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The Incredible Years Program for Children from Infancy to Pre-adolescence:

Prevention and Treatment of Behavior Problems

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DOI: 10.1007/978-1-4419-6297-3_5

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 The Incredible Years 1

Running head: THE INCREDIBLE YEARS TRAINING SERIES

The Incredible Years Program for Children from Infancy to Pre-Adolescence:

Prevention and Treatment of Behavior Problems

Carolyn Webster-Stratton

M. Jamila Reid

The University of Washington

Webster-Stratton, C., & Reid, M. J. (in press). The Incredible Years Program for children from
infancy to pre-adolescence: Prevention and treatment of behavior problems. In R. Murrihy, A.
Kidman & T. Ollendick (Eds.), Clinician's handbook for the assessment and treatment of
conduct problems in youth: Springer Press.
 The Incredible Years 2

The Incredible Years Parents, Teachers, and Children Training Series:

A Treatment Series for Young Children with Conduct Problems

Overview

The incidence of Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) in

children is alarmingly high, with reported cases of early-onset conduct problems occurring in 4-

6% of young children (Egger & Angold, 2006), and as high as 35% of young children in low-

income families (Webster-Stratton & Hammond, 1998). Developmental theorists have suggested

that “early starter” delinquents who first exhibit ODD symptoms in the preschool years have a

two- to threefold risk of becoming chronic juvenile offenders (Loeber et al., 1993; Patterson,

Capaldi, & Bank, 1991) compared to typically developing children (Snyder, 2001). Children

with early-onset CD also account for a disproportionate share of delinquent acts in adolescence

and adulthood, including interpersonal violence, substance abuse, and property crimes. In fact,

the primary developmental pathway for serious conduct disorders in adolescence and adulthood

appears to be established during the preschool period. Early onset conduct problems represent

one of the most costly mental disorders to society because such a large proportion of antisocial

children remain involved with mental health agencies or criminal justice systems throughout the

course of their lives.

Risk factors from a number of different areas contribute to child conduct problems

including ineffective parenting (e.g., harsh discipline, low parent involvement in school, and low

monitoring)(Jaffee, Caspi, Moffitt, & Taylor, 2004); family risk factors (e.g., marital conflict and

parental drug abuse, mental illness, and criminal behavior) (Knutson, DeGarmo, Koeppl, & Reid,

2005); child biological and developmental risk factors (e.g., attention deficit hyperactivity
 The Incredible Years 3

disorders (ADHD), learning disabilities, and language delays); school risk factors (e.g., poor

teacher classroom management, high levels of classroom aggression, large class sizes, and poor

school-home communication); and peer and community risk factors (e.g., poverty and gangs)

(Collins, Maccoby, Steinberg, Hetherington, & Bornstein, 2000). Effective interventions for

children with conduct problems ideally target multiple risk factors and are best offered as early

as possible. Conduct disorder becomes increasingly resistant to change over time, so early

intervention is a crucial strategy for the prevention or reduction of conduct problems, violence,

substance abuse, and delinquency. Children with ODD and CD are clearly identifiable as early as

3–4 years of age, and there is evidence that the younger the child is at the time of intervention,

the more positive the behavioral adjustment at home and at school following treatment.

Intervention that is delivered prior to school entry and during the early school years can

strategically target risk factors across multiple domains; home and school, and through multiple

change agents; parent, teacher, and child. Unfortunately, less than 20% of young children

meeting DSM-IV criteria for ODD are referred for mental health services (Horwitz, Leaf,

Jeventhal, Forsyth, & Speechley, 1992). Even fewer of those referred obtain evidence-based

interventions..

The Incredible Years Treatment Programs

To address the parenting, family, child, and school risk factors for children or adolescents

with conduct problems, we have developed three complementary training curricula, known as the

Incredible Years Training Series, targeted at parents, teachers, and children (from birth to 12

years). This chapter reviews these training programs and their associated research findings.

Incredible Years Parent Interventions

 The Incredible Years 4

Goals of the parent programs. Goals of the parent programs are: (a) to promote parent

competencies and strengthen families by increasing positive parenting, parent–child bonding and

attachment, and self-confidence about parenting; (b) to increase parents’ ability to use play

interactions to coach children’s social-emotional, academic, verbal, and persistence skills; (c) to

reduce critical and physically violent discipline and increase positive discipline strategies such as

ignoring and redirecting, logical consequences, time-out, and problem solving; (d) to improve

parental self-control, depression, anger management, communication skills, and problem

solving; (e) to increase family support networks; and (f) to improve home–school bonding and

increase parents’ involvement in school related activities.

After more than 28 years of program development and evaluation, the Incredible Years

parent treatment consists of a variety of comprehensive, empirically validated programs. Below

we describe each of the well-researched parent programs and their targeted populations.

BASIC parent training treatment program. In 1980, we developed an interactive, video-

based parent intervention program (BASIC) for parents of children ages 2–7 years. In subsequent

years we revised and updated this program to include three separate age range BASIC programs:

the baby/toddler age (0–3years), preschool (3–5 years), and school age (6–13 years). Each of

these revised programs include age appropriate examples of culturally diverse families, children

with varying temperaments, and added emphases on social and emotional coaching, problem

solving, how to set up predictable routines, and support children’s academic success. The BASIC

toddler parent training programs are completed in 12 weekly, 2-hour sessions while the

preschool and school-age programs are 18–20 weekly, 2-hour sessions. The foundation of the

program is brief video vignettes of modeled parenting skills (each program has over 300

vignettes) shown by a therapist to groups of 8–12 parents. The videos demonstrate social
 The Incredible Years 5

learning and child development principles and serve as the stimulus for focused discussions,

problem solving, and collaborative learning. The program is also designed to help parents

understand normal variations in children's development, emotional reactions, and temperaments.

The BASIC program begins with a focus on enhancing positive relationships between

parents and children by teaching parents to use child-directed interactive play, academic and

persistence coaching, social and emotional coaching, praise, and incentive programs. Next,

parents learn how to set up predicable home routines and rules, followed by learning a specific

set of nonviolent discipline techniques including monitoring, ignoring, commands, natural and

logical consequences, and ways to use time-out to teach children to calm down. Finally, parents

are taught how they can teach their children problem-solving skills.

