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TheIncredibleYears® Series:ADevelopmentalApproach

CarolynWebster-Stratton,M.S.,M.P.H.,Ph.D.ProfessorEmeritus

UniversityofWashington

Chapterinbook:Family-CenteredPreventionProgramsforChildrenandAdolescents:Theory,Research,andLarge-ScaleDissemination,editedbyMark,J.VanRyzin,KarolKumpfer,GregoryFosco,andMarkT.Greenberg,2016,pp.42-67.

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TheIncredibleYears® Series:ADevelopmentalApproach

Introduction

Ratesofclinicallysignificantbehavioralandemotionalproblemsareashighas6-15%in3-12yearoldchildren(Egger&Angold,2006;Sawyer,2000).Thesenumbersareevenhigherfor children from economically-disadvantaged families (Webster-Stratton & Hammond,1998). Young children with early-onset behavioral and emotional difficulties are atincreasedriskofdevelopingsevereadjustmentdifficulties,conductdisorders,schooldropout,violenceandsubstanceabuseinadolescenceandadulthood(Costello,Foley,&Angold,2006; Egger & Angold, 2006). However, the good news is that research has consistentlyindicatedthatearly interventionwithevidence-basedparent, teacher,andchildprogramscan prevent and reduce the development of conduct problems, strengthen social andemotional competence and school readiness and, in turn, prevent later development ofsecondaryriskfactorssuchasschoolunderachievementanddeviantpeergroups(Kazdin&Weisz,2010;Snyder,2001).

Multiple risk factors contribute to young children’s behavioral and emotionalproblems including ineffectiveparenting(e.g.,harshdiscipline, lowparent involvement inschool, neglect and low monitoring)(Jaffee, Caspi, Moffitt, & Taylor, 2004); family riskfactors (e.g., marital conflict, parental drug abuse, mental illness, and criminal behavior)(Knutson,DeGarmo,Koeppl,&Reid,2005);childbiologicalanddevelopmentalriskfactors(e.g., attention deficit hyperactivity disorders (ADHD), learning disabilities, and languagedelays); school risk factors (e.g., poor classroom management, high levels of classroomaggression, large class sizes, and poor school-home communication); and peer andcommunityriskfactors(e.g.,povertyandgangs)(Collins,Maccoby,Steinberg,Hetherington,&Bornstein,2000).Effectiveinterventionsforpreventingandreducingbehaviorproblemsideallytargetmultipleriskfactorsandarebestofferedasearlyaspossible.

NeedforEarlyIntervention

Extensive research over the past thirty years has consistently demonstrated thelinks between child, family, and school risk factors and the subsequent development ofantisocialbehaviors.Severalprominentresearchers(e.g.,(Dishion&Piehler,2007;Dodge,1993;Moffitt, 1993; G. Patterson, Reid, & Dishion, 1992; G. R. Patterson & Fisher, 2002)havehelpedcoalescethisliteratureintostronglysupportedtheoriesaboutthedevelopmentof antisocial behaviors which in combination with developmental theory have had someobvious implications for interventions. First, early intervention timed to key childdevelopmentalperiodsiscritical.Treatment-outcomestudiessuggestthatinterventionsforconductdisorders(CD)areof limitedeffectwhenoffered inadolescence,afterdelinquentand aggressive behaviors are entrenched, and secondary risk factors such as academicfailure, school absence, substance abuse and the formation of deviant peer groups havedeveloped(Dishion&Piehler,2007;Offord&Bennet,1994).Second,effectiveinterventionsneed to target multiple risk factors across various settings. The increased treatmentresistance in older CD probands results in part from delinquent behaviors becomingembedded in a broader array of reinforcement systems, including those at the family,school, peer group, neighborhood, and community levels (Lynam et al., 2000). Thirdly,significant advances in brain development research and in the conceptualization andpractice of prevention science in mental health emphasize that interventions must startearly,targetmultiplerisk-andprotectivefactorsandbetiedtotheoreticalandlife-coursemodels.Moreover, ina recentCochrane reviewbyFurlongandcolleagues (Furlonget al.,

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2010) showed that group-based parenting programs improve child behavior problems(whether measured independently or by parents) not only because they strengthenparenting skillsbutbecause theyalso improveparentalmentalhealthdue to the supportprovidedbythegroup.Thissuggeststheaddedvalueofprogramsthatreduceparticipantisolationandstigmatizationandincreasetheirsupportnetworks.

For these reasons, the Incredible Years® (IY) Series, a set of interlocking andcomprehensive group training programs was designed to prevent and treat behaviorproblems when they first begin (infancy–toddlerhood through middle childhood) and tointervene inmultiple areas and settings throughparent, teacher, and child training. Earlyinterventionacrossmultiple contexts can counteractmalleable risk factorsand strengthenprotective factors, thereby helping to prevent a developmental trajectory to increasinglyaggressive and violent behaviors in later life. The model’s hypothesis is that improvingprotective factors such as responsive and positive parent-teacher-child interactions andrelationships as well as group support will lead to improved school readiness, emotionregulation,andsocialcompetenceinyoungchildren.Theseshorttermgainswould,inturn,lead to increased academic achievement and reduced school drop-out, conduct disorders,andsubstanceabuseproblemsinlaterlife.

