Journal of Consulting and Clinical Psychology 1987. Vol. 55, No.

1,76-85

Copyright 1987 by the American Psychological Association, Inc. 0022-006X/87/J00.75

Problem-Solving Skills Training and Relationship Therapy in the Treatment of Antisocial Child Behavior
Alan E. Kazdin, Karen Esveldt-Dawson, Nancy H. French, and Alan S. Unis Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine

The present investigation evaluated the effects of cognitive-behavioral problem-solving skills training (PSST) and nondirective relationship therapy (RT) for the treatment of antisocial child behavior. Psychiatric inpatient children (N = 56, ages 7-13) were assigned randomly either to PSST, RT, or to a treatment-contact control condition (in which children met individually with a therapist but did not engage in specific activities designed to alter antisocial behavior). Children were hospitalized during the period in which treatment was administered and discharged thereafter. The PSST condition led to significantly greater decreases in externalizing and aggressive behaviors and in overall behavioral problems at home and at school and to increases in prosocial behaviors and in overall adjustment than the RT and contact-control conditions. These effects were evident immediately after treatment and at a 1-year follow-up. The RT and control children did not consistently improve over the treatment and follow-up periods. Comparisons with nonclinical (normative) levels of functioning revealed that a significantly higher proportion of PSST children, compared with those in other conditions, fell within the normative range for prosocial behavior at posttreatment and at follow-up. Even so, the majority of PSST children and almost all RT and control children remained outside the normative range of deviant behavior. The implications of the results for further research for antisocial youth are highlighted.

Antisocial behavior among children and adolescents is a significant clinical and social problem. The significance derives from findings that antisocial behaviors (particularly aggressive acts) are relatively prevalent among community samples, serve as the basis for one-third to one-half of clinical referrals among children, are relatively stable over the course of development, often portend major dysfunction in adulthood (e.g., criminal behavior, alcoholism, antisocial personality), and are likely to be transmitted to one's offspring (see Kazdin, in press; Loeber, 1985; Robins, 1981; Rutter & Ciller, 1983). Several treatments have been implemented to alter antisocial behaviors, including diverse forms of individual and group therapy, family therapy, behavior therapy, residential treatment, pharmacotherapy, and a variety of community-based treatments (see Kazdin, 1985). To date, few treatments have been shown to alter antisocial behavior in clinical samples; none has been shown to controvert the poor long-term prognosis. One of the most promising approaches is parent manage-

ment-training, which has been shown to produce therapeutic change in children with aggressive and other antisocial behaviors (see G. Patterson, 1982). Unfortunately, parent management-training is not a viable option for many clinical cases when there is severe family dysfunction, parent psychopathology, and socioeconomic disadvantage (e.g., Dumas & Wahler, 1983) or, of course, when there is no available parent who can participate. Severity of the child's or parents' dysfunction, removal of the child from the home (e.g., due to abuse or neglect), or inability or unwillingness of the parents to participate in treatment obviously restrict the use of parent- or family-based approaches. Other treatment options that focus on the resources of the child need to be considered. Among the more promising approaches are cognitive-behavioral treatments that train the child to use problem-solving skills in situations where interpersonal conflict and antisocial behavior emerge. Several studies have pointed to deficits in interpersonal cognitive problemsolving skills (e.g., generating solutions to problems), in level of cognitive development (e.g., moral reasoning), and in maladaptive cognitive strategies (e.g., impulsivity, attributional set) among aggressive children (see Dodge, 1985; Kendall & Braswell, 1985). Cognitive-behavioral treatments that focus on these processes have produced therapeutic change (e.g., Arbuthnot & Gordon, 1986; Kendall & Braswell, 1982;Lochman, Burch, Curry & Lampron, 1984). However, few studies have utilized clinic samples whose dysfunction was severe or have demonstrated changes on measures related to adjustment at home or at school (see Gresham, 1985; Kazdin, 1985). Thus, the clinical utility of these techniques for antisocial children warrants further attention. Another approach that warrants evaluation is nondirective
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Completion of this research was supported by Grant MH35408 and Research Scientist Development Award MH00353 from the National Institute of Mental Health. The efforts and support of several highly skilled staff, including Danielle Baum, Lisa DeCarolis, Louise Moore, Stephanie Fuderich, Antoinette Rodgers, Debra Colbus, Todd Seigel, Rosanna Sherick, and Sherry Wilson, were pivotal to completion of this project. The authors are also very grateful to Thomas M. Achenbach and Philip C. Kendall, who provided valuable comments and suggestions on an earlier draft. Correspondence concerning this article should be addressed to Alan E. Kazdin, Department of Psychiatry, Western Psychiatric Institute and Clinic, 3811 O'Hara Street, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213.

TREATMENT OF ANTISOCIAL CHILD BEHAVIOR psychotherapy, a technique that focuses on the development of a close interpersonal relationship with the child. Treatment is designed to provide a corrective emotional experience and to permit self-exploration and the expression of feelings (C. Patterson, 1979; Reisman, 1973). Relationship-based treatment is one of the most frequently used variations of child counseling and is advocated for a broad range of child clinical problems, including antisocial behavior (C. Patterson, 1979). Although a few studies of individual or group nondirective therapy have shown improvements in adjustment among antisocial delinquent youths (e.g., Persons, 1966;Redfering, 1972), other studies have shown little or no change (Alexander & Parsons, 1973; Feldman, Caplinger, & Wodarski, 1983). Given the paucity of controlled studies with clinical populations, the technique warrants further study. The present study evaluated the effectiveness of cognitivebehavioral problem-solving skills training (PSST) and nondirective relationship therapy (RT) for seriously disturbed antisocial children. The children were all referred to treatment for antisocial behaviors, primarily for aggression, and were hospitalized on an acute-care service. All children participated in a general ward program during the period in which they were also assigned randomly to one of three conditions in the present study. Children in the two treatment groups (PSST or RT) received individual sessions with a therapist while in the hospital. A control group was included in which children also received individual sessions with a therapist but did not engage in specific therapeutic processes designed to alter antisocial behavior.

