European Child & Adolescent Psychiatry (2023) 32:1599–1608

https://doi.org/10.1007/s00787-021-01932-1

ORIGINAL CONTRIBUTION

Stability of the effects of a social competence training program

for children with oppositional defiant disorder/conduct disorder:
a 10‑month follow‑up
Teresa Del Giudice1 · Timo Lindenschmidt1 · Martin Hellmich3 · Christopher Hautmann1 · Manfred Döpfner1,2 ·
Anja Görtz‑Dorten1,2

Received: 15 December 2020 / Accepted: 17 December 2021 / Published online: 13 March 2022
© The Author(s) 2022

Abstract
The stability and effectiveness of the Treatment Program for Children with Aggressive Behavior (THAV) in terms of reduc-
ing behavioral problems in children with oppositional defiant disorder (ODD) and conduct disorder (CD) were examined at
a 10-month follow-up (FU). A total of 76 families and their children (boys aged 6–12 years), who previously participated
in a randomized controlled trial comparing THAV with an active control group, took part in the 10-month FU assessment.
Outcome measures were rated by parents and included the evaluation of child aggressive behavior, prosocial behavior,
problem-maintaining and problem-moderating factors, and comorbid symptoms. Linear mixed models for repeated measures
(MMRM) were conducted. The results revealed that THAV effects remained stable (problem-maintaining and problem-
moderating factors; comorbid symptoms) and even partially improved (aggressive behavior; ADHD symptoms) over the FU
period. Additionally, the differences between the THAV intervention group and the control group, which were apparent at
the end of the treatment (post), mainly also remained at the FU assessment. It can be concluded that THAV is an effective
and stable intervention for boys aged 6–12 years with ODD/CD.

Keywords Oppositional defiant disorder · Conduct disorder · Cognitive behavioral therapy · Long-term effects

Introduction are highly stable over time and predict later emotional and
behavioral problems in adolescence and adulthood [2–4].
Oppositional defiant disorder (ODD) and conduct disorder With regard to psychotherapeutic interventions, ODD/CD
(CD) are among the most common disorders for which chil- are notably responsive to parent management training (PMT)
dren and adolescents are referred for mental health treat- [5–8], child-centered treatments (cognitive behavioral inter-
ment [1]. Longitudinal studies have shown that ODD/CD ventions (CBT) including social skills training) [9, 10], and
a combination of PMT and CBT programs [5, 11–13].
While PMT is considered as the gold standard, this
Teresa Del Giudice and Timo Lindenschmidt have contributed approach still has some limitations, and some factors remain
equally to the manuscript. untreated, in particular those related to the child (e.g., child’s
inability to handle anger due to affect regulation deficien-
* Teresa Del Giudice
[email protected] cies) [14]. Moreover, regarding therapeutic effects on behav-
ioral problems outside the family (e.g., behavior at school;
1
Faculty of Medicine, School of Child and Adolescent peer relationship problems), CBT interventions that focus
Cognitive Behavior Therapy (AKiP), University Hospital on social skills and cognitive interventions (e.g., problem-
Cologne, University of Cologne, Cologne, Germany
2
solving and anger management strategies) seem to increase
Faculty of Medicine, Department of Child and Adolescent the effects of PMT [13, 15, 16].
Psychiatry, Psychosomatics and Psychotherapy, University
Hospital Cologne, University of Cologne, Cologne, Germany However, many studies only consider the post-treatment
3 effects and neglect to examine the long-term effects, which
Faculty of Medicine, Institute of Medical Statistics
and Computational Biology, University Hospital Cologne, are of great importance given the negative long-term prog-
University of Cologne, Cologne, Germany noses of ODD/CD. In this context, a meta-analysis by van