This chapterwill focus on the underlying theoretical background for the three IYBASIC parent programs (toddler, preschool and school-age) which are considered “core”andanecessarycomponentofthepreventionmodelforyoungchildren.InadditionitwilldiscusshowtheotherIYadjunctparent,teacher,andchildprogramsareaddedtoaddressfamilyriskfactorsandchildren’sdevelopmental issues. InformationregardingIYprogramcontent and deliverymethodswill be briefly described aswell as research evidence, and

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waystopromotesuccessfuldeliveryoftheprograms.Moreinformationregardingspecificprogram objectives can be found on the web site http://incredibleyears.com/about/incredible-years-series/objectives/TheoreticalBackgroundforIncredibleYearsProgramContent&Methods

Themainunderlyingtheoreticalbackgroundforalltheparent,teacher,andchildprogramsincludethefollowing:

• Cognitive social learning theory, and in particular Patterson’s “coercionhypothesis” of negative reinforcement developing and maintaining deviant behavior (G.Pattersonetal.,1992)

•Bandura’smodelingandself-efficacytheories(AlbertBandura,1986)• Piaget’s developmental cognitive learning stages and interactive learning

method(Piaget&Inhelder,1962)•Cognitivestrategiesforchallengingangry,negativeanddepressiveself-talkand

increasing parent self-esteem and self-confidence (Beck, 1979; D'Zurilla & Nezu, 1982;Jacobson&Margolin,1979)

•Attachmentandrelationshiptheories(Ainsworth,1974;Bowlby,1980)Cognitivesociallearningtheory,modeling,self-efficacy,attachmentandrelationship

building,andchilddevelopmenttheoriesunderliethedeliverymethodforalltheIYseries.Video-basedmodelingisbasedonsociallearningandmodelingtheory(A.Bandura,1977),whichcontendsthatobservationofamodelonvideocansupportthelearningofnewskills.IntheIYseries,video-basedmodelinginvolvesshowingparticipantsvignettesofparentsorteachersrepresentingdifferentculturalbackgroundsusingsocialandemotionalcoaching,orpositivedisciplinestrategies,orofchildrenmanagingconflictwithappropriatesolutions.Group leaders use the vignettes to engage participants in group discussion, collaborativelearning and emotional support. Further, participants identify key “principles” from thevignettes, apply them to their personal goals by practicing what they have learned withtheir personal problem situation and then receive direct feedback on their performancefrom thegroup leaderandgroupmembers. Previous research indicates thatparticipantstend to implement interventionswith greater integritywhen they are coached and givenfeedback on their use of the intervention strategies (Reinke, Stormont,Webster-Stratton,Newcomer,&Herman,2012;Stormont,Smith,&Lewis,2007).Afterlearningandpracticingnew strategies in the group, participants make decisions about how they will apply theideastoaddresstheirpersonalgoalsintheirhomesorclassrooms.

The group format has several advantages. First, it is more cost-effective thanindividual intervention and also addresses an important risk factor for children withbehavior problems including the family’s isolation and stigmatization, teacher’s sense offrustration and blame, and children’s feelings of loneliness or peer rejection. Anotherbenefit of the group format is that it helps reduce resistance to the intervention throughmotivational interviewing principles (Miller & Rollnick, 2002) and use of the collectivegroupwisdom. Rather than receiving information solely from an expert, participants aregiventheopportunitytointeractwitheachother.Whenparticipantsexpressbeliefscounterto effective practices, the group leader draws on others to express other viewpoints.Throughthisdiscourse, thegroupleader isabletoelicitchangetalkfromtheparticipantsthemselvesthatmakes itmore likely theywill followthroughon intendedchanges.Whengroupleaderspositionthemselvesinthe“expertmodel”arguingforchange,itismorelikelytocementtheattitudesofparticipantswhoareresistanttotheintervention(see(Miller&Rollnick,2002).Ontheotherhand,videovignettesallowgroupleaderstoelicitbehavioralprinciples from the parents’ insights and serve as the stimulus for collaborative learningandpracticeexercises.

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Group leaders always operatewithin a collaborative contextwhich is designed toensure that the intervention is sensitive to individual cultural differences and personalvalues. The program is "tailored" to each parent, teacher or child's individual needs andpersonal goals as well as to each child's personality, developmental ability and behaviorproblems. The collaborative therapy process is also provided in a text for group leaders,titled Collaborating with Parents to Reduce Children’s Behavior Problems: A Book forTherapistsUsingtheIncredibleYearsPrograms(Webster-Stratton,2012a).

IncredibleYears® CoreParentProgramsTheBASIC (core)parent trainingconsistsof4differentcurrciulumdesigned to fit

the developmental stage of the child: Baby Program (4 weeks to 9 months), ToddlerProgram(1-3years),PreschoolProgram(3-5years)andSchool-AgeProgram(6–12years).Each of these recently updated programs emphasize developmentally appropriateparenting skills and includeage-appropriate videoexamplesof culturallydiverse familiesandchildrenwithvaryingtemperamentsanddevelopmentalissues.Theprogramsrunfrom9-22weeks,dependingontheageofthechildandthepresentingissuesoftheparentsandchildren in the group. The recommended program length and protocols for delivery islongerforolderchildrenandforhigherriskfamiliesandchildrenandcanbefoundonthewebsite..

Foreachoftheseparenttrainingprograms,trainedand,ideally,accreditedIYgroupleaders/cliniciansuseDVDvignettesofmodeledparentingskills(over300vignettes,eachlastingapproximately1–3minutes)whichareshowntogroupsof8–12parents.Thevideovignettesdemonstratechilddevelopmentaswellasparentingprinciplesandserveas thestimulus for focused discussions, self-reflection, problem solving, practices, andcollaborativelearning.Theprogramsaredesignedtohelpparentsunderstandtypicalchilddevelopmental milestones and varying temperaments, child safety-proofing andmonitoring,aswellasage-appropriateparentingresponses.

