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To cite this article: Elizabeth V. Brestan & Sheila M. Eyberg (1998) Effective psychosocial treatments of conduct-disordered
children and adolescents: 29 years, 82 studies, and 5,272 kids, Journal of Clinical Child Psychology, 27:2, 180-189, DOI:
10.1207/s15374424jccp2702_5
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Journal of Clinical Child Psychology Copyright O 1998 by
1998, Vol. 27, NO. 2, 180-1 89 Lawrence Erlbaum Associates, Inc.
ments: videotape modeling parent training program (Spaccarelli, Cotler, & Penman,
1992; Webster-Stratton, 1984, 1994) and parent-training programs based on Patter-
son and Gullion's (1968)manual Living With Children (Alexander & Parsons, 1973;
Bernal, Klinnert, & Schultz, 1980; Wihz & Patterson, 1974). Twenty of the 82 studies
were identiJiedas supporting the eficacy of probably eficacious treatments.
As part of the Division 12 Task Force on Effective from this process and their supporting studies, and we
Psychosocial Interventions: A Lifespan Perspective provide a brief description of treatments identified as
(Johnson, 1995), our task was to review the psychoso- well established. The current list of studies spans the
cia1 treatment outcome literature for children and ado- years from 1966 to 1995 and is a "working list," in that
lescents with conduct problem behavior, including spe- there may be important treatments we have missed in
cific problem behaviors as well as oppositional defiant our search. Our task is a continuing one, and we encour-
disorder (ODD) and conduct disorder (CD), and to age and welcome nominations of additional treatment
identify empirically supported treatments (ESTs) for outcome studies that are not included in the present
these youngsters. As noted by Lonigan, Elbert, and list.'
Johnson (this issue) in their introduction, there are
many ways suchtreatments might be defined. In this re-
view of studies, we apply criteria for probably effica- Identifying the "82"
cious treatment and well-established treatment, as
originally defined by the Division 12 Task Force on We identified 82 outcome studies of treatment for
Promotion and Dissemination of Psychological Proce- conduct problem children that form the database for
dures (1995; see also Chambless et al., 1996) and that our review. The Clinical Psychologist has periodi-
we refer to in this article as the "Chambless criteria." cally published calls for nominations for the empirical
This article describes the methods and decision rules lyvalidated treatments list and literature submitted in
we used in identifying the probably efficacious treat- response to such calls relevant to child and adolescent
ments and well-established treatments for conduct conduct problems was forwarded to us for considera-
problems in children and adolescents and the descrip- tion. In addition, we reviewed the articles included in
tive and methodological characteristics of the treat- four large meta-analyses of child treatment: Weisz,
ment literature that we reviewed. We list the treatments Weiss, Alicke, and Klotz (1987); Weisz, Weiss, Han,
identified as probably efficacious and well established Granger, and Morton (1995); Serketich and Dumas
(1996); and Durlak, Fuhrman, and Lampman (1991).
The four meta-analyses had conducted literature
Portions of this article were presented at the 104th meeting of the searches to identify the existing child treatment out-
American Psychological Association, Toronto, August, 1996. come studies, and we are grateful that we were able to
We thank Pamela Bryan and Stacey Hoffman for their help with
data collection for this project.
Requests for reprints should be sent to SheilaM. Eyberg, Depart-
ment of Clinical and Health Psychology, University of Florida, P.O. 'submit articles to Sheila Eyberg, Department of Clinical and
Box 100165, Health Science Center, Gainesville, F'L 32610. E- Health Psychology, University of Florida, P.O. Box 100165, Health
mail: seyberg@hp.ufl.edu Science Center, Gainesville, FL 32610.
CONDUCT PROBLEM BEHAVIOR
that we were able to take advantage of such extensive unspecified sex. In the 26 studies that repor.ted chil-
prior work. The meta-analyses included studies pub- dren's mean ages, the average mean age of the children
lished up to 1993. To locate treatment outcome studies was 9.89 years (SD = 3.98).
published between 1993 and 1995, we used techniques
similar to those described by Weisz et al. (1995; e.g.,
computer literature searches, paging through journals Methodological Sophistication
by hand2).