13
Vol.:(0123456789)
1600 European Child & Adolescent Psychiatry (2023) 32:1599–1608

Aar and colleagues [17] encompassing 40 studies examined The effectiveness of the program has been demonstrated
the long-term effects [follow-up (FU) assessment up to 3 in two previous analyses [11, 22]. In a study employing a
years] of PMT on disruptive child behavior and found that within-subject design which included 6–12-year-old boys
the post-treatment effects remained stable. However, the with peer-related aggressive behavior, growth rates for all
long-term effects of CBT interventions were not considered. parent-rated outcome measures were found to be signifi-
Furthermore, a meta-analytic review by Fossum and col- cant during treatment, and a comparison with the waiting
leagues [18] identified 56 studies (published between 1984 phase indicated a stronger decrease in aggressive behavior
and 2010) that examined the longer term impact (with a and a stronger increase in prosocial behavior during treat-
mean FU period of 8.9 months; SD = 6.5) of PMT (k = 34), ment [22]. In a randomized controlled trial (RCT) evalua-
CBT (k = 7), a combination of PMT and CBT (k = 12) or tion, THAV (n = 50) was compared with an active control
family therapy (FT; k = 3) on conduct problems and opposi- involving group play (PLAY; n = 41). The between-group
tional behaviors (within the clinical range before treatment). evaluation showed mostly moderate treatment effects for
Overall, the findings again indicated a stability of treatment THAV compared to PLAY in parent ratings on aggressive
effects. None of the included studies found a significant behavior, comorbid symptoms, psychosocial impairment,
deterioration in ODD/CD symptoms in the FU period com- quality of life, parental stress, and negative expressed emo-
pared to post-treatment, and overall, there was even a small tions at post-assessment [11].
(non-significant) further reduction in conduct problems after In the current analysis, we subsequently examined
treatment was over (effect size = 0.08). Moreover, the meta- whether these effects (based on parent ratings) remain at
analysis revealed that changes in conduct problems were a 10-month FU assessment. Besides testing the stability of
significantly larger in the studies that examined PMT in treatment effects, the present study also seeks to shed light
combination with CBT or CBT alone compared to studies on the differences between THAV and PLAY at 10-month
that examined PMT alone or FT. The study by Lochman FU. In sum, our hypotheses were as follows: (a) improve-
and Wells [13] comes to comparable findings. Their analy- ments in child behavior (based on multiple parent-rated
ses showed that the Coping Power Program (a child CBT outcome measures) through THAV treatment would be
program) have sustained effects 1 year after the program sustained 10 months later (comparison of post-treatment
has ended, especially when parent components are added. versus 10-month FU controlling for pre-treatment); (b) the
Children of the intervention group showed lower rates of significant effects of THAV compared to PLAY shown at
self-reported covert delinquent behavior and of parent-rated post-assessment would also be apparent at 10-month FU.
substance use at FU that at the baseline than did the control
group.
However, most of the studies considered here predomi- Methods
nantly examined the stability of treatment effects (i.e.,
within-group change: comparison of post-treatment versus Ethical considerations
FU), while only a small number of studies, e.g., [19, 20],
also investigated whether there were differences between The protocol of the study conducted at the University of
the treatment and control group at FU (i.e., between-group Cologne (Clinical trials.gov Identifier: NCT01406067) was
comparison). These studies mostly did not find any signifi- approved by the ethics committee of the University Hospi-
cant differences between the groups at FU, possibly due to tal, Cologne. The study was performed in accordance with
the fact that control group participants had received adequate the ethical standards laid down in the 1964 Declaration of
therapy in the interim. Helsinki and its later amendments. All participants provided
Overall, it appears that the number of studies on long- written informed consent.
term effects of cognitive interventions in ODD/CD is con-
siderably low. A closer look also shows that there are hardly Participants and procedure of the study
any studies that analyze the difference between the treatment
and the control group at FU. Further studies are strongly Figure 1 describes the participant flow. For pre-assessment,
needed in this area. a total of 181 patients were referred to the outpatient unit of
The aim of the present study was therefore to evaluate the clinic between January 2011 and January 2013 due to
the long-term effects of the Treatment Program for Children severe conflicts with peers and/or family members. Based on
with Aggressive Behavior (THAV) [21]. THAV mainly con- inclusion and exclusion criteria, they were screened for eligi-
sists of a patient-focused intervention program (CBT), which bility. Children were eligible for inclusion if they were male,
is combined with parent interventions (PMT) and teacher- aged 6–12 years, with an IQ > 80 (in the Culture Fair Intel-
and peer-focused interventions according to the individual ligence Test) and an ICD-10 diagnosis of CD (F91), mixed
needs of the patient. disorder of conduct and emotions (F92), or hyperkinetic

13
European Child & Adolescent Psychiatry (2023) 32:1599–1608 1601

Fig. 1  Participant flow diagram

Assessed for eligibility (n = 181)

Total: n = 80 cases excluded

Reasons:
Not meeting inclusion/exclusion criteria (n = 31)
Not fulfilling general study conditions (n = 7)
Declined to participate (n = 42)

Allocated to intervention THAV Allocated to intervention PLAY

(n = 50) (n = 51)

41 completed PLAY; 10 dropped out after

50 completed THAV randomization (ethical reasons)

Follow-up completer Follow-up completer

(n = 42) (n = 34)

conduct disorder (F90.1), as determined using the semi- decided to exclude these patients from further analysis,
structured interview for disruptive behavior disorders (ODD, because an imputation of missing values in this control
CD; DCL-DBD) of the German Diagnostic System for Chil- group (e.g., with last observation carried forward) would
dren and Adolescents (DISYPS-II) [23]. Moreover, since have favored the treatment group. These ten patients which
the goal of the intervention was to treat peer conflicts, peer- are excluded from PLAY did not differ statistically on the
related aggressive behavior had to cause persistent impair- SCL-DBD symptom score (t = 1,20, df = 49, p = 0.237)
ments in relationships with other children (based on clini- at pre-2. Besides these 10 patients, all other randomized
cal rating in the semi-structured interview). In addition, the patients completed the THAV and PLAY conditions.
child had to have a high symptom score (Stanine score ≥ 7) After 10 months, the participating families were reas-
on the German Symptom Checklist for Disruptive Behavior sessed, and were then asked to participate in the FU
Disorder (SCL-DBD) total score of the DISYPS-II [23] at assignment. The percentage of participants available at
the pre-assessment. Exclusion criteria were the presence of 10-month FU was approximately 84% (THAV: n = 42;
a primary comorbid disorder (e.g., autism) according to the PLAY: n = 34) of the original sample. The reduced num-
judgment of the clinician, a planned change in medication ber of participants was mainly due to the fact that some
in a child receiving psychotropic medication, other child families no longer wished to participate in the study or had
psychotherapy, and insufficient German-language skills of moved away and could no longer be contacted.
the parents.
Of the original sample of 181 patients, 38 patients were
excluded, because they did not fulfill the inclusion cri- Measurement time points
teria or because they met exclusion criteria (e.g., other
active child psychotherapy). Further 42 patients were not The dependent measures were administered to both groups
interested in participating in the study. Thus, a total of at five time points: Pre 1 (before a waiting period; patients
101 patients were randomized to THAV or PLAY, using were assessed for eligibility at the Screening), Pre 2 (after
a block randomization with a block size of 4 and random the baseline waiting period of 6 weeks; patients were reas-
selections from all 6 permutations. Ten patients dropped sessed and randomized), Within (after half of treatment
out from the PLAY condition after randomization due to had been completed), Post (after a 24-week treatment
ethical objections of the therapists (i.e., that active THAV period; patients were reassessed), and FU (10 months after
treatment was necessary, because the child was at risk of post; patients were reassessed). In the present paper, the
school exclusion due to behavioral problems). Except for data of Pre 2, Post, and FU (controlling for pre-treatment)
these 10 patients, all other randomized patients completed are analyzed.
the THAV (n = 50) and PLAY (n = 41) conditions. We