While participation in the group based IY training program is recommendedbecauseofthesupportandlearningprovidedbyotherparents,thereisalsoaHome-basedCoachingModel foreachparentingprogram.Thesehome-basedsessionscanbeofferedtoparentswhocannotattendgroups,orasmake-upwhenparentsmissagroupsession,ortosupplementthegroupprogramforveryhighriskfamilies.

Goalsof each theprogramsare tailored specifically to the targetedagegroupanddevelopmental stage of the child and include: (a) promoting parent competencies andstrengtheningfamiliesbyincreasingpositiveparenting,parent–childattachment,andself-confidence about parenting; (b) increasing parents’ ability to use child-directed playinteractions to coach children’s social-emotional, academic, verbal, and persistence skills;(c) reducing critical and physically violent discipline and increasing positive disciplinestrategies such as ignoring and redirecting, logical consequences, time-out, and problem-solving; (d) increasing family support networks; and (e) strengthening home–schoolbonding and parents’ involvement in school related activities and connections withteachers.

The Incredible Years Parenting Pyramid® serves as the architectural plan fordeliveringcontentandisusedtodescribetheprogramcontentstructure. Ithelpsparentsconceptualize effective parenting tools and how these tools will help them achieve theirgoals. The bottom of the pyramid depicts parenting tools that are used liberally, as theyformthefoundationforchildren’semotional,socialandacademiclearning.Thebaseofthepyramidincludestoolssuchaspositiveparentattention,communication,andchild-directed

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playinteractionsdesignedtobuildsecureandtrustingrelationships.Parentsalsolearnhowtousespecificacademic,persistence, socialandemotionalcoaching tools tohelpchildrenlearntoself-regulateandmanagetheirfeelings,persistwithlearningdespiteobstacles,anddevelopfriendships.Onestepfurtherupthepyramidparentsaretaughtbehavior-specificpraise,incentiveprograms,andcelebrationsforusewhengoalsareachieved.Nextparentsdiscuss the use of predictable routines and household rules which scaffold children’sexploratorybehaviorsand theirdrive forautonomy. The tophalfof thepyramid teachesparentingtoolsthatareusedmoresparingly,toreducespecifictargetedbehaviors. Theseincludeproactive discipline tools such as ignoring of inappropriate behaviors, distractionandredirection. Finally,attheverytopofthepyramidaremoreintrusivedisciplinetoolssuchasTimeOuttocalmdownforaggessivebehaviorsandlogicalconsequences.Afterthetopofthepyramidisreached,thelastpartofthetrainingfocusesonhowparentscancomebackdownthepyramidtothebaseofthepyramid.Thisrefocusesparentsonpositiveandproactive strategies for teaching children to problem solve, self-regulate, and manageconflict. At this point parents have all the ncessary tools to navigate some of theuncomfortable, but inevitable, aspects of their interactions with their children. A basicpremiseofthemodelistwofold:first,apositiverelationshipfoundationmustprecedeclearandpredictabledisciplinestrategies.Thissequenceofdeliveryofcontent iscritical to theprogram’s success. Second, attention to positive behavior, feelings, and cognitions shouldoccurfarmorefrquentlythanattentiontonegativebehaviors,feelingsandcognitions.Toolsfrom higher up on the pyramid onlyworkwhen the postive foundation has been solidlyconstructedwithsecurescaffolding.

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IncredibleYears® AdjunctstoParentProgramsIn addition to the core BASIC parenting programs there are also supplemental or

adjunct parenting programs to be used in combination with BASIC for particularpopulations. The ADVANCE parenting program, offered after completion of the BASICpreschool or school-age programs, was designed for selective high-risk and indicatedpopulationsandfocusesonparents’interpersonalriskfactorssuchasangeranddepressionmanagement, effective communication, ways to give and get support, problem-solvingbetweenadults,andwaystoteachchildrenproblemsolvingskills.ThecontentofboththeBASIC and ADVANCE programs is also provided in the text that parents use for thepreschoolandschool-ageprograms,titledTheIncredibleYears:ATroubleshootingGuideforParents (Webster-Stratton, 2005; Webster-Stratton & Reid, 2006). A second optionaladjuncttrainingtothePreschoolProgramistheSchoolReadinessProgramforchildrenages3–4 years that is designed to help parents support their children’s preliteracy andinteractivereadingreadinessskills.AthirdoptionaladjunctfortheToddler,Preschool,andEarlySchoolAgeprogramsistheAttentiveParentingProgramforchildrenages2to8years.This group prevention program is designed to teach parents social, emotional andpersistence coaching, reading skills and how to promote their children’s self-regulationskillsandproblem-solvingskills.Thereareprotocolsforboththetoddleragegroupandtheearly school age period. The Attentive Parenting Program is not designed for parents ofchildrenwithbehaviorproblems,althoughcanbeusedforthispopulationaftertheBASICparentingprogramiscompletedandparentshavelearnedthebasicparentingtools.Finally,themostrecentAutismProgramisforparentsofchildrenontheautismspectrumorwhosechildren have language delays. It can be used independently or in conjunction with theBASICpreschoolprogram.

