
movement occurred, she was required to sit on the toilet for 40 min or until
a bowel movement occurred at the next scheduled toilet sitting. Defecation
resulted in no more sitting that day. If no bowel movement occurred, she
was required to sit for 90 min or until a bowel movement occurred at the
next scheduled toilet sitting. Any bowel movement outside of scheduled
toilet sittings also resulted in the child being able to avoid the remain-
ing toilet sittings for the remainder of that day. The treatment resulted in
increased levels of successful bowel movements on the toilet.

Token Economy
A token economy involves the delivery of a conditioned reinforcer (e.g.,
a token, point, or other stimulus) that can later be exchanged for another
reinforcer. According to Cooper et al. (2007), token economies consist
of three components including a list of target behavior or responses,
tokens or points that will be earned for exhibiting the target response(s),
and a menu of items or activities for which the points or tokens can be
exchanged. When implementing a token economy, considerations need to
be made regarding the conditioning of the tokens, the menu of backup or
primary reinforcers, and the schedule with which the backup reinforcers
are accessed. Breakdowns in any of these areas can reduce the effective-
ness of the procedure. For example, if the tokens are not explicitly tied
to the backup reinforcer(s), they will not affect the individual’s behavior.
Similarly, if the menu or backup reinforcers include nonpreferred stim-
uli, are arbitrarily selected (e.g., without the use of a stimulus preference
assessment), or the stimuli are only available on a very lean schedule, the
effect of the program could be limited. Token economies are often used in
large group settings such as classrooms, residential treatment centers,
and group-living environments.

Field, Nash, Handwerk, and Friman (2004) implemented a token economy

to decrease the inappropriate behavior (or, conversely, to increase the appro-
priate behavior) displayed by three children living in a residential treatment
center. Each child had been diagnosed with various psychiatric disorders
including conduct problems, ADHD, and PTSD. The existing, centerwide token
economy was in place for each participant; however, the children’s behavior
continued to be unacceptable. The experimenters increased the schedule of
token exchanges from a single exchange each day to two exchanges per day.
This change in scheduled exchanges resulted in both a decrease in problem
behavior and an increase in the percentage of exchange opportunities during
which the participants earned the backup reinforcer.
Mangus, Henderson, and French (1986) described the use of a token
economy system to improve the on-task physical activity time exhibited by
children with autism in an educational setting. In their study, a peer tutor
was trained to deliver a token on a predetermined schedule (the schedule
differed for each of the five participants, based on the participants’ per-
formance during the last three days of baseline data collection) contingent
on engagement in a physical education activity (i.e., walking on a balance
beam). Tokens could be exchanged for edible reinforcers from a reinforce-
ment menu once five tokens had been earned. Results of the study indi-
cated that the on-task, physical activity of four of the five participants
varied as a function of the token economy intervention. Specifically, when
the token economy was in place, higher levels of on-task physical activity
were observed. When the token economy was not in place, lower levels of
on-task physical activity were observed.

Consequence-Based Intervention Strategies: Extinction

Extinction is a procedure that consists of the discontinuation of rein-
forcement for a behavior with a previous history of reinforcement for the
purpose of reducing that behavior. In contrast to the variations of differential
reinforcement (described later in this chapter), extinction-only procedures
do not include reinforcement for alternative responses or decreases in the
rate of the target response. Typically, the reinforcer that is withheld during
any extinction procedure is one that has been identified as maintaining a
target behavior (i.e., is a functional reinforcer).
Iwata, Pace, Kalsher, Cowdery, and Cataldo (1990) treated the escape-
maintained SIB exhibited by six children with developmental disabilities.
Treatment consisted of extinction and guiding the child through tasks
contingent on occurrences of problem behavior (a response-blocking com-
ponent was added for one participant), thus interrupting the aberrant
response-reinforcement relationship identified during a functional analy-
sis of the consequences maintaining problem behavior. Reductions in SIB
were observed for each of the six participants. Compliance increased for
five of the six participants (compliance data were not presented for the
remaining participant), although compliance was not explicitly targeted for
change (i.e., no consequences had been programmed for this response).
Magee and Ellis (2000) described the sequential application of extinction
to the problem behavior exhibited by two children with attention-deficit/

hyperactivity disorder. One child’s problem behavior (out of seat) was main-
tained by escape from task. This behavior decreased following the imple-
mentation of extinction. However, an increase in other behavior problems
(yelling, inappropriate gestures, and destruction) was observed. Using a
multiple baseline design, extinction was sequentially applied to each topog-
raphy. A decrease in each topography was observed following the applica-
tion of the extinction procedure. The second child’s problem behavior was
maintained by social positive reinforcement (attention). When the extinction
procedure was first applied to object mouthing, that behavior decreased.
However, increases were noted for two other responses, destruction and
aggression. When extinction was implemented for each response, respond-
ing again decreased to near-zero levels.
Although these examples suggest that extinction can be an effective
approach to treatment, its use has some limitations that preclude it from
being used as the sole treatment component. First, implementing extinc-
tion can result in temporary increases in problem behavior at the outset of
treatment (i.e., extinction burst), an outcome that can be especially prob-
lematic when treatment targets behavior that has the potential to cause
injury. Second, extinction can lead to variations in response topography,
including aggressive behavior.
To further evaluate these two drawbacks, Lerman, Iwata, and Wallace
(1999) reviewed 41 data records for individuals whose treatments included
an extinction component and for whom aggression was neither a target
response nor programmed for reinforcement at any point during assess-
ment. Their review identified extinction-induced response bursts for 39%
of the 41 reviewed cases. Similarly, Lerman et al. noted extinction-induced
aggression in 22% of the data records included in their sample. A third
drawback with extinction-only procedures is that they do not teach the
individual alternative methods to obtain the reinforcer. Each of these three
limitations can be addressed by including a differential reinforcement
component to treatment. Differential reinforcement programs include con-
tingent reinforcement of an alternative response, or the absence of the
target response, is targeted for reinforcement, thus increasing the likeli-
hood of an appropriate alternative behavior. This additional component
can improve the effectiveness and limit the drawbacks associated with
extinction-only procedures.
Again, looking at the data provided by Lerman et al., when the extinc-
tion-based procedure included a differential reinforcement, noncontin-
gent reinforcement, of some antecedent manipulation as a component of
treatment, extinction bursts were evident in only 15% of cases. Similarly,
extinction-induced aggression was also only evident in 15% of cases when
extinction was accompanied by other treatment components.

Consequence-Based Intervention Strategies:

Differential Reinforcement
Differential reinforcement is a consequence-based procedure that
consists of the reinforcement of one response class (i.e., a set of responses
maintained by the same reinforcer or reinforcers) and withholding

reinforcement for another response class (Cooper et al., 2007). Behavior

analysts have developed several variations of differential reinforcement-
based treatments. These treatment strategies are typically implemented
to reduce a target problem behavior, whereas some include a component
designed to increase a target appropriate behavior (e.g., compliance). When
used for the purpose of reducing a target behavior, differential reinforce-
ment involves two components: reinforcement of behavior(s) other than
the target behavior or the reinforcement of decreasing rates of the target
behavior, and withholding of reinforcement following the occurrence of the
targeted problem behavior (Cooper, et al.).
Although behavior analysts often use differential reinforcement pro-
cedures for the purpose of reducing problem behaviors, it should be
noted that differential reinforcement is also often used for the purpose
of shaping new appropriate behaviors. As with all reinforcement-based
procedures, differential reinforcement procedures can include positive or
negative reinforcement.

Differential Reinforcement of Alternative Behavior

(Including Functional Communication Training)
Differential reinforcement of alternative behavior (DRA) is a procedure
that consists of the reinforcement of a specified behavior that is different
from the behavior that has been targeted for reduction (but not necessarily
incompatible with that target response). In a typical application, all occur-
rences of the behavior targeted for reduction are placed on extinction,
and reinforcement is available for each appropriate response. One exam-
ple of DRA treatment is functional communication training (FCT). This
treatment consists of identifying the functional reinforcer responsible for
the maintenance of problem behavior, and then delivering that reinforcer
contingent on an appropriate communicative response (Carr & Durand,
1985). When this procedure is implemented in such a manner that the
reinforcer responsible for problem behavior is withheld (i.e., extinction is
in place) contingent on that response or set of responses, it fits within the
parameters of a DRA treatment.
It should be noted that researchers have compared the effectiveness
of FCT with and without this extinction component. In one notable study,
Hagopian, Fisher, Sullivan, Acquisto, and LeBlanc (1998) found that FCT
without extinction was minimally effective for 11 participants. Some par-
ticipants displayed a reduction in problem behavior, but none achieved a
90% reduction. Three of the 11 participants exhibited an increase in prob-
lem behavior of atleast 50% when FCT was conducted without extinction.
By contrast, FCT with extinction was effective in achieving a 90% reduc-
tion in 44% of applications (11 of 25). No increases in problem behavior
were reported when FCT was implemented with an extinction component.
There have been several articles published regarding the utility of FCT
in the behavior analytic literature. Derby et al. (1997) described the long-
term effects of FCT as treatment for the problem behavior exhibited by
four young children with developmental disabilities. Each of the children
displayed reductions in target problem behavior and exhibited increases

in or acquisition of appropriate communication following FCT implementa-

tion. This study demonstrated the robust effectiveness of FCT because the
children’s problem behavior was maintained by different functions (both
positive and negative reinforcement), including one child whose problem
behavior was maintained by multiple functions, and the treatment effects
were observed across a longer than two-year time period.
Other DRA procedures focus on increasing appropriate behavior such
as compliance with instructions. Reed, Ringdahl, Wacker, Barretto, and
Andelman (2005) implemented differential reinforcement of alternative
behavior to increase the compliance and decrease the problem behavior
exhibited by two children with developmental disabilities. Each child’s
problem behavior was maintained by escape from tasks. During treat-
ment, compliance with the tasks resulted in a 30 s break from instruc-
tion (i.e., negative reinforcement). Problem behavior resulted in immediate
guidance through the task (i.e., extinction). For each child, compliance
increased and problem behavior was reduced relative to baseline when the
DRA treatment was in place.

Differential Reinforcement of Incompatible Behaviors

Differential reinforcement of incompatible behaviors (DRI) is a pro-
cedure that is very similar to DRA except that the designated alternative
behavior targeted for reinforcement is incompatible with the behavior that
has been targeted for reduction.
Friman and Altman (1990) implemented a DRI schedule to address the
disruptive behavior exhibited by a 4-year-old boy with developmental dis-
abilities. The target response for the child was out-of-seat behavior. During
the treatment procedure, parents delivered reinforcers (praise and edibles)
contingent on the child exhibiting an incompatible behavior (i.e., staying in
his seat) for specified intervals (initially, 10 s). If the child left his seat, he was
reseated and the reinforcer was not delivered at the end of the interval. The
treatment resulted in a decrease in out-of-seat behavior and a correspond-
ing decrease in other inappropriate behavior (e.g., mouthing and throwing
objects), whereas appropriate behavior (toy play) increased slightly.
Buzas, Ayllon, and Collins (1981) described the use of a DRI proce-
dure to reduce the SIB (biting lip and tongue, picking at lips and mouth,
biting inside of cheek, gouging tongue frenulum, and falling out of wheel-
chair) exhibited by a young boy with Lesch–Nyhan Syndrome. The par-
ticipant’s SIB was so severe that he spent the majority of his day in
mechanical restraints. On the occasions when restraint was removed (for
hygiene activities, dressing, etc.), almost immediate attempts at SIB were
observed (e.g., tearing his lip with fingernail). In this case study, an array
of responses incompatible with SIB (drawing, throwing plastic darts, play-
ing games, doing puzzles, eating candy, playing catch, reading while hold-
ing a book, adding and subtracting numbers on a die, typing, wheeling
his wheelchair, and learning sign language) resulted in access to attention
from various therapists and caregivers.
When this DRI procedure was in place, the participant was able
to interact out of restraint for up to three-and-a-half hours without

attempting to engage in SIB. When the procedure was not in place and
restraints were removed, attempts at SIB were observed within 5 to 15
minutes. Although this study is descriptive and lacks systematic experi-
mental control, it is included here because of the clinically significant out-
comes achieved. The behavioral problems associated with Lesch–Nyhan
syndrome are notoriously resistant to treatment, both pharmacologic
and behavioral in nature. One potential reason for this difficulty in treat-
ment is that the reinforcers relevant to the behavior are unidentifiable or
change too often to allow for systematic evaluation. The described study
demonstrates the potential utility of arranging a differential reinforce-
ment-based treatment when a reinforcing consequence can be identified
and manipulated.

Differential Reinforcement of Low Rates of Behavior

Differential reinforcement of low rates of behavior (DRL) is a procedure
that consists of the reinforcement of a behavior targeted for reduction but
on a schedule of reinforcement that is leaner than what was in place prior
to the implementation of the DRL procedure (i.e., the schedule of rein-
forcement in place in the natural environment). With the DRL procedure,
the behavior targeted for reduction is reinforced only following a specified
length of time in the absence of the behavior. In addition, as the reductions
of the target behavior are observed over time, the length of the interval
can be systematically increased in order to bring about lower and lower
rates of the target behavior (often referred to as differential reinforcement
of diminishing rates; DRD).
Wright and Vollmer (2002) reported the use of a DRL procedure to
reduce the rapid eating exhibited by a teenage girl with developmental
and physical disabilities. The procedure consisted of reinforcing bites (i.e.,
allowing access to the bite) only if bite attempts occurred on a predeter-
mined interval. If the participant attempted to take a bite of food before the
predetermined interval elapsed, that bite was blocked. If the participant
attempted to take a bite of food after the predetermined interval elapsed,
the bite was allowed (i.e., reinforced). The authors noted that the DRL pro-
cedure was more effective if the time interval was adjustable and based on
the mean interresponse time (IRT) from the preceding five sessions than
if it was fixed (i.e., 15 s for every session). The DRL procedure resulted in
longer time between bite attempts relative to baseline which translated to
a decrease in the participant’s bite rate.
Deitz and Repp (1973) reported a series of three experiments in which
DRL schedules were used to reduce the disruptive behavior exhibited by
a student diagnosed with a developmental disability, a classroom of stu-
dents diagnosed with developmental disabilities, and a group of high school
students enrolled in regular education. In each experiment, there was a
decrease in disruptive behavior exhibited by either the target individual or
the class as an aggregate when the DRL schedule was implemented. The
treatment effects were maintained when the DRL schedule was withdrawn
during Experiment I (single student). However, treatment effects were lost
when the DRL schedules were withdrawn during Experiments II and III.

Differential Reinforcement of Other Behavior

Although DRA, DRI, and DRL-based treatments target increasing
a specific appropriate response along with reducing the target problem
behavior, differential reinforcement of other behavior (DRO) consists of
the delivery of reinforcers contingent on the absence of identified problem
behavior for a specified time period. Whereas reinforcement involves the
presentation of a stimulus contingent on a target behavior, DRO entails
the contingent application of a reinforcing consequence (either positive or
negative) for the nonoccurrence of a target behavior. Other terms that are
sometimes used for DRO include differential reinforcement of the omission
of behavior and differential reinforcement of zero rates of behavior.
Ringdahl et al. (2002) described the use of a DRO-based treatment to
reduce the stereotypic hand movements exhibited by an adolescent boy
with developmental disabilities. The stereotypic hand movements exhib-
ited by the participant were serious in nature because they could trigger
photosensitive grand mal seizures. The researchers were unable to identify
any social reinforcers maintaining the problem behavior and noted that
the behavior only occurred when adult supervision was not provided. A
reinforcer assessment indicated that video games could potentially func-
tion as a reinforcer for appropriate behavior. Following assessment, access
to video game time was allowed contingent on time intervals during which
the participant did not engage in the target response. Initially, the DRO
interval was set at 10 s (based on the average time between hand-flapping
episodes during baseline) and gradually increased to 600 s (10 min) by the
end of treatment. Decreases in repetitive hand movements were observed
when the DRO procedure was in place.
Watson and Sterling (1998) used a DRO procedure to reduce vocal
tics exhibited by a 4-year-old girl. A functional analysis of this behav-
ior indicated the vocal tics were maintained by social consequences in
the form of adult attention. During treatment, adult attention was with-
held or removed when vocal tics occurred. Alternatively, adult attention
was provided following brief intervals (15 s) with no vocal tics. The interval
was increased by 10 s following three consecutive deliveries of the rein-
forcer until the DRO interval reached the terminal length of 300 s (5 min).
A decrease in the rate of the vocal tic was observed when the DRO was
implemented. This decrease was still apparent at one-, three-, and six-
month follow-up visits.

Thinning Differential Reinforcement Schedules

One limitation of DR approaches to treatment, particularly DRA/FCT
and DRI programs, is that the target individual can access reinforcers at
any time contingent on appropriate behavior. If delivery of the reinforcer
requires the presence of a caregiver, such programs can be labor intensive.
As well, the individual may spend all of his time accessing the reinforcer,
which can compete with academic or vocational goals. Thus, one goal of
treatment is to reduce the availability of the reinforcer by increasing the
response requirement or implementing a delay to reinforcement.

Lalli et al. (1999) provided access to differential positive reinforcement

contingent on compliance in the treatment of the escape-maintained prob-
lem behavior displayed by five individuals 21 years old or younger. The pro-
grammed positive reinforcement schedule resulted in increases in compliance
and decreases in problem behavior exhibited by each participant. The
response requirement to obtain the positive reinforcer was then increased for
three of the five participants. At the outset of treatment, compliance resulted
in positive reinforcement on a fixed-ratio (FR) 1 schedule. That schedule was
increased to at least FR 10 for each of these three participants. This change
in schedule did not result in degradation of treatment effects.
Hagopian, Contrucci Kuhn, Long, and Ruch (2005) implemented FCT
for three boys diagnosed with PDD spectrum disorders admitted to an inpa-
tient hospital setting for the assessment and treatment of severe behavior
problems including aggression and disruption. Functional communica-
tion training resulted in decreases in problem behavior for each child. The
authors thinned the schedule by implementing a delay between occur-
rences of appropriate requests and delivery of the reinforcer (attention or
preferred tangible items). The delays were progressively increased if the
participant exhibited less than 0.2 responses per minute (RPM) of problem
behavior for two consecutive sessions at a given delay. If two sessions of
greater than 0.2 RPM of problem behavior was observed, the delay was
reduced to the previously longest successful delay. This progression con-
tinued until a terminal goal was met for each participant. For each of the
three participants, delays of at least 4 min were achieved. One interesting
finding from this study was that allowing the participants access to com-
peting reinforcers during the delay interval allowed for quicker attainment
of the terminal delay length and fewer occurrences of problem behavior.

Antecedent Approaches to Treatment

The majority of ABA treatments focus on manipulating consequences
to change behavior, however, there are some treatments that focus on
manipulating antecedents relevant to the target behavior. For the pur-
poses of this chapter, four antecedent-based interventions are highlighted.
These interventions include: procedures that manipulate establishing
operations, stimulus control procedures, prompt procedures, and proce-
dures that provide choice-making opportunities.

Establishing Operations
The relationship between environment and behavior is often described
as a 3-term contingency. The three components of this contingency are
what happens prior to the response (the antecedent, or A), the behav-
ior the individual exhibits (B), and what happens immediately following
the behavior (the consequence, or C). Often, this 3-term contingency is
denoted as A-B-C. A complete understanding of the antecedent requires
that behavior analysts take into account variables that alter the effective-
ness of a stimulus as a reinforcer. The term that has historically been
used to describe this relationship between the environment and reinforcer

effectiveness or value is “establishing operation” (EO; Michael, 1982). More

recently, the term “establishing operation” has been replaced with the term
“motivating operation” (MO) when the effect is an increase in the value of
the reinforcer and the term “abolishing operation” (AO) when the effect is
a decrease in the value of the reinforcer (Laraway, Snycerski, Michael, &
Poling, 2003). These operations (motivating or abolishing) affect behavior
by either increasing (via an MO) or decreasing (via an AO) responding.
The most salient example of MOs and AOs are deprivation and satia-
tion. Deprivation consists of withholding the stimulus that functions as
a reinforcer from the individual. Deprivation has at least two effects.
First, it results in an increase in the value of the stimulus as a reinforcer.
Second, it results in an increase in responding that occurs as a function
of that reinforcer. Conversely, satiation consists of presenting a suffi-
cient amount of the stimulus that functions as a reinforcer and has two
opposite effects: a decrease in the value of the reinforcer and a related
decrease in responding that occurs as a function of that reinforcer.
In application, EOs can be manipulated in a number of ways. When
attempting to decrease a target response, the identified reinforcer for that
response can be provided on a noncontingent basis during treatment (i.e.,
reinforecers are delivered on a relatively dense fixed-time schedule; Ringdahl,
Vollmer, Borrero, & Connell, 2001). Alternatively, the functional reinforcer
could be provided to the individual prior to exposing her to the context(s) in
which the target response has historically been likely to occur (e.g., Vollmer &
Iwata, 1991; Berg et al., 2000). When attempting to increase a target response,
the reinforcer can be withheld prior to training (e.g., Vollmer & Iwata, 1991).
Lalli, Casey, and Kates (1997) used a fixed-time (FT) reinforcement
schedule to reduce aberrant behavior exhibited by two children with
mental retardation and one child with a developmental disability. The FT
schedule specified when reinforcers were to be delivered. Delivery occurred
independent of the child’s behavior. The specific FT schedules used during
treatment reflected the mean latency to problem behavior during baseline
for each child. Decreased rates of problem behavior were observed with
all three children when the FT schedule was implemented. One possible
explanation for the decrease in aberrant behavior was that the FT sched-
ule of reinforcement resulted in satiation indicating AO effects.
Taylor et al. (2005) manipulated the EO associated with preferred
snacks to increase peer-directed mands (i.e., requests) exhibited by three
children with autism. MOs were altered through the restriction of the pre-
ferred snacks and access to the snacks was made contingent on mands
that were peer-directed. When the MO was in place, rates of peer-directed
mands were observed at high rates. Conversely, when the MO was not in
place, mands decreased to near-zero rates for each of the children. The
results demonstrated that targeted appropriate behaviors can be increased
through the direct manipulation of MOs.

Stimulus Control
Stimulus control is demonstrated when a particular behavior is reli-
ably occasioned by specific antecedent stimuli (Sulzer-Azaroff & Mayer,

1991). In terms of the 3-term contingency, stimulus control describes a

relationship between environment and behavior that consists of A (the
antecedent) reliably occasioning B (the behavior), which results in C (the
consequence or reinforcement). One way stimulus control can be estab-
lished is by pairing specific responses with reinforcement only when they
occur in the presence of specific antecedent stimuli, and withholding rein-
forcement when those specific responses are exhibited in the absence of
the specific antecedent stimuli. This process is often programmed in labo-
ratory research. However, it can also occur naturally as individuals are
exposed to different stimulus contexts and their specific reinforcement
schedules. For example, behavior may come under stimulus control due to
the different ways a child’s parents respond to his or her behavior.
In the presence of the father, problem behavior might always result
in attention. Conversely, in the presence of the mother, problem behavior
might have no differential consequence. If attention from care providers is
a reinforcer, the child might begin engaging in problem behavior only in
the presence of the father. In a similar fashion, punishment of a behavior
in the presence of a specific stimulus might result in that behavior being
inhibited in the presence of the stimulus. Using the same example, if the
child’s mother always delivered an aversive consequence (e.g., timeout or
spanking) following problem behavior, but the father provided no differen-
tial consequence, the child might stop engaging in problem behavior in the
presence of the mother only.
When stimulus control is apparent as exhibited by differential respond-
ing correlated with specific stimuli, treatment might focus on transfer-
ring stimulus control to improve behavior across stimulus contexts. Ray,
Skinner, and Watson (1999) used stimulus control procedures to increase
compliance exhibited by a five-year-old boy diagnosed with autism. Dur-
ing baseline, the investigators evaluated compliance when demands were
delivered by the child’s teacher as compared to when demands were deliv-
ered by the child’s mother. The likelihood that the child would comply with
demands was increased when his mother delivered demands as opposed
to when his teacher delivered demands. This finding suggested that stimu-
lus control had been established.
Using that information, the investigators next implemented a series of
procedures in which the teacher was paired with the mother during demand
situations. Initially, the child’s mother delivered three demands and the
teacher delivered one demand and compliance was observed at high rates
with both adults. Over time, a fading procedure was used in which the teacher
delivered an increasing number of the demands and the child’s mother deliv-
ered fewer of the demands while compliance continued at high rates. Eventu-
ally, the child’s mother was faded completely out of the demand situation, the
teacher delivered all of the demands, and compliance continued at high rates.
The results of Ray et al. (1999) suggested the fading procedure resulted in a
transfer of stimulus control from the child’s mother to the teacher.
In a similar study, Knoff (1984) used stimulus control procedures to
treat problem behavior exhibited by two boys, 9 and 10 years of age, who
engaged in aggression, disruption, and oppositional behavior. With each of
the children, problem behavior was occurring at high rates in the presence

of a paraprofessional during morning and noon recesses. Likewise, with

each of the children, appropriate behavior was reliably occurring at high
rates in the presence of their classroom teacher. The goal of the stimulus
control procedures was to generalize the apparent stimulus control that the
presence of the teacher was exerting over appropriate behavior to the para-
professional during recess times. The procedure consisted of the teacher
attending each recess period during the first week. High levels of appropri-
ate behavior were immediately observed with each of the children during
the first week. During subsequent weeks, the teacher spent fewer and fewer
days attending recess periods until she was completely faded out. After the
teacher was completely faded out of the recess, high levels of appropriate
behavior continued to be observed with each of the children suggesting that
stimulus control had been generalized or to the paraprofessional.

Prompt Procedures
Cooper et al. (2007) defined prompts as supplementary anteced-
ent stimuli intended to occasion specific responses. Whereas response
prompts (i.e., graduated guidance) target behavior, stimulus prompts tar-
get the antecedent conditions that exist prior to the occurrence of specific
behavior (i.e., antecedents). Behavior analysts use stimulus prompts as
auxiliaries to be removed over time as the intended behavior occurs more
reliably in the presence of natural stimuli (discriminative stimuli). Prompts
are often used during initial phases of treatment programs to facilitate the
acquisition of specific responses. Following acquisition, the prompts can
then be systematically faded so that naturally occurring stimuli will come
to reliably occasion the acquired behavior.
Taylor and Levin (1998) and Shabani, Katz, Wilder, Beauchamp, Tay-
lor, and Fischer (2002) each used a prompting procedure to promote social
initiations with children with diagnoses of autism. The investigators used
a tactile prompting device located in the children’s pockets. Specifically,
the device was programmed to vibrate for 3 to 5 s whenever the investiga-
tors activated it using a remote control. The investigators initially paired
a vocal model with the tactile prompt to bring about social initiations,
and then gradually faded the vocal model as the children independently
exhibited social initiations following tactile prompts. The use of the vocal
modeling and tactile prompts resulted in high rates of social initiations
exhibited by the children across both studies.
In addition, Shabani et al. (2002) also attempted to fade the tactile
prompt with two of the three participants by systematically reducing the
frequency of the prompts over time. The results suggested that fading the
tactile prompt was partially successful for each of the particiapants as
social interactions continued, but at lower and more variable rates.
Rivera, Koorland, and Fueyo (2002) used picture prompts to promote
sight word reading with a nine-year-old boy diagnosed with a learning dis-
ability. The picture prompts, which were generated by the child himself,
were illustrated representatives of the targeted sight words. Initially, the
experimenters reviewed with the child the meaning of each of the targeted
sight words and had him generate illustrations for each of the words on

large index cards. As the child’s sight-word reading accuracy increased,

the index cards on which he drew the illustrations were reduced and the
colors that he was allowed to use were systematically lightened until the
illustrations were successfully faded from the program. Even as the picture
prompts were faded, the child continued to exhibit a high level of accurate
sight-word reading.

Another antecedent-based intervention that has been demonstrated
to be effective involves providing choice-making opportunities. Numerous
studies have shown that providing choice can serve to decrease problem
behavior and increase appropriate behavior including academic and voca-
tional task engagement. Furthermore, choice has been conceptualized as
a functional variable (i.e., a reinforcer for appropriate behavior) in and of
itself rather than simply a means to identify highly preferred stimuli (Dun-
lap et al., 1994).
Dibley and Lim (1999) provided choice-making opportunities dur-
ing treatment with a 15-year-old girl diagnosed with a severe intellectual
disability. Choice-making opportunities were incorporated into various
activities including meal-time routine, toileting routine, and leisure time
activities for the purpose of increasing compliance and decreasing prob-
lem behaviors. During baseline, the adolescent was prompted to engage
in each step that made up the respective activities and no choices were
incorporated. During treatment, the adolescent was prompted to engage in
each step that made up the respective activities with various opportunities
for choice embedded throughout each of the activities. For example, during
the toileting routine, the adolescent was provided with a choice between
initiating the activity immediately or following a 10-min delay, basin or
sink for hand washing, and hand-towel or hand dryer. When choices were
provided, compliance was observed at higher levels and problem behavior
was observed at lower levels when compared to baseline. These results
were consistent across each of the three targeted activities.
Dunlap et al. (1994) incorporated choice-making opportunities into
treatment programs for three young boys aged 11, 11, and 5 for the pur-
pose of decreasing noncompliance and aggressive behavior. Two of the
children received opportunities to make choices during instructional times
in the form of menus containing several academic tasks. Choice-making
opportunities for the third child were incorporated into reading time. Spe-
cifically, the child was allowed to pick a book from an array prior to story-
time. When choices were provided, each child exhibited lower levels of
noncompliance and problem behavior and task engagement was observed
at higher levels than those observed during baseline.

Combining Antecedent and Consequence-Based Treatments

Often, more than one treatment is selected for implementation. Such
treatment packages might be constructed of both antecedent and consequence-
based components. Ringdahl et al. (2002) provided one such example.

Treatment evaluated in that study combined DRA with instructional fading

in the treatment escape-related problem behavior exhibited by a girl diag-
nosed with autism. The consequence portion of the treatment was a dif-
ferential reinforcement schedule that specified the delivery of brief breaks
contingent on appropriate compliance (i.e., completion without exhibiting
problem behavior) with academic tasks. The antecedent component of the
treatment was systematically increasing the number of instructions that
were delivered during a 5-min work session, as long as problem behav-
ior remained low, until a terminal goal of one instruction per min was
achieved. Results of this study suggested that this combination of treat-
ment components resulted in successful treatment with fewer occurrences
of problem behavior than a consequence-based treatment (DRA) alone.
Marcus and Vollmer (1996) combined antecedent and consequence-
based treatments in the treatment of SIB and aggression displayed by a
young girl with developmental disabilities. Their investigation evaluated a
treatment comprised of two components: NCR (antecedent) and differential
reinforcement of compliance (consequence). Results of the study indicated
that the treatment package was effective in reducing problem behavior. In
addition, the treatment was effective in teaching the young girl how to use an
alternative, appropriate communicative response to obtain the reinforcer that
maintained problem behavior. The use of the package allowed for effective
treatment while limiting some of the side effects (e.g., response bursts) some-
times observed during behavioral treatments with an extinction component.

Generalization is one of the stated characteristics of applied behavior
analysis (Baer et al., 1968). According to Cooper et al. (2007), generalization
is a broad term that refers to a number of behavior change outcomes. During
clinical application of ABA-based treatments, there is often an attempt
to expand the effects of treatment from the clinical setting to the natu-
ralistic environment (i.e., stimulus/setting generalization). Stimulus/set-
ting generalization refers to the occurrence of a behavior under different
conditions than which the behavior was acquired. Cooper et al. point out
that this behavior change can occur without being directly taught. How-
ever, some behavior analysts attempt to facilitate this outcome through
programming. Literature-based examples of generalization can be broken
into two broad categories. Some studies describe the naturally occurring
spread of effects across setting, time, and stimuli, whereas others describe
systematic processes to achieve generalization.
Bonfiglio, Daly, Martens, Lin, and Corsaut (2004) described the effects
of various reading interventions on the reading accuracy of a third-grade
girl. The participant was exposed to performance-based, skills-based,
and combined performance-based and skills-based reading interventions.
Each treatment was demonstrated to improve reading behavior. The effects
of treatment were noted across time and reading passages. These effects
were achieved without specific programming. The authors hypothesized
that generalization, particularly across passages, was a function (or, par-
tially a function) of a fluency threshold.

Eikeseth and Nesset (2003) described a treatment designed to improve

vocal articulation exhibited by children with phonological disorder. As part
of their treatment, the goal was to bring about mastery of a variety of tar-
get sounds (i.e., vocally produce the sounds without articulation errors).
Toward this end, the two participants were exposed to a treatment that
included sufficient response-exemplars. Specifically, a set of ten words
was programmed to be used to teach the child the sound. During treat-
ment, participants received tokens that could be exchanged for individually
determined back-up reinforcers contingent on correct articulation or close
approximations of the therapist’s vocal model. Results suggested that both
participants mastered each sound without needing to be exposed to all ten
target words. The necessary number of words needed varied from one to
eight. Thus, according to Eikeseth and Nesset, “after acquiring correct artic-
ulation of some words containing a particular target sound, other words
containing the same target sound were subsequently echoed correctly with-
out training” (p. 33–334). That is, generalized behavior change took place.


Another s tated characteristic of applied behavior analysis is effective-

ness (Baer et al., 1968). Although metaanalyses regarding the effectiveness
of ABA-based treatments are difficult to identify, there are a number of
studies that review the effectiveness of ABA-based strategies in the treat-
ment of severe behavior problems exhibited by individuals with and with-
out developmental disabilities. These reviews and summary papers can
be placed into one of three broad categories: summaries of treatments for
behavior associated with particular disorders (e.g., autism, ADHD), sum-
maries of treatments for specific behavior problems (e.g., SIB, aberrant
behavior, and stereotypy), and summaries of the effects of a specific treat-
ment approach (e.g., NCR and FCT).

Treatment of Behavior Challenges Associated

with Particular Diagnoses
Matson et al. (1996) provided a review of behavioral treatment strate-
gies designed to address the challenging behavior exhibited by individu-
als with autism. Results of their review suggested that behavior analysts
have used methods derived from the principles of operant conditioning to
address a wide range of target behaviors exhibited by children diagnosed
with autism including aberrant behavior, language, and social, daily living,
and academic skills. These authors also found the percentage of interven-
tions reported that used positive procedures outnumbered significantly the
number of interventions that used aversive procedures. Olson and Houli-
han (2000) reviewed behavioral treatments for challenging behaviors asso-
ciated with Lesch–Nyhan disorder. The review suggested that in most cases,
the use of behavioral treatments (i.e., DRO, DRI, extinction) were effective
in treating self-injury exhibited by children with Lesch–Nyhan and that in
many cases the results generalized to other settings and care providers.

Treatment of Specific Problem Behavior

A number of other review papers have summarized ABA-based proce-
dures as they pertain to the treatment of specific behavior problems. Iwata
et al. (1994) reported the use function-based behavior analytic treatment
to reduce self-injurious behavior (SIB) exhibited by adults and children
with developmental disabilities. Effective treatment was defined as a treat-
ment procedure that resulted in a decrease in problem behavior to below
10% of the baseline level for a given individual. Iwata et al. reported that,
when interventions were based on identified functions of SIB, anteced-
ent-based interventions were effective in 84.2% of reported cases, extinc-
tion was effective in 86.8% of reported cases, differential reinforcement
was effective in 82.5% of reported cases, and punishment was effective in
88.2% of reported cases.
Similarly, Asmus et al. (2004) reported the treatment effects of func-
tion-based behavior analytic treatments in the reduction of aberrant
behavior (SIB, aggression, stereotypy, destruction, and disruption) exhib-
ited by adults and children with and without developmental disabilities.
They reported an 80% decrease in aberrant behavior following the imple-
mentation of ABA-based treatments for 76% of the treated individuals.
Rapp and Vollmer (2005) provided a summary of the literature concerning
the treatment approaches to reducing stereotypy (i.e., repetitive behavior
that serves no apparent social function). These authors concluded that
there is ample support in the literature for the effectiveness of ABA-based
treatments (both antecedent and consequence) in reducing stereotypy.

Effectiveness of Specific Treatment Strategies

Finally, several summaries have been published on the effectiveness
of specific ABA-based approaches to treatment. Miltenberger, Fuqua, and
Woods (1998) reported on the effectiveness of habit reversal methods for
the treatment of target behaviors including tics, nervous habits, and stut-
tering. The authors suggested that habit reversal methods have been con-
sistently demonstrated as effective even in the absence of identification
of functions of the treated tics, habits, and stuttering. Carr et al. (2000)
conducted a review of studies that evaluated the use of NCR in the treat-
ment of aberrant behavior. The authors reported that NCR has been an
effective treatment strategy for a variety of problem behaviors exhibited
by individuals with developmental disabilities but included the caveat
that more clinical research needs to be conducted in the area. Taken as a
group, summaries provide a persuasive demonstration of the effectiveness
of ABA-based treatments for a number of childhood behavior challenges
exhibited by children with psychiatric and developmental disabilities.


We have attempted to provide an overview of the conceptual basis for

ABA-based treatments, a description of several of the more common of these
treatments, and a brief discussion of their effectiveness. Applied behavior

analysis-based treatment approaches have an established and effective

history in the treatment of problem behavior and the establishment of
appropriate behavior across a wide range of disabilities. The approach is
not designed to treat the underlying disorder, per se. Instead, ABA-based
treatments target specific behavioral symptoms indicative of an individual’s
diagnosis. Related strategies can be used to either establish new behavior
or decrease existing problem behavior through an analytic process requir-
ing an understanding of the antecedent and consequent variables affect-
ing the target behavior. Although several approaches to behavior change
exist, ABA-based treatments offer an evidence-based methodology with
strong roots in basic and applied research. In our opinion, ABA represents
a state-of-the-art approach to the development of behavior-change programs.


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Cognitive Behavior Therapy


Increasingly, attention is turning to the significance of children’s mental

health. This attention results from a confluence of information sources col-
lectively emphasizing the prevalence of childhood problems. Epidemiologi-
cal estimates for the prevalence rates of childhood emotional and behavioral
disorders range between 15 and 22% (e.g., McCracken, 1992; Roberts, Att-
kisson, & Rosenblatt, 1998; Rutter, 1989; Kazdin & Weisz, 2003a; WHO,
2001). These rates may be underestimates as epidemiological studies often
do not include children exhibiting subclinical distress despite the fact that
these subclinical conditions have been found to be associated with sig-
nificant functional impairments (e.g., Angold, Costello, Farmer, Burns, &
Erkanli, 1999). Childhood difficulties have been associated with problems
in adolescent and adult adjustment (e.g., Colman, Wadsworth, Croudace, &
Jones, 2007). Evidence exists suggesting that childhood psychopathology
has long-term social consequences including truncated educational attain-
ment, teen parenthood, early marriage, and marital instability (e.g., Kes-
sler, Berglund, Foster, Saunders, Stang, & Walters, 1997; Kessler, Molnar,
Feurer & Appelbaum, 2001; Kessler, Foster, Saunders, & Stang, 1995; Kes-
sler, Walters, & Forthofer, 1998; Forthofer, Kessler, Story, & Gotlib, 1996).
Despite the evidence that a large number of children are diagnosed
or at risk for disorder, research has suggested that as few as 40% of chil-
dren experiencing mental health problems receive help and only about
20% receive specialty mental health services (Burns et al., 1995). Hence,
there is a real need for easily accessed, client-acceptable, and effective
interventions for childhood mental health issues. In recent years, the child
therapy literature has grown with a profusion of empirical investigations of

ELLEN FLANNERY-SCHROEDER and ALEXIS N. LAMB ● University of Rhode Island.

J.L. Matson et al. (eds.), Treating Childhood Psychopathology 55

and Developmental Disabilities, DOI: 10.1007/978-0-387-09530-1,
© Springer Science + Business Media, LLC 2009

Table 3.1. General Characteristics of Cognitive Behavioral


Fairly structured
Time-limited (5–20 sessions; 45–50 minutes)
Session agenda setting
Goal setting
Experimental orientation to human behavior
Problem-oriented focus
Collaborative empiricism
Behavioral experiments
Measurable outcomes
Performance-based assessments/procedures
Skill- and knowledge-building
Psychoeducation (e.g., directed reading, rating scales, handouts)
Behavioral methods (e.g., behavioral rehearsal)
Cognitive methods (e.g., cognitive restructuring)

efficacy. Many of these investigative efforts have involved cognitive-behav-

ioral treatments.
Cognitive-behavioral treatments (CBTs) with youth have garnered
a good deal of clinical and research attention of late (e.g., Christner,
Stewart, & Freeman, 2007; Friedberg & McClure, 2002; Graham, 2005;
Kazdin & Weisz, 2003b; Kendall, 2006; Mennuti, Freeman, & Christ-
ner, 2006; Reinecke, Dattilio, & Freeman, 2006a). Cognitive-behavio-
ral approaches have been used for a broad array of childhood problems
including, but not limited to, anxiety, depression, anger, aggression, eat-
ing disorders, autism, and learning difficulties. Numerous treatments
(e.g., self-instructional training, problem-solving therapy, stress inocu-
lation therapy, social skills training) have fallen under the heading of
cognitive-behavioral. These varied treatments, however, share some com-
mon features (see Table 3.1).
Early child treatment models have been downward extensions of
treatments designed for adults. Many researchers have sounded a call
for intervention and prevention programs that are based on theory and
research emerging from the field of developmental and child clinical
psychology (Greenberg, Domitrovich, & Bumbarger, 2001; Holmbeck,
O’Mahar, Abad, Colder, & Updegrove, 2006; Kazdin, 2001; Weisz & Weers-
ing, 1999). All CBTs with children are based on an explanatory model of
behavior that emphasizes cognitive processing, behavior, and affective
responding. CBT finds its roots in classical and operant conditioning and
social learning theory.


In its most basic form, the cognitive-behavioral model posits that one’s
response to events is dependent upon one’s perception or interpretation of
that event. In other words, children respond to a cognitive representation

of the event, not the event itself. If one’s interpretation of the situation
is not supported by the facts or reality, then the thinking is deemed dis-
torted, irrational, or dysfunctional. One of the goals of CBT is to identify
and restructure the dysfunctional thoughts and beliefs related to one’s self,
world, and future (Beck, 1970). The manner in which children think about
situations or events will determine not only their affective response but
also their behavior. These cognitive representations and resulting affect
and behavior are reciprocally determined. That is, changes in one result
in changes in the other. CBT therapists aim to educate children about this
reciprocal relationship and to heighten awareness of their cognitive proc-
esses (i.e., self-statements).
Cognition is thought of as an information-processing system with dif-
ferent levels, structures, and processes. Automatic thoughts, intermediate
beliefs, and schemas comprise three components of the system. Automatic
thoughts are those situation-specific self-statements that we make with-
out deliberation or reasoning. They are closest to our conscious level of
thinking and therefore are easily accessed. Beck and colleagues (1979;
Clark, Beck, & Alford, 1999) have described characteristic errors in logic
in automatic thoughts. Sample categories of cognitive errors include mag-
nification or minimization, overgeneralization, all-or-nothing thinking,
and personalization.
Much research evidence has demonstrated that adults and children
with psychological disorders (e.g., depression, anxiety) have a high fre-
quency of distortions in their automatic thoughts (e.g., Bogels & Zig-
terman, 2000; Haaga, Dyck, & Ernst, 1991; Hollon, Kendall, & Limry,
1986; Kazdin, 1990; Kendall, Stark, & Adam, 1990; Schniering &
Rapee, 2002, 2004; Wright, Beck, & Thase, 2003). Intermediate beliefs
comprise those attitudes, rules, and assumptions that one holds (e.g.,
“If I don’t get an A on my math test, I am a failure.”). These beliefs may
be out of conscious awareness, unspoken, and often reflect conditional
“if-then” thinking. Core beliefs (or schemas) represent thinking which is
absolute (e.g., “I am unlovable.”). These beliefs may be characterized as
“global, rigid, and overgeneralized” rules for interpreting one’s environ-
ment (Beck, 1995, p. 16).
According to Beck’s (1976) content-specificity hypothesis, thought con-
tent is specific to psychological disorder or affective state. As an example,
Beck’s model posits that cognitive processes in depression center on loss,
hopelessness, and failure whereas cognitive processes in anxiety focus
on perceived threat, danger, and uncontrollability. Two relatively recent
studies using both community and clinic-referred samples of children and
adolescents have demonstrated support for the content-specificity hypoth-
esis (e.g., Epkins, 2000; Schneiring & Rapee, 2004) whereas others (e.g.,
Epkins, 1996; Treadwell & Kendall, 1996; Ronan & Kendall, 1997) have
found mixed support.
Once children become adept at metacognition (i.e., thinking about
their own thinking), children are taught strategies to modify their think-
ing. The modification of irrational or distorted thinking occurs through
cognitive (e.g., collection of “evidence” against which to evaluate the
veracity of the irrational thought, Socratic questioning, problem-solving)

or behavioral (e.g., behavioral experiments designed to “test” the valid-

ity of beliefs or to build skills) means. It is important to note, however,
that the reliance on cognitive versus behavioral techniques is often deter-
mined both by the nature of the disorder as well as the age of the child. As
an example, behavioral techniques may have greater utility in work with
younger children.
Contingent reinforcement is often used to enhance a child’s motivation
and involvement in therapy. The process of CBT has often been described
as collaborative empiricism: therapist and child work together to form
and experimentally “test” hypotheses through the collection of behavioral
evidence. Together, therapist and child monitor the progress of therapy,
making necessary revisions and refinements across time.
To best fulfill the goals of cognitive behavioral therapy, one must con-
sider the child’s functioning (e.g., cognitions, affect, and behavior) within a
context. Therapists must consider biological, cultural, social, environmen-
tal factors to best understand the contextual influences impinging upon
the child. The field of developmental psychopathology has come to recog-
nize that change involves a dynamic interplay among the individual char-
acteristics and contextual systems (Cairns, Cairns, Rodkin, & Xie, 1998).
Recognition of these contextual systems is especially important given the
fact that children have little control over choosing and altering their envi-
ronments (Erickson & Achilles, 2004).


Numerous assessment techniques have been researched and cited

in the child assessment literature. Therapists select certain measures
and assessment tools depending on the nature of the information they
seek. For cognitive behavioral therapists, particular assessments are more
widely used than others. These include functional assessment, behavio-
ral observations, interviews, self-report/parent-report measures, and out-
come assessment techniques. The collection of information from multiple
sources known to the child provides the most accurate picture of the child,
his or her difficulties, and the surrounding systems that contribute to
these difficulties. Similarly, using multiple methods to gather information
from the child and family will result in a more thorough understanding of
the target problem (Krain & Kendall, 1999; Pellegrini, Galinski, Hart, &
Kendall, 1993). Assessment tools that differ in the means of information
access will tap into different processes. For example, behavioral obser-
vations carried out by the therapist will provide fundamentally different
information than self-report measures completed by the child and/or the
child’s parents. Each of the aforementioned assessment techniques will be
discussed below.

Functional Assessment
The main goal of a functional assessment is to systematically examine
the problem behaviors exhibited by the child in order to plan the most
effective way of addressing those behaviors. Information regarding the child

or adolescent’s overt behaviors, emotional behaviors, and cognitive/verbal

behaviors is used to ascertain the target problem(s) that need treatment.
After identification of the target problem, a variety of assessments are used
to determine what promotes and reinforces this behavior for the child. These
are commonly referred to as antecedents and consequences of the target
problem. According to Zarb (1992), four different types of assessments are
generally used to conduct functional analyses: repeated self-report meas-
ures, behavioral observations of the child and family, interviews with the
child and family, and school report forms. Combining information from
both the child’s school and the child’s family provides the therapist with a
more complex understanding of why and when the target problem occurs,
thus allowing the therapist to develop the most effective treatment.

Behavioral Observations
Many of the difficulties addressed by CBTs are observable. The anx-
ious child shows obvious signs of fear in certain situations (e.g., sweating,
shaking), the depressed child appears withdrawn and “flat,” and aggres-
sive children demonstrate antagonistic behavior towards others. These
are just a few examples of overt signs characteristic of internalizing as
well as externalizing disorders. Behavioral observation relies upon close
scrutiny of these overt signs to assess how well the child or adolescent is
functioning given the target problem. Observing the child or adolescent in
session allows the therapist to witness first-hand the child’s behavior and
interpersonal functioning. Observing the interactions between the child
and her family can also provide information about how significant others
in the child’s life may be contributing to the development and/or main-
tenance of the target problem. Even brief parent–child interactions in the
therapy setting can be very informative as parents may be unaware of the
impact of their behavior on the child. Consequently, behavioral observa-
tion will provide information that interviews and self-report measures may
not. Additionally, behavioral observation can provide valuable information
when it is implemented in a more natural setting, such as a child’s home
or school. Therapists can develop a greater understanding of the impact of
the targeted problem when they observe the manner in which it interferes
in every-day situations.