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Method Subjects
Child characteristics. The subjects consisted of 56 children ( 1 1 girls and 45 boys). The children were all inpatients of a psychiatric facility where children are hospitalized for 2-3 months. The facility houses 22 children (ages 5-13) at any one time. The children are admitted for acute disorders, including highly aggressive and destructive behavior, suicidal or homicidal ideation or behavior, and deteriorating family conditions. Children were included if they (a) were referred for treatment for their antisocial behavior (including fighting, unmanageability at home or at school, stealing, running away, truancy, or related antisocial behaviors) as identified at intake assessment; (b) were rated by their parent at or above the 98th percentile on either the Aggression or Delinquency scale of the Child Behavior Checklist; (c) were 7-13 years of age; (d) received a full-scale Wechsler Intelligence Scale for Children-Revised (WISC-R; Wechsler, 1974) IQ score of 70 or above; (e) showed no evidence of neurological impairment, uncontrolled seizures, or dementia; and (0 were not receiving psychotropic medication. Children were considered if there was no parent or guardian who could participate in treatment with the child.1 Children were eligible if they were not in the custody of a parent or relative, if they were likely to be placed outside of the home (e.g., in foster care) after hospitalization, or if special family circumstances (e.g., excessive distance from the hospital) precluded parent contact with the treatment facility. Consent to participate was obtained from both child and parent (or legal guardian). The children who met screening criteria ranged in age from 7 to 13 years (M = 10.9) and in full-scale wtsc-R IQ score from 70 to 133 (M = 92.9). Forty-three (76.8%) children were white; 13 (23.2%) were black. Diagnoses of the children, based on Diagnostic and Statistical Manual

of Mental Disorders (DSM-m; American Psychiatric Association, 1980) criteria, were obtained from direct interviews with the children and their parents) immediately before admission and psychiatric evaluation after the child had been admitted. On the basis of these sources of information, two staff members independently completed diagnoses for each child. Agreement on principal Axis I diagnosis yielded a kappa of .76. For any disagreement, the case was discussed to reach a consensus on the appropriate diagnosis. Principal Axis I diagnoses included conduct disorder (n = 32), attention deficit disorder (n = 2), depression (n = 6), adjustment disorder (n = 4), and other mental disorders (n = 12). For the entire sample, 39 (69.6%) of the children received a principal or secondary Axis I diagnosis of conduct disorder. Parent characteristics. The primary caretakers of these children included biological mothers (n = 43); step, foster, or adoptive mothers (n = 6); or other relatives (n = 2). They ranged in age from 24 to 55 years (M = 33.1). Five children (8.9%) were in the custody of youth service agencies and did not come from families; 25 children (44.6%) came from two-parent families; and 26 children (46.4%) came from single-parent families. Head-of-household social class, calculated with the Hollingshead and Redlich (1958) two-factor index, yielded the following breakdown: Class V (18.8%), Class IV (45.8%), Class III (27.1%), Class II (6.3%), and Class 1(2.1%). Estimated monthly income for families ranged from $0 to $500 to more than $2,500 (median range = $500 to $ 1,000). Fifty-one percent of the families were on social assistance. Parent psychiatric diagnoses were obtained by administering a standardized interview individually to each parent within 2-3 weeks of the child's admission. The Schedule for Affective Disorders and Schizophrenia (SADS-L; Endicott & Spitzer, 1978) was administered to measure current and lifetime parent psychopathology. Of the mothers, 62.2% met criteria for current mental disorder; 78.4%, for past mental disorder. Of the 18 fathers available for assessment, 50.0% met criteria for current mental disorder; 66.7%, for past mental disorder. Major depression and substance abuse were the most common diagnoses for mothers and fathers, respectively.

Assessment
The goals of treatment were to reduce antisocial behavior and to improve the children's functioning at home and at school. Consequently, treatment was evaluated with parent and teacher measures that were administered before and after treatment and up to a 1-year follow-up. Pretreatment measures were completed when the child was admitted to the hospital. Posttreatment measures were completed 1 month after the final treatment session after the child had returned home to permit parents and community teachers to base their evaluations on a sufficient sample of the child's behavior. Follow-up assessments were also conducted 4, 8, and 12 months after treatment had been completed. In addition, at the end of the final treatment session, therapists and children were asked to evaluate treatment and the progress that was made. Parent checklist ratings. Parents completed the Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1983). The measure includes 118 items, each rated on a 0-2-point scale. The items constitute multiple behavior-problem scales (first-order factors) derived from factor analyses that were completed separately for boys and girls in different age groups (e.g., 6-11 years, 12-16 years). For the present investigation, the broad-band and summary scales were used because they are applicable to boys and girls of all age groups. Two broad-band behavior problem scales (second-order factors) are

1 Approximately 75% of the children in the psychiatric facility who met screening criteria did not have an available parent who could participate in treatment. The remaining 25% who did have an available parent participated in a separate project investigating the effects of parent management-training.

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KAZDIN, ESVELDT-DAWSON, FRENCH, AND UNIS and simplified but covered the same concepts (e.g., how treatment helped the child in handling problems, in interacting with others, and so on). The second subscale was designed to measure acceptability of treatment. Acceptability refers to judgments about the extent to which the treatment procedures are appropriate, fair, reasonable, and enjoyable to the patient. Eight items were included in this subscale and were drawn, in part, from previous work on the assessment and evaluation of acceptability of treatments for children (e.g., Kazdin, 1984). Items asked the child to evaluate how much they enjoyed treatment, looked forward to coming to the sessions, did not want the sessions to be over, and felt the sessions were interesting and fun.