IncredibleYears® TeacherClassroomManagementProgramThe IncredibleYears®TeacherClassroomManagement(IY-TCM)trainingprogram

is a 6-day group-based program deliveredmonthly by accredited group leaders in smallworkshops(14-16teachers)throughouttheschoolyear inordertoprovideteacherswithongoingsupport.ItisalsorecommendedthattrainedIYcoachessupportteachersbetweenworkshops by visiting their classrooms, helping refine behavior plans, and addressingteacher’sgoals.Thegoalsoftheteachertrainingprogramarethefollowing:(a)improvingteachers’ classroom management skills, including proactive teaching approaches andeffective discipline; (b) increasing teachers’ use of academic, persistence, social, andemotional coaching with students; (c) strengthening teacher–student bonding; (d)increasing teachers’ ability to teach social skills, angermanagement, andproblem-solvingskills in the classroom; (e) improving home–school collaboration, behavior planning andparent–teacher bonding and (f) building teachers’ support networks. A complete andrecentlyupdateddescriptionofthecontentincludedinthiscurriculumisdescribedinthebookthatteachersuseforthecourse,titledIncredibleTeachers:NurturingChildren’sSocial,Emotional and Academic Competence (Webster-Stratton, 2012b). More information aboutthetraininganddeliveryoftheIYteacherprogramcanbefoundelsewhere(Reinkeetal.,2012)(Webster-Stratton&Herman,2010).

IncredibleYears® ChildPrograms(DinosaurCurricula)There are two versions of the IY child program. In the universal prevention

classroomversionteachersdeliver60+social-emotionallessonsandsmallgroupactivitiestwiceaweek,withseparatelessonplansforpreschool-secondgrade.Thesecondversionisa small group therapeutic treatment groupwhere accredited IY group leadersworkwith

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groupsof4–6children in2-hourweeklytherapysessions.Thetherapeuticversionof theprogramcanbeofferedinamentalhealthsetting(oftendeliveredatthesametimeastheBASIC parent program) or can be delivered as a pull-out programduring the school day.Program content is delivered using a series of DVD programs (over 180 vignettes) thatteachchildrenfeelings literacy,socialskills,emotionalself-regulationskills, importanceoffollowingschoolrulesandproblemsolving.Largepuppetsareusedtobringthematerialtolife, and childrenare actively engaged in thematerial through roleplay, games, play, andactivities. Organized to dovetail with the content of the parent training program, theprogramconsistsofsevenmaincomponents:(1)IntroductionandRules;(2)EmpathyandEmotion;(3)Problem-Solving;(4)AngerControl;(5)FriendshipSkills;(6)CommunicationSkills; and (7) School Skills. More information about the child programs canbe found inotherreviews(Webster-Stratton&Reid,2003,2004).

EvidenceSupportingtheIncredibleYearsParentPrograms TreatmentandIndicatedPopulations:Theefficacy1oftheIYBASICparenttreatmentprogramforchildren(ages2–8years)diagnosedwithODD/CDhasbeendemonstrated ineight published randomized control group trials (RCTs) by the program developer plusnumerous replications by independent investigators . See reviewonweb site library andresearch book for review of studies http://incredibleyears.com/books/iy-training-series-book/. Intheearlystudies,theBASICprogramwasshowntoimproveparentalconfidence,increase positive parenting strategies and reduce harsh and coercive discipline and childconduct problems compared to wait-list control groups. The results were consistent fortoddler, preschool and school age versions of the programs. The first series of RCTsevaluated themost effective trainingmethods of bringing about parent behavior change.Thevideo-basedparentgroupdiscussiontrainingapproach(BASIC)wascomparedwiththeone-on-onepersonalized“bugintheear”approachandacontrolgroupindicatingthatthevideo-baseddiscussion approachwas as effective as the one-on-oneparent-child trainingapproach but farmore cost-effective and hadmore sustained results at 1-year follow-up(Webster-Stratton, 1984b). In the next study treatment component analyses compared 3trainingmethods: group discussion alonewithout video led by a trained clinician, groupdiscussionplusvideowithatrainedclinician,self-administeredvideowithnoclinician,anda control group. Results indicated that the combination of group discussion, a trainedclinician, and video modeling produced the most effective and lasting results (Webster-Stratton, Hollinsworth, & Kolpacoff, 1989; Webster-Stratton, Kolpacoff, & Hollinsworth,1988).Nexttheself-administeredvideoprogramwascomparedwithandwithoutclinicianconsultation. There were few outcome differences, except that parent satisfaction washigher for theconsultationcondition (Webster-Stratton,1992). Subsequentlya studywasconducted todetermine theaddedbenefitsof combining theADVANCEprogram(focusedon interpersonal parent problems such as depression and anger management) with theBASICprogram(Webster-Stratton,1994).Resultsindicatedthatthecombinedprogramhadgreater improvements in terms of parents’ marital interactions and children’s prosocialsolution generation in comparison to the BASIC only treatment condition families. As aresultthecombinedBASICplusADVANCEprogramsbecamethecoretreatmentforparentsofchildrendiagnosedwithODDand/orADHDandhasbeenusedforthetreatmentstudiesinthelasttwodecades. Other investigators have replicated the BASIC program’s results with treatment