Whereas observations have the unique advantage of allowing the ther-
apist to witness first-hand certain interpersonal and/or family dynamics
that may be involved in the maintenance of the target problem, interviews
provide the therapist with historical information about the problem. Dur-
ing interviews, therapists have an opportunity to gain knowledge about
relationships within the family as well as child- and parent-reported
strategies for modifying behavior (Pellegrini et al., 1993). Semi-structured
interviews are recognized as being reliable and valid for making diagnoses,
and they are commonly used in CBT assessments (Clark, 2005). The CBT
therapist will not only pay attention to the child’s behavior during the
interview but also to any cognitions that the child may share during the

interview that may be contributing to the target problem. For children and
adolescents, interviews are generally conducted with both the child and
the parents, either separately or together. Interviews with both parent and
child together allow for observation of the interactions, whereas separate
interviews offer greater freedom for both parties to speak openly about the
presenting problem and surrounding issues.

Self-Report Measures
Questionnaires completed by the child or adolescent and his parents
provide yet another source of information for the therapist. For younger
children, more valuable information may be garnered from parent-report
of the child’s behavior. However, when working with adolescents, there are
many self-report measures that address internal states and cognitions.
For example, certain self-report measures assess attributions regarding
the world around them (Pellegrini et al., 1993). This type of information is
generally more difficult to gather during an observation or interview and
may be quite hard for parents to report on accurately. For some children
and adolescents, self-report measures may represent a less intimidating
way to share thoughts and feelings that are otherwise too uncomfortable
to express.
Parent-report forms and teacher-report forms have significant utility
as they provide information about what occurs outside the therapy set-
ting. Teachers and parents spend the most time with children and, as a
consequence, are invaluable sources of information about child function-
ing. Although behavioral observations in the school or home certainly pro-
vide useful information to the therapist, questionnaires are significantly
more cost- and time-effective. Use of these forms during the initial assess-
ment and throughout treatment is essential in the monitoring of treatment
progress (Pellegrini et al., 1993).

Outcome Assessments
As with most types of psychotherapy, cognitive-behavioral therapy
monitors symptomatology throughout treatment to assess progress. If the
child is showing little or no progress, this may be an indication to the
therapist that either the initial conceptualization of the target problem
and corresponding contributing factors is incorrect or that the treatment
formulation may need alteration. Outcome assessments provide an objec-
tive way to evaluate the impact of treatment. Many of the aforementioned
assessments may be implemented as outcome assessments, yet certain
types may be considered more objective than others. For example, self-
report measures and other questionnaires are less likely to be biased by
the therapist’s expectations for treatment gains although they may be
influenced by the child’s expectations.
Re-administration of structured interviews by an independent
diagnostician at the end of treatment also provides a relatively objective
indication of changes in the child’s functioning as a result of receiving
services. Behavioral observations, although somewhat less objective than

questionnaires and structured interviews and certainly more difficult to

code, can also provide useful information about treatment outcome. For
example, observations of a socially anxious child interacting comfortably
with a stranger at the end of treatment can be an excellent index of out-
come if that child was unable to make or sustain eye contact with others at
the beginning of treatment. Such obvious and clinically meaningful treat-
ment gains can easily be captured by behavioral observations.

Cultural Considerations
When providing assessment or treatment services for children of dif-
ferent cultures, it is important to take into account both the appropri-
ateness of the assessment measures as well as norms and expectations
inherent to the child’s cultural background. Many measures that are used
commonly in CBT have not been normed on non-European-American cul-
tures. Consequently, evaluating a child’s score relative to existing norms
may be very misleading. Moreover, research has shown significant differ-
ences across cultures in the prevalence and intensity of different emotions
(Okazaki & Tanaka-Matsumi, 2006).
For example, Latin American individuals report high levels of positive
affect, whereas individuals from Asian cultures generally do not report high lev-
els of positive affect (Okazaki & Tanaka-Matsumi, 2006). As a result, an Asian
American woman who shows low positive affect may “present” as depressed or
dysthymic when actually she is within the normative range given her cultural
background. Alternatively, a Latino American man who might be exhibiting
reduced affect relative to his cultural norms may not be identified as such
if he is evaluated against existing norms. In addition, more research needs
to be conducted on the reliability, validity, and utility of behavioral assess-
ments in other cultures (Okazaki & Tanaka-Matsumi, 2006). Cultures vary
in their conceptualizations of what is considered “appropriate” or “acceptable”
behavior. Thus, therapists are urged to be cautious when assessing children
from other cultures or ethnicities. It is critical to ascertain relevant informa-
tion regarding the child’s cultural background before arriving at conclusions
about target problems and contributing systems.


Common cognitive behavioral therapeutic techniques include affective

education, cognitive restructuring, contingency management, behavioral
rehearsal, problem-solving, and self-monitoring, self-evaluation, and self-
reinforcement. CBTs often use a few, many, or all of these techniques in
the conduct of therapy.

Affective Education
An important first step towards identifying and changing faulty cogni-
tions is recognizing the emotions associated with these thoughts. Children
and adolescents often lack the insight or maturity to realize that their body

produces physiological reactions to emotional states. For example, an anx-

ious child might feel “butterflies in her stomach” when she finds herself in
an anxiety-producing situation. Instead of recognizing, for example, that
she is nervous, this child might conclude that she is sick with a stomach-
ache. Affective education addresses this disconnect between the physical
and psychological experiences of emotional states.
Children and adolescents are often asked to reflect upon ways in
which people demonstrate their feelings. This may be done via role-playing
or charades, by drawing pictures of faces or people experiencing different
feelings, or simply jotting down a few signs that someone is angry, sad,
happy, or confused. This focus on the physical signs of emotions is applied
to the child so that the child is asked to think about what happens to his
or her body when a certain emotion is experienced. For some children, it is
helpful to either provide a drawing of a human body or have them draw a
person on which they can circle or otherwise mark the part of their body in
which they experience a somatic symptom (e.g., drawing a hammer hitting
the head to indicate the experience of headaches). Children and adoles-
cents are encouraged to view these feelings as “clues” to their emotional
experience. In such a way, coping mechanisms can be put into place at
the first physiological signs of emotional distress in an effort to prevent a
worsening of the emotional and/or physical response.

Cognitive Restructuring
A key element of CBT is recognizing and altering the faulty cogni-
tions that underlie the emotional distress. For a depressed adolescent, for
example, the maladaptive automatic thoughts might include, “I’m not good
at anything,” and “No one is ever going to like me.” There are many creative
ways to help children and adolescents identify their automatic thoughts.
One way to illustrate the concept in a more concrete way for younger chil-
dren is to use cartoons and to talk about the character’s “thought bubble”
(see Kendall & Hedtke, 2006). This is a very visual way for children to
gain insight into cognitive processes. Use of cartoon characters can help
to illustrate, for example, that two people in the same situation may have
different thoughts, and, as a result, will experience different emotions
and/or behaviors. Once children have mastered the skill of identifying
their self-talk, they are taught to undergo a rational analysis of that self-
talk. Is there evidence to support their thinking? Is there another way of
looking at the situation? Through this process, children are able to modify
their dysfunctional thinking from irrational to rational, and the cognitive-
behavioral model then predicts a corresponding decrease in emotional and
behavioral distress.

Contingency Management
Cognitive-behavioral therapy places strong emphasis on the consequences
of behavior. In line with the fundamental principles of behavior therapy,
positive consequences will increase the frequency of behavior whereas negative
consequences will reduce the frequency. As such, contingency management

is an effective means to create and sustain behavioral modifications.

Contingency management procedures often include the praising of desired
behaviors and/or planned ignoring of undesired behaviors. Often rewards
are used to heighten engagement in therapy tasks; however, rewards are
only effective to the extent that they are desirable to the child. The rewards
may be material (e.g., small trinkets or toys) or social in nature (e.g., selecting
the dinner menu at home, attending a movie, or staying up a half hour
later at night). Often treatment begins with the provision of material rewards
then shifts into the provision of social rewards later in treatment in order to
enhance the likelihood of sustaining the provision of rewards by parents after
treatment. Consistency in contingency management is essential to promote
effective maintenance of treatment gains.

Behavioral Rehearsal
Behavioral rehearsal is a crucial part of both cognitive and behav-
ioral change. Behavioral rehearsal involves the simulation of situations
inside the therapy room for the purpose of skill development and prac-
tice. Thus, behavioral rehearsal can help children to utilize new ways
of responding to life situations that cause them difficulty. Once new
response patterns are trained in therapy, they are then tested out in “real
world” settings. Some children find it difficult to role-play; others relish
the opportunities. Clearly, the success of behavioral rehearsal is depend-
ent upon a child’s openness to engagement in the activity. Behavioral
rehearsal typically proceeds in a steplike fashion with easier to manage
situations practiced prior to more difficult ones. Corrective feedback is
provided by the therapist; however, the child is encouraged to self-moni-
tor and evaluate her own performance as well. Often modeling of the
skill is necessary when the child’s skill deficit is profound or corrective
feedback is proving ineffective. Once the child demonstrates mastery of
the skill being practiced, therapist and child move to the next more dif-
ficult situation. Homework assignments are critical to ensure that the
skill receives practice in vivo.

Bedell and Lennox (1997) have proposed a problem-solving model
that includes seven steps in the problem-solving process. The seven steps
include: (1) recognize the existence of a problem, (2) define the problem in
a goal-directed manner in which your own and other’s unmet wants are
identified, (3) brainstorm problem solutions without evaluation of their
possible efficacy, (4) evaluate the potential effectiveness of the alterna-
tives generated, (5) select the best alternative or combination of alterna-
tives, (6) implement the chosen solution, and (7) verify the effectiveness
of the chosen solution. Thus, the problem-solving process acknowledges
that there is a conflict to be addressed, and it provides a structured way
for approaching the problem.

The cognitive-behavioral approach requires that the therapist lead

the child through the steps under the guiding principle of collaborative
empiricism. Together, therapist and child brainstorm numerous poten-
tial solutions (some likely ineffective, some silly, some first-rate) without
regard to their potential usefulness until the possibilities are exhausted.
Next, the therapist and child evaluate each item on the list both in terms
of its effect on the child’s thoughts and feelings and in light of the prob-
able consequences of the choice: “If you did this, how would you feel?
Would it help you in this situation to do that?” Once the child has identi-
fied those alternatives likely to be helpful in the resolution of the problem,
he has developed an admirable problem-solving strategy. As with all CBT
techniques, the goal is to teach the child how to independently use prob-
lem-solving so that it becomes a tool that may be frequently referred to by
the child. Problem-solving is applicable to a wide-range of difficulties and
can be used in the treatment of depression, anxiety, anger management,
attentional problems and myriad other challenges.

Self-Monitoring, Self-Evaluation, Self-Reinforcement

In order for children to be able to effectively use many of the above-
mentioned CBT techniques independently, they must have the ability to
reflect on their thoughts, feelings and actions and use that information
to regulate their behavior. Developmental level must be considered when
honing these skills with children and adolescents as younger children may
lack the insight necessary for this process, thus requiring more external
reinforcement at first. For all child clients, self-monitoring, self-evaluation,
and self-reinforcement techniques will need to be modeled by the therapist
so that the child develops an awareness of how to self-monitor.
Depending on the target issue of the child, self-monitoring can be
structured or even scheduled. For example, a child with attention-deficit
problems can be asked at the end of every class at school to write down
how well she did at trying to concentrate during class. In the beginning,
it is helpful to have the child or adolescent record the data when self-
monitoring so that later the therapist and child can evaluate the data
together in the spirit of collaborative empiricism. This allows opportuni-
ties for therapist modeling of self-evaluation and self-reinforcement. For
younger children, a scale or wheel depicting different levels of satisfac-
tion may make the self-evaluation process more concrete and thus more
When training a child to self-reinforce, it is important to illustrate
that decisions about whether a self-reward is deserved is made in light
of effort as well as outcome. Children must be taught to see the nuances
of success in order to reward themselves appropriately. For example,
if a socially anxious child works up the nerve to say hello to another
child on the playground, the anxious child is worthy of self-reward
regardless of the other child’s response. Initially, the self-monitoring,
self-evaluation, and self-reinforcement processes will be externalized as
the therapist models for the child. Homework assignments may include
keeping a log that serves as a record of self-monitoring, self-evaluation,

and self-reinforcement practice. Last, the therapist tapers his or her

guidance as the child develops mastery over the process and begins to
implement the skills independently.


The past few decades have seen a remarkable increase in the number
of studies demonstrating empirical support for the effectiveness of various
forms of psychotherapy. Many of these studies have looked at the overall
effectiveness of therapy. That is, in general, does therapy result in positive
gains? Initial studies focused on outcomes for adults receiving therapy,
and results indicated positive effects (e.g., Shapiro & Shapiro, 1982; Smith,
Glass & Miller, 1980). However, when various orientations and types of
therapy were compared, no significant differences were found. This phe-
nomenon was deemed the “Dodo bird verdict” in reference to Lewis Car-
roll’s Alice in Wonderland in which the dodo bird said, “Everyone has won,
and all must have prizes” (Rosenzweig, 1936). In other words, any form of
psychotherapy results in positive gains, and all these gains are roughly
comparable. The “Dodo bird verdict” implies that the specific technique
used is not as important as some underlying commonality shared by all
forms of psychotherapy.
However, in an attempt to replicate Smith et al.’s 1980 meta-analysis,
Shapiro and Shapiro (1982) found slightly discrepant results. Although
factors such as target problem appeared to have a greater impact on treat-
ment outcome than type of treatment, there was evidence suggesting that
cognitive and behavioral treatments demonstrated greater treatment gains
than other forms of psychotherapy (e.g., dynamic therapy).
Several meta-analyses were conducted to evaluate whether the “Dodo
bird verdict” also applied to child therapy outcomes. Results were mixed.
Each meta-analysis found positive effects for psychotherapy with children
and adolescents, however, results varied in terms of whether all types of
treatment were equally effective. Casey and Berman (1985) found little
support for the superiority of behavioral treatments over nonbehavioral
treatments in their meta-analysis of 75 studies of children 13 or younger
at the time of treatment. Although, in general, behavioral treatments had
better outcomes, Casey and Berman concluded that there were too many
potentially confounding factors (e.g., different target problems) to be able
to attribute differences in outcomes to type of treatment.
Weisz, Weiss, Alicke and Klotz (1987), in a meta-analysis of psycho-
therapy studies including both children and adolescents, found the mean
effect size for behavioral treatments to be significantly greater than non-
behavioral treatments. This difference remained significant even when
analyses were conducted to control for the child’s age, target problem,
and therapist level of training. Later, a subset of the studies included in
the Weisz et al. (1987) meta-analysis were subjected to further analysis
by Weiss and Weisz (1995) to evaluate whether the apparent superiority of
behavioral treatments was due to higher methodological quality of behav-
ioral interventions, resulting in larger effect sizes for those treatments.

Results suggested that the difference in effect sizes for behavioral and
nonbehavioral treatments was not an artifact of methodological quality.
A subsequent meta-analysis by Weisz, Weiss, Han, Granger, and Mor-
ton (1995). also failed to support the “Dodo bird verdict” for psychother-
apy with children and adolescents. Behavioral treatments again exhibited
higher effect sizes than nonbehavioral treatments, although effect sizes
in this study were somewhat more conservative than those found previ-
ously. Weisz, Weiss, et al. (1995) asserted that, because the studies used
in their meta-analysis had not been included in previous meta-analyses,
“the present findings must be seen as rather strong independent evidence
of the replicability of this ‘non-Dodo verdict’” (p. 461). They note, however,
that of the 150 studies involved in this meta-analysis, only 10% included
nonbehavioral treatments. Similarly, there were relatively few nonbehavio-
ral studies in Weisz et al.’s (1987) meta-analysis, thus limiting the poten-
tial generalizability of this sample to all nonbehavioral interventions.
In addition to broader meta-analyses studying the effectiveness of
behavioral versus nonbehavioral treatments, there have been numerous
studies focusing specifically on the efficacy of CBTs with children and ado-
lescents. As Ollendick, King, and Chorpita (2006) have argued, any form of
psychotherapy used in treatment should have first been shown to be effec-
tive in randomized clinical trials (RCTs). These trials allow for comparisons
of CBT to either other forms of treatment or to control groups, and these
comparisons may provide scientific evidence supporting the effectiveness
of CBTs. CBT has been one of the most researched forms of treatment, and
over 300 RCTs have shown it to be an effective way of addressing a range
of Axis I disorders (Wright, Basco & Thase, 2006).
Over the past two decades, structured treatments, such as CBT, have
been shown empirically to be one of the more effective forms of psycho-
therapy (Erickson & Achilles, 2004). During the 1990s, the use of CBT
with children and adolescents was supported by the treatment outcome
literature (Braswell & Kendall, 2001). CBT has been shown to be effective
with children and adolescents with depression, anxiety, attention-deficit
difficulties, oppositionality, aggression, autism, mental retardation, low
self-esteem, poor academic skills, learning disorders, eating disorders,
and other difficulties (Braswell & Kendall, 2001; Clark, 2005; Craighead,
Craighead, Friedburg & McClure, 2002; Kazdin & Mahoney, 1994; Ken-
dall, 1991, 2006; Reinecke et al., 2006b). In fact, CBT is considered a
“probably efficacious” treatment for the treatment of childhood anxiety
disorders (Kazdin & Weisz, 1998; Ollendick & King, 1998), ADHD and
depression (Ollendick et al., 2006) as well as aggression, anger, and con-
duct disorders (Kazdin, 2003, 2005; Larson & Lochman, 2002; Lochman,
Barry, & Pardini 2003).
Although the treatment outcome literature has shown consistent sup-
port for CBT, many clinicians claim that this research is of questionable
utility in nonlaboratory-based treatment clinics (Weisz, Donenberg, Han
& Weiss, 1995). This is due to the possibility of limited transportability of
treatment outcome results. There are many factors that may affect treat-
ment outcome that vary between research settings and clinical practice.
First, study samples in clinical trials may not be representative of the general

population of clinical patients. Whereas clinical clients are often seek-

ing services, study participants are more actively recruited. In addition,
researchers aim to recruit a somewhat homogenous sample so that treat-
ment can focus on one or two target problems, whereas clinicians may find
themselves treating a wide variety of diagnoses and difficulties. Second,
the research experimenters are not comparable to therapists in clinical
practice. They may differ in amount and type of training and supervision.
Research therapists will have undergone intensive pretherapy training on
the intervention being used in the study. Practicing clinicians, however,
rarely receive such training. Third, the manner in which treatment is
administered is unique to research settings. Study participants are not
permitted to obtain simultaneous services elsewhere, and experimenters
must strictly follow treatment protocols. In general practice, however, cli-
nicians may use several techniques depending upon the child or adoles-
cent’s responsiveness to therapy (Ollendick et al., 2006; Weisz, Donenberg,
et al., 1995).
Weisz, Donenberg, et al. (1995) assert that the meta-analyses showing
overall positive effects for psychotherapy must be considered in light of
these limitations. Only nine studies included in the broad meta-analyses
included what they call “clinic therapy” which involves clients, therapists,
and settings that approximate actual clinical practice. All other studies
included in the meta-analyses involved strictly “research therapy.” Weisz,
Donenberg, et al. (1995) calculated the effect sizes for the nine studies
involving “clinic therapy” and found that the mean effect size for these
studies was much lower than that of the “research therapy” studies.
In evaluating this difference, Weisz and colleagues identified two pos-
sible explanations. First, behavioral methods, which generally have higher
effect sizes, are more common in “research therapy” than in clinical prac-
tice. Consequently, the higher effect sizes might actually be due to a greater
percentage of behavioral treatments included in the “research therapy”
studies. If “clinic therapy” studies included more behaviorally based treat-
ments, the difference in effect sizes might be reduced. Second, clients who
actively seek out treatment in clinical settings may be fundamentally dif-
ferent than those therapy clients who are recruited for study participation.
Recruited clients may have less complex problems, rendering them more
likely to be successful in treatment.


CBT is sometimes mistakenly viewed as having little emphasis on the

quality of the therapeutic relationship. However, many CBT therapists
assert that the therapeutic relationship is one of the most essential com-
ponents of treatment (e.g., Beck et al., 1979; Kendall, 1991). Most schools
of therapy view the therapeutic alliance as an important variable in treat-
ment outcome. Most conceptualizations of alliance use Bordin’s (1979)
definition in which alliance is comprised of three facets: an agreement on
goals, an assignment of task(s), and the development of a bond. Cogni-
tive-behavioral therapy clearly emphasizes each of the three facets. It has

been proposed that the therapeutic relationship may be more important in

child versus adult therapy. As children rarely self-refer and therefore may
be unwilling or unable to acknowledge difficulties and adolescents are
in the process of becoming more autonomous, the formation of a strong
therapeutic alliance can be particularly challenging (DiGiuseppe, Linscott,
& Jilton, 1996; Shirk & Karver, 2003; Shirk & Russell, 1998).
A multitude of studies have examined the relationship between thera-
peutic alliance and treatment outcome in adult treatment samples (e.g., Bar-
ber et al., 1999; Gaston, Thompson, Gallagher, Cournoyer, & Gagnon, 1998;
Horvath & Luborsky, 1993; Horvath & Symunds, 1991; Martin, Garske, &
Davis, 2000; Stiles, Agnew-Davies, Hardy, Barkham, & Shapiro, 1998), and
there is a confluence of evidence that efforts to build strong therapist–client
relationships has a positive impact on the results of treatment.
The research on therapy alliance and outcomes in child therapy, how-
ever, is strikingly less well developed. In a meta-analysis of 23 studies
examining relationship variables in child and adolescent therapy, Shirk
and Karver (2003) found the association between therapeutic relationship
and outcome to approximate the results found in studies of alliance–out-
come relations in adults. The correlations were modest (weighted r = .22)
but consistent across developmental levels and types of treatment. Similar
findings were reported by Green (2006) and Kazdin, Marciano, and Whiley
(2005). In contrast, Hogue, Dauber, Stambaugh, Cecero, and Liddle (2006)
found no effect on outcome for alliance measured early in treatment in a
sample of 100 adolescents randomized to CBT or family therapy for sub-
stance abuse.

Therapist Characteristics
Not all therapists are created equal. As Kendall and Choudhury (2003)
note, treatments are often described as though they are equally effective
across therapists. This may be especially true of manualized treatments.
However, we know that therapists differ on a wide variety of dimensions
(e.g., energy, animation, self-disclosure, warmth, flexibility, sociability,
adherence to protocol). Therefore, it is unlikely that they impart little effect
on outcome.
Research on the importance of the therapist’s contributions to thera-
peutic alliance and outcome has been sparse (Garfield, 1997). It stands to
reason that there may be particular therapist characteristics which hasten
(or detract from) alliance and/or treatment outcomes. The importance of
investigating the role of the therapist is heightened by the difficulty in
disentangling the effects of the treatment from the effects of the therapist.
That is, true treatment effects may be obscured by therapist competency
(or incompetency) or other therapist characteristics (e.g., therapist effi-
cacy, therapist training and supervision; Elkin, 1999).
Ackerman and Hilsenroth (2003) examined therapist characteristics
and techniques that have a positive impact on the therapeutic alliance
in therapist–adult client relationships. Therapist characteristics including
being flexible, honest, respectful, trustworthy, confident, warm, interested,
and open were found to be positively correlated with therapeutic alliance.

Little is known, however, about the personal attributes of the therapist

that have a positive impact on the child–therapist alliance. Although one
may assume that the therapist characteristics approximate those found
in the adult literature, more research is needed to draw firm conclusions.
One study investigating therapist flexibility in the administration of a
manualized CBT for childhood anxiety disorders failed to find an association
between therapist-rated flexibility and treatment outcome (Kendall & Chu,

Child Characteristics
Child therapy outcome studies must concern themselves with those
child characteristics that may mediate or moderate outcomes. Age, gen-
der, ethnicity, familial or cultural background, socioeconomic status, and
other child characteristics have received relatively little research attention.
Are there preferred ages or developmental stages for the effective imple-
mentation of cognitive-behavioral interventions? Durlak, Fuhrman, and
Lampman (1991) conducted a meta-analysis on the effectiveness of CBT
for children with a variety of mental health problems. The authors looked
at developmental stage as a moderator of outcome and found a larger
effect size (.92) for children at the formal operational level (age 11–13)
than for children at less advanced levels (age 7–11, effect size = .55; and
age 5–7, effect size = .57). Thus, the authors conclude that children who
are more cognitively mature may be more capable of abstract thinking and
deductive reasoning, making them more likely to benefit from CBT.
Conversely, in a study examining the predictors of remission from
major depressive disorder in children and adolescents treated with CBT,
Jayson, Wood, Kroll, Fraser, and Harrington (1998) found older age to be
associated with the poorest outcomes. Similarly, in the field of anxiety
disorders, there is some evidence to suggest that younger children might
benefit more from CBT than older children, especially when the family is
involved in treatment (Barrett, Dadds, & Rapee, 1996; Hudson, Kendall,
Coles, Robin & Webb, 2002). For example, Southam-Gerow, Kendall, and
Weersing (2001) found that those children who were identified as poor
responders (retained an anxiety diagnosis posttreatment) were more likely
to be older than children in the good treatment response group (no post-
treatment anxiety disorder).
Several hypotheses have been suggested to explain why younger chil-
dren may do better. Older children’s disorders may be more chronic and
resistant to change or they may be more “nonnormative” in the course of
development, making them less well able to navigate the tasks of adoles-
cence. Younger children may benefit more due to an increased involvement
from parents. Last, it might be the case that treatment materials commonly
used in anxiety treatment packages for youth (e.g., Coping Cat; Kendall &
Hedtke, 2006) may be more age-appropriate for younger children. If the
latter is true, it may be that interventions designed for middle childhood
may need substantial modifications prior to use with adolescents.
Gender has received limited attention as a factor in treatment outcomes
of CBT. Although gender has been identified as a significant variable in the

research on depressive disorders, the role of gender in treatment efficacy

remains unclear. Some evidence suggests that adolescent girls show bet-
ter outcomes in psychotherapy outcome research; yet this finding is not
specific to CBTs (Weisz, Weiss, Han, Granger, & Morton, 1995). Research
on CBT outcomes for childhood anxiety disorders yields conflicting find-
ings regarding the effects of gender. Some studies fail to find gender effects
on outcome (e.g., Southam-Gerow et al., 2001); other studies have found
significant effects with female children faring better (e.g., Mendlowitz,
Manassis, Bradley, Scapillato, Miezitis, & Shaw, 1999). Moreover, there
exists some evidence that child gender may influence the effectiveness of
parental involvement in treatment. Barrett et al. (1996) found that females
who participated in a CBT plus family management condition had more
positive outcomes than those in conditions without parental involvement.
Similarly, Cobham, Dadds and Spence (1998) found that girls with an anx-
ious parent were more likely to be diagnosis free if they had participated in
the CBT plus parent anxiety management condition.
Cognitive-behavioral models for the treatment of youth have received
criticism for a lack of developmental sensitivity (e.g., Reinecke et al.,
2006b; Weisz & Weersing, 1999). It is essential to evaluate a child from a
developmental systems framework. As mentioned previously, most CBTs
for children have been adaptations of treatments formulated for adults.
As such, many CBTs for children may be anchored in the “developmental
uniformity myth” (Kendall, Lerner, & Craighead, 1984). This myth holds
that childhood disorders present akin to and are responsive to the same
treatment procedures as adult disorders. Thus, assessments and treat-
ments may fail to consider age, developmental level, timing of intervention,
and other developmental issues.
In the course of development, important changes in reasoning, emo-
tional understanding, judgment, and language among other cognitive
capacities, undergo significant changes in content, organization, and
structure (Toth & Cicchetti, 1999). Given these significant changes during
this developmental period, it may be that childhood and adolescence are
critical periods during which skill building and alteration of one’s devel-
opmental trajectory is possible (Reinecke et al., 2006b). Moreover, it may
be the case that treatments vary in effectiveness across ages or that treat-
ments need to be implemented differently at different ages. For exam-
ple, younger children may require greater in-session flexibility, especially
with the use of manualized interventions. Additionally, younger children
may require the use of more behavioral (versus cognitive) interventions
(O’Connor & Creswell, 2005). Thus, developmentally informed CBT models
are a must.
Holmbeck and colleagues conducted two reviews of the empirical
research examining developmental factors in the design and evaluation of
cognitive-behavioral interventions for adolescents. Although the first review
(1990–1998; Holmbeck, Colder, Shapera, Westhoven, Kenealy, & Updegrove,
2000) found only 26% of the articles directing attention to developmental
issues, a more recent review (Holmbeck et al., 2006) found that 70% of
the articles considered developmental issues in the design and evaluation
of outcome. It appears that developmental issues are receiving increased

attention in recent years, however, Holmbeck and colleagues note that, in

the 2006 study, at least half of the studies failed to interpret results in light
of developmental issues and very few (22%) evaluated age as a moderator
of outcome. Attention to moderator variables such as resiliency, aptitudes,
and protective factors is critical in the development of prevention efforts.


As briefly discussed earlier in this chapter, a cognitive-behavioral

framework must provide explicit attention to the child in various contexts
(e.g., family, school, peer group, ethnicity, culture, religion). Numerous
researchers have proposed that the inclusion of family members (namely,
parents) in the therapeutic process is an effective means to enhance treat-
ment success (e.g., Ginsburg, Silverman, & Kurtines, 1995; Kazdin, 1993;
Kendall, 1994; Silverman, Ginsburg, & Kurtines, 1995). Ginsburg and col-
leagues (1995) have described a transfer of control model in which an
expert therapist passes along knowledge, skills, and methods to the child,
either directly or from therapist to parent to child. However, they note
some “blocks” that may occur in this transfer process. The “blocks” often
involve maladaptive family processes (e.g., parental psychopathology, dys-
functional family relationships).
In order to clear the pathway to facilitate transfer of control, parental
inclusion in therapy is a necessity. Although many therapists support the
inclusion of parents, especially with young children, there remain ques-
tions regarding the degree to which and in what capacity parents should
be involved in child treatment. Are parents informants, consultants, or
co-clients? The degree of parental participation is likely to be determined
in part by child age and type of presenting problem.
Hays (2006) has noted the widespread omission of ethnic and cul-
tural information in clinical research. Research on CBT, for example, has
almost exclusively relied on individuals with European American identities
(Hays, 1995; Iwamasa & Smith, 1996; Suinn, 2003). Thus, the success
and limitations of CBT with minority populations have not been evaluated.
Due to CBT’s experimental orientation to human behavior, there may exist
an implicit assumption that CBT is value-neutral. Hays (2006) notes that
“CBT is as value laden as any other psychotherapy” (p. 7). In fact, CBT’s
emphasis on rationality and definitions of adaptive versus maladaptive
behaviors may conflict with values and ideals prominent in other cultures
(e.g., spirituality). Training in working with diverse populations, sensitiv-
ity workshops, and consultations with experts in cultural diversity are all
necessary to ensure sensitivity.


Despite the apparent efficacy of CBT with children, there remain

substantial numbers of children who do not progress in treatment. Little
research has been conducted on how to address these treatment-resistant

cases. In the case of a less than successful outcome, are there particular
treatment techniques that may be employed? Is medication warranted?
Should frequency or length of treatment sessions be increased? Is work
with parent(s) needed? These questions will linger until treatment research
addresses how to facilitate improvement in all cases. The answers lie in
understanding the mechanisms of therapeutic action in CBT, and despite
much treatment outcome research, research on knowing how and why
CBT works remains sparse (Kazdin & Nock, 2003; Shirk & Karver, 2006).
While research on the efficacy of cognitive-behavioral interventions is
amassing, the majority of randomized clinical trials evaluating CBT have
used waitlist control conditions. Much work remains to evaluate the relative
efficacy of CBT and active control conditions. Also, much of the research has
employed CBT treatment “packages.” That is, most CBT treatments are com-
prised of several cognitive-behavioral elements (e.g., cognitive-restructuring,
homework, problem-solving training); yet little is known about the influence
of individual elements on treatment outcomes. Other methodological consid-
erations include evaluation of CBT efficacy with youth via an examination
of clinical as well as statistical significance (e.g., Kendall, 1999; Kendall &
Grove, 1988, Kendall, Marrs-Garcia, Nath & Sheldrick, 1999). Whereas sta-
tistical significance determines the likelihood that a mean difference may
have resulted by chance, clinical significance can determine the meaningful-
ness of the magnitude of change. In treatment outcome research, clinical
significance may be helpful in evaluating whether deviant scores have been
returned to within normal limits on a particular assessment measure.
There is a clear call for more developmentally oriented research designs.
For example, longitudinal designs would better evaluate CBT’s impact on
developmental processes and trajectories. However, longitudinal designs
bring additional considerations. Issues such as measurement equivalence
remain to be resolved (Kendall & Choudhury, 2003). In the measurement of
a particular construct across time, it is likely that several measures will be
warranted in order to ensure that the measures are developmentally appro-
priate. However, the comparability of these measures is at issue. For exam-
ple, do the Children’s Depression Inventory (Kovacs, 1981) and the Beck
Depression Inventory (Beck,Ward, Mendelson, Mock, & Erbaugh,1961;
Beck, Steer, & Garbin, 1988) measure depression in a similar manner?
How can one evaluate depression across the span of early childhood and
into young adulthood? Longitudinal designs also afford an opportunity to
consider the indirect effects of treatment (Kendall & Kessler, 2002).
Given the long-term social and economic consequences of childhood
psychopathology, researchers should examine for treatment impacts on the
sequelae of targeted disorders (e.g., impact of childhood anxiety treatment on
adolescent or early adulthood substance use). In addition, there is a great
need to generate treatment samples from ethnically and socioeconomically
diverse populations in order to enhance treatment generalizability and trans-
portability. Regarding the latter, there is little reason to believe that all CBTs
found efficacious in the research lab will show a corresponding efficacy in clin-
ical settings. However, the extent to which the results of randomized clinical
trials can be applied in the “real world” remains to be determined by research
(Kendall & Southam-Gerow, 1995; Persons & Silberschatz, 1998; Silverman,
Kurtines, & Hoagwood, 2004; Southam-Gerow, Weisz, & Kendall, 2003).


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Prior to the 1960s, therapy for children typically involved traditional

one-on-one sessions with a therapist addressing intrapsychic issues
rather than specific behaviors (Kotchick, Shaffer, Dorsey, & Forehand,
2004). However, in the early 1960s a paradigm shift started in regard to
psychosocial treatment for children’s behavior problems. This paradigm
shift was the function of several factors (Kotchick et al., 2004) includ-
ing a growing concern that traditional psychodynamic approaches were
not very effective in addressing immediate issues related to children’s
behavior problems nor in changing children’s behavior in the home.
Around the same time period, behavior modification techniques were
beginning to be successfully utilized to change children’s behavior (Wil-
liams, 1959).
The confluence of such factors created momentum for the concept of
therapists training parents to utilize specific behavior management tech-
niques to change their children’s’ behavior. By the mid- to late-1960s the
use of parents as formal behavior change agents for their children’s behavior
started to take hold and the roots of “parent training” were established
(Hawkins, Peterson, Schweid, & Bijou, 1966; Wahler, Winkel, Peterson,
& Morrison, 1965). Although most of the early research in parent training
was conducted by those coming from a behavioral orientation, it should
be noted that the use of parents as change agents was also advocated
by professionals from various orientations including those coming from a
psychodynamic perspective (e.g., Zacker, 1978).


for Medical Sciences and Arkansas Children’s Hospital

J.L. Matson et al. (eds.), Treating Childhood Psychopathology 79

and Developmental Disabilities, DOI: 10.1007/978-0-387-09530-1,
© Springer Science + Business Media, LLC 2009

Gerald Patterson’s (1982) research on coercive parent–child inter-

actions offered a major contribution to the early development of parent
training. His model on reciprocal influences provided an explanation as to
how the behavior of both parents and children contribute to the escala-
tion of child aggression and behavior problems. The model explained how
children use high rates of aversive behaviors to stimulate parental atten-
tion, and in turn, this parental attention reinforces the children’s aversive
behavior. Such parental attention can involve either giving in to the aver-
sive behavior or using coercive tactics (e.g., nagging, yelling) in an attempt
to stop the aversive behavior.
Patterson’s model also helped explain how children’s behavior simul-
taneously reinforces and escalates parental use of coercive tactics through
negative reinforcement. Thus his model of reciprocal influences helped
explain how children’s disruptive behavior can escalate while parent
management tactics become more punitive and coercive. Such coercive
exchanges within the home were believed to be “basic training” for the
development of aggression and disruptive behavior that generalizes to other
settings. The entry into this coercive cycle was considered to be ineffective
parenting, especially in regard to child compliance to parental directions
during the preschool years (McMahon & Wells, 1998).
Since its development in the 1960s, behavioral parent training has
gone through three distinct stages of development (McMahon & Forehand,
2003). The first stage, during the 1960s and early 1970s, focused on the
initial development of a “parent training” intervention model. The parent
training model, based on Tharp and Wetzel’s (1969) triadic model, utilized a
therapist (consultant) who taught the parent (mediator) to reduce the child’s
(target) disruptive behavior (McMahon & Forehand, 2003). The research
conducted during this first stage was largely limited to case studies or single-
case designs. However, during this first stage, evidence was obtained that
demonstrated that, at least in the short-term, parent training interventions
could produce changes in both parent and child behaviors.
At about the same time, researchers also started to examine different
strategies (e.g., written instructions, videotaped instruction, modeling, etc.)
for teaching parents how to use specific behavior management strategies
(e.g., Flanagan, Adams, & Forehand, 1979; Nay, 1975; O’Dell, Mahoney,
Horton, & Turner, 1979; O’Dell, Krug, O’Quinn, & Kasnetz, 1980). Par-
ents could learn to effectively use specific techniques through a variety of
instructional modes. However, there was also the realization that although
parents could be taught basic behavior modification techniques through
various instructional modes, to effectively address significant child behav-
ior problems interventions for parents needed to be more multifaceted
and take into account the complexities of parent–child interactions in the
home (Kazdin, 1985).
The second stage of parent training research, from the mid-1970s
to the mid-1980s, focused on social validity and the generalization of
treatment effects. Issues examined included whether behavior changes
observed in the clinic generalized to the home, whether improvements
were seen in behaviors other than the target behaviors (behavioral gen-

eralization), and whether behavior changes were maintained over time

(temporal generalization).
The third stage in the development of parent training, from the mid-
1980s to present, has focused primarily on ways to enhance the effective-
ness of parent training. The primary focus of parenting training research
since its beginnings has been in the area of children’s disruptive behav-
ior. This focus has been the result largely due the belief that disruptive
behavior in the home is often inadvertently developed, exacerbated, or
sustained by maladaptive parent–child interactions (Kazdin, 2003; Pat-
terson, 1982). These maladaptive interaction patterns include reinforcing
disruptive behavior, the use of ineffective parental directions, and the fail-
ure to adequately reinforce appropriate behavior. Today parent training is
considered one of only a handful of empirically supported treatments for
children’s externalizing behavior problems (Kazdin, 2005). The following
section summarizes this research base.



There have been hundreds of studies that have evaluated programs

designed to train parents to intervene with their children’s problems. The
volume of studies examining the effects of parent training is reflected in
the number of reviews that have been published. From 1972 to 2006,
there have been no less than 17 narrative reviews (Atkeson & Forehand,
1978; Berkowitz & Graziano, 1972; Chronis, Chacko, Fabiano, Wymbs, &
Pelham, 2004; Dembo, Sweitzer, & Lauritzen, 1985; Graziano & Diament,
1992; Johnson & Katz, 1973; Kohut & Andrews, 2004; Mooney, 1995;
McAuley, 1982; Moreland, Schwebel, Beck, & Well, 1982; O’Dell, 1974;
Sanders & James, 1983; Todres & Bunston, 1993; Travormina, 1974; Wiese,
1992; Wiese & Kramer, 1988) and at least four quantitative reviews (Cedar
& Levant, 1990; Lundahl, Nimer, & Parsons, 2006; Lundahl, Risser, &
Lovejoy, 2006; Serketich & Dumas, 1996) that have specifically focused on
parent training outcomes.
In addition to the above reviews, other papers have examined par-
ent training interventions as part of a broader review of psychosocial
treatments for children and adolescents in general (Weisz, Weiss, Han,
Granger, & Morton, 1995) and specific child and family problems, such as
conduct problems (Brestan & Eyberg, 1998; Bryant, Vissard, Willoughby,
& Kupersmidt, 1999; Dumas, 1989; Kazdin, 1987; Miller & Prinz, 1990;
Webster-Stratton, 1991) and ADHD (Chronis, Jones, & Raggi, 2006; Pelham,
Wheeler, & Chronis, 1998).
As indicated by the number of reviews, parent training interventions
are among the most frequently and rigorously studied of the psychosocial
interventions for children. To illustrate the scope of studies, a recent quan-
titative analysis of parent training outcomes with disruptive behaviors
identified 430 studies published in peer-reviewed journals between 1974
and 2003 (Lundahl, Risser, & Lovejoy, 2006). The literature on the effi-

cacy of parent training interventions varies considerably in terms of study

methodology, program features, and participant characteristics. In this
section, we examine the immediate, generalization, and moderator effects
of training parents to intervene with their children.


There is substantial evidence that supports the short-term effectiveness

of parent training as a general treatment approach. Lundahl, Risser, and
Lovejoy (2006) conducted a meta-analysis of experimental and quasi-
experimental studies that evaluated the effects of parent training pro-
grams on child behavior, parent behavior, and parent perceptions. This
study examined 63 studies from 1974 to 2003 that included 83 treatment
groups. Overall, this study reported immediate effect sizes of .42, .47, and
.53 for child behavior, parent behavior, and parent perceptions outcomes,
respectively. The magnitude of these effect sizes can be considered
moderate.1 These effect sizes compare favorably to the average effects
of other behavioral (d = .54) and nonbehavioral (d = .30) psychotherapy
treatments (Weisz et al., 1995).
Many of the early reviews focused almost exclusively on behavioral
parent training programs as they represent the majority of studies. Non-
behavioral parent training programs tend to lag behind behavioral pro-
grams not only in number, but also in methodology. For example, of the 63
experimental studies review by Lundahl, Risser, and Lovejoy (2006), only
14 parent training programs had a nonbehavioral focus. In their study,
the behavioral programs were found to have significantly higher meth-
odological rigor than the nonbehavioral programs. There are also other
differences between behavioral and nonbehavioral parent training studies
that make comparisons difficult. The majority of behavioral studies used
clinical samples, whereas the majority of nonbehavioral studies used non-
clinical samples.
Furthermore, parent training programs with different theoretical ori-
entations tend to target different outcomes, making direct comparisons
impossible. Nonetheless, several narrative reviews have examined the
methodology and efficacy of parent training programs from different theo-
retical orientations (i.e., reflective, Adlerian, & behavioral; Dembo et al.,
1985; Mooney, 1995; Todres & Bunston, 1993). All three reviews noted
that few studies met the criteria for well-designed investigations, and the
diverse methodologies precluded direct comparisons of efficacy. All three
reviews reported mixed results, with positive findings following what would
be expected from the specific theoretical orientation. For example, the
Adlerian programs showed a greater percentage of positive findings in the
outcome domain of parental attitudes and perceptions, and behavioral pro-
grams showed a greater percentage of positive findings on child behavior.

Cohen (1988) defined effect sizes as small, d = .2, medium, d = .5, and large, d = .8.

The largest subgroup of parent training outcome studies are those that
evaluated programs which train parents in behavioral child management
strategies to address deviant behaviors, such as aggressiveness, temper
tantrums, and noncompliance. Behavioral parent training (BPT) typically
included strategies such as differential reinforcement of other behavior,
extinction, and time-out. An early narrative review was supportive of
the efficacy of BPT with deviant behavior. Atkeson and Forehand (1978)
reviewed 24 studies which included three outcome measures (observa-
tions, parent collected data, and parent completed measures) and reported
positive results in all three outcome domains.
Serketich and Dumas (1996) conducted a meta-analysis of stud-
ies evaluating the effects of behavioral parent training program on child
antisocial behavior and parental adjustment. They analyzed 27 studies
from 1969 to 1992 that included 36 comparisons between experimental
and control groups. In these studies, 22 received some form of indi-
vidually administered BPT and 13 received BPT in a group format. The
average numbers of sessions was 9.53 (SD = 4.17). This study reported
a mean effect size for overall child outcome of .86, which is considered
large (Cohen, 1988). The mean effect sizes for child outcome based on
parent, observer, and teacher were .84, .85, and .73, respectively. The
mean effect size for outcomes of parental adjustment was moderate at
.44. As a result of the favorable outcome evidence, behavioral parent
training for oppositional children has been designated by the American
Psychological Association Task Force as an empirically validated inter-
vention (Chambless et al., 1996).
Several studies have evaluated the efficacy of BPT programs with par-
ents of children with ADHD. Seven of eight studies which compared BPT
with no treatment reported positive findings (Anastopoulos et al., 1993;
Duby, O’Leary, & Kaufman, 1983; O’Leary, Pelham, Rosenberg, & Price,
1976; Pisterman et al., 1989; Pisterman et al., 1992; Sonuga-Barke, Daley,
Thompson, Laver-Bradbury, & Weeks, 2001; Thurston, 1979). However,
the effects of BPT were not found to be superior to a cognitive-behavioral
self-control therapy (Horn, Ialongo, Popovich, & Peradotto, 1987; Horn,
Ialongo, Greenbert, Packar, & Smith-Winberry, 1990) or stimulant medi-
cations (Firestone, Kelly, Goodman, & Davey, 1981; Horn et al., 1991;
Klein & Abikoff, 1997; Pollard, Ward, & Barkley, 1983; Thurston, 1979).
BPT has not been shown to enhance treatment response when com-
bined with medications (Firestone et al., 1981; Horn et al., 1991; Klein &
Abikoff, 1997; Pollard et al., 1983). However, there is some evidence that
suggests that combining BPT with medications may allow for lower doses of
medications (Horn et al., 1991) or lead to enhanced outcomes in functioning
(social skills; improved parent–child relationships; parenting) and consumer
satisfaction (Hinshaw et al., 2000; Multimodal Treatment Study of Children
with ADHD Cooperative Group, 1999). Reviews of parent training interven-
tions with ADHD populations have concluded that more systematic study is
needed but that existing studies provide sufficient evidence to consider par-
ent training an effective treatment for ADHD (Chronis et al., 2004; Kohut &
Andrew, 2004; Pelham, Wheeler, & Chronis, 1998).

BPT has been evaluated with other specific childhood problems.

Graziano and Diament (1992) reviewed 186 empirical studies that evalu-
ated the efficacy of BPT with childhood problems. In addition to problems
with conduct and hyperactivity, studies have examined BPT with children
with mental retardation, physical disabilities, autism, overweight, enu-
resis, fears, and other specific behavioral problems. They concluded that
the BPT showed clear positive results for conduct problems and discrete
child behavior problems (e.g., enuresis, fears, weight reduction), some
success with hyperactivity, and mixed results with autism and mental
retardation. For the latter two conditions, they suggested that BPT may
be more effective in improving parent outcomes than child behavior. A
recent randomized controlled trial of parent education and skills training
interventions supports this notion (Tonge et al., 2006). This study showed
significant improvements in the functioning of parents of young autistic
children following treatment relative to the control group.
There have also been some mixed results evaluating BPT with chil-
dren with anxiety disorders. A recent study tested Parent Child Interaction
Therapy (PCIT; a manualized BPT program) with three families of children
with separation anxiety using a multiple-baseline design (Choate, Pincus,
Eyberg, & Barlow, 2005). This study found clinically significant changes in
both separation anxiety and disruptive behaviors. Another study raised the
question of what specific treatment components were active in producing
change in children with separation anxiety (Silverman et al., 1999). This
randomized clinical trial compared interventions that included an expo-
sure-based behavioral parent training component with a control group
offered parent therapeutic support and information. The results showed
improvement in measures of both child and parent functioning across all
groups. These results suggested that generic parent support and educa-
tion is as effective as parent training with an “active” therapeutic compo-
nent for children with separation anxiety.
Lundahl, Nimer, and Parsons (2006) conducted a meta-analysis of
studies evaluating the effects of parent training programs on parent risk
factors related to child abuse and documented abuse. They identified 23
studies from 1970 to 2004 that included 25 parent training treatment
groups. Of the 23 studies, 17 used pre–post only designs. The parent
training interventions used in these studies varied on a number of char-
acteristics, including theoretical orientation (behavioral, nonbehavio-
ral, mixed), location of intervention (home, office, mixed), delivery mode
(group, individual, mixed), and number of sessions. Immediately following
parent training, parents showed moderate improvement in outcome vari-
ables. The average effects sizes were .60 for attitudes linked to abuse, .53
for emotional adjustment, .51 for child-rearing skills, and .45 for docu-
mented abuse. There was a significant difference between the effect sizes
of studies with a control group (d = .30) and those without (d = .62) for the
emotional adjustment outcome variable, suggesting (at least for this vari-
able) that the effects are more in the small to moderate range.
In a recent randomized trial of an enhanced Parent Child Interaction
Therapy program (PCIT; a manualized BPT program) with physically abu-
sive parents (Chaffin et al, 2004), parents receiving PCIT showed significant

reductions in negative parent behaviors in a structured parent–child inter-

action observation compared to the control group. Other measures of child
and parent behavior and parent functioning showed improvements across
both experimental and control groups.
Cedar and Levant (1990) conducted a meta-analysis of studies that
evaluated the efficacy of the Parent Effectiveness Training program (PET;
Gordon, 1970) on the behavior and cognitive adjustment of both children
and parents. Most of the studies were doctoral dissertations rather than
peer reviewed journals. PET is based on a reflective/Rogerian approach
rather than a behavioral orientation and consists of training parents in
the use of active listening, “I” messages, and conflict resolution. Cedar and
Levant examined 26 studies from 1975 to 1990. Their analyses found no to
small effects on outcomes related to child attitudes and behaviors (ds = .12
& .03, respectively), small to moderate effects for child self-esteem (d = .38),
small to moderate effects on parent attitudes and behavior (ds =.41 & .37,
respectively), and large effects on outcomes related to parental knowledge
of course content (d =1.10).