From these initial sources, we retained all articles that The Chambless criteria for well-established treat-
described a prospective study of a treatment in which a ments and probably efficacious treatments are pre-
measured goal of the intervention was to decrease con- sented by Lonigan et al. (this issue). To identify studies
duct problem behavior. Thus, retrospective stuhes in of conduct problem treatments meeting the Clhambless
which hypotheses for the effectiveness of an interven- criteria that include the phrase "good design," we se-
tion and identification of participants were made after an lected the four minimal criteria of good design de-
intervention had already been implemented were not in- scribed by the Division 12Task Force on Effective Psy-
cluded. We defined a conduct problem as any behavior chosocial Interventions: A Lifespan Perspective
that is listed in the Diagnostic and Statistical Manual (Johnson, 1995). Specifically, use of comparison
of Mental Disorders (4th ed.; DSM-IV; American group, random assignment,reliable measures,' and de-
Psychiatric Association [APA], 1994) as a symptom scriptive statistics were included in our review of each
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of ODD or CD or a probl~erndescription that is consis- of the studies. INe also recorded seven additionalcriteria
tent or synonymous with these symptoms, such as identified by the task force for a methodlologicdlysophis-
temper tantrums, disruptive classroom behavior, or ticated study, some of which are included in additional
delinquency. If a treatment was applied to a sample Chambless criteria for well-established treatments. These
that was heterogeneous with respect to problems but criteria allowed us to describethe methodo1ogit:al sophis-
explicitly reported having children or adolescents tication of the 82 studies of treatment outcome for chil-
with conduct problems in the sample, or if the treat- dren with conductdisordered behavior.
ment was applied to children with comorbid diagno- Table 1 displays the methodological criteria we re-
ses that expliicitly included conduct problems as one corded and the percentage of treatment outcome studies
cornpanent, it was retained in aur review. Treatments with conduct-disordered children and adolescents that
for substance abuse were not included in our purview met each criterion. Summarized in this way, sm impres-
because substance abuse comprises a distinct sive picture emerges of the methodology that character-
DSM-IVdiagniostic category and has a large and sepa- izes this literature. Over half of the criteria for meth-
rate literature of its own. We also did not include com- odological soplhistication have been used in over half of
ponents analyses (e.g., time-out with no back up vs. the studies published. In addition, by including studies
time-out with a spank back up), but instead addressed from only peer-reviewed journals, we were (ableto al-
only complete treatments, protocols, or "packages" low editors to determine that appropriate statistical
intended for use in actual practice. Finally, we in- treatment of data was used. The data in Table 1 show
cluded only studies that were published in a peer- that all but one of the 8 1 groupdesign studies5used a
revi~wedjournal; treatment evaluations described in comparison goup to rule out alternative explanations
dissmations or chapters were not reviewed. Our rea- for significant changes resulting from treatment. Most
son for this exclusion was our attempt to increase the of the studies (84%) also used reliable mcasures of
validity of our decisions by relying on the peer-review child cond~ctto assess treatment outcomie. Use of
process to promote completeness and accuracy of re-
porting, analyzing, and interpreting the study design ' ~ annotated
n list of the 82 studies reviewed, dest:ribing basic
and results. treatment, participant, and design characteristics, including the
Use of these methods yielded 82 studies investigat- Chambless criteria met, is available on the Section 1 World Wide
ing treatment outcomes with conduct-disordered chil- Web site (http://www.psy.fsu.edu/-lonigan/sectionl.htm),
4~ measure was operationally defined as having reli,sbilityestab-
dren or adolescents for our r e ~ i e wThese
. ~ 82 studies
lished if this fact was reported in the study article, if the measure was
included 3,917 boys, 883 girls, and 472 children with cited in Sattler's (1992) Assessment of'Children,or if the author re-
ported a reliability coefficient for the measure established on the
study sample. When studies had several measures-some withestab-
'~ournals included Behavior Mad@cation, Behavior Research lished reliability and s g w wi@out established reliability-we re-
and Therapy, Behavior Therapy, Child and Family Behavior Ther- quired that over half of the measures used to evaluate the p r i m q out-
apy, Child Development, Cognitive Thei6apy and Research, Journal come (e.g., child conduct) have established reliability ta meet the
of Clinical Psychology, Journal of Abnormal Child Psychology, criterion of reliable measures. When studies had measures with both
Journal ofApphed Behavior Analysis, Journal elf Clinical Child Psy- established and not-established reliability, Chambless lcriteria were
chology, Journal of Consulting and Clinical Psychology, Journal of coded only for the: measures with established reliability.
