Therapeutic assessment for preadolescent boys with oppositional defiant disorder: a replicated single-case time-series design.
ABSTRACT The Therapeutic Assessment (TA) model is a relatively new treatment approach that fuses assessment and psychotherapy. The study examines the efficacy of this model with preadolescent boys with oppositional defiant disorder and their families. A replicated single-case time-series design with daily measures is used to assess the effects of TA and to track the process of change as it unfolds. All 3 families benefitted from participation in TA across multiple domains of functioning, but the way in which change unfolded was unique for each family. These findings are substantiated by the Behavior Assessment System for Children (Reynolds & Kamphaus, 2004). The TA model is shown to be an effective treatment for preadolescent boys with oppositional defiant disorder and their families. Further, the time-series design of this study illustrated how this empirically grounded case-based methodology reveals when and how change unfolds during treatment in a way that is usually not possible with other research designs.
- SourceAvailable from: J.D. SmithJournal of Personality Assessment 07/2013; · 1.29 Impact Factor
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ABSTRACT: Multicultural responsiveness and adaptation have been a recent area of emphasis in prevention and intervention science. The changing demographics of the United States demand the development of intervention strategies that are acceptable and effective for diverse cultural and ethnic groups. The Family Check-Up (FCU) was developed to be an intervention framework that is flexible and adaptive to diverse cultural groups (Dishion & Stormshak, 2007 ). We empirically evaluated the extent to which the intervention is effective for improving youth adjustment and parent-child interactions for diverse cultural groups. A sample of 1,193 families was drawn from 2 large-scale randomized prevention trials conducted in diverse urban middle schools. We formulated 3 groups on the basis of youth self-identification of ethnicity (European American, African American, Hispanic) and examined group differences in the hypothesized mediating effect of family conflict (FC) on later antisocial behavior (ASB). Path analysis revealed that youths in the intervention condition reported significantly less ASB over a 2-year period (Grades 6-8). Moreover, youth-reported reductions in FC at 12 months were an intervening effect. Ethnicity did not moderate this relationship. Consistent with one of the primary tenets of coercion theory, participation in the FCU acts on ASB through FC across diverse ethnic groups, lending support to the multicultural competence of the model. Limitations of this study are discussed, along with areas for future research.Journal of Clinical Child & Adolescent Psychology 04/2014; · 1.92 Impact Factor
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ABSTRACT: Objective: This study examines observations of client in-session engagement and fidelity of implementation to the Family Check-Up (FCU) as they relate to improvements in caregivers' positive behavior support (PBS) and children's problem behavior in the context of a randomized prevention trial. The psychometric properties of fidelity scores obtained with a new rating system are also explored. Method: The FCU feedback sessions of 79 families with children with elevated problem behavior scores at age 2 were coded by trained raters of fidelity, who used an observational coding system developed specifically for this intervention model. Results: Path analysis indicated that fidelity to the FCU results in greater caregiver engagement in the feedback session, which directly predicts improvements in caregivers' PBS 1 year later (β = 0.06, 95% CI [.007, .129]). Similarly, engagement and PBS directly predict reductions in children's problem behavior measured 2 years later (β = -0.24, 95% CI [-.664, -.019]). Conclusions: These results suggest fidelity within the context of this randomized intervention trial. Ratings of fidelity to the FCU covary with observed improvements in parenting and children's problem behavior in early childhood. Overall reliability of the fidelity scores was found to be acceptable, but some single-item reliability estimates were low, suggesting revisions to the rating system might be needed. Accurately assessing fidelity and understanding its relationship to change during intervention studies is an underdeveloped area of research and has revealed some inconsistent findings. Our results shed light on the mixed conclusions of previous studies, suggesting that future research ought to assess the role of intervening variable effects, such as observed engagement. (PsycINFO Database Record (c) 2013 APA, all rights reserved).Journal of Consulting and Clinical Psychology 07/2013; · 4.85 Impact Factor
Therapeutic Assessment for Preadolescent Boys With Oppositional Defiant
Disorder: A Replicated Single-Case Time-Series Design
Justin D. Smith, Leonard Handler, and Michael R. Nash
University of Tennessee, Knoxville
The Therapeutic Assessment (TA) model is a relatively new treatment approach that fuses assessment
and psychotherapy. The study examines the efficacy of this model with preadolescent boys with
oppositional defiant disorder and their families. A replicated single-case time-series design with daily
measures is used to assess the effects of TA and to track the process of change as it unfolds. All 3 families
benefitted from participation in TA across multiple domains of functioning, but the way in which change
unfolded was unique for each family. These findings are substantiated by the Behavior Assessment
System for Children (Reynolds & Kamphaus, 2004). The TA model is shown to be an effective treatment
for preadolescent boys with oppositional defiant disorder and their families. Further, the time-series
design of this study illustrated how this empirically grounded case-based methodology reveals when and
how change unfolds during treatment in a way that is usually not possible with other research designs.
Keywords: case-based, oppositional defiant disorder, therapeutic assessment, time-series, treatment
The evidence-based practice movement has ushered in an era of
great scrutiny regarding the effectiveness of psychological inter-
ventions. Despite the presence of a number of well-established
treatments for oppositional and conduct problems, the corpus of
research on interventions for children and families is not strong,
and most empirically supported treatments are almost always
entirely based on behavioral and cognitive-behavioral principles
(Ollendick, King, & Chorpita, 2006). This is not to say that other
treatment modalities are unsupported. Rather, they have yet to be
sufficiently tested (Ollendick et al., 2006). Clearly, additional
rigorous examination of child-focused interventions is warranted,
as well as the development of innovative family-based approaches
for common childhood problems.