Internalizing and Externalizing, which reflect inward-directed (e.g., schizophrenia, depression) versus outward-directed (e.g., aggression, delinquency) problems. The Total Behavior Problem score includes items loading on the first-order factors plus the items that do not load on specific scales. Of primary interest for present purposes was the impact of treatment on the Externalizing scale, which includes a broad array of antisocial behaviors (e.g., fighting, destroying property). In addition to the behavior problem scales, the CBCL includes three a priori social-competence scales: the Activities scale (child participation in activities), the Social scale (child interactions with others), and the School scale (child's academic performance at school), which together yield a Total Social Competence score. Teacher checklist ratings. To evaluate performance at school, the children's teachers completed the School Behavior Checklist (SBCLForm A2 Miller, 1977). The measure includes 96 items that assess behaviors among children 7-13 years old. Behavioral characteristics are rated by the child's teacher as true or false. Factor analyses have yielded six scales that include Low Need Achievement, Aggression, Anxiety, Academic Disability, Hostile Isolation, and Extraversion. Of these scales, the Aggression scale was selected because it reflects the central focus of treatment. In addition to this scale, the overall summary scale, Total Disability, was examined. This scale reflects a summary score of behavioral symptoms included in the six scales. The SBCL also includes five additional items in which the teacher rates, on 9-point Likert scales, the child's intellectual ability, academic skills and performance, emotional adjustment, and personal appeal. These ratings were summed and utilized for evaluation as the teachers' global ratings of school adjustment. The CBCL and SBCL were selected for several reasons. First, the measures sample a broad range of childhood dysfunction, including aggressive behaviors and other antisocial behaviors that served as the basis for clinical referral. Second, each measure includes facets of prosocial behavior. The CBCL includes three social-competence scales; the SBCL includes overall ratings of school adjustment. Scales reflecting prosocial behaviors and adjustment were of interest because treatment was devoted to the development of prosocial behaviors as well as to the reduction of antisocial behavior. Finally, both the CBCL and SBCL have been carefully evaluated with clinic and nonclinic populations. Transformed scores facilitate interpretation of the measure in relation to normal (nonclinic) same-age peers. Therapist evaluations. Immediately after the final treatment sessions, therapists completed the Therapist Evaluation Inventory (TEI), a 15item scale constructed for the present study and designed to evaluate progress made by the child. The measure includes two a priori subscales. The first subscale included 6 items in which the therapist evaluated the child's progress in treatment. The items, each rated on a 5point Likert scale, required the therapist to evaluate how receptive the child was to treatment, how well the child grasped the strategies or approach, and how much was learned by the child in the sessions. The second subscale included 9 items that focused on the likelihood that the child would show improvements in the future. Therapists rated the extent to which the child was likely to improve at home and at school, the degree of favorable impact that therapy was likely to have on the child's life, how well treatment affected the child's ability to handle interpersonal problems outside of treatment, and how well the child would be able to exert self-control. The purpose of the TEI was to examine the relation between the therapist's evaluations and the child's posttreatment functioning.2 Child evaluations. At the end of the final treatment session, children completed a Child Evaluation Inventory (CEI). The measure included 19 items, each rated by the child on a S-point scale, that constituted two subscales. The first subscale included 11 items in which the child was asked to evaluate his or her progress in treatment. The items were similar to those on the TEI. The questions in the child form were reworded

Treatment Administration
Because all children were inpatients, the treatment and control conditions of the present study were superimposed upon the general milieu program.3 This program included a variety of routine ward activities and day-to-day contact with direct-care workers and other staff. The ward activities and structure were directed toward care and management of the children rather than toward specific regimens to treat conduct disorders or other dysfunctions. Yet, time-out and seclusion contingencies were included routinely to manage uncontrollable behavior. There was no other general ward program (e.g., token economy) as part of the management of the children, although there were structured routines, staff praise, and occasional loss of privileges. Therapeutic treatments, when deemed advisable for individual children (e.g., medication trials, psychotherapy, individualized behavioral programs) were superimposed on the general ward program. However, for all children in the present project, individualized programs or other specific treatments were not provided beyond those reported.

Treatment Conditions
Children who met criteria for participation were assigned randomly to one of four therapists and three conditions. Problem-solving skills training. Children (n = 20) assigned to this condition received PSST, which was administered individually in 20 sessions. Sessions lasted approximately 45 min and were administered 23 times per week. Treatment was completed while the child was in the hospital. After completion of the sessions, the child was discharged. Therapy was modeled after the treatment procedures developed by Spivack, Platt, and Shure (1976) and by Kendall, Padawer, Zupan, and Braswell (in Kendall & Braswell, 1985). The modifications were made to emphasize interpersonal situations with significant others (e.g., parents, siblings, teachers, peers) and to include opportunities for individualizing content and addressing referral concerns and situations in which the child had engaged in antisocial and oppositional behavior. The treatment combines cognitive and behavioral techniques to teach problemsolving skills (e.g., generating alternative solutions, means-ends and consequential thinking, and taking the perspective of others) that the child can use to manage interpersonal situations. Training began initially by teaching the child to use the problemsolving approach with academic tasks (selected at grade level) and games (e.g., checkers). The tasks became increasingly complex over the course of sessions. The bulk of treatment was devoted to enacting interpersonal situations through role playing where the child applied the approach (i.e., invoking specific problem-solving steps). In each session, practice, modeling, role playing, corrective feedback, and social reinforcement were used to develop problem-solving skills. Response cost

2 Copies of the Therapist Evaluation Inventory and the Child Evaluation Inventory are available from the authors. 3 The term milieu here is used to denote a general ward-management program rather than milieu therapy.

