767880

research-article2018
PPSXXX10.1177/1745691618767880KazdinTreatment of Aggressive and Antisocial Child Behavior Services

Perspectives on Psychological Science

Developing Treatments for Antisocial 1­–17

© The Author(s) 2018
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DOI: 10.1177/1745691618767880
https://doi.org/10.1177/1745691618767880

Trials and Uncontrolled Tribulations www.psychologicalscience.org/PPS

Alan E. Kazdin
Department of Psychology, Yale University

Abstract
The article describes my research on the development and evaluation of psychosocial treatments for children who
engage in extremes of antisocial behavior (e.g., aggression, property destruction, theft). I begin with my “story” of
how the focus on interventions started as I worked in various settings (rehabilitation facilities, schools, hospitals, and
outpatient clinical services) and with children, adolescents, and adults. The main stream of treatment research and
findings with antisocial child behavior is highlighted along with tributaries that led naturally from the outcome research.
Our trials are complemented by tribulations that apply to evidence-based psychosocial interventions more broadly.
Most individuals in need of psychological services in the United States and worldwide receive no treatment. Much
can be done right now with novel models of treatment delivery that draw on multiple disciplines (e.g., public health,
business, entertainment, economics, robotics and artificial intelligence, and law and social policy). More research on
interventions that do not or cannot reach most people in need is quite limited in value to me. Finally (and belatedly)
my attention has turned to ways of exerting impact, and for that, evidence-based interventions are necessary but hardly
sufficient.

Keywords
treatment development, child antisocial behavior, treatment delivery

The major focus of my work has been on developing
and evaluating psychological interventions. The work
has encompassed diverse treatments (e.g., imagery-
based therapy, cognitively based interventions, token
economies), populations (e.g., children, adolescents, and
adults; individuals institutionalized because of severe
intellectual disabilities or psychiatric disorders), and set-
tings (e.g., education and special education classrooms,
psychiatric hospitals, rehabilitation facilities, the home,
and outpatient clinical services). The need to develop
treatments that are evidence-based is obvious and
slightly embarrassing to make explicit, given that this
has not always been a priority in clinical psychology and
other mental-health professions. Apart from the obvious
need for effective interventions, treatment research has
been a useful platform to address basic as well as applied
questions about clinical problems and contextual influ-
ences (e.g., family characteristics, context) that affect
both the problems and effects of interventions.
In psychology, treatment and other types of applied
research often are frowned on and demeaned, a
characteristic that has been recognized throughout the
history of psychology in America (e.g., Ladd, 1894;
Tyler, 1973). This is interesting because, historically,
application emerged early (e.g., in Gestalt psychology,
functionalism, behaviorism; e.g., Hergenhahn & Henley,
2013). Priority has been and continues to be accorded
to basic science, conceptual models, and elaborating
the nature of phenomena, regardless of whether there
is any application at the moment. That is fine as long
as two provisos are added. First, one can begin at any
place on the basic-applied (bipolar) dimension and
move back and forth. Where one begins is not as criti-
cal as where one ends; that is, with a deeper under-
standing of the phenomenon of interest and, if needed,
what can be done to control, alter, or improve some
facet of that. Second, there are calamitous individual
Corresponding Author:
Alan E. Kazdin, Department of Psychology, Yale University, 2
Hillhouse Ave., New Haven, CT 06520-8205
E-mail: alan.kazdin@yale.edu
2 Kazdin
and social problems that are part of the human condi-
tion. Psychiatric disorders, broadly conceived, among
children, adolescents, and adults are among them. The
challenge for us as scientists is whether and how the
content and methodological approaches of our disci-
pline and science more generally can make a genuine
difference to individuals, various groups, and to society
at large. In that regard, it is noteworthy that psychologi-
cal science is actively involved in many areas in which
there are important applications (e.g., space travel,
robotics, self-driving cars, climate change, education,
child rearing, rehabilitation of veterans, law and the
courts, sports, and many more).
This article focuses on my primary line of applied
research: the treatment of children and adolescents with
extremes of aggressive, antisocial, and violent behavior.
I review the impetus for the focus on interventions, the
findings from a program of research that has identified
two effective treatments, and why I do not want to do
that work anymore. We want evidence-based treatments
and to do all that we can to deploy science to reduce
the burdens of mental illness. Yet my work, in keeping
with what is standard work for much of my cohort, is
neglecting arguably the most critical treatment problem.
Permit me to not state that problem explicitly at this
point with the desperate hope that piquing curiosity
may lead an elite few to actually read further.
Impetus for Research on Interventions
Although a variety of influences contributed to my
intervention focus, a few challenges played a very direct
role. At various points in my career, I have been in a
position in which there is a need to change behavior
and adaptive functioning of individuals who were hav-
ing difficulties in getting along with others, were com-
pletely unmanageable at home or at school, and who
could not stay out of trouble (e.g., at school, with the
law). The first occasion occurred in graduate school
(Northwestern University), where I began an initial
interest, in keeping with the zeitgeist, of placing psy-
chotherapeutic interventions on firm empirical footing.
Behavior therapy was emerging along with new jour-
nals, and controlled studies of a variety of treatments
began to appear. Within the context, my advisor, noting
my budding interest in behavior change, suggested that
I explore a part-time job opportunity at a nearby facility
for children, adolescents, and adults with a range of
emotional and behavioral problems and intellectual
disabilities.
At the job interview, the director, a clinical psycholo-
gist, asked me to work at the facility part-time and make
therapeutic changes that would help individual clients,
beginning with adolescents and adults in the sheltered
workshop part of the facility, so they could be placed
in jobs in the community. I weepily confessed and
threw myself on the mercy of the court by admitting I
knew nothing about the clientele or the problems they
evinced, let alone how to have any influence on them.
His reply was stunning, discomforting, and welcoming.
He noted that the facility included expert professionals
from all the mental-health professions as well as coun-
seling, rehabilitation, and nursing, but no one seemed
to know what to do to have concrete impact on prob-
lem behaviors or skills that the clients needed. I again
reiterated that what I brought to the setting would be
ignorance, heavily seasoned with a thorough lack of
expertise, which only seemed to strengthen his resolve.
After more interviewing, he walked me to an empty
office far away from his but near the portion of the
facility where he wanted me to work. He pointed to
the empty chair in a fully equipped but plainly unoc-
cupied office and asked me to take the job and sit there
for as many weeks or months as it took to learn what
I needed and then when ready to change behaviors of
the clients on the “floor” (a vast room with many indi-
viduals, staff, work stations, and more) that would put
them in a position for community placement. I took the
job part-time, which accommodated my graduate school
schedule, and spent the time in the office for several
weeks. Eventually, I did what the director asked.
Many promising interventions were emerging in
behavior therapy. From my office, I wrote to key leaders
at the time, read their articles on behavior change, and
began to learn the emerging literature in applied behav-
ior analysis (i.e., the application of operant condition-
ing toward therapeutic and other applied ends). I also
called some of these leaders to ask for more details
than their articles provided about implementation. It
was during this time that I began to study intensively
both the content and methods (single-case experimen-
tal designs) of the approach.