Generalization Effects
It is reasonable to assume that changing parents’ behavior would result
in some generalization of treatment effects across time and settings and to
untreated siblings. Although there is some supporting evidence for such
generalization, confidence in the generalizability of treatment effects would
be increased with additional studies with improved methodology, such as
larger sample sizes, multiple outcome measures, and control groups.
Three of the four meta-analytic studies reviewed above evaluated the fol-
low-up effects of parent training. The long-term effect (interval not reported)
of the PET program showed an attenuation of overall effect over time, from
small to moderate (d = .35) to small (d = .24; Cedar & Levant, 1990). Of the
23 studies that evaluated the efficacy of parent training programs on child
abuse risk factors reviewed by Lundahl, Nimer, and Parsons (2006), five
studies reported follow-up effects for child-rearing behaviors and six stud-
ies reported follow-up effects on parental attitudes and emotional adjust-
ment. The effects were moderate for child-rearing attitudes (d =.65) and
small for emotional adjustment and child-rearing behaviors (ds =.28, .32,
respectively). Both of these reviews did not report separate follow-up effects
for studies that employed control groups at follow-up and those that did
not. Lundahl, Risser, and Lovejoy (2006) reported on the follow-up effects
(1 to 12 months post treatment) of behavioral parent training programs.
They reported the effects of those studies that employed a control group
at follow-up and those that did not. Studies that include a control group
at follow-up can provide a more accurate picture of the long-term impact.
The follow-up impact of the programs that used a control group at follow-
up was shown to maintain in the moderate range for parent perceptions
(d =.45) and to attenuate from moderate in magnitude at post-test to small
at follow-up for child behavior (d =.21) and parenting skills (d = .25).
A couple of recent studies reported follow-up effects of BPT with physi-
cally abusive parents and parents of children with Oppositional Defiant

Disorder. Chaffin and his colleagues (2004) reported follow-up data (median
interval of 2.3 years) in their randomized controlled trial of a BPT program
with physically abusive parents. Forty-nine percent (49%) of parents in the
control group (standard community group intervention) had a re-report for
physical abuse at follow-up compared to 19% of parents assigned to the
BPT group. Reid, Webster-Stratton, and Hammond (2003) reported on a
two-year follow-up of 159 four- to eight-year-old children diagnosed with
Oppositional Defiant Disorder and treated with a behavioral parent train-
ing program (Incredible Years). At posttreatment, 46.2% of participants
who received parent training alone and from 55% to 59.1% who received
parent training in combination with teacher or child training, showed
clinically significant changes (defined as a 20% reduction in ratings of
behavior) at posttreatment compared to 20% of controls. At the two-year
follow-up, the percentage of participants who received the parent training
alone or in combination with teacher or child training who showed clini-
cally significant improvements was 50%, 81.8%, and 60%, respectively. No
control group was used at this two-year follow-up.
There is some support for the generalization of behavioral parent
training treatment effects to untreated siblings. Four studies showed
significant improvements in the untreated siblings observed compliance
(Humphreys, Forehand, McMahon, & Roberts, 1978; Eyberg & Robinson,
1982) and deviant behavior (Arnold, Levin, & Patterson, 1975; Wells, Fore-
hand, & Griest, 1980) at posttreatment. In one study, the improvements
were maintained at a six-month follow-up (Arnold et al., 1975). Eyberg
and Robinson (1982) reported significant improvements in observed par-
ent behavior with untreated siblings and no significant reductions in the
number or intensity of negative sibling behaviors.
Two early studies failed to show generalization of treatment effects
from clinic to school settings (Breiner & Forehand, 1981; Forehand et al.,
1979). However, McNeil, Eyberg, Eisenstadt, Newcomb, and Funderburk
(1991) reported significant improvements in teacher-rated deviant behav-
ior and observations of appropriate and compliant behaviors at school in
ten children treated with a BPT program relative to controls. In this study,
they selected subjects who showed high levels of behavior problems across
home and school settings at pretreatment and who all showed clinically
significant improvements in home behavior after treatment.

Moderator Effects
A number of child, parent, and program characteristics have been
associated with parent training outcomes, such as child age, child IQ,
family’s socioeconomic status, parental social support, parental educa-
tion level, parental functioning, family stress, and ethnicity (see Graziano
& Diament, 1992 for review); however, relatively little research has been
done where these characteristics have been studied as independent vari-
ables. Lundahl, Risser, and Lovejoy (2006) assessed moderator effects of
parent training in their meta-analysis. They found financial disadvantage
to be the most salient moderator of outcomes. Children and parents from
non-disadvantaged families benefited more across the child behavior, parent

behavior, and parental perception outcome constructs compared to dis-

advantaged families. They also found that marital status was a moderator
of child behavior outcomes. Studies with a higher percentage of single
parents (Number of studies (k) = 29) did not show as much change as
studies with a lower percentage of single parents (k = 16). There have been
some mixed results related to child’s age and parent training outcomes in
three quantitative reviews. The Lundahl, Risser, and Lovejoy (2006) and
the Cedar and Levant (1990) meta-analyses found no relationship between
age and positive outcomes, whereas Serketich and Dumas (1996) reported
a positive relationship between age and positive outcomes.
There have been some program characteristics associated with parent
training outcomes, including the format of training and number of ses-
sions. In their meta-analysis, Serketich and Dumas (1996) found a non-
significant correlation between the effect size for the overall child outcome
and the format of the treatment (individual vs. group). Studies have found
individual, group, and self-administered BPT to be equally effective and
superior to a no-treatment control group (Webster-Stratton, 1984; Web-
ster-Stratton, Kolpacoff, & Hollinsworth, 1988).
Lundahl, Risser, and Lovejoy (2006) also found no differences in effect
sizes between face-to-face and self-directed interventions. However, they
reported that among the 20 studies that treated financially disadvantaged
families, individual parent training resulted in significantly greater improve-
ments in child and parent behavior than group parent training. There were
no differences between individual and group treatment in the parental per-
ceptions outcome domain. Lundahl, Nimer, and Parsons (2006) found that
studies whose programs were more than 12 sessions had greater improve-
ments in parental attitudes linked to abuse compared to programs with fewer
than 12 sessions. No differences in child-rearing behavior were found between
programs with low and high number of sessions.



There have been a substantial number of studies evaluating parent

training programs from different theoretical orientations and across differ-
ent child problems. As a whole, the research is supportive of the immedi-
ate effectiveness of parent training across many parent and child outcome
domains. Parent training can be considered at least moderately effective
which compares very favorably to the effects found for other psychotherapy
treatments. More specifically, there is sufficient evidence to consider behav-
iorally oriented parent training programs efficacious in treating children
with oppositional and ADHD problems. Although results are mixed and
more studies needed, there is evidence to support the generalization of parent
training effects across time, and some evidence to suggest generalization
across settings and to untreated siblings in some families.
Of course there are limitations in examining the effectiveness of par-
ent training programs in general by relying on the results of meta-analytic
reviews. As stated previously, parent training programs vary significantly

across a number of factors (e.g., theoretical basis, format and content

of the intervention, target behaviors, length of the intervention, etc.) and
some programs are more effective than others.


As is clear from the review of the empirical support for parent train-
ing, programs vary significantly. In order to provide a better understanding
of some of these differences, as well as more details regarding specific
programs, the next section highlights several selected parent training pro-
grams. In order to impart the greatest understanding of parent training
programs, within the confines of this chapter, some programs are described
in detail and others are briefly summarized.

Parent Programs That Target Externalizing Behavior Problems

Helping the Noncompliant Child (HNC)
Helping the Noncompliant Child is a behavioral parent training program
that targets young children (two to eight years old) who exhibit high levels
of noncompliance to parental directions (McMahon & Forehand, 2003).
The extensive research base and evaluation studies supporting this pro-
gram are thoroughly summarized in McMahon and Forehand (2003) and
in Forehand and McMahon (1981). It is included on several “best practices”
lists for evidence-based treatment programs for conduct problems (Brestan
& Eyberg, 1998), child abuse (Saunders, Berliner, & Hanson, 2004), and
the prevention of substance abuse and delinquency (Alvarado, Kendall,
Beesley, & Lee-Cavaness, 2000; Webster-Stratton & Taylor, 2001). This
clinic-based program involves a therapist working with individual families.
The child attends all sessions with her parent(s). The primary goals of the
program are to improve child compliance to directions and to decrease
disruptive behavior through teaching parents more appropriate ways of
interacting with their child.
The intervention consists of two major phases. During Phase 1, dif-
ferential attention skills are taught that are designed to improve the par-
ent–child relationship as well as increase desirable behaviors. Phase 2
involves compliance training skills that assist parents in dealing with non-
compliance and other problematic behavior. A detailed training manual is
available for therapists (McMahon & Forehand, 2003).
The instructional format for each session follows a standard process
that includes didactic instruction and discussion of a specific skill, the
therapist demonstrating the skill through modeling and role-playing, the
parent practicing the skill with the therapist, the skill is then introduced
to the child, the parent then practices the skill with the child while the
therapist provides cues/feedback, and finally a homework assignment is
given to allow the parent to practice/utilize the skill at home.
Skills addressed in the program include attending, rewarding, ignor-
ing, directions, and time-out. Phase 1 of the program involves teaching

parents the effective use of the skills of attending, rewarding, and ignoring.
Phase 2 involves teaching parents to give effective directions and how to
use time-out appropriately. The clinical program typically takes 8–12 ses-
sions to complete. The number of sessions varies from family to family
because HNC uses a competency-based approach which requires parents
to achieve a certain level of competence with a skill before the next skill is
introduced. Details regarding the specific skills are provided below.

Phase 1 (Differential Attention Skills)

Attending. Attending is a skill that parents can use to help increase their
child’s desirable behaviors. It also helps lay the groundwork for a more posi-
tive parent–child relationship. After discussing, modeling, and role-playing
the skill with the parent(s) the therapist helps the parent master the skill
through practicing it in what is called the “child’s game.” This is a time where
the child selects the play activity (e.g., playing with blocks) and the parent is
nondirective. The parent is taught to simply describe a child’s activity while
eliminating directions and questions addressed to the child. This practice
allows the parent to master the skill of attending that will later be used to
increase desirable behavior. This skill is the focus of the intervention until the
parent demonstrates competence. This competence is assessed using specific
behavioral criteria recorded during a structured observation.
Rewarding. The second skill involves teaching the parent to praise or
reward the child’s positive behavior. This skill is taught using the same
instructional procedures and is practiced using the “child’s game.” The
types of rewards that are taught consist of labeled verbal (e.g., “I really
like it when you pick up your toys!”) and physical (e.g., hug, pat) rewards.
Parents are taught to focus on and reward prosocial behaviors rather than
negative behaviors. The parent has to demonstrate competence before the
next skill is introduced.
Ignoring. The third component of the initial phase of the program
involves teaching a parent to ignore minor unacceptable behavior, such
as whining and fussing. Again, the standardized instructional procedures
are used. The parent is taught an ignoring procedure that involves no eye,
physical, or verbal contact when minor unacceptable behaviors occur.
Differential Attention Plans. After the parent has mastered the skills
of attending, rewarding, and ignoring, the therapist assists the parent in
targeting specific child behaviors to increase using differential attention.
Parents use the skills taught in Phase 1 to implement differential attention
plans with guidance provided by the therapist.

Phase 2 (Compliance Training Skills)

The second phase of the program consists of teaching parents two
primary components of disciplinary skills: how to give effective instructions
to the child and how to use a time-out procedure appropriately.
Giving effective instructions. Parents are taught the elements of giving
effective instructions/commands to their child. The parent practices giving

instructions to their child within the “parent’s game.” Unlike the “child’s
game” which is used to teach Phase 1 skills and involves the parent being
nondirective, the “parent’s game” involves the parent taking direction of
the activities (e.g., the parent issues frequent instructions/commands
while directing the activity). The therapist provides feedback to the parent
regarding the directions being issued (e.g., how they could be improved).
The parent is also taught to attend to or praise their child’s compliance to
their directions.
Time-out. Parents are taught a specific time-out procedure to use
with their child. The child is also informed about the time-out protocol
within the session. The therapist provides guidance to the parent in terms
of issues related to time-out. The therapist then helps the parent utilize a
clear instruction sequence that guides the parent in how to manage com-
pliance and noncompliance to parental directions.
Standing rules. Once the parent is effectively implementing the clear
instruction sequence at home, the use of standing rules is introduced.
Standing rules are typically “If … then … ” statements (i.e., rules that
specify the consequences for specific behavior). The therapist assists the
parents in developing appropriate standing rules.
Extending the skills. The therapist discusses with the parents how
they can use the skills they have been taught to manage their child’s
behavior outside the home.



Given early evidence that parents could be effectively taught child

management skills through written instructions (O’Dell, Krug, Patterson,
& Faustman, 1980; O’Dell et al., 1982) a booklet was written for parents
that provided them with information on the core skills taught in the HNC
program. An initial evaluation of this booklet in a randomized study found
that the booklet appeared to be effective in helping parents learn the basic
skills and utilize them to improve their children’s behavior (Long, Rickert,
& Ashcraft, 1993). This led to a book, Parenting the Strong-Willed Child,
being written for parents that contains a self-guided approach to learning
the core skills of HNC (Forehand & Long, 2002).
A six-week parenting class program (total of 12 hours) has also been
developed based on the HNC program and the Parenting the Strong-Willed
Child book. During each weekly 2-hour class, one of the core skills is taught
to parents as well as an additional topic. Additional topics discussed in the
class include creating a more positive home, improving communication,
developing more patience, building positive self-esteem, and problem solving.
A recent evaluation of this parenting class suggested that the class can
lead to improved parenting, reduced child behavior problems, and reduced
parenting stress (Conners, Edwards, & Grant, 2007).
It should be noted that both the self-guided and parenting class for-
mats are intended for parents whose children have relatively mild problems

whereas the clinical HNC program is intended for parents whose children
have more significant behavior problems.

Other Parent Programs That Primarily Target Externalizing

Behavior Problems
There are numerous other evidence-based parent-training programs
that have been found to be effective in reducing children’s externalizing
behavior problems. Three of these programs will be briefly discussed.

Parent-Child Interaction Therapy (PCIT)

PCIT (Brinkmeyer & Eyberg, 2003) is similar in many ways to the
Helping the Noncompliant Child (HNC) program. This similarity is a func-
tion of the fact that both programs were developed from the early work of
Constance Hanf (1969). Both programs focus on young children with dis-
ruptive behavior, have two phases, and are delivered to individual families
by a therapist. The two phases in PCIT are: child-directed interaction, and
parent-directed interaction. Training is provided through didactic instruc-
tion, modeling, role-playing, and coaching. In PCIT, children attend most
but not all of the sessions with their parents. Only the parents attend
a single teaching session at the beginning of each phase. During these
teaching sessions the parents are taught all of the skills for that phase
(whereas in HNC the skills are taught sequentially within each phase).
PCIT also emphasizes the role of traditional play therapy as part of their
child directed interaction phase. There is extensive evidence supporting
the effectiveness of PCIT (see Brinkmeyer & Eyberg, 2003).

The Incredible Years (TIY)

TIY training series (Webster-Stratton & Reid, 2003) is a comprehen-
sive program that has intervention components for parents, teachers, and
young children (two to eight years old). TIY is an extremely well-evaluated
program (see Webster-Stratton & Reid, 2003). The goals of the parent-
training component are to promote parent competencies and strengthen
families. This is a videotape modeling/group discussion program. The
BASIC parenting training program takes 26 hours to complete (13 weekly
2-hour group sessions). The videotapes used in the program contain 250
short vignettes (one to two minutes each) of modeled parenting skills.
The vignettes are show to groups of 8 to12 parents with a therapist lead-
ing group discussion. The program focuses on teaching parents how to
enhance the parent–child relationship through the use of child-directed
interactive play, to use praise, and to use incentives. The program also
teaches parenting techniques such as monitoring, ignoring, use of effec-
tive directions, time-out, and natural and logical consequences.
Webster-Stratton has also developed an ADVANCE parent training
program (Webster-Stratton & Reid, 2003). This is a 14-session videotape-
based program that can be used following completion of the BASIC pro-
gram. The ADVANCE program has four primary components: personal

self-control, communication skills, problem-solving skills, and strength-

ening social support and self-care.

Triple P
Triple P (Positive Parenting Program) developed by Sanders (Sanders &
Ralph, 2004) is a unique parent-training program. Developed in Australia
and currently being used around the world, Triple P is a multilevel parent-
training program that targets children 2–12 years old. The program has
five levels. Level 1 is a universal parent information strategy that makes
general parenting information available to all parents through the use of
various strategies including tip-sheets and promotional media campaigns.
Level 2 consists of a brief one- or two-session primary healthcare-based
parenting intervention targeting children with mild behavior problems.
Level 3 is a four-session more intensive parenting intervention that targets
children with mild to moderate behavior problems. Level 4 is an eight- to
ten-session individual or group parent-training program targeting children
with more significant behavior problems. Level 5 is an enhanced behav-
ioral family intervention program that is utilized for significant behavior
problems that are complicated by other factors (e.g., marital conflict, high

Parent Programs That Target Internalizing Behavior Problems

As discussed previously, the vast majority of parenting programs have
been developed to address children’s externalizing behavior problems.
However, a limited number of parenting programs have been developed
to specifically address internalizing behavior problems. These parent pro-
grams, unlike the programs for externalizing problems, are often used in
an adjunctive manner to interventions that involve working with the child
directly. This reflects the belief that: (1) although parenting may be a con-
tributing factor to children’s internalizing problems it typically plays a less
central role than it does with externalizing problems; and, (2) other inter-
vention approaches working directly with children (e.g., cognitive-behavior
therapy) have been found to be effective.
In several studies researchers have found that the risk for the develop-
ment of internalizing disorders in children is associated with parent–child
interactions that involve parental overcontrol, less granting of autonomy,
and low maternal warmth (Hudson & Rapee, 2001; Rapee, 1997; Sique-
land, Kendall, & Steinberg, 1996). Child anxiety may also result in parental
distress and changes in parenting practices including changes in terms
of parental expectations and demands that may maintain or exacerbate
children’s anxious and avoidant behaviors through negative reinforcement
(Kendall & Ollendick, 2004). Therefore, although cognitive-behavioral ther-
apy has been found to be an effective treatment for childhood anxiety dis-
orders, researchers have recommended the involvement of parents in the
treatment process as a way to improve outcomes (Barrett & Farrell, 2007).
Barmish and Kendall (2005) reported several common components of
parent-focused interventions for childhood anxiety:

Removing the reinforcement of children’s anxious behavior. This included

teaching parents contingency management strategies to extinguish avoidant
behavior and expressions of fear and to reward courageous behavior. Specific
strategies included planned ignoring, verbal praise, privileges and tangible
Modeling appropriate behavior. This included teaching parents how to
gain greater awareness of their own anxious behaviors and how to become
better models for the children. Parents were also taught problem-solving
skills, how to restructure their cognitions, and to engage in appropriate
responses to anxiety-provoking situations.
Reducing family conflict. This included teaching parents specific
strategies to improve communication, parent–child relationships, and
reduce conflict.
Other. Other techniques used by some programs included teaching par-
ents about the etiology of anxiety (and the role of the family), relaxation training,
and how to build a support network with other parents of anxious children.
Barmish and Kendall (2005) conducted a review and meta-analysis
of nine controlled studies that have involved parents in the treatment of
child anxiety. Unfortunately, there was large variability across the stud-
ies including such factors as the content of parent sessions, number and
format of sessions, and who attend the parent sessions. This variabil-
ity precluded any definitive conclusions to be drawn. The reported effect
sizes for CBT treatment without parental involvement ranged from small
to medium for self-reported data to large for parent-reported measures.
When the treatment programs involved parents, the effect sizes ranged
from small to large for self-reported measures to large for diagnostician
and parent-reported measures.

FRIENDS for Life Program

One program that targets internalizing behavior problems is The
FRIENDS For Life Program (Barrett & Farrell, 2007; Barrett & Shortt,
2003), which targets childhood anxiety, and includes a parent component.
This treatment program, which was initially designed to be a group-based
intervention (it has also been adapted for individual clinical use), has a
primary child-focused cognitive-behavioral component. That is, the pri-
mary focus is working with children directly to address their dysfunctional
cognitions. The parent and family skills component is designed to be run
in a group format for approximately 6 hours (typically four 1.5 hour ses-
sions). The major focus of the parent/family skills component (Barrett &
Farrell, 2007; Barrett & Shortt, 2003) is to:
- Encourage parenting strategies including attending to and reinforc-
ing their children’s coping, approaching behaviors, and parental
modeling of appropriate coping behavior to their children
- Teach parents self-awareness and appropriate management of their
own stress and anxiety.

- Increase parents’ awareness of at-risk time for their children, how

they can coach their children to cope, and reinforcing their chil-
dren’s appropriate attempts to cope.
The parent component follows along with the FRIENDS components for
the children. Barrett and Farrell (2007) have outlined the specific strat-
egies of the parent component for each component as indicated by the
FRIENDS acronym as summarized below.
Feelings. Parents are encouraged to focus on their own responses
to fear and anxiety and on learning the skills of anxiety awareness. The
importance of accepting individual differences, particularly in response to
feelings, is discussed.
Remember to relax. Have a quiet time. Parents are taught relaxation skills
and are encouraged to practice and coach other family members. Parents are
also encouraged to ensure that the family has regular periods of quiet time.
Parents are also encouraged to reinforce relaxation practice in children. Par-
ents are supported and encouraged to spend quality time with their children.
I can do it! I can try my best! Parents are encouraged to become aware
of their own cognitive style and how their responses to stress model opti-
mism or pessimism to their children. Parents are encouraged to use positive
thoughts and to notice and reward their children for positive thoughts.
Parents are also asked to use positive prompts (e.g., “You can do it, you’ve
done it before”) with their children.
Explore solutions and coping step plans. Parents are taught how to
help their child develop coping step plans (based on a fear hierarchy). They
are given examples of coping step plans and rules to help ensure the success
of coping step plans.
Now reward yourself! You’ve done your best! Parents are encouraged
to notice brave/confident behaviors and reward approach behaviors.
Parents are also taught to ignore complaining and avoidance behaviors.
Don’t forget to practice. Parents are taught to encourage their child to
use their FRIENDS plan. They are also encouraged to role-play with their
children how to utilize the skills to handle upcoming challenges.
Smile! Stay calm for life. Parents are encouraged to help their children
recognize they have effective strategies for overcoming challenges they will

Parent Programs That Target Developmental Disorders

The role of parents in the treatment of children with developmental dis-
orders has significantly changed over the past several decades. Parents have
moved from being minimally, if at all, involved in their children’s treatment
to being integrally involved. This transition has been especially significant for
some disorders such as autism. In the not too distant past, parenting style
(cold and rejecting) was considered to be the cause of autism (Bettleheim,
1967). Fortunately, autism is no longer considered an emotional problem
related to parenting but rather a neurodevelopmental disorder for which
parents can play an important role in helping interventions succeed.

The literature on parent training for children with developmental dis-

orders and specifically autism has, for the most part, developed separately
from the parent training literature for areas such as disruptive behavior
disorders (Brookman-Frazee, Stahmer, Baker-Ericzen & Tsai, 2006). In
reviewing the literature on parent training and autism spectrum disor-
ders (ASD) Brookman-Frazee and colleagues (2006) identified some gen-
eral differences when compared to more traditional parent training studies
for disruptive behavior disorders. They report that parent groups for ASD
tend to be smaller and that studies often include single case examples,
single case design, and more descriptive reports. Programs for ASD tend to
include more modeling of behaviors for parents. They also tend to include
more home treatment components and fewer strictly didactic components
for parents.
The degree of parental participation varies significantly across treat-
ment programs for ASD and other developmental disabilities. The level
of parental involvement is discussed below for some of the most popular
treatment programs for ASD.

Planned Activities Training (PAT)

Planned Activities Training (Lutzker & Steed, 1998) is a parent-training
approach that focuses on antecedent prevention of challenging behav-
iors. Unlike many other parent-training approaches that rely primarily on
contingency management techniques, PAT teaches parents to plan and to
structure activities in order to prevent challenging child behaviors. PAT
has been used successfully to reduce inappropriate behaviors with vari-
ous groups including children with developmental disabilities (see Lutzker
& Steed, 1998). PAT involves teaching parents time-management skills,
how to choose activities, how to explain activity rules, incidental teach-
ing, feedback, and reinforcement. This training of parents is provided by a
therapist across five structured sessions with an individual family. Train-
ing initially involves teaching parents to use the techniques for activities
that are not problematic. As parents master the techniques more prob-
lematic activities and settings are targeted. Training involves extensive
modeling, parent practice, and performance feedback. Training sessions
are typically conducted in family homes and in settings where challenging
behaviors occur.

Parent Involvement in Lovaas’s Treatment Program

for Autism
The early applied behavior analysis (ABA) interventions focused on the
child and did not involve the parents. However, in an early study by Lovaas
and his colleagues (Lovaas, Koegel, Simmons, & Long, 1973) it was noted
that children who were discharged back to families who were eager to par-
ticipate in treatment did much better in maintaining skills (or improving
skills) learned during the one-year treatment program (Lovaas, 2003). This
anecdotal evidence was seminal in Lovaas’ understanding of the need for
parental involvement with the children diagnosed with autism. However,
the extensive demands of parental implementation of an ABA intervention

(for at least 40 hours a week) requires a lifestyle change that is impossible

for many parents.
It should be noted that the effectiveness of using parents for the deliv-
ery of an ABA program is not clear. A recent study compared the outcomes
of ABA intervention provided by parents with that provided by students
(Smith, Groen, & Wynn, 2000). At four-year follow-up the children enrolled
in the student therapist group made more gains than the children in the
parent therapist groups on IQ tests, visual spatial skills, and in specific
aspects of language. There is some evidence to suggest that parents who
participate in parent training for their children with autism continue to
use some of the behavioral techniques they were taught, but many tend
to stop using the complete set of operant learning procedures including
ongoing formal data collection (Harris, 1986).

Pivotal Response Training (PRT)

Pivotal Response Training (PRT) was developed as a modified behavio-
ral intervention for children with autism (Koegel, O’Dell, & Koegel, 1987).
PRT focuses on addressing pivotal areas of functioning that can lead to
widespread collateral changes in other behaviors (Koegel, Koegel, & Brook-
man, 2003). Although specific target behaviors are determined based on
individual needs, much of the focus is on communication skills and social
communication interactions. PRT differs from traditional operant train-
ing in several ways including: (1) that it allows the child to take the lead
in what toys/stimulus items are used in a session, (2) it rewards goal-
directed attempts at correct responses, and (3) it uses more direct/natural
reinforcers in training. PRT has been found to change not only the target
behaviors but also improve the affective relationship between parent and
child, resulting in lower stress during family interactions, and improve
positive communication (Koegel, Bimbela & Schreibman, 1996). The addi-
tion of a parent support group to the standard parent-training program
has been found to improve the performance of parents in the use of the
PRT techniques (Stahmer & Gist, 2001).
In Koegel’s PRT, parents serve as key coordinators and interventions
for the program. Initially, the individually tailored parent-training program
focuses on introducing basic behavioral interventions (e.g., antecedents,
behavior, and consequences), characteristics of the pivotal area of motiva-
tion, and identifying learning opportunities in the natural environment
(Koegel, Koegel, & Brookman, 2003). The training program involves exten-
sive parent practice with clinician provided feedback on parent implemen-
tation of each procedure. Specific skills taught to parents (Koegel, Koegel,
& Brookman, 2003) include:
- How to present clear instructions and questions, use child-selected
stimulus materials, and use direct natural reinforcers
- How to intersperse previously learned tasks with new acquisitions
tasks (interspersing maintenance trials)

- How to reinforce a child’s attempts to respond to instructional mate-

rials or natural learning opportunities
Koegel’s research indicates that most parents reach criterion (80% correct
use of the motivational procedures within the natural environment) within
25 hours of training.

TEACCH Program (Treatment and Education of Autistic

and related Communication-handicapped Children)
The TEACCH program, developed by Eric Schopler and his colleagues
at the University of North Carolina at Chapel Hill, can be conceptualized
as a network for the state of North Carolina that provides services for
children with autism, education and support for families, research and
training for professionals, as well as a base for international education,
research, and training. It is not a single intervention. Working with the
families of individuals with autism is a major component of this program
(Marcus, Kunce, & Schopler, 2005).
The initial work of Eric Schopler was a direct response to the psy-
choanalytic theories of the 1960s that parents were the cause of a child’s
autism. Some of his earliest research looked at parents of children with
autism and found that these parents did not have thought disorders as
originally reported in the literature (Schopler & Loftin, 1969a, 1969b).
His early research also found that parents of children with autism were
able to accurately evaluate the variations their children’s developmental
progress and that these evaluations were consistent with standardized
testing results (Schopler & Reichler, 1972). These studies were seminal in
incorporating parent involvement and parent report as part of the evalua-
tion and treatment of the child with autism.
Education, training, and parent support are included in the core mis-
sion statement of the TEACCH model. The key values of the TEACCH model
include: (1) respecting the parent’s knowledge of their child, (2) respecting
the individuality of each family, (3) respecting the love parents have for
their child, (4) respecting the resilience of parents in finding solutions in
the face of intense stress, (5) respecting the contributions parents make
in advocating and developing new services, and (6) respecting the needs
of parents for accurate information, emotional support, comprehensive
services, and professional guidance for their child with autism (Mesibov,
Shea, & Schopler, 2006).
The TEACCH program involves parents at various levels (Marcus,
Kunce, & Schopler, 2005). Parents are educated about autism, trained
to work directly with their child, and to participate in advocacy efforts.
Specific training efforts, in working with their child, include helping them
establish positive routines through structured teaching. The TEACCH pro-
gram utilizes a collaborative model in working with parents. The exact
content of parent training efforts varies based on the child’s stage of devel-
opment and individual family needs.

Stepping Stones Triple P (SSTP)

The Triple P (Positive Parenting Program; Sanders, 1999), which utilizes
behavioral family interventions and parent management training, has
been modified for use with children with autism (Roberts, Mazzucchelli,
Studman & Sanders, 2006). Stepping Stones Triple P (SSTP) modifies the
original program by including material sensitive to families of children
with disabilities. It also covers issues relevant to this population and addi-
tional factors that could contribute to behavioral issues (i.e., problems
with communication skills).
A randomized control trial of SSTP (Roberts, Mazzucchelli, Studman &
Sanders, 2006) with parents of children with autism found that the SSTP
program resulted in a decrease in child behavior problems. Parenting
changes included mothers becoming less overreactive and fathers becom-
ing more effective in their discipline strategies. Raters found parents to be
more positive in their praising of children’s behavior. These results were
maintained at a six-month follow-up.
The modification of existing parent training for uses with different
populations, as described above, is a trend that will most likely increase
in the future.


From its early development in the 1960s, parent training has made
great strides. It has grown from an intervention focused on helping parents
to address specific child behaviors to a method of intervention used for a
variety of child problems and disorders. No other psychological therapy
for children has been as extensively studied (Kazdin, 2005). Meta-analytic
reviews of the parent-training literature suggest that parent training is at
least moderately effective. These results are very favorable when compared
to the effects found for other psychotherapy approaches. Such research
findings have resulted in parent training being considered one of the rel-
atively few empirically supported treatments for children’s externalizing
behavior problems. The use of parent training in other areas of childhood
psychopathology and developmental disorders is less well established but
is rapidly gaining support.
Unfortunately, parent training is not a panacea nor is it consistently
effective. Much work remains to be conducted to fully understand factors
that impact the effectiveness of parent training interventions. A greater
understanding is needed of how contextual factors such as ethnicity/cul-
ture, socioeconomic status, parental psychopathology, and various family
stressors relate to parent training interventions. Parent-training interven-
tions certainly need to better address issues related to ethnicity and cul-
ture, which are known to affect parenting, if treatment outcomes are to be
maintained in our increasingly diverse society.
At this stage of the development of parent-training interventions, more
effectiveness trials are needed (the primary focus to this point in time
has been on efficacy trials) (Weisz & Kazdin, 2003). That is, there is a

growing need to move beyond assessing treatment outcomes in controlled

research settings to assessing outcomes when parent-training interven-
tions are used in “real world” clinical settings. Related to this issue is the
need to study how to most effectively train clinicians in parent-training
approaches. Most research studies to date (efficacy trials) have utilized
therapists who are extensively trained over long periods (e.g., graduate
students who are trained over years in a particular parent-training pro-
gram). How can therapists at the community-level be trained to a level of
proficiency that will maintain the effectiveness of the intervention? It is
questionable whether traditional continuing education methods (e.g., writ-
ten manuals, one- to two-day training workshops with no ongoing training
support or supervision) are adequate. Perhaps newer technologies (e.g.,
Web-based tutorials and/or booster training sessions, Web-based group
supervision) will be used to assist in training efforts.
Finally, there is a need for research involving direct comparisons of
different parent-training interventions to determine which approaches are
most effective under which conditions. At the present time, there are many
parent-training interventions that have been demonstrated to be effective;
however, it is often difficult for clinicians to know which approach is best
for a specific family with whom they are working.
In conclusion, parent training has come a long way but still faces
many challenges as this approach to intervention continues to evolve. The
future of parent training looks bright as researchers and clinicians will
continue to use, improve, and study this very promising intervention for
treating and preventing child problems.


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Conduct Disorders


Disruptive behaviors—defined here as behaviors that are associated

with diagnoses of Oppositional Defiant Disorder (ODD) or Conduct Disorder
(CD)—are the most common reason for referral to mental health services for
children and adolescents (Kazdin, 2003). The behaviors that comprise these
diagnoses include argumentativeness, temper tantrums, often being angry
or resentful, lying, stealing, hurting or threatening to hurt others, cruelty
to animals, setting fires, and destruction of property (American Psychiatric
Association, 2000). Kazdin (2003) estimates “conservatively” that between 1.4
million to 4.2 million children in the United States meet criteria for CD alone.
Conduct problems or other externalizing behavioral difficulties constitute the
most common referral issues for children and adolescents for mental health
services (Brinkmeyer & Eyberg, 2003). The presence of these symptoms can
be detected early in childhood (Webster-Stratton & Reid, 2003), making them
amenable to treatment as long as candidates for intervention are identified
and followed through with the prescribed treatment recommendations.
ODD and CD encompass a broad array of acts, and young person
need not exhibit all, or even most, of the symptoms of ODD and CD
to warrant a diagnosis or be a candidate for intervention. Noncompli-
ant behavior is frequently demonstrated in children with ODD or CD;
however, many parents whose children do not meet diagnostic criteria
for these disorders commonly report seeking outpatient mental health
services for noncompliance in their children (McMahon & Forehand,
2003). One of the initial symptoms of conduct problems to emerge in
children is lying (Christophersen & Mortweet, 2001). Specific behaviors


L. HARRISON ● The University of Southern Mississippi

J.L. Matson et al. (eds.), Treating Childhood Psychopathology 107

and Developmental Disabilities, DOI: 10.1007/978-0-387-09530-1,
© Springer Science + Business Media, LLC 2009

that are associated with ODD and CD may in and of themselves be

reason referring a young person for treatment, including bullying, rigid-
ity/stubbornness, and temper tantrums (Christophersen & Mortweet,
2001; McMahon & Forehand, 2003).
Researchers also suggest that oppositional behaviors, including argumen-
tativeness and temper outbursts, typically predate the onset of the more
severe behaviors that comprise CD (Greene, Biederman et al., 2002; Loeber,
Green, Lahey, Christ, & Frick, 1992). To wit, current and well-supported
interventions are geared toward early identification and treatment of oppo-
sitional and noncompliant behaviors more so than severe conduct prob-
lems which have a low base rate among young children (e.g., McMahon
& Forehand, 2003). It should be noted that we use the terms “conduct
problems, conduct disorders, and behavioral problems” essentially inter-
changeably and in reference to behaviors that comprise, or are similar to,
the symptoms of ODD and CD. The reason behind the above consideration
is that individual symptoms of either diagnosis may warrant intervention,
CD often encompasses symptoms of ODD, a diagnosis of CD supersedes
a diagnosis of ODD, and it may be difficult to clearly distinguish among
CD, ODD, and an exaggeration of typical developmental processes, partic-
ularly in preschool-aged children and adolescents (American Psychiatric
Association, 2000).
The designs of treatments for conduct disorders have not only been
an artifact of the theoretical perspectives that predominate at a given time
but more specifically reflect the presumed causal factors (e.g., environ-
mental, cognitive) at play in the onset and persistence of these behaviors.
For example, researchers point to infrequent use of positive parenting and
inconsistent or harsh parenting as factors in development and mainte-
nance of child conduct problems (Gardner, Sonuga-Barke, & Sayal, 1999;
Gardner, Ward, Burton, & Wilson, 2003). Therefore, as described below,
many treatments for conduct disorders focus on these very parent fac-
tors through discussion and modeling of positive parental strategies (e.g.,
labeled praise, positive reinforcement based on clear contingencies) as well
as effective, consistent punishment strategies (e.g., time out). Hart, Nel-
son, and Finch (2006) caution that these theoretical perspectives are just
that, and care must be taken to not be unduly biased or exclusive in our
assessment, conceptualization, and treatment of child conduct problems.
They describe the importance of the therapeutic relationship, the impor-
tance of family relationships and parents, the influence of peers, and the
consideration of an individual’s risk and protective factors as factors that
generally cut across various interventions for these problems.
Regardless of the presumed etiology of conduct disorders, the need
for effective treatment is evident in the numerous domains in which con-
duct problems are related to impaired functioning and the fact that many
conduct problem behaviors have a victim. Our discussion of treatment
for conduct disorders focuses on psychosocial, as opposed to pharma-
cological treatments, given (a) the lack of pharmacological treatments
geared specifically to ODD and CD symptoms; (b) the fact that the medici-
nal treatments that are implemented with children with conduct prob-
lems typically target comorbid conditions of these problems (e.g., mood

disorders, Attention-Deficit/Hyperactivity Disorder [ADHD]) and (c) the

evidence supporting psychosocial interventions in the reduction of these
symptoms. The improvements in conduct problems that have been found
for psychopharmalogical interventions have typically been short in dura-
tion (Farmer, Compton, Burns, & Robertson, 2002). Thus, although more
research and treatment innovation are certainly needed, the evidence base
for psychological/behavioral treatments of youth conduct disorders is rel-
atively strong.
With the recent and still-emerging emphasis on evidence-based prac-
tice using empirically supported treatment strategies, there exists great
potential for both the expansion and synthesis of ideas on how to inter-
vene regarding specific problem behaviors at various developmental peri-
ods. The treatments that are considered empirically supported target both
the symptoms of ODD and CD, including a particular emphasis on parent-
ing strategies to reduce noncompliance as well as work on individual cop-
ing strategies for anger-provoking events (see Brestan & Eyberg, 1998).
However, the empirically supported psychosocial treatments for ADHD
also may be effective for reducing conduct problems insofar as they also
include strategies for reducing noncompliance and target the poor impulse
control that may be at the root of many child externalizing behaviors.
From the review of interventions that follows, it is apparent that many
of the empirically supported treatments for conduct disorders share a view
on some of the main causal pathways for problem behaviors among youth
and on the techniques that will abate conduct problem symptoms. Nev-
ertheless, key questions remain as to the most essential aspects of com-
mon strategies such as parent training (Anastopolous & Fairley, 2003), as
well as the extent to which therapist fidelity to these interventions occurs
and the extent to which it is necessary (Brinkmeyer & Eyberg, 2003). The
relevance of these questions for evidence-based practice and the further
advancement and innovation of such practice is discussed below.
What remains an ever-pressing issue is that of the influence of develop-
mental issues in determining the need for intervention and in the selection of
intervention strategies for conduct disorders. That is, there is much research
indicating that an onset of conduct problems prior to adolescence is associ-
ated with more persistent and severe problems than is a later onset (Loeber
et al., 1993; Moffitt, 2006). Therefore, the need for early intervention is clear.
Specific treatment programs such as those reviewed in these chapters are
typically most useful for specific developmental periods rather than one-size-
fits-all across childhood and adolescence. Treatments for conduct disorders
are only as effective as their appropriateness for the developmental level of
the child, thus making the consideration of development in the research on
which the interventions are based critical.
The goal of this chapter is to provide a description of the unique and
common elements of empirically supported interventions for conduct dis-
orders, as well as our view—in light of current research and theory—as
to the future directions that this work will likely take. Researchers have
indicated that a variety of approaches can be effective in reducing child
conduct problems (e.g., Nock, 2003). For example, the evidence supporting
cognitive-behavioral or behavioral parenting interventions for preventing or

treating child conduct problems is extensive. Therefore, we cannot provide

an exhaustive review of each treatment approach, its specific features, and
its empirical support in this chapter. Indeed, we seek to give an overview of
the issues inherent in treating child conduct disorders and of the current
strategies that are evidence-based. We begin with a discussion of parent-
based interventions given their utility for treating a variety of behavioral
problems in children beginning at a very young age.


Common Elements
That parent-based strategies are, or are part of, many of the empiri-
cally supported treatments for conduct problems speaks to the potential
influence of the youth’s immediate home environment in the development
of conduct problems and in the usefulness of environmental interventions
in the reduction of these problems. It is important,to note that regardless
of the specific hypothesized developmental pathway toward conduct prob-
lems for a given young person, parent-based interventions are develop-
mentally necessary for young children who generally lack the capacity to
directly participate in treatment in lieu of their parents. Indeed, consider-
ing the potential etiological effects of contextual factors, it has been argued
that intervention for children with an early onset of conduct problems
should have parent-based treatment as its central component (Beaucha-
ine, Webster-Stratton, & Reid, 2005).
Empirically supported parenting interventions generally target
child noncompliance and have some theoretical foundation based on
Patterson’s (1982) model of coercive parent–child interactions. Specifi-
cally, parenting practices that are thought to negatively reinforce child
noncompliance (e.g., withdrawing a request/command after repeated
refusals by the child) are replaced by clear commands and immediate
negative consequences for noncompliance. Furthermore, Patterson’s
model suggests that increasingly harsh parenting strategies are used as
child noncompliance increases, and such strategies are positively rein-
forced by the child’s eventual compliance in the face of harsh parenting
or threat thereof.
Parent-based interventions seek to emphasize positive reinforcement
for compliance in the form of praise, privileges, or larger, more long-term
rewards as well as to diminish the likelihood of increasingly aversive
parenting practices by promoting the use of immediate and consistent
punishment strategies such as time-out. Response cost (i.e., removing
tokens, privileges, or points when inappropriate behavior occurs) can pro-
vide an alternative to time-out (Forehand & McMahon, 2003). However,
the improvement of parent–child interactions through the use of positive
parenting strategies (i.e., parental attention, positive reinforcement) is
emphasized before the implementation of punishment strategies for misbe-
havior (cf., Webster-Stratton & Reid, 2003). Such models seem warranted
in light of evidence demonstrating that increases in positive parenting

practices are a mediating factor in improved child behavior (Gardner, Burton,

& Klimes, 2006) and that changes in parenting skills are a better predic-
tor of child outcome from parent-based treatment than change in parental
mood or parental confidence (Gardner et al., 2006; Hutchings, Lane, &
Gardner, 2004).
Specifically, parent training or family-based treatments for conduct
disorders routinely progress through the normal initial discussions and
modeling of positive attention and praise, to skills such as appropriate
commands, making attention and reinforcement contingent upon child
behavior, and use of a time-out for negative behaviors (see McMahon &
Wells, 1998). Additional treatment methods emphasize the use of ignor-
ing minor misbehaviors, the need for parents to be more proactive as
opposed to reactive in their plans to deal with problematic behaviors,
and the use of natural consequences for certain misbehavior (Webster-
Stratton & Reid, 2003).
Initial sessions of parent-based programs often begin with a psy-
choeducational component so that parents can better understand their
children’s difficulties and the rationale for the planned treatment. This
understanding may aid parents in being less emotionally reactive to the
child’s behaviors. Thus, parental anger management is often a component
of treatment, promoting a model of effective coping skills resulting in par-
ents being less likely to interact angrily—and thus problematically—with
his or her child.
Specific parenting techniques may be discussed didactically (e.g.,
Barkley, 1997), practiced and modeled in vivo (see Brinkmeyer & Eyberg,
2003), modeled using videotape (see Webster-Stratton & Reid, 2003), or
often, some combination of these approaches. Naturally, in-session mode-
ling and practicing of parenting skills will not be a component of treatment
once the child reaches a certain age. For example, Parent–Child Interac-
tion Therapy (PCIT; see below) is based on such in vivo practice but is
geared toward children ages three to six (Brinkmeyer & Eyberg, 2003).
It should be noted that these interventions are not synonymous with
family therapy approaches that emphasize problematic family boundaries
as factors that exacerbate a child’s problems such as in structural family
therapy (Minuchin, Montalvo, Guerney, Rosman, & Schumer, 1967) or that
emphasize family interactions across multiple generations and ways for
the child/adolescent to individuate adaptively as in a Bowenian approach
(see Hart et al., 2006). To date, these specific approaches have not dem-
onstrated empirical support for child conduct disorders, although a study
by Santisteban and colleagues (2003) found positive results particularly
in the reduction of adolescent substance use as well as peer-based delin-
quency and conduct problems for Hispanic adolescents who were treated
with a brief model of strategic family therapy. Furthermore, as discussed
below, family therapy that takes a multifaceted approach has shown some
benefits in terms of reducing adolescent problem behavior as well as in
addressing some of the risk factors for such behavior.
Finally, not all programs targeted at parents of children with conduct
problems focus exclusively on parenting practices in relation to the child’s
behavioral difficulties. Broader family-based approaches (see Kazdin, 1987)

have also targeted parental stress, parental problem-solving, and marital dis-
cord insofar as they exacerbate the child’s misbehavior (Lochman, 1990). Such
factors can be addressed within the context of individual parent treatment,
couples therapy, during the course of a child’s treatment for conduct prob-
lems, or in parenting groups designed for parents of children with conduct
problems. Such issues could be addressed generally in parenting groups, as
many of the empirically supported parenting interventions are group-based
and may include discussion of family issues that are often associated with
child problem behaviors. In fact, given their effectiveness, group therapy for
parents of children with externalizing problems have been touted as more
cost effective than individual parent-based treatment (Chronis, Chacko, Fabi-
ano, Wymbs, & Pelham, 2004) provided that the approach to parent training
is amenable to group work.