Counseling Psychology, and Journal c!f the American Academy of he one single-case, design study included in our' review was
Child and Adolescent Psychiatry. Guevremont and Foster (1993).
BRESTAN & EYBERG
Table 1. Percentage of 82 Child and Adolescent Treatment Outcome Studies Meeting Selected
Methodological Criteria
measures with established reliability lends internal va- treatment outcome and the percentage of studies in our
lidity to the results by increasing confidence that differ- review that included that feature. The criterion labeled
ences found between the treatment conditions are real. masked assessment typically refers to keeping inter-
Further, three fourths of the outcome studies used ran- view raters or observation coders uninformed as to the
dom assignment of participants to groups, which as- treatment group assignment of the participants being
sures that the differences between treatments are not assessed. This criterion is closely related to measure-
due to systematic bias. ment reliability. Interrater agreement greatly increases
The last criterion included in the minimal criteriafor one's confidence in the accuracy of ratings but only if
good experimental design is the use of descriptive sta- the raters are uninformed, yet only half of the studies
tistics. These are typically percentages or means that we reviewed reported using masked assessment. Al-
are calculated to describe the treatment-relevant char- though it is possible that some studies using unin-
acteristics of the participants. They describe the charac- formed assessors did not report this in the article, the
teristics thought to affect the extent to which a treat- peer-review process would be expected to catch such
ment will "work" for a child with similar charac- an oversight in most cases. We coded such articles as
teristics. The descriptive statisticswe selected as essen- lacking masked assessment.
tial were sex, age, race, socioeconomic status (SES), The number of participants included in the treatment
and reliable diagnosis or clear specification of the prob- group(s) is a pivotal decision in the study design be-
lems that led to selectian for the study and were the fo- cause it determines whether the study has enough
cus of treatment. Unlike the other minimal criteria for power to detect true differences that may exist between
good design, relatively few studies in our review (32%) treatments. In addition, there may be important moder-
described the participants sufficiently. Closer inspec- ating effects of participant characteristics that cannot
tion of the data indicated that 49% of the studies did not be examined due to inadequate power. Although we
report the raciaVethnic breakdown, 42% of the studies recognize that determination of an adequate sample
did not report SES data, and 5%did not report the crite- size is dependent on many factors, we selected 12 par-
ria used for participant selection (e.g., diagnosis of ticipants per treatment condition as an arbitrary lower
ODD or CD, specific child problems such as temper limit for determining differences. Although, as pointed
tantrums, aggressiveness),It was the earlier studies that out by Chambless and Hollon (in press), a study needs
accounted for most of the failures to report in all of the 50 participants per condition to have the conventional
five categories of participant characteristics. To sum- 80% power for a significance test of a medium differ-
marize the 82 outcome studies in terms of minimal cri- ence between two treatment groups; the median sample
teria for good experimental design then, the data show size per treatment condition across psychotherapy re-
that a substantial majority d the studies of conduct- search is 12 (Kazdin & Bass, 1989). Therefore, we se-
disordered children and adolescents have used random- lected 12as a meaningful point of comparison to evalu-
ized group designs andrelibblelaeasures,but relatively ate outcome studies in the child conduct problem
few of these studies have reported descriptive statistics literature. For purposes of establishing "equivalence"
sufficiently to indicate with confidence the populations to an already-established treatment, however, we se-
to whom the results c m generalize. lected 25 participants per treatment condition as an ar-
Table 1show$additional methodologicalcharacter- bitrary lower limit, based on the recommendation from
istics that are features of a sophisticated design for the Task Force on Promotion and Dissemination of
CONDUCT PROBLEM BEHAVIOR
Psychologjcal Procedures (1995). The data for studies length of follow-up intervals and the potentid for dif-
with conduct-disordered children in Table 1 suggest ferential drop out in the follow-up samples. Short-term
that many of these studies, like outcome studies in gen- follow-up data (less than 6 months) typically show
eral, are losing important information on potentially ef- good maintenance of treatment gains after the immedi-
ficacious treatments due to insufficient power. ate posttreatment "high," but long-tern1follow-up (i.e.,
Closely related to sufficient sample size is the attri- beyond 12 months), although less rigorously evaluated
tion rate in treatment outcome studies. Attrition, which in general, has typically found poor maintenance for a
refers to the loss of participants before the outcome and substantial proportion of treatment comp1el:ers (Du-
follow-up evaluations, reduces the number of partici- mas, 1989;Eyberg, Edwards, Boggs, &Foote, in press;
pants who can be included in the major analyses of Kazdin, Bass, Ayres, & Rodgers, 1990; Mclvlahon &
change and thereby affects the power of the study to de- Wells, 19139). Although there is a point of dirninishing
tect treatment effects. Attrition can also provide one in- returns in following treatment effects, conduct prob-
dex of treatment outcomie-families may drop out of lems in children are a significant risk factor for later an-
treatment because it is not effective for their child. tisocial behavior and need to be followed throughout
Whatever the reason for dropping out, attrition limits the period of childhood to identify factors associated
the generdizability of results that are based on treat- with later recurrence, when it happens, and to develop
ment completers. Further, differential attrition shifts effective after-care strategies.