After a few months, I made some modest efforts to
work with the staff directly in charge of the clients. We
intervened and evaluated programs with individual cli-
ents to address their specific problem areas (e.g., wildly
explosive tantrums, extreme social withdrawal, seeming
inability to accept change in activities or tasks, loud
and constant negative comments and complaining).
This required the methods of behavior analysis (e.g.,
developing reliable objective measures—none of that
self-report business, establishing measurement reliabil-
ity, conducting observations) and evaluating the impact
of using the rigorous yet flexible methods of single-case
designs (e.g., continuous assessment over time, altera-
tion of conditions to test for causal relations, iteration
of interventions when interventions were not having
the desired effect; see Kazdin, 2011a).
Treatment of Aggressive and Antisocial Child Behavior Services 3
Very soon I was working daily with the staff on the
floor who implemented the procedures and I was infre-
quently in my office. We started to make changes in
the behaviors of many clients. Some of the modest
projects and demonstrations even saw light of day (e.g.,
Kazdin, 1971; Kazdin & Polster, 1973). I began to
explore some procedures and their nuances to under-
stand how they worked and how to improve their
impact (e.g., Kazdin, 1972b, 1973a, 1973b). This eventu-
ally led to review articles on various techniques (e.g.,
Kazdin, 1972a, 1973e; Kazdin & Bootzin, 1972), and
even some books (e.g., Kazdin, 1975, 1977b, 1978).
This job lasted for 3 years and had enormous influ-
ence on my later and present work. The challenge of
that job: what could be done to effect change in a
reliable and marked fashion? The substantive thrust of
operant procedures and the methodology proved
extremely helpful. Group designs and the focus on
means, statistically significant differences, and effect
sizes were hardly useful or even relevant, when, for
example, one is called on to change the behaviors of
a 16-year-old male, who constantly swore out loud, said
nasty things to women all day, and had outbursts from
what seems the slightest or no real provocation. It
would be wonderful to understand the underpinnings
of these behaviors but of course that is no guarantee
that one can then make the needed changes. Yet, absent
the knowledge, could we change the behaviors and
attitudes of that adolescent? In that case, we could. Yes,
I had my failures as well and understanding these gen-
erated ideas of what might be done differently to
improve treatment effectiveness (e.g., Kazdin, 1973e).
A second factor that influenced my intervention focus
was an extension of the previous experience. A super-
intendent of a local school district learned of the work
I was doing at the facility highlighted previously and
asked me to implement and evaluate similar interven-
tions on a larger scale in several school classrooms. Here,
too, there was some accountability with the job where
the metric was behavior change (disruptive behaviors,
performance of academic tasks) of “problem students”
in classrooms. The most dramatic introduction to my first
student was a brilliant 10-year-old boy, who allegedly
walked on top of all the desks (in a U-shaped arrange-
ment in class) during a lesson, stepped on the papers
and classwork of his classmates in the process, spoke
very loudly while he was walking as the teacher was
trying to present a lesson, and then went to the front of
the room and “fondled the teacher.” I believed none of
this, so I observed by sitting in the back of the room for
a couple of days. Everything was true exactly as stated.
Beyond any one child, the overall mandate for this
position was more accountability. What could be done
to effect change? Beyond workshops for teachers on
some of the uplifting usual cliché themes (e.g., empow-
erment, setting limits), could the teachers and I work
together in ways that had direct impact on classroom
and academic child behavior and could I demonstrate
that? Here, too, variations of procedures I had been
working with and the methodological demands (e.g.,
operational definitions of the goals, ensuring they were
reliably assessed, evaluating intervention effects over
time) were valuable. I worked in several classrooms
helping to design and implement interventions for indi-
vidual students as well as for entire classrooms. After
this project, I continued to work in schools and to con-
duct studies to improve the impact of behavior-change
techniques as well as to better understand how they
worked (e.g., Kazdin, 1973c, 1973d, 1974a, 1977a; Kazdin
& Forsberg, 1974; Kazdin & Geesey, 1977; Kazdin &
Mascitelli, 1980; Kazdin, Silverman, & Sittler, 1975).
By the third occasion, I was at midcareer, and I moved
from an academic psychology department to a psychiatry
department at a medical school (Western Psychiatric
Institute and Clinic, University of Pittsburgh School of
Medicine). I was placed in charge of an inpatient service
for children (Children’s Psychiatric Intensive Care Ser-
vice). As the name suggests, children were admitted
because of severe clinical dysfunction and often were
brought to the hospital by ambulance or police and on
a gurney. The main clinical problem leading to admission
was extreme aggressive and antisocial behavior. As a
preview of coming attractions, my first case was a
12-year-old boy who stabbed his father (life-threatening
injury) while the father was raping his mother, who was
screaming for help. The boy grabbed a kitchen knife,
ran into the bedroom, sliced the back of the father’s leg
from just a little below the back of the knee to the bot-
tom of the tendon near the ankle, and ran out of the
house. The boy then stole a car and crashed it when the
police finally caught up with him. This behavior was part
of a long string of aggressive and violent acts, but this
one led to immediate hospitalization.
The department chairman at the time noted that no
one knew what to do (i.e., how to treat children with
patterns of extreme aggressive and antisocial behavior)
and that it would be very important to commit my
efforts and resources of the setting to that problem. The
locked inpatient service included staff representing
multiple disciplines (child psychiatry, psychology, social
work, nursing, rehabilitation, and education). On the
service, we tried many reasonable treatment options
(e.g., various medications, social skills training, tradi-
tional individual and group therapy sessions, and a
structured milieu) and occasionally even allowed par-
ents to try options they viewed as reasonable (e.g.,
exorcism) and that had no less evidence than interven-
tions we were trying. We decided to develop and
4 Kazdin
evaluate treatments for the children. That led to a
3-decade research program with a central stream and
many tributaries. This article is about that line of work.1
Overall, the three influences I have highlighted had
obvious commonalities, namely, could anything be
done to make a difference, where “make a difference”
meant something visible that affected functioning in
daily life? Virtually all the work was with individuals,
one at a time, in light of the individual problem domains
or deficits of each person and the contexts in which
they were to function. Happily, there were guidelines
from procedures in basic research (experimental analy-
sis of behavior) and a methodology (single-case
designs) that permitted both a clinically relevant and,
as needed, rigorous evaluation. In addition, the bar was
high sometimes but also clear. For example, in one of
my jobs, the challenge was to reduce the head-banging
of institutionalized adolescents. In this context, reduc-
ing head banging from 90 to 60 times per hour might
be dramatic and “significant” statistically, but is not of
much help in reducing the heavy medication used to
sedate these individuals and keeping the adolescents
out of straightjackets all day. Being “close” to the goal
can be encouraging, but it is very clear when one
misses the target and more is needed. 2
Research From Treatment Program
Overview of the sample
On the inpatient service, the interventions were
designed for children referred for aggressive, antisocial,
and violent behavior and who could not function in
their homes or at school. The main psychiatric diagnosis
of these children was conduct disorder (American Psy-
chiatric Association, 2013), which refers to a broad pat-
tern of rule-breaking behaviors such as initiating fights,
destroying property, being physically cruel to people
or animals, stealing from others, forcing someone into
sexual activity, setting fires, lying, being truant, running
away, and bullying. These are not single instances of
one or two behaviors but include multiple behaviors
that continue in an ongoing way (Hill & Maughan, 2001;
Kazdin, 1995b; National Institute for Health and Medical
Research, 2005). As a clinical and social problem, con-
duct disorder has some critical features, including
•• A relatively high prevalence rate (conservatively,
between 2% and 9% of youth, depending on the
age range of the child or adolescent);
•• Presence of other disorders that co-occur, espe-
cially attention deficit-hyperactivity disorder,
depression, and anxiety;
•• A high rate of clinical referrals (e.g., 33%–50% of
child cases referred for outpatient treatment);
•• Untoward long-term outcomes for such children
in adulthood (e.g., approximately 67%–80% are
likely to meet criteria for a psychiatric disorder
in adulthood);
•• Untoward consequences for others including sib-
lings, peers, parents, teachers, as well as strangers
who are targets of antisocial and aggressive acts;
and
•• Exorbitant monetary costs as youths traverse a
variety of services and settings (e.g., emergency
room visits, special education, foster placement,
and mental health, juvenile justice, and social
services) over the course of their lives.