Examples of Empirically Supported Treatments

An important and influential approach to parent-based treatments for
conduct problems is the Living with Children program that was originally
developed by Patterson and Guillion in 1968 (Patterson & Guillion, 1968;
see Brestan & Eyberg, 1998). This program is conducted primarily with the
parents in an individual training format typically targeted at children ages
two to eight. This manualized treatment teaches skills such as attending
and rewards, ignoring, helping the parent with the effective use of differ-
ential attention regarding the child’s behavior, finding ways to eliminate
coercive cycles of parent–child interactions, establishing clear and consist-
ent rules, and behavioral generalization to other settings. That is, it follows
a sequence now generally adopted across parenting programs. Such skills
are taught using psychoeducation, homework assignments, role-plays,
and modeling. Living with Children and subsequent adaptations have
demonstrated positive outcomes in a variety of controlled studies (Brestan
& Eyberg, 1998), but recent studies on this specific program have not been
conducted (Farmer et al., 2002). Nevertheless, the innovativeness of the
theoretical foundation of this program and its approach has clearly influ-
enced more recently developed parent-based treatment programs.
A unique approach falling under the rubric of parent management
training is Carolyn Webster-Stratton’s “Incredible Years: Early Childhood
BASIC Parent Training” (see Webster-Stratton & Reid, 2003) which is
particularly oriented toward parents of children ages 6 to 12. However,
a similar program also developed by Webster-Stratton is geared toward
children who are younger (Webster-Stratton & Reid, 2003). This treatment
approach is unique in that it makes use of videotape modeling. It occurs in
a group setting rather in an individual format. It consists of ten videos that
demonstrate appropriate and inappropriate interactions to the parents
and can be used for parents of children of all ages. The videos facilitate
a group discussion with the parents. In addition to the traditional parent
management techniques that are taught, BASIC incorporates the skills of
logical consequences and response cost (Webster-Stratton & Reid, 2003).
Furthermore, a key tenet of this treatment is that parents can reduce
their children’s oppositional behaviors and even more significant conduct

problems by abandoning harsh or overly critical parenting and employing

consistent use of the kinds of strategies that are common to parent-based
programs (e.g., positive reinforcement, response cost, time-out, etc.). This
approach and variations of it have been shown to have positive effects on
child conduct up to one year later (Webster-Stratton & Hammond, 1997).
The intervention is particularly effective when combined with parent dis-
cussion groups or a child-focused component (see Farmer et al., 2002)
which is discussed below.
The program developed by Russell Barkley (1997) for parents of ele-
mentary school-aged children generally follows the above approach and is
based on the coercive cycle of parent–child interactions. Many of the spe-
cific strategies of this program (e.g., clear, short parental commands) are
geared toward accommodating the specific difficulties that children with
Attention-Deficit/Hyperactivity Disorder (ADHD) might have. In addition,
this program provides a good model for beginning treatment with psych-
oeducation on noncompliance and other conduct problems with a discus-
sion of both the child and familial factors that may lead to or help sustain
such behaviors.
The program progresses through discussion of attending to a child’s pos-
itive play behavior using a set-aside parent–child play time during which the
parent provides attention to the child’s behavior with very limited questioning
and no commands. In a subsequent session, parents are encouraged to fre-
quently praise and reinforce child compliance with commands—and to give
more opportunities for compliance—so that the child understands the contin-
gency between compliant behavior and the positive consequences that follow.
The sessions that follow are consistent with the sequence of steps described
above in which positive parenting skills are first introduced, followed by pun-
ishment strategies, with specific homework and handouts concerning each
skill being provided to parents (Barkley, 1997).
This intervention program is typically conducted in groups but can be
easily adapted to individual families. Relatively unique aspects of this pro-
gram include detailed discussions of the importance of praising/attend-
ing to a child’s independent play behaviors, managing behavior in public
places, and establishing effective home–school notes such that school
behaviors are subject to contingencies at home. As with other approaches,
much emphasis in this program is placed on clear consistent expecta-
tions and immediate praise for compliance and punishment (i.e., response
cost, time-out) for noncompliance. The importance of attending to positive
behaviors and ignoring/withholding attention from negative behaviors is
also a focus.
This program has been extended to adolescents in a separate treat-
ment format (Barkley, Edwards, & Robin, 1999), combining elements of
the parenting approach implemented for younger children just described
and family therapy centered on effective family communication and prob-
lem-solving skills. Each of the parenting skills discussed and practiced
in the program for younger children is presented first in the adolescent
program, with modifications made so that the strategies are developmen-
tally appropriate (e.g., grounding instead of time out). Behavioral contracts
are used as a version of a reward point system, but the adolescent is

involved in the planning of the contract. The rationale for the adolescent’s
increased involvement includes a more sophisticated understanding of the
approaches used to improve his or her behavior and family relationships,
the benefits of having the adolescent as part of the intervention process,
making the parent accountable for providing appropriate consequences
contingent upon the adolescent’s behavior, and making the adolescent
responsible for meeting the behavioral expectations set forth by the con-
tract (see Barkley et al., 1999).
The second phase of this program is family-focused and deals with
the importance of improving family communication habits in reducing
the teen’s problematic behaviors. In addition, unreasonable beliefs (e.g.,
expectations of perfect compliance, expectations of negative outcomes if
the adolescent is granted some autonomy) are discussed as a precipitant
of many hostile adolescent–parent interactions. Finally, the family mem-
bers practice their communication and problem-solving skills in sessions
with direction and guidance from the therapist. Of course, a wealth of
evidence supports the effectiveness of the parenting strategies introduced
in the first part of this program, although less is known about develop-
mental adaptations for adolescents. Recent evidence has also specifically
supported the benefits of family-based intervention such as that provided
in the second part of this program for symptoms associated with ADHD
and ODD (Anastopolous, Shelton, & Barkley, 2005).
An example of a parent-focused intervention with clear empirical sup-
port for reducing child oppositional and noncompliant behavior is PCIT
developed by Sheila Eyberg and colleagues (see Brinkmeyer & Eyberg,
2003). This program is oriented toward a variety of child acting-out behav-
iors ranging from talking back to authority figures to aggression and is
based on both attachment and social learning theories. More specifi-
cally, maladaptive parent–child attachment (e.g., low tolerance for child
emotional expressiveness) and patterns of escalating and aversive par-
ent–child interactions are thought to contribute to the child’s aggression,
poor coping skills, and noncompliance (Eyberg & Brinkmeyer, 2003). In
this approach, however, the parent is the agent of change in the child’s
behavior. In other words, PCIT does not focus on enhancing the child’s
coping skills per se.
As with many other parenting programs, PCIT begins with a focus
on child-directed interactions, a difference being that parenting skills
surrounding such interactions are modeled and practiced in vivo with
regular practice assigned between sessions as opposed to only being dis-
cussed and assigned as subsequent homework. Indeed, therapists in PCIT
serve as “coaches” in that they discuss and model parenting skills and
then observe the parents’ use of these skills in session (Brinkmeyer &
Eyberg, 2003). During child-directed interactions, the parent is charged
with “praising the child’s behavior, reflecting the child’s statements, imi-
tating and describing the child’s play, and using enthusiasm (i.e., PRIDE
skills; Brinkmeyer & Eyberg, 2003; p. 207). In other words, the parent
is cautioned not to make commands during this time or to control the
activities in which he or she engages with the child. Instead, the parent
ignores minor misbehavior during these interactions and discontinues the

interaction should the child’s behavior become difficult to manage. These

interactions are thought to target the attachment-related influences on
the child’s disruptive behaviors.
The focus of sessions—when the parent has mastered the skills neces-
sary during child-directed interactions—shifts to parent-directed interac-
tions. These interactions are based on social learning processes whereby
the parent’s skills for issuing effective commands, ignoring minor disrup-
tive behaviors, and implementing consequences for continued or more
severe disruptive behaviors are discussed, modeled, and practiced in ses-
sion. Parents are taught the importance of clear concise commands, and
as with other empirically supported parenting interventions, PCIT empha-
sizes consistency in the consequences provided for both compliant and
noncompliant behaviors.
PCIT is most effective and useful for children ages three to six
(see Brinkmeyer & Eyberg, 2003). Systematic progress monitoring is
a feature of this program that is essential given that PCIT is perform-
ance-based, not time-limited. That is, new parenting techniques are not
discussed, modeled, and practiced until previous skills have been mas-
tered. Progress is monitored through direct observations of parenting
behaviors and child disruptive behaviors in session. Research points
to the effectiveness of this approach in terms of both child behavior
and reports of parental satisfaction (see Brinkmeyer & Eyberg, 2003).
In addition to the parenting skills emphasis described briefly above,
PCIT, as do other programs for parents of children with conduct prob-
lems includes a parent relaxation component with the perspective that
parental stress will likely exacerbate problematic parent–child interac-
tions and child misbehavior.
A relatively recently developed program designed by Ross Greene and
colleagues (Greene, Ablon, & Goring, 2002)—also geared primarily toward
parents of school-aged children and known as collaborative problem-solving—has
a somewhat different approach and rationale from traditional parent-based
programs. Indeed, although the targets of this intervention (e.g., temper out-
bursts) are within the purview of traditional parenting programs, the presumed
cause of these behaviors is different, thus leading to different considerations
as to the families who would benefit from this approach.
In short, rather than an emphasis on contingencies to motivate
increased child compliance and decreased conduct problems as in tra-
ditional parent training, collaborative problem-solving emphasizes on
enhancing the abilities of both parents and children to resolve disa-
greements or issues that typically result in child outbursts (Greene et
al., 2004). The psychoeducational component of this program focuses
on the cognitive and intrapersonal factors that may be associated with
children’s aggressive outbursts such as poor frustration tolerance, poor
adaptability to change, and emotional dysregulation. A key skill for par-
ents to develop in this approach is to distinguish between situations in
which they must implement consequences for child misbehavior, situ-
ations that call for collaboration between parent and child in resolving
an issue, and situations in which the parent’s expectations are unreal-
istic (Greene et al., 2004).

Therefore, although traditional parent management strategies are

a facet of collaborative problem-solving, particularly for clear problem
behaviors (e.g., aggression toward others), the parent is called upon to
be flexible in which an expectation or rule is less clear or important but
that may make the difficult-to-adapt child quite frustrated. Collaborative
problem-solving has been shown to be at least as effective as parent train-
ing for reducing oppositional behaviors and may be a more appropriate
intervention strategy for parents of children who meet criteria for ODD in
addition to subclinical levels of mood symptoms (Greene et al., 2004). This
approach has recently been applied in inpatient settings, with the use of
collaborative problem-solving approaches on the part of direct care staff
being associated with reductions in the use of seclusion and restraint for
the youth in the facilities (Greene, Ablon, & Martin, 2006). The existence
of a program such as this and the evidence supporting it underscore a
need to tailor interventions geared toward conduct problems or conduct
problemlike symptoms as closely as possible to the presumed etiology of
those problems.


Common Elements
The development of individual-based treatments (i.e., those that
involve direct work with the child or adolescent) for conduct disorders
speaks to the role of the youth’s individual tendencies in the develop-
ment and maintenance of many problem behaviors. In addition to various
familial risk factors for conduct problems, youth with such problems may
also have poor interpersonal skills as well as cognitive distortions or defi-
ciencies (Kazdin, 2003). Many treatment programs geared directly toward
youth with conduct disorders are born out of presumed interpersonal and
intrapersonal etiological factors. For example, the individual’s (perceived)
reinforcement and punishment history for a set of behaviors as well as his
cognitive appraisal of a situation and of the available consequences for a
set of behaviors may serve to shape some conduct problem behaviors such
as aggression.
Thus, individual-based treatments tend to emphasize cognitive and
behavioral strategies to reduce the frequency of problem behaviors and
to improve the youth’s positive coping responses to anger-provoking situ-
ations. The programs may be geared toward increasing cognitive activity
(i.e., impulse control) or altering maladaptive cognitive strategies (i.e., hos-
tile attributional biases) that may contribute to conduct problem, includ-
ing aggressive, behaviors (see Crick & Dodge, 1996; Lochman & Wells,
1996) These programs also typically include social skills training given the
social skills deficits that are often part of the clinical picture for children
with conduct problems (Kazdin, 2003) as well as social problem-solving
skills so that an individual can employ effective and prosocial behaviors in
difficult peer contexts.

Even authors who have discussed those individual factors recognize

the interaction of individual and environmental factors in explaining a
person’s clinical presentation (Barkley, 1997). The most influential of
these factors are most likely to be related to parent–child interactions and
parenting practices. Therefore, it is usual practice to include a parent or
family component with any child/adolescent individual treatment for con-
duct disorders. There exists a strong empirical basis for combining par-
ent and youth treatment components when developmentally and clinically
appropriate, as the combination of these components often outperforms
either component alone in the reduction of conduct problems (e.g., Kaz-
din, 2003; Webster-Stratton & Hammond, 1997). Benefits have also been
demonstrated for embedding individual-based treatments within univer-
sal prevention programs (e.g., teacher in-service; general parent meetings)
compared to individual-based programs without universal prevention
components (Lochman & Wells, 2002).
As noted above, parenting programs that have a group design could be
considered more cost effective than interventions administered to individ-
ual parents or sets of parents. However, some significant practical prob-
lems have been noted with group therapy with individual youth or with
parents. Those barriers include differential acquisition and understand-
ing of new skills across group members, differential practice of skills out-
side sessions, and inconsistent attention at settings (Kazdin, 2003). The
individual-based programs discussed differ in terms of their initial format
being group or individual; however, the key elements of these programs
and the rationale behind the skills thought to reduce conduct problem
behavior are very likely amenable to presentation in either format.

Examples of Empirically Supported Treatments

The Coping Power Program (Lochman & Wells, 1996) has an extensive
child component, although a formal parent component designed similarly
to those reviewed above is also part of the program. This program has
demonstrated positive outcomes particularly in terms of child aggression
and substance use (see Lochman, Barry, & Pardini, 2003). In short, the
individual-based program in Coping Power is an intervention that focuses
on anger management and social problem-solving skills and is conducted
in groups of late elementary school- to middle school-aged children identi-
fied at-risk based on teacher ratings of aggression. The program has both
cognitive and behavioral components, the latter exemplified by the reward
system that is based on the child’s weekly progress on targeted behavioral
goals. The emphasis on coping skills and social problem-solving skills and
the techniques for developing those skills (e.g., positive self-statements)
exemplifies the cognitive aspect of the program.
The program includes an initial psychoeducational component cen-
tered on identifying physiological cues to anger, differing levels of anger
and other emotions, and relaxation skills. The role of cognitions in facili-
tating or impeding effective anger coping is also introduced, and the pro-
gram proceeds with a substantial cognitive focus. Social problem-solving

skills are then introduced to emphasize the accurate identification of prob-

lems, considering all possible courses of action, and then consideration
of the positive and negative consequences of each behavioral choice. This
problem-solving model is repeated throughout the remainder of the ses-
sions. The program also has a significant modeling component whereby
not only do the individuals in the group learn coping skills from others
as well as model them in the group, but they also create a video illustrat-
ing the coping skills developed in the program as a sort of public service
The final six to ten sessions focus on applying problem-solving skills
geared toward particular peer contexts, reviewing the progress of each
group member, and planning for the generalization of these skills to indi-
viduals’ various contexts. The group format allows for role-playing activities
that involve identifying problematic social cognitions (e.g., hostile attribu-
tional biases) and that allow practice of effective social problem-solving
skills (e.g., resistance to peer pressure; see Lochman & Wells, 1996).
A similar program to the Coping Power Program is an anger control
training program entitled the Chill Out Program (Feindler & Guttman,
1994) which has enjoyed considerable empirical support. However, this
program has been more specifically geared toward adolescents, whereas
the Coping Power Program is specifically geared toward aiding at-risk
youth in making the transition to middle school. The Chill Out Program
subscribes to the idea that adolescents lose control of their anger due to
deficits in both cognitive and behavioral skills (Feindler, Ecton, Kingsley,
& Dubey, 1986; Feindler, Marriott, & Iwata, 1984), and as such, it seeks
to rectify such deficits by focusing on the underlying cognitions (e.g., hos-
tile attributional bias) involved in the expression of anger and impulsiv-
ity that is typically associated with these cognitive distortions (Feindler
et al., 1986).
The Chill Out Program is designed for use with adolescents aged 13 to
18 who have already demonstrated aggressive behavior in their environ-
ment. It is a highly structured program conducted in a group setting with
typically eight individuals per group. There are ten sessions, each of which
focuses on a specific skills being taught, then modeled, rehearsed through
role-play, and then applied to the natural environment. The skills taught
at the ten sessions are rules and reinforcers, relaxation, self-monitoring,
triggers, refuting aggressive beliefs, assertion techniques, self-instruction
training, problem-solving training, thinking ahead, and program review
(see Feindler & Guttman, 1994).
Feindler and others (Feindler, 1990; Lochman & Lampron, 1988) have
noted that the anger control training may only be useful for a limited
period of time immediately following treatment and not as effective long-
term. In addition, it has been noted that anger control training tends to
be more effective when it is used in conjunction with other behavioral
strategies (e.g., consistent consequences for problem behaviors; Lochman
& Lampron, 1988). Another investigation demonstrated empirical support
for the Chill Out Program has also been indicated on self-report measures,

but reduction in aggression or other conduct problem behaviors has not

been clearly documented through direct behavioral observations. That is,
individuals’ own cognitive processes or self-efficacy may clearly change,
but the generalization to their actual behavior is not clear (Feindler &
Guttman, 1994).
Another individual-based approach with a similar theoretical founda-
tion is Problem-Solving Skills Training (PSST) developed by Alan Kazdin
(see Kazdin, 2003). PSST is a cognitive-behavioral therapy that has empiri-
cally demonstrated effectiveness for the treatment of conduct disorders
and is based on the theory that many youth conduct problems are related
to cognitive distortions (see Kazdin, 2003). The goal for PSST is to change
the ways in which adolescents perceive, code, and experience the world
based on research that has demonstrated that aggressive and antisocial
adolescents tend to make hostile and inaccurate attributions towards
other people’s behavior which creates problems in their social environ-
ments (Crick & Dodge, 1994). PSST is conducted in an individual format
and is targeted at children ages 7 to 13.
The treatment emphasizes teaching children how to cope effectively
in interpersonal situations that are frequently encountered but ones in
which the child experiences difficulty. It is a very structured approach that
teaches children five problem-solving steps to use in their interpersonal
relationships. These steps include identifying and defining the problem,
developing solutions to the problem, evaluating the solutions from the set
of solutions that the child generated, making a decision, and evaluated
the decision (Kazdin, 1996). More specifically, youth are taught to work
through common social problems or upsetting situations that they face in
their own environments, break the situation down into objective identifi-
able elements, and then develop response options that include prosocial
behaviors. The therapist facilitates the development of problem-solving
skills through modeling each set of skills during sessions. Through PSST
the cognitive work moves from being practiced out loud to becoming more
covert and automatic (Kazdin, 2003).
PSST has demonstrated many positive outcomes across multiple
measures and multiple settings up to one year later (Kazdin & Wassell,
2000), with favorable comparisons to a variety of control conditions and
other interventions (Kazdin, 2003). As noted above, PSST has also been
used in combination with parent management training techniques and has
shown to be effective when used in this manner as well (Christophersen
& Mortweet, 2001). It is important to note that PSST has been associated
not only with a decrease in aggression and other symptoms of conduct
disorders, but also with an increase in prosocial behaviors (Kazdin, 2003).
The moderators of treatment outcomes discussed more fully below also
seem to attenuate the outcomes associated with PSST, although the addi-
tion of some attempt to address parental stress has demonstrated benefits
(Kazdin, 2003). Therefore, some of the evidence base points to the need
to intervene simultaneously in different ways with different systems in
order to best target the factors contributing to the maintenance of conduct


Existing treatment approaches for child conduct disorders also include
multifaceted approaches that take either a broad multisystemic approach
(e.g., Henggeler & Lee, 2003) or have multiple related components that
target multiple recipients in multiple settings (e.g., Conduct Problems Pre-
vention Research Group, 1992). These programs have been influential in
how treatments for conduct problems are viewed. Specifically, they have
provided evidence that youth with conduct disorders can be effectively
treated in home-based interventions (e.g., Henggeler, Schoenwald, Bor-
dvin, Rowland, & Cunningham, 1998) and through in-school strategies
(Lochman, Lampron, Gemmer, & Harris, 1987), rather than automatically
equating conduct disorders with a need for treatment in more restrictive
For example, Multisystemic Therapy (MST; Henggeler & Lee, 2003)
has enjoyed considerable empirical support and approaches conduct
problems from a broad perspective, taking into account the influence of
the youth’s various contexts on her behavior problems. MST is particu-
larly oriented toward adolescents and comprises multiple levels of treat-
ment that include the individual, family, school, peers, and neighborhood.
Treatment is actually conducted in each of these contexts as appropriate
and feasible (see below).
The parent component of the Incredible Years Program was described
above, yet this program is an example of one with well-defined child and
teacher components. Therefore, it can function as a multifaceted program
or any combination of the three elements could be used in treatment
depending on the needs of the child and adults in his home or school
contexts. As does the parent component, the child component uses social
learning principles in developing basic coping skills as well as has an
emphasis on helping the youth set appropriate behavioral goals.
According to Webster-Stratton and Reid (2003), this program as a
whole promotes parent–teacher communication and encourages parents
to become involved in monitoring the child’s performance and behavior in
school. The school component is particularly geared toward classroomwide
interventions for the prevention of disruptive behaviors as opposed to tar-
geting one specific child or a small group of children for in-school interven-
tion. Researchers have demonstrated that the addition of parent, teacher,
and/or child components to the treatment package using The Incredible
Years Program enhances outcomes regarding the target child’s conduct
problem symptoms (Webster-Stratton & Reid, 2003).
In most multifaceted programs, parents are still exposed to tradi-
tional parent-training techniques, and although the presumed cause
of the youth’s problems is thought to be reciprocal between the youth
and his or her contexts, the parent may still be seen as the primary
agent of change. Such as discussed below, family-based work within
these models seeks to directly target family communication and con-
flict, and such an emphasis is thought to be associated with decrease

in adolescent problem behaviors such as substance use (Borduin et al.,

1995; Henggeler, Borduin, & Melton, 1991; Schmidt, Liddle, & Dakof,
1996). The degree to which schools and other contexts are formally
involved in treatment varies with the particular treatment approach
that is implemented.

Examples of Empirically Supported Treatments

As mentioned above, MST (Henggeler et al., 1998) is targeted at at-risk
adolescents who have previously engaged in severe misconduct and are at
risk for being removed from their homes. This approach believes the child
cannot be viewed outside the many systems of which they are a part (i.e.,
schools, families, neighborhood, culture, community). It stresses the need
to include all these symptoms in treating the individual child. The primary
goal of this approach is to decrease misconduct and to help the child func-
tion in his environment. It is an intensive program that makes use of many
clinicians and caregivers as well as careful monitoring of those involved
in the treatment of the child. This treatment is unique from others in that
quality assurance checks are embedded in the treatment protocol (see
Henggeler & Lee, 2003).
MST is conceptually based on five key assumptions, namely that
behavior problems are multidetermined, that caregivers are the key to
positive long-term outcomes, that effective treatment must be comprised
of treatment that has strong empirical support, that barriers to service
access and delivery must be addressed in regard to treatment, and that
treatment fidelity is maintained by quality assurance checks. Treatment
is targeted at all environments and systems in which the child is involved,
and as such, this treatment seeks to promote strong cooperation from all
(Henggeler & Lee, 2003). MST includes intervention in the home which
has increased participation and decreased attrition (Henngeler, Pickrel,
Brondino, & Crouch, 1996). There are nine core treatment principles that
guide treatment. These include finding the fit between problems and the
child’s broader system, being positive and strength-focused, increasing
responsibility, present focused/action-oriented and well-defined interven-
tions, fits child’s developmental level, continuous effort, evaluation, and
generalization (see Henggeler & Lee, 2003).
Although each aspect of MST (i.e., therapy, supervision, consultation)
is manualized and fidelity takes on particular importance, the extent to
which various contexts are involved varies by case (Henggeler & Lee, 2003).
However, for MST to progress, family engagement is crucial, and strate-
gies for forming meaningful partnerships among the treatment team and
additional systems are also needed. The treatment team is accountable for
monitoring progress and managing any factors that appear to be imped-
ing progress. Goals for treatment are established and monitored week by
week, with all relevant systems for attaining those goals being engaged in
treatment (Henggeler & Lee, 2003).
MST has been found to decrease criminal behavior, substance abuse,
and internalizing problems (Kazdin & Weisz, 1998; Stanton & Shadish,
1997; Farrington & Welsh, 1999). In a sample of youth presenting in psychiatric

emergencies, MST resulted in a 75% reduction in days hospitalized and a

50% reduction in days that the child spent in an out-of-home placement
(Schoenwald, Henggeler, Brondino, & Rowland, 2000). MST has also led to
improved family relations and parent–child interactions (Brunk, Henggeler,
& Whelan, 1987) as well as improving peer relations (Henggeler, Melton,
& Smith, 1992). Because of the intensive nature of MST, including having
an interventionist available for support at all times, treatment team mem-
bers keep low caseloads, and treatment is limited to three to five months
(Henggeler & Lee, 2003).
The FAST (Families and Schools Together) Track Program (Conduct
Problems Prevention Research Group, 1992) is an example of a program
that involves targeting risk factors for conduct problems such as parenting
practices, academic and social difficulties, and community factors. This
program is geared toward young elementary school-aged children and
includes strategies such as home visits to target parenting practices and
other familial factors relevant to child problem behaviors, social problem-
solving training for children, academic tutoring particularly in reading, and
classroom management strategies for teachers. The FAST Track Program
also includes a traditional parent management program that includes an
emphasis on fostering positive parent–school communications.
This program is designed from the standpoint that early intervention in
multiple domains that influence the child’s social and behavioral develop-
ment is optimal and that fostering consistency and communication across
the contexts will improve the child’s behavioral, social, and academic out-
comes (Conduct Problems Prevention Research Group, 1992). Each of the
components of the FAST Track Program has demonstrated positive short-
term effects; however, the long-term effectiveness, particularly of the pro-
gram as a whole, needs further investigation (Frick, 1998).
Similar to the approach for adolescents developed by Barkley and
colleagues (1999) and described above, a recent investigation by Hogue,
Dauber, Samuolis, and Liddle (2006) found that a family-based intervention
that included work with both parents and adolescents simultaneously (i.e.,
Multidimensional Family Therapy; Liddle, 2002) demonstrated positive out-
comes on adolescent substance use. It should be noted, however, that the
adolescent-focused strategies within this intervention (e.g., drug refusal
skills, anger management, impulse control) seemed to be particularly use-
ful in reducing family conflict and increasing family cohesion (Hogue et al.,
2006). Multidimensional Family Therapy (MDFT) has also demonstrated
usefulness for more varied adolescent behavior problems (e.g., Dennis
et al., 2004; Liddle, Rowe, Dakof, Ungaro, & Henderson, 2004). Therefore,
for adolescents with externalizing problems, it may be that approaches
which incorporate both individual and family-based work, rather than an
exclusive focus on either will be most likely to yield positive results. MDFT
fits that bill insofar as it includes individual, parent, and family interac-
tional domains (Liddle, Rodriguez, Dakof, Kanzki, & Marvel, 2005).
However, MDFT is truly multifaceted in that an extrafamilial domain
is included whereby direct attempts are made to address school fail-
ure and lack of positive community connections as risk factors for a
teen’s conduct problems. More specifically, MDFT interventionists

work directly with school officials regarding academic planning for the
adolescent and work with the family on ways to engage the adolescent
in positive extracurricular activities. The influence of peer affiliations
is also addressed in this intervention through discussions of friendship
choice and the influence of decisions in that domain on the youth’s
outcomes (see Hogue et al., 2006). A formal focus on community-based
factors is unique, even though tight control over how such extramilial
factors are implemented and the behavioral contingencies in place in
such contexts cannot be fully addressed. MDFT also seeks to address
parental risk factors for youth problems both within the intervention
(e.g., parenting skills; family communication) but also through addi-
tional resources (e.g., parental drug treatment; increasing social sup-
port; Hogue et al., 2006). An initial clinical trial of MDFT found it to be
as effective as a traditional cognitive-behavioral intervention but more
effective for the long-term maintenance of positive outcomes in the form
of reduced substance use (Liddle, 2002).


The term “residential treatment” has been used to describe a number
of varied approaches to intervention beyond outpatient care. We have thus
far focused our discussion on treatments that are applied in outpatient
settings, although elements of these treatments (e.g., Coping Power) could
be applied within a residential setting. Although obviously less intensive in
surroundings, outpatient treatments are not necessarily shorter in dura-
tion than residential treatments, particularly inpatient hospitalizations
(see Lyman & Barry, 2006). More restrictive than most outpatient treat-
ment models are day treatment models—also referred to as partial hos-
pitalization programs—which provide a therapeutic environment during
the day including academic instruction such that the child is not removed
from the home environment. The range of services available in these set-
tings are broader than those often employed in outpatient settings and
include individual therapy, group therapy, psychopharmacological inter-
ventions, and classroom accommodations.
Several additional treatment models involve removal of the youth
from the home environment at least for some period of time and in that
sense, are considered residential. These placements include short term
respite care, group-home care, residential treatment centers, inpatient
hospitalization, and institutionalization (Lyman & Barry, 2006). The
specific treatment strategies within each of these models are diverse
ranging from virtually nonexistent in some respite care or group-home
settings to quite intensive in any of these settings. For instance, and
depending often on local resources, group-home care may or may not
include a formal treatment regimen conducted by trained professional.
Each of these treatment models also varies in size and scope. It should
also be kept in mind that children may be placed in residential settings

primarily because of significant problems and/or safety concerns in

their home environments and not necessarily because they themselves
are exhibiting significant emotional or behavioral problems. Although
theoretically the more similar the residential treatment setting is to the
youth’s home setting (i.e., the more the setting mimics a home), the
more generalization of behavioral gains from the treatment setting to
the home environment. However, there are no data to indicate whether
this is the case.
Perhaps because of the numerous forms of residential or inpatient
treatments that are typically geared toward youth with the most severe,
persistent, or complex conduct problems, the research literature on these
programs is relatively limited. The large number of treatment models that
vary in structure, clientele, length, restrictiveness, and scope make well-
designed controlled studies very difficult to conduct (see Lyman & Barry,
2006). The limited evidence in support of these interventions may be a
consequence of the lack of close empirical examination. However, it has
also been argued that residential treatments are less likely than commu-
nity-based interventions to reduce child conduct problems because the
treatment focuses largely on the child and occurs in a separate context
than the one in which the problems developed (Hart et al., 2006). That
is, in light of the evidence supporting parent-based treatments for child
conduct problems, it would make sense to provide such interventions
first before resorting to a more restrictive placement for the child. Indeed,
although residential treatments offer immediate respite for both the child
and caretakers, the benefits may very well not be sustained both within
the program and upon discharge.
An argument can be made, on the other hand, that removal of the
child from a problematic environment can be beneficial, even necessary,
for the treatment of conduct disorders. Residential interventions provide
a controlled environment often with expansive behavioral contingencies,
as well as the opportunity for the youth to receive individual, group, and
pharmacological interventions. However, research does not support sig-
nificant improvements in symptoms for many youth, particularly if they
return to their previous environment (Hart et al., 2006; Lyman & Barry,
2006). The adjustment for both the child and family after residential care
has ended can be quite difficult, although the availability of wraparound
services that include the parents as part of the services provided by the
residential facility, particularly at the end of services, can aid in this tran-
sition (Lyman & Barry, 2006).
In addition, because of the external controls on the youth’s behavior
inherent in such settings, it is not clear to what extent the youth devel-
ops effective self-control or coping skills that she will then be able to uti-
lize once out of the residential setting (Barker, 1993). Similarly, although
residential treatments often demonstrate a decrease in conduct problems
within the milieu, it is unclear if such gains are above and beyond what
the youth would achieve through intensive behavioral interventions out-
side of the residential setting (Lyman & Barry, 2006). Still, some children’s
behavior problems can be so severe or have cause for safety concerns that
residential treatment may be viewed as a suitable short-term option.

Children served by the various residential treatment models present

with issues such as severe impulsivity, erratic or disorganized behavior,
severe internalizing problems, and/or threats to harm themselves or oth-
ers (Lyman & Barry, 2006). The available information on youth who attend
residential treatment facilities suggests that they often do not live with
both biological parents which includes coming from foster care or other
similar placements, have parents with a history of psychopathology and/
or substance abuse problems, have experienced and/or witnessed abuse
or violence, have families with little social support or cohesion, and have
a history of being involved in or around criminal activity (Lyman & Barry,
2006). Assuming that family instability is the root cause of the youth’s
conduct problems, it has been argued that alternative home placements—
particularly given the relatively low cost of such solutions—may make the
most sense (Hussey & Guo, 2002).
Given the concerns regarding the effectiveness, cost, and restrictive-
ness of residential treatment on the one hand, and the need for intensive
interventions in some instances on the other, Lyman and Barry (2006)
discuss four considerations based on those initially proposed by Wilson
and Lyman (1982). First, youth should be treated in the least restrictive
setting possible in light of the youth’s diagnosis, severity of conduct prob-
lems, and level of behavioral and emotional stability. Therefore, in some
instances (e.g., threat to harm self or others) intensive placements—even
if short term—are warranted. Second, the treatment components should
be related to the antecedents of the child’s problems, such that if coer-
cive parent–child interactions appear to be a main factor in the child’s
behavior problems, then home- or parent-based treatments are indicated.
Third, the treatment should be cost-effective based on considering the
effectiveness of the selected intervention, the monetary cost, the expected
duration, and the social cost of treatment failure. Finally, the treatment
structure, focus, and resources should match the youth’s problems and
developmental level.
In short, although some residential programs may be quite benefi-
cial for some children, particularly those with particularly severe conduct
problems and/or severely adverse environmental conditions, there is lim-
ited evidence supporting their long-term effectiveness. Moreover, in light
of the monetary expense involved with such interventions, their cost-
effectiveness relative to other community-based interventions is not favo-
rable. A general overview of residential treatment centers and inpatient
hospitalization is given below. In the past 15 to 20 years, a number of
more specified residential models have been developed (e.g., wilderness
therapy, boot camps). See Lyman and Barry (2006) for a more complete
discussion of these and other residential models, including their potential
benefits and drawbacks.

Examples of Residential Treatments

Again, because of the myriad philosophies, structures, and models
of residential treatments, it is not possible to discuss in detail a particu-
lar, easily replicated program. Nevertheless, because of the use of such

programs in the treatment of youth conduct disorders, it makes sense to

discuss some features of such programs and how they target behavioral
problems. As the term implies, residential treatment centers are typically
located in facilities that do not mimic a typical single-family home setting.
However, many models include locating client living quarters and activity
areas in smaller units consisting of approximately 15 to 20 youth (Lyman &
Barry, 2006). Peers also take on importance in residential centers through
their involvement in group therapy, the need for youth to practice appro-
priate self-control and coping strategies with others who may engage in
behaviors that are upsetting to the youth, and the ability of peers to model
and reinforce adaptive behaviors. Residential programs typically provide
an academic component, and formal therapeutic services administered by
trained staff (e.g., psychologists, psychiatrists, social workers) are also a
core component of these interventions.
Residential treatment centers also often incorporate contingency
management systems such that, for example, youth are provided different
levels of privileges for meeting certain behavioral goals. Therefore, direct
care staff training in residential programs is of utmost importance, as
staff members are called upon to administer both positive and negative
consequences for behaviors throughout the day and throughout activi-
ties. Furthermore, low resident-to-staff ratio appears to be important in
therapeutic effectiveness including settings in which the youth’s present-
ing problems are rather severe (Friman, Toner, Soper, Sinclair, & Shana-
han, 1996). Close contact between staff and residents likely serves both
therapeutic and safety functions. Because of the relative severity of youth
served in such centers and their close proximity to each other and to staff,
behavioral disruptions can occur often. However, residential treatment
centers typically have clear staff procedures for dealing with such inci-
dents to prevent them from escalating. These procedures include time-out,
restraint, and seclusion with the least restrictive strategy that will still
maintain safety being implemented first (Lyman & Barry, 2006).
Many programs also incorporate a psychoeducational model such
as originated by Hobbs (1966) wherein youth learn and practice cop-
ing skills as well as more prosocial behavioral choices rather than an
exclusive focus on managing behaviors as they occur in the milieu. In
such a model, the child still has contact with his family, and the family
is informed of treatment plans throughout the residential stay with the
hopes of treatment gains being more readily generalized to the home
setting after discharge.
Much less similar to a youth’s home environment is an inpatient
hospital setting. Daily activities in these settings tend to be much more
structured and monitored, with limited opportunity for recreational
activities or time outside the unit. Medical professionals necessarily
staff these settings, whereas psychologists, social workers, and teachers
may also be involved in service provision in inpatient settings. Inpatient
placements have moved more toward an emphasis on psychopharma-
cological than psychological treatments (see Lyman & Barry, 2006),
perhaps as a function of the emergent cases served and managed care
necessitating shorter-term stays in inpatient units. Therefore, they

are often effective and necessary for youth whose emotional and/or
behavioral state is dangerous to themselves or others and whose psy-
chological difficulties seem to have some organic component. Inpatient
hospitalization is primarily focused on crisis stabilization as opposed
to long-term treatment. The usefulness and cost-effectiveness of hos-
pitalization for conduct disorders is quite limited, although such an
approach may be warranted and effective for substance abuse problems
in particular (see Lyman & Barry, 2006).


The interventions discussed above, particularly the outpatient inter-

ventions with parent, child, and/or teacher components have enjoyed a
great deal of empirical support. The APA Task Force for identifying empiri-
cally supported treatments presents summaries of the treatments that
have met the criteria to be considered well established and those meet-
ing the criteria of being probably efficacious. These empirically supported
treatments, some of which are summarized above, are discussed on the
website: www.effectivechildtherapy.com. It is expected that the attention
to, and debate concerning, evidence-based practice will only further the
efforts of professionals and the public at large to consider what works in
designing, seeking, or implementing the treatments most likely to amel-
iorate child conduct problem symptoms. This evidence base also serves
as the foundation for further research and innovation in the design of
interventions that might demonstrate even more effectiveness, for longer
periods of time, and/or for a broader range of youth.
With well-developed supported interventions in existence, it becomes
the charge of practitioners and training programs to make evidence-
based practice the centerpiece of their work and training of treatments
for conduct disorders. For example, as noted above, empirically supported
parenting interventions generally include an emphasis on positive rein-
forcement and increasing positive behaviors first before an emphasis on
strategies to punish noncompliance. In part, the theoretical rationale for
such a strategy is to provide guidance to children on “what to do” instead
of only what behaviors not to engage in, as well as to improve the quality
of parent–child interactions (e.g., Barkley, 1997). Therefore, to emphasize
punitive strategies in parent training first would be doing so against the
preponderance of empirical evidence.
In addition to the mediating effects of positive parenting practices
resulting from parenting programs, these approaches to intervention are
also thought to be most effective through the reduction of coercive par-
ent–child interactions and when management strategies are more clearly
and consistently associated with the child’s behavior (Reyno & McGrath,
2006). Furthermore, parenting programs can be effective in not only reduc-
ing the target child’s conduct problem symptoms, but also in improving
parent–child interactions, parental consistency, and even sibling behavior
(see Gardner et al., 2006). More important, it appears that the effects of
evidence-based treatments for conduct problems maintain some level of

positive outcomes over time (Gardner et al., 2006). The length of treat-
ment varies with the approach and severity of the child’s problems, but for
parenting interventions in particular, having a greater number of sessions
is associated with poorer outcomes, often because of poor parental adher-
ence or performance while moving through the sequence of parent training
steps implemented in most programs (see Hogue et al., 2006).
Although fairly well-developed theoretical rationales exist for the treat-
ment of conduct disorders through psychoanalytical perspectives (e.g.,
self-psychology; see Liberman, 2006), the evidence supporting these inter-
ventions is lacking. Unlike the approaches outlined in this chapter, self-
psychology takes a nondirective approach whereby the therapist seeks to
understand the youth’s subjective world view. Such an approach is likely
quite limited for young children and/or youth who have difficulty with
verbal expression. It should also be noted that verbal reasoning deficits
are often associated with child conduct disorders (Lynam & Henry, 2001;
Speltz, DeKlyen, Calderon, Greenberg, & Fisher, 1999), further calling into
question the utility of this treatment for a sizable segment of the popula-
tion who exhibit conduct problems.
The presumed cause of child conduct problems from this perspective is
that of unrealistic, or immature, narcissism that develops—at least in part—
from inappropriate or absent parental response to child distress (Liberman,
2006). Although narcissism has been found to be related to child and ado-
lescent problem behaviors (Barry, Frick, & Killian, 2003; Barry, Grafeman,
Adler, & Pickard, in press), it is unclear how the self-psychology approach
to assessing child narcissism would fit with current approaches to common
approaches for assessing the construct in youth and adults. The intervention
itself seeks to alter the youth’s unrealistic self-perceptions and to foster resil-
ience in the face of adversity. Such goals could certainly reduce the likelihood
of acting-out behaviors, but the evidence of the presumed causal model and
the intervention itself are quite limited.
More recent efforts have sought to understand the intervening vari-
ables that indicate for whom and under what circumstances treatments
for conduct disorders are most effective. For example, Beauchaine and col-
leagues (2005) examined the short-term treatment outcomes for children
with an early onset of conduct problems. They found that parental risk fac-
tors (i.e., drug abuse, marital discord, maternal depression) and child risk
factors (e.g., comorbid internalizing problems) influenced treatment out-
comes. For example, although children with comorbid internalizing prob-
lems presented with higher externalizing problems than children without
internalizing problems, the rate of improvement of the former group was
greater. That is, children and families who present with multiple risk fac-
tors—thus complicating the clinical picture—can still, and often do, ben-
efit greatly from intervention targeting parenting skills and child conduct
problems. Kazdin and Whitley (2006) similarly demonstrated that children
with comorbid presentations exhibited the most change in response to
intervention and outcome symptom levels equivalent to children with a
single primary clinical problem.
Of course, clients presenting for treatment of child conduct disorders—or
any other clinical issue for that matter—vary in the degree to which they

present with other factors that might complicate treatment planning and
call into question the applicability of evidence-based treatments. With the
influence of such risk factors (e.g., comorbidity) on the severity of the child’s
presentation and response to intervention having been demonstrated (see
Beauchaine, Gartner, & Hagen, 2000; Kazdin & Whitley, 2006), it is clearly
indicated that interventions are not one-size-fits-all. Recent efforts to address
issues surrounding the influences of comorbidity and other indices of case
complexity (e.g., low SES) only serve to inform practitioners of the potential
benefits of many evidence-based interventions as well as instances in which
further examination and innovation are needed.
The design of interventions in terms of their target recipients and set-
tings does seem to influence the specific conduct problem behaviors that
are affected. In particular, for families of children with conduct problems,
a parent-based component is essential for reducing the child’s symptoms,
whereas teacher-based interventions appear to be particularly useful for
reducing disruptive classroom behaviors (see Beauchaine et al., 2005).
Based on the performance of standalone in relation to combined interven-
tions, it has been argued that for young children in particular, parenting
interventions should be the front-line intervention for younger children
with supplemental teacher- or child-based interventions as indicated
(Beauchaine et al., 2005).
However, research cited above has demonstrated the benefits of add-
ing components of treatment compared to a single intervention approach.
In addition, for older children and adolescents, it may be necessary to
include a direct intervention with the young person, considering parent
and teacher interventions as supplemental. Even with the most compre-
hensive approach to intervention involving all important systems or con-
texts, conduct problems remain difficult to treat. As noted by Beauchaine
and colleagues (2005), treatment nonresponders are of concern for prac-
titioners and researchers, but they also are the basis of all advancements
in treatment design. That is, moderators of treatment outcome for youth
with conduct disorders are variables that are present at the outset of treat-
ment. Therefore, awareness of the variables that appear to predict treat-
ment response allows for the selection of the most appropriate treatment
for the presenting child.
The age of the child is one such variable in regard to treatment for
conduct problems, not only in terms of with whom treatment is per-
formed but also with the general expectation that earlier intervention
increases the likelihood of meaningful reduction in conduct problems
(see Webster-Stratton & Reid, 2003). The youth’s developmental level
and developmental trajectory of problem behaviors is a similarly impor-
tant consideration. For example, a preschool- or early school-aged child
would likely not comprehend the cognitive coping strategies that are
the bedrock of treatment approaches such as Coping Power or PSST.
Likewise, older but developmentally delayed youth would likely ben-
efit less from such cognitive strategies than those that emphasize clear
behavior-consequence contingencies. Another such variable may be the
level of perceived social support experienced by families going through
treatment (Dadds & McHugh, 1992).

Similarly, family isolation, single parent status, and social disadvantage

have been found to interfere with progress in family therapy approaches
for treating child conduct problems (e.g., Brestan & Eyberg, 1998; Dumas,
1986; Miller & Prinz, 1990; Webster-Stratton, 1985). Conversely, parents
have reported qualitatively that increasing social support and being able to
discuss problems with other parents can be effective in enhancing parent-
ing skills and ameliorating child behavior problems (Stewart-Brown et al.,
2004). However, Dadds and McHugh (1992) have noted how difficult it is to
make meaningful changes in a family’s social support system or resources
within typical treatment approaches. The wider examination and dissemi-
nation of treatment approaches such as MST may help advance the field in
this direction from its focus on capitalizing on the strengths in each of the
child’s contexts and engaging more of those contexts to allow treatment to
most effectively work through systemic barriers to the improvement of the
youth’s behavior.
Because many of the empirically supported treatments for conduct
disorders appear to be most effective the earlier they are initiated, and
because researchers suggest that an early onset of conduct problems is a
predictor of persistence of such problems (e.g., Moffitt, 2006), comprehen-
sive evidence-based assessment of conduct problems becomes essential
(see McMahon & Frick, 2005 for a review). A lack of appropriate assess-
ment and intervention may result in problematic behavioral patterns
becoming less malleable and in the emergence of additional risk factors
(e.g., delinquent peer affiliations) that would make treatment more com-
plex (Beauchaine et al., 2005).
Not surprisingly given the vital role of parents in the treatment of con-
duct disorders, parental psychopathology has been shown to be not only
a risk factor for the development and maintenance of conduct problems,
but also a factor in treatment response (see Chronis et al., 2004; Reyno
& McGrath, 2006). Kazdin and Whitley (2006) found that greater familial
barriers to treatment participation were associated with worse outcomes
in a study of parent management training and problem-solving skills
training for children with ODD or CD. A recent study also demonstrated
that assessment of specific aspects of parental functioning better informed
intervention and improved outcomes for families receiving an empirically
supported treatment for conduct problems than did more global assess-
ments of family needs (Bierman, Nix, Maples, & Murphy, 2006).
It is not uncommon for parents to simultaneously seek parenting
interventions while also seeking individual treatment for their own dif-
ficulties. As described above, many parenting interventions have included
components that focus on parental stress and strategies to manage that
stress apart from an exclusive focus on the child’s behavior problems in
an attempt to target some of the parental/familial factors that might nega-
tively influence treatment response. Moreover, direct efforts at addressing
some of these factors (e.g., poor father involvement in treatment, the inter-
vening role of parental psychopathology) have been described (Chronis
et al., 2004), contributing further to the evidence base.
Additional research brings to light the need for comprehensive assess-
ment of the child, parent(s), and contexts so that optimal treatment plans

are implemented. A child factor that has been associated with poorer treat-
ment outcomes is the presence of psychopathy-linked characteristics, or
callous-unemotional (CU) traits (Hawes & Dadds, 2005). More specifically,
Hawes and Dadds (2005) found that CU traits were associated with poorer
outcomes among children with ODD following parent training, even when
controlling for parental education, child age, and parental adherence to
treatment. CU traits include a relative lack of empathy and guilt as well as
flat affect (see Frick, Bodin, & Barry, 2000).
Researchers have found that CU traits moderate the relation between
parenting practices and conduct problems (Wootton, Frick, Shelton, & Sil-
verthorn, 1997; Oxford, Cavell, & Hughes, 2003), thus perhaps predicting
the attenuated effects of parenting interventions for the conduct prob-
lems of children with these traits. CU traits are particularly important to
understand in light of intervention planning and design given the associa-
tion of these features with particularly severe, varied, and persistent child
conduct problems (Barry et al., 2000; Christian et al., 1997). Research-
ers in this area suggest that children with this interpersonal style tend
to be insensitive to punishment cues in laboratory situations (O’Brien &
Frick, 1996) and to respond more to rewards than to punishments such as
time-out (Hawes & Dadds, 2005). Thus, it is imperative that pretreatment
assessments consider the presence of CU traits and that interventions
be developed that effectively address the unique presentation of conduct
problem symptoms for this subset of youth.


Limited, although emerging, research has examined the effectiveness

of adaptations of existing interventions for conduct problems. Bierman
and colleagues (2006) have noted that individualized interventions are
quite appealing but that the evidence regarding these adaptations is lim-
ited. Greene and colleagues (2004) have referred to such adaptations as
“indispensable” (p. 1163), and some treatment approaches (e.g., collabora-
tive problem-solving) do not prescribe a particular topic or coverage of a
specific skill to a particular sequence of sessions.
Given the advocacy of evidence-based practice in psychology, not just
for treating child conduct disorders, and the evidence in support of these
interventions relative to usual clinical practice (Weisz, Jensen-Doss, &
Hawley, 2006), understanding if and how adapted treatment plans may be
useful is an essential question. A primary question in this regard is that of
therapist fidelity to a treatment program or protocol. The degree to which
therapists adhered to the guidelines of a particular program is unclear in
much of the research showing positive effects of treatment for conduct
disorders. On the other hand, it is unclear to what extent therapist fidelity
is necessary to achieve positive behavioral outcomes.
To further advance the knowledge, use, and effectiveness of evidence-
based interventions, successful adaptations must be disseminated, and
judgments regarding the need for making adaptations must follow guide-
lines that can be easily documented and followed by other professionals.