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populationsinmentalhealthclinics,ordoctor’sofficeswithfamiliesofchildrendiagnosedwith conduct problems or high levels of behavior problems (Drugli & Larsson, 2006;Gardner, Burton, & Klimes, 2006; Lavigne et al., 2008; Perrin, Sheldrick, McMenamy,Henson,&Carter,2014;Scott,Knapp,Henderson,&Maughan,2001;Spaccarelli,Cotler,&Penman, 1992; Taylor, Schmidt, Pepler, &Hodgins, 1998). A recentmeta-analytic reviewexamined the IYparent trainingprogramsregardingdisruptiveandprosocialbehavior in50 studieswhere the IY intervention groupwas comparedwith control or a comparisongroup.Resultswerepresentedfortreatmentpopulationsaswellasindicatedandselectivepreventionpopulations.Findingsreportedtheprogramtobesuccessfulinimprovingchildbehavior in a diverse range of families, especially for children with the most severeproblemsandtheprogramwasconsidered“well-established”(Menting,OrobiodeCastro,&Matthys,2013). SeveralstudieshavealsoshownthatIYtreatmenteffectsaredurable1-3yearsposttreatment (Webster-Stratton, 1990). Two long-term followup studies evaluated familieswhose childrenwere diagnosedwith conduct problems and had received treatmentwiththeIYparentpogram8-to12-yearsearlier.Onestudyindicatedthat75%oftheteenagerswere typically adjusted with minimal behavioral and emotional problems (Webster-Stratton,Rinaldi,&Reid, 2010).A recent studyby an independent investigator reportedthat parents in the IY BASIC parent condition expressed greater emotional warmth andsupervised their adolescentsmore closely, thanparents in the control conditionwhohadreceived individualized “typical” psychotherapy offered at that time. Moreover, theirchildren’sreadingabilitywassubstantially improved inastandardizedassessment(Scott,Briskman,&O'Connor,2014).

PreventionPopulations:Additionally,4RCTshavebeenconductedbythedeveloperusing the prevention version of the BASIC program with multiethnic, socioeconomicallydisadvantaged families in schools, (Reid,Webster-Stratton,&Beauchaine,2001;Webster-Stratton,1998;Webster-Stratton,Reid,&Hammond,2001a).Resultsshowedthatchildrenwhosemothers received theBASICprogramshowed fewerexternalizingproblems,betteremotionregulation,andstrongerparent-childbondingthancontrolchildren.Mothersintheparent interventiongroupalso showedmore supportiveand less coerciveparenting thancontrolmothers(Reid,Webster-Stratton,&Hammond,2007).

Atleast6RCTsbyindependentinvestigatorswithhighriskpreventionpopulationshave found that the BASIC parenting program increases parents’ use of positive andresponsive attention with their children (praise, coaching, descriptive commenting) andpositivedisciplinestrategies,andreducesharsh,critical,andcoercivedisciplinestrategies(seereview(Webster-Stratton&Reid,2010).Thesereplicationswere“effectiveness”trialsin appliedmental health settings, schools and doctor’s clinical practices, not a universityresearch clinic, and the IY group leaders were existing staff (nurses, social workers andpsychologists)atthecentersordoctor’soffices(Perrinetal.,2014).Theprogramhasalsobeen found to be effective with diverse populations including those representing Latino,Asian,AfricanAmerican,andCaucasianbackgroundintheUnitedStates(Reidetal.,2001),andinothercountriessuchastheUnitedKingdom,Ireland,Norway,Sweden,Holland,NewZealand,Wales,andRussia(Gardneretal.,2006;Hutchingsetal.,2007;Larssonetal.,2009;Raaijmakersetal.,2008;Scott,Spender,Doolan,Jacobs,&Aspland,2001;Scottetal.,2010).These findings illustrate the transportability of the BASIC parenting program to otherculturesandcountries.

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EvidenceSupportingtheIncredibleYearsChildProgramsasanAdjuncttoIYParent

Programs

Treatment:Three RCTs have evaluated the effectiveness of combining the small-groupchild-training (CT)program toparent training (PT) for reducing conductproblemsand promoting social and emotional competence in children diagnosed with ODD/CD(Webster-Stratton&Hammond,1997;Webster-Stratton,Reid,&Hammond,2004).Resultsindicated that children who received the CT only condition showed enhancedimprovementsinproblemsolving,andconflictmanagementskillswithpeerscomparedtothose inthePTonlycondition.Onmeasuresofparentandchildbehaviorathome,thePTonlyconditionresultedinmorepositiveparent-childbehavioralinteractionsincomparisontointeractionsintheCTonlycondition.One-yearfollow-upassessmentsindicatedthatallthechangesnotedimmediatelypost-treatmentweremaintainedovertime.Moreover,childconductproblemsathomehaddecreasedovertime.Analysesoftheclinicalsignificanceofthe results suggested that the combined CT + PT condition produced themost sustainedimprovements in childbehavior at1-year follow-up. For this reason theCTprogramwascombinedwiththePTprograminarecentstudyforchildrendiagnosedwithADHD.Resultsreplicated the earlier studies with children with ODD (Webster-Stratton, Reid, &Beauchaine,2011).TherehasonlybeenoneRCTbyanindependentinvestigatoroftheCTsmallgroupprogram(Drugli&Larsson,2006). Prevention:One RCT has evaluated the classroom prevention version of the childprogram with Head Start families and primary grade classrooms in schools addressingeconomically disadvantaged populations. Matched schools were randomly assigned tointervention or control conditions. In the intervention classrooms teachers offered thecurriculum in biweekly sessions thoughout the year. Results from multi-level models ofreportsandobservationsof153teachersand1,768students indicatedthat teachersusedmorepositivemanagementstrategiesandtheirstudentsshowedsignificantimprovementsin school readiness skills, emotional self-regulation and social skills, and reductions inbehavior problems in the classroom. Intervention teachers showed more positiveinvolvement with parents than control teachers. Satisfaction with the programwas highregardlessofthegradelevels(Webster-Stratton,Reid,&Stoolmiller,2008).Asubsampleofparentsofindicatedchildren(duetohighlevelsofbehaviorproblemsbyteacherorparentreport) were selected and randomly offered either the combined parent program plusclassroom intervention, or classroom only intervention, or control group.Mothers in thecombined condition reported their children had fewer behavior problems and moreemotional regulation than parents of children in classroom only condition or controlcondition.Mothersinthecombinedconditionhadstrongermother-childbondingandweremore supportive and less critical than classroom only or control conditions. Teachersreportedmothersinthecombinedconditionweresignificantlymoreinvolvedinschoolandtheir children had fewer behavior problems. This study indicates the added value ofcombining a social and emotional curriculum for students in the classroom with the IYparentprograminschools(Reidetal.,2007).