Need for two treatments
An intervention that seemed very promising for these
children was parent management training (PMT),
derived at the time from two bodies of research: (a) the
seminal conceptual and empirical work of Patterson
and his colleagues that focused on coercive sequences
of parent-child interactions and how they promote
aggressive behavior in the home and how altering these
sequences can change that behavior (e.g., Patterson,
2016; Reid, Patterson, & Snyder, 2002) and (b) advances
in applied behavior analysis on how to change behavior
(e.g., use of establishing operations, functional analysis,
differential reinforcement schedules; e.g., Cooper,
Heron, & Heward, 2007; Kazdin, 2013). These lines can
be translated into multiple concrete techniques to alter
both parent and child behavior.
PMT focuses on changing parent behavior and how
parents interact with their children. The treatment uses
learning-based procedures to develop behavior and
includes modeling, prompting and fading, shaping,
positive reinforcement, practice and repeated rehearsal,
extinction, and mild punishment. Treatment sessions
use many of the same behavior-change techniques on
parents that parents will use with their children to
develop prosocial behavior. Parents are seen in the
sessions; occasionally children are brought in to review
and practice specific procedures with the parents.
Treatment sessions can be characterized as action ori-
ented, with most of the time spent modeling and prac-
ticing skills to achieve desired performance in the
parent. Perhaps a useful way to characterize the pro-
cedure is to recall the difference between a magician
and a psychologist. A psychologist pulls habits out of
rats. PMT is not about rats but it is about repeated
practice and building habits.
PMT was a not a viable option for many children on
the inpatient service because parents experienced some
limiting condition (e.g., major psychiatric or substance
abuse disorder, in and out of prison, selling illicit drugs,
Treatment of Aggressive and Antisocial Child Behavior Services 5
alcohol, or sex from their homes, training their child
how to engage in antisocial behavior such as stealing).
In some cases, children were taken away from their
parents (e.g., due to physical or sexual abuse or having
dangerous living environments). In cases in which no
adult was readily available, we needed a treatment for
the child that did not require parent participation.
For these children, we developed cognitive problem-
solving skills training (PSST), which focuses on cogni-
tive processes, a broad class of constructs that pertain
to how individuals perceive, code, and experience the
world. Individuals who engage in conduct problem
behaviors, particularly aggression, show distortions and
deficiencies in various cognitive processes (e.g., Hubbard,
McAuliffe, Morrow, & Romano, 2010; Lochman, Powell,
Whidby, & FitzGerald, 2012). Examples include generat-
ing alternative solutions to interpersonal problems (e.g.,
different ways of handling social situations), identifying
the means to obtain particular ends (e.g., making
friends) or consequences of one’s actions (e.g., what
could happen after a particular behavior), making
misattributions to others of the motivation for their
actions, perceiving how others feel, and expectations
of the effects of one’s own actions. Deficits and distor-
tion among these processes relate to teacher ratings of
disruptive behavior, peer evaluations, and direct assess-
ment of overt behavior. Our program initially drew
heavily on the pioneering work of Shure and Spivack
(e.g., Shure, 1992; Spivack & Shure, 1982) in the context
of young children and prevention programs in the
schools.
In PSST, the child is trained to engage in a sequence
of steps or self-statements designed to help him or her
look carefully at the demands of the situation, consider
what might be alternative positive (rather than aggres-
sive) ways of responding, consider the consequences
of different actions, select one of those responses, and
act out the solution in a role-play situation in the treat-
ment session. The therapist models how to apply the
self-statements to situations (e.g., being bullied, being
threatened, and being asked to steal something by a
friend) the child may encounter and how to complete
the sequence of steps. PSST sessions include intensive
practice and role playing in using the steps and in
responding to increasingly more complex and provoca-
tive social situations in the session. There is also a
graded and increasingly realistic series of “homework”
assignments in which the steps are applied by the child
at home, at school, and in other settings.
PMT and PSST have some common components,
including the emphasis on repeated practice of the
desired behaviors, heavy use of modeling and other
antecedents (e.g., prompts, establishing operations),
praise by the therapists to develop the behavior, and
implementation of techniques in everyday settings. For
both treatments, we began to develop a manual (spe-
cific guidelines for what therapists ought to do and say
for each session and options for handling obstacles)
and immediately started pilot testing the procedures
with parents and children on the inpatient service. The
pilot testing was an iterative process designed to estab-
lish feasibility and acceptability. First and foremost, the
PSST sessions had to be engaging, fun, and perhaps
even gamelike, just to get children to the sessions. On
the inpatient service, it was possible for a child to be
asked to come to a treatment session, only to give an
obscene gesture and a stark statement perfectly consis-
tent with that gesture, in a situation in which a simple
“no thank you” would have been perfect. Effectiveness
presupposes that someone comes to the treatment, so
that was our early emphasis! After about 12 or so
months of applying and revising PMT and PSST treat-
ment, the number of treatment changes began to
approach asymptote and were minor (better phrasing,
changing of examples and games) so we moved to
more formal empirical evaluations (see Kazdin, 2005).
Randomized controlled trials
My intervention research before this point included
both group designs (randomized controlled trials
[RCTs]) and single-case experimental designs, quite dif-
ferent in assessment, hypothesis testing, and data analy-
ses. All the evaluations that followed now were RCTs.