The Therapeutic Assessment (TA) model (e.g., Finn, 2007; J. D.
Smith, Wolf, Handler, & Nash, 2009; Tharinger, Finn, Wilkinson,
& Schaber, 2007) is a focused intervention for adults, adolescents,
children, and couples that fuses psychological assessment and brief
psychotherapy. TA blends the extensive conceptualizing benefits
of assessment with therapeutic techniques (Finn, 2007). The TA
interventional process begins immediately upon first patient con-
tact. The psychological assessment process itself is the substrate
upon which the intervention is grounded.
TA with children and families incorporates systemic, develop-
mental, and narrative theory principles into a child-focused, family
intervention. Systemic theory emphasizes the importance of con-
textual influences on behavior, addressing larger interpersonal and
social systems when planning effective treatments (Tharinger,
Finn, Austin, et al., 2008). Experts in child therapy generally agree
on the importance of using a systemic approach that treats the child
within the greater context of the family (e.g., Dishion & Storm-
shak, 2007). The importance of a systemic approach has been
recognized in recent years by some in the field of assessment
psychology as well, resulting in what experts are referring to as a
paradigm shift in the way child assessments are conducted (Finn,
2007; Handler, 2007; Tharinger, Finn, Austin, et al., 2008). TA
also relies heavily on narrative theory (Josselson, Leiblich, &
McAdams, 2007), unrepresented among current empirically sup-
ported treatments for childhood disruptive behavior disorders.
TA has been applied to adults, couples, children, adolescents,
and families. The body of research examining the use of TA with
children is growing, with promising results to date. The use of TA
has yielded preliminary evidence of effectiveness in treating chil-
dren’s aggressive and oppositional behaviors in a clinical case
study (Hamilton et al., 2009) and an empirical case study (J. D.
Smith, et al., 2009). A number of other clinical case studies
suggest TA might be effective in treating other common child-
hood/family problems (e.g., Purves, 2002; J. D. Smith, Finn,
Swain, & Handler, 2009; J. D. Smith, Nicholas, Handler, & Nash,
2009; Tharinger et al., 2007). One group study found treatment
acceptability and symptom improvement in children and families
after completing TA (Tharinger et al., 2009). The small body of
empirical research with adults and adolescents has also demon-
strated effectiveness using group comparison studies (e.g., Finn &
Tonsager, 1992; Newman & Greenway, 1997; Ougrin, Ng, & Low,
2008). In this study, we examine the efficacy of TA with pread-
olescent boys with oppositional defiant disorder (ODD) and their
Justin D. Smith, Leonard Handler, and Michael R. Nash, Department of
Psychology, University of Tennessee, Knoxville.
This work was supported by a grant from the Society for Personality
Assessment to Justin D. Smith. The authors express their appreciation to
Stephen E. Finn for the generous contribution of his time in completing the
treatment integrity ratings.
Correspondence concerning this article should be addressed to Justin D.
Smith, who is now at University of Colorado at Denver School of Medicine,
Department of Psychiatry, Division of Clinical Psychology, Box F546, 13001
E. 17th Place, Denver, CO 80045. E-mail: firstname.lastname@example.org
2010, Vol. 22, No. 3, 593–602
© 2010 American Psychological Association
families. We use a replicated single-case design with daily time-
series measures. Daily measures allow the researcher to examine
the effectiveness of the intervention and track the process of
change across time. We hypothesize that participation in TA will
lead to improvement in the child’s ODD symptoms, as evidenced
by reductions across multiple behavioral areas, as reported by the
parent(s) and child on the Behavior Assessment System for Chil-
dren (Reynolds & Kamphaus, 2004) and daily measures using
phase-effect analyses. Second, Finn (2007) proposed that benefits
from TA continue beyond the completion of the formal interven-
tion. We test whether this is the case.
Oppositional Defiant Disorder in Children
ODD is one of the most common disorders among children in
clinical populations, with one study finding a lifetime prevalence
estimate of 10.2% in the United States (Nock, Kazdin, Hiripi, &
Kessler, 2007). This and other studies have found higher rates for
boys than for girls and have found that the incidence rate of ODD
peaks around age 10 (Maughan, Rowe, Messer, Goodman, &
Meltzer, 2004). A number of individual risk factors have been
identified as precursors of ODD, such as biological, psychosocial,
and functional factors (for a review, see Burke, Loeber, & Birma-
her, 2002). But the pathogenesis of ODD is complex: Intrafamilial
social processes and familial risk factors are consistently impli-
cated in the development of ODD (Johnston & Mash, 2001). Some
studies suggest that parenting practices are at least a partial con-
tributing factor in the development of disruptive behavior disor-
ders (Frick & Loney, 2002; C. Smith & Farrington, 2004). For
example, lack of parental supervision; lack of parental involve-
ment; inconsistent discipline practices; child abuse (Connor,
2002); lack of warmth and positive involvement (Kashdan et al.,
2004; Stormshak, Bierman, McMahon, & Lengua, 2000); and
negative, physically aggressive punishment (Kashdan et al., 2004;
Stormshak et al., 2000) have all been linked to the disorder. Given
the strong connection between ODD and familial factors, it is not
surprising that many empirically supported treatments for this
disorder target multiple levels, most commonly the child and
parent and, at times, the family as a whole (Loeber, Burke, &
Pardini, 2009). Interventions focused exclusively on the child are
not promising (Burke et al., 2002); the most successful treatment
models typically include intervention components for both the
child and parents (see Pardini, 2008, for a review of empirically
supported ODD treatments).