It has been shown that the more specific the areas of functioning on which
such judgments are based, the greater likelihood of positive outcomes for
adapted interventions (Bierman et al., 2006). Therefore, a call for evi-
dence-based practice is not to limit the flexibility of clinicians or the appli-
cability of interventions to specific clients with conduct problems, but to
ultimately allow our field to widen the evidence base and to enhance the
services provided to the youth and families who we serve.
A similar area of inquiry is the degree to which efficacious treatments
show effectiveness for a broader range of settings, trained professionals,
and clients. The generalizability of evidence-based treatments has been
called into question based largely on the relative homogeneity of clients
participating in clinical trials and heterogeneity of clients presenting in
clinical practice settings (Dulcan, 2005; Westen, Novotny, & Thomp-
son-Brenner, 2004). Chorpita (2003) has clearly described a number of
important practice considerations (e.g., supervision, addressing attrition,
demographics, payment options, client’s prior experience with treatment,
etc.) that must be made for efficacious treatments to most readily demon-
strate effectiveness.
Furthermore, an expanding body of literature has examined the
adaptability of existing interventions to clients from diverse backgrounds
(e.g., Forehand & Kotchick, 1996; Santisteban et al., 2003) or the effec-
tiveness of interventions developed for clients from nondominant cultures
(e.g., Non-English-speaking background; Sonderegger & Barrett, 2004).
Of course, direct investigations of the outcomes for interventions with
diverse clientele are preferable to assumptions that existing treatments
for conduct problems will translate directly to diverse clientele. A complete
consideration of the strides made in these areas as well as the numer-
ous unanswered questions for treatment and treatment outcome research
would be too extensive for the present discussion.
Because of the level of similarity among empirically supported treat-
ments for child conduct problems, it remains unclear as to which elements
of these interventions are more or less dispensable. To address this question,
dismantling studies that incorporate multiple intervention conditions and
that include frequent assessment of processes and outcomes are necessary
(Kazdin & Nock, 2003). Such an undertaking would be daunting but could
be useful in further streamlining interventions and informing practition-
ers as to the key aspects of treatment on which to focus. Without extensive
research on this issue, we still remain optimistic about the current state of
treatment for youth conduct problems in that the treatment packages that
exist—if imparted to the practicing public—have demonstrated that they
can improve the functioning and lives of youth and their families.
Perhaps the clearest conclusion from the literature on developmental
trajectories of children with conduct disorders and the treatment of these
problems is the need for early prevention/intervention. Webster -
Stratton and Reid (2003) noted that “the primary developmental pathway
for serious conduct problems in adolescence and adulthood appears to be
established during the preschool period” (p. 224). It is has been concluded
that such efforts—particularly for the youngest children—should include
a parent-based or family-based perspective with attention devoted to ways

in which services can be most accessible to families (Centers for Disease

Control, 2004). In light of the existing evidence-based interventions, sound
efforts in this regard can reduce the likelihood of the poor outcomes for
which children with an early onset of conduct problems are at risk. Early
treatment also has broader societal implications given the cost of juvenile
delinquency and adult antisocial behavior in the form of intensive residen-
tial treatments, incarceration, and the impact on victims.


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Treatment of
Hyperactivity Disorder

Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common

neurobehavioral disorder affecting school-age children. Studies suggest
that approximately 8–12% of children (9.2 in males and 3.0 in girls)
meet diagnostic criteria for the clinical disorder of ADHD (Faraone,
Sergeant, Gillberg, & Biederman, 2003). Approximately 40–70% of those
diagnosed with ADHD will have persistent symptoms into adolescence
and adulthood with substantial risk of job instability, mood and anxiety
disorder, motor vehicle accidents and substance abuse. ADHD is
characterized by various symptoms of inattention, and/or impulsivity
and is conceptualized as a spectrum, with a range of severity from mild
variation of normal behavior to a chronic and severe condition. ADHD
affects the individual, the family, and society and can have negative
impact on multiple areas of functioning (Wolraich, Hannah, Baumgaertel
& Feurer, 1998, American Academy of Pediatrics, 2000). Children with
the disorder often suffer from impaired interpersonal relationships with
family and peers, academic underachievement and poor self-esteem
(Goldman, Genel, & Bezman, & Slanetz, 1998). In addition, children with
ADHD commonly exhibit other comorbid developmental and psychiatric
disorders that may complicate the intervention plan (Table 6.1; Pliszka,
1998; Spencer, Biederman & Wilens, 1999).

DITZA ZACHOR • Tel Aviv University, Tel Aviv, Israel.

BART HODGENS • Civitan International Research Center, University of Alabama at Birmingham.
CRYSHELLE PATTERSON • Sparks Clinics, University of Alabama at Birmingham.

J.L. Matson et al. (eds.), Treating Childhood Psychopathology 139

and Developmental Disabilities, DOI: 10.1007/978-0-387-09530-1,
© Springer Science + Business Media, LLC 2009
140 DITZA ZACHOR et al.

Table 6.1. ADHD Comorbid Disorders

ADHD: Common Comorbid Disorders
Developmental Dimension
Poor academic performance
Learning Disability
Mental Retardation
Autism Spectrum Disorders
Tic Disorders (e.g., Tourette Syndrome)
Behavioral Disorders
Oppositional Defiant Disorder
Conduct disorder
Depression / Dysthymia
Obsessive Compulsive Disorder

Clinicians who diagnose and treat children with ADHD should develop
a comprehensive treatment plan that recognizes the complexity and
chronic nature of the disorder. First, a diagnosis of ADHD requires that
the child meet criteria from the Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition (DSM–IV) in terms of core symptoms, onset, duration,
and functional impairment in more than one setting (American Academy
of Pediatrics, 2001). During the initial assessment, clinicians should first
obtain information regarding the nature of the child’s symptoms (mostly
inattention, behavioral difficulties, etc.) and then determine the severity
of the core ADHD symptoms, existence of comorbidities, and the extent of
the impairment seen across the different environments.
Because the diagnosis of ADHD and the possible need for chronic
medical treatment may cause concerns and even anxiety for the family
and the child, it is important to provide counseling prior to initiation of
therapy. In addition, clinicians should be aware of the family expectations
from the treatment and their treatment preferences, thereby optimizing
compliance and clinical outcome.
Next, it is important to set individualized treatment goals. The American
Academy of Pediatrics (AAP) guidelines suggest several outcome measures
based on the most disabling core ADHD symptoms (e.g., decrease disruptive
behaviors, improve academic performance, improve relationship with family,
teachers, and peers and improve self-esteem). It is advisable to choose
measurable goals that can assess progress from a baseline state (American
Academy of Pediatrics, 2001).
Treatment of ADHD consists of two general categories, medication
management and behavioral treatment strategies. The following sections
describe these treatment strategies in detail, as well as the benefits of
a multimodal strategy. The multimodal approach combines the careful
medication management of ADHD with proven psychosocial interventions
such as parent education, educational intervention, and behavioral therapy
in a comprehensive approach. Throughout this chapter, frequent reference
is made to the Multimodal Treatment Study of children with ADHD (MTA),
the largest randomized clinical trial for the treatment of ADHD ever
conducted (MTA Cooperative Group, 1999a). Therefore, it merits particular
attention before discussing treatment approaches in detail.


In 1992, the National Institute of Mental Health (NIMH) and six

teams of investigators began a multisite clinical trial to systematically
investigate the effectiveness of medication and behavioral treatments for
ADHD. The MTA remains the largest ADHD clinical trial to date and its
findings continue to be reported and debated (e.g., Arnold, et al., 2004).
The design of the treatment protocols, study methodology, and research
design were all carefully considered by a steering committee composed
of representatives from the six clinical sites and reflected state-of-the-art
procedures at the time (Arnold, Abikoff, & Cantwell, 1997). Utilizing a
parallel group design, 576 children (96 from each site) ages 7–9 years were
randomly assigned to one of four treatment conditions: (1) a medication
management-only strategy, (2) a behavioral treatment-only strategy,
(3) a combination strategy, and (4) a community-care comparison group.
This large sample size nearly doubled the total number of children with
ADHD that had ever participated in a rigorously controlled clinical trial for
treatment of ADHD prior to that time (Jensen, Hinshaw, Swanson, et al.,
2001). The participating children were selected to reflect a broad range of
comorbid conditions (e.g., ODD, anxiety), a diversity of referral settings
(e.g., school, mental health clinic), and a range of socioeconomic levels.
The treatment period was 14 months. The MTA Medication strategy
involved an initial titration period, testing placebo versus three different
doses of methylphenidate (5 mg, 10 mg, and 15/20 mg, depending on child’s
weight). Other medications could be introduced after the first month if a
desirable response wasn’t achieved. Ongoing treatment involved monthly
meetings with the family and monthly contact with the child’s teacher.
The medication treatment was maintained throughout the 14-month
period. The MTA Behavioral treatment strategy was initially intense and
then faded to monthly meetings over the last 4–6 months of the treatment
period. Parents received behavioral parent training over 35 sessions (8
individual, 27 group sessions) to teach them behavior management tech-
niques and coordinating the child’s care in school.
Children also participated in an 8-week summer treatment program, an
intensive manualized program that is discussed in detail in another section
of this chapter. During the first 12 weeks of the school year, each child was
assigned a behavior aide who was directly supervised by the same therapist
who was responsible for the behavioral parent training and supervised the
counselors in the summer treatment program. This same therapist met with
each child’s teacher in the fall and spring on a consultative basis. An effort
was made to teach parents and teachers to “carry on” as the behavioral
treatment components were faded except for monthly follow-up visits.
The MTA Combined treatment strategy was a combination of these
two strategies with an emphasis on making their implementation as effi-
cient for the family as possible. The Community-care comparison group
was given a list of referral sources within the community and treatment
consisted of whatever was agreed to by the parents and the care provider.
Overall, the community care group had much less frequent contact (i.e.,
2.3/year) with care providers and took less medication on average (18.7 mg
total daily dose).
142 DITZA ZACHOR et al.

When considering treatment effects for the core symptoms of ADHD

(i.e., inattention, impulsivity, and hyperactivity), careful medication man-
agement was the most effective single treatment; that is, the Medication
and Combined strategies were clearly superior to the Behavioral strategy
and Community-care groups. The Medication and Combined groups did
not differ on any of the measures of ADHD symptom outcomes. However,
when other areas of functioning (e.g., social skills, academic functioning,
and parent–child interactions) were evaluated, the Combined treatment
appeared to offer some advantages although these were often not statisti-
cally significant based on the strict criteria initially established by the MTA
Using a composite score based on all outcome measures (Conners, et al.,
2001), as well as when measures were combined across settings (Hinshaw,
2007), the Combined treatment strategy was found to have significantly bet-
ter treatment effects than all other treatments. Parents and teachers also
provided much higher consumer satisfaction ratings for both behavioral
treatment strategies (i.e., Combined and Behavioral). Subsequent analyses
indicated that for children with a comorbid anxiety disorder, the addition of
a behavioral treatment strategy either alone or in combination with medica-
tion was clearly more effective. This finding also held true for families receiv-
ing public assistance. No other analyses of potential moderator effects were
found to be significant in the initial analysis.
The initial findings of the MTA were widely disseminated with some
news agencies reporting that behavioral interventions “didn’t work” in
treating ADHD (Arnold, et al., 2004). The principal investigators for the
MTA have clearly stated in subsequent articles that this is not the case
(Jensen, 2001). The MTA study did not include a “no treatment” control
group for comparison and all four treatment groups showed a substan-
tial reduction of symptoms over the treatment period. The results for the
behavioral treatment strategies are actually quite robust when considered
in the context of the strong effects consistently achieved with stimulant
medications on ADHD symptoms (Arnold, Chuang, Davies, Abikoff, Con-
ners, & Elliot, 2004). For example, children in the Behavioral group did
at least as well as children in the Community-care group, most of whom
were being treated with stimulant medications. Also, three-fourths of the
Behavioral group were satisfactorily managed for the 14-month treatment
period without taking any medication.
Another criticism of the initial MTA findings is that they report on
treatment effects after the behavioral intervention was faded and
medical treatment was still active (Pelham, 1999). This aspect of the
research design was based on the view that attempting to promote the
generalization of behavioral treatment effects as the intensive program
components were withdrawn was desirable and more closely reflected “real-
world” practice (Jensen, 1999). The impact of this aspect of the research
design in evaluating the true contribution of behavioral interventions to
the treatment of ADHD remains a subject of ongoing discussion (Arnold
et al., 2004). A primary goal of future research efforts is determining what
“dose” of behavioral intervention is sufficient to provide benefits; that is,
how intensive does the treatment have to be?

Regardless of the issues surrounding the evaluation of behavioral

intervention effects, the MTA study clearly demonstrated the very strong
effects of carefully managed medical treatment on symptoms of ADHD.
This finding is consistent with the results from previous studies (Schachar,
Tannock, Cunningham, & Corkum, 1997) demonstrating the short-term
robust efficacy of medication management out to a period of 14 months.
A follow-up of these treatment groups after 24 months revealed that the
two most beneficial groups who used medication show deterioration of
effectiveness because these groups had a larger number of cases that
stopped medication. This deterioration may reflect the lack of maintenance
of an effective intervention. The effects of the behavioral therapy although
smaller than that of medication, were maintained, suggesting that
generalization occurred (MTA Cooperative Group, 2004a).


The neurobiological basis of pharmacotherapy in ADHD has been based

on the catecholamine mechanism of action in the central nervous system
(CNS). The frontal subcortical-cerebellar circuits are rich in dopaminergic
synapses and control a set of executive functions (inhibition, working mem-
ory, set shifting, planning and sustained attention, regulation of reward
systems and arousal states; Castellanos & Tannock, 2002). The pattern
of neuropsychological deficits in ADHD might originate from deregulation
of these CNS circuits. The underlying causes of ADHD are not well under-
stood, but there is considerable evidence indicating that dopaminergic and
noradrenergic neurotransmission are dysregulated in ADHD. Support for
this concept comes from different studies:
The action of drugs that increase the synaptic availability of dopamine
and norepinephrine on ADHD symptoms.
Animal models of ADHD (created via lesions in dopamine pathways).
Structural and functional neuroimaging studies showing that brain
regions rich in dopaminergic innervations are associated with ADHD.
Various genes coding for proteins involved in dopaminergic neuro-
transmission were associated with ADHD (Cheon et al., 2003; Cas-
tellano, & Tannock, 2002; Krause, Dresel, Krause, Kung & Tatsch,
2000; Solanto, 2002).
The main pharmacotherapy for ADHD has for decades been the
stimulant drugs methylphenidate and amphetamine, which are believed
to enhance neurotransmission of dopamine and epinephrine. Methyl-
phenidate is thought to act primarily by blocking reuptake of dopamine
transporters, whereas amphetamines are thought to exert their effect by
blocking noradrenergic transporters and by facilitating neurotransmitter
release. Because ADHD symptoms of inattention and hyperactivity/impul-
sivity reflect possible dysregulation of the monoamines system, stimulants
are thought to normalize the function of the relevant brain regions by
enhancing the neurotransmission of dopamine and norepinephrine in
therapeutic doses.
144 DITZA ZACHOR et al.

The AAP guidelines recommend that stimulant agents that have

been Food and Drug Administration (FDA)-approved as ADHD treat-
ments should be used to achieve the desired treatment goals in chil-
dren with ADHD. A large body of evidence supports the effectiveness
of stimulants in treating ADHD symptoms and endorses their use as
first-line treatment (reviewed in Biederman, & Faraone, 2005; Lopez,
2006). Randomized, controlled trials have consistently demonstrated
the efficacy of stimulants for reducing the core symptoms of hyperactiv-
ity, impulsivity, and inattention.
Studies also documented improvement in classroom behavior, aca-
demic achievements, conduct, and self-esteem of children and ado-
lescents with ADHD. The majority of children with ADHD (70%) are
effectively treated with stimulant medications. With appropriate dose
titration and selection of the most effective stimulant, up to 90% of
children with ADHD would respond favorably (Hechtman et al., 2004;
Mannuzza & Klein, 2000).
The most common stimulants in use are methylphenidate and amphet-
amine (Dexedrine and Adderall, a mixture of four neutral amphetamine
salts). Both drug groups are classified as Schedule II controlled substances
and are available in short-acting (4 hours), intermediate (8 hours), and
long acting (12 hours; Table 6.2). The immediate-release stimulants have
a relatively short duration of action, which is a challenging limitation dur-
ing the school day. Children treated with the short-acting stimulants will
often need multiple doses throughout the day to provide coverage of ADHD
symptoms both at school and during after school activities. The need for
an “in school” second dose, or a third dose for leisure time activities, may
cause embarrassment, stigma, and peer ridicule for the school-aged chil-
dren. This may result in lack of compliance, loss of effectiveness in the
afternoon, and more problems with symptoms control.
Stimulant medications have a rapid onset of action, a flexible dosing
schedule, and many choices of medications that facilitate the development
of an individual treatment plan. The decision with which type of medica-
tion to start therapy should take into account age, desired duration of
action, response type, side effects, and availability.

Table 6.2. Immediate Release Stimulant Medications

Active Ingredients Drug Name (Hours) Special Consideration
Methylphenidate (MPH) Ritalin 3–4 2–3 times a day
Maximal dose: 60 mg Methylin 2–3 times a day Chewable
Focalin 2–3 times a day d-MPH isomer
Dextroamphetamine DextroStat 4–5 × 2 daily
Maximal dose: 40 mg Dexedrine
Mixed salts of amphetamines Adderall 4–6 2–3 times a day depending on
Maximal dose: 40 mg dose Scored tablets

New Advanced System Delivery Stimulants

New developments in stimulant treatment have led to better quality
of care. One of the major advances in stimulant treatment has been the
development of long-acting formulations with range of action between 8–
12 hours (Table 6.3). These regimens provide coverage for most of the day,
prevent humiliation in front of peers, and enable the child to complete
his homework and participate in extracurricular activities. Recently, the
pharmaceutical companies have developed more technologically advanced
formulations of MPH, combining the advantages of both immediate release
(IR) and extended release (ER) MPH by using innovative delivery systems.
These advances permitted the production of long-acting medications that
provide rapid onset of effect with prolonged duration of action in a single
dose intended for once-daily administration.
Ritalin LA is an example of an intermediate release regimen, which
was designed to mimic a twice-daily regimen, releasing 50% of the dose
immediately and the other 50% approximately 4 hours later. Ritalin LA™
uses SODAS technology (IR beads contain MPH within sugar spheres and
delayed release beads that are coated with a polymer controlling the rate
at which the drug diffuses out of the pellet) to achieve bimodal release
profile. This drug offers a level of clinical efficacy similar to the effect of
immediate release MPH (Biederman et al., 2003).

Table 6.3. Sustained Release Stimulant Medications

Active Ingredients Drug Name (Hours) Special Consideration
Methylphenidate Ritalin SR 4–8 Tablets must be swallowed whole
(MPH) Maximal dose: 60 mg
Ritalin LA 4–8 Bimodal release system Capsules must
be swallowed whole or sprinkled on
Maximal dose: 60 mg
Metadate ER 4–8 Tablets must be swallowed whole
Metadate CD 4–8 Capsules must be taken whole,
available in dose packs
Maximal dose: 60 mg
Methylin ER 4–8 Tablets must be swallowed whole
Focalin XR 4–8 d-MPH isomer
Maximal dose: 20 mg
Concerta 12 OROS delivery system
Maximal dose: 72 mg
Daytrana 9 wear Transdermal patch
Dextroamphetamine Dexedrine 6–8 Maximal recommended
Spansules daily dose: 45 mg
Mixed salts of Adderall XR 10–12 Maximal recommended
amphetamines daily dose: 40 mg
Amphetamine prodrug: Vyvance 10–12 Maximal recommended
Lisdexamfetamine daily dose: 70 mg
146 DITZA ZACHOR et al.

An example of an extended release drug is the osmotic release oral

system (OROS) that was designed to mimic three doses of MPH (12 hours)
duration of action (Concerta™). About 22% of the dose is contained in the
tablet overcoat and is released immediately, and the remainder of the dose
is released from a trilayer core through a controlled ascending osmotic
process (Wolraich, Greenhill & Pelham, 2001).
Another example is the controlled-delivery methylphenidate extended
release capsule (Metadate CD™), which utilizes Diffucaps technology, a
multiparticulate bead delivery system. Contained within each capsule is a
combination of IR MPH and ER MPH coated beads proportioned in 30:70
ratio yielding a biphasic, ascending dose-proportional pharmacokinetic
profile preventing tolerance development (Hirshey-Drisken, D’Imperio,
Birdsall & Hatch, 2002).
Another method of delivery is the MPH transdermal system (MTS) patch,
which permits sustained absorption of the drug through the skin and into
the bloodstream using DOT matrix technology that combines adhesive
properties and effective drug release vehicle (Anderson & Scott, 2006). MTS
delivery results in a uniform systemic drug delivery while avoiding first-
pass metabolism by the liver. The transdermal patch (Daytrana™) is the
only nonoral medication available for the treatment of ADHD and is FDA-
approved. MTS use allows physicians to control the daily dose and the
duration of effect by using different patch sizes and changing wear time.
The ability to remove the patch permits greater flexibility in dosing for those
children who need to stop and start treatment at different times of the day.
It may be a suitable solution for those who have difficulty swallowing pills,
have rapid metabolism of the drug, or suffer from late-day side effects.
The most widely prescribed medication for ADHD is the racemic mix-
ture of both the d-threo and l-threo enantiomers of MPH (National Insti-
tute of Health, 1998). However, the clinical efficacy of d,l-MPH is thought
to be mediated by the d-enantiomer (Weiss, Wasdell & Patin, 2004). Foca-
lin™ (d-MPH), a new formulation of the active d-isomer, was as effective as
d,l,-MPH for the treatment of ADHD even in half dose, thus providing use
of the lowest effective dose and possibly limiting the occurrence of serious
side effects.
In the amphetamine group, Adderall XR™ is a two-component
extended release capsule (50:50% beads), designed to produce pulsed-
release amphetamine salts mixture yielding a therapeutic effect that lasts
throughout the day and evening in one morning dose (Biederman, Lopez,
Boellner, & Chandler, 2002).
Lisdexamfetamine dimesylate (Vyvance™) is a prodrug of d-ampheta-
mine, which was recently approved by the FDA for use in ADHD. This
compound is a conditionally bioreversible derivative of amphetamine,
meaning that it is conjugated to a specific amino acid. The compound
is activated only when the amino acid is cleaved from the amphetamine
molecule during metabolism. Following ingestion, the pharmacologically
active s-amphetamine molecule is gradually released by rate-limiting
hydrolysis. This medicine provides an extended duration of effect that is
consistent throughout the day, with reduced potential for abuse, over-
dose toxicity, and drug tampering. Clinical studies documented significant

improvements in the children’s behavior throughout the day on ADHD rat-

ing scales for three examined doses (30, 50, 70 mg) compared with placebo
(Biederman, Krishnan, Zhang, McGough, & Findling, 2007).
Modafinil™ is a new stimulant that is structurally and pharmacologi-
cally different from other stimulant medications for ADHD and has low
potential for abuse. Modafinil has been used to promote wakefulness for
narcolepsy. The mechanism of action is not entirely known, but it appears
that Modafinil alters the balance of gamma-aminobutyric acid and gluta-
mate, which results in activation of the hypothalamus, and increases the
metabolic rate in the thalamus, amygdala, and hippocampus (Rugino &
Copley, 2001; Rugino & Samsock, 2003). In a double-blind placebo-con-
trolled study in children with ADHD, one 300 mg dose of Modafinil per
day greatly improved symptoms that were rated by teachers, clinicians,
and parents. A larger dose of 400 mg did not add greater effect than
the lower dose. All the doses were well tolerated and the most common
adverse effects were insomnia, headache, decreased appetite, abdomi-
nal pains, cough, fever, and rhinitis (Turner, Clark, Dawson, Robbins, &
Sahakian, 2004).

Adverse Effects of Stimulant Medications

Adverse effects of stimulants are usually mild and can be managed
by changing the dose, the timing, or the type of stimulant. The most
common side effects are decreased appetite, transient headache and
stomachache, sleep problems, and behavioral rebound. Somatic
complaints described on the first days of use, typically resolve within one
to two weeks of treatment. Rarely appetite suppression will lead to weight
loss and growth suppression. Published reports on the effect of long-
term stimulant therapy on growth are controversial. Some early reports
suggested stimulants may induce growth suppression (Poulton & Powel,
2003). The MTA study found mild growth suppression in height after
ten months of consistent use of stimulant medication (MTA Cooperative
Group, 2004b). More recent reports using standardized tools such as
body mass index (BMI) charts and Z-scores, have not reported significant
effects on height or weight growth over time. In addition, several long-
term studies suggested that deficits in weight and height are reversible
and not of clinical significance even with continued treatment for two to
three years (Faraone, Biederman, Moonuteau, & Spence, 2005; Zachor,
Roberts, Hodgens, Isaacs, & Merrick, 2006).
Infrequently, children can become socially withdrawn, extremely unre-
sponsive, dizzy, and extremely focused on trivial information as a side
effect of stimulant medication. These side effects are more common in
young children with mental retardation or with other developmental prob-
lems. Most of the side effects abate with long-term treatment. In very rare
cases, side effects that are more serious can occur, such as hallucinations,
exacerbation of tics, and adverse cardiovascular events.
About 20% of children with ADHD are affected by chronic tic disorder,
whereas about half of the cases with chronic tics or Tourette syndrome
also meet criteria for ADHD. Usually, ADHD is diagnosed two to three years
148 DITZA ZACHOR et al.

before first tic onset. Some concerns exist that stimulants may increase
the risk of first-onset tics or worsening of pre-existing tics. Early reports
showed stimulants might raise the risk for tics in patients with a personal
or family history of tics (Lowe, Cohen, Deltor, Kremenitzer, & Shaywitz,
1982). These authors claimed that Tourette syndrome or tics in a child are
a contraindication to the use of stimulants. However, recent reports chal-
lenge this view and a metaanalysis of studies with high methodological
quality (double-blind placebo-controlled) revealed that there seems to be
no elevated risk of first-onset tics during stimulant treatment (Roessner,
Robatzek, Knapp, Banaschewski, & Rothenberger, 2006)
In addition, stimulants are believed to lower the threshold for sei-
zures but a diagnosis of epilepsy is not an absolute contraindication to the
use of stimulants. Although several studies have revealed that stimulants
do not exacerbate well-controlled epilepsy, children should be monitored
closely for exacerbation of seizures while on the medication. A recent study
reported 2% seizures in a stimulant-treated group of children diagnosed
with ADHD. This rate is not exceptionally high given that an estimated 1%
of unselected children will have at least one afebrile seizure by 14 years
of age. This study found that epileptiform EEGs identified a subgroup of
children with ADHD with seizure risk of up to 20%, whereas normal EEGs
indicated minimal risk (<1%) for seizures. The risk was not attributable to
stimulant use (Hemmer, Pasternak, Zecker, & Trommer, 2001).
Stimulant drugs are controlled substances with addictive potential and
therefore parents have raised their concerns about their children being
prone to abuse and addiction after long-term treatment. Studies looking
at these questions have shown that the pharmacotherapy of ADHD has
a significant “protective effect” and instead of causing substance abuse
actually reduces the risk for this disorder by 50% (Wilens, Faraone, Bied-
erman, & Guanawardene, 2003).
Recently, a warning was added to the label of Adderall XR cautioning
that misuse of amphetamines can lead to serious cardiovascular events
and to sudden death. Although these cases are rare, it is important to
verify underlying structural cardiac abnormalities, inquire about family
history of unexplained cardiac deaths before initiation of treatment with
stimulants, and provide adequate cardiac monitoring afterward. A recent
study that evaluated cardiovascular safety of mixed amphetamine salts
extended release on about 3,000 children with ADHD demonstrated both
efficacy and cardiac safety (Donner, Michaels, & Ambrosini, 2007).

Titration of Therapy for ADHD and Strategies for Managing

Adverse Effects
The decision regarding which agent to initiate therapy with should take
into account age, desired duration of effect, and availability. Both methyl-
phenidate and amphetamine are each about 70% effective in alleviating the
symptoms of ADHD. A trial of both types in succession before giving up on
stimulants can increase collective effectiveness to 90%. It is recommended
to start at the lowest-level dosage available. In the absence of significant side
effects, it is possible to titrate up a dose every week until a positive effect

is achieved. Parents and teachers reports, verbally or preferably through

ADHD-rating scales, are important to maximize the medication response.
Children with ADHD, Combined Type, particularly those with behav-
ior problems, will benefit from 12 hours therapy duration ideally with one
single morning dose. Treatment can continue on weekends or vacations
to improve the child’s function in leisure and family times if needed. Chil-
dren with ADHD, Inattentive Type may take the medication only during
school time or while engaging in academic activities (short or intermediate
drugs). In special circumstances, such as having poor weight gain or loss
of weight, medication holidays are necessary.
It is recommended to monitor growth by measuring height, weight,
and blood pressure every six months or more frequently in extenuating
circumstances (loss of weight, poor appetite). Studies do not support the
need for regular blood tests (such as complete blood count or liver and
renal profiles). However, the pediatrician should decide to perform such
tests in case of medical problems (growth suppression, abdominal pains).
If the side effects of the medication do cause substantial problems for
the child, physicians can try alternative approaches to reduce the discomfort.
For example, if sleep problems occur, it is possible to reduce or eliminate the
afternoon dose or move dose to earlier time. If there is behavior rebound with
the immediate-release regimen, a trial of a sustained-release medication can
improve the problem, or adding a small dose in the afternoon may address
this situation. When appetite is severely affected, the child can take the dose
after meals, or he can have frequent high-caloric healthy snacks during the
day. Drug holidays should also be considered in this case.

Nonstimulant Medications
Although 80–90% of children who are diagnosed with one of the ADHD
subtypes will respond to one of the stimulant medications favorably, some
children will not show effective control of the symptoms or will be intolerant
of stimulants. Nonstimulant medications such as Atomoxetine (Strattera),
antidepressants, and alpha-adrenergic agents have shown benefit in con-
trolling symptoms of ADHD, although the response has not been as effec-
tive as that of stimulants (Table 6.4).

Table 6.4. Nonstimulant Medications

Group’s Name Medications
Tricyclic Antidepressants Amytriptline
Alpha 2 agonists Clonidine
Others Atomoxetine
150 DITZA ZACHOR et al.

The most established and extensively studied nonstimulant treat-

ments for ADHD have been the tricyclic antidepressant group. Studies
show these medications are superior to placebo in controlling ADHD symp-
toms. Their use is not approved in pediatric ADHD because of their low
margin of safety, possible cardiac side effects, and the requirements for
careful monitoring of levels and adverse effects. The tricyclic antidepres-
sants have a potential risk for serious cardiovascular adverse events (i.e.,
unexplained deaths in four children treated with desipramine), although
the link between the treatment and the events remained uncertain
(Biederman, Thisted, Greenhill, & Ryan, 1995).
Atomoxetine (Strattera™), a selective norepinephrine reuptake inhibi-
tor with no significant effect on dopamine, is another relatively new
nonstimulant approved for ADHD treatment by the Food and Drug
Administration (FDA) in children and adults. Controlled trials have
shown superiority of Atomoxetin to placebo for the treatment of ADHD
symptoms and in improving self-esteem, interpersonal and family rela-
tionships, and overall functioning (Barton, 2005). Therefore, Atomoxetine
can be an alternative for children who cannot tolerate or do not respond
to stimulants. The degree of response to atomoxetine is slightly lower
than that to stimulants and therapeutic effects may appear after several
weeks of treatment.
Advantages are the long duration of action, little or no abuse potential,
no effect on sleep, and good tolerability. In addition, atomoxetine is not
a schedule II controlled substance. The half-life of atomoxetine is about
five hours but after two to four weeks of therapy, when maximal response
is achieved, clinical effects appear to be long lasting. Tapering is neces-
sary when discontinuing the medicine. There is no major effect on growth
with atomoxetine. In addition, atomoxetine (a weak antidepressant) may
be useful for children with comorbid anxiety, sleep disorder, or tics as
no increase in tics has been documented. The most common side effects
reported with atomoxetine use include upset stomach, decreased appetite,
nausea, dyspepsia, vomiting, tiredness, dizziness, somnolence, and mood
swings. These side effects tend to be transient occurring during initiation
and titration of the medicine. The FDA required that atomoxetine carry a
black box warning indicating the possibility of severe liver injury in rare
cases, and of increased risk of suicidal thinking in children and adoles-
cents (http://www.fda.gov).
The group of α adrenergic agonists, such as clonidine and guanfacine,
is occasionally a useful option for ADHD treatment. Both drugs are not
presently approved by the FDA for ADHD treatment but are used to augment
stimulant therapy especially to control extreme impulsivity. Clinicians
should consider treatment with α agonists when ADHD is associated
with tic disorder or Tourette syndrome and especially if treatment with
stimulants makes the tics worse. A meta-analysis of clinical trials involving
clonidine (a weak blood pressure medicine) concluded that this medicine
is effective as a second-line therapy, although the clinical effect is lower
than that of stimulants. A high rate of side effects are associated with
clonidine treatment including, sedation, irritability, sleep disturbance,
blood pressure drop, hypotension (new onset blood pressure lower than

the 5th percentile for age and gender), dry mouth, and dizziness (Connor,
Fletcher, & Swanson, 1999).
Guanfacine is less sedating and has a longer duration of action than
clonidine. A randomized placebo control study of guanfacine for children
with ADHD and tic disorder found guanfacine was well tolerated, and
improvement of ADHD symptoms was similar to or better than with other
nonstimulant medications but less than with stimulant treatment (Schahil
et al., 2001). Dosing of guanfacine should start low and move upward
slowly to avoid sedative and hypotensive effects. In addition, abrupt with-
drawal of guanfacine is not recommended and frequent blood pressure
monitoring is suggested.
Report of sudden deaths that have occurred after patients took α
agonists with methylphenidate raised concerns about the safety of these
drugs combination. A phase III clinical trial examining the benefit of an
extended-release formulation (once daily) of guanfacine has concluded
and documented clinical significance. However, the adverse effects profile
of these new drugs needs to be further examined before their routine use
in ADHD treatment.
Bupropion, an atypical antidepressant, has modest efficacy in improv-
ing symptoms of ADHD as shown in open label and controlled small trials
(Wilens et al., 2005). Some studies suggest bupropion could be helpful for
patients with comorbid depression, bipolar disorder or substance abuse
(Wilens, Prince, Spencer, et al., 2003). The drug may exacerbate tics and
increase the threshold for seizures with increasing doses. Therefore, it is
contraindicated in children with seizure or tic disorders.
Omega-3 fatty acids are a family of long-chain polyunsaturated fatty
acids. Several natural observation studies have found lower levels of omega
3 fatty acids in persons with ADHD. Randomized controlled small studies
of enhanced dietary intake of the fatty acids have had ambiguous results.
Two studies found no improvement in ADHD-related symptoms and one
study showed improvement only in a few measures. Serious side effects were
not reported with omega-3 treatment (Hirayama, Hamazaki, & Terasawa,
2004; Richardson & Puri, 2002). The current approach is that dietary
supplementation with omega-3 fatty acids may have some theoretical beneficial
effects for children with ADHD. However, there is insufficient evidence at this
time to substantiate the efficacy and safety of this treatment.



The presence of ADHD with one or more comorbid disorders is asso-

ciated with significant additional morbidity and therefore complicates
treatment of ADHD (Spencer, Biederman & Wilens, 1999). The treatment
approaches to some of the comorbid disorders are discussed, with an
emphasis on medical treatment: ADHD with disruptive behavior disorders
[oppositional defiant disorder (ODD); conduct disorder (CD); aggressive
152 DITZA ZACHOR et al.

ODD manifests as a persistent pattern of negative and defiant

towards adult authority, whereas CD presents as a repetitive pattern of
more severe rule breaking and violation of social norms. Sometimes these
disorders occur with more severe ADHD symptoms. The primary treatment
approach for ODD alone is behavioral intervention. However, the treatment
approach of psychostimulants and atomoxetine for some of the comorbid
disorders can be very effective in treating a range of disruptive behaviors,
including both ODD and CD symptoms, although they are only labeled
for ADHD. The MTA study found that ADHD symptoms respond robustly
to stimulant medication in the presence of ODD or CD. MTA subjects
with ADHD, CD, or ODD responded best to a combination of behavior
and medication treatments (MTA Cooperative Group, 1999 b). Children
who display ADHD symptoms along with aggression or other disruptive
behavior disorder symptoms, but are not responsive to treatment with
stimulants, may benefit from combined therapy of stimulants and other
groups of medications.
A variety of pharmacotherapeutic agents can be added to stimulants.
The group of selective serotonin reuptake inhibitors (SSRI) can improve
symptoms of aggression, as studies implicated serotonergic mechanisms
in aggression; anticonvulsant mood stabilizers such as carbamazepine
and sodium valporate are also effective as adjunct therapy for ADHD and
episodic dyscontrolled behavior (reviewed in: Newcorn, & Ivanov, 2007).
The best data are for risperidone and quetiapine (antipsychotics) in
treating CD and/or aggression with comorbid ADHD (Aman, DeSmedt,
Derivan, L yons, & Findling, 2002; Findling et al., 2007).

ADHD with Mood Disorders

Many children with ADHD experience demoralization because ADHD
symptoms may lead to impaired academic, social, and athletic success. A
demoralized mood often improves as the ADHD symptoms resolve. However,
pharmacologic treatments for ADHD have little impact on prominent
depressive symptoms because the two disorders appear to have independent
trajectories (Biederman, Mick, & Faraone, 1998). When the depressive
symptoms are mild it is reasonable to treat the ADHD first as stimulants
have a faster rate of onset than antidepressants. Then, the mood symptoms
need to be re-evaluated and if present, a more targeted treatment should be
implemented. If the child has marked depression or suicidal ideation, a mood
treatment should be initiated first and only when improved, treatment for
ADHD symptoms should follow. Psychosocial treatments (such as cognitive-
behavioral therapy) combined with medication are usually the most effective
intervention for mood disorders. When pharmacotherapy is considered,
the most common treatment for ADHD with depression is a combination of
stimulant with a drug from the SSRIs group (TADS Study Team, 2003).

ADHD and Anxiety

The combination of ADHD and anxiety has been reported in many studies
(reviewed in Waxmonsky, 2003). Initial studies found that stimulants were

typically less effective and possibly anxiogenic. However, recent studies

and especially the results of the MTA study found that stimulants were
robustly effective for ADHD symptoms and did not worsen anxiety symp-
toms. In addition, the MTA study showed that behavioral intervention
was very effective for children with anxiety and ADHD, and had a positive
impact on their academic and social functioning. In fact, children with
anxiety responded to all treatments in the MTA (behavioral and medica-
tion) better than children with only ADHD did (Jensen et al, 2001). When
children with ADHD had combined comorbidities of anxiety and ODD/CD
behaviors, the combination of medication and behavioral intervention was
superior to either treatment alone.

ADHD with Autism Spectrum Disorder (ASD)

The co-occurrence of these two complex disorders is common and can
occur in up to 50% of children with ASD. The ADHD-like symptoms in
ASD often impair functioning and interfere with the ability of the affected
children to benefit from behavioral and educational intervention. There
are few studies that examined the safety and efficacy of stimulant medica-
tion in ASD. Earlier studies reported little benefit and a large number of
adverse effects including increased irritability, stereotypies, and hyperac-
tivity (Sporn & Pinkster, 1981).
More recent studies have been generally more promising with respect
to both effectiveness and side effects. The gains included improved atten-
tion span and diminished hyperactivity, explosive rage, oppositionality and
aggression and to some extend decline in stereotypies and inappropriate
language. Side effects reported in recent studies included irritability, tan-
trums, tearfulness, social withdrawal, aggression, and skin picking. Clini-
cal benefits with few side effects were observed with lower-dose stimulants
use (Posey et al., 2007).
Overall the approach for stimulant use in ASD and ADHD is that they
can provide effective adjunctive therapy for more than 50% of the children.
Therefore, physicians should try them first and closely monitor children
for unwanted effects that may be higher than the rate seen in children
with ADHD alone.
Recent studies examined the effectiveness of atomoxetine in children
with ASD. Significant improvement in ADHD symptoms was documented,
but lesser improvement in irritability, social withdrawal, stereotypy, and
repetitive behaviors was noted (Arnold et al., 2006; Posey et al., 2006).
The group of α adrenergic agonists has been frequently used in ASD to
treat hyperarousal symptoms. Drowsiness and sedation are common side
effects of this group. Very few small size studies have looked at the benefit
of this group of medications in ASD, however (Frankhauser, Karumanchi,
German, Yates, & Karamanchi, 1992). Atypical antipsychotics (risperidone)
are sometimes used to treat hyperactivity and inattention in ASD (Williams
et al., 2006). In one double-blind placebo-controlled study, treatment with
omega-3 fatty acids supplements for children with ASD produced signifi-
cant improvement on the hyperactive and stereotypy measures without
side effects (Amminger et al., 2007).
154 DITZA ZACHOR et al.

It is likely that with the implementation of any of the aforementioned

medication regimens, children with ADHD-like symptoms and a diagno-
sis on the autism spectrum could then benefit from intensive behavioral
interventions. Interventions for children diagnosed with an Autism Spec-
trum Disorder include small-group or one-on-one behavioral and edu-
cational interventions that are delivered for at least 10–15 hr per week.
They include well-known treatment models such as the UCLA Young
Autism Project, Treatment and Education of Autistic and Related Com-
munication Handicapped Children, and the Denver Model (Shattuck &
Gross, 2007).


Numerous interventions and therapies have been developed and touted

as effective treatments for ADHD but only three interventions have stood
the test of randomized clinical trial in controlled scientific studies and
consistently been found to provide meaningful benefits to the child with
ADHD: behavioral parent training, classroom behavior management, and
summer treatment programs (e.g., Chronis, Jones, & Raggi, 2006; Pelham &
Fabiano, 2008). These evidence-based treatment approaches are reviewed
in detail in the following sections.

Behavioral Parent Training: Overview

Raising a child diagnosed with ADHD places strain on family relation-
ships and family functioning, necessitating the use of a family-based treatment
approach such as parent training (Pelham, Wheeler, & Chronis, 1998).
In these families, elevated levels of parental stress and diminished parental
sense of competence are often present (Mash & Johnston, 1990). Behavioral
parent training is now a well-established treatment for children diagnosed
with Attention-Deficit/Hyperactivity Disorder (ADHD; Pelham & Fabiano,
2008). Although previously deemed probably efficacious (Pelham et al.
2008), a recent review by Pelham and Fabiano (2008) provides evidence
that behavioral parent training is a well-established treatment for ADHD.
In the review article by Pelham and Fabiano (2008), 22 studies, published
since 1998, assessing the effectiveness of behavioral parent training, were
examined. The cited studies used mostly group-based behavioral parent
training programs, consisting of 8–16 sessions. Behavioral parent training
was found to be more effective than other conditions, including attention
placebo, nondirective parent counseling, and wait-list control. In addition
to treating children with ADHD, behavioral parent training has a history
of successfully treating Oppositional Defiant Disorder (ODD) and Conduct
Disorder (CD; Brestan & Eyberg, 1998).
Parent training improves parental child management skills (Barkley,
Guevremont, Anastopoulos, & Fletcher, 1992; Pelham & Fabiano, 2008;
Wells, Chi, Hinshaw, Epstein, Pfiffner, Nebel-Schwain, et al. 2006), reduces
overall child symptoms of ADHD, and improves other disruptive behavior
problems (Anastopoulos, Shelton, DuPaul, & Guevremont, 1993). There is

also thought to be an increase in parental confidence, a reduction in par-

ent stress, and an improvement in family relationships (Anastopoulos
et al., 1993).
Parent training is typically most effective with children 4 through 12
years of age (Anastopoulos & Farley, 2003). In addition, it can typically be
delivered in 8 to 12 sessions in a group or individual format. Sessions typi-
cally range from one hour, when conducted individually, to 90 minutes,
when conducted in a group setting. Individual behavioral parent train-
ing is thought to offer several advantages over group-based approaches,
including an increased ability to be flexible with the pace and content
of the sessions. Group sessions are, however, thought to be more cost-
effective, provide parents with a greater level of social support, and often
produce effects equivalent to individual parent-training sessions (Chronis,
Chako, Fabiano, Wymbs, & Pelham, 2004). Chronis and colleagues (2004)
suggest an approach to parent training which first includes all parents
being enrolled in group-based behavioral parent training with additional
individual sessions scheduled as needed for parents who do not maximally
benefit from group-based treatment or for those parents who drop out of
group-based treatment.
A variety of behavior management strategies is presented throughout the
parent training sessions. Parents are asked to practice these strategies
daily at home, at their children’s school, and in public places. Although
there are many different programs (Cunningham, Bremner, & Secord,
1997; Forehand & McMahon, 1981; Pfiffner, Mikami, Huang-Pollock,
Easterlin, Zalecki, & McBurnett, 2007) for parent training they share many
features in common. The following discussion of the specific components
of behavioral parent training will use those from the program developed by
Barkley and Anastopoulos (Barkley, 1987; Anastopoulos & Barkley, 1990;
Barkley, 1997) as a representative example.

Components of Parent Training

In the initial session of parent training, an overview of ADHD is pro-
vided. This discussion includes the neurological bases of ADHD, diagnostic
criteria for the disorder, typical comorbid features, and the developmental
course of the disorder. Parents are provided additional Web and literary
resources as well, in order to facilitate the ongoing development of their
knowledge of ADHD and associated features.
During the second session of the program, there is a discussion of
family factors that often lead to parent–child conflict. More specifically,
child characteristics (i.e., temperament, ADHD diagnosis), parental char-
acteristics (i.e., parental psychopathology, medical illness, temperament),
family stress (i.e., time management, financial strains), and parenting
style (i.e., ability to set up situations: antecedents; ability to respond to
appropriate and inappropriate behavior: consequences) are discussed. A
great emphasis is placed on a parents’ own ability to alter their parent-
ing style, whereas the other family factors are less amenable to change.
General behavioral principles are discussed in this session, including how
antecedents and consequences can be altered to elicit appropriate child
156 DITZA ZACHOR et al.

behavior. Positive reinforcement, ignoring, and punishment strategies are

also discussed in detail.
In the third session, positive attention is covered, as well as the spe-
cific positive attention strategy of Special Time. Special Time is designed to
increase the parents’ positive attention toward appropriate child behavior.
The importance of positive attention is highlighted with the discussion of
the tendency for children diagnosed with ADHD to have negative interac-
tions with their parents, peers, and teachers. As a result of these negative
interactions, these children often function in environments that are nega-
tive, overly directive, and corrective. Special Time is introduced as a strat-
egy that allows parents to dispense positive attention in a nondirective and
noncorrective manner. In addition, these opportunities help to improve
parent–child relationships, which are often damaged by negative, overly
directive, and corrective interactions. Outside of Special Time, parents are
encouraged to “catch their child being good” and praise any instance of
appropriate behavior noted.
In the fourth session, additional relevant discussions ensue with
respect to positive attention. Parents are encouraged to positively attend to
their children while their children are engaging in independent play. The
child is given appropriate expectations (e.g., “I have a phone call to make.
I need you to sit here quietly and play with your toys.”). While parents are
engaging in the phone call, they are to interrupt themselves and praise
the child for playing quietly before the child has a chance to interrupt
the phone call. This way, the child gets positive attention for engaging in
appropriate behavior, rather than for interrupting.
Also discussed is the importance of paying attention to children’s
compliance. Parents are encouraged to set up sessions where there is a
high probability that their children will comply (e.g., bring the cookies to
the table, give the dog a treat) and then positively attend to instances of
compliance. Commands are also discussed, within the context of neces-
sary characteristics of commands for children diagnosed with ADHD (e.g.,
initiate eye contact with the child to ensure he or she is listening, use one-
step commands, issue commands that will be followed through on, issue
simple commands, make directive statements). Parents are encouraged to
have their children repeat the command back to them, to ensure that they
heard and understood the command.
In the fifth session, a home-reward system is established. Parents dis-
cuss privileges that their children have access to at home, which are often
found to be noncontingent on the children’s appropriate and inappropriate
behavior. Next, a request list is created highlighting up to ten chores or
rules that the child is expected to engage in/follow at home. Another list is
developed with rewards/privileges that the child earns on a daily, weekly,
and long-term basis. Point values are assigned for both the reward list and
the chore list.
The system is designed to promote child compliance by allowing
the child access to rewards and privileges in a manner contingent on
appropriate behavior. In terms of rewards, children nine years and
younger use plastic tokens, and children above nine use a point reward
system. Tokens/points are earned when a child engages in a chore on

the first parental request. Children are allowed to “cash in” their points
or tokens for privileges on their list. Bonus chips/points can also be
dispensed when children follow rules/complete chores without parent
request or when children complete chores with a positive attitude. Set-
ting up the home-reward system is often a difficult step in the parent-
training program, as parents may often feel as if they have attempted
to implement similar systems in the past with no success. Parents are
reminded of the impact of consistency with such a strategy and are also
provided additional phone support by the therapist outside the session
if necessary.
The sixth session introduces the response cost condition. It is impor-
tant to note that up until this point in the program, there have been no
negative components. Parents are encouraged to begin to remove tokens
or points for noncompliance for one or two behaviors on the request list.
The response cost condition will often increase children’s levels of compli-
ance with parental requests, as they often do not want to lose tokens or
points that they have earned. Parents are cautioned not to get into a nega-
tive behavior spiral with their child. More specifically, if a child does not
comply with a command on the third request, the parent is encouraged to
no longer remove tokens or points and instead remove privileges or insti-
tute a time out.
The seventh session covers time out in great detail. First parents
are asked to discuss their experience with the use of time out from rein-
forcement, in order to gauge the parents’ experiences with the strategy.
Although many parents often reveal that they have used their own time
out procedure unsuccessfully in the past, the therapist encourages the
parent to consider the components of this time out procedure. Parents
are asked to think of one or two more serious behaviors (i.e., hitting,
destroying property, repeated noncompliance) that would warrant the
use of time out. The components of time out are then discussed, which
include: the child serving a minimum amount of time in time out (i.e.,
one minute for one year of age); parents only approaching the time out
area when the child has been quiet for the last thirty seconds of time
out, in order to avoid reinforcing inappropriate behavior; parents reis-
suing the command that led the child to time out, which at times begins
the time out procedure again, if the child refuses to comply with the
command again.
The eighth session explores the use of behavior management strategies in
public places (e.g., grocery stores, department stores, libraries, churches).
The public situations are first discussed, and parents are asked to think
ahead about situations that may be potentially problematic, bringing
about difficult behavior. Next, parents are asked to set up their expecta-
tions for the situation and clearly explain these to the child. An incentive
for compliance in the situation is established, along with a negative con-
sequence for noncompliance. The parent must have the child repeat back
the discussed expectations, reward for compliance, and punishment for
The ninth session explores any issues the parent and/or child may be
having within the school domain. General education about parental rights
158 DITZA ZACHOR et al.

and classroom accommodations or curriculum modifications (i.e., Section

504 Plans; Individualized Education Plans; IEP) is provided. In addition,
preparations for treatment termination are made. First in this session,
however, school issues are discussed. Parents are encouraged to establish
and maintain positive and collaborative relationships with their children’s
teachers and schools. Specific parental and child rights are also covered.
In addition, empirically supported classroom accommodations (i.e., daily
report card; DRC) for children diagnosed with ADHD are presented. A dis-
cussion about the steps to setting up a DRC then ensues, including setting
up a meeting with the teacher, establishing appropriate target behaviors
for the daily report card, establishing blocks of times when the child’s
behavior will be rated, and determining classroom and/or home contin-
gencies for appropriate behavior.
Strategies covered during the course of the parent-training program
are then reviewed. Parents discuss situations that they believe might be
problematic in the future, along with ways that they might address such
situations. Parents are strongly encouraged to adhere to the program for
a period of time, prior to eventually implementing a system that relies
on more natural consequences and contingencies. Any issues related to
termination are then discussed, including the necessity for additional
services (e.g., medical evaluation, school consultation). A booster ses-
sion is then scheduled.
The tenth and final session is typically a booster session, which is
likely to occur nearly one month after the ninth session. During this ses-
sion, strategies covered during the course of the parent-training sessions
are again reviewed, with particular attention given to situations or strat-
egies that have presented difficulties for the families. At the end of this
session, families and the therapist determine whether additional booster
sessions might be necessary (Anastopoulos & Farley, 2003).