Apart from the obvious feature of assigning participants
to conditions randomly, the designs also required
•• Specifying inclusion and exclusion criteria for
selection of cases (participants);
•• Devising treatment manuals to specify exactly
what the treatments were, in our case on a session-
by-session basis;
•• Monitoring and documenting the proper execu-
tion of treatment daily (treatment integrity);
•• Ensuring and documenting completion of lengthy
assessments before, during, and after treatment;
and
•• Retaining families in treatment (minimizing can-
cellations and not showing up, dropping out).
With clinical samples, or at least ours, invariably
there were extenuating circumstances that had, as a
common final pathway, obstacles in conducting treat-
ment and retaining someone in treatment. Before treat-
ment, difficult family circumstances (e.g., multiple
stressors, conflict with partners or relatives, receipt of
social assistance) portend obstacles. During treatment,
any one or more of these might emerge and often did:
6 Kazdin
revelation of child or sexual abuse, domestic violence,
a parent selling drugs, parental prostitution in the
home, a parent removed from the home (prison, hos-
pitalization), a parental crisis as a result of clinical dys-
function, a child expelled from school, parental
separation and divorce, parental suicide attempt or
completion, and, believe it or not, much more. We
decided early that if there was a conflict between exe-
cution of the research and clinical care (addressing a
problem, issue, or focus outside of the treatment man-
ual), we would always give priority to clinical care and
treat or refer the case outside of the project.
In short, conducting an RCT belies what might be
involved. Early in my career, I conducted RCTs in a
university setting in which most of the “clients” were
college students, seen for a brief period, and the goal
was to test novel treatments to reduce fear and avoid-
ance (e.g., Kazdin, 1973a, 1974b, 1974c). In the context
of clinical work, now the studies were much more
intricate and required mobilizing a dedicated staff with
high levels of specialization in delivering psychother-
apy; contending with multiple child and family prob-
lems and crises; monitoring recruitment and patient
flow through intake, treatment, and all assessments;
and expertise in tracking, feedback systems, and data-
base management. Each RCT required approximately 3
to 5 years to complete from recruitment to end of data
analyses, unless there was follow-up, which added a
year or two. In addition, the trials are very expensive,
mostly because of staff costs. Typically, families cannot
afford treatment, and any insurance reimbursement that
might be available cannot begin to cover the real costs
of providing services. The many trials could not have
been done without grants to fund individual studies as
well as more enduring funds from various government
agencies and private foundations. 3 Graduate students
and undergraduates might participate in training experi-
ences related to treatment or assessment, yet in light of
the time commitment for training and executing the
treatment and the complexities of handling the clinical
issues that emerged in contact with the families, a dedi-
cated employed staff has been essential.
Treatment outcome research
After piloting and devising the treatments and securing
initial funding, we began to carry out the trials to see
whether treatments in fact had any impact in child
behavior at home and at school. In separate studies,
PMT and PSST were compared with a relationship-play
therapy condition, a treatment commonly used in the
treatment of children. The treatments were significantly
better than the comparison conditions. We continued
improving on the treatment and asking additional
research questions. We began the work on an inpatient
clinical service; therapy was carried out while we had
the child on the patient service and saw the child in
PSST (if no parent could participate) or with the parents
whom we prepared for the child’s discharge (e.g., with
weekend visits of the child in which the parents could
try out their new skills on an abbreviated scale). It
became more feasible to carry out our work entirely
on an outpatient basis. I now directed an outpatient
clinic (Child Conduct Problem Clinic) in the same psy-
chiatry department and received referrals for children
primarily with problems of aggressive and antisocial
behavior. We continued the two treatments because it
still was the case that for some families, participation
of the parent was not feasible.
The clinic continued for several years, including a
move to my present position (Yale University), where
the research has been in place for 28 years (Kazdin,
2011b). We have now evaluated versions of both PMT
and PSST in multiple RCTs (please see Table 1), begin-
ning with basic comparisons of PMT and PSST. Overall,
these are the main findings:
1. PMT and PSST alone each produce reliable and
significant reductions in antisocial behavior and
increases in prosocial behavior among children
(ages 5–15). The combination of the two treat-
ments produces greater outcome benefits than
either treatment alone, but it is not clear whether
or when the added cost of providing both inter-
ventions (two therapists, twice the number of
sessions) is warranted.
2. The benefits of treatment are evident in perfor-
mance at home, at school, and in the community,
both immediately after treatment and up to a
1-year follow-up assessment; these benefits are
evident not only in indices of statistical signifi-
cance but also in indices of clinical significance
(e.g., return of symptom levels to within sex- and
age-based normative data for nonclinical
samples).
3. Improvements are not plausibly explained by the
passage of time, repeated contact with a thera-
pist, or nonspecific (common) treatment factors
associated with participation in treatment, given
comparisons of treatment with other intervention
and control conditions.
4. The effects of treatment have been obtained with
both inpatient and outpatient cases.
5. Level of parent and family stress and family
adversity (e.g., on social assistance, interpersonal
conflicts at home, domestic violence) influence
participation in treatment and treatment out-
come. Adding a treatment component to address
Treatment of Aggressive and Antisocial Child Behavior Services 7

Table 1.  Main Studies to Evaluate Treatment Outcome and Therapeutic Change

Investigation Sample, design, and objective Main findings

Kazdin, Esveldt- Inpatient children (ages 7–13, N = 56) PSST led to significantly greater decreases than
Dawson, RCT; PSST, relationship therapy, and treatment the other treatment and control conditions in
French, & Unis contact control. externalizing and other behavioral problems
(1987a) at home and at school and greater increases in
prosocial behavior; the effects remained at a 1-year
follow-up assessment.
Kazdin, Esveldt- Inpatient children (ages 7–12, N = 40) Combined treatment showed significantly greater
Dawson, RCT; PSST+PMT combined and treatment changes externalizing and prosocial behaviors than
French, & Unis contact control (where both parents and child the control condition; the effects were maintained at
(1987b) were seen as in the combined treatment). a 1-year follow-up.
Kazdin, Bass, Inpatient and outpatient children (ages 7–13, Both PSST conditions showed significant changes
Siegel, & N = 112) on measures of problem and prosocial behavior
Thomas (1989) RCT; Compared, PSST, PSST with in vivo compared with relationship therapy; PSST with
practice, and Relationship therapy. in vivo practice led to greater improvements in
behaviors at school than PSST alone, but these
differences were no longer evident at 1-year follow-
up.
Kazdin, Siegel, & Outpatient children (ages 7–13, N = 97) All treatments improved child functioning on measures
Bass (1992) RCT; Evaluated effects of PSST, PMT, and of externalizing symptoms and prosocial behavior;
PSST+PMT. the combined treatment led to significantly greater
changes immediately after treatment and at a
1-year follow-up and placed more children within
the nonclinical (normative range) in levels of
functioning.
Kazdin, Outpatient children (ages 4–13, N = 75) At the end of treatment children who terminated
Mazurick, & Evaluated therapeutic change of completers and prematurely showed greater impairment at home,
Siegel (1994) dropouts and factors that account for their at school, and in the community compared with
different outcomes. children who completed treatment. However, these
differences were accounted for primarily by severity
of impairment at pretreatment rather than by
receiving less treatment.