TREATMENT OF ANTISOCIAL CHILD BEHAVIOR (loss of chips) was also used for errors in carrying out the problemsolving approach (e.g., skipping a step). The chips, provided at the beginning of each session, could be exchanged for small toys and prizes at the end of each session. As part of treatment, children were assigned homework in which they identified situations in their daily lives in which the problem-solving approach could be applied and eventually utilized the approach by themselves in real-life situations. Chips were also earned for completing homework assignments, based on information obtained through the child's report, on interviews, and on reenactments of homework situations within the sessions. Relationship therapy. Children (n= 19) in this condition received 20 individual treatment sessions of nondirective relationship therapy. The focus of the individual sessions, each lasting approximately 45 min, was on developing a close relationship with the child and providing empathy, unconditional positive regard, and warmth. Therapists focused on helping the child to express feelings. Therapy was modeled after principles and procedurers outlined by C. Patterson (1979) and Reisman (1973). There were some important diiferences in the administration of RT that departed from administration with adults. Activities and play materials were available for early sessions so that child and therapist could talk in the context of playing a game. In later sessions, various themes were discussed, including interpersonal situations involving peers, parent(s), teachers, siblings, and individualized problem areas (based on referral concerns). Children in RT also received chips based on completion of their sessions, and these could be exchanged for prizes. The games and activities used in early sessions, the emphasis on interpersonal themes, and the focus on individualized problem areas were similar across PSST and RT. In PSST, the games and tasks were the focus for teaching specific problem-solving skills; in RT, they were subservient to the goals of establishing a trusting relationship and discussing the child's feelings. Treatment-contact control. To partially control for repeated therapist contact and attendance at special sessions outside of the usual ward routine, a treatment-contact control group (n= 17) was included. The purpose was to provide an opportunity for children to have special treatment meetings with a therapist but not to provide problem-solving skills training or individual nondirective psychotherapy. Children in this condition met with a therapist for 20 individual sessions. The number of sessions and their schedule were identical to those of the treatment groups. However, sessions were less than half the duration (20 min) of those of PSST and RT. The reason for the difference in duration was to adhere to the goals of the control group (i.e., individualized contact with a therapist) and to avoid in-depth discussion of affectladen material likely to emerge in more protracted sessions. The critical feature of this condition was to provide the therapist and child with time together. The therapist's task in the sessions was to engage the child in discussion of routine activities (e.g., in class, with friends) on the unit. Although the primary medium of exchange was conversation, there was no attempt to probe the child's feelings or clinical problems or to develop insight, self-acceptance, or related processes. The therapist played games (e.g., checkers) if the child wished, as long as the child and therapist were together in a session without the interaction or interruption of others.

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detailed. Training utilized extensive role playing and modeling to master the treatment, at which point training cases were assigned. These initial training cases of children received close supervision, which included direct observation of each session, review of tapes with individual therapists on a session-by-session basis, discussion of the case, and group meetings to review cases. Therapist supervision continued throughout the course of the investigation with individual meetings with therapists, group meetings, and weekly case review. Treatment sessions were videotaped or audiotaped for supervision purposes.

Treatment Integrity
To sustain the integrity of treatment (Yeaton & Sechrest, 1981): (a) therapists followed a treatment manual that delineated each treatment on a session-by-session basis; (b) therapists saw two to three training cases in each condition before seeing cases for the study; (c) therapists were provided with several materials to foster the correct execution of each session, including checklists that prescribed the necessary materials for each session, the specific themes or tasks that needed to be covered, and related information; (d) therapists were required to provide documentation of the session, including summaries of what had transpired, any unique features, duration of session, and child progress; and (e) therapists were provided with ongoing clinical supervision, feedback, and training throughout the investigation.

Attrition
Fifty-six children were assigned randomly to treatment. Of these, 51 (91.191) completed treatment. Of the 5 subjects who did not complete treatment, 2 were from the PSST condition; 1, from the RT condition; and 2, from the control condition. Reasons for failing to complete treatment included premature termination of hospitalization (against medical advice, n = 2) and child refusal to come to treatment (n = 3). The sample of 51 subjects was reduced further by the failure of four families to consent to or to provide assessment of child performance at home or at school after treatment. Posttreatment data analyses were based on 47 (83.9%) of the 56 originally assigned subjects, who included 17 of 20 (85.0%) PSST children; 14 of 19 (73.7%) RT children; and 16 of 17 (94.1%) control children. At the 1-year follow-up assessment, data were available from the parents and/or teachers of 42 (75.0%) of the original 56 cases.

Results Preliminary Analyses Factorial multivariate analyses of variance (M ANOV AS) examined the effects of child age, gender, race, and IQ; diagnoses; and parent (or guardian) age, current or past mental disorder, welfare status, and Hollingshead class on CBCL and SBCL scales. For continuous variables (e.g., age, IQ), median splits were used to divide the sample and to test for differences on the dependent measures for these analyses. No differences were obtained as a function of subject and demographic variables at pretreatment, posttreatment, or follow-up assessment periods. The MANOVAS also revealed no significant differences among the treatment and control groups on subject or demographic variables or pretreatment CBCL and SBCL scores. Treatment Effects

Therapists
Four female clinicians (ages 25-31) served as therapists. Each had completed postgraduate course work in child development or other mental-health-related fields and had 1-2 years of direct-care experience with children and families on the clinical service, prior to the study. The therapists participated in an intensive training program for approximately 6 months to learn each treatment technique. The treatments were detailed in manual form in which the contents of each session, the materials, the order of presentation, and sample dialogues were

The MANOVAS revealed no significant differences as a function of therapist or of Therapist X Condition. Hence therapist