Factors Influencing Treatment Effectiveness

The location of treatment delivery may be an important factor in
treatment adherence (Pelham & Fabiano, 2008). In a study by Barkley
et al. (2000), behavioral parent training delivered in a medical setting was
not found to be effective. Further analysis of this study revealed that a
majority of the parents contacted did not choose to participate in the program
in this setting. Another program, the Cunningham’s COPE: Community
Parent Education Program (1998), has found success in providing parent-
training programs in the school, early childhood education settings, and
community centers, locations that are more accessible to families. In
addition, this program provides the flexibility of day and evening group
times. The COPE program also offers a children’s social skills group along
with each session of the parent program (Cunningham et al., 1998).
Although initial studies have found that this is an effective approach
for parent training, further research with the COPE program is necessary
in order to establish empirical support for providing such treatment in
community settings (Chronis et al., 2004). Nonetheless, the location of
parent training groups, flexibility in scheduling sessions, along with avail-

ability of child programs are important factors contributing to treatment

adherence and possibly treatment effectiveness.
In addition, many uncontrolled factors may also affect treatment out-
come. More specifically, moderators of treatment effectiveness include
child and family characteristics (e.g., gender, age, comorbidity, socioeco-
nomic status, parent psychopathology), therapist characteristics (e.g., level
of training), and treatment dosing (e.g., treatment intensity). A potentially
negative moderator of treatment effectiveness is parental psychopathol-
ogy; however, the evidence in support of negative effects is less clear-cut.
More specifically, some studies found no effect for parental psychopathol-
ogy (Pelham & Hoza, 1996), whereas others found negative moderating
treatment effects for maternal ADHD (Sonuga-Barke, Daley, & Thompson,
2002). It is speculated that parents with symptoms of ADHD may experi-
ence difficulty sustaining attention during sessions and difficulty consist-
ently implementing behavioral strategies and medication (Chronis et al.,
Maternal depression is also suspected to have a negative impact on
behavioral parent training for mothers of children diagnosed with ADHD;
however, there are no empirical findings suggesting a relationship between
maternal depression and decreased effectiveness of parent training. Some
research has been done (Sanders & McFarland, 2000; Chronis, Gam-
ble, Roberts, & Pelham, 2002) where there were components designed to
address maternal depression added to a behavioral parent training pro-
gram. These studies state that the interventions had a positive effect on
outcome for families. An issue with the research that has been done to
date assessing these factors is that most of the extra components/ inter-
ventions for maternal depression have been done after the parent-training
groups. Thus, it is difficult to say whether this is an appropriate approach
to addressing maternal depression or whether treatment interventions
would be more effective if they occurred prior to the mother’s participation
in behavioral parent training. Further research is needed to address these
treatment issues.
Also important to consider is parental expectations regarding paren-
tal involvement and child improvement during behavioral parent training
(Plunket, 1984). As a result of such moderating factors, treatment compo-
nents addressing these issues have been added to existing parent-training
programs. Additional research is needed in order to determine the effec-
tiveness of adjunctive interventions, which specifically target parent and
child factors not covered in parent training (Chronis et al., 2004). None-
theless, these factors must be considered when assessing family adher-
ence to and benefit from parent training programs.


Children with ADHD often experience difficulties in the school set-

ting. More specifically, while at school, children are required to have
the skills to plan, control their coordination, evaluate the procedures
involved in following the norms in appropriate interactions with adults
160 DITZA ZACHOR et al.

and classmates, and actively participate in the teaching/learning proc-

ess. These tasks are often more difficult for children diagnosed with
ADHD. As a result of such difficulties, children with a diagnosis of
ADHD often deal with social rejection in the school setting (Miranda,
Jarque, & Tarraga, 2006). Thus, school-based interventions are an
important adjunct in addition to behavioral parent training and medi-
cation management (Chronis et al., 2004). Stimulants, although help-
ful in reducing symptoms of ADHD, have not been demonstrated to
produce long-term changes in the general academic performance or the
interpersonal functioning of children with ADHD. Pelham and Gnagy
(1999) noted that “simply medicating children, without teaching them
the skills they need to improve their behavior and performance, is not
likely to improve the children’s long term prognosis (p. 226).”
Classroom behavior management strategies include token econo-
mies, contingency contracting, response cost, and time out. Self-evalu-
ation is also a strategy that has some efficacy in improving behavior
among children diagnosed with ADHD. In addition, other instructional
strategies are often effective (e.g., social skills training, task modifica-
tion). These strategies are explored toward the end of this section; how-
ever, first there is a brief review of the existing literature of classroom
behavior management.

There is substantial evidence that behavioral classroom management
is a well-established intervention for children diagnosed with ADHD
(Pelham & Fabiano, 2008). Studies by Barkley et al. (2000) have
demonstrated the effectiveness of classroom behavior management
strategies. In fact, in the study conducted by Barkley and colleagues
(2000), only the groups that included a school-based component
benefitted from treatment. These authors assessed ADHD symptoms
rated by teachers, teacher-rated social skills, and independent
observations of classroom behavior. All measures showed significant
improvement relative to control conditions.
In addition, a study by Van Lier, Muthen, Van der Sar, & Crijnen,
(2004) used a behavior management game called the Good Behavior
Game, where the children earned rewards for contingent good behavior.
Teachers and children chose the norms (rules) for the classroom and
the rewards for following them. The children were divided evenly into
teams. As a result of the system, ADHD-related problems were signifi-
cantly reduced. Another study by Northup et al. (1999) showed interac-
tive effects of methylphenidate and multiple classroom contingencies.
The program consisted of four conditions (1) contingent teacher rep-
rimands; (2) brief nonexclusory time out: child was turned away from
the desk, people, and all other activities if a specific negative behav-
ior occurred; (3) no interaction: ignoring all student behavior; and (4)
alone: children were assigned a task alone, which they did without a
teacher present.

Student’s behavior was significantly less disruptive in conditions where

there were contingent behavior management strategies (e.g., reprimands
and time out) than in other conditions. There was also a medication con-
dition, which was alternated for students. Children appeared to perform
better during the medication and behavior management condition when
compared to their behavior during the placebo and behavior management
condition alone.
DuPaul and Hoff (1998) looked at self-evaluation, and considered it a
possible alternative to a contingency management approach for address-
ing the disruptive behavior of students in elementary school exhibiting
ADHD behaviors. In this study, disruptive student behaviors were first
brought under the control of a contingency management system and then
they were later transferred to the self-management system. With the use
of self-evaluation, students maintained their behavioral changes in the
absence of teacher feedback. Ardoin and Martens (2004) examined the
accuracy and sensitivity of students’ ratings before and after self-evalu-
ation training. All students accurately rated their target behaviors after
training, which was found to decrease disruptive behavior. Despite these
studies, there is limited evidence that self-management strategies are con-
sistently successful for children diagnosed with ADHD.
Social skills training is an instructional component of school intervention.
Training can occur daily in the classroom, through a paired-buddy system
approach, and through other sports-related activities. Overall, it is reported
that parents and teachers endorse fewer behavioral problems and symptoms of
inattention (Anahalt, McNeil, & Bahl, 1998; Evans, Axelrod, & Langberg, 2004)
and normalization of peer relationships after such classroom interventions/
instructions (Hoza, Mrug, Pelham, Greiner, & Gnagy, 2003).
Some researchers have investigated multiple strategies in the class-
room including: token economy, response cost, time out, self-instruction,
reinforced self-evaluation, training in social skills, training in study skills,
or instructional management procedures (Anahalt et al., 1998; Barkley
et al., 2000; Shelton et al., 2000; Hoza et al., 2003). In general, these inter-
ventions showed positive results according to parent and teacher meas-
ures (e.g., fewer problematic behaviors, improved adaptive functioning).
The studies that included follow-up demonstrated continued improvement
up to two months after the interventions (Miranda & Presentacion, 2000);
however, long-term follow-up (two years after) of children previously in
treatment conditions showed no differences between those children who
received treatment and those that did not (Shelton et al., 2000). These
findings highlight the need for continual treatment and classroom support
for children diagnosed with ADHD, given the chronic and pervasive nature
of this disorder. Given that these studies had multiple components, it is
also difficult to determine which specific techniques produced improve-
ments (Miranda et al., 2006).
Next, there is a discussion of classroom behavior management strate-
gies including token economies, contingency contracting, response cost,
and time out. Self-evaluation and other instructional strategies are also
briefly discussed.
162 DITZA ZACHOR et al.



The goal of classroom interventions is to optimize the behavioral and

social functioning of children diagnosed with ADHD, while also addressing
the academic achievement and performance in the classroom. As this is
being accomplished, it is important to take an educative approach where
we not only focus on reducing problematic behavior, but also teaching
alternative prosocial behaviors. In all, this type of approach will require
the development and implementation of behavior plans, which require
classroom and teacher support (DuPaul & Stoner, 2003).
Teachers should be trained on the intervention design, delivery, and
outcome evaluations. It is important that the development of a treatment
plan be empirically based. It is also important that appropriate evaluation
measures be used in the classroom. More specifically, reinforcement
values and the function of problematic behavior should be assessed
systematically. Guidelines set forth by DuPaul and Stoner (2003; p.142)
suggest the following for the development of classroom interventions.
(1) Intervention development, evaluation, and revision are data-based
activities; (2) intervention development, evaluation, and revision are driven
by child advocacy and focused on attainment of clearly defined, socially
valid child outcomes; (3) intervention procedures must be thoroughly
identified and defined, as well as implemented with integrity by persons
with clearly delineated responsibilities; (4) Effective interventions produce
or lead to increased rates of appropriate behavior and/or improved rates
of learning, not solely decreases in undesirable behavior; (5) prior to its
implementation, an intervention’s effects on the behaviors of the identified
child, the teacher, and on the classroom are unknown.
Contingency management (i.e., altering antecedents and con-
sequences) is thought to have the most positive effects on behavior.
In addition, positive reinforcement is thought to be the cornerstone
of classroom-based behavior management programs. Most programs
include contingent social praise; however, with children diagnosed with
ADHD, more powerful contingencies (e.g., token economies, contin-
gency contracting, response cost, and time out from reinforcement) are
often necessary to promote behavioral change (Barkley, 1998). DuPaul
and Stoner (2003) recommend a more proactive and reactive approach,
where events that precede inattentive and disruptive behaviors should
be manipulated to prevent problematic behaviors from arising. Reactive
strategies should not only include a punitive response, but also positive
when appropriate behavior is noted to occur. Another important factor
for interventions in the classroom is that they are most effective when
introduced at the point of performance (Goldstein & Goldstein, 1998).
Thus, the strategy must be implemented in close proximity to the target
In addition, interventions need to be individualized, taking into
account the child’s academic skills, the function of the behavior, the tar-
get behaviors, and any limiting factors related to the setup of the class-
room (i.e., teacher’s approach). An effective approach to intervention for

children with ADHD is one where a number of individuals help to imple-

ment the program (i.e., teachers, parents, peers, identified student; Teeter,
1998). Working in this manner provides a more comprehensive approach
to problematic behavior, where the teacher is not solely responsible for
implementing programs and rewarding all classroom behavior.
Before creating a classroom program for children diagnosed with
ADHD, DuPaul and Stoner (2003, pp. 145–147) suggest that the child’s
treatment team consider the following issues.

(1) There should first be a thorough assessment of the presenting

problem, including a functional assessment.
(2) Children diagnosed with ADHD typically require more frequent
and specific feedback. Thus, contingencies should be delivered
in a continuous manner. Gradually, reinforcement schedules can
become less dense.
(3) The programs should be based on contingent positive reinforce-
ment. Verbal reprimands are also effective if they are given in a
neutral, consistent, and immediate manner following the problem
behavior (Pfiffner & O’Leary, 1993).
(4) When the target behavior is one that occurs during independent work
periods, task instructions should not involve more than a few steps.
The child should be asked to repeat the steps back to the teacher.
(5) Goals in the classroom should include academic products and
performance (i.e., accuracy and work completion) rather than
specific task-related behaviors (i.e., attention to task or staying in
one’s seat). This is important because it promotes accurate teacher
monitoring and organizational skills. Also, these behaviors are
incompatible with inattentive and disruptive behaviors, and may
lead to a reduction in these behaviors (Pfiffner & O’Leary, 1993).
(6) Preferred activities should be used as reinforcers (i.e. free choice,
access to classroom computer). Reinforcers should be rotated as
needed, in order to keep the children interested in them. A reward
“menu” should be created from direct questioning from the child,
regarding what he or she would like to earn. The teacher can also
observe the child engaging in his or her preferred activities in order
to create the reward menu.
(7) In order to increase the likelihood that the child will engage in
appropriate behavior during academic periods, “priming” is rec-
ommended. This includes the teacher reviewing a list of possible
rewards for appropriate behavior prior to beginning the academic
work. This way, the child has a clear idea of what he or she will
earn following the work period, if he or she meets the target
(8) Finally, the intervention program must be routinely monitored and
evaluated. Changes in the contingency program could be based on
teacher-observed problems in the system. In addition, independ-
ent observers may also be enlisted to evaluate effectiveness and
fidelity of the program. Such information will help to determine
whether additional teacher training or support is necessary.
164 DITZA ZACHOR et al.

A discussion of classroom management strategies in greater detail

now follows.

Token Economy
Token economies provide immediate reinforcement, specific rewards,
and potent rewards, which are often required for children diagnosed with
ADHD. In a token economy, one or more problematic behaviors are tar-
geted for intervention. Target behaviors that focus on academic products
(i.e., completion of a specific number of problems, at a specific rate of accu-
racy) or specific actions (i.e., appropriate interactions with a peer) are often
appropriate. Behaviors that can be easily monitored should be selected.
In addition, the type of secondary reinforcer should be identified. These
can include poker chips, check marks, stickers on a card, or points. For
younger children, more tangible rewards are often recommended, whereas
older children may respond well to check marks or points. A token econ-
omy is not recommended for children under the age of five, rather primary
reinforcers (i.e., praise, social attention) are often suggested. The values
of target behaviors can then be determined. That is, the number of tokens
earned for completion of a target behavior is established.
The teacher and child then develop a list of rewards or privileges
for which the tokens can be exchanged. This list should include
low, medium, and high-cost items. Parents should be encouraged to
participate in this process, and also provide similar reinforcement
contingencies in the home setting. The child should then be taught the
new system. Initial targets are to be set at a level to ensure child success.
Tokens should be exchanged for classroom privileges at least once
daily. In addition, an ongoing evaluation of such a system is necessary,
where new behaviors could be added, mastered behaviors deleted, and
rewards changed or updated. A response cost (i.e., removal of tokens)
system may be incorporated when some appropriate behavior has been
achieved. The system should continue to be changed in order to promote
behavioral improvement and generalization. For example, as a child
masters a multistep task, the child should begin to receive tokens for
task completion and tokens for completion of each step should be faded
(DuPaul & Stoner, 2003).

Contingency Contracting
Another method of classroom behavior management is contingency
contracting. With this technique, there is a negotiated contractual agree-
ment between a student and a teacher. Desired behavior and consequences
contingent on this behavior are discussed. This strategy is most effective
with children above the age of seven. In addition, a contingency contract
with children diagnosed with ADHD should not include an extended delay
between the behavior and designated consequences. Reinforcements at
the end of a work period or at the end of the school day may be most
appropriate (DuPaul & Stoner, 2003).

Response Cost
Response cost includes the loss of privileges and points or tokens contin-
gent upon negative behavior. Response cost, used in concordance with posi-
tive reinforcement procedures, is often successful. When used with positive
strategies, response cost increases on-task behavior, seatwork productivity,
and academic accuracy in children diagnosed with ADHD (DuPaul, Guevre-
mont, & Barkley, 1992). An important point to consider when implementing
a system that includes a response cost condition is that the program should
emphasize positive aspects (i.e., earning points/tokens/stickers) over the
negative response cost component. This will be important in order to con-
tinue to motivate the child to engage in appropriate behavior.

Time Out
Time out is another type of mild punishment strategy that may be used
for the classroom. This technique involves restricting a child from positive
reinforcement. In order to be effective, this approach must be used when
there is a reinforcing environment to be removed from, when the function
of the child’s behavior is to gain teacher attention, when it is implemented
immediately after the negative behavior occurs, and when the smallest
amount of time for the strategy to be effective (e.g., one to five minutes) is
used. Similar to the use of response cost strategies, time out should only
occur with ongoing positive reinforcement. Time out should only be used
if more positive and less restrictive behavioral strategies have failed to
address the negative behavior. However, more aggressive or severely dis-
ruptive behaviors should immediately result in the use of strategies such
as time out (DuPaul & Stoner, 2003).

Daily Report Cards

Home–school communication systems, such as daily report cards,
are effective in promoting behavioral change in the classroom. The benefit
to such systems include the child receiving direct contingent feedback
on behavior, daily feedback from a child’s teacher is received by parents
(Chronis et al., 2004), and the possibility of reinforcement for appropriate
behavior in both the home and school environment is present. Please see
an example of a daily report card [adapted from Barkley (1997)] in Figure
6.1. Target behaviors are established for the child. These behaviors are
rated across subject areas throughout the school day.
The ratings include a 1–5 rating pertaining to how well the child per-
formed the behavior in question. This lends itself nicely to both a school
and home token economy system, where the child can earn a certain
number of tokens per appropriate rating. Likewise, response cost condi-
tions could be employed, where the child loses tokens or points for nega-
tive ratings. Although teachers can control the rewards for behavior in the
school setting, they have little control over the home-based rewards for
school behavior. Another drawback to this system is the delay involved in
166 DITZA ZACHOR et al.

Daily Report Card
Please rate behavior today in the areas listed below.
Use the following 1-5 ratings:
5 = excellent 4 = good 3 = fair 2 = poor 1 = very poor
Initial the box at the bottom of the column rated.
Send this card home each day! Add comments about
behavior on the back or bottom of the card.
Examples of Behaviors to be rated: Class periods

8–9 9–10 10–11 Lunch 12–1 1–2 2–3

1. Turned in homework/class
2. Began assignment with 3 or
fewer prompts.
3. Completed assignment with
80% accuracy
4. Followed Classroom Rules
Teacher’s initials

FOR _____ (Check them as you do them):

Wrote homework assignments

Teacher checked off homework assignments
Packed books needed for homework
Homework folder
Math book
Science book
Reading book
Social Studies book
Spelling book

Teacher Comments or Updates:

Figure 6.1. Daily Report Card (adapted from Barkley, 1997).

the home-based rewards, which may be difficult for children diagnosed

with ADHD (DuPaul & Stoner, 2003).
In order for this type of system to be successful, target behaviors/goals
should be stated in a positive manner. In addition, academic and behavioral
goals should be included in such a system. One or two of the target behaviors
should be readily attainable by the child. This will help the child to be moti-
vated by the system, and make it more probable for him or her to eventually
achieve more difficult target behaviors. In addition, it is important for the sys-
tem to only include three to four target behaviors in order to keep the teacher
and child from becoming overwhelmed. The daily report card allows for fre-
quent, specific quantitative feedback throughout the school day. In addition,
frequent feedback prevents the loss of motivation for children. For example,

if the child does not meet his target behaviors in the morning, there are still
several chances for him to meet the target behavior throughout the school
day. In addition, there must be long- and short-term rewards implemented
at home for such a system to be successful. Parental involvement in a daily
report card system is essential in its success. Ongoing monitoring and evalu-
ation is also important with such a system.


A goal for the treatment of children with ADHD is often to increase

self-control, which is quite difficult for children diagnosed with ADHD,
given their difficulties with inattention, hyperactivity, and impulsivity.
Self-management systems for ADHD include self-monitoring and self-rein-
forcement. These strategies are often referred to as cognitive-behavioral
interventions, given that they focus on changing cognitions and behavior.
Given the difficulties that children with ADHD have with internalization
of language, these strategies are not commonly used with this population
(Miranda et al., 2006). Research has not found these strategies to be con-
sistently successful (Abikoff, 1985), thus, they are only briefly discussed.

This strategy includes the observation and self-recording of instances
of target behaviors. Typically an auditory or visual cue is used to remind
the child to record her behavior at a specific time. The child would then
record the behavior on a graph on her desk. Attention-related behaviors
have been found to increase with the use of such a strategy (Barkley,
Copeland, & Sivage, 1980). However, some suggest that self-monitoring
is most effective when a child is monitoring task completion or accuracy
instead of attentive behavior.

With self-reinforcement, children are required to monitor, evaluate,
and reinforce their own performance. This type of system is often useful
when other more externally based systems are being faded out (Barkley,
1989). In addition, this type of strategy may be more acceptable at the
secondary level, given that children in this age range are likely to be reluc-
tant to engage in an overt contingency management system (DuPaul &
Stoner, 2003). It is important to keep in mind that children diagnosed with
ADHD often have difficulty accurately rating their own behavior. Often
there is a tendency to remember positive behaviors rather than negative or
off-task behavior. Thus, it will be important to have a discussion with the
child regarding expectations for behavior, including what might warrant
a lower rating. The child will also need to be informed of privileges that
may be earned. The goal of such as a system is to eventually train the
child to monitor his or her own behavior, without constant feedback from
a teacher (DuPaul & Stoner, 2003).
168 DITZA ZACHOR et al.

Instructional Strategies
In addition to contingency management strategies, children with
ADHD also benefit from more instructional strategies in the areas of aca-
demics, learning, and study and social skills (DuPaul & Stoner, 2003).
Peer tutoring is an instructional strategy that can be helpful for children
diagnosed with ADHD. This consists of two students working together on
an academic activity, with one student providing assistance, feedback,
and/or instruction. For this strategy to be successful, it is important for
there to be a one-to-one ratio, that the instruction remain self-paced by
the learner, that there is continuous prompting, and that there is frequent
and immediate feedback about the quality of performance.
In addition, task modifications can also help to improve the performance
of children diagnosed with ADHD. This involves revising the curriculum or
aspects of it in an attempt to reduce problem behaviors. One such strategy
is choice-making, where a student chooses an academic task from two or
more options. Dunlap et al. (1994) examined this modification and found
that it resulted in reliable and consistent increases in task engagement and
a reduction in disruptive behavior. Increased task structure is also noted to
improve behavioral functioning in the classroom (Zentall & Leib, 1985).
Social skills instruction is also another important strategy for children
diagnosed with ADHD, given their difficulties with making and keeping
friends. Typically social skills training consists of role-playing a variety of
skills, such as asking questions, listening, cooperating, complimenting, and
so on. Researchers have approached social skills trainings from many fronts.
More specifically, at times the children practice the skills daily in the classroom
(Anahalt et al., 1998). Other methods include a social skills review with a peer
through a buddy system (Hoza et al., 2003). Social skills training can also be
woven into sports activities, where students practice their social skills in a
less-structured environment (Evans et al., 2004; Hoza et al., 2003).
In summary, classroom behavior management strategies include token
economies, contingency contracting, response cost, and time out. Self-evalu-
ation and other instructional strategies have also led to some behavioral and
social improvement for children diagnosed with ADHD. Such systems should
include an individualized approach to addressing child needs, while using
data to guide the creation, implementation, and revisions of the program. The
most successful school-behavior plans for children diagnosed with ADHD are
those which include a team approach (i.e., teachers, parents, peers), where
there is adequate support and training for each member of the team. In addi-
tion, classroom behavior plans should be implemented in an ongoing man-
ner, given the chronic nature of ADHD.


There is a consensus from numerous empirical sources that behavioral

parent training and behavior contingency management in the classroom
are well-established treatment approaches for children with ADHD (e.g.,
Chronis, Jones, & Raggi, 2006; Lonigan, Elbert, & Johnson, 1998; Pelham

& Fabiano, 2008). More recently, convincing evidence for the treatment
efficacy of intensive summer treatment programs has been presented (Pel-
ham & Fabiano, 2008). These programs are peer-based interventions and,
therefore, emphasize the development of social skills within an appropriate
social context. In this way, they are similar to other social skills programs
that utilize peers but these other programs have generally failed to meet
the stringent criteria for a well-established, evidence-based intervention
for ADHD (e.g., Antshel & Remer, 2005). Summer treatment programs dif-
fer from other behavioral peer interventions in terms of the intensity and
comprehensiveness of the intervention.
Summer treatment program (STP) interventions are typically day-
long programs conducted for multiple weeks (e.g., five to eight weeks)
thereby delivering hundreds more hours of treatment compared to the
typical outpatient program. The intervention adopts a broad skills-
building approach conducted concurrently with contingency manage-
ment systems such as a point or token system and time out procedures.
The focus on the development of socially important functional skills
and the use of direct observational methods during group peer interac-
tions are hallmarks of the program.
Figure 6.2 illustrates a daily schedule for a STP with three groups.
The typical STP program is multifaceted and incorporates numerous
intervention components including social skills training, problem-solv-
ing discussions, sports skills and team membership development, aca-
demic and art instruction, contingency management systems, parent
education, and a home-based reward program (Pelham, Greiner, &
Gnagy, 2004). The program’s extensive procedures have been manual-
ized and incorporate features for daily monitoring of a broad range of
child behaviors and daily monitoring of counselors and teachers for
treatment fidelity (Pelham, et al., 2004). Because of the intensity and
comprehensive nature of the program, however, it is considerably more
difficult to implement than typical psychosocial interventions, a factor
that may currently limit its clinical utility in typical community settings
(Pelham & Fabiano, 2008).
The STP model was designed as an intensive summer day-treat-
ment program primarily for children with ADHD and related disorders.
The model for the STP has been developed over a period of 25 years by
William Pelham, first at Florida State University, then the University of
Pittsburgh, and currently at SUNY Buffalo (Pelham et al., 2004). This
program has also been established and replicated in sites across the
country, as well as internationally (Yamashita et al., 2006). The STP
was an integral component of the psychosocial treatment package of
the Multi-modal Treatment Study, the largest randomized clinical trial
ever conducted for the treatment of ADHD (MTA Cooperative Group,
1999a). As a result of its exceptional record in clinical, training, and
research endeavors, the STP was named in 1993 as a Model Program
for Service Delivery for Child and Family Mental Health by the Section
on Clinical Child Psychology and Division of Child, Youth, and Family
Services of the American Psychological Association (Pelham, Fabiano,
Gnagy, Greiner, & Hoza, 2005).
170 DITZA ZACHOR et al.

Prior to 1998, the evidence base supporting the effectiveness of STPs was
relatively weak, relying primarily on uncontrolled pre–post studies (Pelham &
Hoza, 1996) and analogue studies (e.g., Pelham & Bender, 1982). A number
of these earlier studies also focused on ADHD medication trials because the
STP model provides an excellent setting in which to evaluate medication
effects (e.g., Pelham, McBurnett, Milich, Murphy, & Thiele, 1990). For exam-
ple, STPs have been an important site for the development of the methylphe-
nidate transdermal patch, now approved for the treatment of ADHD by the
FDA (Pelham, Manos et al., 2005). More recently, however, attention has been
focused on the systematic and well-controlled study of the treatment efficacy
of behavioral components of STPs and establishing the empirical support for
their therapeutic potential. This is due in part to the inclusion of the STP as
a component of treatment for the MTA study.
As discussed in another section of this chapter, debate continues over
how best to interpret the results of this large multisite collaborative study
(e.g., Pelham, 1999) but the empirical support for the role of intensive
behavioral interventions such as STPs in improving the functional impair-
ments associated with ADHD appears to be quite strong (e.g., Chronis,
Fabiano, & Gnagy, 2004). In fact, several recent studies have found that
STPs yield treatment effect sizes that are comparable to those reported for
stimulant medications.
Pelham et al. (2000), as part of the MTA study, examined the incre-
mental effect of a well-controlled medication regimen when combined
with the intensive STP treatment across a broad range of measures,
including parent and teacher ratings, classroom observations, and
academic performance. This study differed from earlier MTA reports
because it measured treatment effects while each intervention (i.e.,
behavioral and medication) was active. In 1999, the initial report of
the MTA (MTA Cooperative Group, 1999a,b) showed large incremen-
tal effects of medication over behavioral intervention alone and small
incremental improvement for the combination of treatments over medi-
cation alone, however, it was conducted when most of the behavioral
treatment package (including the STP) had been stopped or faded.
The Pelham et al. (2000) study compared the two treatments when
both were active and found that the introduction of adjunctive stimulant
medication to an ongoing STP had no effect on the rate of improvement
and produced relatively few incremental gains on measures of acute

Morning Afternoon
8:00–8:15 – Social Skills 12:15–1:15 – Softball
8:15–9:00 – Soccer skills 1:30–2:30 – Art/Snack
9:15–10:15 – Soccer game 2:45–3:00 – Yoga
10:30–11:30 – Learning Center 4:00–5:00 – Recess/ Departure
11:30–12:00 – Computer Skills
11:45–Noon – Lunch
Figure 6.2. A typical STP schedule.

functioning. On 30 of 35 treatment outcome measures the combination

treatment group did not differ from the behavioral intervention of the STP
and parent training. A notable measure showing an incremental benefit
for medication was peer ratings of acceptance, suggesting peers may have
been more sensitive to some aspect of medication response. The study
authors argue that the traditional approach to behavioral interventions
that involve fading and stopping the more intensive procedures may not
be appropriate for externalizing behavior disorders such as ADHD, given
the known chronicity of this disorder.
Only two studies to date have evaluated the entire multicomponent
behavioral STP intervention to a control condition in which treatment
components are removed. Kolko, Bukstein, and Barrett (1999) manipu-
lated both medication and behavioral interventions in classroom and
recreational settings in a STP located in an urban setting with children
exhibiting ADHD and comorbid disruptive behavior disorders. They
reported that medication and behavioral intervention each demon-
strated unique and incremental effects on behavior that differed across
settings and individual children. The behavioral intervention improved
oppositional behavior in both settings and improved ADHD symptoms,
prosocial behavior, and peer conflicts in the classroom. Behavioral
intervention resulted in incremental effects beyond the effects of medi-
cation on negative behavior in the recreational setting.
Medication improved ADHD symptoms in both settings, and oppo-
sitional behavior and peer conflicts in the recreational setting. There
were no incremental effects of medication beyond behavioral interven-
tion in the classroom. Chronis et al. (2004) utilized a BAB treatment
withdrawal experimental design in which the behavioral components of
the STP (i.e., contingency management procedures, time out, and social
skills training/problem-solving) were withdrawn in the sixth week of
the program. Four groups comprising 44 children participated in the
study. The withdrawal phase left the remaining aspects of the program
intact (i.e., close adult supervision, high staff-to-child ratio, feedback
on behavior, sports skills training). The treatment phase was reintro-
duced after two days and even earlier for two groups whose disrup-
tive behavior presented safety concerns. Across numerous measures
of behavior, academic functioning, and teacher, counselor, and child
ratings, substantial behavioral deterioration occurred during the with-
drawal period. Behavior returned to previous levels when the behavio-
ral intervention procedures were reinstated.
The STP incorporates a wide range of specific behavioral procedures
with proven evidence-based efficacy, including: time out, a point system,
individualized target behaviors, daily report cards, social skills training,
and a parent-training program. The parent-training component involves
weekly sessions throughout the duration of the program and is char-
acterized by a very high attendance rate. Parents are given challenging
parenting problems and encouraged to problem-solve in small groups
(Cunningham, Bremmer, & Boyle, 1995). Regarding the social skills
training component, the STP has typically emphasized a small number
of general social skills (e.g., validation, cooperation) that are discussed in
172 DITZA ZACHOR et al.

role-playing and problem-solving sessions at the beginning of each day

then discussed before and after each activity.
More recently, the STP at the University of Alabama at Birmingham
developed a more comprehensive social skills training component that
incorporates 14 specific behaviors, scripted role plays for counselors and
children, and weekly rewards (Patterson & Guion, 2007). The time out pro-
cedure in the typical STP is notable for having built-in incentives for com-
pleting a time out appropriately (i.e., reduced time) and disincentives for
lack of cooperation with time out (i.e., additional time added). Individual
target behaviors are developed for each child at the end of the first week
Therefore, it is difficult to determine the effect of any specific pro-
cedure within this broad context without systematically evaluating the
impact of each procedure while holding other components of the program
constant. This was the goal of a recent study by Fabiano et al. (2004) of
the time out procedure. The STP time out procedure is used when children
exhibit any of three behaviors: intentional physical aggression, intentional
property destruction, or repeated noncompliance.
A relatively unique aspect of the STP time out procedure (at least in
terms of researched variables) is the opportunity for the child to earn
an incentive for appropriate behavior during time out, that is, reduced
time. For example, if the child is issued a 20-minute time out for physical
aggression and goes immediately to the time out area without complaint
and remains there quietly, the time out is reduced to only 10 minutes. On
the other hand, the child can also have their time out escalated if they
exhibit any negative behaviors during the time-out, up to a maximum of
one hour.
Fabiano et al. evaluated the effectiveness of three types of time
out procedures versus a no time out condition in which no time outs
were issued. The three types of time-out were the typical escalating/
de-escalating procedure described above, a short (5-minute), and long
(15-minute) time out with no contingency on time out behavior. All three
types of time out were more effective than the no time out condition in
reducing the occurrence of physical aggression, property destruction, and
repeated noncompliance in both classroom and recreational settings. These
results were obtained while all other aspects of the intensive treatment
remained in effect. There were no group differences between the three time
out procedures, suggesting that the commonalities (e.g., removal from
a reinforcing activity) were more important than the parameters under
investigation. In evaluating the impact of adding the time out procedure
to the treatment package, the study authors found effect sizes that were
comparable if not superior to the effect sizes obtained when stimulant
medication therapy was added.
The effects of STP behavioral interventions versus stimulant medi-
cation therapy have been evaluated more specifically in the program’s
classroom environment in two studies (Carlson, Pelham, Milich, & Dixon,
1992; Pelham, et al., 1993). Both studies employed a crossover experi-
mental design in which behavioral intervention procedures were imple-
mented during some weeks but not others, and behavioral intervention
was crossed with stimulant medication therapy.

Both studies reported significant improvements across a wide range of

objective and teacher-reported measures when the behavioral intervention
procedures were in effect. However, the effects of the behavioral interven-
tion were not significant for all measures and were smaller in size than
the effects of high doses of stimulant medication. A possible explanation
for the relatively weak effect is that the children continued to receive the
full behavioral intervention when they were not in class (e.g., during rec-
reational activities and art class) and this may have had a carryover effect
into the classroom.
More recently, Pelham, Burrows-MacLean, et al. (2005) extended this
research design to the entire STP and crossed it with four doses of stimulant
medication, including a no-medication condition. Behavioral interventions
were removed for alternating weeks for four weeks and medication conditions
were varied across days for each child. The results showed significant effects
of medication and behavioral interventions across classroom and recreational
settings. When combined with behavioral interventions, the lowest dose of
medication produced effects similar to those associated with the highest does
of medication alone. Employing odds ratios, Pelham et al. demonstrated that
the combined use of medication and behavioral interventions produced sig-
nificantly better treatment response than either treatment used alone. For
example, the sequence of adding the behavioral intervention to a low dose
of medication improved the odds of obtained a positive daily report card by
ten times, whereas the sequence of adding the low dose of medication to the
behavioral intervention improved the daily report card odds by four times.
The empirical support for the treatment efficacy of summer treatment
programs is impressive. Concern has been expressed, however, regard-
ing the lack of evidence for the generalization of treatment gains into the
school and home environments (Barkley et al., 2000). This concern has
been addressed to some extent by advocating for the implementation of
STPs within the context of a comprehensive approach to the treatment of
ADHD, one that recognizes the need for intensive interventions and poten-
tially long-term involvement (Pelham, Fabiano, et al., 2005).
Pelham et al. report an approach to treatment that includes a Sat-
urday Treatment Program following the STP. This is a bi-weekly program
that meets September through May with a format and goals similar to the
STP. This program is coupled with school meetings for the establishment
of interventions in the classroom to which the child is returning and peri-
odic booster sessions for parents, all of which provides an ongoing level of
support for the child and family throughout the school year.
Another possible concern regarding STPs is the cost/benefit ratio for
this type for service (Jensen, Hinshaw, Swanson, et al., 2001). This is an
important issue that can be furthered delineated into two more specific
questions: what is the minimal level of behavioral intervention required to
achieve desired results, and which children are going to benefit most from
these interventions? Current research is focused on answering these two
questions. Pelham and his research group are systematically evaluating
the effects of altering the length, staff-to-child ratios, and other aspects of
the STP model to determine the most important parameters for behavior
change and how to most efficiently deliver an intensive service.
174 DITZA ZACHOR et al.


There have been many methods and procedures highly touted as effec-
tive treatments for ADHD (e.g., Feingold, 1974) but only a handful have
stood the test of randomized and well-controlled clinical trials and repli-
cation. These are the evidence-based approaches described in this chap-
ter, that is, medication (primarily stimulants), parent behavioral training,
classroom management strategies, and intensive peer-based interven-
tions such as the summer treatment program that incorporate all of these
approaches in a comprehensive package. Even among these scientifically
validated approaches, it appears they are effective only when active and
may not lead to enduring changes if stopped.
Increasingly, researchers and clinicians in the ADHD field recognize
the chronic and intractable nature of this disorder as they attempt to
further develop and refine intervention methods that provide the needed
level of support and treatment on a continual and long-term basis. The
heterogeneity and variability in both the behavioral phenotype of ADHD,
its likely underlying neural bases, and the many genetic, physical,
and psychological contributing etiological factors are also increasingly
recognized as adding to the complexity of devising treatment strategies
that will apply effectively to the disorder as a whole (e.g., Nigg & Casey,
2005). It is clear that a unitary treatment approach will likely never be
the case and the continuing developments in neuroscience, molecular
genetics, and other scientific fields will likely lead to further refinements
and the identification of important ADHD subtypes, which have direct
implications for treatment.
Currently, clinicians are encouraged to carefully monitor the treat-
ment response of each child with ADHD and consider the relative mer-
its of a multimodal approach that incorporates some combination of the
strategies described in this chapter. Researchers are currently evaluat-
ing the critical components of the multimodal approach, in particular the
sequence with which different treatments are introduced and the relative
“dose” of each treatment that is required to produce the desired level of
change and sustain it over time. Parents of children with ADHD have made
it clear that the level of change they desire for their families goes beyond
the simple reduction of ADHD symptoms and includes the improvement of
functioning in all important areas of daily living.


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PTSD, Anxiety,
and Phobia


The treatment of childhood anxiety disorders is one of the most interest-

ing and gratifying experiences in clinical psychology. For example, by using
techniques such as exposure to feared stimuli, a clinician can regularly effect
significant reductions of psychopathology in many youth in as little as a single
session for some disorders (e.g., specific phobias; cf., Öst, Svensson, Hellström,
& Lindwall, 2001). Moreover, the clinician is afforded the invigorating oppor-
tunity to handle and manage various stimuli (e.g., snakes, dogs, and insects)
that defy the common treatment session stereotype. Although certainly not all
anxiety disorders are so quickly amenable to treatment efforts, there has been
something of a renaissance in child anxiety treatment research since the intro-
duction of evidence-based practices (EBPs) over a decade ago and the identifi-
cation of the first empirically supported treatments (ESTs) for children.
Simultaneously, however, this attention and research is overdue and
deserved. There is an urgent need to continue child treatment research,
particularly with anxiety disorders. Based upon a recent review, it has
been estimated that between 2.4% and 23.9% of preadolescent children
have anxiety disorders depending on the disorder(s), sample, time period,
and methodologies used (Cartwright-Hatton, McNicol, & Doubleday, 2006).
Moreover, results of at least one study indicate that by 16 years of age 36.7%
of children will meet diagnostic criteria for at least one DSM-IV disorder
(i.e., Diagnostic and Statistical Manual of Mental Disorders–fourth edition,
American Psychiatric Association, 1994), and that 9.9% will meet criteria for
an anxiety disorder (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003).
Anxiety disorders in children have been associated with interference
in academic endeavors (Last, Hansen, & Franco, 1997) and even include

THOMPSON E. DAVIS III • Louisiana State University

J.L. Matson et al. (eds.), Treating Childhood Psychopathology 183

and Developmental Disabilities, DOI: 10.1007/978-0-387-09530-1,
© Springer Science + Business Media, LLC 2009

statistically and clinically significant decrements in intellectual ability (i.e.,

IQ) when compared to children with no psychopathology (Davis, Ollendick,
& Nebel-Schwalm, 2008). Childhood anxiety disorders are also commonly
associated with social (e.g., social incompetence) and emotional (e.g., depres-
sion) difficulties that can further affect healthy development (e.g., Grills &
Ollendick, 2002; Kovacs, Gatsonis, Paulauskas, & Richards, 1989; McGee,
Feehan, Williams, & Anderson, 1992). Moreover, the effects of anxiety have
been found to continue into young adulthood and include increased risks
for added psychopathology and educational difficulties (Cantwell & Baker,
1989; Seligman & Ollendick, 1999; Woodward & Fergusson, 2001).
Even though child anxiety treatment research has flourished over the
last decade with 26 randomized clinical trials (RCTs) included in the review
that follows, much of the extant literature remains dated with monumen-
tal gaps in our understanding of how to best treat child anxiety disorders.
For example, although studies are underway, no RCTs have been pub-
lished to date specifically examining the effects of treatment on generalized
anxiety disorder, separation anxiety disorder (note: several studies have
examined them in combination with other disorders; e.g., Kendall, 1994),
or panic disorder.
This chapter briefly reviews anxiety and its disorders affecting children
and then elaborates on the current state of the empirical evidence sup-
porting behavioral and cognitive-behavioral treatments. Those interested
in more detailed descriptions of cognitive-behavioral therapy or pharma-
cotherapy are directed to Chapters 3 and 5 in this volume. Additionally,
the reader is directed to Chapter 10 in the companion volume (Matson,
Andrasik, & Matson, in press) of this work and to the recent review by
Silverman and Ollendick (2005) for more detailed assessment procedures
and recommendations.


Normative and Diagnostic Considerations

Anxiety and fear are common emotional responses and not typically
the focus of clinical attention unless they are experienced with unusual
intensity, frequency, duration, or content (DSM-IV-TR, American Psychi-
atric Association, 2000). Nonclinical fear and anxiety are even adaptive
and healthy emotional experiences and display a normative pattern across
development. The occurrence and intensity of fears typically decrease with
age (Gullone, 2000), whereas the capacity for worry increases with age
and cognitive development (Muris, Merckelbach, Meesters, & van den
Brand, 2002). Children’s development emotionally can be loosely tied to
their development cognitively (i.e., tied to developmental capabilities from
concrete to increasingly elaborate and abstract thought). Children move
from very specific, concrete fears of the surrounding environment during
infancy (e.g., loud noises, separation); to fears of the supernatural, physi-
cal harm, and criticism in childhood; and finally to fears of social situa-
tions, global events, and more abstract or anticipatory concerns (Gullone,

2000). Most of these fears subside with age, however, a fear of death and
danger generally persists throughout development (Gullone, 2000).
Clinical levels of fear and worry typically distinguish themselves from
this common developmental course by an undue persistence and intensity
of fearful and anxious reactions. Most fears and anxieties are presum-
ably corrected through disconfirmatory experiences (e.g., corrective infor-
mation, positive encounters, experience coping with negative encounters,
repeated exposures) in concert with increases in cognitive-developmental
capabilities. As a result, strong lingering fears and worries are typically
the subject of clinical attention. DSM-IV-TR attempts to incorporate this
developmental understanding of psychopathology through the setting of
somewhat arbitrary duration criteria for children. Depending upon the
anxiety disorder, symptoms must be present for one to six months in chil-
dren before a diagnosis can be made. For example, given the normative
development of fear outlined above, psychopathological fear in children
must persist for at least six months before a diagnosis is warranted (cf.
specific phobia; DSM-IV-TR). Unfortunately, beyond this and other minor
developmental adaptations, the assessment, diagnosis, and treatment of
children is still overly influenced by theories and practices from the adult
literature, although approaches based on children are slowly emerging
(Barrett, 2000).
Depending upon how one counts disorders in the DSM-IV-TR, there
are as many as 13 broad anxiety-related diagnostic categories applicable
to children: separation anxiety disorder, panic disorder, agoraphobia, spe-
cific phobia, social phobia, obsessive-compulsive disorder, posttraumatic
stress disorder, acute stress disorder, generalized anxiety disorder, anxiety
disorder due to a medical condition, substance-induced anxiety disorder,
anxiety disorder not otherwise specified, and adjustment disorder with
anxiety or mixed with anxiety and depressed mood. Although the valid-
ity of the DSM nosology has been repeatedly challenged (e.g., Achenbach,
2005), these anxiety disorders are generally meant to capture variations in
the focus of the anxiety or fear and its maladaptive expression (e.g., social
worries, separation worries, pervasive worry). The present chapter focuses
on several disorders that have been the primary focus of research with
children (see Table 7.1).

Even though anxiety disorders are among the most prevalent mental
health concerns in children, the various paths leading to their acquisition
have not been completely determined at this time. The literature is divided
into associative, nonassociative, and integrated accounts. Although a
detailed discussion of this debate is beyond the scope of this chapter (see
Fisak & Grills-Taquechel, 2007; Muris, Merckelbach, de Jong, & Ollen-
dick, 2002), four pathways of acquisition have been suggested that can
work individually or in combination: acquisition by way of direct condi-
tioning experience, acquisition by way of vicarious learning, acquisition by
way of information about the stimulus, and acquisition by nonassociative
means (Ollendick & King, 1991; Rachman, 2002).