Kazdin (1995a) Outpatient children (ages 7–13, N = 105) Child severity and scope of dysfunction, parent
Evaluated of moderators of change among stress, and family dysfunction predicted symptoms
families that received PMT or PSST+PMT. and prosocial functioning at the end of treatment,
but the effects varied by outcome (at home or at
school). The proposed moderators even when
significant were not strongly related to outcome.
Kazdin and Outpatient children (ages 7–13, N = 120) Children more deficient in cognitive/academic skills
Crowley Examined relation of intellectual functioning and and more severely impaired improved significantly
(1997) severity of symptoms on responsiveness to with treatment but less than their less impaired
PSST. counterparts.
Kazdin and Outpatient children (ages 3–13, N = 304) Treatment completion was strongly related to
Wassell (1998) Examined the relation of treatment completion therapeutic change with greater change among
and therapeutic change among children who those who completed treatment. However, 34%
received PSST, PMT, or PSST+PMT. of those who dropped out early made significant
improvement compared with those who remained
in treatment (78%). Predictors for improvement
did not vary as a function of whether individuals
dropped out or completed treatment.
Kazdin and Outpatient children (ages 3–13, N = 200) Perceived barriers to participation in treatment was
Wassell (1999) Examined predictors of therapeutic change. related to therapeutic changes in the children.
Greater barriers were associated with less change;
the findings could not be explained by several child,
parent, and family variables.
(continued)
8 Kazdin
Table 1. (Continued)
Investigation Sample, design, and objective
Kazdin and Outpatient children (ages 2–14, N = 169)
Wassell Examined relation of parent psychopathology
(2000a) and quality of life as moderators of
therapeutic change in children who received
PSST, PMT, or PSST+PMT.
Kazdin and Outpatient children (ages 2–14, N = 250)
Wassell Examined therapeutic changes in children,
(2000b) parents, and families and the predictors of
these change among children who received
PSST, PMT, or PSST+PMT.
Kazdin and Outpatient children (ages 6–14, N = 127)
Whitley (2003) RCT: All families received PSST+PMT; half
were assigned to receive a supplementary
component to address parental stress.
Kazdin, Outpatient children (ages 3–14, N = 138)
Marciano, & Evaluated child-therapist and parent-therapist
Whitley (2005) alliance as a predictor of therapeutic change
among families that received PMT alone or
PSST+PMT.
Kazdin, Whitley, Outpatient children (ages 6–14, N = 77)
& Marciano Evaluated child-therapist and parent-therapist
(2006) alliance as a predictor of therapeutic change
among families that received PSST+PMT.
Kazdin and Outpatient children (ages 2–14, N = 218)
Whitley Evaluated parent-therapist alliance, pretreatment
(2006a) parent social relations, and parenting practices
developed with PMT among families that
received PMT alone or PSST+PMT.
Kazdin and Outpatient children (ages 3–14, who met criteria
Whitley for ODD or CD; N = 315)
(2006b) Evaluated comorbidity (0, 1, or > 1 comorbid
disorders separately for ODD and CD cases
and case complexity (SES, scope of child
dysfunction, parent and family stress and
dysfunction, barriers to treatment). Children
received PSST, PMT, or PSST+PMT.
Kazdin and Outpatient children (ages 6–13, referred
Durbin (2012) for oppositional, aggressive, or antisocial
behavior; N = 97). Evaluated predictors of
alliance and whether they could account for
the relation of alliance to therapeutic change.
All cases received PSST+PMT.
Rabbitt et al. Outpatient children (ages 6–13, referred
(2016) for oppositional, aggressive, or antisocial
behavior; N = 60)
RCT: Evaluated two variations of computer
delivered treatment of PMT that varied in
the amount of contact and guidance with
the therapist. A third group of participants
(n = 60) matched and drawn from the clinic
database involving in-person treatment.
Main findings
Greater parent psychopathology and lower quality of
life at pretreatment predicted therapeutic changes,
controlling for SES and child severity of dysfunction.
Greater perceived barriers to treatment by parents
was associated with less therapeutic change on the
part of the children.
Child, parent, and family functioning improved over
the course of treatment. Moderators of treatment
varied as a function of child, parent, and family
outcomes.
Treatment with the component to address parental
stress was associated with greater therapeutic
change among the children and reduced barriers to
treatment perceived by the parents.
A more positive therapeutic alliance (for either child
or parent) was associated with greater therapeutic
change, fewer experienced barriers to treatment,
and greater acceptability of treatment. SES, parent
dysfunction and stress, and pretreatment child
dysfunction did not account for the findings.
Both alliances predicted therapeutic changes of the
children. The parent-therapist alliance predicted
improvements in parenting practices in the home;
effects not explained by SES, parent and child
dysfunction, and/or parental stress.
Alliance predicted parent improvements over the
course of treatment; alliance was partially mediated
by pretreatment parent social relations.
Children were not different in outcomes as a function
of comorbidity or case complexity; greater change
(pre vs. post) was associated with more dysfunction
(multiple comorbidities and greater family
complexity) but the end points (post) were not
different. Barriers to treatment moderated treatment
outcome; greater barriers were associated with less
change in the children.
Child-therapist alliance contributed to therapeutic
change. The stronger the alliance, the greater the
change. Pretreatment social competence of the child
and level of intellectual functioning predicted the
quality of alliance but did not account for or explain
the alliance-outcome connection.
The two treatments were equally effective in the
degree of therapeutic change among the children.
The changes of the two groups were at the level of
in-person treatment using the benchmark group for
comparison. The two computer delivered treatments
were no different in the parent-therapist alliance,
despite greatly reduced contact with the therapist in
one of the group. On the other hand, parents in the
group with the therapist present and helping with each
session evaluated their treatment as more acceptable
than did parents in the reduced contact group.
(continued)
Treatment of Aggressive and Antisocial Child Behavior Services 9
Table 1. (Continued)
Investigation Sample, design, and objective
Kazdin et al. N = 138, 39 girls and 99 boys, ages 6–13),
(2018) received PMT.
RCT; one half received enhanced version
to optimize expectancies, bonding,
professionalism of treatment; other half
standard PMT in the setting.
Note: CD = conduct disorder; ODD = oppositional defiant disorder; PMT = parent management training; PSST = problem-solving skills training;
RCT = randomized controlled trial; SES = socioeconomic status. The table includes studies that had treatment outcome as the major focus. Many
of our other studies are cited in the text on related topics (e.g., participation in treatment) and are not included here.
parent sources of stress improves treatment out-
come of the child.
6. European American and African American fami-
lies benefit equally, once level of stress and
demographic variables are controlled. (Too few
families of other ethnic groups precluded addi-
tional comparisons.)
7. Treatment effects are evident not only in child
behavior but also in reductions in stress and
parent depression and improved family
relations.
8. Online delivery of the treatment via the Internet
is just as effective as in-person treatment.