13
1602 European Child & Adolescent Psychiatry (2023) 32:1599–1608

Interventions THAV aims to modify social-cognitive information pro-

cessing, impulse control, social problem-solving, social
The treatment and control interventions were conducted skills, and social interactions in these situations. It combines
by 13 experienced child therapists or therapists in training. patient-, parent-, teacher-, and peer-focused interventions.
The same therapists administered both the treatment and Patient-focused interventions are the main component, while
control interventions. The therapists received weekly group parent-, teacher-, or peer-focused interventions are added
supervision by a senior child therapist (A.G-D). With regard according to the individual needs of the patient. Treatment
to treatment integrity and treatment adherence, therapists with THAV comprises 24 weekly child sessions (lasting for
indicated that they spent 88% of the total treatment time on 45 min each) and additional sessions or shorter contacts
specific modules of the THAV treatment program. For the with parents. According to the study inclusion criteria, all
PLAY condition, only the general outlines of the interven- patients had high symptom scores (Stanine scores ≥ 7) prior
tion were given, indicating which interventions were/were to treatment on the parent-rated SCL-DBD total score. At
not allowed. Therapists were supervised regularly, and treat- post-assessment, 66% of patients in the THAV condition
ment integrity was rated globally as good-to-excellent by had dropped below this cut-off (indicating normalization).
the supervisor. In the following section, THAV and PLAY For a more detailed description, see Görtz-Dorten and col-
are described in detail. A comparative overview can also be leagues [11, 22].
found in Table 1.
Group play (PLAY)
The treatment program for children with aggressive
behavior (THAV) The active control condition (PLAY) consisted of educa-
tional group play, with 3–5 children in each group. Each
THAV is a CBT intervention for children aged 6–12 years group received 12 fortnightly sessions (lasting for 90 min
with peer-related overt aggressive behavior. It provides each) over 24 weeks. The sessions utilized techniques to
individualized treatment for problem-maintaining factors activate resources and provided the opportunity to prac-
in specific daily life situations, which each respective child tice prosocial interactions in groups. For instance, social
has experienced in the previous weeks. Depending on the play interactions and projects were offered that aimed to
problem-maintaining factors specific to each individual, develop cooperative interaction (e.g., making a movie

Table 1  Description of treatment and control interventions

THAV PLAY

Type of treatment CBT intervention Educational group play (3–5 children)

Number of sessions 24 weekly child sessions (each 45 min) 12 fortnightly sessions (each 90 min)
Individualized vs. standardized
Individually tailored to address the need of Not tailored to specific problems of the child
child and his/her parents and the parents
Main component Patient-focused interventions: (1) psychoe- Patient-focused interventions: (1) resource-
ducation and development of a therapeutic activating exercises; (2) practicing prosocial
relationship; (2) social-cognitive interven- interactions in groups; (3) conflict resolution
tions; (3) anger control training; (4) social guidance
problem-solving and skills training; and (5)
relapse prevention
No implementation of specific problem-solv-
ing techniques or other cognitive interven-
tions
Number of parent sessions An average of 8 sessions or shorter contacts Two parent group sessions (90 min)
Content of parent sessions (1) Identifying problems and competencies; psychoeducation on appropriate general par-
(2) Teaching parents how to device social enting strategies
rules, communicate effective commands; (3)
Teaching how to use rewarding the child, how
to use appropriate methods of punishment; (4)
Identify and modify parental dysfunctional
thoughts
Additional modules Involvement of teachers if needed –

Notes. THAV treatment program for children with aggressive behavior, PLAY group play control