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KAZD1N, ESVELDT-DAWSON, FRENCH, AND UNIS

was not included as a factor in the evaluation of treatment effects. Analyses of covariance (ANCOVAS) were used to evaluate treatment effects at each assessment period using pretreatment performance as the covariate. Multiple comparison tests of means (adjusted from covariance analyses) were computed where overall significant effects were obtained. Changes over the course of treatment and follow-up were evaluated by withingroup t tests. Postlreatment. Posttreatment assessment was conducted 1 month after completion of treatment and hospital discharge to allow parents and teachers the opportunity to evaluate the child's behavior. Means and standard deviations for parent and teacher measures are presented in Table 1; ANCOVAS appear in Table 2. At posttreatment, significant group differences were evident for the Internalizing scale, Externalizing scale, and Total Behavior Problem scale of the CBCL. Two CBCL social-competence scales, namely, the Activities scale and the School scale, also reflected group differences. On the SBCL, significant group differences were evident for Aggression, Total Disability, and overall ratings of school adjustment. To evaluate the source of the differences for significant effects, multiple comparison tests were completed. Bonferroni (tests were conducted to control family-wise error rates for an alpha of .05 (Myers, 1979). The comparisons revealed a relatively consistent ordering of groups (see Table 3). Children who received PSST showed significantly less dysfunction on the CBCL and SBCL scales than RT and control children. The PSST children also showed significantly greater participation in social activities and progress at school (on the CBCL) and overall school adjustment (on the SBCL). Although the RT group showed lower behavior-problem scores and higher prosocial behavior than the control group on all but one of the CBCL and SBCL scales, the differences did not attain statistical significance. Within-group t tests were computed to evaluate change from pre- to posttreatment. The results (Table 4) indicated significant improvements for the children who received PSST on each of the behavior-problem scales and school performance on the CBCL and on Aggression, Total Disability, and overall adjustment on the SBCL. The RT children improved on externalizing behavior on the CBCL and on the Aggression scale of the SBCL. Control children showed nonsignificant improvements in internalizing behavior and significant decrements in participation in social activities and school performance as measured by the CBCL. One-year follow-up. The CBCL and SBCL were readministered to parents and teachers 4, 8, and 12 months after treatment. The results for the different follow-up periods did not lead to different conclusions about the impact of treatment or about the relative standing of the treatment and control conditions. Consequently, for summary purposes and to evaluate the impact of treatment at the final assessment point, only results for the 1-year follow-up are presented and discussed (Tables 1 and2).4 As is evident in Table 2, at the I-year follow-up, significant group differences continued to be evident for the Internalizing scale, the Externalizing scale, and the Total Behavior Problem scale of the CBCL. Yet, group differences were no longer evident for the Activities scale at the end of 1 year. Of the social-competence scales, the School scale remained significantly different

Table 1 Means and Standard Deviations for the Child Behavior Checklist (CBCL) and the School Behavior Checklist (SBCL) From Pretreatment Through Follow-Up
Pretreatment Measure Posttr eatment

Follow-up

SD

SD

SD

Problem-solving skills training CBCL Internalizing Externalizing Total behavior problem Activities Social School SBCL Aggression Total Disability Global school adjustment

71.9 78.5 79.0 44.1 26.9 32.8 77.0 71.5 16.7

7.2 4.9 5.5 9.7

12.6

9.9
11.4

63.8 66.8 67.5 49.1 32.3 42.2 63.1 59.7 25.6

9.6 9.4 9.8 6.5

11.9 10.5 12.5

63.3 69.6 68.5 44.6 33.5 38.3 66.2 64.3 25.5

8.7 7.9 8.4

11.6 11.1 10.5 11.7

7.9 5.5

9.3 6.1

8.0 3.8

Relationship therapy CBCL Internalizing Externalizing Total behavior problem Activities Social School SBCL Aggression Total Disability Global school adjustment

70.8 77.6 77.9 44.0 33.1 29.4 76.8 72.9 18.9

11.2

6.6 7.9
11.3

9.4
10.1 10.7

70.9 73.8 75.4 42.2 29.7 27.4 71.6 69.0 21.4

6.0 5.4 7.1 9.6 8.8

10.3 10.8

68.9 77.5 78.0 42.3 32.0 30.5 76.1 70.9 20.6

6.4 5.8 7.8 8.3 9.2

10.4 11.7

9.5 5.7

7.1 5.0

6.8 5.6

Treatment-contact controls CBCL Internalizing Externalizing Total behavior problem Activities Social School SBCL Aggression Total Disability Global school adjustment

71.8 77.2

12.2

783
46.5 31.8 32.0 81.8 73.3 19.5

6.0 8.1 7.0

11.8

7.6
11.7

68.7 77.1 77.3 42.2 30.5 28.0 79.3 72.3 19.7

12.2

8.4 9.3 8.5

10.1

7.4
13.0

71.0 80.5 79.5 40.9 28.8 27.9 78.7 72.1 20.3

8.9 8.6
10.9

9.4
11.7

6.9
16.2 11.8

9.3 5.6

7.6 4.8

6.0

Note. Scores are normalized T scores derived from the Child Behavior Profile (see Achenbach & Edelbrack, 1983).

among groups. On the SBCL, Aggression, Total Disability, and global ratings of school adjustment also showed group differences at the 1 -year follow-up. Multiple-comparison tests were computed on the adjusted means from the ANCOVAS at the 1-year follow-up for those effects that attained significance. The results (Table 3) showed that PSST children were rated as significantly less deviant than RT and control children on the behavior-problem scales of the CBCL and SBCL and higher in school performance and teacherrated school adjustment. The results indicated that several of

Additional tables and data analyses that include 4- and 8-month

follow-up assessments are available on request.