Related areas
Efforts to improve treatment and understand key com-
ponents have led to mini programs of research. Here
are the main ones.
Therapeutic alliance.  The study of the relationship of
adult clients to therapists in therapy for adults has been
the subject of thousands of studies (Norcross, 2011). Cli-
ent relations with the therapist are less well studied in
child therapy. We have shown that child-therapist (in
PSST) and parent-therapist (in PMT and PSST) alliances
relate to several outcomes. The more positive the child-
therapist and parent-therapist alliance during treatment,
the greater the therapeutic change of the child and
improvements of the parents in parenting practices, the
fewer barriers parents experience during treatment, and
the more favorably parents rate the acceptability of the
treatment. Interestingly, parent-therapist alliance can be
explained in part by parent relationship style in the home
and social and supportive relationships outside of the
home that parents show before coming to treatment
rather than something that emerges ex nihilo in the treat-
ment sessions. Likewise, the child-therapist alliance can
be explained in part by the child’s level of intelligence
(IQ) and social competence before the child enters
Main findings
PMT led to marked changes in treatment outcome. The
two variations were no different. The pattern of data
(negative skew, ceiling effects) across the outcome
and process measures would have made it difficult to
show an incremental effect of the enhancements in
this study if in fact there were any.
treatment (Kazdin & Durbin, 2012; Kazdin, Marciano, &
Whitley, 2005; Kazdin & McWhinney, 2018; Kazdin &
Whitley, 2006b; Kazdin, Whitley, & Marciano, 2006).
Moderators of treatment. Several characteristics of
parents and children, beyond alliance, moderate thera-
peutic change, including severity of child dysfunction,
child IQ, parent stress, parent psychopathology, and oth-
ers. Children and families with multiple adversities begin
treatment as much more extreme on measures of disor-
der but improve and are no different in symptoms and
prosocial functioning at the end of treatment from those
with fewer adversities. The most robust moderator of our
treatment has been parental report of barriers to partici-
pation in treatment. These barriers reflect stressors that
compete with participating in treatment, perceived treat-
ment demands, perceived relevance of treatment, and
obstacles in relation to the therapist. The higher the per-
ceived barriers, whether evaluated by parents or therapists,
the less the therapeutic change among the children, a rela-
tion not accounted for by such other factors as severity of
parent or child dysfunction, or stress in the home (Kazdin,
1995a; Kazdin & Crowley, 1997; Kazdin, Holland, & Crow-
ley, 1997; Kazdin, Holland, Crowley, & Breton, 1997; Kazdin
& Wassell, 1999, 2000a, 2000b; Kazdin & Whitley, 2006a,
2006b).
Participation in treatment.  Cancelling and not show-
ing up for treatment is a problem in psychotherapy;
approximately 40% to 60% of individuals drop out early
(Kazdin, 1996). We have studied the problem, challenged
key assumptions empirically, and developed a concep-
tual model of dropping out and how it can be reduced.
We have evaluated who drops out, when they drop out,
and whether one can reliably predict each of these. Note
that dropping out (commonly referred to as “premature
termination”) does not necessarily mean failing or doing
poorly in treatment. In our work, among those who drop
out of treatment very early, 34% report large improve-
ments in the behaviors of their children (Kazdin, 1990,
1995a; Kazdin & Mazurick, 1994; Kazdin, Mazurick, &
10 Kazdin
Bass, 1993; Kazdin, Mazurick, & Siegel, 1994; Kazdin,
Stolar, & Marciano, 1995; Kazdin & Wassell, 1998). Indeed,
in many instances during treatment, individuals convey
that they are about to drop out because they have seen
marked therapeutic changes and perceive no need to
continue and complete our planned regimen. We devel-
oped a model (barriers to participation in treatment) that
focused on facets related to the interface of the client
with the treatment, as I mentioned previously, to explain
dropping out, have tested the model, and even tested
whether intervening could improve participation (Kazdin,
Holland, & Crowley, 1997; Kazdin, Holland, Crowley, &
Breton, 1997; Nock & Kazdin, 2005).
Along the way.  My presentation of the research might
sound organized and linear. There were many projects
and excursions along the way, some dictated by efforts to
understand more about the population or disorder and
others to develop the needed tools to carry out the
research. As one example of the former, we have looked
at predictors of parent abuse. In everyday life, parent
abuse usually means that the parent is raising a teenager
but in clinical work with violent children, parents are
physically harmed and beaten by their children. It seemed
important to document that and identify potential predic-
tors (Nock & Kazdin, 2002).
In terms of developing tools, we have had to devise
many measures to address critical questions, including
the following:
1. The Hopelessness Scale for Children—to mea-
sure pessimism and risk for suicidality (e.g.,
Kazdin, French, Unis, Esveldt-Dawson, & Sherick,
1983)
2. Interview of Antisocial Behavior—to measure a
full range of symptoms of conduct disorder and
delineate overt and covert behaviors (e.g.,
Kazdin & Esveldt-Dawson, 1986)
3. Children’s Hostility-Guilt Inventory—to distin-
guish overt actions from grudges and internal
anger (e.g., Kazdin, Rodgers, Colbus, & Siegel,
1987)
4. Barriers to Participation in Treatment—to
develop and test a model of why people drop
out of treatment (e.g., Kazdin, Holland, Crowley,
& Breton, 1997)
5. Treatment Acceptability—to measure the extent
to which therapists, parents, and children con-
sider a given intervention reasonable or appro-
priate (e.g., Kazdin, Bass, Siegel, & Thomas,
1989)
6. Management of Children’s Behavior Scale—to
assess child-rearing practices, with particular
emphasis on punishment (e.g., Perepletchikova
& Kazdin, 2004)
7. Children’s Pleasure Scale—to measure anhedonia
or the experience of pleasure among children
(e.g., Kazdin, 1989)
8. Parent Expectancies for Child Therapy—to mea-
sure extent to which parent expectancies for
treatment corresponded to actual demands of
treatment (e.g., Nock & Kazdin, 2001)
For each measure, we completed a basic study or
two to develop and evaluate the scale (e.g., various
forms of reliability and validity) and went on to use the
measure to address the original questions we had in
mind. More formal and extensive scale development
(e.g., normative work, special scale analyses) was not
part of the agenda and were not completed. Even so,
some of the measures (e.g., 1 through 5) have been
used by others well beyond our research program and
have more data than our modest studies provided.
The research on PMT for conduct problems has led
to an enormous (and international) demand from par-
ents to our clinical service to help with the “normal”
challenges of child rearing. To paraphrase more than
one parent, “You can get children to stop beating up
their peers, destroying property, or setting fires, but can
you get my child to go to bed on time or to eat vege-
tables or can you have my adolescent ditch the ‘atti-
tude,’ nasty comments, and sigh of disgust when I just
ask her ‘how was school’?” For our treatment team,
addressing these challenges was a therapeutic oasis
compared with our daily fare with clinically referred
children. Consequently, we divided our time to provide
PMT for parents interested in this focus. For staffing
and funding, we could never satisfy the demand.