13
European Child & Adolescent Psychiatry (2023) 32:1599–1608 1603

together, constructing game materials together and then higher degree of symptoms/prosocial behavior. By averaging
playing with them) or to provide the opportunity to prac- the associated item scores, three subscale scores (opposi-
tice socially competent ways of solving conflicts (e.g., shar- tional behavior, antisocial behavior, and prosocial behav-
ing, negotiating) [24]. Children were supported to solve ior) and a total score can be formed. The SCL-DBD has
conflicts and to develop cooperative interactions, and were been shown to be a factorially valid and internally consist-
also praised for socially competent behavior and for their ent (Cronbach’s α = 0.69–0.90) parent and teacher question-
own general competencies (e.g., being good at sports). No naire [27]. When diagnostic accuracy was examined using
specific problem-solving techniques (e.g., development of receiver operating characteristic analyses, the SCL-DBD
alternative solutions, evaluation of solutions) or other cog- was found to be excellent at discriminating between chil-
nitive interventions (e.g., identification of anger thought) dren with ODD/CD in a community sample and those in a
were implemented. Moreover, these sessions did not provide clinical sample (area under the curve [AUC] = 0.91), and
skills training with role-play and rehearsal, or interventions showed satisfactory diagnostic accuracy for detecting ODD/
to support transfer to real life (e.g., therapeutic homework CD within the clinical sample (AUC = 0.76) [27].
assignments). Parents attended two parent group sessions The Child Behavior Checklist for Ages 4–18 (CBCL
(90 min each), during which they received psychoeducation 4–18) [28] is a parent-rated questionnaire assessing a broad
on appropriate general parenting strategies. However, these spectrum of child behavioral and emotional problems. It
general parenting strategies were not tailored to the specific consists of 118 problem behavior questions associated with
problems of the child and the parents were not trained to two superordinate scales that reflect externalizing and inter-
implement these techniques in their daily parenting behavior. nalizing syndromes, with higher scores indicating a higher
At post-assessment, 26% of patients in the PLAY condition degree of symptoms. Furthermore, the items can be aggre-
dropped below the cut-off on the parent-rated SCL-DBD gated into eight syndrome scales; however, we did not cal-
total score. A Chi-square test of the distribution of deterio- culate these scales in the present study. The German version
rated or unchanged patients compared to improved patients of the CBCL has been shown to be robust and highly reliable
showed a statistically higher percentage of improved patients (CBCL: Cronbach’s α = 0.69–0.93), and all subscale scores
in the THAV condition compared to the PLAY condition. as well as the total score have shown factorial validity [29].
For a more detailed description, see Görtz-Dorten and col- The parent-rated Symptom Checklist for attention deficit
leagues [11]. hyperactivity disorder (SCL-ADHD) from the DISYPS-II
[23] was used to assess all ADHD symptoms according
Assessment to ICD-10 and DSM-IV criteria, as well as competencies
(endurance, attention, and reflexivity). Parents rated each of
The Questionnaire for Aggressive Behavior of Children the 20 items on a 4-point Likert scale ranging from 0 (not at
(FAVK: Fragebogen zum aggressiven Verhalten von all) to 3 (very much), with higher scores indicating a higher
Kindern) [25] is a parent-rating scale which assesses the degree of symptoms. The SCL-ADHD has been shown to
following maintaining factors of peer- and adult-related be a factorially valid and internally consistent (Cronbach’s
aggression: (1) disturbance of social-cognitive information α = 0.80–0.94) parent questionnaire [30, 31].
processing, (2) disturbance of social skills, (3) disturbance
of impulse control, and (4) disturbance of social interac- Statistical analysis
tion. Parents rated each of the 25 items on a 4-point Likert
scale ranging from 0 (“not at all”) to 3 (“very much”), with Differences between THAV and PLAY regarding the sup-
higher scores indicating a higher degree of symptoms. For port received during the FU period (psychological outpatient
total scores on peer-related aggression-maintaining factors treatment, pharmacotherapy, inpatient treatment, and train-
(FAVK-total peer) and adult-related aggression-maintaining ing therapy), which was assessed by questionnaire (parent
factors (FAVK-total adult), mean standardized scores (sum rating), were evaluated by Chi-square test. The stability of
of item scores)/(number of items) were calculated. Confirm- effects (comparison of post-treatment versus 10-month FU
atory factor analyses (CFA) of the parent ratings confirmed controlling for pre-treatment), and the differences between
the hypothetical four-factor model, and satisfactory internal THAV and PLAY at 10-month FU, were evaluated using
consistencies were found (Cronbach’s α > 0.70) [26]. linear mixed models for repeated measures (MMRM) with
The SCL-DBD [23] is part of the DISYPS-II [23] and the fixed effects group, time, baseline value, and the interac-
measures symptoms of ODD and CD according to the DSM- tion group*time (REML, Satterthwaite adjustment for small
IV and ICD-10 as well as prosocial behavior. The question- sample size). Thus, outcome values are implicitly handled
naire comprises 25 items that are rated with regard to their under the assumption “missing at random”: [32]. A random
severity on a 4-point Likert scale ranging from 0 (“not at cluster effect was specified by group (to account for partial
all”) to 3 (“very much”), with higher scores indicating a clustering), and for the residuals, an unstructured covariance

13
1604 European Child & Adolescent Psychiatry (2023) 32:1599–1608

matrix was allowed over time. Specific contrasts with 95% (­ dpost/FU = 0.06–0.43). These differences were not significant,
confidence intervals and p values were derived from esti- with the exception of the scales SCL-DBD ODD for both
mated marginal means. Effect sizes (Cohen's d) were cal- THAV and PLAY, the SCL-ADHD total for THAV and the
culated, again with 95% confidence intervals. Calculations CBCL-Internalizing problems for PLAY. Here, the values
were performed with Stata/SE 16.1 [33] and SPSS Statistics at FU assessment were significantly lower than those at
26 [34]. post-assessment.
Furthermore, Jacobson’s Reliable Change Index (RCI) A comparison of THAV and PLAY at the FU assessment
was calculated [35] to indicate clinically significant change. revealed, on a descriptive level, lower problem behavior and
Based on means of the SCL-DBD total (pre-treatment vs. higher prosocial behavior in the THAV group compared
FU), patients were divided into three groups: (1) worsened, to PLAY, with effect sizes in the low-to-moderate range
(2) unchanged, and (3) improved. ­(dTHAV/PLAY = 0.22–0.71). These contrasts were significant
for the scales SCL-DBD ODD and SCL-DBD Prosocial
behavior.
Results Figure 2 illustrates the course of mean values over pre-2
(after the waiting period), post (after the treatment period),
Sample characteristics including ICD-10 diagnosis at base- and FU (after the FU period) for THAV and PLAY for
line, age at FU assessment, treatment received during the the primary outcomes (FAVK-F total Peer and SCL-DBD
FU period, and average waiting time are reported in Table 2. ODD).
Chi-square tests indicated no significant differences between
THAV and PLAY regarding treatment received during the
Clinical significance
FU period [psychological outpatient treatment (Χ2(1) = 3.25,
p = 0.07); pharmacotherapy (Χ2(1) = 0.03, p = 0.95); training
The results of the analysis of clinical significance of the
therapy (e.g., on reading and spelling training) (Χ2(1) = 0.74,
changes on the SCL-DBD reveal that compared to pre-
p = 0.39)].
treatment, 0.0% of patients in the THAV condition deterio-
Results of the MMRM including means and SDs (post
rated, 10% did not change reliably, and 90% improved at FU
and FU) as well as effect sizes are detailed in Table 3.
assessment. In the PLAY condition, 2.5% deteriorated, 39%
On a descriptive level, both THAV and PLAY yielded a
did not change reliably, and 58.5% improved. A Chi-square
reduction in problem behavior from post-assessment to FU
test of the distribution of deteriorated or unchanged patients
assessment, with effect sizes in the low-to-moderate range
compared to improved patients showed a statistically signifi-
cant higher percentage of improved patients in the THAV
Table 2  Sample characteristics at follow-up assessment
condition ­(Chi2(1) = 32.00, p < 0.001).