TREATMENT OF ANTISOCIAL CHILD BEHAVIOR Table 2 Analyses ofCovariance at Posttreatment and Follow- Up Assessment period Dependent measure CBCL' Internalizing Externalizing Total behavior problem Activities Social School SBCL" Aggression Total Disability Global school adjustment Posttreatment Follow-up

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lem scale and SBCL Total Disability scale were examined for children who participated in the study relative to nonclinical samples within the same age range, as derived from normative data for these measures (see Achenbach & Edelbrock, 1983; Miller, 1977). Using their analyses of clinic and nonclinic samples, Achenbach and Edelbrock (1983) identified the 90th percentile as a 5.26** 11.30*** 9.94*** 5.16** <1 15.16*** 7.92*** 10.25*** 6.15" 3.60* 8.24*** 6.76** 1.70 <1 10.63*** 3.86* 3.19* 7.31** cutoff score for the upper limit of the normal range for the Total Behavior Problem score. Scores below this percentile fall within the nonclinical (normal) range. For present purposes, the 90th percentile criterion was used to define the upper limit of the normal range on the CBCL Total Behavior Problem scores and on the SBCL Total Disability score. Achenbach and Edelbrock (1983) also suggested the 10th percentile as the lower limit of the nonclinical range on the Total Social Competence score (the sum of the three CBCL social scales). Children below this percentile are more deviant in their prosocial behavior than 90% of children in nonreferred normative samples. Group means. The initial concern is the extent to which children in the alternative groups fell within the nonclinical range. To address this question, T scores that defined the boundary of the normal range were used as a criterion to evaluate performance for treatment and control children for CBCL Total Behavior Problem scale, SBCL Total Disability scale, and CBCL Total Social Competence scales. Figure 1 presents mean T scores for children in the PSST, RT, and contact-control groups as well as '/'score cutoffs based on data obtained from nonclinic samples. The figure shows that children who received PSST made marked changes on the CBCL (upper panel), but their mean remained well above the upper limit of the normative range at posttreatment and follow-up. For Total Disability from the teacher evaluations (lower panel), PSST children fell within the nonclinic range at posttreatment, but these gains were not

Note. CBCL = Child Behavior Checklist; SBCL = School Behavior Checklist. 1 Posttreatment, df = 2, 42; Follow-up, df = 2, 30. b Posttreatment, df= 1,40; Follow-up, df= 2, 36. *ps.05. **ps:.01. ***p<;.001.

the group differences evident at posttreatment were sustained at the 1-year follow-up. The RT and control children were not significantly different from each other on any of the measures. To examine behavior change after treatment, within-group (tests were computed from posttreatment to 1-year follow-up assessment. The PSST children showed no significant changes from posttreatment to the 1-year follow-up. The RT children showed a significant increase in externalizing behavior, t(lO) -2.93, p < .05, on the CBCL. Control children showed significant increases on the Externalizing scale, f(9) = -2.80, p < .05), and on the Total Behavior Problem scale, t(9) - 2.46, p < .05, of the CBCL. No significant changes were evident on the SBCL from posttreatment to follow-up for RT or control groups. Overall, the few changes that did transpire from posttreatment to 1-year follow-up were in the direction of increased deviant behavior for RT and control children. Within-group t tests (Table 4) indicated that from pretreatment to 1 -year follow-up, PSST children significantly improved on seven of the nine CBCL and SBCL scales. Within-group changes over this same period were not significant for RT and control children. Actually, at follow-up control children were significantly worse on the CBCL School scale relative to pretreatment.

Table 3 Multiple-Comparison Tests on Adjusted Means at Posttreatment and 1-Year Follow- Up Posttherapy Measure CBCL Internalizing Externalizing Total behavior problem Activities School SBCL Aggression Total Disability Global school adjustment PSST Follow-up

RT

TC

PSST

RT

TC

63.6 66.3 67.0 49.3 39.9 64.6 60.4 26.0

71.4. 74.0. 76.0, 42.6. 29.3. 72.6, 68.4. 21.3.

68.5. 77.5. 77.3. 41.6. 28.4. 77.1. 72.1. 19.4.

62.9 69.7 68.1

69.4. 77.7. 78.6.

71.0. 80.2. 79.4,

Clinical Impact of Treatment

These results suggest that PSST produced significant changes and that this group was superior to RT and the contact-control condition at posttreatment and follow-up. Yet a major concern is the extent to which the treatment produced clinically important changes. Although there is no standardized way to assess clinical significance in outcome research, one way is to evaluate the extent to which treatments brought child behavior within the nonclinical range of functioning (Kazdin, 1977). Normative data are available for both the CBCL and the SBCL that permit delineation of a range of behavior for nonclinic samples. To reflect an overall level of dysfunction, CBCL Total Behavior Prob-

39.7
66.8 64.1 26.8

31.2.
76.1. 70.2. 20.7,

27.7.
77.3. 71.9. 20.1.

Note. PSST = problem-solving skills training; RT = relationship therapy; TC = treatment-contact control. CBCL = Child Behavior Checklist; SBCL = School Behavior Checklist. For a given measure at posttreatment or follow-up, means that share the same subscript are not significantly different. All differences are significant at p < .05, using Bonferroni 1 tests. Dash indicates that comparisons were not made because the overall test was not statistically significant.

82
Table 4

KAZDIN, ESVELDT-DAWSON, FRENCH, AND UNIS

Within-Group t Tests From Pretreatment to Posttreatment and From Presentment to Follow- Up

PSST

RT
Pretreatment to posttreatment
(12) <l 2.36* 1.20 <1 -1.17 -1.62 (12) 2.18* 1.92 1.82

TC

Dependent measure CBCL Internalizing Externalizing Total behavior problem Activities Social School SBCL Aggression Total Disability Global school adjustment

Pretreatment to posttreatment
(16) 3.42" 6.03*** 5.46"* 1.96 1.14 3.97" (14) 6.10*" 5.17*" 5.72"*

Pretreatment to follow-up
(12) 3.23" 4.07" 3.77"

Pretreatment to follow-up
(10) < < < <

Pretreatment to posttreatment
(15) 2.01 <1 <1 -2.25* <1 -3.16" (15) 1.21 <1 <1

Pretreatment to follow-up
(9) < < <

<1 <|
3.28" (13) 5.18"* 3.75" 5.00"*

.58
<

.17
< ( 0) <

.13 .95

.49* ( 14) < < <l

Note. PSST = problem-solving skills training; RT = relationship therapy; TC = treatment-contact control. CBCL = Child Behavior Checklist; SBCL = School Behavior Checklist. Parentheses indicate degrees of freedom. Negative t values indicate that the change is in the direction of deterioration (increased deviance, decreased prosocial behavior). ps.05. "p<:.OI. *"ps.001.