Evidence Supporting Incredible Years Teacher Classroom Management (IY-TCM)

ProgramasanAdjuncttoIYParentPrograms

TheIY-TCMprogramhasbeenevaluatedinonetreatment(Webster-Strattonetal.,2004) and two prevention RCTs (Webster-Stratton et al., 2001a;Webster-Stratton et al.,2008)and fiveRCTsby independent investigators (seereview(Webster-Stratton,2012c).Research findings have shown that teachers who participated in the training usedmoreproactive classroom management strategies, praised their students more, used fewercoercive or critical discipline strategies, and placed more focus on helping students to

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problem solve. Intervention classrooms were rated as having a more positive classroomatmosphere, increases in child social competence and school readiness skills, and lowerlevelsofaggressivebehavior.InastudywhereBASICparentalonetreatmentconditionwascompared with a treatment condition that combined BASIC with the IY-TCM teachertraining programandwith thecombinationofBASICplus IY-TCMplusCTprograms theresults indicated that combing IY-TCM and/or CT programs with BASIC parent trainingresultedinenhancedimprovementsinclassroombehaviorsaswellasmorepositiveparentinvolvementintheirchild’seducation.ArecentstudyhasreplicatedthebenefitsoftheIY-TCMprogramaloneforenhancingparentinvolvementintheirchildren’seducation(Reinkeetal.,2014).

FactorsAffectingInterventionOutcomes

In addition to studying the specific trainingmethods (group support vs self-administeredvideo vs combined video plus group support) and the benefits of adding adjunctcomponents to the IY Basic Parenting Series programs (advance parenting, teacher andchild training), over the past 30 years a number of studies have been conducted todeterminemediator,moderators and predictors of outcomes. For example, parental andfamilial factors such as life stress, depression, marital adjustment, socioeconomic status,parental age, ethnicity and history of substance abuse (Beauchaine, Webster-Stratton, &Reid,2005;Hartman,Stage,&Webster-Stratton,2003;Reidetal.,2001;Webster-Stratton&Hammond, 1990), father involvement in treatment (Webster-Stratton, 1984a) andintergenerational family psychiatric history of antisocial behavior (Presnall, Webster-Stratton, & Constantino, in press ) have been analyzed in regard to treatment response.Additionally, child risk factors such as age, gender, psychiatric comorbidity, degree ofexternalizing problems, and comorbidity with attentional factors (Hartman et al., 2003)(Webster-Stratton, 1996; Webster-Stratton, Reid, & Hammond, 2001b) andanxiety/depression (Beauchaineet al., 2005)aswell asphysiologicalmeasuresof cardiacactivity and reactivity (Beauchaine et al., 2013) were also analyzed. In general resultsindicatedthebeneficialeffectivenessofIYparentprogramsirrespectiveoffamilyvariablessuch as depression, stress level, socio-economic status, and family psychiatric history.Counter to expectation, one study showedbetter long term child outcomeswith youngermothers and thosewith a history of parental substance abuse (Beauchaine et al., 2005).Moreover, the IY programs were equally effective regardless of child gender, age orcomorbiditywithattentionalproblems(Hartmanetal.,2003)oranxiousdepressionscores(Beauchaineetal.,2005).However,critical,harshandineffectiveparentingbothpredictedandmediatedoutcomeat1-yearfollow-up(Beauchaineetal.,2005)andlong-termfollow-up (Webster-Strattonetal.,2010).These findingssuggest that specificparentinggoalsbeachieved before the parent program is discontinued, or that parents who still have highlevels of coercive parenting (despite improvements from baseline) be selected forcontinued treatmentwith theadvanceparentprogramuntil therapeutic effectivenesshasbeenachieved.

Implementationwithfidelity

Animportantaspectofaprogram’sefficacyisfidelityinimplementation.Indeed,iftheprogramisnotrigorously followed(forexample, ifsessioncomponentsaredispensedwith,programdosagereduced,necessaryresourcesarenotavailable,orgroupleadersnottrained or supported with accredited mentors), then the absence of effects may beattributednottotheinefficacyoftheprogrambuttoalackoffidelityinitsimplementation(Hutchingsetal.2008).RecentresearchwiththeIncredibleYearsBASICparentingprogramshowsthatimplementationwithahighdegreeoffidelitynotonlypreservestheanticipated

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behavior changemechanisms but is predictive of behavioral and relationship changes inparents, which, in turn, are predictive of social and emotional changes in the child as aresultoftheprogram(Eamesetal.,2010).

Oneimportantaspectthatfacilitatestheapplicationofaprogramwithfidelityisthestandardization of program content, structure, processes, methods and materials. InIncredibleYears,allcomponentsrelatingtotheimplementationoftheprogramcontentaredescribed in detail in DVDs and manuals, which also lay out the basic theoretical andempiricalelementsofeachpartof theprogram.ForWeisz(Weisz,2004),oneofthemainadvantagesof the IncredibleYearsprograms, fromthepointofviewofclinicalpractice, ispreciselytheprogram’saccessibilityforclinicaluse,alongwithitsappealingnatureandlowabandonmentrates.