Importance of Time-Series Designs in Psychological
Despite the endorsement of time-series as true experiment,
worthy of standing alongside group designs in psychotherapy
outcome research (e.g., Kazdin, 1992; Peterson, 2004), no inter-
vention has reached empirically supported status based on the
weight of time-series findings alone (Borckardt et al., 2008). Many
now argue that case-based time-series designs ought to be used
more often, precisely because these designs can reveal not only
efficacy but also the trajectory of clinical improvement across time
(e.g., Chambless & Ollendick, 2001; Kazdin, 2007; Morrison,
Bradley, & Westen, 2003; Peterson, 2004). When we track change
continuously through treatment we then have a better chance to
observe mechanisms at play. Kazdin (2007) made this point when
he called for clinical research designs that reveal mechanisms.
Skinner (1938) made a similar point about single-organism re-
search being especially well suited for understanding how (and
under what conditions) new behavioral repertoires emerge.
Method Part 1: Treatment Protocol
Participant Selection and Referral Procedures
Parents referring boys for assessment or child/family psycho-
therapy at a university outpatient clinic within the specified age
range (9–12 years) were scheduled for an intake appointment with
the clinician/researcher (first author). Prior to meeting with the
clinician, the family completed a demographic questionnaire (ages
of family members, education, ethnicity, household income, par-
ents’ or caregivers’ education, number of children, child’s school,
etc.). The initial meeting included a semistructured clinical inter-
view, rather than the typical structured interview used in laboratory
procedures, which covered the source of referral, presenting prob-
lem and history, familial history of mental health, the child’s
homocidality/suicidality, relevant medical history, and mental sta-
tus examination. Significant attention was given to the determina-
tion of an ODD diagnosis. The clinician’s diagnoses were con-
firmed in consultation with the supervising psychologist (second
The Therapeutic Assessment Model for Children
This study employed the comprehensive family TA model previ-
ously presented in the literature except that only one clinician con-
ducted the assessment, as opposed to the two-clinician condition
typically used (see Hamilton et al., 2009; J. D. Smith, et al., 2009;
Tharinger et al., 2007, for examples of the comprehensive model).
This was done to make the model more accessible to practitioners in
real-world clinical settings. TA with children and families consists of
roughly nine weekly 1–2-hr sessions composed of an initial meeting;
three or four test-administration sessions; a family intervention ses-
sion (Tharinger, Finn, Austin, et al., 2008); a summary/discussion
session (Finn, 2007; Tharinger, Finn, Hersh, et al., 2008); a child
feedback session (Tharinger, Finn, Wilkinson, et al., 2008); and a
follow-up session (Finn, 2007), which typically occurs 60 days after
the child feedback session. The TA model for children is presented in
Figure 1, which also includes elements of the research design that will
be discussed in later sections. Although the intended model assumes
consecutive weekly visits, these cases were more typical of how
clinicians encounter clients in real-world settings and included ses-
sions missed because of vacations, illnesses, and other circumstances.
Similarly, total hours for each case varied and are reported in the
Defining principles and goals.
tive relationship among the clinician, the child, and his or her
family. From the first contact, the family works in partnership with
the clinician to determine the direction of the assessment (Finn,
2007) and is then closely involved in each aspect of the treatment
thereafter. The clinician’s relationship with each family member
also becomes a venue for gathering important information about
family processes and dynamics (Finn, 2007; Tharinger et al.,
TA emphasizes a collabora-
SMITH, HANDLER, AND NASH
2007). A shared curiosity about the family’s problems is allowed
to emerge through collaboration and the therapeutic relationship.
The American Academy of Child and Adolescent Psychiatry
(2007) reported that “successful treatment of ODD requires the
successful establishment of a therapeutic alliance with the child
and family” (p. 131). The family TA model relies heavily on
narrative theory (e.g., Josselson et al., 2007) when describing the
broad goal or outcome of the family TA model, which is to assist
families in developing more cohesive, compassionate, accurate,
and empathic stories about their child and the family (Tharinger et
al., 2007). The clinician focuses on the existing story the family
holds about the child’s problems and attempts to identify elements
of this story that can be altered to understand more accurately what
is occurring within the family. Finn and Tonsager’s (1997) land-
mark article further describes the differences between therapeutic
approaches to assessment and the more traditional paradigm often
characterized as an information-gathering approach.
The initial meeting.