To help with the everyday challenges, we have pre-
pared many materials for parents, including the
following:
1. A free online course (Everyday Parenting: The
ABCs of Child Rearing; https://www.coursera
.org/learn/everyday-parenting)
2. A web page with resources for parents (http://
www.alankazdin.com)
3. Trade books (Kazdin & Rotella, 2008, 2013)
4. A set of parent-friendly articles on specific proce-
dures to promote behavior change (use of rein-
forcement schedules to eliminate behavior,
shaping, time out from reinforcement) and to cau-
tion against the use of other procedures (e.g.,
spanking, reprimands) that can impede prosocial
functioning if not actually do harm (see http://
www.slate.com/authors.alan_kazdin.html)
Treatment of Aggressive and Antisocial Child Behavior Services 11
In addition, I have a separate life from my academic
job and research to help disseminate science of parent-
ing via the media (approximately 2–4 hours per week),
speaking regularly to parents and teachers, and other
activities to help parents with everyday childrearing
challenges.
General comment
The studies I have highlighted use group designs evalu-
ated with statistics in the usual ways. What is lost is
that we have worked with thousands of individual chil-
dren and parents. We work with them individually, get
to know their lives and stories over a period of months,
often in too much detail, and see their challenges as
well as our successes and failures. The information from
the intensive focus on individuals has guided many
hypotheses, studies, and foci. For example, we knew
firsthand that dropping out of treatment “prematurely,”
the standard term in use, was not quite correct. We
could recount scores and scores of people who were
on the brink of dropping out and then stopped treat-
ment because it was working really well—that is, not
prematurely at all. Apart from one study to demonstrate
this (Kazdin & Wassell, 1998), we met as a team, recalled
individual stories of multiple families in detail, and
developed a measure and conceptual model to explain
dropping out that led to many studies (highlighted pre-
viously under Participation in Treatment).
In clinical work and clinical training, there are no
well-developed guidelines of how to draw on what one
observes, generate a mini-theory, and devise a feasible
experiment either to test the principle (lab study) or
application (in the clinic). Likewise, in psychology and
certainly within clinical psychology, rarely is there any
training in qualitative methods or mixed methods, both
of which would be very well suited both to generate
and test hypotheses in the context of clinical work.
Perhaps all that is needed is just good science and facil-
ity in hypothesis generation unrelated to clinical work
(e.g., W. J. McGuire, 1997). In my case, a highly trained,
inquisitive, and creative staff helped turn challenges
and perplexing problems into something that we could
study.
Shifting the Focus to a Broader Problem
My work in context
We achieved the original goals of our program, namely,
to develop evidence-based interventions for conduct
problems. My work represents a larger body of research
with investigators developing and evaluating treatments
(e.g., Miller, 2009; Nathan & Gorman, 2015; Weisz &
Kazdin, 2017). There are now hundreds of treatments
for many different disorders even though the specific
count and criteria for inclusion vary (Kazdin, 2018;
Substance Abuse and Mental Health Services Adminis-
tration [SAMHSA], 2017). With an abundance of evidence-
based interventions, perhaps there is much to celebrate.
Yet the interventions are not widely adopted or even
routinely included in the training of mental-health pro-
fessionals. Even more than that, there is a broader
problem.
Although treatment research has advanced, so has
work on psychiatric epidemiology and the description
of the rates and distribution of mental illness in the
community. For example, we now know that 26% of
the U.S. population meet criteria for at least one psy-
chiatric disorder within the past 12 months (Kessler,
Chiu, Demler, & Walters, 2005; Kessler et al., 1994). This
increases to 46% of the population over the course of
life (Kessler, Berglund, et al., 2005). For ease of com-
putation, consider that approximately 25% of the U.S.
population experiences a psychiatric disorder during a
given year and 50% during their lifetime. From a U.S.
population of approximately 326 million, this translates
to more than 80 million and 160 million people, respec-
tively. It is important to add that these estimates are
conservative because some disorders (e.g., schizophre-
nia), subsyndromal (subclinical) disorders, and institu-
tionalized populations with disorders often are omitted
from the surveys (Kazdin, 2018).
Separate lines of research have addressed the extent
to which individuals in need of services receive them.
Regarding adults, in the United States, approximately
70% of individuals in need of services do not receive
any services (Kessler, Demler, et  al., 2005). Ethnic
minority groups (e.g., African, Hispanic, and Native
Americans) have even less access to care than do Euro-
pean Americans (e.g., T. G. McGuire & Miranda, 2008;
Olfson, Marcus, Druss, Pincus, & Weissman, 2003; Wells,
Klap, Koike, & Sherbourne, 2001).
From work on prevalence and treatment, we know
now that there is a huge treatment gap. The treatment
gap refers to the difference in the proportion of people
who have disorders (prevalence) and the proportion of
those individuals who receive care (Kohn, Saxena,
Levav, & Saraceno, 2004; Patel et al., 2010). The treat-
ment gap is not unique to the United States. Beyond
the United States, the World Health Organization
(WHO) provided extensive data on the treatment gap
from surveys of over 60,000 adults in 14 countries in
the Americas, Europe, Middle East, Africa, and Asia.
Receiving services consisted of any contact (even just
one) with a health professional (e.g., psychiatrist, psy-
chologist), general medical or other professionals (e.g.,
general practitioner, occupational therapist), religious
12 Kazdin
counselors (e.g., minister, sheikh), and traditional heal-
ers (e.g., herbalist, spiritualist; WHO World Mental
Health Survey Consortium, 2004). The percentage of
respondents who received treatment for emotional or
substance-use disorders during the previous 12 months
ranged from a low of 0.8% (Nigeria) to a high of 15.3%
(United States). These numbers convey that the vast
majority of individuals in need of services (99.2% and
84.7%, respectively, by subtracting the above percent-
ages from 100%) did not receive treatment. A useful
summary of the situation in the United States and
worldwide is that the most commonly received inter-
vention for mental disorders is nothing, that is, no
treatment.
There are all sorts of barriers to receiving profes-
sional care (e.g., stigma, lack of reimbursement for
services, mental-health illiteracy). Yet a key barrier is
the dominant model of delivering psychosocial inter-
ventions and this applies to evidence-based and non-
evidence-based interventions. Most psychosocial
interventions for children, adolescents, and adults are
delivered with a model that has three interrelated
characteristics:
1. Treatment sessions are provided in person and
one-to-one with a client (child, couple, family).
2. Treatment is administered by a highly trained
(e.g., master’s or doctoral level) mental-health
professional.
3. Sessions are held at a clinic, private office, or
health-care facility.
These characteristics inherently limit the scalability of
treatment and the reach to special groups especially
unlikely to receive care.