Inthecontextofimplementationwithfidelity,thetrainingandsupervisionofgroupleaders warrants great attention (Webster-Stratton, 2004). First, carefully selected andmotivated group leaders receive 3 days of training by accreditedmentors before leadingtheirfirstgroupofparentsorteachers.Thenitishighlyrecommendedtheycontinuewithongoing consultationwith IY coaches and/ormentors as theyproceed through their firstgroup. They are encouraged to start videotaping their sessions right away and to reviewthese videoswith their co-leaderusing the group leader checklist andpeer review forms(Webster-Stratton,2004). It is also recommended that they send thesevideos foroutsidecoachingandconsultationbyanaccreditedIYcoachormentorassoonaspossible.Groupleadersfindthisvideoreviewimmenselyhelpfulandsupportive.

Theprocessofgroupleaderaccreditationisdemanding,involvingtheleadershipofat least two complete groups, video consultation, and a positive final video groupassessmentbyanaccreditedmentorortraineraswellassatisfactorycompletionofgroupleader group session protocols andweekly participant evaluations. This process ensuresthatleadersaredeliveringtheprogramwithfidelity,whichincludesbothcontentdelivery(requirednumberofsessions,vignettes,roleplays,brainstorms)andtherapeuticskills.Thewholeprocessofcoaching,consultation,andaccreditationofnewgroupleaders iscarriedoutbyanetworkofnationalandinternationalaccreditedIYmentorsandtrainers.ArecentRCT has shown that providing group leaders with ongoing consultation and coachingfollowing the 3-day workshop leads to increased group facilitator proficiency, programadherenceanddeliveryfidelity(Webster-Stratton,Reid,&Marsenich,2014).

PlanningandImplementationofIYProgramsAccordingtoRiskLevelofPopulation

TheBASICparentprogram(baby,toddler,preschoolorschool-ageversion)isconsideredamandatory or a “core” component of the prevention intervention training series. TheADVANCE program isoffered inaddition to theBASICprogram for selectivepopulationssuch as families characterized as depressed or with considerable marital discord, child-welfarereferredfamilies,orfamilieslivinginshelters.Forindicatedchildrenwithbehaviorproblemsthatarepervasive(i.e.,apparentacrosssettingsbothathomeandatschool)itisrecommendedthatthechilddinosaurtrainingprogramand/orteachertrainingprogrambeofferedinconjunctionwiththeparenttrainingprogramtoassurechangesatschoolordaycare.ForindicatedchildrenwhoseparentscannotparticipateintheBASICprogramduetotheir own psychological problems, delivery of both the child and teacher program isoptimal.

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Again the pyramid is used to depict the levels of intervention according to risk level ofpopulations.Asseen in this figure,Levels1and2are the foundationof thepyramidandrecommenda seriesofprograms that couldbeoffereduniversally to all parentsof youngchildren(0-6years).Theseprogramscouldbeoffered inpediatrician’soffices,HeadStartprograms,daycarecenters,preschoolsandelelmentaryschools.Thegroupformatisacostefficient way of disseminating information to large numbers of people as a strategy tooptimize positive parent-child interactions and to strengthen children’s social andemotionalcompetenceandschoolreadinesssothattheyarereadytostartthenextphaseoftheireducation.

Once children are in day care or preschool, providing universal supports for allchildrenatthisyoungageincludesenhancingthecapacityofdaycare,preschool,andHeadStartteacherstoprovidestructured,warm,andpredictableenvironmentsatschool.Thus,level 2 also involves training all early childhood teachers in effective classroommanagement strategies using the IY-TCM Program. After this training is completed andteachers also have the opportunity to receive training to deliver the classroom childdinosaur curriculumas auniversal social skills intervention.This includes threedifferentsetsoflessonplansforpreschool,kindergartenandgrades1and2.Ideallychildrenreceivethis curriculum for three subsequent years, resulting in a strong emotional and socialfoundationby the time theyaresevenyearsold.Thissocialandemotionalcompetence istheorized to contribute to higher academic competence as children progress throughschool.

Level3istargetedat“selective”orhighriskpopulations.Thesearepopulationsthat

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aresocio-economicallydisadvantagedandhighlystressedbecauseofincreasedriskfactorssuch as parental unemployment, low education, housing difficulties, single parenthood,poor nutrition, maternal depression, drug or alcohol addiction, child deprivation, newimmigrant status, or lack of academic preparedness for school. These economicallydisadvantagedparentswouldbenefitfromthecompletebaby,toddler,andearlychildhoodparentprogrambecauseofthesupportprovidedinthegroups,thehopeforchangeshownto them by group leaders, as well as their experiential learning that despite economicobstaclestheycanprovidethebestearlyyearsofemotional,socialandcognitiveparentingpossible for their children. In addition, the teachers and care providers of these childrencouldreceivetheIY-TCMprogramsothattheyareskilledatmanagingclassroombehaviorsproblems, which are exhibited at higher rates in this population. Lastly, 3-8 year oldchildreninthesefamilieswouldbenefitfromtheclassroomDinaSocialandEmotionalSkillsCurriculum at least twice a week year round. This investment in building the social andemotional abilities in the first eightyearsof life for thesevulnerable children canhelp tobreaktheintergenerationaltransmissionofdisadvantage.