ADVANCE parent training treatment program. In 1989 we expanded our theoretical and

causal model concerning conduct problems and developed the ADVANCE treatment program

(updated in 2008). This program was designed to be offered after parents complete the BASIC

parenting program and focuses on helping parents with adult intra- and interpersonal skills. The

content of this 10–12-session video program (over 90 vignettes) consists of five components: (a)

personal self-control, anger management, positive self-talk, and other coping strategies; (b)

communication skills for talking effectively with partners, teachers, and other adults; (c)

problem-solving conflict situations with partners, extended family members, teachers, and

employers; (d) problem solving with children and conducting family meetings; and (e)

strengthening social support and self care. We theorized that a broader-based training model

would help mediate the negative influences of these personal and interpersonal factors on

parenting skills and promote increased maintenance and generalizability of treatment effects.
 The Incredible Years 6

The content of both the BASIC and ADVANCE programs is also provided in the recently

revised text that parents use for the program, titled The Incredible Years: A Troubleshooting

Guide for Parents (Webster-Stratton, 2006)

SCHOOL parent training treatment. More than 50% of parents who completed our parent

training programs requested guidance on issues surrounding homework, communication with

teachers, behavior problems at school, and promoting their children's academic and social skills.

In addition, 40% of teachers reported problems with children's compliance and aggression in the

classroom and requested advice on how to manage these problems. Clearly, integrating

interventions across settings (home and school) and agents (teachers and parents) to target school

and family risk factors fosters greater between-environment consistency and offers the best

chance for long-term reduction of antisocial behavior.

In 1990 we developed an academic skills training intervention (SCHOOL) as an adjunct

to our school age BASIC program, and in 2003 a school readiness intervention as an adjunct to

our preschool BASIC program. These two interventions each consist of four to six additional

sessions usually offered to parents after the BASIC program is completed. For parents of school

age children, these sessions focus on collaboration with teachers, ways to foster children's

academic readiness and school success through parental involvement in school activities and

homework, and the importance of after-school and peer monitoring. For the parents of preschool

children, the sessions focus on interactive reading skills and ways to promote children’s social,

emotional, self-regulation, and cognitive skills. Program components include teaching parents to:

(a) help children feel confident in their own ideas and ability to learn; (b) prepare children for

school by facilitating pre-reading skills (pre-school) and supporting/ encouraging older children

with homework routines and limits on “screen time”; (c) support children’s discouragement and
 The Incredible Years 7

learning difficulties by setting realistic goals, encouraging their persistence with difficult tasks,

and using academic coaching to motivate and reinforce learning progress at home; and (d)

collaborate with teachers to jointly develop plans that address behavioral issues at school.

Incredible Years Teacher Training Intervention

When children with behavior problems enter school, negative academic and social

experiences escalate the development of conduct problems. Aggressive, disruptive children

quickly become socially excluded, and peers begin to respond to aggressive children in ways that

increase the likelihood of reactive aggression. This peer rejection leads to association with

deviant peers, which increases the risk for higher levels of antisocial behavior. In addition

teacher behaviors (low rates of praise, high rates of critical/harsh discipline, ineffective

management strategies, low emphasis on teaching social-emotional competence) and

classroom/school characteristics (high student-teacher ratio, no tolerance school discipline

policies, high classroom levels of children with special needs) are associated with increased

aggression, delinquency, and poor academic performance. Rejecting and non-supportive

responses from teachers further exacerbate the problems of aggressive children.

In 1995 (revised 2003) we developed a 6-day (42-hour) teacher training program with the

goal of promoting teacher competencies and strengthening home–school connections by doing

the following: (a) improving teachers’ classroom management skills, including proactive

teaching approaches and effective discipline; (b) increasing teachers’ use of academic,

persistence, social, and emotional coaching with students; (c) strengthening teacher–student

bonding; (d) improving home–school collaboration and parent–teacher bonding; and (e)

increasing teachers’ ability to teach social skills, anger management, and problem-solving skills

in the classroom. A complete description of the content included in this curriculum is described
 The Incredible Years 8

in the book that teachers use for the course, titled How to Promote Social and Emotional

Competence (Webster-Stratton, 2000).

Incredible Years Child Training Intervention (Dinosaur School)

Research has indicated that children with conduct problems are more likely to have

certain temperamental characteristics such as inattentiveness, distractibility, impulsivity, and

attention-deficit/hyperactivity disorder (ADHD). Other child factors have also been implicated in

early-onset conduct disorder. For example, deficits in social-cognitive skills and negative

attributions contribute to poor emotional regulation and aggressive peer interactions. In addition,

studies indicate that children with conduct problems have significant delays in their peer-play

skills—in particular, difficulty with reciprocal play, cooperative skills, taking turns, waiting, and

giving suggestions (Gottman, 1983; Webster-Stratton & Lindsay, 1999). Finally, reading,

learning, and language delays are also associated with conduct problems, particularly for “early

life course persisters” (Moffitt & Lynam, 1994). Academic difficulties and behavior problems

exacerbate one another in a bidirectional spiral whereby academic problems lead to

disengagement, increased frustration, and lower self-esteem, which contribute to the child’s

behavior problems. At the same time, negative classroom behavior limits a child’s ability to be

engaged in learning, to follow teacher’s instructions, and to achieve academically. Thus, a cycle

is created in which one problem exacerbates the other. This combination of academic delays and

conduct problems contributes to the development of more severe CD and school failure.

In 1990 we developed a child treatment program to directly focus on the social learning

and academic deficits of children diagnosed with ODD or conduct problems (ages 4–8). This 22-

week program (revised 2006) consists of a series of DVD programs (over 180 vignettes) that

teach children problem-solving and social skills. Organized to dovetail with the content of the
 The Incredible Years 9

parent training program, the program consists of seven main topic areas: Introduction and Rules;

Empathy and Emotion; Problem Solving; Anger Control; Friendship Skills; Communication

Skills; and School Skills. The children meet weekly in groups of six children for 2 hours. To

enhance generalization, the video vignettes involve real-life conflict situations at home and at

school (playground and classroom), such as teasing, being rejected, and destructive behavior.