the random composition of the treatment groups and
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needed to establish equivalence. Rather than ignore all ruled out. The second criterion that can establish a
of the comparative literature, however, Chambless and probably efficacious treatment is a demonstration of
Hollon recommended, as an interim solution, that stud- efficacy in a study meeting all the criteria for a well-
ies with 25 to 30 participants per group (thus allowing a established treatment except replication by an inde-
reasonably stable estimate of treatment effects) and pendent research team.
with no trends for the established treatment to be supe-
rior be accepted as equivalent in efficacy for present
purposes. Treatments Identified as
Replication protects against drawing a false conclu- Well Established
sion about a treatment based on some anomaly affect-
ing the study results and is a key feature of the well- Two treatments designed for children with conduct
established treatments. The criteria for a well- problem behaviors were found to have the strong em-
established treatment include the stipulation that a rep- pirical support required of treatmentsjudged to be well
lication study must be conducted by independentinves- established according to the Chambless criteria. These
tigators or investigatory teams. For this review, we de- treatments each address the full constellation of behav-
fined studies by independent teams as studies iors that characterize conduct-disorderedchildren and,
conducted in laboratories at different institutions with collectively, provide new and current standards of care
different authors. Among the studies of conduct- across the developmental spectrum of childhood. Each
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disordered children, we found that replication by inde- of these treatments has several supporting studies
pendent teams was rare. among which there are studies sufficient to support the
The final criteria for studies used to identify a well- well-established treatment criteria and no studies we
establishedtreatment include use of a treatment manual found that provide disconfirming data. Studies of these
to guide treatment and clear specificationof the partici- treatments demonstrated superiority to psychological
pant characteristics (see Table 1; Lonigan et al., this is- placebo or another treatment.
sue). Both of these criteria were considered in describ-
ing methodalogically sophisticated studies and
discussed earlier. These two criteria were the ones most Parent Training Based on
frequently not met by studies that were otherwise meth- Living With Children
odolagically sophisticated.Recall that 60%of the stud-
ies reviewed did not report using a treatment manual Parent-training programs based on Patterson and
and 78%did not; fully describe the participants. It was Gullion's (1968) manual Living With Children are
most commanly the raciaUethnic data for the sample based on operant principles of behavior change and de-
that were missing (49% of studies). These two criteria signed to teach parents to monitor targeted deviant be-
had the greatest influence on which studies were finally haviors, monitor and reward incompatible behaviors,
included in the lists of both the well-established treat- and ignore or punish deviant behaviors of their child.
ments and the probably efficacious treatments. The treatment has been found superior to control
groups in several controlled studies including Alexan-
der and Parsons (1973); Bernal, Klinnert, and Schultz
Probably Efficacious Treatment (1980); Firestone, Kelly, and Fike (1980); and Wiltz
and Patterson (1974). Treatments using the lessons
There are four alternative criteria for the identifica- from Living With Children have generally been short-
tion of a probably efficacious treatment (see Table 2; term behavioral parent-training programs and have
Lonigan et al., this issue), but only the first two criteria been compared to standard treatments for children with
were relevant to the current review: There must be two conduct problems (e.g., psychodynamic therapy,
studies showing that the treatment is more effective client-centered therapy) in addjtion to no-treatment
than wait-list control or two studies otherwise meeting control groups. The study participants have included
criteria for a well-established treatment but conducted both boys and girls across a broad age range selected for
by the sameinvestigator or research team. A study that treatment based on referral from parents and juvenile
demonstrates the superiority of a treatment over a court as well as symptoms consistent with diagnoses of
wait-list control group, although not adequate for use ODD and CD (e.g., noncompliance and aggression) as
in determining a well-established treatment, is a rec- determined by rating scale data.