Variable Total sample THAV PLAY

(N = 76) (n = 42) (n = 34)
Discussion
ICD-10 diagnosis at
baseline
F91.1 2 (2.6%) 1 (2.4%) 1 (2.9%) THAV is an individualized CBT treatment program for
F91.2 1 (1.3%) 1 (2.4%) 0 boys aged 6–12 years with a diagnosis of ODD/CD, which
F91.3 57 (75.0%) 25 (76.2%) 32 (73.5%) is combined with parent- (PMT), teacher- and peer-focused
F92.8 2 (2.6%) 1 (2.4%) 1 (2.9%) interventions. In the previous studies, THAV has been shown
F90.1 14 (18.4%) 7 (16.7%) 7 (20.6%) to be effective in reducing aggressive behavior problems
Age (years): mean (SD) 9.9 (1.86) 10 (1.89) 9.9 (1.86) [11, 22]. In particular, a study employing a within-subject
at FU design, which compared the course of symptoms during a
Treatment during FU 6-week waiting period with the course during the subsequent
period (yes: frequency) THAV treatment period, demonstrated a significant decrease
Psychological treatment 20 8 12 in peer-related and adult-related aggressive behavior and a
Medical therapy 12 7 5 significant increase in prosocial behavior. Furthermore, the
Inpatient treatment 0 0 0 RCT evaluation indicated that when compared to an active
Training therapy 5 2 3 control involving group play (PLAY), THAV is specifically
Waiting period: months 10.11 (2.96) 10.0 (3.04) 10.24 (2.88) effective in reducing peer-related aggression, with a low-to-
(SD) moderate-effect size dTHAV/PLAY = -0.46) and in improving
Notes: THAV Treatment program for children with aggressive behav- aggressive and rule-breaking behavior and prosocial behav-
ior, PLAY group play control ior, with moderate-effect sizes.

13
European Child & Adolescent Psychiatry (2023) 32:1599–1608 1605

Table 3  Patient outcomes (parent ratings) on main scales; means and standard deviations for the two assessment points, Cohen’s d effect sizes,
and the results of the analysis of covariance (ANOVA)
Scale Group Descriptive statistics MMRM
Mean (SD; n) Post Mean (SD; n) FU Contrast post-FU Effect size (gain) Contrast PLAY- Effect size
estimate (95% CI); THAV (FU) (Cohen’s
p value Estimate (95% CI); d)
p value

FAVK-total (peer) THAV 0.91 (0.40; 48) 0.75 (0.54; 34) 0.12 (– 0.05 to 0.30 0.30 (– 0.03 to 0.47
0.28); 0.16 0.63); 0.07
PLAY 1.16 (0.51; 35) 1.03 (0.62; 29) 0.11 (– 0.06 to 0.22
0.29); 0.21
FAVK-total (adult) THAV 0.63 (0.37; 48) 0.55 (0.39; 33) 0.09 (– 0.04 to 0.24 0.16 (– 0.06 to 0.37
0.22); 0.17 0.38); 0.15
PLAY 0.83 (0.44; 35) 0.71 (0,50; 29) 0.10 (– 0.05 to 0.23
0.24); 0.18
SCL-DBD (ODD) THAV 1.03 (0.53; 48) 0.80 (0.53; 40) 0.23 (0.04–0.40); 0.43 0.46 (0.08–0.84); 0.60
0.02 0.02
PLAY 1.48 (0.66; 35) 1.23 (0.78; 34) 0.22 (0.02–0.43); 0.33
0.04
SCL-DBD (CD) THAV 0.17 (0.14; 48) 0.13 (0.10; 39) 0.03 (– 0.02 to 0.21 0.07 (– 0.01 to 0.41
0.07); 0.26 0.16); 0.10
PLAY 0.22 (0.17; 35) 0.21 (0.20; 33) 0.01 (– 0.05 to 0.06
0.06); 0.87
SCL-DBD (proso- THAV 1.92 (0.41; 48) 1.97 (0.40; 42) – 0.05 (-0.19 to – 0.12 – 0.03 (– 0.47 to – 0.71
cial behavior) 0.09); 0.45 – 0.10); 0.01
PLAY 1.76 (0.44; 35) 1.66 (0.51; 34) 0.10 (– 0.06 to 0.23
0.26); 0.23
SCL-ADHD (total) THAV 0.95 (0.58; 48) 0.80 (0.57; 42) 0.16 (0.01–0.30); 0.28 0.13 (– 0.14 to 0.22
0.04 0.40); 0.35
PLAY 1.14 (0.59; 35) 0.99 (0.54; 34) 0.12 (– 0.04 to 0.20
0.29); 0.15
CBCL (internaliz- THAV 0.21 (0.18; 48) 0.18 (0.16; 41) 0.02 (– 0.02 to 0.11 0.07 (– 0.00 to 0.49
ing problems) 0.07); 0.30 0.13); 0.06
PLAY 0.27 (0.22; 35) 0.19 (0.17; 31) 0.06 (0.00 to 0.11); 0.27
0.04
CBCL (externaliz- THAV 0.39 (0.20; 48) 0.31 (0.17; 41) 0.06 (– 0.01 to 0.30 0.12 (– 0.01 to 0.45
ing problems) 0.12); 0.08 0.25); 0.07
PLAY 0.56 (0.26; 35) 0.47 (0.30; 33) 0.06 (– 0.01 to 0.23
0.14); 0.09

Notes. FAVK questionnaire for aggressive behavior, SCL-DBD symptom checklist for disruptive behavior disorder, ODD oppositional defiant
disorder, CD conduct disorder, SCL-ADHD symptom checklist for attention deficit hyperactivity disorder, CBCL child behavior checklist

FAVK-F total (peer) SCL-DBD (ODD)

2.5 THAV 2.5 THAV
2 2
Mean scores

Mean scores

PLAY PLAY
1.5 1.5
1 1
0.5 0.5
0 0
Pre2 Post FU Pre2 Post FU

Fig. 2  Comparison of mean scores of pre-2-assessment (Pre2), post-assessment (Post), and follow-up assessment (FU) for the FAVK-F total
(peer) and the SCL-DBD in THAV and PLAY