The goals of this program are to promote children’s competencies and reduce aggressive and

noncompliant behaviors by doing the following: (a) strengthening social skills (turn taking,

waiting, asking, sharing, helping, and complimenting); (b) promoting use of self-control and self-

regulation strategies; (c) increasing emotional awareness by labeling feelings, recognizing the

differing views of oneself and others, and enhancing perspective taking; (d) promoting children’s

ability to persist with difficult tasks; (e) improving academic success, reading, and school

readiness; (f) reducing defiance, aggression, peer rejection, bullying, stealing, and lying and

promoting compliance with teachers and peers; (g) decreasing negative cognitive attributions and

conflict management approaches; and (h) increasing self-esteem and self-confidence.

Group Process and Methods Used in Parent, Teacher, and Child Training Programs

All three treatment approaches rely on performance training methods and group training

including video modeling, role play, practice activities, and live feedback from the therapist and

other group members. In accordance with modeling and self-efficacy theories of learning,

parents, teachers, and children participating in the program develop their skills by watching

video examples of key skills, discussing and sharing their reactions to the videos, and then

modeling or role playing skills themselves. Video examples provide a more flexible method of

group training than didactic verbal instruction or sole reliance on role play because a wide

variety of models, settings, and situations can be used as examples. The goals of this approach
 The Incredible Years 10

are to provide better generalization of the content and, therefore, better long-term maintenance;

to provide a variety of learning methods—visual, verbal, and performance; to be low-cost

because of the group format; and easily disseminated because of the extensive videos and

manuals.

The video vignettes show parents, teachers, and children of differing ages, cultures,

socioeconomic backgrounds, temperaments and developmental abilities, so that participants will

perceive at least some of the models as similar to themselves and will therefore accept the

vignettes as relevant. Vignettes show models (unrehearsed) in natural situations responding

effectively as well as times when they are responding less effectively in order to demystify the

notion there is "perfect parenting or teaching" and to illustrate how one can learn from one's

mistakes. This approach also emphasizes our belief in a coping and collaborative interactive

model of learning (Webster-Stratton & Herbert, 1994); that is, participants view a video vignette

of a situation and then discuss and role-play how the individual might have handled the

interaction more effectively. Thus participants improve upon the interactions they see in the

vignettes. This approach enhances participants' confidence and develops their ability to analyze

interpersonal situations and select an appropriate response. In this respect, our training differs

from some training programs where the therapist provides the analysis and recommends a

particular strategy.

The video vignettes demonstrate behavioral principles and serve as the stimulus for

focused discussions, problem solving, and collaborative learning. After each vignette, the

therapist solicits ideas from group members and involves them in the process of problem solving,

sharing, and discussing ideas and reactions. The therapists' role is to support and empower group

members by teaching, leading, reframing, predicting, identifying key developmental or teaching

 The Incredible Years 11

principles and role playing (Webster-Stratton & Hancock, 1998). The collaborative context is

designed to ensure that the intervention is sensitive to individual cultural differences and

personal values. The program is "tailored" to each teacher, parent, or child's individual needs and

personal goals as well as to each child's personality and behavior problems.

This program also emphasizes a commitment to group members’ self-management. We

believe that this approach empowers participants in that it gives back dignity, respect, and self-

control to parents, teachers, and children who are often seeking help at time of low self-

confidence and intense feelings of guilt and self-blame (Webster-Stratton, 1996). By using group

process, the program not only is more cost-effective but also addresses an important risk factor

for children with conduct problems; the family's isolation and stigmatization. Parent groups

provide that support and become a model for parent support networks (see Webster-Stratton &

Herbert, 1994.) The child groups provide children with conduct problems some of their first

positive social experiences with other children. Moreover, it was theorized that the group

approach would provide more social and emotional support and decrease feelings of isolation for

teachers as well as parents and children.

As with the teacher and parent programs, the child treatment program uses video

modeling examples in every session to foster discussion, problem solving, and modeling of

prosocial behaviors. The scenes selected for each of the units involve real-life conflict situations

at home and at school (playground and classroom). The videotapes show children of differing

ages, sexes, and cultures interacting with adults or with other children. After viewing, the

vignettes, children discuss feelings, generate ideas for more effective responses, and role-play

alternative scenarios. In addition to the interactive video vignettes, the therapists use life-size

puppets to model appropriate behavior and thinking processes for the children. The use of
 The Incredible Years 12

puppets appeals to children on the fantasy level so predominant in this preoperational age group.

Because young children are more vulnerable to distraction, are less able to organize their

thoughts, and have poorer memories, we use a number of strategies for reviewing and organizing

the material, such as: (a) playing "copy cat" to review skills learned; (b) using many video

examples of the same concept in different situations and settings; (c) using cartoon pictures and

specially designed stickers as "cues" to remind children of key concepts; (d) role playing with

puppets and other children to provide practice opportunities and experience with different

perspectives; (e) reenacting video scenes; (f) rehearsing skills with play, art, and game activities;

(g) homework, so children can practice key skills with parents; and (h) letters to parents and

teachers that explain the program’s key concepts and asking them to reinforce these behaviors.