In addition to the determination of study
participation and diagnosis described above, the initial meeting
with the parents had a number of goals: (a) Establish a safe and
trusting environment, (b) enlist the parents as collaborators in the
assessment process, (c) establish a set of assessment questions
(Finn, 2007) that will guide the treatment and (d), follow-up
inquiry in regard to the family’s questions (Finn, 2007).
ferred to the second, third, fourth, and sometimes fifth sessions of
TA as standardized testing of the child (e.g., J. D. Smith &
Handler, 2009; Tharinger et al., 2007). Although many psycho-
logical test instruments are administered and used in their pro-
scribed fashion, so as not to affect nomothetic comparisons, TA
adherents emphasize obtaining additional information through
such procedures as an extended inquiry (Handler, 2005); testing of
the limits (Handler, 1998, 2005); and other follow-up procedures,
some as simple as asking the child to reflect on the testing
experience or particular responses. The additional information
gleaned from these nonstandardized procedures often illuminates
the nomothetic test results, while also providing the clinician with
an opportunity to hear the child’s “story” (Finn, 2007). For exam-
ple, during the free-response phase of the Rorschach inkblot
method, a child may see “a green dragon breathing fire and flying
over a village of frightened people.” Following the inquiry, the
Previous publications have re-
clinician might ask the child to tell a story about the dragon, thus
illuminating themes related to the child’s experiences and provid-
ing a personal basis for interpretation of the formal scoring of this
response. Similarly, a child may be asked to elaborate on a par-
ticular response on the Millon Pre-Adolescent Clinical Inventory
of Personality (Millon, Tringone, Millon, & Grossman, 2005),
such as why the child answered “true” to losing his or her temper
easily. The clinician might ask the child, “What came to mind
when you answered this question?” Again, the child’s associations
to this question provide a context for interpretation. The parents,
who are observing the test administration, also benefit from hear-
ing their child’s responses in the context of daily life.
To increase uniformity, a battery of self-report (e.g., Millon
Pre-Adolescent Clinical Inventory of Personality [Millon, Trin-
gone, Millon, & Grossman, 2005], Behavior Assessment System
for Children [Reynolds & Kamphaus, 2004]) and performance-
based (e.g., Wechsler Intelligence Scales for Children [Wechsler,
2003], Rorschach inkblot method [Exner, 2003], The House-Tree-
Person Test [Buck, 1966]) psychological assessment instruments
were administered to each child during the test administration
sessions.1In two of the cases, additional measures were also
included to test for attention-deficit/hyperactivity disorder and a
learning disorder. Results of the testing were not indicative of
Family intervention session.
family sessions (Tharinger, Finn, Austin, et al., 2008), use various
procedures to introduce the family’s problems-in-living into the
room and provide an opportunity for those problems to be worked
through with the clinician. These sessions help the clinician and
family better understand family interactions and the way in which
they may help or hinder the family’s capacity to deal with the
child’s problem behaviors (Tharinger, Finn, Austin, et al., 2008).
Tharinger, Finn, Austin, et al. (2008) described a number of
potential outcomes of a family session: (a) Family sessions allow
the clinician to observe the child in the family context, while
testing systemic hypotheses and helping parents to also develop a
systemic view of the child’s problems. (b) As families begin to
adopt a more systemic understanding, the child may feel less
blamed and, over time, gain self-esteem. (c) Family sessions can
also be an opportunity to test possible interventions and provide
the family with a positive experience of family therapy. (d) Family
sessions can also serve to foster positive family relationships.
Family sessions often use established family therapy techniques
and activities, such as family sculpture (Constantine, 1978) and
family psychodrama (Flomenhaft & DiCori, 1992).
As noted above, family sessions are tailored to the specific
needs of each family, and the clinician is allowed to use many
different techniques that have the potential of meeting the ses-
sion’s goals. For example, to help the parents develop a more
systemic understanding of their child’s problems, one family in
this study was asked to play a board game. First they played
Family intervention sessions, or
1Test selection and the subsequent duration of test administration is
typically determined by the assessment questions. However, for the pur-
poses of research in which the clinician/researcher knew the presenting
problem (ODD) a priori, a battery of test instruments was preselected to
increase uniformity across cases, reduce potential test effects, and assess
multiple factors related to ODD symptomatology and etiology.
2 3 4 5 6 7 8 9
(≈10 Days) (Weekly Meetings) (≈60 Days)
Family Intervention Session
Child Feedback Session
research design elements.
A priori timeline of the therapeutic assessment model and
THERAPEUTIC ASSESSMENT FOR BOYS WITH ODD
together (child, mother, and father) while the clinician observed.
The parents then took turns playing the game with their son or
observing the interaction via the video link alongside the clinician.
This exercise was meant to illustrate for the parents the need for
parental unity, which resulted in greater structure for the child.
Afterward, in discussion with the clinician, the parents accurately
reported that their son was much more likely to “bend the rules” of
the game and behave disruptively when only one parent was
playing with him. When both parents were engaged in the task at
the same time, their son was better behaved, and the parents
reported more confidence in their ability to manage him because of
the support of their spouse.
ing feedback to the parents in the form of collaborative dialogue.
Planning for this session is a crucial component in how effective
the overall assessment can be. Finn and colleagues’ (Finn, 2007;
Tharinger, Finn, Hersh, et al., 2008) concept of “levels” of infor-
mation helps to structure the order in which findings will be
presented. Level 1 feedback is information that is consistent with
the parents’ currently held views. Level 1 information is readily
accepted, raises little anxiety, and validates clients’ external real-
ity. Level 2 information is not wholly in disagreement with the
parents’ existing story, but it may require reformulation of the
current view and, thus, might cause some anxiety. Information that
is entirely dystonic to the parents’ story is termed Level 3. This
kind of feedback has the potential to raise the parents’ anxiety
substantially and, without the proper preparation, might be re-
The clinician organizes the assessment questions, from Level 1
to Level 3, on the basis of (a) the parent’s preliminary understand-
ing of the question, (b) its congruence with the test findings and
conclusions, and (c) evidence during the previous sessions that
indicates a shift in the parents’ understanding of the child (Thar-
inger, Finn, Hersh, et al., 2008). Using the previously described
family session as an example, even though these parents initially
were unable to articulate that a unified parental unit was important
in behavioral management of their son, the clinician determined
that this feedback was now Level 2. The parents had experienced
the results and were able to identify this answer fairly well during
the family session, indicating minimal anxiety related to integrat-
ing this finding into the understanding of their son.