sustained 1 year later. Finally, for social competence (Figure 2), the means for all groups were within the lower boundary of the nonclinical range before treatment. After treatment, PSST children showed greater penetration into this range, whereas the other groups moved in the direction of decrements in social behavior. Individual cases. The mean scores do not reflect the performance of individual children and their progress. Chi-square tests evaluated the proportions of group members who fell within the normative range for the Total Behavior Problem, Total Disability, and Total Social Competence scores. Two groups of children were delineated separately for each measure, namely those who fell within the nonclinic range (based upon the cutoff scores) and those who did not. 5 For each analysis, children were excluded if their pretreatment scores fell within the normal range. Table 5 summarizes the proportion of children who fell within the nonclinic range at different assessment periods. The results indicated significant differences in proportions for the Total Disability scale at posttreatment. More children from the PSST group fell within the normal range at posttreatment than did RT or control children. However, these differences were no longer significant at the 1-year follow-up. For the social-competence measure, significant differences were evident in the proportions of children within the nonclinic range at both posttreatment and follow-up. A significantly higher proportion of PSST children fell within the nonclinic range than RT and control children.

nificant treatment effect for the improvement ratings, F(l, 12) = 6.08, p < .05. Multiple comparisons tests (Bonferroni ( tests) indicated that PSST children (M = 28.8) were considered by therapists to be more likely to improve in the future than were RT (M = 22.5) or control (M = 20.6) children. These latter groups were not different from each other. Pearson product-moment correlations were computed between therapist evaluations and CBCL and SBCL summary scales at posttreatment and 1-year follow-up to examine if therapist ratings were related to child functioning at home and at school. Therapist ratings of child improvements correlated negatively with Total Disability scores at posttreatment and followup (rs = -.44 and -.53, both p < .03). Thus, the more favorable were therapist's predictions of improvement, the less deviant were children at school, as rated by classroom teachers who completed the SBCL. Therapist evaluations of in-session progress or improvement were unrelated to CBCL scales at posttreatment and follow-up. Child evaluations. The Child Evaluation Inventory yielded two subscales reflecting the children's evaluations of progress they made in therapy and of treatment acceptability. Therapist X Condition ANCOVAS yielded no differences on these scales.6 Pearson product-moment correlations were com-

Supplementary Analyses
Therapist evaluations. The TEI yielded measures from the two subscales. namely, the therapist's rating of the child's progress within the sessions and the prediction of posttreatment improvements. The ANCOVAS (3 X 4) were completed to evaluate whether progress or improvement ratings varied as a function of treatment condition or therapist. The results yielded a sig-

Normative data and percentile equivalents are available from the assessment manuals for the CBCL (Achenbach & Edelbrock, 1983) and the SBCL (Miller, 1977). To compute whether a child's score falls within the normal range, raw scores must be examined because different raw scores may yield the same r scores (see Achenbach & Edelbrock, 1983). 6 The absence of differences on the child acceptability ratings does not convey that the treatments were equally acceptable or unacceptable to the children. Each of the eight items on the Acceptability subscale of the CEI was scored on a 5-point scale, with a total possible score of 40. A moderate rating (score of 3 on each item) would yield a total score of 24. The means for PSST, RT, and control groups were 39.7, 37.2, and 36.7, respectively, which suggested a high degree of acceptability. Given that the means were all close to the maximum total score, it is possible

TREATMENT OF ANTISOCIAL CHILD BEHAVIOR

83

progress were correlated positively with child evaluations of treatment acceptability (r .40, p < .04). The greater were therapist ratings of progress within sessions, the more acceptable was treatment viewed by the children. Therapist predictions of improvement were unrelated to the child's ratings of progress or acceptability.

Discussion
The results indicated that (a) problem-solving skills training led to significantly greater changes than relationship therapy and treatment-contact control conditions, (b) the betweengroups differences and within-group changes of PSST were sustained up to 1-year follow-up, and (c) the effects of treatment were evident on measures of child behavior at home and at school. There was some evidence that treatment effects were attenuated over the course of follow-up. Nevertheless, at the 1year follow-up, children who had received PSST evinced significant reductions in total behavioral problems at home and at school and improvements on measures of school performance rated by the parent and of overall school adjustment rated by the teacher. In contrast, children in the other groups made either
PRE POST FU ASSESSMENT 12

few gains over the course of treatment and follow-up (the RT group) or became significantly worse on selected measures (the control group). To evaluate the clinical impact of treatment, performance of treatment and control children was compared with normative data from nonclinic samples. The results indicated that the proportion of children who fell within the normative (nonclinic) range for behavioral problems was greater for the PSST group than for the other groups. The differences were especially marked for prosocial behavior (social competence) at posttreatment and follow-up. Even so, the majority of children in the PSST group remained outside (i.e., more deviant than) the upper level of the nonclinic range for CBCL Total Behavior Problem scale and SBCL Total Disability scale.