Evidence for the Effects of Treatment

Effects of Parent Training Program

The efficacy of the Incredible Years BASIC parent treatment program for children (ages

3–8 years) diagnosed with ODD/CD has been demonstrated in several published randomized

control group trials by the program developer and colleagues at the University of Washington

Parenting Clinic (Reid, Webster-Stratton, & Hammond, 2007; Webster-Stratton, 1981; Webster-

Stratton, 1982, 1984, 1990a, 1992, 1994, 1998; Webster-Stratton & Hammond, 1997; Webster-

Stratton, Hollinsworth, & Kolpacoff, 1989; Webster-Stratton, Kolpacoff, & Hollinsworth, 1988;

Webster-Stratton, Reid, & Hammond, 2004). In all of these studies, the BASIC program has

been shown to significantly improve parental attitudes and parent–child interactions, and

significantly reduce harsh discipline, and child conduct problems compared to wait-list control

groups and other treatment approaches. In the third of these studies, treatment component

analyses indicated that the combination of group discussion, a trained therapist, and video
 The Incredible Years 13

modeling produced the most lasting results in comparison to treatment that involved only one

training component (see Webster-Stratton, Hollinsworth, & Kolpacoff, 1989, and Webster-

Stratton, Kolpacoff, & Hollinsworth, 1988).

In addition, the BASIC program has been replicated in five projects by independent

investigators in mental health clinics with families of children diagnosed with conduct problems

(Drugli & Larsson, 2006; Larsson et al., 2008; Lavigne et al., 2008; Scott, Spender, Doolan,

Jacobs, & Aspland, 2001; Spaccarelli, Cotler, & Penman, 1992; Taylor, Schmidt, Pepler, &

Hodgins, 1998). These replications were “effectiveness” trials; that is, they were done in applied

mental health settings, not a university research clinic, and the therapists were typical therapists

at the centers not research therapists. Three of the above replications were conducted in the

United States, two in United Kingdom, and one in Norway. This illustrates the transportability

of the BASIC parenting program to other cultures.

In our fourth study, we examined the effects of adding the ADVANCE intervention

(parent intra- and interpersonal skills) component to the BASIC intervention (Webster-Stratton,

1994) by randomly assigning families to either BASIC parent training or BASIC + ADVANCE

training. Both treatment groups showed significant improvements in child adjustment and

parent–child interactions and a decrease in parent distress and child behavior problems. These

changes were maintained at follow-up. ADVANCE children showed significant increases in the

number of prosocial solutions generated during problem solving, in comparison to children

whose parents received only the BASIC program. Observations of parents' marital interactions

indicated significant improvements in ADVANCE parents' communication, problem-solving,

and collaboration skills when compared with parents who did not receive ADVANCE.

Moreover, ADVANCE parents reported significantly greater consumer satisfaction than parents
 The Incredible Years 14

who did not receive ADVANCE. These results suggest that focusing on helping parents to

manage personal distress and interpersonal issues through a video modeling group discussion

treatment (ADVANCE) added significantly to treatment outcomes for our BASIC program.

Consequently a 20–24 week program that combines BASIC with ADVANCE has become our

core treatment for parents with children with conduct problems.

In our sixth and seventh studies respectively, we examined the additive effects of

combining the child training intervention (Dinosaur School) and teacher training with the parent

training program (BASIC + ADVANCE). Both studies replicated positive results from the

ADVANCE study and provided data on the advantages of training children and teachers as well

as parents. (Study results are presented below, see section on child and teacher training results.)

Parent training treatment: Who benefits and who does not? We have followed families

longitudinally (1, 2, and 3 years post treatment), and have completed a 10–15-year follow-up of

the children and their families. We assessed both the statistical and clinical significance of

treatment effects. In assessing clinical significance, we looked at the extent to which parent or

teacher reports indicated that the children were within the nonclinical range of functioning or

showed a 30% improvement if there were no established normative data, and whether families

requested further therapy for their children's behavior problems at the follow-up assessments.

These outcome criteria were chosen to avoid reliance on a single informant or criterion measure,

thereby providing greater validity to the findings. In our 3-year follow-up of 83 families treated

with the BASIC program, we found that while approximately two-thirds of children showed

clinically significant behavior improvements, 25%-46% of parents and 26% of teachers still

reported clinically significant child behavior problems (Webster-Stratton, 1990b). We also found

that the families whose children had continuing externalizing problems (according to teacher and
 The Incredible Years 15

parent reports) at our 3-year follow-up assessments were more likely to be characterized by

marital distress, or single-parent status, maternal depression, lower social class, high levels of

negative life stressors, and family histories of alcoholism, drug abuse, and spouse abuse

(Webster-Stratton, 1990b; Webster-Stratton & Hammond, 1990).

Hartman (Hartman, Stage, & Webster-Stratton, 2003) examined whether child ADHD

symptoms (i.e., inattention, impulsivity, and hyperactivity) predicted poorer treatment results

from the parent training intervention. Contrary to Hartman’s hypothesis, analyses suggested that

the children with ODD/CD who had higher levels of attention problems showed greater

reductions in conduct problems than children without attention problems. Similar findings for

children with ADHD were reported in the UK study (Scott et al., 2001). An ongoing study is

evaluating the parent and child treatments with young children whose primary diagnosis is

ADHD.

Rinaldi (2001) conducted an 8- to 12-year follow-up of families who were in the

ADVANCE study previously discussed . She interviewed 83.5% of the parents and adolescents

from the original study (now 12–19 years of age). Results indicated that over 75% of the

teenagers were typically adjusted with minimal behavioral and emotional problems.

Furthermore, parenting skills taught in the intervention had lasting effects. Important predictors

of long-term outcome were mothers’ post-treatment level of critical statements and fathers’ use

of praise. In addition, the level of mother-child coercion immediately posttreatment was a

significant predictor of teen adjustment.

Evidence for Effects of Parent Programs as Prevention

In the past decade, we have also evaluated the parent programs as a selective prevention

program with multiethnic, socioeconomically disadvantaged families in two randomized studies;

 The Incredible Years 16

one with low income Head Start families and another with unselected primary school children.

Results of all these studies suggest the program’s effectiveness as a method of preventing the

development of conduct problems and strengthening social competence in preschool children

(Reid, Webster-Stratton, & Hammond, 2007; Webster-Stratton, 1998; Webster-Stratton, Reid, &

Hammond, 2001). These studies also showed that programs were equally effective for families

from diverse cultural and ethnic backgrounds including Latino, Asian, and African American

families. (Reid, Webster-Stratton, & Beauchaine, 2001). The study with primary school children

evaluated the effects of the parent intervention with an indicated, culturally diverse population.