The way in which feedback is provided in TA has been found to
have a significant impact on the changes experienced by the client
(e.g., Finn, 1996; Finn & Tonsager, 1992; Newman & Greenway,
1997). Following this session, the clinician summarizes the ses-
sion’s discussion in the form of a letter, using everyday language,
rather than the traditional, often jargon-filled, psychological eval-
uation report (for examples of letters to parents provided in family
TA, see Smith & Handler, 2009 and Tharinger et al., 2007).
Child feedback session.
Feedback to the child in TA is often
given in the form of an individualized fable or story that is tailored
to the emotional capacities of the child and family (Tharinger,
Finn, Wilkinson, et al., 2008). However, other methods of feed-
back to children are also acceptable within the parameters of the
TA model. The goal of this session parallels that of the TA as a
whole: Provide the child with a more accurate, cohesive, empathic,
and compassionate story (Tharinger et al., 2007). The clinician
summarizes important events in the child’s life that have contrib-
uted to his or her current situation, while also instilling a sense of
This session involves provid-
hope for the future. Children have been found to feel more under-
stood and validated through a successful feedback session, in
which a fable is provided to the child. Fables and other forms of
child feedback provide an experience of positive accurate mirror-
ing (Tharinger, Finn, Wilkinson, et al., 2008). J.D. Smith, et al.
(2009) and Tharinger, Finn, Wilkinson, et al. (2008) provide
examples of fables used in a TA.
Finn (2007) noted the importance of a
follow-up session 4–8 weeks after the completion of the TA. He
found that many families benefit from the experience and recom-
mendations of the TA, but when much of the information is
dystonic, families need a booster session to further integrate the
TA experience into their existing story. This session also allows
the clinician an opportunity to receive feedback about how TA
affected the family and then reevaluate the recommendations and
conclusions in light of new information. It is important to note that
none of the families entered into any child/family treatment during
the follow-up period, which was a condition of inclusion in the
One defining feature of the family TA model is use of live
video, which allows parents to observe the assessment of their
child in real time. During test-administration sessions, parents
observed the child and clinician in an adjacent room via video link.
The clinician met briefly with the parents before each session to
prepare. They were provided with test materials to follow along as
they were administered to the child and were encouraged to take
notes. The clinician then met with the child in the adjacent room.
The last half hour of each session was reserved for “miniconsul-
tations” (Tharinger et al., 2007) between the clinician and parents.
The initial meeting, family intervention session, child feedback
session, and follow-up session included the child and his parent(s),
whereas the summary/discussion session involved only the clini-
cian and parents.
Method Part 2: Elements of the Research Protocol
Participant Selection and Description
In accordance with specified criteria for replicated single-case
design experiments, a small set of successive cases (n ? 3) with
the same presenting diagnosis was examined (Chambless & Ol-
lendick, 2001; Ollendick et al., 2006). Participants were not re-
cruited for participation in a research study, in an effort to increase
generalizability and limit sample-selection bias. Further, it was the
intention of the researchers to examine the efficacy of the TA
model with children commonly encountered in real-world clinical
settings, which is in contrast to a highly controlled sample typi-
cally sought in treatment-outcome studies.
Screening was conducted during the initial meeting, based on
the following inclusion and exclusion criteria: Male child, age
9–12 years, meets diagnostic criteria for ODD as defined by the
Diagnostic and Statistical Manual of Mental Disorders (4th ed.,
text rev.; DSM–IV; American Psychiatric Association, 2000). The
child must be free of organic brain deficits, including head trauma
or mental retardation, and cannot be displaying psychotic symp-
SMITH, HANDLER, AND NASH
toms; one parent or guardian must be willing and able to attend
each and every session. This parent or guardian also must be free
of severe psychopathology (e.g., autism, brain damage, psychosis).
The parent(s) consent(s) to their expected level of involvement and
that of child; the family is not currently participating in a child-
focused family/child intervention and agrees not to seek treatment
during the 60-day follow-up period; clients referred under court
order were not accepted. Those families meeting criteria for study
inclusion were given the option of participation in TA or tradi-
tional therapy/assessment. An information sheet was provided to
the parents describing the TA model and the research aspects of
The children of the three families included in this case study
were two Caucasian and one mixed-race (Caucasian/African
American) child, ages 10, 11, and 11 years. Two families consisted
of single, divorced mothers (without partners in the home),
whereas the third family was composed of married biological
parents. Each of the children had at least one sibling. The annual
reported household incomes were $21,000, $27,000, and $90,000.
The educational level of the parents included a graduate equiva-
lency diploma, two bachelor’s degree recipients, and one parent
with a graduate degree. Two families had never sought medication
for the child, whereas the third child was currently on an attention-
deficit/hyperactivity disorder medication.