13
1606 European Child & Adolescent Psychiatry (2023) 32:1599–1608

The aim of the present study was to examine the stabil- To summarize, as the RCT study on post-treatment effects
ity of the effectiveness of THAV at a 10-month FU. We already demonstrated [11], the present findings now indi-
hypothesized that the improvements in child behavior, as cate that the multimodal approach of THAV is superior to
rated by the parents, through THAV treatment would be the active group play of PLAY—not only immediately after
sustained 10 months later from post-treatment to FU, and therapy but also 10 months later. At this point, it is difficult
that the significant effects of THAV compared to PLAY to compare our findings with previous research, because
shown at post-assessment would also be apparent at the we found only two studies [19, 20] that, besides investi-
10-month FU. Overall, the results of our study confirm our gating the stability of effects of CBT (and PMT) on ODD/
hypotheses. Comparable to previous studies on long-term CD, also looked at the differences between the groups at the
effects of CBT and PMT interventions on ODD/CD [17, FU assessment. The first study, by Cavell and Hughes [19],
18], the comparison of post-treatment versus 10-month examined the post-treatment and long-term effects of a CBT
FU indicated the long-term maintenance of treatment out- program (training in problem-solving skills, and consultation
comes. In particular, in THAV, there was no significant with parents and teachers) compared to a ‘Standard Mentor-
deterioration in symptoms of CD and prosocial behav- ing’ program (that was carried out with minimally trained,
ior, or in problem-maintaining and problem-moderating unsupervised mentors) in highly aggressive children. The
factors. Moreover, there was even a further significant authors did not find any group differences at the FU assess-
improvement in oppositional behavior and comorbid ment. However, the study also did not reveal any significant
ADHD symptoms. Similar to Fossum and colleagues [18], group differences at the post-treatment assessment. The sec-
we mostly found small-to-moderate-effect sizes. When ond study, by Pepler and colleagues [20], investigated the
clinical significance analysis is considered, it appears that efficacy of a combined CBT and PMT program compared to
90% of patients in the THAV condition improved at FU an untreated comparison group (waiting list) in aggressive
assessment compared to pre-treatment. Similar findings girls. The study revealed a difference between the groups at
are also seen in the study by Lochman and Wells [13]. post-treatment, but did not find any significant differences
Here, it was shown that the Coping Power intervention between the groups at FU, with the latter being due to the
moved aggression boys’ self-, parent-, and teacher-rated fact that the control group participants had received adequate
behavior problems from a nonnormative range at pre-treat- therapy in the interim. These two studies are therefore also
ment to a normative range by the 1-year FU. difficult to compare with our findings, as in our study, there
The described stability and even partial improvement was no significant difference between THAV and PLAY
are evident not only in the THAV but also on almost all with respect to treatment received during the FU period.
scales in the PLAY condition. On the scale of CBCL- The present study has several strengths and limitations.
Internalizing behavior, the PLAY condition even shows a One strength is that we looked not only at the stability of the
stronger improvement than the THAV condition over the THAV treatment but also at the stability of the differences
FU period. This can possibly be explained by the fact that between THAV and PLAY at FU assessment. To the best
the group condition offers good opportunities for improv- of our knowledge, our study is the first to demonstrate on
ing social skills and an easier transfer to the natural envi- one hand that the therapeutic effects of a multimodal thera-
ronment. The only exception is the SCL-DBD-Prosocial peutic approach for ODD/CD with a focus on child-based
Behavior, which shows a slight, non-significant deteriora- interventions remain stable over a certain period of time,
tion in the PLAY condition over the FU time. and on the other hand that the effects are superior to those of
When comparing THAV and PLAY at FU, it emerged an active control group in the long term. A further strength
that the significant differences between the two condi- of the study is that we examined an active control group
tions found at post-treatment assessment were mostly instead of a waitlist control group. It can be assumed that
also apparent 10 months later (SCL-DBD-ODD, SCL- the differences found between THAV and the control group
DBD-Prosocial Behavior). In contrast to post-treatment would have been even greater if children of the control group
[11], no significant difference between the two conditions had received no therapy at all. Besides other strengths of
was found on the FAVK-F-Peer and CBCL-Externalizing the study, such as the high percentage of participants (84%)
behavior at FU. However, these values narrowly missed retained in the FU, several limitations have to be mentioned.
significance (p = 0.07). With regard to effect sizes, compa- First, ten patients dropped out from the PLAY condition
rable values between post-treatment and FU were evident, after randomization because of ethical objections by the
although some values were slightly higher at the FU (SCL- therapists. For these patients, the more effective treatment
DBD-CD: dpost = 0.27 vs. dFU = 0.41; SCL-DBD-Prosocial according to the hypotheses of the trial was strictly indi-
behavior: dpost = 0.42 vs. dFU = 0.71; CBCL-Internalizing cated according to the regulations of the ethics committee,
behavior (dpost = 0.28 vs. dFU = 0.49). which required that the patients must not be put at a disad-
vantage due to their participation in the trial. Even though