Children who received the intervention showed fewer externalizing problems, better emotion

regulation, and stronger parent–child bonding than control children. Mothers in the intervention

group showed more supportive and less coercive parenting than control mothers (Reid, Webster-

Stratton, & Hammond, 2007). Similar results were reported by independent investigators with

selective and indicated prevention populations including a study conducted in the United

Kingdom (Gardner, Burton, & Klimes, 2006; Gross et al., 2003; Hutchings & Gardner, 2006;

Miller Brotman et al., 2003). One study reported the effectiveness of the IY (Incredible Years)

parent program with foster parents (Linares, Montalto, MinMin, & Oza, 2006).

Summary and significance. Over the past 28 years studies have shown that parent training

is a highly effective therapeutic method for producing significant behavior change in children

with conduct problems and with high-risk populations (i.e., socioeconomically disadvantaged).

These findings provide support for the notion that parenting practices play a key role in

children's social and emotional development.

 The Incredible Years 17

Effects of Teacher and Child Training Treatment and Prevention Programs

To date, there have been two randomized studies by the developer and one by an

independent evaluator evaluating the effectiveness of the child training program for reducing

conduct problems and promoting social competence in children diagnosed with ODD/CD. In the

first two studies (Drugli & Larsson, 2006; Webster-Stratton & Hammond, 1997), clinic-referred

children (with ODD) and their parents were randomly assigned to one of four groups: a parent

training treatment group (PT), a child training group (CT), a child and parent training group (CT

+ PT), or a waiting-list control group (CON). Post-treatment assessments indicated that all three

treatment conditions resulted in significant improvements in parent and child behaviors in

comparison to controls. Comparisons of the three treatment conditions indicated that CT and CT

+ PT children showed significant improvements in problem solving as well as conflict

management skills, as measured by observations of child interactions with a best friend;

differences among treatment conditions on these measures consistently favored the CT

conditions over the PT only condition. On measures of parent and child behavior at home, PT

and CT+ PT parents and children had significantly more positive interactions in comparison to

CT parents and children.

One-year follow-up assessments indicated that all the significant changes noted

immediately posttreatment were maintained over time. Moreover, child conduct problems at

home significantly decreased over time. Analyses of the clinical significance of the results

suggested the combined CT + PT condition produced the most significant improvements in child

behavior at 1-year follow-up. However, children from all three treatment conditions showed

increases in behavior problems at school 1 year later, as measured by teacher reports (Webster-

Stratton & Hammond, 1997).

 The Incredible Years 18

Another study (Webster-Stratton, Reid, & Hammond, 2004) tested the effects of different

combinations of parent, child, and teacher training. Families with a child diagnosed with ODD

were randomly assigned to one of six groups: (a) Parent training only; (b) Child training only; (c)

Parent training and teacher training; (d) Parent training, teacher training, and child training; (e)

Child training and teacher training; or (f) Waitlist control.

As expected, results for the parent training component replicated earlier studies with

parents in all three conditions that received parent training showing significantly less negative

and more positive parenting than parents in conditions that did not receive training (Webster-

Stratton & Reid, 1999). Children in all five treatment conditions showed reductions in aggressive

behaviors with mothers at home, and at school with peers and teachers, compared with controls.

Treatment effects for children’s positive social skills with peers were found only in the three

conditions with child training compared with controls. Trained teachers were rated as less

critical, harsh, and inconsistent, and more nurturing than control teachers. Most treatment effects

were maintained at 1-year follow-up. In summary, this study replicated our previous findings on

the effectiveness of the parent and child training programs and indicated that teacher training

significantly improves teachers’ classroom management skills and improves children’s

classroom aggressive behavior. In addition, treatment combinations that added either child

training or teacher training to the parent training were most effective.

Two other randomized control group studies (Raver et al., 2007; Webster-Stratton, Reid,

& Hammond, 2001) have evaluated the teacher training curriculum in a prevention setting with

Head Start teachers. In the study by the developer, parent–teacher bonding was reported to be

significantly higher for experimental than for control mothers. Experimental children showed

significantly fewer conduct problems at school than control children, and trained teachers
 The Incredible Years 19

showed significantly better classroom management skills than control teachers. In the second

study by an independent investigator (Raver et al., 2007) 5 days of the Incredible Years Teacher

Program were delivered to teachers in combination with weekly visits by mental health

consultants who “coached” teachers as they implemented management strategies. Results

showed that Head Start classrooms in the treatment condition had significantly higher levels of

positive classroom climate, teacher sensitivity and behavior management than classrooms in the

control condition with medium to high effect sizes.

Lastly, a recent study (Webster-Stratton, Reid, & Stoolmiller, 2008) was completed using

the teacher training and classroom Dinosaur curriculum in Head Start and with primary schools

that serve high numbers of economically disadvantaged children. Results showed significant

improvements in conduct problems, self-regulation, and social competence compared with

control students. Effect size was particularly high for children with high baseline levels of

conduct problems. Another prevention study using the curriculum in schools reported reductions

in playground aggressive behavior compared to control schools (Barrera et al., 2002).

Who benefits from Dinosaur child training? Analyses on 99 children diagnosed with ODD

who received child treatment were conducted to examine the effects of child hyperactivity,

parenting style, and family stress on treatment outcome. The hyperactivity or family stress risk

factors did not have an impact on children's treatment response. Negative parenting, on the other

hand, did negatively impact children’s treatment outcome. Fewer children who had parents with

one of the negative parenting risk factors (high levels of criticism or physical spanking) showed

clinically significant improvements compared to children who did not have one of the negative

parenting risk factors. This finding suggests that for children whose parents exhibit harsh and

coercive parenting styles, it is important to offer a parenting intervention in addition to a child

 The Incredible Years 20

intervention (Webster-Stratton, Reid, & Hammond, 2001). Our studies also suggest that child

training significantly enhances the effectiveness of parent training treatment for children with

pervasive conduct problems (home and school settings) because of its added benefits for children’s

classroom peer interactions and social competence.