Only these three families were offered participation in the study,
and there was no attrition. Informed consent and assent for treat-
ment and research was obtained during the initial meeting. Al-
though clinical consensus and research suggests that attention-
deficit/hyperactivity disorder, conduct disorder, anxiety, and
depression are commonly comorbid with ODD (Connor, 2002),
potential participants were only excluded from the study if a
diagnosis of conduct disorder was also present, per DSM–IV cri-
teria for ODD diagnosis. Two of the included children only met
diagnostic criteria for ODD, whereas the third also met diagnostic
criteria for an anxiety disorder.
The clinician, clinician training, and supervision.
nician for this study was a Master’s-level graduate student (first
author) in a clinical psychology doctoral program. Formal training
included two graduate-level assessment courses, as well as a 1-day
introductory and a 4-day intermediate workshop in therapeutic
assessment, conducted by the model’s creator, Dr. Stephen E.
Finn. A therapeutic assessment expert (second author) provided
ongoing supervision and training. The therapist also conducted
preliminary, supervised training cases.
Finn and colleagues’ publications, de-
scribing each of the model’s components in detail, provide the
conceptual, theoretical, and technical framework to allow for im-
plementation and replication of the model. A formal treatment
manual is not necessary if it is replaced by a clear description of
the treatment that provides an operational definition of the inter-
vention (Chambless & Ollendick, 2001).
Treatment adherence and therapist competence.
treatment integrity checks occurred during supervision of the cli-
nician, and expert integrity ratings were also conducted: Dr. Ste-
phen E. Finn, the creator of the family TA model, independently
assessed adherence (the degree to which an intervention is deliv-
ered as intended) and competence (level of skill shown by the
therapist in delivering the treatment). Nine complete sessions,
comprising 9 total hours, were pseudorandomly selected: At least
two sessions were included from each case and a representative
selection of different session types (i.e., test administration, family
session, etc.) were included. The two dimensions were rated on a
0–9 scale (0 ? not at all, 9 ? extremely). Each of the nine sessions
received one overall score for adherence (M ? 6.9) and compe-
tence (M ? 6.3).
Measures and Data-Analytic Strategy
ents, five or six dependent variables were established for monitor-
ing symptoms specific to each child and the family’s overall
distress, based on the family’s assessment questions. For example,
the mother in Case 1 felt that increased patience between she and
her son would indicate change had occurred. Thus, she reported
her own patience with her son as one daily measure and her son’s
patience with her as another measure (the specific dependent
variables chosen for each family are presented in the Results
section). This procedure is a hybrid that the clinician/researcher
used to facilitate the research design. An individualized paper
record was provided for the family to complete daily. Parents were
instructed to complete the record when the child went to sleep each
night. Some items required the parent to ask the child about his
feelings (e.g., the child’s self-esteem). The intact parental unit was
instructed to come to a consensus. Completed records were peri-
odically returned when the family arrived for scheduled meetings;
the records were then collected by the clinic secretary, so the
clinician would remain blind to the results while treatment was
A replicated single-case A-B-phase design with follow-up was
used to test the hypothesis that the child and family would benefit
as a result of participation in the family TA. Tracking of daily
measures began at the initial meeting. A pretreatment baseline
period of at least 10 days was collected prior to the first test
administration session, where it could be said that active interven-
tion began, which was followed by a minimum 60-day follow-up
period. We have termed these periods the baseline (B), interven-
tion (I), and follow-up (F) phases. To determine the effectiveness
of the family TA treatment, and to illuminate the process of
change, three phase-effect comparisons were conducted: Analysis
1 compares the baseline and intervention periods to determine if
the onset of treatment resulted in symptomatic change; Analysis 2,
a comparison of the intervention and follow-up periods combined
to the pretreatment baseline, indicates if change occurred as a
result of treatment onset and beyond; and Analysis 3, which
compares the baseline and intervention periods combined to the
follow-up period, provides evidence of change after treatment
ceased. When the results of these three comparisons are examined
holistically, the process of change is revealed and the researcher is
able to determine when change occurred, not simply if it occurred.
Simulation modeling analysis (Borckardt, 2006) for time series
was used, which compares the symptom scores of different data
streams (i.e., the baseline, intervention, and follow-up periods)
while accounting for autocorrelation (the nonindependence of se-
quential observations from the same informant), which is inherent
in time-series data. An effect size is generated for the observed
During the initial interview with the par-
THERAPEUTIC ASSESSMENT FOR BOYS WITH ODD
difference between the data streams in each phase (level change),
as well as the probability of obtaining that effect size in a null
distribution. No data-transformation methods were used. Because
the daily measures for each family are not independent, the highly
conservative Bonferroni (1935) correction was used to determine
statistical significance. In a similar vein, because dependent vari-
ables reported by each family are not independent, we tested for
within family cross correlation.
Missing values were addressed using the expectation-
maximization algorithm (Dempster, Laird, & Rubin, 1977), which
was found to be superior to other missing data methods, such as
listwise deletion, mean substitution, and mean of adjacent obser-
vations (Velicer & Colby, 2005), in time-series data streams with
up to 40% missing data. Missing data for Cases 1 and 2 were
minimal, ranging from 5.6% (Case 1) to 14.8% (Case 2). Missing
data for the dependent variables of Case 3 ranged from 22.3% to
31.5%, which was predominantly due to the mother misplacing 21
days of daily measures at the end of the intervention phase.