Level 4 on the pyramid is targeted at “indicated populations”, where children orparents are already showing symptoms ofmental health problems. For example, parentsreferred tochildprotectiveservicesbecauseofabuseorneglect, fosterparentscaring forchildren who have been neglected and removed from their homes, or children who arehighly aggressive but not yet diagnosed as having ODD or CD. As can be seen on thepyramid,thislevelofinterventionisofferedtofewerpeopleandoffersalongerandmoreintensive parenting program by a higher level of trained professionals. These parents orcaregiverswould complete the entire age appropriateBASICparentingprogram followedbytheADVANCEprogram.

The teachers of these children should receive the IY-TCM program and offer theclassroom Dina Classroom Social, Emotional and Problem Solving Skills curriculum. Inaddition to this Dina classroom curriculum, children with symptoms of externalizing orinternalizingproblemsorADHDaretargetedtobepulledoutofclasstwiceaweekforthesmallgrouptherapeuticDinosaurprogramdeliveredbyschoolpsychologistsorcounselorsorspeciallytrainedsocialworkersorspecialeducationteachers.Thesechildrenwillmeetin small groups (4-6 children) to get extra coaching and practice with social skills,emotional regulation, persistence coaching and literacy, and problem solving. This willreinforce the classroom learning of this program and will send these children back to aclassroomwherepeersunderstandhowtorespondmorepositivelytotheirspecialneeds.Inotherwordsthewholeclassroomcommunityhaslearnedsolutionstohowtorespondtoapeerwhomaybeaggressiveoronewhoissad,withdrawnorlonely. Level 5 is themost comprehensive intervention, addressingmultiple risk factorsandisusuallyofferedinmentalhealthclinicsbytherapistswithgraduateleveleducationinpsychology, social work, or counseling. One of the goals of each of the prior levels is tomaximize resources andminimize the number of childrenwhowill need these time andmore cost intensive interventions at level 5. At a minimum the parents will receive theentireBASICandADVANCEcurriculum for24-28weekswhile thechildrenattend2-hourweekly therapeutic small group child Dina groups at the same time. Therapists dovetailthesetwocurriculaandkeepparentsandteachersfullyinformedoftheskillschildrenarelearningintheirchildgroupssothattheycanreinforcetheseathomeorintheclassroom.Additionally, if parents need individual coaching in parent-child interactions this can beprovided in the clinic setting or in supplemental home visits using the home coachingprotocols. Child and parent therapists work with parents to develop behavior problemplansandconsultwithteachersinpartnershipstocoordinatetheirplans,goalsandhelpfulstrategies.Successfulinterventionsatthislevelaremarkedbyanintegratedteamapproach

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with clear communication among all the providers and adult caregivers in the varioussettings where these children spend their time. Ideally mental health agencies wouldembody these services within schools which allows for less stigmatization for parents,greatercoordinationwithteachersregardingbehaviorplansandmorefrequentlypulloutgroupsforchildren.Conclusion

Future directions for research on IY programs should include evaluatingways topromote the sustainability of results such asby targetingparentswhosebaselineorpostintervention parenting practices are particularly harsh or ineffective with additionalresourcessuchasofferingagreaternumberofsessions,additionalprogramadjunctssuchas IY Advance Program, or IY Child Program and ongoing booster sessions. Similarlyresearch concerningmatching children to appropriate treatment combinations is needed.Forexamplechildrencouldbeassignedtotreatmentprogramconditionsaccordingtotheirparticular comorbidity combinations. Our research suggests that children with ODD arecomorbid for other diagnoses such as ADHD, depression or anxiety, language delays andAutism. Spectrum Disorder. Our initial findings suggest that children scoring high onAttention Problems or with ADHD will fare better when IY-TCM or CT components areaddedtothePTprogram.Furtherresearchisneededforidentificationofchildrenforwhomthe current interventions are inadequate. Finally our newest IY baby program, AttentiveParenting program and Autism program are in need of RCTs to determine theireffectiveness.

At a time when the efficient management of human and economic resources iscrucial, the availability of evidence-based programs to parents and teachers should formpart of the public healthmission. While the IY programs have been shown in dozens ofstudies to be transportable and effective across different contexts worldwide,unfortunately, barriers to fidelity delivery impede the possibility for successful outcomesfor parents, teachers and children. The lack of sufficient funding has led to IY programsbeing delivered by group leaders without adequate training, sufficient support, coachingand consultation, andwithout agencymonitoring or assessment of outcomes. Frequentlythe programs have been sliced and diced and components dropped in order to offer theprogram in a dosage that can be funded. Few agencies support their group leaders tobecome accredited, and the program is often not well established enough to withstandstaffing changes in an agency. Thus, the initial investment that an agencymaymake topurchase theprogramand train staff is often lost over time. Ifwe thinkof disseminatingevidence- based programs like constructing a house, it is as if the contractors hiredelectricians and plumberswhowere not certified, disregarded the architectural plan andused poor quality, cheaper materials. Under these conditions, the building will not bestructurallysound.Justlikebuildingastablehouse,itisimportantthefoundationandbasicstructure fordeliveringevidence-basedprogramsbestrong. Thiswill includepicking theright evidence-based program for the level of risk of the population and developmentalstatus of the children and adequately training, supporting and coaching group leaders sothey become accredited and providing quality control. In addition, providing adequatescaffoldingthroughtheuseoftrainedandaccreditedcoaches,mentorsandadministratorswho can champion quality delivery will make all the difference. With a supportiveinfrastructuresurroundingtheprogram, initial investmentswillpayoff intermsofstrongfamily outcomes and a sustainable intervention program that canwithstand staffing andadministrativechanges.

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