Case Example: Stewart

The following section presents a case in which the Incredible Years Parent, Teacher, and

Child Training Programs were used to treat a young boy, Stewart. Stewart is a 6 year old who

presented with ODD and ADHD. His problems occurred at home, at school, and with peers. This

case study outlines how the three different Incredible Years Programs (parent, teacher, and child)

can be applied flexibly and synergistically to attend to individual family needs and address issues

of comorbidity.

Intake Information

Susan and Tim Jones were referred to the Parenting Clinic by their school psychologist

because of difficulties at home and at school with their 6-year-old son, Stewart. Stewart had a

substantial reputation at the school for his aggressive and oppositional behavior. At the time that

the Joneses came to the clinic, his teacher had told his parents that she did not believe her

classroom was an appropriate place for Stewart. In addition to these problems at school,

Stewart’s behavior at home was extremely volatile. He would frequently “lose control of his

behavior” and engage in extended temper tantrums during which he would call his parents

names, refuse to comply with any requests, and become aggressive or destructive. Both parents

described feeling helpless to change Stewart’s behavior once it reached these proportions. Their

usual parenting style was to talk and reason with Stewart, but they felt that this merely escalated

his behavior. They also had tried a number of different discipline strategies (e.g., Time-Out, loss
 The Incredible Years 21

of privileges), that did not seem to work to change Stewart’s behavior. Susan and Tim were also

concerned about the effect that his difficulties were having on his self-esteem. Stewart had begun

talking about the fact that no one liked him at school, that he had no friends, and that he was the

dumbest kid in his class. Lastly, Susan and Tim reported that Stewart’s behaviors were putting a

significant strain on the family’s functioning. Both felt his problems were their main focus, to the

exclusion of other activities and interests. They felt that they no longer had control over their

family and were worried that Stewart’s behavior was on an irreversible trajectory.

Treatment

Treatment began in October, following the assessment period. Stewart and his parents

came to the University of Washington Parenting Clinic each week for a two-hour group that

lasted 24 weeks. During that time Stewart attended the child group with 5 other children (3 boys

and 2 girls, ages 4–7), and his parents attended the parenting group.

Parent group. During the initial group, parents described their children and their reasons

for coming to the clinic. Many of the parents, and Susan, in particular, described how isolated

she felt as a parent of a “problem child.” She felt that they could no longer socialize with their

friends because Stewart was not able to behave appropriately. She felt judged by other parents

and felt that she was a bad parent because nothing she did worked with Stewart. Tim expressed a

sense of relief at being in a group where he was free to talk about his son’s issues without

judgment from other parents. Susan and Tim expressed goals for Stewart primarily in terms of

his happiness and self-esteem, although they believed that to achieve these goals, they would

need to find ways to reduce his oppositional behavior, improve his social skills, and increase his

cooperation with authority.

 The Incredible Years 22

The first 4–5 sessions of the group were focused on child-directed play interactions. Since

almost all adult-child interactions with Stewart involved a power struggle, and since his negative

behaviors had placed such great strain on the parent–child relationship, the first goal of therapy

was to use child-directed play to begin to change the dynamic of this relationship. Tim and Susan

were encouraged to play with Stewart on a daily basis where their job was to follow Stewart’s

lead, be an “appreciative audience,” and not to make demands, give instructions or even ask

questions as long as he was appropriate in his behavior. These play sessions were designed to give

Stewart some power in the relationship in an appropriate setting, to show him that his parents

valued him, and to give his parents a time when they could just enjoy his creativity and playfulness

without feeling as if they had to make him behave in a certain way. At first, Tim and Susan

reported that he rejected their attempts to play with him. They were encouraged to be persistent

and to make regular attempts each day to engage with him in this positive way. Gradually Stewart

began to look forward to this time playing with his parents and seemed excited that they were

willing to play on his terms. Although much of Stewart’s behavior outside of the play sessions

continued to be negative and challenging, Stewart’s parents reported that he seemed calmer after

play sessions, and that they had moments of feeling connected and appreciative of his strengths.

They gradually also began to address some of Stewart’s ADHD behaviors during these play

sessions by using focused persistence coaching to comment when they saw Stewart being

persistent, calm, or patient with an activity. For example, they learned to say such things as, “You

are really concentrating and working hard on that puzzle, you just keep trying and are going to

figure it out.”

As these play sessions became more enjoyable, parents were taught to use social and

emotion coaching with him one-on-one. This coaching helped him to develop emotional literacy,
 The Incredible Years 23

to express his feelings rather than to strike out at someone when frustrated. He also was helped to

use social skills by coaching him when he was sharing, waiting, helping, and taking turns.

The ignoring and limit setting units were challenging for Tim and Susan. Both were used

to reasoning with Stewart when he was misbehaving. They understood the principle of ignoring

when Stewart was annoying or verbally abusive; however, they had difficultly following

through. Stewart was very persistent with his whining and tantrums, and both parents needed

support and encouragement to stick to their discipline plans. Stewart frequently swore and called

his parents names, which they found difficult to ignore. When they did ignore, he would also cry

and yell that they didn’t love him and would then become very destructive. Strategies to help

Tim and Susan involved teaching them to use calming self-talk (e.g., " I can stay calm, I can

handle this") and reframing strategies (e.g., "He will feel safer when he learns there are

predictable limits"). They had tried using Time-Out but had always given up part way through

the process because of Stewart’s aggressive and destructive behavior. Group problem solving

helped them to plan ways to keep Stewart and the house safe during a destructive Time-Out. All

of these solutions were role played with the group so that Tim and Susan felt equipped to try

them out at home and prepared for his oppositional responses. With this support, they managed

to successfully complete several lengthy Time-Out sequences with Stewart. There was a marked

shift in their self-confidence after this point. Although Stewart continued to have very difficult

days, they felt more equipped to handle his behavior at home. They also noticed that the

frequency of these very intense tantrums decreased markedly.