ommended first demonstration of efficacy (Kazdin, Because there have been many studies evaluating
1986), and a replication increases confidence that the parent training based on Living With Children (Patter-
obtained treatment effect was not due to chance. For son & Gullion, 1968) and they have varied in their
treatments designated as probably efficacious on the methodological rigor and support for the efficacy of
basis of being more effective than a waiting-list con- this treatment, we considered all of the controlled out-
trol group, however, experimenter bias cannot be come studies, as suggested by Chambless and Hollon
CONDUCT PROB'LEM BEHAVIOR
videotape lessons. The treatment has been tested in modeling. The delinquency prevention program
several studies, including Spaccarelli, Cotler, and (Tremblay, Pagani-Kurtz, Masse, Vitaro, & Phil,
Penman (1992); Wehster-Stratton (1984, 1990, 1995; Vitaro & Tremblay, 1994) is also designed for
1994); and Webster-Stratton, Kolpacoff, and Hol- preschool-age children.
linsworth (1988), in which it has been compared to Treatments for older children with conduct problem
wait-list control groups and to alternative parent- behaviors are represented in the probably efficacious
training formats. The studies have typically included treatments as well. Research teams led by Kazdin,
both boys and girls in the 4- to 8-year-old age range studying problem solving skills training (Kazdin,
who have been selected for treatment based on either Esveldt-Dawson, French, & Unis, 1987,a, 1987b;
parent referral for behavior problems or diagnostic Kazdin, Siegel, &Bass, 1992), and by Lochman, study-
criteria for ODD or CD. ing anger coping therapy (Lochman, Burch, Curry, &
Parents ~ c e i v i n gvideotape modeling parent train- Lampron, 1984; Lochman, Lampron, Gemmer, & Har-
ing have rated tbeir children as having fewer problems ris, 2989:t, have each conducted rigorous evalluations of
after treatment than control parents, and these parents treatments for school-age children (see Talble 2). Fi-
have rated themselves as having better attitudes toward nally, four treatments for conduct-disordened adoles-
their child and greater sdf-confidence regarding their cents have attained probably efficacious treatment
parenting rola. Parsnts receiving the videotape treat- status: anger controVstress inoculation (Feindler, Mar-
ment have also shown better parenting skills than con- riott, & Iwata, 1984; Schlichter & Horan, 1981), asser-
trol parents on observational measures in the home, and tiveness training (Huey & Rank, 1984), multisystemic
their children have shown greater reduction in observed therapy (Borduin et al., 1995; Henggeler, Melton, &
deviant behavior. Smith, 1992; Henggeler et al., 1986), and rational-
emotive therapy (Block, 1978).
Table 2. The Probably Eficacious Treatments and the Studies Supporting Their Efficacy
of the participants. Families from diverse raciaVethnic behavior can be frustrating and annoying for parents,
backgrounds constitute a growing proportion of mental and successful treatment of these subclinical ]problems
health referrals, and matching children to treatments can relieve considerable parenting stress.
based on culture-specific variables may be hportant We believe that future studies should include chil-
(see Sue, 1990). Certainly it is important to ensure that dren diagnosed with ODD and CD, as this will1 provide
therapists conducting experimental interventions are the consistent classification that is crucial for scientific
aware and respectful of e x h child's sociocultural con- rigor in treatment outcome research. We encourage
text (Kaslow et al., 1997). We must also actively seek treatment researchers to study clinic-referredl children
diversity in study populations to examine the effects of and adolescents and to allow and examine comorbidity
ethnicity on treatment outcome. in participants, to increase in every way po!ssible the
We did find, however, that there are several inter- congruence between the treatments used in research
ventions with gaod evidence for the improvennent of di- and those used in clinical practice. It is only with con-
agnosed ODD and CD. Review of the 29 studies using gruence between treatment research and the real world
well-established and pro~bablyefficacious treatments of conduct-disordered children in treatment that re-
revealed h t 28% of the studies included participants search can inform practice as to the effectiveness of
meeting the DSM-IZZ-R (APA, 1987) or DSM-IV ESTs.