Behavior Assessment System for Children—Version 2
(BASC–2; Reynolds & Kamphaus, 2004).
ing and follow-up, the BASC–2 was administered to the parents
(form PRS–C or PRS–A) and child (form SRP–C or SRP–A). This
measure assesses the child’s observable behaviors on multiple
dimensions, including behavioral problems, emotional distur-
bances, and adaptive functioning. The BASC–2 manual (Reynolds
& Kamphaus, 2004) provides reliability evidence for these ver-
sions of the rating forms. The rating forms showed internal con-
sistency, test–retest reliability, and interrater reliability. The parent
and child report forms were scored using the BASC–2 ASSIST
Scoring and Reporting Software (Reynolds & Kamphaus, 2004).
Percentile ranks and T scores presented for Case 2 are the average
of both parents’ reports, whereas Cases 1 and 3 are the mother’s
report. Scores in the clinical (T score ? 70 for the clinical scales;
T score ? 29 for the adaptive scales) or at-risk (T score ? 60–69
for the clinical scales; T score ? 30–40 for the adaptive scales)
range are presented.
Parent Experience of Assessment Survey—Version 1
(PEAS; Finn, Tharinger, & Austin, 2007).
report assesses six factors relevant to the parents’ experience of
assessment using a 1–5 Likert-type scale. The six subscales are
Learned New Things, Positive Clinician–Parent Relationship, Col-
laboration, Positive Clinician–Child Relationship, Family Involve-
ment in Child’s Problem, and Negative Feelings About the As-
At the initial meet-
This 64-item parent
sessment. The PEAS was administered at the follow-up session to
obtain an overall impression of the parents’ experience. Pilgrim
and Tharinger (2010) found acceptable reliability of the PEAS’
subscales in a sample of 32 parents.
Cross-correlations were run for all combinations of dependent
variables within each case. Variables in which an increase was
desired were recoded. Results indicated a significant relationship
between the dependent variables at Lag 0, suggesting that reported
scores on the measured indices were highly related on a day-to-day
basis. All cross correlations were significant at Lag 0 (Ranges:
Case 1 r ? .48–.92, Case 2 r ? .64–.94, Case 3 r ? .19–.76).
Because of the high cross-correlations, we chose to create a com-
bined score of all dependent variables to obtain a global measure
of improvement. All variables were given the same valence, so that
a decrease indicated improvement, and a mean score was calcu-
lated for each day across the variables of each case. The phase-
effect results of the combined variable were congruent with the
significance and pattern of results for the individual dependent
variables. Thus, we have chosen to report results of the combined
score for brevity and simplicity.
Case 1 included nine sessions (17 direct contact hours) span-
ning 153 total days (baseline N ? 14, intervention N ? 79;
follow-up N ? 60). The mother completed six indices of change
daily: (1a) overall family distress, (1b) intensity of worst anger
outburst, (1c) mother showed patience with son, (1d) son
showed patience with mother, (1e) mother handled son well
today, (1f) number of anger outbursts. The comparison between
the baseline and intervention periods (Analysis 1; see Table 1)
resulted in a statistically significant effect (r ? .696; Bonferroni
correction ? p ? .008), which indicates that reported symptom
scores during the baseline improved significantly after the onset
of treatment but prior to follow-up. Next we examined whether
improvement continued through the follow-up period by com-
paring the baseline symptom scores with those reported during
the intervention and follow-up periods combined (Analysis 2).
The effect (r ? .602) was again significant, indicating that
ceasing treatment did not result in a return to prior symptom
levels. Last, to examine whether symptom improvement oc-
curred during the follow-up period itself (i.e., symptom im-
provement is not contingent upon being in treatment), we
Results of Time-Series Phase-Effect Analyses: Combined Dependent Variable Scores
Analysis 1 Analysis 2 Analysis 3
BIBI ? FB ? IF
The specific affective or behavioral dependent variables measured daily in each case are presented in the text. Phase effects assess level change.
?Significant p value using the Bonferroni correction (Case 1 ? .008, Case 2 ? .025, Case 3 ? .008).
B ? baseline; I ? intervention; F ? follow-up; pAR(Lag 1) ? the level of autocorrelation of subsequent observations for the entire data stream.
SMITH, HANDLER, AND NASH
compared the baseline and intervention period symptom scores
with those reported during the follow-up period (Analysis 3).
Again, this case showed significant improvement (r ? .326).
Results of the BASC–2 for Case 1 were consistent with the
daily measures (see Tables 2 and 3). Although the child’s
self-report at baseline had few elevations, all elevated scales
were within normal limits at follow-up. Similarly, all scales of
his mother’s report were within normal limits at follow-up. It is
important to note that she reported that her son’s aggression and
conduct problems had decreased, he appeared less depressed,
and his adaptability and activities of daily living had improved.
Case 2 included 10 sessions (17 direct contact hours) spanning
141 total days (baseline N ? 10, intervention N ? 56, follow-up
N ? 75). Five indices of change were measured on a daily basis by
the child’s mother and father, who were instructed to come to an
agreement for each of the day’s ratings: (2a) overall family dis-
tress, (2b) intensity of worst anger outburst, (2c) intensity of
defiance, (2d) intensity of irritation behaviors, (2e) son dealt with
frustration well. Results of the three phase-effect analyses indi-
cated a similar trajectory of improvement to Case 1: Analysis 1,
r ? .611; Analysis 2, r ? .490; and Analysis 3, r ? .686
(Bonferroni correction ? p ? .025). The BASC–2 results indi-
cated substantial improvement across nearly all domains that were
identified as normative problems at baseline. All reported eleva-
tions at baseline dropped into the normative range at follow-up,
with the exception of the parent’s unchanged score on Social
Case 3 included 10 sessions (18 direct contact hours) spanning
184 total days (baseline N ? 49, intervention N ? 72, follow-up
N ? 63). The case had a significantly longer pretreatment baseline
period (49 days) because of an unforeseen medical problem that
occurred after the initial meeting and prior to treatment beginning.