The adult communication and problem-solving material was also useful to Tim and

Susan. They had a strong relationship; however, their focus on Stewart was so all-consuming and

so reactive that they rarely spent time communicating about their plan for working together to
 The Incredible Years 24

manage his behavior. Consequently, they sometimes had difficulty backing each other up

because they hadn’t agreed in advance about how to handle a problem. The communication and

problem-solving sections of the curriculum helped them to set aside time to make proactive plans

for managing family issues, as well as helping them realize that they also needed some time for

themselves to reconnect on adult issues.

Working with the school and teacher training. Although Susan and Tim grasped the

concepts in the parenting group and worked hard to implement new strategies at home, they were

experiencing significant conflict with the school. Even after Stewart’s behavior began to improve

at home, it continued to worsen at school. His teacher repeatedly requested that he be removed

from her classroom, and Stewart was so unhappy at school that it became a battle to get him to

school in the mornings. Susan and Tim received daily negative reports about Tim’s behavior.

Tim, Susan, and Stewart’s teacher and principal were all frustrated, and the parent–school

relationship had become quite adversarial. Tim and Susan reported that whenever they met with

the principal and the teachers, they felt personally attacked, and felt responsible for defending

Stewart, even though they agreed that his behavior had been unacceptable.

Although Stewart’s teacher was not happy about having him in her class, she did agree to

attend 4 days of teacher training at the clinic. This training gave her a chance to express her

frustration with the classroom situation and to share ideas with other teachers who also had

challenging students. She reported that she had a class of 25 children, 5 of whom had special

needs. Stewart’s behavior was the most severe, and, in her opinion, he frequently set off her

other challenging children so that she felt unable to manage the situation. Through a series of

parent–teacher conferences, a meeting with the principal, and support from other teachers during

the teacher training as well as help from the therapists, things slowly began to improve. Stewart’s
 The Incredible Years 25

parents, teacher, and the IY therapists worked collaboratively to set up a simple behavior plan for

Stewart in the classroom. This plan focused on a few positive behavioral goals with frequent

reinforcement, a wiggle space for times when Stewart was having difficulty sitting still, and a

back-up Time-Out plan for severe negative behavior. Stewart was able to earn breaks for

successfully completing manageable parts of his school work. He was also given sanctioned

reasons to move around the classroom since it was difficult for him to sit still for long periods of

time. Peer issues were also addressed. His teacher made a concerted effort to highlight Stewart’s

strengths to the class. As part of his behavior plan he was able to earn chances to assist other

children (an activity that had proven to be very reinforcing to him in our child Dinosaur group at

the clinic). On the playground, Stewart was initially limited to activities in a smaller, well-

supervised area, and through appropriate behavior was able to earn the privilege of expanded

recess. Lastly, Stewart was also referred for a special education evaluation, which eventually led

to a part-time classroom assistant who was able to relieve some of the pressure on his teacher.

Child Dinosaur Social Skills and Problem Solving Group. Stewart was initially resistant

to the idea of coming to the child groups. His negative experience with school made him

extremely reluctant to participate in any activity that seemed remotely like school. During the

first few sessions, the therapists had the puppets model that they, too, had been scared or mad

when they first came to Dinosaur school, but that they soon started to like the group and had

made good friends. After this initial processing, the therapists ignored Stewart’s complaints

about being in the group and instead focused on praising and giving tokens for any appropriate

behavior that he exhibited. They noticed that while he was reluctant to volunteer answers or

participate on his own, if he was asked to help another child with an answer or a project, he

quickly became involved. Initially Stewart sought attention from the other children in the group
 The Incredible Years 26

by being disruptive and inappropriate. The other children were taught to ignore this inappropriate

behavior. Stewart was also put in charge of helping to monitor other children’s friendly and

positive behavior. This provided him with an opportunity to receive attention and positive

approval from others. After 4 sessions, Stewart began to report to his parents that he liked

Dinosaur school. Two of the other boys in the group became friends with Stewart, and they

began to have some play dates after school. From this point on, Stewart was consistently positive

about coming to the group, and his parents reported that he seemed happy about a group peer

activity for the first time in his life.

A second issue for Stewart during the child groups was difficulty sitting and attending for

more than a few minutes at a time. The therapists arranged the format of the group such that

children had frequent opportunities to change activities and move around. After showing the

children a video vignette, therapists would lead a brief discussion with the puppet and then have

children role-play the situation. They continually interspersed sedentary activities with more

active rehearsal and “hands-on” learning. Stewart was reinforced for attentive behavior, but the

therapist also ignored considerable wiggling and movements, if he was engaged in the lesson.

Stewart was also allowed to leave the group and go to a “wiggle space” if he was unable to sit

still. As long as the activities changed frequently and the therapists monitored Stewart’s

attention-level and need to move around, they were able to keep him engaged and on-task.

Social, persistence, and emotion coaching were also an important part of Stewart’s

treatment plan. In order to gradually increase Stewart’s ability to focus and concentrate on a given

activity, therapists worked hard to identify times when Stewart was focused, calm, working hard,

working carefully, and sticking with an activity. They noticed that Stewart’s attention span was

immediately longer whenever descriptive commenting was used, most likely because he enjoyed
 The Incredible Years 27

the attention and wanted it to continue. This provided many opportunities to comment on his

persistence. Since Stewart was also easily dysregulated and quick to get angry, attention was given

to times when he was calm, regulated, and content. When Stewart started to become angry, his

feelings were labeled, and then the therapist predicted that he would be able to stay calm and try

again (if he tantrumed, he was ignored.) Stewart’s social behaviors were also encouraged through a

combination of descriptive commenting, modeling, and coaching. If Stewart spontaneously

engaged in a friendly behavior, the therapists’ labeled that behavior: e.g. “Wow, Stewart, you just

asked for that block in a friendly voice.” At times, they also modeled a behavior themselves (or

used a puppet to model the behavior). “Stewart, I’ve got an extra train car. I would like to share it

with you.” They also provided direct coaching to Stewart when they saw he wanted something but

was not expressing himself. “Stewart, it looks like you’re frustrated that you don’t have more train

track. Can you ask Dylan if he will let you use some more pieces?”