13
European Child & Adolescent Psychiatry (2023) 32:1599–1608 1607

it represents a methodological shortcoming of our study, Hospital Cologne. The authors wish to thank all families that partici-
we decided to exclude the patients from further analyses, pated in this study.
since the alternative—an imputation of missing values in
Author contributions All authors contributed to the study conception
this control group (e.g., with last observation carried for- and design. Material preparation and data collection were performed
ward)—would have favored the treatment group and thus by TL, MD, and AGD. Statistical analyses were performed by TDG,
the research hypotheses. Second, the results are restricted TL, and MH, and reviewed by CH, MD, and AGD. The first draft of the
to boys, and further research should therefore also focus manuscript was written by TDG and TL, and all authors commented
on previous versions of the manuscript. All authors read and approved
on girls. Third, the influence of callous-unemotional traits the final manuscript.
was not assessed in the FU. The impact of limited proso-
cial capacities and of psychopathic or callous-unemotional Funding Open Access funding enabled and organized by Projekt
personalities on the effect of THAV and PLAY should be DEAL. The study received financial support from the School of Child
considered in further studies. Fourth, all outcome meas- and Adolescent Behavior Therapy at the University Hospital Cologne.
ures were based on parent ratings. As such, the results are
Availability of data and materials The datasets generated and analyzed
influenced by the parents' perceptions and expectancies and during the current study are not publicly available due to obligation to
may be biased due to effort justification. However, this bias secrecy toward the participants.
may be similar in both conditions. Moreover, parents cannot
make an accurate statement about their children’s behavior Code availability Not applicable.
at school. Here, teacher ratings would have been helpful.
However, although we also collect the teachers’ question- Declarations
naires at FU assessment, we did not include these in the
analyses due to a high number of missing data. Likewise, we Conflict of interest A.G.-D. and M.D. receive royalties from publish-
ing companies as authors of books and treatment manuals on child
also collected self-ratings from the age of 10 years, but here behavioral therapy and of assessment manuals, including the treatment
too, there were too few available data. Future studies should manual for THAV, which is evaluated in this trial. The other authors
consider not only parent ratings but also self- and teacher are not aware of any conflicts of interest regarding this work.
ratings to draw a more complete picture. Fifth, parents could
Ethics approval The protocol of the study conducted at the University
not be fully blinded, because they actively took part in the of Cologne (Clinical trials.gov Identifier: NCT01406067) was approved
intervention. Nevertheless, parents were blinded to the spe- by the ethics committee of the University Hospital, Cologne. The study
cific hypotheses of the study and many of the parents in the was performed in accordance with the ethical standards laid down in
PLAY condition actually believed that this was the interven- the 1964 Declaration of Helsinki and its later amendments.
tion that was expected to be more effective. Finally, adher- Consent to participate All participants provided written informed
ence to the interventions should be considered in further consent.
studies. Information on adherence on THAV can be found
in the RCT article [11], but an analysis of the differences in Consent for publication All parents gave consent for publication prior
to the study.
adherence between THAV and PLAY also seems interest-
ing, as PLAY may be an effective treatment method and not
simply an unspecific control group. Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
Conclusion were made. The images or other third party material in this article are
included in the article's Creative Commons licence, unless indicated
Overall, the study found that the effects of the individu- otherwise in a credit line to the material. If material is not included in
ally tailored treatment program THAV, which combines the article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
patient-focused (CBT) with parent- (PMT), teacher-, and need to obtain permission directly from the copyright holder. To view a
peer-focused interventions, were retained at a 10-month FU copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/.
assessment. The effects that were found at the end of the
treatment remained stable and even partially improved over
the FU period. Additionally, the differences between THAV References
and the active control group PLAY, which were apparent
at the end of the treatment (post), mainly also persisted 1. Kimonis ER, Frick PJ, McMahon RJ (2014) Conduct and oppo-
10 months later. sitional defiant disorders. In: Mash EJ, Barkley RA (eds) Child
psychopathology. Guilford Press, New York, pp 145–179
2. Fergusson DM, Horwood LJ, Ridder EM (2005) Show me the
Acknowledgements The study received financial support from the child at seven: the consequences of conduct problems in childhood
School of Child and Adolescent Behavior Therapy at the University