Consider just one facet of the model: its reliance on
mental-health professionals. In the United States, for
example, there are too few trained mental-health pro-
fessionals. They are heavily concentrated in urban areas
rather than in many areas with few or no services and
are infrequently trained to accommodate many popula-
tions for which there is great need (e.g., children, ado-
lescents, older adults; Health Resources and Services
Administration, 2010; Hoge et al., 2007; National Acad-
emies of Sciences, Engineering, and Medicine [NAS],
2017; SAMHSA, 2013). In addition, the ethnic and cul-
tural diversity of mental-health professionals does not
come close to matching the diversity of the population
in need of treatment and that has direct implications
for clients seeking, remaining in, and profiting from
treatment (e.g., Griner & Smith, 2006; Kim, Ng, & Ahn,
2005; Zane et  al., 2005). In relation to treatment for
psychological dysfunction, the situation of too few
professionals in relation to the need is projected to
become much worse through 2025 (NAS, 2017).
From interventions to models of delivery
If most people in need receive nothing, merely design-
ing more effective treatments that cannot be delivered
is of little use, outside of tests of principle or of proce-
dures that might one day be delivered in novel ways.
Consider for a moment that a single pill was devised
that was effective for the treatment of multiple cancers.
This would be marvelous scientific breakthrough. But
consider for a moment that the pill was the size of a
beach ball and had to be swallowed whole. An “effec-
tive” treatment in this case requires a way of being
delivered that in fact could be used by people in need.
We need effective interventions as a first step but ways
of ensuring they can be delivered. And so it is with
evidence-based psychotherapies. To the vast majority
of people in need, they are beach balls, not consum-
able, and hence of little use in their lifetimes. I find that
hard to swallow, so I am now out of the treatment
development and evaluation business.
My own shift in focus now is on models of delivery:
how the interventions provided can be scaled to reach
individuals in need and to demonstrate impact (Kazdin,
2017, 2018). There are several such models with names
unfamiliar within psychology and include task shifting,
best-buy interventions, disruptive innovations, enter-
tainment education, social networking, and others.
These models draw on many different disciplines,
including public health, business, entertainment, eco-
nomics, robotics and artificial intelligence, and law and
social policy. Their characteristics permit scaling inter-
ventions to reach large numbers of individuals in need,
to reach many special groups least likely to receive
services, and in varying degrees sidestep some of the
barriers (e.g., stigma, cost, lack of mental-health profes-
sionals) that contribute to the treatment gap. Moreover,
some of the models draw on the now extensive evi-
dence that lay individuals can be trained to administer
evidence-based treatments and are just as effective in
administering psychological treatments to patients with
significant mental disorders as are mental-health profes-
sionals (e.g., Balaji et  al., 2012; Bolton et  al., 2014;
Kilpela et al., 2014; Nadkarni et al., 2017; Patel et al.,
2016; Rahman et  al., 2016; Rahman, Malik, Sikander,
Roberts, & Creed, 2008).
Closing Comment
My intervention research began with the naive view
that our main if not sole task was developing effective
Treatment of Aggressive and Antisocial Child Behavior Services 13
treatments for serious mental disorders and related psy-
chological slings and arrows of life, regardless of
whether they rose to the level of a disorder. To be sure,
we do need evidence-based treatments. And, within
clinical psychology and psychiatry, the flow of RCTs of
such treatments continues to gush from our best jour-
nals. Yet now that we are armed with many evidence-
based treatments, we must look to whether they are
reaching people, whether they are having impact, and
whether they reduce the burdens of mental illness.
Currently, it is a very small and elite group that
receives individual therapy, evidence-based or not. And
with about 50% of the U.S. population likely to experi-
ence a psychiatric disorder in their life time, we need
much more than interventions for the select few. The
problem is not with the interventions per se but rather
the manner in which they are delivered, namely, the
dominant model to which I referred.
Our research now must look at scalability (improving
the number and proportion of individuals who receive
treatment) and reach (connecting with special popula-
tions that are routinely neglected.) Currently, we have
the means (models of delivery) that could have enor-
mous impact on reducing the treatment gap (see
Kazdin, 2018). Invariably, there is more to know and
we always want better and more science. Yet it is
important, at least for me, to keep in mind that the most
common intervention for mental disorders among those
people in need in the United States and worldwide is
no treatment. It does not need to be that way, based
on what we know. Perhaps understandably, even if
rather delayed, I am shifting my own priorities to ways
of reaching people in need of services and practices
that can be scaled.
The research and career I have highlighted perhaps
can be characterized by the dialectic process described
by the German philosopher Georg Wilhelm Friedrich
Hegel (1770–1831; Rosen, 1982). This process includes
the familiar three stages consisting of thesis, antithesis,
and synthesis. Developing and establishing evidence-
based interventions might be considered the thesis or
beginning stage. I thought these treatments would auto-
matically be adopted and help many people. In light
of the treatment gap I have highlighted, my work moved
to the antithesis stage. This stage, a bit too extreme,
but where I am now, reflects my view that in principle
and practice, evidence-based treatments cannot have
much impact. The dominant method of establishing and
evaluating evidence-based treatments (meta-analyses)
is of little help in deciding what really has palpable
impact on anyone. And, the dominant model of treat-
ment delivery precludes reaching the masses in need
of services. On the horizon, I see use of novel models
of delivery as a synthesis stage that combines or
integrates the truths of both prior stages. That is, we
need evidence-based treatments but with empirically
established assurances that they can be delivered, reach
people in need, and have impact in ways that reduce
the individual, family, and social burdens of mental
disorders. Of course, the issues are not about “me” and
what I see but rather about a neglected crisis. In the
wings in the United States (and worldwide), there are
desperate individuals and their families who will receive
no treatment for their mental disorders. That is antitheti-
cal to the goals we treatment researchers probably
began with as we started our programs of research.
Action Editor
Robert J. Sternberg acted as action editor and editor-in-chief
for this article.
Declaration of Conflicting Interests
The author(s) declared that there were no conflicts of interest
with respect to the authorship or the publication of this
article.
Notes
1. Children were also admitted for episodes of depression and
suicidality. In addition, we began a line of research on the eval-
uation and characteristics of depression and suicide attempt.
This program continued for several years but is not covered in
this article.
2. Close to but missing the target is nicely illustrated in the well-
known statistics poem, “Hiawatha Designs an Experiment,” in
which statistical analysis, real-life hitting of a target, and their dif-
ferences are described (see http://www.columbia.edu/~to166/
hiawatha.html; Kendall, 1959).
3. The research highlighted here received support from the
National Institute of Mental Health (NIMH) through various
grant mechanisms (e.g., Research Project Grants [R01], Research
Scientist Development and Research Scientist Awards, MERIT
[Method to Extend Research in Time] Award) spanning over 3
decades. Additional funding of my work came from the John D.
and Catherine T. MacArthur Foundation, the Leon Lowenstein
Foundation, the Rivendell Foundation of America, the Robert
Wood Johnson Foundation, the William T. Grant Foundation,
the Jack Parker Corporation, the Blue Guitar Foundation, the
Community Foundation of New Haven, and Yale University.
I am deeply indebted to these sources. No less essential to
the work has been the remarkable staff, pre- and postdoc
colleagues, and student interns who have served at the Yale
Parenting Center over the years.
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