Summary of treatment. Stewart’s behavior improved at home as Susan and Tim begin to

use more effective limit setting, combined with frequent positive interactions and coaching his

social behaviors. There continued to be explosive incidents throughout the treatment period, but

they became less frequent, and Susan and Tim became confident in their ability to handle the

problems. The Dinosaur child group quickly became a reinforcing activity for Stewart, and he

made some of his first friends in the group and was proud of these interactions. This was in sharp

contrast to his negative feelings about peers and school. He also learned specific social and

problem-solving skills that he began to use with peers in social situations. School changes were

most difficult, but parents, teachers, and therapists all worked hard to continue to implement new

strategies there. Stewart's difficult behavior and explosive episodes at school continued, but were

reported to be less frequent and less intense. In addition, the school and the teacher began to feel
 The Incredible Years 28

equipped to handle the behaviors and they worked collaboratively with Stewart’s parents to set

goals and modify his behavior plan as needed.

New Programs

In recent years the Incredible Years parent programs (BASIC) have been extended to

include new programs for older children (8-13 years) as well as infants (0-12 months) and

toddlers (1-3 years). Current studies are in progress to evaluate the effectiveness of these

programs. The intervention model for these two programs is similar to all of our other programs

and includes video vignettes of families and their young children. Below is a summary of the

content for each program.

BABY-TODDLER Program. The new BABY-TODDLER curriculum is split into two

programs. The first program covers the baby 0–12 months of age and can be completed in 8–10

sessions (the toddler program is delivered in 18 sessions and is described above). The content of

the Baby Program includes: (a) getting to know your baby; (b) parents as responsive

communicators and babies as intelligent language learners; (c) providing physical and visual

stimulation for your baby; (d) learning to read babies’ minds; (e) gaining support; and (f) the

emerging sense of self. Parents attend these groups with their babies and participate in hands-on

role plays and exercises with their own babies. Pilot groups are currently being run in Seattle

with parents referred by the child welfare system and in Wales with low-income families.

Preliminary clinical reports show that these groups are well evaluated by parents; attendance and

satisfaction ratings have been very high in both pilot programs.

SCHOOL-AGED Program. The new SCHOOL-AGED curriculum for 8–13 year olds

consists of 16–18 sessions. New vignettes for this age group include: (a) special time and

projects; (b) social, emotional and persistence coaching; (c) encouraging home responsibilities;
 The Incredible Years 29

(d) rules and discussions regarding computer and TV use, and drugs and alcohol; (e) following

through with rules; (f) selective ignoring and avoiding arguments; and (g) imposing

consequences. The first 12 weeks focus on social and emotional skills and home behavior

followed by 4 sessions in which parents learn how to encourage and support their child’s

academic competence. This includes promoting reading habits, helping children with homework

assignments, fostering good learning habits and routines, and working with schools. It is highly

recommended that the ADVANCE program with its focus on problem solving and family

meetings is also delivered in conjunction with the BASIC program, especially when working

with parents of antisocial children. Over the past year this program has been evaluated in

England with severely antisocial children ages 9-13 years. Preliminary results show high parent

evaluations by parents as well as high program attendance.

Directions for Future Research

Although our programs were first designed and evaluated to be used as clinic-based

treatments for diagnosed children and their parents and teachers, our more recent evaluations

have shown the programs to be equally effective in preventive settings with high-risk families

and children. This prevention model has allowed us to research our intervention with families

who might not seek or receive mental health services in traditional clinic settings, and also with

at-risk children before their behaviors have reached clinical levels.

As more is known about the type, timing, and dosage of interventions needed to prevent

and treat children’s conduct problems, we can further target children and families to offer

treatment and support at strategic points. By providing a continuum of services we believe we

will be able to prevent the further development of conduct disorders, delinquency, and violence.

For example, the prevention versions of the classroom social skills intervention, parent training,
 The Incredible Years 30

and/or teacher training might be offered as universal prevention to all children in a school.

Children who continue to exhibit significant behavior problems might be offered the treatment

versions of the programs. For those children requiring additional treatment, more research is

needed to understand what constellation of treatments (parent, teacher, child) would best fit their

particular needs.

Ongoing research is evaluating the IY programs with new populations including

neglectful and abusive families referred by Child Protective Services, children with ADHD, and

families from many different countries around the world including Russia, Turkey, Australia,

Holland, and Scandinavia.

Summary and Conclusions

In summary, a review of our research suggests that interactive video training methods are

effective treatments for early-onset ODD/CD. Our most effective parent intervention includes

both parenting skills and training in marital communication, problem solving and conflict

resolution, and ways to foster children's academic and social emotional competence. These

findings document the need for interventions that strengthen families' protective factors

(specifically, parents' interpersonal skills and coping skills) so that they can cope more

effectively with the added stress of having a child with conduct problems. Our research has also

suggested that child and teacher training are a highly effective strategy for addressing children’s

social deficits and improving social skills, problem-solving strategies, and peer relationships.

The addition of child or teaching training seems to be particularly helpful for children with

pervasive conduct problems (school and home) and with peer relationship difficulties.

Our intervention studies, which target different combinations of risk factors, can be seen as an

indirect test of the different theoretical models regarding the development of conduct disorders.
 The Incredible Years 31

We started with a simple parenting skills deficit model and have evolved to a more complex

interactional model. In our current model, we hypothesize that the child's eventual outcome will

be dependent on the interrelationship between child, parent, teacher, and peer risk factors.

Therefore, the most effective interventions should be those that involve schools, teachers, and the

child's peer group as well as parents.

 The Incredible Years 32

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 The Incredible Years 39

Author Note

This research was supported by the NIMH Research Scientist Development Award

MH00988, NIMH 5 R01 MH067192, and 5 R01 MH074497. Correspondence concerning this

chapter should be addressed to Carolyn Webster-Stratton, University of Washington, School of

Nursing, Parenting Clinic, 1107 NE 45th St. Suite #305, Seattle, WA 98105.

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