13
1608 European Child & Adolescent Psychiatry (2023) 32:1599–1608

for psychosocial functioning in adulthood. J Child Psychol Psy- children and adolescents with conduct problems. J Child Fam
chiatry 46(8):837–849 Stud 25:15–29
3. Loeber R, Burke J, Pardini DA (2009) Perspectives on opposi- 19. Cavell TA, Hughes JN (2000) Secondary prevention as context for
tional defiant disorder, conduct disorder, and psychopathic fea- assessing change processes in aggressive children. J Sch Psychol
tures. J Child Psychol Psychiatry 50(1–2):133–142 38(3):199–235
4. Washburn JJ, Romero EG, Welty LJ, Abram KM, Teplin LA, 20. Pepler D, Walsh M, Yuile A, Levene K, Jiang D, Vaughan A,
McClelland GM et al (2007) Development of antisocial person- Webber J (2010) Bridging the gender gap: Interventions with
ality disorder in detained youths: The predictive value of mental aggressive girls and their parents. Prev Sci 11(3):229–238
disorders. J Consult Clin Psychol 75(2):221 21. Görtz-Dorten A, Döpfner M (2019) Therapieprogramm für Kinder
5. Webster-Stratton C, Reid MJ, Hammond M (2004) Treating chil- mit aggressivem Verhalten (THAV) [Treatment Program for Chil-
dren with early-onset conduct problems: Intervention outcomes dren with Aggressive Behavior]. Hogrefe, Göttingen
for parent, child, and teacher training. J Clin Child Adolesc Psy- 22. Görtz-Dorten A, Benesch C, Hautmann C, Berk-Pawlitzek E,
chol 33(1):105–124 Faber M, Lindenschmidt T et al (2017) Efficacy of an individual-
6. Kazdin AE (2010) Problem-solving skills training and parent man- ized social competence training for children with oppositional
agement training for oppositional defiant disorder and conduct defiant disorders/conduct disorders. Psychother Res 27:326–337
disorder. In: Weisz JR, Kazdin AE (eds) Evidence-based psycho- 23. Döpfner M, Görtz-Dorten A, Lehmkuhl G (2008) DISYPS-II:
therapies for children and adolescents. Guilford Press, New York, Diagnostik-System für psychische Störungen im Kindes- und
pp 221–226 Jugendalter nach ICD-10 und DSM-IV [DISYPS-II: diagnostic
7. Menting AT, de Castro BO, Matthys W (2013) Effectiveness of the system for psychiatric disorders in children and adolescents], 3rd
Incredible Years parent training to modify disruptive and proso- edn. Hans Huber, Bern
cial child behavior: A meta-analytic review. Clin Psychol Rev 24. Görtz-Dorten A, Döpfner M (2008) Diagnose-Checklisten aus
33(8):901–913 dem Diagnostik-System für Psychische Störungen im Kindes- und
8. National Institute for Health and Care Excellence (2013) Antiso- Jugendalter (DISYPS-II) – Gütekriterien und klinische Anwend-
cial behaviour and conduct disorders in children and young peo- ung. Zeitschrift Klinische Diagnostik und Evaluation 1:378–394
ple: Recognition, intervention, and management. National Clinical 25. Görtz-Dorten A, Döpfner M (2010) Fragebogen zum aggres-
Guideline Number 158. National Institute for Health and Care siven Verhalten von Kindern (FAVK) [German questionnaire for
Excellence. IOP Publishing Nice. https://​www.​nice.​org.​uk/​guida aggressive behaviour]. Hogrefe, Göttingen
nce/cg158. Accessed 9 Sep 2020 26. Benesch C, Görtz-Dorten A, Breuer D, Döpfner M (2013) Erfas-
9. Battagliese G, Caccetta M, Luppino OI, Cardi BC, V, Mancini F, sung aggressionsauslösender und -aufrechterhaltender Faktoren
et al (2015) Cognitive-behavioral therapy for externalizing disor- bei Kindern mit oppositionellen und aggressiven Verhaltens-
ders: A meta-analysis of treatment effectiveness. Behav Res Ther störungen im Eltern-, Lehrer- und Selbsturteil: Zur Reliabilität
75:60–71 und Validität des Fragebogens zum aggressiven Verhalten von
10. Webster-Stratton C, Reid J, Hammond M (2001) Social skills Kindern (FAVK). Z Klin Psychol Psychother 42(4):1–11
and problem-solving training for children with early-onset 27. Görtz-Dorten A, Ise E, Hautmann C, Walter D, Döpfner M (2013)
conduct problems: Who benefits? J Child Psychol Psychiatry Psychometric properties of a German parent rating scale for ODD
42(7):943–952 and CD (FBB-SSV) in clinical and community samples. Child
11. Görtz-Dorten A, Benesch C, Berk-Pawlitzek E, Faber M, Haut- Psychiatry Hum Dev 45(4):388–397
mann C, Hellmich M et al (2019) Efficacy of individualized social 28. Achenbach TM (1991) Manual for the child behaviour checklist
competence training for children with oppositional defiant dis- 4–18 and 1991 profile. University of Vermont, Department of
orders/conduct disorders: a randomized controlled trial with an Psychiatry, Burlington
active control group. Eur Child Adolesc Psychiatry 28(2):165–175 29. Döpfner M, Plück J, Kinnen C, für die Arbeitsgruppe Deutsche
12. Kazdin AE, Siegel TC, Bass D (1992) Cognitive problem- solv- Child Behavior Checklist (2014) Manual deutsche Schulalter-For-
ing skills training and parent management training in treatment men der Child Behavior Checklist von Thomas M. Achenbach.
of antisocial behaviour in children. J Consult Clin Psychol Elternfragebogen über das Verhalten von Kindern und Jugendli-
60(5):733–747 chen, (CBCL/ 6–18R), Lehrerfragebogen über das Verhalten
13. Lochman JE, Wells KC (2004) The coping power program for von Kindern und Jugendlichen (TRF/6–18R), Fragebogen für
preadolescent aggressive boys and their parents: outcome effects Jugendliche (YSR/11–18R). Hogrefe, Göttingen
at the 1-year follow-up. J Consult Clin Psychol 72(4):571–578 30. Breuer D, Wolff-Metternich T, Döpfner M (2009) Die Erfas-
14. Helander M, Lochman J, Högström J, Ljótsson B, Hellner C, sung von Merkmalen von Aufmerksamkeitsdefizit/Hyperaktiv-
Enebrink P (2018) The effect of adding Coping Power Program- itätsstörungen (ADHS) anhand von Lehrerurteilen. Zur Validität
Sweden to Parent Management Training-effects and moderators und Reliabilität des FBB-HKS. Z Kinder Jugendpsychiatr Psy-
in a randomized controlled trial. Behav Res Ther 103:43–52 chother 37(5):431–440
15. McCart MR, Priester PE, Davies WH, Azen R (2006) Differential 31. Erhart M, Döpfner M, Ravens-Sieberer U, BELLA Study Group
effectiveness of behavioral parent-training and cognitive-behavio- (2008) Psychometric properties of two ADHD questionnaires:
ral therapy for antisocial youth: A meta-analysis. J Abnorm Child comparing the Conners’ scale and the FBB-HKS in the general
Psychol 34(4):525–541 population of German children and adolescents – results of the
16. Masi G, Milone A, Paciello M, Lenzi F, Muratori P, Manfredi BELLA study. Eur Child and Adolesc Psychiatry 17:106-11
A et al (2014) Efficacy of a multimodal treatment for disruptive 32. Molenberghs G, Thijs H, Jansen I, Beunckens C, Kenward MG,
behavior disorders in children and adolescents: Focus on internal- Mallinckrodt C et al (2004) Analyzing incomplete longitudinal
izing problems. Psychiatry Res 219(3):617–624 clinical trial data. Biostatistics 5(3):445–464
17. van Aar J, Leijten P, de Castro BO, Overbeek G (2017) Sustained, 33. Stata Statistical Software 16 (2019) StataCorp, TX
fade-out or sleeper effects? A systematic review and meta-analysis 34. SPSS Statistics 26 (2019) IBM Corp, Armonk
of parenting interventions for disruptive child behavior. Clin Psy- 35. Jacobson NS, Truax P (1991) Clinical significance: a statisti-
chol Rev 51:153–163 cal approach to defining meaningful change in psychotherapy
18. Fossum S, Handegård BH, Adolfsen F, Vis SA, Wynn R (2016) research. J Consult Clin Psychol 59:12–19
A meta-analysis of long-term outpatient treatment effects for

13