(APA, 1994) criteria for ODD or CD. Twenty-one per- The "typical" conduct-disordered child in treatment
cent of t h studies
~ reported that the participants were studies is a9-year-old Caucasian boy from a lower mid-
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court-refexred for treatmat or had a history of serious dle income background, whose mother may a~rmay not
oriminal activity. Thus, 49% of the studies providing be participating in his cognitive-behavioral treatment
evidence for the efficacy of well-establishedand proba- for conduct problems. In our review, we found little in-
bly effica~ioustreatments included a clinical popula- formation from which to know whether this boy would
tion with a high magnitude of behavior prob1e:ms. In the do better, or worse, in his particular treatment if he were
remaining half of the studies, 17% af the p,?rticipants a girl or from arninority background, or if his family (or
were identified by extreme scores on behavior ratings, his therapist) belonged to a higher or lower socioeco-
17% included participants who were parent- or nomic group. We also do not know if the boy would do
teacher-referred for treatment, 14% included children better or worse in this treatment if he wen: older or
who displayed behaviors or symptoms consistent with younger than he was. Of all the demographic variables,
a dimptive behavior disorder (e.g., aggression, non- however, age i~our best bet for the variable with great-
compliance), and 3.4% (1 study) included participants est potential impact on treatment matching.
who were: socially rejected by peers. Altholugh these Two recent studies (Dishion & Patterson, 1992;
latter methods of participant recruitment do not specifi- Ruma, Burke, &Thompson, 1996)colmpwd the effec-
cally meet DSMcriteria for a disruptivebehavior disor- tiveness of behavioral parent training across many ages
der, it is possible that some of these children had clini- and suggested that this type of treatment is miore effec-
cally significant problems that would have warranted tive in reducing behavior problems in younger than
an ODD or CD diagnosis. Among the treatment pack- older children. Cognitive developmental theory, on the
ages including participants who met DSM criteria for other hand, would predict that cognitive treatments for
ODD or CD were parent-child interaction thmapy (Ey- conduct problems would be more effective for older
berg et al,, 1995),assertiveness training (Huey & Rank, than for younger (preschool-age) children. As an index
1984), problem-solving shrills training (Kudin et al., of a child's cognitive, social, or emotional 1e:vel ofde-
1987a, 1987b; Kazdin et al., 1992), and a videotape velopment, age is a likely moderator of outcome for all
modeling parent-Waining program (Webste~$tratton, treatments of conduct problem behavior (Eyberg,
19g4). Tthe treatment packages that included children Schuhmann, & Rey, 1997) and sho~ldble incorporated
who were court-referred for treatment-a seirious clas- routinely into future treatment study designs. Interac-
sification in its own right-were multisystem~ictherapy tions of age with child sex and ethnicIracia1background
(Henggeler et al., 1992; Borduin et d.,1995), parent- should also be examined whenever a treatment study
training programs based on Living With Children (Pat- has sufficient range and sample size.
terslan & Gullion, 1968X and anger control training In the design of future studies, the literatureon treat-
with stres~inaculation(Schlichter & Horan, 1981). We ments for conduct problems is ready to address many
believe these studies provide good evidence far effec- questions beyond, "Does this treatment work?" We
tive treatment of clinical populations with cmduct dis- must now address the question, 'Tor whom does this
orders as b y all reported a significant decreasein chil- treatment work?" There are other immediatequestions:
dren's disruptive behavior. Whereas the remaining "Is this treatment cost-effective?' "When is this treat-
probably efficacious treatments reported efficacy for ment nor enough?' How long doas this treatment
the treatment of nonclinioal papulations, their impor- work?' "How can we prevent relapst:?' We also need
tance should not be discoanted, as many behaviors dis- to ask, Is this treatment equivalent to, or better than,
played by children with subdlinical levels of disruptive Living Mith Children or videotape modeling?"
BRESTAN & EYBERG
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Vitaro, F., LTremblay, R. E. (1994). Impact of aprevention program Received May 2,1997
on aggressive children's friendship and social adjustment. Revision received October 31, 1997
Journal of Abnormal Child Psychology, 22,457-475. Accepted December 10, 1997