Table 7.1. Characteristics of DSM–IV–TR Anxiety Disorders Chosen for Review

Disorder Description
Separation SAD is the only specifically childhood anxiety disorder in the DSM-IV-TR.
Anxiety The primary feature is persistent concern, excessive distress, and/or
Disorder (SAD) worry associated with real or imagined (e.g., kidnappers) separation
from home or primary attachment figures.
Panic Disorder The primary feature of PD is the presence of an intense, recurring, and
(PD) generally unpredictable, physiological reaction and anxious sensation
(i.e., a panic attack) that leads to significant concern, worry, or avoid-
ance behavior.
Specific Phobia The primary feature of SP is a markedly intense fear of specific identifia-
(SP) ble objects, animals, situations, environments, and the like that evoke
an anxiety response and lead to significant avoidance and/or distress.
Social Phobia The primary feature of SoP is a markedly intense fear of social situations
(SoP) or performances in which social evaluation may take place leading to
an anxiety response and significant avoidance and/or distress.
Obsessive- The primary features of OCD are persistent obsessions (thoughts or
Compulsive impulses) or compulsions (repetitive compensatory behaviors), and
Disorder (OCD) typically both, that significantly interfere with life for more than one
hour each day.
Posttraumatic The primary features of PTSD follow exposure to death or a life-threaten-
Stress Disorder ing situation in which helplessness, fear, hopelessness, or horror were
(PTSD) intensely experienced. Features fall into re-experiences of the trauma,
avoidance of trauma cues and situations, numbing, and increased,
persistent physiological hyperarousal.
Generalized The primary feature of GAD is persistent (occurring more days than not),
Anxiety excessive, uncontrollable worry regarding myriad domains and topics
Disorder (GAD) that is associated with intense somatic symptoms or disturbance.

In addition, the case may be that learned and innate accounts of fear and
anxiety acquisition are merely different extremes on the same continuum
(Marks, 2002). Developmental experiences and the unique predispositions
of a child may lead to an acute, innate, defensive fear or anxiety at one end
or a traditionally conditioned disorder resulting from traumatic experience
at the other. In essence, the developmental question regarding the etiology
of anxiety may be how much association to a stimulus is required given a
particular child or adolescent’s innate predisposition and intensity of phys-
iological response to the stimulus (Marks, 2002).

Family also plays a role in the development and maintenance of anxiety.
The child is most often seen as the patient in therapy, however, the
effects of the family environment and relational ties to its members can
have varying influences on child anxiety. The literature on the rela-
tionship between family and anxiety in children has generally focused
on parental acceptance, overcontrol or overprotection, and the parental
modeling of anxious behaviors. According to a review of nonretrospective

studies by Wood, McLeod, Sigman, Hwang, and Chu (2003), parents

who were observed to be more critical and less accepting were associ-
ated with children with anxiety or anxiety disorders. Similarly, anxiety
in children has been associated with parents observed to be overcon-
trolling or overprotective. Finally, parental modeling of anxiety was also
associated with increased child anxiety in the literature. Generally,
findings were stronger for studies using behavioral observation com-
pared to self-report (Wood et al., 2003).
Although the direction of these influences has yet to be established, the
family environment and its members are variables that the clinician must
incorporate into treatment. For example, slightly better long-term treat-
ment response has been found for children receiving a cognitive-behavio-
ral treatment designed to address these family issues than for children not
receiving the family component (Barrett, Dadds, & Rapee, 1996).

Throughout a typical day discussions regularly focus on “feeling” a
certain way. Objectively, this “feeling” is a very complex event composed of
physiology, behavior, and cognition (Lang, 1979) and has been the subject
of decades of psychological theory and empiricism. Several theories of
emotion have been developed to explain the relative contributions of physi-
ology, behavior, and cognition to an emotional response. For example, Beck
and Clark (1997) proposed a three-stage schema-based model in which
the initial perception of threat is increasingly elaborated upon through
automatic and strategic processing. Accordingly, anxiety is thought of as
a system of cognitive biases and inaccurate or excessive threat determina-
tions. Barlow (2002) has advanced a triple vulnerability theory in which
biological, generalized psychological, and specific psychological vulner-
abilities interact with stress and chance pairings of panic symptoms (i.e.,
“false alarms”) to produce psychopathology. Similarly, Mineka and Zinbarg
(2006) have updated the learning model by incorporating prior learning
experiences and temperament with more emphasis on social learning
and vicarious learning experiences, in addition to direct experiences and
elaborating on common misconceptions of the associative approach.
Recently, however, an information-processing approach has been dem-
onstrated to be a particularly relevant theory for evaluating treatments for
childhood anxiety (Davis & Ollendick, 2005). Bioinformational theory is
based on an information-processing model of fear in adults, but has grown
to become a theory of the organization of emotion and emotional response,
especially as adapted and elaborated into Emotional Processing Theory
(EPT; Foa & Kozak, 1986, 1998). According to Lang, Cuthbert, and Bradley
(1998), emotions are “action dispositions” that are cued by the stimulation
of relevant associative networks contained in long-term memory (p. 656).
These networks differ from other knowledge structures by incorporating
direct connections to motivational components and are organized within
the broad appetitive and aversive systems (Lang et al., 1998).
Emotional networks and emotional responses can be categorized
broadly as belonging to either approach and pleasure networks or fight

and flight networks. These networks, in turn, are composed of associations

of concepts and units of information. These units of information are sub-
divided into three conceptual types: response, stimulus, and meaning
(Drobes & Lang, 1995; Foa & Kozak, 1998; Lang et al., 1998). Response
units evolved from Lang’s early work and are associated with the three
components of an emotional response: physiology, behavior, and cognition.
Stimulus units contain information relating to the sensations associated
with a stimulus and serve to cue much of the associative network. Mean-
ing units serve to connect sensations and responses and contain semantic
or declarative knowledge (Drobes & Lang, 1995; Lang et al., 1998).
Lang et al. (1998) stated two main assumptions of bioinformational
theory. First, emotional networks are triggered by an accumulation of
information that matches units of information represented in long-term
memory. Given the context and qualities of this incoming information,
little, part, or all of an emotional network may be activated. Also, lan-
guage is not a necessary component in this process (Lang et al., 1998).
An emotional network is composed of a great deal of information broadly
categorized into the three types mentioned previously. Language is utilized
to encode and activate some parts of an emotional network; however, lan-
guage is not the sole means of encoding or processing emotion.
Emotional networks are composed of complex associations among units
of information, such as conditioning experiences, representations of stim-
ulus qualities, behavioral responses, physiological responses, and verbal
responses. The conscious processing of many of these associations is not a
prerequisite of their encoding or activation. Causal connections frequently
elude the attention of the conscious mind (e.g., classical conditioning). As
such, language is but a small part of the information that can trigger the
activation of an emotional network (Lang et al., 1998). The theory does, how-
ever, allow for representations to be processed by the conscious mind. These
representations are interpreted to be the subjective experience of emotion.
Second, Lang et al. (1998) assume that increased coherence within an
emotional network will increase the likelihood for activation of that net-
work. More specifically, when units of information in an emotional network
have increased associative strength among them (i.e., greater coherence),
the activation of a single unit is more likely to facilitate the stimulation of
other representational units in the network and evoke the emotion. In addi-
tion, the repeated activation of an emotional network potentiates its activa-
tion and has a priming effect. The resulting coherence allows vague stimuli
to more readily access the emotional network and activate varying degrees
of the emotional response. For example, a curled hose detected in weeds
will readily initiate the processing of a snake phobic individual’s associated
emotional network (Lang et al., 1998). In this way, a variety of different
stimuli may activate an emotional network that has greater coherence.
Any of the three types of units stimulate the activation of associated
units in the emotional network. The emotional network is activated when
incoming information increasingly overlaps with units of information con-
tained in that network. The matching information begins to aggregate in
working memory until an emotional network is triggered. The subsequent
constellation of physiological, behavioral, and cognitive responses is an

emotion. The emotional intensity, verity, and response depend on the

type and number of units of information activated within a network. The
result is that an emotion is a differentially assembled amalgam of sensory,
motoric, physiological, and semantic elements.
The process described above is a dynamic one. One part of the process
does not occur in a void without the others. Incoming information leads
to the activation of emotional networks which further leads to emotional
responding which leads to more incoming information and so forth. The
processing of these emotional networks is key to the actual structure of
that network changing or remaining the same (Lang, 1977). Moreover, ini-
tial findings have indicated children may process aspects of emotion in
behavioral, cognitive, and physiological ways similar to that of adults (e.g.,
affective pictures; McManis, Bradley, Berg, Cuthbert, & Lang, 2001).
As described above, bioinformational theory provides an account of
the activation of fear and anxiety networks and associated responses. In
essence, fear and anxiety are conceived of as neural programs that facili-
tate escape and the avoidance of danger or threat (Foa & Kozak, 1986).
Everyone experiences fear and anxiety, and in most circumstances that
fear and anxiety dissipate as the potential for harm decreases. Patho-
logical fears and worries differ, however, from other networks in several
meaningful ways. Pathological networks incorporate inaccurate views of
the world that are accompanied by exaggerated emotional responses, the
avoidance of harmless stimuli, and an overall resistance to change (Foa &
Kozak, 1986, 1998).
Bioinformational theory also incorporates an explanation for incom-
plete emotional responses to stimuli. Rachman (1976) suggests that
there are eight possible combinations of physiological disturbance, avoid-
ance behavior, and subjective fear (cognition) when considering emo-
tional responding. When all three components of an emotional response
are concordant (i.e., positively correlated) and synchronous (i.e., change
together; Rachman & Hodgson, 1974), then the network has been fully
activated (Lang, 1977). However, when the characteristics of the stimu-
lus are insufficient to activate the entire network, no response or a par-
tial response may result (Lang, 1977). The lack of covariation among the
response components is called discordance, and the potential for emo-
tional responses to change independent of one another or change inversely
is termed desynchrony (Rachman & Hodgson, 1974). The properties of
the stimulus situation are not sufficient in these instances to evoke the
full emotional response. Additionally, desynchrony may be the result of
a particular response being potentiated after repeated activation. In this
instance, the associative network is organized primarily around stimuli
that activate a particular response component.
Desynchrony depends on several factors. Specifically, “it is a function
of the intensity of emotional arousal, level of demand, therapeutic tech-
nique, length of follow-up, and choice of physiological measure” (Hodg-
son & Rachman, 1974, p.325). Desynchrony is thought to decrease during
high arousal, increase during high demand (i.e., increasing motivation),
and vary by treatment modality. Even so, a critical component of treat-
ment outcome seems to be the activation of the entire emotional network

(Foa & Kozak, 1986, 1998; Lang, 1979). Therapeutic technique (e.g., expo-
sure) may, however, necessitate the uncoupling of fear (i.e., physiological-
affective response and verbal-cognitive response) and behavioral avoidance
(Hodgson & Rachman, 1974). Even so, the synchrony of heart rate (physiol-
ogy) and subjective units of distress (cognitions) has been associated with
greater treatment benefit and desynchrony between these components with
a lack of response to treatment (Vermilyea, Boice, & Barlow, 1984).

Applying Theory to Practice

Treatment as Modification of an Emotional Network
According to bioinformational theory and EPT (Foa & Kozak, 1986,
1998), a lack of emotional processing is a critical element in the main-
tenance of pathological fear and anxiety. Emotional processing prompts
alterations in emotional networks that can lead to an increase or decrease
in emotional responding (Foa & Kozak, 1986). Lang (1977) suggested that
the modification of an emotional network is dependent upon at least partial
activation of that network. Vivid imagery or representations of a stimulus
will activate more information units and lead to increasingly comprehen-
sive processing of the network.
In order for emotional processing to occur, the network must be
accessed and new information must be introduced (Foa & Kozak, 1986). It
is important to note that this new information should be considered just
that—new learning—and not the “unlearning” of previous responses (e.g.,
Myers & Davis, 2002). Essentially, a new context-dependent inhibitory
response has been learned that does not destroy previous learning, but
rather provides an alternative to it (Bouton, 2004). The avoidance associ-
ated with an anxious or phobic response not only negatively reinforces the
behavior (i.e., reinforcement for leaving an anxiety-provoking situation)
but also interrupts any activation that would lead to emotional process-
ing. Emotional processing can also lead to the exacerbation of an existing
pathological fear network. If the activation of a pathological fear network
were associated with the introduction of new negative information, then an
increase in phobic responding would be expected to occur (Foa & Kozak,
1986). For example, existing dog phobia symptoms would be expected to
become more severe subsequent to a dog bite.
Emotional processing is also integral to any successful therapeutic
intervention according to EPT. As before, the memory network must be
engaged and new information must be assimilated into the network. In
therapy, however, the information introduced into the emotional network
must be inconsistent with previous phobic experience and associated mem-
ory structures (Foa & Kozak, 1998). Meaningful therapeutic benefit occurs
as the result of network modification. If treatment were successful and the
pathological fear network were activated and modified, then the intensity of
the fear response should decrease. For example, systematic desensitization
could be described as accessing memory through exposure and offering
new physiological and behavioral information (i.e., relaxation) that is coun-
ter to the physiological information held in the pathological network.

Developmental Psychopathology
A complete approach to treating childhood anxiety requires consider-
ation of developmental psychopathology and the broader context of how
psychopathology interacts with the child’s emotional, cognitive, and social
growth. Successful development requires negotiating myriad developmental
milestones and integrating each successive achievement into an increas-
ingly adaptive outcome. Conversely, incomplete milestones, trauma, and
insults can impede development leading to maladaptive outcomes from the
failure to traverse developmental milestones during key sensitive and critical
periods (Ollendick & Vasey, 1999; Toth & Cicchetti, 1999). In particular, the
individual differences in any one child must be considered through notions
of equifinality (i.e., that different developmental pathways and experiences
can lead to the same outcome) and multifinality (i.e., that similar develop-
mental pathways and experiences can lead to different outcomes).
As a result, treatment of any one disorder in any one child becomes a
complex endeavor in which the child’s memories, experiences, family, rela-
tionships, traumas, responses, etc. are all integrated into unique emotional
networks that have become maladaptive and pathologized and have been
associated with unique developmental insults. For example, an older child
with a fear of separating from a parent (i.e., separation anxiety) not only
presumably suffers from a resistant and maladaptive emotional network
in need of corrective information (i.e., therapy), but has also likely suffered
from social and emotional insults associated with failing to obtain norma-
tive experiences away from the parent. Moreover, treatment for this child
may not just involve providing corrective information through child therapy
and attempting to remedy any developmental insults or deficiencies through
psychoeducation and social skills training, but also may require addressing
the context in which the psychopathology has developed and been main-
tained (e.g., addressing overcontrolling parental behavior). In sum, child
therapy becomes reliant on a thorough and complete assessment of the
child and family in order to plan the best treatment and attempt to remedy
any variables maintaining psychopathology.

According to bioinformational theory and EPT, pathological fear and
worry, consistent with a diagnosis of an anxiety disorder, are types of
emotional networks composed of various conceptual units. These highly
coherent conceptual units are stored in memory and represent various
aspects of the stimulus, responses to the stimulus, and knowledge about
the stimulus. Stimuli that are insufficient to fully activate the emotional
network (i.e., mildly evocative) or that activate only one or two response
components create desynchronous responding.
Therapy leading to emotional processing can be most effective when
there is a concordant pattern of emotional responding and access to the
entire emotional network is achieved. This is typically best achieved through
exposure (e.g., Kendall et al., 2005). With network activation, erroneous
associations and beliefs, avoidant behaviors, and intense physiological

responses may be countered by new information about the stimulus. In

this way, new information is integrated into the information structure
providing alternate inhibitory learning to decrease the intensity of patho-
logical emotional responses (i.e., reduction of subjective fear, physiological
symptoms, avoidant behaviors, and catastrophic cognitions).
A developmentally informed approach is also necessary in which a
child’s psychopathology is considered within context of the family, the
attainment of developmental milestones, and individual differences due to
equifinality and multifinality. Finally, a thorough assessment is necessary
in order to understand the individual differences unique to any one child
and plan for comprehensive treatment.


Evidence-Based Assessment (EBA)

Given that anxiety can be thought of as resistant networks of exag-
gerated emotional responses (Foa & Kozak, 1986, 1998), it follows that
an assessment should include a thorough evaluation of the emotion and
the components of the anxiety response—namely, physiology, behavior,
and cognition—in addition to the overall subjective emotional experience
(Davis & Ollendick, 2005). Current evidence-based guidelines with children
include a variety of techniques: (1) using structured or semi-structured
diagnostic interviews in addition to open clinical interviews to determine
the presence or absence of anxiety disorders, (2) using rating scale infor-
mation from multiple-informants to quantify symptoms and monitor treat-
ment progress, and (3) using direct observation or behavioral avoidance
tasks to offer additional information and assist in planning for treatment,
especially when exposure is to be used (Silverman & Ollendick, 2005).
Some of the more widely utilized assessment instruments for child-
hood anxiety include the Anxiety Disorders Interview Schedule for Children
for DSM-IV, (ADIS-C/P; Silverman & Albano, 1996), the Child Behavior
Checklist and other Achenbach forms (CBCL; Achenbach, 1991), the Mul-
tidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan,
Stallings, & Conners, 1997), and the Revised Children’s Manifest Anxiety
Scale (RCMAS; Reynolds & Richmond, 1978; see Silverman & Ollendick,
2005 for a review of evidence-based assessment of anxiety in children).
Assessment for childhood anxiety should always utilize multiple
informants from differing environments. Within the anxiety disorders (and
childhood disorders generally) there is commonly disagreement among
reporters as to the presence, absence, and severity of disorders (e.g., Grills
& Ollendick, 2002; Jensen et al., 1999; Silverman & Ollendick, 2005). At
the same time, these disagreements are not trivial and may not represent
misconceptions on the part of the child. For example, Jensen et al. (1999)
reported that when discrepancies existed between parents and children
regarding the presence of an anxiety disorder, clinician verification sug-
gested that both the parents and the children were equally good at accu-
rately identifying an anxiety disorder in roughly 60% of cases.

In other words, children were accurate in reporting anxiety disorder

symptoms their parents did not and vice versa. This finding may impli-
cate differential findings for certain anxieties at certain ages based on the
informant: for example, young children may not realize the unusualness
of their responses although their parents do, whereas adolescents may
be too embarrassed or secretive to outwardly appear anxious (Jensen et
al., 1999). However, support for the hypothesized role of age in explaining
informant discordance is mixed at present (e.g., Choudhury, Pimentel, &
Kendall, 2003; Grills & Ollendick, 2003). In addition, there may be better
agreement between parents and children on symptoms of disorders than
the disorders themselves (Comer & Kendall, 2004). Even though informant
disagreement seems the rule, certain fear- or anxiety-evoking stimuli may
only be encountered in isolated or specific situations making information
from additional respondents valuable (e.g., teacher-report). Although the
issue of digesting information from multiple informants is more compli-
cated than this brief review (cf. De Los Reyes & Kazdin, 2005; Grills &
Ollendick, 2003; see Silverman & Ollendick, 2005 for a review), the need
for multiple sources of information in addition to independent clinician
verification is apparent.
A discussion of the dimensional versus diagnostic assessment of
disorders is beyond the scope of this work (i.e., continuum or rating scale
versus categorical or diagnostic assessments of psychopathology), however,
valid and reliable assessment from both a dimensional and diagnostic per-
spective is crucial in current EBP, and the two are not necessarily mutu-
ally exclusive (Achenbach, 2005). As Silverman and Ollendick (2005) point
out, “if one wishes to use the treatment that possesses the most research
evidence, it is important to first have confidence … that the youth … with
whom one is working [is] in fact suffering primarily from clinical levels of
anxiety” (p. 384). This confidence and certainty is even more crucial given
the field’s increasing receptiveness to ESTs. As a result, both dimensional
and categorical considerations of child psychopathology are important.
An empirical investigation of the necessity of EBA procedures in plan-
ning treatment and their relation to therapeutic outcome has yet to be
conducted (e.g., does using diagnostic interviews result in better treat-
ment outcomes; Nelson-Gray, 2003). Even so, it is important to consider
that empirically supported treatments typically derive their evidence from
RCTs that employ specific and detailed assessments. Consequently, the
failure to use evidence-based assessment in clinical practice, even when
one intends to use an empirically supported treatment, can foreseeably
lead to less than ideal outcomes. Given the heterogeneity of the categorical
diagnostic system (e.g., children with the same diagnosis sometimes meet-
ing almost no overlapping criteria), poor assessment practices could lead
to convergence on a diagnosis and selection of a treatment that may have
limited or no effect. Essentially, assessing children in ways other than
those used in the RCTs might mean one is treating an altogether different
anxiety (although again this has yet to be tested).
For example, imagine a child with a history of anxiety presenting
to you with symptoms of panic and lightheadedness. In particular, she
presents for symptoms primarily following a surgical procedure in which

anesthesia was ineffectually administered (i.e., she reported being semi-

conscious, feeling surgical tugging, etc. but minimal pain). Discussion of
the case may converge upon panic disorder or posttraumatic stress dis-
order focusing on either her history or the traumatic experience; how-
ever, an accurate assessment is needed to also rule out a specific phobia
(i.e., blood-injection-injury type). Although evidence-based therapies exist
for all three diagnostic possibilities, the effective use of these therapies
hinges on obtaining an accurate diagnosis, in particular because the expo-
sures would differ in clinically meaningful ways that could be detrimen-
tal if applied inaccurately (e.g., relaxing in the presence of the stimulus
compared to learning to apply tension or tense muscles when exposed).
Inaccurate diagnosis could lead to the incorrect, although evidence-based,
treatment of having an individual with a specific phobia (and vasovagal
syncope; i.e., propensity toward fainting) relax during exposure.

Functional Assessment
In addition, it has been pointed out that both dimensional and categor-
ical systems do not readily address the functions of child psychopathology
(Scotti, Morris, McNeil, & Hawkins, 1996). These functions are frequently
addressed either directly or indirectly in treatment, but not reflected in
the treatment literature or in the current diagnostic systems. Even though
functional analysis has been used extensively with children with intel-
lectual and developmental disabilities to assess problem behavior (for a
review see Hanley, Iwata, & McCord, 2003), little has been done to bring
this important behavioral assessment to other disorders.
Functional analysis involves “the identification of variables that influ-
ence the occurrence of problem behavior” (Hanley et al., 2003, p.147).
Problem behavior is thought to have certain functional attributes: to obtain
tangible items, escape demands, receive attention, and/or for reasons that
cannot be determined (i.e., an automatic function). These functions can be
assessed through careful and lengthy experimental sessions that carefully
alter the contingencies of a situation (e.g., experimental functional analy-
sis; cf. Iwata, Dorsey, Slifer, Bauman, & Richman, 1982/1994) or more
efficiently through interviews (e.g., Questions About Behavioral Func-
tion, QABF; cf. Matson, Bamburg, Cherry, & Paclawskyj, 1999). Although
these practices have become the gold standard of behavioral assessment
for those with disabilities, practices involving the functional assessment
and treatment of typically developing children with psychopathology have
trailed far behind (see Chapters 7, 14, and 15 in Volume 1 for a review of
behavioral assessment techniques in those with intellectual or develop-
mental disabilities; Matson, Andrasik, & Matson, in press).
Likewise, limited attempts have been made to address the functions
of anxious behavior, and although treatments may broadly incorporate
family components they fall short of advances seen with other popula-
tions (e.g., in those with intellectual and developmental delays). Even so,
functional analysis has become more common in the assessment of school
refusal/phobia in children (e.g., Kearney & Silverman, 1993). Also, cogni-
tive-behavioral functional analysis has become a common practice prior to

cognitive-behavioral interventions, but these unstructured interviews are

far from the systematic observations reviewed above. A cognitive-behavio-
ral functional analysis interview typically involves six broad components:
(1) probing for the origins of the anxiety disorder, (2) determining what cat-
astrophic cognitions typically accompany exposure to feared stimuli, (3)
cataloguing the behavioral responses to exposure, (4) obtaining a descrip-
tion of any panic or physiological symptoms experienced, (5) attempting to
uncover any environmental contingencies that might maintain anxious or
fearful behavior, and (6) creating a fear hierarchy for graduated hierarchi-
cal exposure (Ollendick, Davis, & Muris, 1994).
This process is typically completed prior to offering the child and/or
caregiver a rationale for cognitive-behavioral treatment and can be helpful
in individualizing the description of how treatment will proceed. Cognitive-
behavioral functional analyses can be conducted with the child, parent(s)/
guardian(s), or both depending on how much detail any one informant can
provide. In addition, the presence of parents during or after these inter-
views can be helpful in resolving disagreements and discrepancies that may
emerge during assessment (see discussion on multiple informants above).



No introduction to treatments for childhood disorders is complete without

discussing evidence-based practice (EBP; i.e., evidence-based assessment,
EBA; evidence-based treatment, EBT; and more specifically empirically
supported treatment, EST). EBP began in the 1990s as practices from the
medical community crossed over into psychology, in particular, efforts to
study treatments in order to subsequently provide the most efficient and
effective care to patients. Propelled by reviews and meta-analyses indi-
cating the positive impact of psychotherapy with children and the need
for more research (e.g., Casey & Berman, 1985; Kazdin, Bass, Ayers, &
Rodgers, 1990), the movement reached a zenith with the release of a key
report by the Task Force on Promotion and Dissemination of Psychological
Procedures (i.e., the Task Force; Task Force, 1995).
This report and subsequent updates set forth varying levels of criteria
by which evidence for the efficacy of psychotherapies could be evaluated
and also reported various “empirically supported (validated) treatments”
based on the literature at that time (Task Force, 1995; followed by Chamb-
less et al., 1996, 1998; and Chambless & Ollendick, 2001; also see the
Journal of Clinical Child Psychology, Volume 27, 1998 and the Journal of
Consulting and Clinical Psychology, Volume 66, 1998 for special issues on
ESTs). Interventions were classified as either “well-established,” “probably
efficacious,” or “experimental” according to their support in the literature.
Treatments found to be well established meet the highest criteria set
forth by the Task Force (1995). In at least two randomized clinical trials or
a series of rigorous case studies (more than nine), well-established treat-
ments must be found equivalent to other established treatments or superior
to pill, psychological placebo, or other therapies of lesser empirical support.

Equivalency must also be with adequate sample sizes to detect differences

(i.e., approximately 30 participants per group; Kazdin & Bass, 1989).
Additionally, the studies for a well-established treatment must use a
treatment manual and must specify the characteristics of the participants.
Finally, the randomized clinical trials supporting a well-established treat-
ment must be conducted by at least two different investigators or investiga-
tory teams. Investigations supporting probably efficacious treatments have
been found lacking in meaningful ways and have not met the rigorous cri-
teria required for well-established status. The studies supporting probably
efficacious treatments need only find treatment superior to wait-list control
conditions. Alternatively, it may be that well-established criteria were met,
but the research was carried out by one investigator or investigative team.
As for experimental treatments, the studies supporting these treatments do
not meet the criteria or methodology necessary to meet probably efficacious
status or may have not yet been examined in the literature.
Following the clarion call for the empirical study of treatments, however,
it was not predicted that stalwart opposition to the EBP movement would
develop from within the field itself (Ollendick, King, & Chorpita, 2006). The
push toward the empirical substantiation and evaluation of clinical practice
has been an unexpectedly controversial one. As a result, a brief review of this
debate does have bearing on the review of ESTs for child anxiety disorders
which follows and is in order to provide context for the chosen review criteria.
Even among those who support an evidence-based approach, there is
disagreement about what should be the focus of review: treatments (i.e.,
ESTs) or therapeutic components/techniques (i.e., empirically supported
principles of change, ESPs). Initially, the major EST reports emphasized
identification of ESTs (cf. Task Force, 1995; Chambless et al., 1996, 1998;
Chambless & Ollendick, 2001) although that emphasis was not applied
consistently (see Rosen & Davison, 2003 for a review). Critics rightfully
indicated that this effort neglected discernment of mechanisms of change
and also created an opportunity for abuse (e.g., Tryon, 2005). In their
depiction of “Purple Hat Therapy,” Rosen and Davison (2003) point out that
using EST criteria could lead to the inappropriate repackaging of ESTs for
gain while neglecting the mechanism of change (e.g., taking an efficacious
exposure treatment and adding in a purple hat worn by the patient so as
to create a “new” EST which can be proprietarily marketed). A meaningful
debate is then whether EBT research should focus on ESTs or ESPs.
Research addressing both approaches is needed, but an inappropriate
assumption is made when studies of multicomponent treatments are used to
support the efficacy of individual treatment components. For example, Men-
zies and Clark (1993) used reinforced practice and modeling to treat children
with water fear. This study has been construed as supporting “exposure for
simple phobia” (Chambless et al., 1998, p.11). As exposure was not examined
independently from the reinforced practice or modeling conditions, conclu-
sions about exposure itself cannot be made (e.g., were results due to exposure
alone or a necessary combination of exposure with reinforced practice?).
There is even considerable debate as to what constitutes exposure
(e.g., format, duration, mechanisms of change; see below, Facing Your
Fears: Exposure). As a result, studies carefully examining the components

of treatments in isolation are necessary in order to advance this question.

Moreover, it remains to be demonstrated whether cobbling together ESPs
in clinical practice is an effective approach. A compromise, however, can
be seen in the efforts to evaluate modular therapy that manualizes various
cognitive-behavioral techniques in a single program that can be individu-
alized (e.g., Chorpita, Taylor, Francis, Moffitt, & Austin, 2004).
Although there has been disagreement and controversy about using EBP,
others have advocated even stricter evaluations of the treatment literature.
Particularly in the area of childhood anxiety, work by Davis and Ollendick has
attempted to advance an empirically and ethically based approach to treating
children. Realizing that ESTs may not exist for all disorders, an evidence-
based approach to practice is advanced whereby clinicians have an ethical
obligation to assemble and work from the available evidence (Ollendick &
Davis, 2004). A system of Web-based searching strategies and updated EST
websites are highlighted to facilitate and expedite use by busy professionals.
As a result, they have asserted that failure to use ESTs when they do exist
and persist in the use of “invalidated treatments is not only bad practice but
also unethical” (Ollendick & Davis, 2004, p.293).
Citing criticisms and weaknesses of the current EST criteria, Davis and
Ollendick (2005) have gone on to propose even more detailed evaluation by
hybridizing EST criteria with emotion theory (i.e., bioinformational theory; see
previous description). Using EST criteria, they reviewed both the overall empirical
support for a particular intervention and also the support for an intervention’s
effects on the individual components of an emotional response (i.e., physiology,
behavior, and cognition, as well as the overall subjective emotional experience).
Their review of treatments for phobias and fear in children found that almost
all of the studies reviewed included measures of behavior and subjective fear;
however, most did not include measures of cognition or psychophysiology. This
finding was surprising and it was concluded that a “disconnect” exists between
efficacy research and theory (Davis & Ollendick, 2005, p.156).
Studies on treatments meant to specifically target certain components
of the phobic response frequently did not measure theorized mechanisms
of change or even the specific targets of the interventions (e.g., only one of
six studies of cognitive-behavioral therapy included a measure of cogni-
tion). Although there is disagreement as to whether treatments must dem-
onstrate efficacy across all emotional response components (e.g., Bergman
& Piacentini, 2005), there does appear to be agreement that researchers
must begin to include measures of these components in future treatment
studies if the debate is to be advanced.


Facing Your Fears: Exposure

Exposure has become a central component of most treatments for
anxiety disorders. Exposure, simply defined, is merely encountering or
experiencing fear- or anxiety-provoking stimuli. Unfortunately, consensus

on exposure quickly dissipates beyond acknowledgment of its centrality to

anxiety treatments and this most basic definition. Specifically, two main
questions about exposure exist: how should exposure be implemented and
by what mechanism(s) does exposure have an effect?

Exposure can be conducted via two media. In vivo exposure involves
actually exposing an individual to an evocative stimulus and is contrasted
with imaginal exposure (also called in vitro exposure) which involves
the individual imagining the stimulus. Bioinformational and emotional
processing theories would generally advocate the use of in vivo exposure
so as to activate more of the emotional network; however, the nature of the
anxiety disorder, the safety and well-being of the individual, and the avail-
ability of stimuli must also be considered.
For example, in vivo exposure may be better suited to specific fears,
the characteristics surrounding a traumatic event (e.g., the setting and
environment), and easily obtained and manageable stimuli (e.g., dogs).
This is in comparison to, for example, myriad generalized worries, the
actual traumatic occurrence (e.g., assault), and more unique or prohibitive
stimuli (e.g., finding tall buildings in rural areas for fear of heights or the
prohibitive cost and lack of access for fear of air travel) for which imaginal
exposure may be more appropriate. Finally, a combined approach can be a
viable alternative in which imaginal exposure can be used to supplement,
accentuate, and amplify the effects of in vivo techniques.
Exposure has also been administered in two “doses” in the literature:
either all at once or gradually. Exposure can be administered all at once
in procedures termed “flooding” (in vivo) or “implosion” (imaginal). Flood-
ing and implosion involve exposure to the most challenging or evocative
presentation of a stimulus or situation all at once. For example, an indi-
vidual phobic of heights would be taken to the top of a very tall building
or guided to imagine being on such a building. By contrast, gradual expo-
sure involves using either in vivo or imaginal techniques to slowly guide
an individual through a hierarchy of increasing fear or anxiety. Using the
same examples, graduated in vivo exposure may involve gradually pro-
gressing from exposure at the second floor of a building to the third and
so forth whereas imaginal exposure may involve envisioning the same.
Currently, consensus exists that flooding or implosion may be needlessly
aversive, whereas a graduated approach is more humane, inviting, and
less of a threat to motivation and possible attrition, especially with chil-
dren (Kendall et al., 2005).
Another question relevant to the use of exposure therapy is the “dosing”
or schedule for any particular “dose.” The literature is mixed and unclear at
this point as to whether a massed or spaced approach to exposure is pre-
ferred, especially with children. Is exposure best administered all in a sin-
gle session of extended duration, or across several sessions with little time
between exposures (i.e., massed exposure), or during trials more approximat-
ing the typical one-hour weekly session across multiple weeks (i.e., spaced
sessions akin to most manualized treatments)? Although controversial, the

adult literature can be construed as supporting a massed approach or mini-

mizing the intervals between exposures (e.g., Chaplin & Levine, 1981; Foa,
Jameson, Turner, & Payne, 1980; Lang & Craske, 2000).
Even so, at the very least no support has been found for needlessly
spacing sessions (Chambless, 1990; Herbert, Rheingold, Gaudiano, &
Myers, 2004; Lang & Craske, 2000). In children, one study was identified
that examined massed and spaced exposure. Davis, Rosenthal, and Kel-
ley (1981) found that children receiving three hours of massed exposure
therapy using actual stimuli (i.e., as opposed to approximations/toys) had
superior outcomes to those children receiving exposure therapy in three
weekly one-hour doses.
Similarly, Öst et al. (2001) found that children responded well to a three-
hour massed intervention for specific phobia, although they did not make
comparisons to spaced exposures. Moreover, most children reported that the
treatment had gone as they had expected it would (75.4%) and were satisfied
with the intervention (82.1%; Svensson, Larsson, & Öst, 2002). Accordingly,
it seems that children are at least capable of participating in massed treat-
ment and that they may not find it unduly cruel or aversive. It may be more
effective than spacing sessions. Currently, best practice may come down to
a combination of the anxiety disorder(s) to be treated, current EST manuals
and formats, clinical judgment, and patient and parent choice.

Mechanisms of Change
Although exposure is easily defined in the most basic of terms, questions
remain as to what aspects or mechanisms of change in exposure impart
therapeutic benefit. Several potential mechanisms have been advanced:
such as counterconditioning, habituation, extinction, cognitive change, and
the development of coping skills (Kendall et al., 2005; Tryon, 2005). These
various mechanisms of change are theoretically wed to different therapeutic
interventions, but may occur to varying degrees in all exposure therapies
whether acknowledged or not. Even so, only one study has even examined
potential mediators of outcome, although any of the RCTs reviewed below
could have (Treadwell & Kendall, 1996; for a review see Prins & Ollendick,
2003). As a result, the review that follows focuses on the main ESTs for
childhood anxiety disorders and the degree to which these therapies tar-
get various components of the emotional response. The reader is reminded,
however, that even though many interventions are decades old, little effort
has been made to resolve the disconnect between theory and research that
would better elucidate mechanisms of change (cf. Davis & Ollendick, 2005).

Systematic Desensitization (SD)

SD is based on classical conditioning theory and deep muscle relaxation
(Jacobson, 1938). Wolpe (1958) based treatment procedures on etio-
logical principles similar to those observed in laboratories. The assumption
is that a previously unconditioned stimulus, through stimulus pairings or

traumatic exposure, has become a conditioned stimulus leading to the

conditioned phobic response. From this perspective, therapeutic inter-
vention should make “use of particular responses that, through inhibit-
ing anxiety, weaken neurotic habits” (Wolpe, 1958, p. 112). As a result,
the goal is to engage in counterconditioning. A clinician frequently starts
by developing a fear hierarchy and then choosing a counterconditioning
agent or technique (e.g., relaxation training). Whereas the anxiety-inhib-
iting response is typically some form of relaxation or breathing, Wolpe
(1958) indicated that any anxiety-inhibiting response performed during
the hierarchical exposure might be appropriate (e.g., humor, eating, and
even sexual behavior). Once an inhibiting response is chosen, the patient
progresses through either imaginal or in vivo hierarchical exposures while
performing the response. As a result, the associative strength between the
conditioned stimulus and the unconditioned stimulus decreases because
it ceases to predict the response in the presence.
Wolpe (1958) indicated that the goal of SD is to inhibit the “automatic
response pattern or patterns that are characteristically part of the organ-
ism’s response to noxious stimulation” and thereby eliminate avoidance
behavior (p. 34). This elimination of avoidant behavior through inhibition
is accomplished by physiological training (e.g., relaxation) as the new
response is gradually paired with each step of the fear hierarchy. Although
there is also a secondary goal of slowly augmenting exposure without sub-
sequent avoidance, it is clear that this intervention primarily targets the
“autonomic response patterns” and, hence, the physiology of the emo-
tional response (Davis & Ollendick, 2005). Little impetus is placed on the
behavioral component beyond merely adjusting exposure intensity so as to
prevent avoidance; almost no emphasis is placed on changing the cogni-
tive component (Davis & Ollendick, 2005).
Of relevance, support for a counterconditioning approach to the treat-
ment of anxiety has been under increasing scrutiny. Theoretically, the
inclusion of techniques whose purpose is to interfere with the activation
of the emotional network should impair the effectiveness of the exposure
(Lang, 1977). In practice with adults, relaxation has been shown to be
less effective than exposure with cognitive techniques (Craske, Brown, &
Barlow, 1991), and in children has been shown to be less effective than
other behavioral techniques using exposure (Bandura, Blanchard, & Ritter,
1969). As a result, some have concluded a counterconditioning explana-
tion of SD is not supported by the extant literature (Tryon, 2005).

Reinforced Practice (RP)

Research in the 1960s and 1970s indicated that graduated repeated
practice, positive reinforcement, and clinician direction and feedback all
served as powerful techniques for attenuating anxiety (Ollendick & Cerny,
1981). In combination, these procedures came to be called “reinforced
practice” or “contingency management” and included repeated hierarchical
exposures (i.e., “practice”) during which patient approach behavior was

encouraged using reinforcement and verbal feedback (Leitenberg &

Callahan, 1973). Use with fears and phobias increased and a direct link
to operant principles could be observed in conceptualizations of “fear [as]
not only a response of glands and smooth muscles, [but as] a reduced
probability of moving toward a feared object and a heightened probability
of moving away from it” (Skinner, 1988, p.172). RP for fear and anxiety
is focused on schedules of reinforcement, learning histories, and similar
operant considerations with little attention devoted to feelings, sensations,
or thoughts co-occurring with the fear or anxiety.
As a result, RP is carried out by using reinforcement to strengthen
positive associations to the fear- or anxiety-evoking stimulus thereby
weakening negative associations. The sole goal is to achieve an increased
probability of approach behavior through operant principles (Davis &
Ollendick, 2005). Emphasis is placed on the behavioral component of the
emotional response with little to no emphasis on cognition or physiology.
Of note, RP and SD are occasionally confused in the literature, either for
each other or for “distraction” during an exposure. This confusion is espe-
cially apparent when SD uses a tangible item instead of relaxation training
(e.g., Rapp, Vollmer, & Havanetz, 2005). The key determinant in whether
an intervention is RP or SD is when the tangible item is provided to the
child. For example, a clinician may decide to use a child’s favorite doll
during an exposure session. If the doll is provided at the beginning of the
exposure, then it presumably has a counterconditioning effect during the
exposure (i.e., SD); however, if the doll is only provided contingent upon
the completion of a step in the hierarchy, then the clinician would be using
the doll as reinforcement for approach behavior (i.e., RP).

Modeling and Participant Modeling (PM)

Ritter (1965, 1968) developed PM (also called “contact desensitiza-
tion”) based on work grounded in social-learning theory. PM is rooted in
modeling or the theory that learning can occur vicariously by observing
others (i.e., models). Modeling, as described by Bandura (1969), is success-
ful by altering behavior and its consequences through the observation of
social models. As applied to treatment, anxiety and fear can be assuaged by
watching a model interact with a feared stimulus or situation. The result of
the observation is vicarious extinction (i.e., new inhibitory learning) as the
associations between the conditioned stimulus and unconditioned stimu-
lus are weakened (Bandura, 1969; Bouton, 2004; Myers & Davis, 2002).
In PM, the clinician goes beyond the role of mere social model and
takes a more interactive approach. The goal in PM is to integrate the
patient into the task with added verbal and behavioral instruction from
the clinician. In this way, a clinician frequently models a response and
then assists the patient in completing the response. PM has the benefit of
allowing a clinician to disassemble a complex task into manageable and
directed interactive steps. For example, the larger step of petting a dog
during exposure becomes one of having the clinician model the task and

then gradually shape successive approximations in the observer through

physical and verbal direction.
The object of modeling is to alter behavior (Bandura, 1969), although
with the added participant component there is a notable skill-building
component. The elimination of avoidance is also important and crucial in
modeling and PM as the observer must observe the model to benefit. “PM
requires a patient to view, approximate, and undertake various behavioral
experiments that eventuate in no aversive outcomes” (Davis & Ollendick,
2005, p. 150). Although this process is grounded in social-learning theory,
there is also a significant component that can be conceptualized as cog-
nitive. Therapy also involves testing and disconfirming distorted beliefs
about the stimulus or situation as “the absence of anticipated negative
consequences is a requisite condition for fear extinction” (Bandura, Blanchard,
& Ritter, 1969, p. 174; italics added). Adding anticipation to the disconfirm-
atory process suggests an emphasis that is distinctly cognitive and beyond
strict notions of vicarious extinction.

Cognitive-Behavioral Therapy (CBT)

As the name implies, CBT integrates two distinct and influential
interventions: cognitive therapy and behavior therapy. CBT capitalizes
on any or all of the previously mentioned behavioral techniques but
adds techniques to address faulty cognition. This integration is achieved
through an understanding that psychopathology reflects an information-
processing bias and that these biases become incorporated into stable
schemas (cognitive structures) which direct behavior and cognition (Beck,
1993). Integration is achieved when a relationship is posited in which
information-processing biases and dysfunctional behavior and distress
are reciprocally linked (Beck, 1993). As a result, CBT challenges chil-
dren’s cognitive distortions while simultaneously implementing behav-
ior therapy techniques (e.g., modeling, exposure, operant conditioning,
relaxation; Kendall, 1993; Kendall et al., 2005). Essentially, a hybrid
approach is achieved; therapy focuses on eliminating avoidance behav-
ior while also identifying, testing, and countering automatic thoughts
of threat, vulnerability, and danger plaguing the conscious mind (Beck,
1991, 1993).
As a result, psychopathology is the emergence and dominance of a
negative cognitive structure (i.e., schema) in conjunction with disordered
or dysfunctional behavior (Beck, 1991). Cognitive aspects of treatment
are focused upon altering these cognitive structures or developing new
structures to “re-interpret” the environment (Kendall, 1993). According
to Kendall and Suveg (2006), the primary cognitive structures that need
to be addressed are distortions (e.g., catastrophic thought, maladaptive
thoughts and expectations) and deficiencies (e.g., incomplete attainment
of developmental milestones, poor problem-solving, impulsivity). Even so,
behavioral techniques are used to varying degrees.

In isolation, this is simply behavior therapy; however, techniques using

exposure, social learning, and operant and classical conditioning can be
very effective when combined with treatments designed to address cog-
nitive distortions and deficiencies. Behavioral interventions can provide
concrete opportunities to test cognitive distortions or incorporate psych-
oeducation, problem-solving, and skill-building to assist with deficiencies.
In addition, family-based techniques can be incorporated as necessary to
accentuate treatment effects and alleviate potential familial confounds to
treatment success and generalization.
Borrowing from the previous discussion on EPT (Foa & Kozak, 1986,
1998), theoretically, CBT for anxiety disorders allows a clinician to acti-
vate relevant emotion networks and incorporate additional information
into these structures. Information may be related to stimulus properties,
meaning, or the components of the emotional response: cognitive (e.g.,
challenges to and information not supporting catastrophic or distorted
thought), behavioral (e.g., information regarding new schedules of rein-
forcement or punishment based on exposure or new contingencies in
effect), or physiological (e.g., the results of habituation during steps in a
fear or anxiety hierarchy).
For example, cognitive-behavioral exposure therapy for a child with
fears of public speaking can be corrective in many ways. First, CBT can
introduce new meaning and cognitive responses by challenging and test-
ing catastrophic thoughts (e.g., “I’ll mess up.”). Second, it can impart skills
used for coping, addressing others, and for public speaking (e.g., how to
handle stress and worry, use a podium and a microphone, use proper
etiquette). Third, CBT can be used to reduce avoidance behavior and rein-
force successive approximations of the task (e.g., using a fear hierarchy to
make approach more manageable and by using verbal reinforcement so as
to increase the probability of approach). Finally, it offers the opportunity to
experience and habituate to physiological symptoms (e.g., pounding heart,
sweating). In this example, these various components of CBT are woven
together almost seamlessly. Ideally, CBT will evoke the full network and
offer corrective information on various aspects of the stimulus, its mean-
ing, and one’s response (Davis & Ollendick, 2005). As a result, CBT places
some degree of emphasis on altering all three components of the anxiety
response (Davis & Ollendick, 2005).



The following review of treatments for childhood anxiety focuses on

ESTs (i.e., not ESPs) for anxiety and incorporates a review of both overall effi-
cacy and response component efficacy (i.e., componential analysis; Davis
& Ollendick, 2005). This review also firmly applies the EST criteria as
originally stated (Task Force, 1995) and refined by Chambless and col-
leagues (Chambless et al., 1996, 1998). Namely, that from “a research
perspective, no treatment is ever fully validated; there are always more

questions to ask” and that the primary goal is better patient care through
“… the decision on whether a particular treatment has sufficient empiri-
cal validation to warrant its dissemination for widespread clinical training
and implementation …” (Task Force, 1995, p. 3).
This goal of setting the agenda for dissemination, training, and patient
care necessitates that a high standard be used for determining empirical
status. This emphasis is especially urgent given that even recent exami-
nations of the literature continue to indicate that EBTs for youth produce
better outcomes than care as usual, even in those with severe levels of
psychopathology (Weisz, Jensen-Doss, & Hawley, 2006). Unfortunately,
as it stands, the evidence-based movement has become mired in political
debate and efforts to obtain the “prize” of EST status (Rosen & Davison,
2003) at the expense of the original intentions of disseminating and train-
ing the best practices for treating children.
Subsequently, the following review focuses on RCTs for anxiety disor-
ders in children using the original criteria (cf. Task Force, 1995; Chambless
et al., 1996, 1998) in an effort to determine those treatments for which the
most rigorous evidence has accrued. An emphasis is placed on studies that
either verify diagnostic status in their samples or where a specific diagnosis
or diagnostic category can be reasonably assumed through a preponderance
of the clinical assessment evidence and sample description (cf. Chambless
& Ollendick, 2001). Studies were excluded from the review if they did not
clearly indicate randomization of participants to a condition, did not specify
even the most basic characteristics of the sample (e.g., age, male vs. female),
assessed and treated symptoms that could not be verified as in the clinical
range and/or indicative of a particular anxiety disorder (e.g., “test anxiety”
or social isolation studies), and/or had equivalent results between or among
conditions but insufficient power to detect differences and invoke the EST
equivalence criterion (cf. Kazdin & Bass, 1989). Moreover, as little research
has attempted to isolate ESPs, this review focuses on identifying ESTs with
the most support in the extant literature.
Finally, in addition to reporting overall empirical status for the treat-
ments reviewed, a componential analysis is presented of the effects of
treatment on the components of the emotional response (cf. Davis & Ollen-
dick, 2005). Specifically, outcome data are examined and the effects of
treatment on the subjective experience, physiological response, behavio-
ral response, and cognitive response of the emotion are categorized using
EST criteria guidelines. Outcome data for this analysis need also not be
in any one strict form or use a single type of informant or medium. For
example, the behavioral component could be examined using a behavio-
ral task, observational coding, self-report, or parent-report. The results of
these reviews are summarized in Tables 7.2 and 7.3. Table 7.2 shows the
evidence from each study leading to the conclusions regarding empirical
support, and Table 7.3 indicates the actual levels of support merited for a
particular treatment for a particular disorder.
To date, no published RCTs with children that met these review
criteria were identified for Panic Disorder/Agoraphobia (see Ollendick,
1995 for results of a multiple-baseline design study), separation anxiety

Table 7.2. Examination of Empirical Support for Various Anxiety Disorder

Evidence for Efficacy at Treating Response
Component Symptoms
Disorder/Treatment Study Physiology Behavior Cognition Subjective
Specific Phobia
ISD vs. W-L Cornwall NR TX > W-L * TX > W-L
et al.
ICBT vs. EMDR Muris et al. ns CBT > TX * CBT > TX
ICBT vs. EMDR vs. Psychological Placebo
Muris et al. * = * CBT > TX
ICBT vs. ICBT+ParCBT Öst et al. ns TXs > W-L * TXs > W-L
vs. W-L (2001)

Social Phobia
I+GBT vs. Psychological Beidel et al. * TX > Pla- * TX > Placebo
Placebo (2000) cebo
GCBT vs. GCBT+Par vs. Spence et al. NR ns * TXs > W-L
W-L (2000)
GCBT vs. W-L Gallagher * TX > W-L * TX > W-L
et al.