Figure 1. Mean r scores for the problem-solving skills training (PSST), relationship therapy (RT), and control groups for the Total Behavior Problem scale of the Child Behavior Checklist (CBCL, upper panel) and the Total Disability scale of the School Behavior Checklist (SBCL, lower panel). The horizontal line represents the upper limit of the nonclinical (normal) range of children of the same gender and age. The T scores below this line fall within the normal range. Note that FU 12 designates 12-month follow-up.

puted to examine if child evaluations of treatment correlated with the CBCL and SBCL scales. At posttreatment, child evaluations of progress correlated positively with parent ratings of social competence (r = .41, p < .03). The more the children viewed themselves as making progress, the more likely the parent rated them as socially competent on the CBCL. Child evaluations of progress tended to be negatively correlated (r = .29) with total behavioral symptoms on the CBCL at posttreatment, but this failed to attain statistical significance (p < .08). Interestingly, at posttreatment acceptability was correlated negatively with CBCL Total Behavior Problem scores (r = - .41, p < .03) and positively with Total Social Competence (r = .39, p < .04). Children who viewed treatment as more acceptable scored lower in behavioral problem and higher in social competence at posttreatment. However, none of these relations was maintained at the 1-year follow-up assessments. Convergence of therapist and child ratings. Therapists and children both rated how much progress was made in treatment. Pearson product-moment correlations indicated a small and nonsignificant correlation between therapist and child evaluations of progress (r = .36, p < .07). Therapist evaluations of

PRE

POST

FU

12

ASSESSMENT

that a ceiling effect precluded differences in acceptability ratings. Nevertheless, the results suggest that the children viewed the treatments as highly acceptable.

Figure 2. Mean T scores for the problem-solving skills training (PSST), relationship therapy (RT), and control groups for the Total Social Competence scales of the Child Behavior Checklist (CBCL). (The horizontal line represents the lower limit of the nonclinical [normal] range of children of the same gender and age for these prosocial behaviors. The T scores above this line fall within the normal range. Note that FU 12 designates 12-month follow-up.)

84
Table 5

KAZDIN, ESVELDT-DAWSON, FRENCH, AND UNIS changes in self-concept) that RT produces. Also, the critical conditions of treatment (e.g., empathy, unconditional positive regard) may not have been sufficiently high to produce change. These and other possible interpretations cannot be excluded on the basis of the present data. Few controlled trials of RT exist with antisocial children. Hence this treatment needs to be explored further, with improvements in design not evident here, before the impact can be evaluated definitively. 3/17 17.6 0/13 0.0 2/16 12.5 2.43 Therapist and child evaluations yielded interesting results. Child evaluations indicated that treatment and control interventions were both rated as highly acceptable. Child evaluations of acceptability were correlated negatively with parent ratings of deviant behavior and positively with prosocial behavior after treatment. Therapist evaluations of improvement at the end of therapy were negatively correlated with teacher ratings of deviant behavior after treatment and at the I year follow-up. These results suggest that both child and therapist evaluations can predict performance subsequent to treatment. There are several limitations of the present study, both within the design and from the setting and circumstances of treatment. First, all children were inpatients and hence were exposed to another intervention, namely, hospitalization. Although there is no firm evidence that inpatient hospitalization improves antisocial behavior (see Kazdin, 1985), it is reasonable to consider its potentiating and interactive effects in applying other interventions. Thus, the present results may not extend to nonhospitalized youths.

Proportion of Children Who Fell Within Range ofNonclinic Samples at Posttreatment and Follow-Up
PSST RT

TC

Measure Posttreatment Total behavior problem Social competence total Total Disability' One-year follow-up Total behavior problem Social competence
total Total Disability1

8/13 61.5 0/9 0.0 1/9 11.1 11.60*' 8/12 66.7 4/12 33.3 2/15 13.3 8.28*

3/13 23.1 1/11

5/10 50.0 0/6 5/13 38.5 2/10

9.1

1/10 10.0 1.18

0.0 0/7 0.0 8.31* 20.0 2/14 14.3 2.28

Note. PSST = problem-solving skills training; RT = relationship therapy; TC = treatment-contact control. Children with a raw score at or below the 90th percentile on the Total Behavior Problem scale or Total Disability scale or above the 10th percentile on the social-competence total at pretreatment were excluded from these proportions. 1 Scale of the School Behavior Checklist. Other scales are from the Child Behavior Checklist. b df= 2. ps.OS. " p s . O l .

Although the magnitude of change produced with treatment leaves a great deal to be desired, the results from the PSST condition are noteworthy. The results suggest that cognitive-behavioral problem-skills training can effect changes in a seriously disturbed clinical population, that the changes are evident on community-based measures, and that changes are sustained at least up to 1 year. These findings are consistent with recent studies of impulsive, aggressive, and delinquent youths that show significant improvements following cognitive-behavioral interventions (e.g., Arbuthnot & Gordon, 1986; Kendall & Braswell, 1982; Lochman et al., 1984). These studies have also shown significant changes on measures of behavior at home, at school, and in the community, but the magnitude of the effects needs to be bolstered to achieve clinically significant outcomes. Of interest were the findings for relationship therapy, which was found to produce effects no different from treatment-contact control conditions. Yet, children who received RT tended to fare somewhat better than control children. For example, control children became significantly worse on school performance over the course of follow-up, whereas RT children did not. Failure to obtain systematic improvements with relationship therapy in the present study is consistent with other studies that have examined similar modalities of treatment with antisocial youths (e.g., Alexander & Parsons, 1973; Feldman et al., 1983). In the treatment of antisocial youths, research suggests that relationship factors may be necessary but are insufficient to effect change (Alexander, Barton, Schiavo, & Parsons, 1976). There are several possible explanations for the absence of differences between relationship and contact-control conditions. The hospital setting may, in some way, interfere with the efficacy of relationship therapy. Alternatively, the outcome measures may have been insensitive to the sorts of effects (e.g.,

Second, treatment effects were examined without evaluation of the role of child, parent, and family characteristics or scrutiny of treatment process variables. Because of the paucity of outcome studies with severely dysfunctional youths, the present investigation addressed a preliminary concern about whether therapeutic changes could be achieved with a relatively severe group of antisocial children. Further work is warranted that at once attempts to bolster the strength of treatment and to make and test predictions about child, family, and treatment variables that influence outcome (see Kazdin, in press). The findings of the present study suggest that cognitive-behavioral treatment can be applied to severely disturbed children and that it leads to reliable and sustained improvements, at least up to 1 year. The differences in statistical and clinical significance of the changes underscore the limitations of the results and the need for further work.

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Received January 13, 1986 Revision received April 2, 1986