Obsessive-Compulsive Disorder
ICBT vs. Med de Haan * = NR *
et al.
ICBT+Med vs. ICBT vs.
Med vs. Pill Placebo
POTS (2004) * NR NR *
ICBT vs. GCBT vs. W-L Barrett et al. NR NR NR =

Posttraumatic Stress Disorder

ICBT vs. ParCBT vs.
ICBT+ParCBT vs. Com
Deblinger * ns * ns
et al.
ICBT vs. ICBT+ParCBT King et al. NR TXs > W-L ns TXs > W-L
vs. W-L (2000)
GCBT vs. W-L Stein et al. * ns * TX > W-L
ICBT+ParCBT vs. Child- Cohen et al. * CBT > TX * ns
centered (2004)

Childhood Anxieties (combined)

ICBT vs. W-L Kendall NR TX > W-L TX > TX > W-L
(1994) W-L
ICBT vs. ICBT+ParBT Barrett et al. NR TXs > W-L * ns
vs. W-L (1996)


Table 7.2. (continued )

Evidence for Efficacy at Treating Response
Component Symptoms
ICBT vs. W-L Kendall et al. NR TX > W-L TX > W-L TX > W-L
GCBT vs. GCBT+ParBT Barrett * TXs > W-L * ns
vs. W-L (1998)
ICBT+ParBT vs. W-L King et al. NR TX > W-L TX > W-L TX > W-L
GCBT vs. W-L Silverman et NR TX > W-L * TX > W-L
al. (1999)
ICBT vs. GCBT vs. W-L Flannery- TX > TX > W-L TX > W-L
Schroeder W-L
et al.
(2000) NR
GCBT+ParCBT vs. W-L Shortt et al. NR TX > W-L * TX > W-L
GCBT vs. Psychological Ginsburg et * * * TX > Placebo
Placebo al. (2002)
GCBT vs. Psychological Muris et al. * * * TX > Placebo
Placebo (2002)
ICBT vs. ICBT+ParCBT Nauta et al. * TXs > W-L * TXs > W-L
vs. W-L (2003)
GCBT vs. Spence et al. NR TXs > W-L * TXs > W-L
GCBT+Internet vs. (2006)
Key: “*” = not measured, “=” = groups were equivalent, Com = Community Care/Treatment as usual, E/
RP = exposure with response prevention, G = group, I = individual, Med = medication, NR = component
was measured but not reported (e.g., a total score was reported but not a subscale containing the needed
information), ns = no significant differences, Par = parents involved with treatment, TX(s) = treatment or
treatments, SD = systematic desensitization, W-L = wait-list control.

disorder, or generalized anxiety disorder as separate diagnostic entities

(i.e., in RCTs specifically designed to determine the effects of treatment
on that disorder). However, several studies have examined various anxiety
disorders in combination (e.g., the well-known CBT RCT by Kendall, 1994).
Given this, the review focuses on the empirical support for treatments of
specific phobia, social phobia, obsessive-compulsive disorder, posttrau-
matic stress disorder, and a final category deemed “childhood anxieties.”
This combined group is composed of studies that meet the Task Force’s
(1995) guidelines, even for specificity of the sample; however, the studies
did not focus on a single anxiety diagnosis (e.g., GAD, SoP, and SAD in a
single sample).

Specific Phobia (SP)

Utilizing the review criteria specified, four RCTs were identified that
lend empirical support to the behavioral treatment (BT) and cognitive-behavioral
treatment of clinically significant specific phobias. For BT, Cornwall, Spence,
and Schotte (1996) examined the effects of SD (specifically emotive

Table 7.3. Empirically Supported Treatments for Anxiety Disorders Affecting

Children and Their Effects on the Components of an Emotional Response
Level of Empirical Support
Disorder and
Treatments Overall Status Physiology Behavior Cognition Subjective
Specific Phobia
SD Experimental Exper Exper Exper Exper
CBT Probably Exper Prob Exper Prob
Social Phobia
BT Probably Exper Prob Exper Prob
CBT Probably Exper Exper Exper Prob
Obsessive-Compulsive Disorder
CBT Well Established Exper Exper Exper Exper
Posttraumatic Stress Disorder
CBT Well Established Exper Prob Exper Prob
Childhood Anxieties (combined)
CBT Well Established Exper Prob Prob Well Est
Key: BT = behavior therapy, CBT = cognitive-behavioral therapy, Exper = experimental empirical status,
Prob = probably efficacious empirical status, Well Est = well established empirical status, SD = systematic

imagery: a technique involving hierarchical exposure with an imagined

“superhero.”) on children with phobias of the dark. Results indicated signif-
icantly better outcomes in behavior and on self-reports with SD compared
to a wait-list group, warranting experimental status (i.e., needs replica-
tion or comparison to a more rigorous intervention/placebo). Three stud-
ies examined the effects of CBT on specific phobias (Muris, Merkelbach,
Holdrinet, & Sijsenaar, 1998; Muris, Merkelbach, Van Haaften, & Mayer,
1997; and Öst et al., 2001). Although the studies by Muris and colleagues
were crossover studies, information regarding comparisons from pretreat-
ment to posttreatment prior to the crossover does produce results consist-
ent with an RCT design. Overall, results from these RCTs indicate CBT for
childhood-specific phobia merits probably efficacious status as it has been
found superior to another treatment in two studies and to a wait-list control
on a third. Specifically, CBT was superior to eye movement desensitization
and reprocessing (EMDR) in the studies by Muris and colleagues and supe-
rior to wait-list on a variety of measures (Öst et al., 2001).
An analysis of the effects of SD on the components of the emotional
response indicates experimental status for all three responses (i.e., physi-
ology, behavior, and cognition) as well as the subjective experience of
anxiety. Cornwall et al. (1996) included measures of behavior and rating
scales of subjective fear that indicated treatment was superior to wait-list;
however, these findings require replication in clinical child populations.

Moreover, a measure of psychophysiology was obtained (i.e., physiological

anxiety: Revised Children’s Manifest Anxiety Scale, RCMAS; Reynolds &
Richmond, 1978) but not examined. Componential analysis for CBT indi-
cates experimental status for both the physiological and cognitive com-
ponents (i.e., no significant differences in groups in two studies). CBT for
the behavioral component can be considered probably efficacious given
its demonstrated superiority to two other treatment conditions but only in
one group of researchers (see Tables 7.2 and 7.3), whereas probably effica-
cious status is warranted for the subjective experience of fear and anxiety.
Of note, these conclusions regarding EST status and the studies included
for review differ from those of Davis and Ollendick (2005) and from Ollen-
dick and King (1998). Difference can be directly attributed to the more
stringent criteria being applied in the current review and the emphasis
on examining studies using children with actual specific phobias and not
analogue fears.

Social Phobia (SoP)

RCTs supporting the treatment of SoP in children include two using
CBT conducted in a group format (Gallagher, Rabian, & McCloskey, 2004;
Spence, Donovan, & Brechman-Toussaint, 2000) and one utilizing BT in a
mixed individual and group format (Beidel, Turner, & Morris, 2000). The
CBTs incorporated a variety of techniques including exposure, cognitive
challenges/therapy, social skills, modeling or participant modeling, and
psychoeducation (Spence et al., 2000 also included relaxation). Results
of both CBT trials indicated treatment gr oups were superior to wait-list
conditions on numerous measures, including diagnostic outcomes. As a
result, group CBT for SoP merits probably efficacious status. The BT trial
included a variety of techniques similar to the other trials including psy-
choeducation, social skills training, modeling, and exposure, but did not
reportedly include an explicitly cognitive component. BT trial results were
also significant and superior to a study skills psychological placebo. As a
result, BT also merits probably efficacious status by having met a more
rigorous standard. Specifically, according to EST criteria, Beidel et al.
(2000) met all the criteria for a well-established treatment with the excep-
tion of independent replication.
Componential analysis of the three studies indicates that none con-
tained a measure that could be considered cognitive. Spence et al. (2000)
included a measure of physiology but did not report on those data (physi-
ological anxiety, RCMAS). All three RCTs did, however, include measures
of the behavioral component and of the subjective emotional experience.
In addition to rating scale data, Beidel et al. (2000) included a behavioral
observation. Results from these data indicate that BT is probably effi-
cacious at treating the behavioral response given BT was superior to a
psychological placebo on these measures and observations. Furthermore,
BT was superior to psychological placebo on several self-reported meas-
ures of the subjective experience of anxiety, thereby meriting probably
efficacious status. Turning to CBT, Spence et al. (2000) assessed phobic
behavior using both parent-report questionnaires and direct observation;

however, they found no significant differences between CBT and wait-list

conditions. On a parent-report measure Gallagher et al. (2004), however,
did find CBT superior to wait-list. Taken together and given the level of evi-
dence (i.e., one significant comparison to a wait-list), CBT for SoP still war-
rants experimental status for the behavioral response. In contrast, CBT’s
effects on the subjective experience of anxiety merits probably efficacious
status as both studies found a wait-list inferior to CBT on numerous self-
report measures.

Obsessive-Compulsive Disorder (OCD)

Three RCTs meeting the review criteria were identified and used to
determine the overall and componential EST status for this disorder
(Barrett, Healy-Farrell, & March, 2004; de Haan, Hoogduin, Buitelaar,
& Keijsers, 1998; POTS, 2004). All three of these studies used forms of
manualized CBT that included psychoeducation, cognitive interventions,
and exposure and response prevention (E/RP). Overall, results from these
studies indicate individual CBT is more effective than clomipramine
(de Haan et al., 1998), pill placebo (POTS, 2004), and a four- to six-week
wait-list condition (Barrett et al., 2004). These effects were also obtained
across two different groups of researchers and all three used participants
diagnosed with OCD. Group CBT was provided by Barrett et al. (2004) and
was found to be equivalent to individual CBT and superior to the wait-list
condition. Given this level of evidence, CBT for OCD meets the criteria for
a well-established intervention.
Of note, these conclusions are made tentatively and are in need of
replication. Even though CBT is considered the treatment of choice for
OCD based on the results of this review and numerous other studies (e.g.,
open trials; for a review see Turner, 2006) further RCTs are necessary.
The results of POTS (2004) are intriguing as a combined approach to OCD
(i.e., both medication and CBT) was found to be superior to both CBT
and sertraline administered separately, which did not differ from each
other (although site differences were apparent). As a result, it may be that
the actual best practice is a combination approach, especially for serious
cases. Finally, parents were involved to varying degrees in all three trials
which may have contributed to treatment success.
Componential analysis of EST status led to conclusions that CBT
provided either in individual or group format merited only experimental
status for addressing the components of the emotional response. This
finding was especially disappointing given all three studies included the
Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS; Goodman
et al., 1989; Scahill et al., 1997) and one study included a measure hav-
ing a physiological symptoms scale (Multidimensional Anxiety Scale for
Children, MASC; March, 1997). Specifically, studies consistently reported
and analyzed only the total score instead of also examining the obses-
sions severity and compulsions severity scores which might have added to
empirical support for the cognitive and behavioral components. Barrett et
al. (2004) did include a measure of subjective anxiety; however, no differ-
ences between groups over time were observed.

Posttraumatic Stress Disorder (PTSD)

Cohen, Deblinger, Mannarino, and Steer (2004), Deblinger, Lippman, and
Steer (1996), King et al. (2000), and Stein et al. (2003) all reported on trials
of CBT for PTSD or clinically significant PTSD symptoms. As with the pre-
vious reviews, all four included manualized CBT and included techniques
such as cognitive coping skills, psychoeducation, graduated exposure, cog-
nitive therapy, and other techniques. Outcomes from these studies indicate
CBT for PTSD in children meets well-established status. Parent and child
CBT was found superior to child-centered therapy (Cohen et al., 2004) and
the combination of child CBT and child and parent CBT (i.e., two separate
groups collapsed) was superior to a combination of parent-only CBT and
care as usual in the community (Deblinger et al., 1996). In addition, two tri-
als found CBT superior to wait-list conditions (King et al., 2000; Stein et al.,
2003). As a result, CBT for PTSD has been found superior to another treat-
ment or placebo in at least two trials by two different research groups.
The effects of CBT on the components of the emotional response indi-
cate it meets experimental criteria for physiology and cognition; however,
probably efficacious status is warranted for the behavioral component and
the subjective experience of anxiety. King et al. (2000) was the only study
to measure cognition (i.e., coping self-efficacy; no significant differences
among groups) and physiology (i.e., RCMAS; physiological anxiety scale not
examined). The effects of PTSD on behavior were measured in all four tri-
als, but only two found differences: King et al. (2000) found significant dif-
ferences with CBT superior to a wait-list and Cohen et al. (2004) found CBT
superior to another treatment. Finally, all four trials measured subjective
anxiety with only King et al. (2000) and Stein et al. (2003) finding CBT
superior to wait-list conditions leading to probably efficacious status.

Childhood Anxieties
Frequently, studies in this category compared CBT to CBT with an
alteration (i.e., group vs. individual format, child and parent or family
treatment vs. child treatment) and/or to wait-lists. CBT to CBT comparisons
were often difficult to separate and appeared to suffer from insufficient
power to obtain differences (cf. Kazdin & Bass, 1989). As a result, gen-
eral impressions of outcomes are conservatively reported in an attempt
to summarize frequently inconsistent (e.g., mother vs. father vs. child vs.
clinician reports) or vacillating results (e.g., changes in the superiority of
a group from post to follow-up to later follow-up). Moreover, preference
in interpreting outcomes was given to the results of diagnostic depictions
and widely used measures (e.g., CBCL, RCMAS, FSSC-R).
Excluding some studies where results generally appeared to be equiv-
alent (e.g., Manassis et al., 2002), 12 RCTs were identified and examined.
As a whole, well-established status for CBT with children is warranted as
Ginsburg and Drake (2002) and Muris, Meesters, and van Melick (2002)
all found CBT superior to a psychological placebo intervention. Moreover,
the 10 additional studies included for review found CBT superior to vary-
ing wait-list conditions in every instance (see Tables 7.2 and 7.3; Barrett,

1998; Barrett et al., 1996; Flannery-Schroeder & Kendall, 2000; Kendall,

1994; Kendall et al., 1997; King et al., 1998; Nauta, Scholing, Emmelkamp,
& Minderaa, 2003; Shortt, Barrett, & Fox, 2001; Silverman et al., 1999;
Spence, Holmes, March, & Lipp, 2006). Conservatively, however, it may be
more appropriate to assert that group CBT merits well-established status
and that individual CBT or CBT with a family or parent component merit
probably efficacious status (see Table 7.2).
Componential analysis of CBT for these combinations of childhood
anxiety indicates experimental status is warranted for the physiological
response. None of the 12 studies reviewed reported on or examined physi-
ological results, even though 8 included measures that could have been
tapped. Behavior was measured in some form in 10 of the 12 studies
with all 10 finding CBT superior to a wait-list condition, resulting in prob-
ably efficacious status. Only four studies included a measure of cognition;
however, results all supported the superiority of CBT to a wait-list and
probably efficacious status. Finally, all 12 studies included a measure of
the subjective experience of anxiety with eight RCTs finding CBT superior
to wait-list and two RCTs finding CBT superior to a psychological placebo.
Given this level of evidence, CBT’s effects on the subjective experience of
anxiety are well established.
Notably, the use, influence, or adaptation of the CBT by Kendall was
clearly observable to varying degrees in almost all of the 12 studies (i.e.,
Coping Cat Workbook; Kendall, 1990; Kendall & Hedtke, 2006). Briefly,
this CBT focuses on “recognizing anxious feelings and somatic reactions
to anxiety, clarifying cognition in anxiety provoking situations, developing
a plan to cope with the situation, and evaluating performance and admin-
istering self-reinforcement as appropriate” (Kendall, 1994, p. 103). With
the Coping Cat program, children are taught to use the acronym FEAR
to guide their coping and exposure in session and through weekly home-
work assignments: “F”eeling frightened, “E”xpecting bad things to happen,
“A”ttitudes and actions that can help, and “R”esults and rewards (Kendall,
1990). Approximately one-half of the 16 or more sessions are devoted to
psychoeducation, coping, relaxation training, and so on with the remain-
ing sessions focusing on exposure.


The preceding review of empirically supported treatments for child-

hood anxiety disorders attests to the benefits of the growth in treatment
research over the last decade. Of the four specific anxiety disorders for
which RCTs have been conducted using clinical child samples, probably
efficacious or well-established treatment options exist for each disorder.
Moreover, for the combined childhood anxiety disorder studies, prob-
ably efficacious support or better exists for a variety of treatment options
including formulations with the individual child, the child and the family
or parent, or variations with a group format.
Overall, although these studies have excelled in including measures
of the behavioral component and the subjective anxiety experience, more

focus needs to be placed on the physiological and cognitive components. In

particular, only 2 of the 26 RCTs examined measures that could be consid-
ered physiological. Even more disappointing, 12 of the remaining 24 RCTs
included measures that address psychophysiology only to neglect or not
report their examination in treatment outcomes (e.g., RCMAS physiological
anxiety). Similarly, 5 of the 26 RCTs included measures of cognition, with
3 others not reporting treatment outcomes (i.e., CY-BOCS obsessions).
Summarizing, it would seem Davis and Ollendick’s (2005) conclu-
sion of a disconnect existing between treatment theory and RCT prac-
tice applies broadly to all disorders of childhood anxiety included in this
review. In addition to including cognitive and physiological assessments
in CBT RCTs, more effort also needs to focus on the use of alternate treat-
ments or placebos over wait-list controls and CBT to CBT comparisons.
An examination of Table 7.3 reveals that even with 24 RCTs examining the
behavioral component (included and reported in 22 of the 26 RCTs), stud-
ies made such frequent use of wait-list conditions, CBT to CBT compari-
sons, or suffered from inadequate power (cf. Kazdin & Bass, 1989) such
that well-established status was achieved for no intervention.
Of note, a potentially rich focus for future RCT examination would be
the comparison of CBT to the behavioral techniques of past decades. These
techniques (e.g., PM, RP, and SD) showed considerable empirical promise
in mostly analogue fear samples in previous reviews (cf. Davis & Ollendick,
2005; Ollendick & King, 1998) and are frequently incorporated into CBT
protocols. It would be beneficial and timely to examine their merit singly
against CBT in demonstrably clinical child samples.
Similarly, it is also disappointing that the studies reviewed generally
did not include examinations of the mechanisms of change and potential
ESPs. Such examinations would be easy to accomplish with the exist-
ing datasets and have been fruitful (Treadwell & Kendall, 1996, and the
impact of treatment on negative self-talk). Moreover, such mediational
testing (cf. Baron & Kenny, 1986; Holmbeck, 1997; Kraemer, Wilson, Fair-
burn, & Agras, 2002) would assist in the study and empirical support of
ESPs as well as the ESTs being examined. Such analyses and refinements
are crucial for further treatment development and refinement, especially
for the children with anxiety receiving therapy. Specifically, in examin-
ing the 12 studies of combined childhood anxieties for which arguably
the most widely studied and disseminated CBT or an adaptation/variant
was used (i.e., The Coping Cat), on average across the studies roughly
43% of children receiving CBT still met criteria for their primary anxiety
disorder at posttreatment assessment (range 11.8% to 50.0%). This very
rough estimate (e.g., differences in samples, time of assessment, meas-
ures), however, indicates a great deal more needs to be done for even well-
established interventions.
The criteria implemented in the current study were necessarily strict
in adherence to the important function of ESTs: to identify those treat-
ments deserving emphasis for training, dissemination, and practice. An
effort to avoid questing for the “prize” of EST status was embodied in the
conservative approach taken (e.g., adherence to the Task Force criteria,
preponderance of evidence suggesting clinical disorders or symptoms for

inclusion). Although this approach led to results that are generally more
conservative than those of previous EST reports and reviews, it is believed
these more accurately reflect the state of the science in treating psychopa-
thology. For example, as previously mentioned, Menzies and Clarke (1993)
was used to suggest probably efficacious status for “exposure” (cf. Chamb-
less et al., 1998) for “water phobia” (Menzies & Clarke, 1993), but also did
so using arguably analogue participants who on average at pretreatment
could at least proceed down to about neck depth in a pool, if not farther
with hesitation.
A developmental approach to childhood anxiety disorders and their
treatment is also needed. Future researchers should aspire to move RCTs
toward a more developmentally sensitive and informed model, compared
to the continuing downward extension of adult treatments (Barrett, 2000).
Such work can be advanced by examining moderators and mediators of
treatment, and has begun by examining various treatment techniques
designed to target potential etiological and maintenance factors of anxiety
particular to children (e.g., family treatment in Barrett et al., 1996) and
by examining the effects of CBT for anxiety on those with severe intellec-
tual, emotional, and developmental delays (e.g., Davis, Kurtz, Gardner,
& Carman, 2007). However, the study of the effects of childhood anxi-
ety on development and of the ability of treatments to remediate psycho-
pathological developmental insults is also necessary. A developmentally
appropriate approach involves moving beyond a mere diagnostic assess-
ment to incorporate outcome measures of the entire emotional response
and indicators of a child’s developmental functioning and trajectory. This
observation points to a gap in the current treatment literature: the need
to consider factors beyond psychopathology including a child’s emotion
regulation, progression through developmental milestones and develop-
mental capabilities, and overall environment (Southam-Gerow & Kendall,
2000, 2002).
In sum, research into the treatment of childhood anxiety disorders has
blossomed over recent years with cognitive-behavioral EBTs at the forefront.
Although this renaissance has led to the development and study of elegant
therapies, controversy still surrounds their evaluation and study. Future
research should focus on the mechanisms of change and moderators of
outcome (i.e., for what individuals does treatment work or is treatment
most effective?). The various refinements and formats of CBT for child-
hood anxiety will likely prove beneficial considering the equifinality and
multifinality of psychopathology. Given the heterogeneity of pathways to
childhood anxiety, it is likely that specialized treatments addressing these
moderating and mediating variables will be ideal (e.g., cognitive-behavioral
family interventions for families in which anxious functional behavior is
reinforced or individual CBT for children from chaotic families for whom
little familial support of treatment procedures exists). These more complex
questions of applicability of ESTs (i.e., treatment effectiveness) are likely to
be ones of greater interest to practitioners and critics of EBP.
In closing, a framework for future EBP progress is offered using the
following circular process: (1) planners of RCTs should actively attempt
to address weaknesses pointed out in the literature, (2) active treatment

or placebo comparison conditions should be incorporated into RCTs in

addition to wait-lists for more rigorous comparisons, (3) measures of the
various components of anxiety and development should be purposefully
included and examined, (4) mediational and moderational analyses should
be undertaken to elucidate ESPs and mechanisms of change and to exam-
ine developmental variables, (5) future evaluations of these treatment
studies should adhere strictly to Task Force criteria, and (6) efforts should
be made to disseminate EST findings to academic, research, and practice


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Strategies for
Depression in Youth

There is a well-developed literature on depression in adults, including

risk factors, phenomenology, correlates, course, and biological substrates
(Kessler et al., 2003). Examination of both psychopharmacologic and
psychosocial treatments is extensive (de Maat, Dekker, Schoevers & de
Jonghe, 2007), and treatment guidelines have been developed to direct cli-
nicians’ interventions (American Psychiatric Association, 2006). However,
examination of depression in youth has commenced much more recently,
and the research literature to guide treatment is less well-developed. The
last 25 years have seen a surge in our understanding of the phenomenol-
ogy, course, correlates and etiology of youth depression. Despite the many
questions that remain, the field has moved forward in the development of
efficacious treatment strategies.
Recent data support the use of selective serotonin reuptake inhibitors
(SSRIs) in the treatment of youth depression (Emslie, et al. 1997; 2002;
Keller et al., 2001; Wagner et al., 2003, 2004) but do not suggest efficacy
for tricyclic antidepressants (Keller et al., 2001). Given the rates of adverse
events in clinical trials with youth (Cheung, Emslie & Mayes, 2005), their
limited efficacy (Hamrin & Scahill, 2005), and recent concerns about the
potential for increased risk of self-harm associated with SSRIs in youth
(United States Food and Drug Administration, 2004), there is a strong
need for the development of effective psychosocial treatments as treatment
alternatives and supplements to medication in the comprehensive treat-
ment of depressed youth.


J.L. Matson et al. (eds.), Treating Childhood Psychopathology 221

and Developmental Disabilities, DOI: 10.1007/978-0-387-09530-1,
© Springer Science + Business Media, LLC 2009

Although depression appears to be relatively rare prior to adolescence,

representing only 3% of school-aged youth (Costello et al., 1996), its incidence
increases significantly post-puberty (Costello et al., 1996; Lewinsohn, Hops,
Roberts, Seeley & Andrews, 1993; Kessler & Walters, 1998), with 20% of
youth expected to experience a depressive episode by age 20 (Lewinsohn et al.,
1993). Literature to date suggests important differences in adolescent-onset
and preadolescent-onset depression. First, earlier onset depression may be
associated with a more pernicious course than later onset depression (Kovacs,
Feinberg, Crouse-Novak, Paulauskas, & Finkelstein, 1984).
Second, early-onset depression frequently disrupts important develop-
mental processes during the elementary school years and is likely to result
in reduced psychosocial competence (Puig-Antich et al., 1985a; 1985b).
Thus, compared to nondepressed school-aged youth, depressed school-
aged youth are more likely to enter adolescence with fewer skills to cope
with an increasingly demanding environment.
Third, although research generally supports the role of negative attribu-
tional processes in adolescent depression (Garber & Flynn, 2001), the data on
the role of cognitions in preadolescent depression is less clear (Nolen-Hoek-
sema & Girgus, 1995). During the elementary school years children are still
developing schemas for understanding and making sense of events.
Fourth, although the data suggest strong continuity between adolescent
and adult depression (Bardone, Moffitt, Caspi, & Dickson, 1996; Fleming,
Boyle, & Offord, 1993; Lewinsohn, Rohde, Klein, & Seeley, 1999; Pine,
Cohen, Gurley, Brook, & Ma, 1998; Weissman et al., 1999), studies of pre-
adolescent-onset depression suggest high rates of ongoing maladjustment
and psychiatric disorders but less specificity for later depression. In sum,
there is evidence that adolescent-onset and preadolescent-onset depression
differ in important ways. For these reasons we have chosen to examine treat-
ments for adolescent and preadolescent depression separately.
In this chapter we describe the primary psychosocial treatments
approaches that have been investigated for depression in youth. First,
we outline some of the critical issues to consider in treatment for youth
depression. Second, we review the literature on treatment efficacy. Third,
we outline directions for future research.


Discovering and deciding upon the important issues that contribute

to a child’s depression is not only one of the first steps in determining
the course of treatment but it is also one of the most difficult tasks to
undertake. Although children might acknowledge some symptoms or
issues, they often may be dismissive or unaware of issues that feed the
depression. However, understanding the context within which the child
develops, including developmental phase effects, comorbidity, familial
processes, stress, and cultural background is essential to conducting an
assessment that adequately informs treatment.
As evidenced by the paucity of preadolescent treatment studies outlined
in the treatment outcome tables in this chapter, the majority of the treatment

outcome literature on youth depression has focused on adolescents.

Although a few treatment development studies have been conducted with
diagnosed school-aged youth (Flory, 2004; Kaslow, Baskin, Wyckoff, &
Kaslow, 2002; Kovacs et al., 2006; Tompson et al., 2007), there has not
been a single randomized control trial that exclusively targeted preadoles-
cents with diagnosed depression. The few existing trials conducted with
preadolescents have focused on those with high levels of depressive symp-
toms rather than diagnosable disorders.
In addition, research findings on the relationship between the child’s
age and treatment outcome have been mixed. Weisz and colleagues (Weisz,
Thurber, Sweeney, Proffitt, & LeGagnoux, 1997) found that therapy was
more effective for children (ages 4–12) than for adolescents (ages 13–18).
However, in their review of 150 different studies of the effects of psychotherapy
with children and adolescents, Weisz and colleagues (Weisz, Weiss, Han,
Granger, & Morton, 1995) found that treatment outcomes were superior for
adolescents compared to children. More specifically, they reported a mean
effect size of 0.48 for children under the age of 12 and a mean effect size of
0.65 for children over 12.
A recent meta-analysis (Weisz, McCarty & Valeri, 2006) specifically
examining treatment for depressed youth found that, excluding trials with
mixed child and adolescent samples, the effect size for studies of youth
under age 13 was not significantly different from the effect size for treatment
of adolescents (0.41 versus 0.33). However, the effect size for the younger
children (vs. adolescents) was based on a very small number of trials (n = 7)
all of which were selected based on depressive symptoms versus diagnoses,
which likely led to less severe depression in the child samples.
Clearly, there is a need for a better understanding of the relation-
ship between age and treatment outcome, particularly in relation to youth
depression. Such research should be informed by the developmental tasks
and changes associated with preadolescence and adolescence and the
ways in which they interact with various treatment approaches.
Each developmental phase brings with it tasks to be completed in order
for the youth to successfully move toward the next developmental stage.
These particular tasks interact differently with the youth’s vulnerability
and symptom expression at various stages of development. For example,
specific developmental considerations that differ between youth’s preado-
lescent years and adolescent years include their changing cognitive capac-
ity and social influences.
The preadolescent’s cognitive development may contribute to an
expression of depressive symptoms that differs from that of adolescents or
adults (Harter, 1999). It has been suggested that preadolescents have not
yet gained capacity for formal operational thinking and abstract reason-
ing necessary for the formation of internal, global, and stable explanation
cognitive styles that are associated with depression (Turner & Cole, 1994).
For example, preadolescents endorse hopelessness less frequently than
adolescents, likely due to the fact that they have not yet gained the level of
generalization necessary for an understanding of the concept (Carlson &
Kashani, 1988; Stark, Sander, & Hauser, 2006). In addition, although pre-
adolescents tend to rely heavily on their parents for guidance, feedback,

and support in negotiating the outside world, adolescents are shifting their
focus from family to peers as the primary unit of socialization.
During adolescence, youths begin to increasingly attend to environ-
mental information from their peers, leading to higher levels of peer-related
stress (Rudolph & Hammen, 1999; Wagner & Compas, 1990). Adolescents’
advanced cognitive perspective-taking abilities also cause social com-
parisons to become a central means of evaluating their self-worth (Stark,
Sander, & Hauser, 2006). Effective treatment strategies should therefore
be tailored to the specific socialization needs and cognitive capacities of
youth at different developmental stages.
Adolescent depression frequently presents with comorbid conditions.
Indeed, research suggests that upwards of half of the youth with diagnos-
able depression also meet criteria for another Axis I disorder (Lewinsohn,
Rohde & Seeley, 1998). Comorbidity may be even higher in younger chil-
dren (Kovacs, 1996). Common comorbidities include anxiety disorders and
attention deficit disorders in both preadolescent and adolescent youth,
as well as substance abuse during adolescence (Kovacs, 1996). Risk for
depression may be particularly heightened in individuals with Asperger’s
syndrome, Autism and associated development disabilities (Ghaziuddin,
Ghaziuddin, & Greden, 2002; Matson & Nebel-Schwalm, 2007; Saulnier
& Volkmar, 2007), and there is a strong need to enhance strategies for
assessing depression in these individuals (Matson & Nebel-Schwalm,
2007). Knowledge of the disorders that both parallel and likely contribute
to and interact with youth depression is crucial to understanding chil-
dren’s ongoing depression and psychosocial difficulties.
Familial processes are also key factors associated with youths’ risk
and vulnerability to depression. Parental psychopathology has often been
associated with youth depression (Beardslee, Versage, & Gladstone, 1998).
Research suggests that children of depressed parents are three times
more likely to develop depression than children of nondepressed parents
(Downey & Coyne, 1990). Findings from multiple studies also show that
children of depressed parents have higher rates of depression diagnosis,
recurrence, and chronicity than those of nondepressed parents (Ham-
men, Burge, Burney, & Adrian, 1990; Wickramaratne & Weissman, 1998;
Beardslee, Keller, Lavori, Staley, & Sacks, 1993; Billings & Moos, 1986;
Lee & Gotlib, 1991).
In addition to the genetic and biological risk factors that may account
for these associations, psychosocial factors in families may also contrib-
ute (Goodman & Gotlib, 2002). First, parental depression may affect the
parents’ ability to effectively care for the child (Downey & Coyne, 1990).
Observational data show that mothers who are depressed exhibit more
sad and irritable affect than nondepressed mothers during interactions
with their children (Cohn, Campbell, Matias, & Hopkins, 1990; Hops et
al., 1987; Radke-Yarrow & Nottelmann, 1989). Second, parental depres-
sion may increase stress within the family, thereby affecting the child’s
stress level. For example, children of depressed mothers report more epi-
sodic and chronic stressors than those of nondepressed mothers (Adrian
& Hammen, 1993). Taken together, these studies underscore the need to
understand the complex role of the family in the etiology and maintenance

of youth depression. Such understanding should inform treatment plan-

ning in terms of determining the target of treatment (child, parents, both)
and the most appropriate treatment strategies (medication, family-focused
treatment, or individual treatment).
Researchers have indicated that stress is one of the predominant path-
ways to the development of and manifestation of youth depression (Stark,
Sander, & Hauser. 2006, Stark et al., 2005). Knowledge of the role that
stress plays in the youth’s environment is therefore crucial in designing
and implementing effective treatments. In terms of the etiology of youth
depression, the diathesis-stress model posits that stress activates under-
lying vulnerabilities to produce the disorder (Monroe & Simons, 1991).
There has been some research to suggest that youths’ maladaptive cogni-
tions are the diathesis in this model. For example, research by Rudolph
and colleagues (Rudolph, Kurlakowsky, & Conley, 2001) shows youth
stress to be a precursor to control-related beliefs that are then associated
with higher levels of depressive symptoms.
In addition to its causal role, stress may also contribute to the main-
tenance of depression. Depressed youth report more negative life events
and chronic stress on both questionnaires (Compas, 1987) and on objec-
tive ratings of stress based on life stress interviews (Garber & Robinson,
1997; Hammen, 2002). Families of depressed youths even report high lev-
els of stress and negative life events (Hammen, 2002). Childhood depres-
sion is particularly associated with negative interpersonal events (such
as conflicts with peers) (Monroe, Rohde, & Seeley, 1999) and events that
are caused by the depressed youth himself or herself (such as failure in a
class; Rudolph et al., 2000). Comparisons between depressed children and
those with externalizing disorders show that depressed children report
more dependent, interpersonal stress than children with externalizing dis-
orders. However, no differences emerge between the groups on independ-
ent life stress (Rudolph et al., 2000).
Other research has shown that some stressors that are independent
of the child’s control are associated with depressive symptoms in chil-
dren. For example, researchers indicate that children in families with
less money are relatively more likely to experience depressive symptoms
(as indicated by teacher reports) than those with more money (Aber,
Brown, & Jones, 2003). In addition to experiencing heightened stress,
depressed children and adolescents are also more likely to use avoidant
coping strategies to manage stress (Chan, 1995). Conversely, children’s
use of more adaptive coping strategies for managing stressors is asso-
ciated with fewer depressive symptoms (Jeney-Gammon, Daugherty, &
Finch, 1993). In response to the powerful role of stress and coping in
youth depression, key components of certain evidence-based treatments,
such as Interpersonal Psychotherapy for Depressed Adolescents (IPT-A;
Mufson et al., 1999, 2004), include careful assessment of negative situa-
tions and problems as well as the implementation of coping strategies and
skills for managing them.
Cultural background is another key factor that relates to the manifes-
tation of youth depression and its treatment. Existing research on ethnic-
ity and depression indicates that various racial groups experience differing

levels of depression severity, varied symptom expression, and different

likelihoods of receiving treatment (Stark, Sander, & Hauser, 2006). For
example, Iwata, Turner, and Lloyd (2002) found that African American,
U.S.-born Hispanic, non-U.S.-born Hispanic, and non-Hispanic white ado-
lescents and young adults provided different responses to symptoms as
reflected on the Center for Epidemiologic Studies Depression Scale (CES-
D). More specifically, they found that the African American respondents
scored low on depressed affect symptoms and high on somatic symptoms,
whereas the U.S.-born Hispanic respondents scored low on the interper-
sonal symptoms but had higher levels of low positive affect.
In addition, researchers have found differences in the level of men-
tal health service utilization across racial groups. For instance, Cuffe
and colleagues (Cuffe, Waller, Cuccaro, Pumariega, & Garrison, 1995)
found that although African American adolescents had higher scores on
a measure of depression, they were less likely than European American
adolescents to receive outpatient treatment for any disorder and were
more likely to drop out of treatment early. Taken together, these find-
ings indicate that response to treatment might differ according to the
client’s ethnic background. In fact, some of the authorities on ethnicity
and culture have argued that findings from the majority of the current
clinical trials may not generalize to minorities (Bernal, Bonilla, & Bellido,
1995; Bernal & Scharron-Del-Rio, 2001; Hall, 2001; Sue, 1998). Clearly,
depressed youths (and likely their treatment providers) hold beliefs and
values about psychopathology and treatment that are influenced by their
various cultural backgrounds (Weisz, Jensen Doss, & Hawley, 2005).
Therefore, a sensitive understanding of these differences is essential to
accurate assessment and effective planning of treatment and treatment


Adolescent Depression
As reviewed briefly above, research on correlates of depression in youth
emphasizes its association with negative cognitions (review, Garber & Flynn,
2001), disturbed interpersonal relationships (review, Kaslow, Jones, Palin,
Pinsof, & Lebow, 2005), and stress (Rudolph et al., 2000). Accordingly,
treatments for adolescents have focused broadly on changing maladaptive
cognitions or on improving interpersonal functioning. Studies vary in their
inclusion of subjects with diagnosed depressive disorders versus subjects
with high levels of depressive symptoms. It is not clear the degree to which
findings from studies of youth with high depressive symptoms generalize
to youth with a diagnosable depressive disorder. Table 8.1 includes studies
conducted with youth with diagnosed depressive disorders. The 17 stud-
ies include 12 with a cognitive behavioral intervention condition, 3 with an
interpersonal therapy condition, 2 with social skills conditions, and 2 with
family therapy conditions. Four studies include comparison with medica-
tion conditions. Table 8.2 includes interventions conducted with youth

experiencing high levels of depressive symptoms and reviews six interven-

tions all of which are cognitive behavioral in their approach.

Maladaptive Cognitions
As illustrated in Tables 8.1 and 8.2 cognitive behavioral interven-
tions have been more thoroughly investigated than any other intervention
approach for adolescent depression. The specific cognitive interventions
used have varied across treatment studies. These studies have compared
cognitive behavioral treatment with different conditions, examined its
delivery in different formats (group vs. individual), looked at longer-term
follow-ups, and examined the role of parallel parent groups in enhancing
treatment efficacy.
Of the 12 studies of diagnosed depressed youth that included a cogni-
tive behavioral treatment condition, nine support the superiority of CBT
in comparison to control conditions. The efficacy of cognitive-behavioral
interventions has been demonstrated when compared to wait-list or no-
intervention conditions in three studies. CBT showed superiority in all
studies comparing it to wait-list control (Clarke, Rohde, Lewinsohn, Hops,
& Seeley 1999; Lewinsohn, Clarke, Hops, & Andrews, 1990; Rosello & Bernal,
1999), but in only one of the three studies comparing it to usual care
(Asarnow et al., 2005).
In one of the studies in which CBT did not show an advantage (Clarke
et al., 2005) the usual care consisted primarily of medication (SSRI) inter-
vention. Both studies (Clarke et al., 2002; 2005) underscore the impor-
tance of understanding what participants are receiving in “usual care”
Five studies have compared CBT to other psychosocial treatments, and
it has been shown to be superior to systemic family therapy, supportive
therapy (Brent et al., 1997), relaxation training (Wood, Harrington, & Moore,
1996), and life skills training (Rohde, Clarke, Mace, Jorgensen, & Seeley,
2004). However, in one study comparing it to Interpersonal Therapy (IPT),
IPT had a larger effect size and greater enhancements in social functioning
and self-esteem (Rosello & Bernal, 1999).
In the three studies that included medication arms, one was not
designed to compare the two interventions (Asarnow et al., 2005), one
found medication alone to be superior to CBT (TADS team, 2004), and one
found CBT to be superior to medication intervention (Melvin et al., 2006).
In the study by Asarnow and colleagues (2005) 418 adolescents in primary
care settings (ages 13–21) were randomly assigned to a six-month “quality
improvement” intervention or usual care. Those in the quality improve-
ment intervention had access to a care manager, who educated them about
depression and treatment options, and participants could select medica-
tion or CBT treatments. Although the study was not designed to evaluate
the relative efficacy of CBT and medication, the quality improvement inter-
vention overall was associated with significantly lower depressive symp-
toms, and adolescents were somewhat more likely to prefer CBT.
In the study conducted by Melvin and colleagues (2006) 73 adoles-
cents (ages 12–18) were randomly assigned to the CBT alone, medication
Table 8.1. Randomized Clinical Interventions Trials for Adolescents with Diagnosed Depression
Diagnostic/ Treatment Post-treatment
Reference Subjects Risk Assessment Format(s) Intervention Type(s) Assessment Impact of Treatment
Asarnow, Jaycox, Ages Either: (1) Endorsed Individual (1) 6-month quality Immediate Intervention patients, compared
Duan, 13-21 “stem items” for MDD improvement with usual care patients, reported
LaBorde, Rea, (n=418) or DD from the CIDI-12, intervention significantly higher mental health
Murray, et al., 1 week or more of (2) Usual care care utilization, fewer depressive
2005 past-month depressive symptoms, higher mental
symptoms, and a total health-related quality of life, and
CES-D score≥16, or greater satisfaction with mental
(2) CES-D score≥24 health care.
Brent, Holder, Ages Diagnosis of MDD based Family (1) Systematic Immediate The CBT group had faster response,
Kolko, Birmaher, 13-18 on K-SADS Interview Individual Behavior Family fewer cases of diagnosable MDD
Baugher, (n=107) and Therapy at the end of the treatment,
Roth, et al., 1997 BDI ≥ 13 (2) CBT a lower number of depressive
(3) Supportive symptoms, and were more likely
therapy to be remitted than other groups.
No difference between family and
supportive therapies.
Clarke, Rohde, Ages Diagnosis of MDD or DD Group (1) Adolescent Immediate; CBT was associated with higher
Lewinson, Hops, 14-18 based on the Coping with 12 months; depression recovery rates
& Seeley, 1999 (n-=123) K-SADS interview Depression 24 months (66.7% vs. 48.1% in wait list
Course (CWD-A) condition) and greater reduction
(2) CWD-A with in depressive symptoms.
nine-session Addition of parent group had
parent group no significant effect. Booster
(3) Wait list control sessions accelerated recovery
among youth still depressed at
the end of acute treatment but
did not reduce recurrence.
Clarke, Hornbrook, Ages Diagnosis of DSM–III–R Group (1) Usual care plus Immediate; No significant differences between
Lynch, Polen, 13-18 MDD and/or DD group CBT 12 months; CBT and usual care, either for
Gale, O’Conner, (n=88) based on the K-SADS program (CWD-A) 24 months depression diagnoses, continuous
et al., 2002 interview (2) Usual care depression measures, nonaffective
mental health measures, or
functioning outcomes.
Clarke, Debar, Lynch, Ages Diagnoses of DSM–IV Individual (1) Brief CBT plus Immediate; CBT program showed advantages
Powell, Gale, 12-18 MDD based on the treatment as 26 weeks; on the Short-Form-12 Mental
O’Conner, et al., (n=152) K-SADS-PL interview usual (primarily 52 weeks Component Scale and reductions
2005 SSRI) in treatment as usual outpatient
(2) Treatment as visits and days’ supply of all
usual medications. No effects were
detected for MDD episodes; a
nonsignificant trend favoring
CBT was detected on the CES-D.
Diamond, Reis, Ages Diagnoses of DSM–III–R Family (1) Attachment- Immediate; At post-treatment, 81% treated no
Diamond, Sique- 13-17 MDD based on the Based Family 6 months longer met criteria for MDD vs.
land, & Isaacs, (n=32) K-SADS Therapy (ABFT) 47% of patients in the waitlist
2002 (2) Minimal-con- group. The ABFT patients showed
tact, waitlist greater reduction in depressive
control group and anxiety symptoms and family
conflict. At follow-up, 87% of the
ABFT patients continued to not
meet criteria for MDD.
Fine, Forth, Gilbert Ages Diagnosis of MDD or Group (1) Therapeutic Immediate; At posttest both groups improved;
& Haley, 1991 13-17 DD based on K-SADS Support Group 9 Months TSG significantly more effective
(n = 66) Interview (TSG) vs. than SSG in reducing depression
83% (2) Social Skills on K-SADS with more subjects in
female Group (SSG) non-clinical range. Group differ-
ences disappeared at follow up.
Lewinsohn., Clarke, Ages Diagnosis of major, Group; (1) Adolescent only Immediate; Significantly fewer youths in the
Hops & Andrews, 14-18 minor, or intermittent Family CBT training 1 month; treatment groups met criteria
1990 (n = 59) depression based on group 6 months; for depressive disorders after
K-SADS interview with (2) Adolescent- 12 months; treatment and at follow up.
mother and adolescent parent CBT 24 months Significantly improved on self-
training groups reported depression, anxiety,
(3) Wait list control number of pleasant activities,
and depressogenic thoughts.
Trend for adolescent-parent
condition to out-perform
adolescent only group.

Table 8.1. (continued)
Diagnostic/ Treatment Post-treatment
Reference Subjects Risk Assessment Format(s) Intervention Type(s) Assessment Impact of Treatment

Melvin, Tonge, King, Ages Diagnosis of DSM–IV Individual (1) CBT Immediate; All groups showed significant
Heyne, Gordon & 12-18 MDD, DD, or DDNOS (2) Antidepressant 6 months improvement on outcome
Klimkeit, 2006 (n=73) based on the K-SADS medication measures and this was
(Sertraline) maintained at follow-up.
(3) Combined CBT Combined group was not superior
and medication to monotherapy. CBT alone was
superior to medication alone.
Mufson, Weissman, Ages Clinician diagnosis of Individual (1) Interpersonal Immediate IPT-A patients reported greater
Moreau, & 12-18 MDD based on the psychotherapy decrease in depressive
Garfinkel, 1999 (n=48) HRSD for depressed symptoms, improved social
adolescents functioning, and improved
(IPT-A) problem-solving skills
(2) Clinician compared to controls. In the
monitoring IPT-A condition 74% recovered
compared to 46% in the control
Mufson, Dorta, Ages DSM–IV diagnosis of Individual (1) IPT-A Immediate IPT-A associated with fewer clinician-
Wickramaratne, 12-18 MDD, DD, adjust- (2) Treatment as reported depression symptoms
Nomura, Olfson, (n=63) ment disorder with usual on the HAMD, better functioning
& Weissman, depressed mood, on the C-GAS, better overall
2004 or DDNOS and social functioning on the Social
HAMD≥10 and a Adjustment Scale-Self-Report,
C-GAS score≤65 greater clinical improvement,
and greater decreases in clinical
severity on the Clinical Global
Impressions scale.
Reed, 1994 Ages Clinician diagnosis of Group (1) Social skills Immediate; Skills group participants scored
14-19 MDD or DD training 6-8 weeks significantly high