Six indices were measured daily: (3a) overall family distress, (3b)
intensity of worst anger outburst, (3c) reaction to directives,
(3d) son felt good about himself today, (3e) reaction to change,
(3f) reaction to disappointment. Phase-effect Analyses 1 and 2 did
not yield significant effects: r ? .091 and r ? .132. Analysis 3
resulted in a significant phase effect of r ? .435 (Bonferroni
correction ? p ? .008), indicating symptom improvement oc-
curred after treatment ceased. The BASC–2 reports indicated sub-
stantial improvements across multiple domains of functioning. The
mother’s report showed dramatic improvement. At baseline, nine
scales reached the clinical level (Hyperactivity, Aggression, Con-
duct Problems, Depression, Atypicality, Withdrawal, Attention
Problems, Adaptability, and Social Skills), whereas two additional
scales (Somatization and Activities of Daily Living) were in the
at-risk range. At follow-up, no scales fell into the Clinical range.
Although still At-Risk at follow-up, the improvement in reported
Aggression was substantial with a 39-point decrease from baseline.
Parents’ reports of participation in the family TA were generally
positive across the subscales of the PEAS measure. Parents reported
that they learned new things about their child and his problems
(aggregate score ? 4.67 out of 5), were able to develop a positive
relationship with the clinician (4.90), felt that the TA process was
collaborative (4.78), felt that their child developed a positive relation-
ship with the clinician (4.70), and learned how the family was in-
volved in the child’s problems (4.48). The score of 1.80 in regard to
the parents’ negative feelings about the assessment was acceptable.
BASC–2 Child Self-Report
Case 1Case 2Case 3
BaselineFollow-up Baseline Follow-upBaseline Follow-up
Attitude to School
Attitude to Teachers
Locus of Control
Sense of Inadequacy
Relations with Parents
aHigher scores on the adaptive scales are desirable.
BASC–2 ? Behavior Assessment System for Children—Version 2 (Reynolds & Kamphaus, 2004).
bT scores in the clinical range.
cT scores in the at-risk range.
THERAPEUTIC ASSESSMENT FOR BOYS WITH ODD
Families with a preadolescent boy presenting with ODD expe-
rienced demonstrable benefits in multiple areas of functioning
after participation in TA. Across the three cases, the child’s symp-
toms improved after the onset of treatment, as per daily measures
and the BASC–2. Thus, the TA model appears to be a potentially
efficacious intervention for this disorder. The research design
employed in this study has the potential to illuminate the process
and trajectory of change, not just overall effectiveness. Broadly
speaking, our results indicate that all three cases improved signif-
icantly from baseline to follow-up, but the daily time-series anal-
yses suggest that each case had its own idiographic trajectory,
which deserves further examination.
The broad improvement experienced by Cases 1 and 2 appeared
to have been initiated early in the treatment, during the active
intervention period, with evidence of continued improvement
through the follow-up period. However, Case 3 did not realize
benefits during the intervention period itself, but the follow-up
period marked a time of significant improvement for this family.
Across all three cases, the results of the BASC–2 support the
findings of the time-series data: The children improved in domains
conceptually consistent with ODD, such as aggression, school
problems, anxiety, and depression. Our second hypothesis, that
families would continue to experience benefits beyond the formal
intervention, was also supported.
The results of the PEAS indicate consumer acceptability of the
family TA model, which was also found by Tharinger et al. (2009).
High scores on the subscales of this measure, particularly the
clinician’s relationship with the parents and the child, collabora-
tion, and the family’s involvement in the child’s problems, also
suggest that the clinician of this study was successful in achieving
the broad goals of the TA model. The parents’ reports of the
clinician’s relationship with the family also suggest that a thera-
peutic alliance was established.
The results of this study expand the body of empirical research
on the therapeutic effectiveness of the TA model with children.
Evidence indicates that children with ODD (and their families)
benefited from participation in this treatment. Using a time-series
design, the current study—and two previous empirical case studies
(J. D. Smith, Nicholas, et al., 2009; J. D. Smith, Wolf, et al.,
2009)—showed that the child and family benefit from TA. The
timing and trajectory of the improvement appears variable.
According to the guidelines put forth by the Task Force on Pro-
motion and Dissemination of Psychological Procedures (Ollendick et
al., 2006), our findings satisfy the requirements for inferring that TA
is possibly efficacious. Without question, large-group studies con-
ducted in a laboratory setting with a comparison group will provide
sharper estimates of both aggregate benefit and more discerning
inferences about cause. Still, it is the continuous measurement of key
indices over time that renders case-based (and group) time-series
designs so immediately relevant to the question of mechanism: It
enables us to observe how mutative aspects of the therapy operate in
BASC-2 Parent Report
Case 1 Case 2Case 3
BaselineFollow-up BaselineFollow-up BaselineFollow-up
Activities of Daily Living
48 42 5875 5876 4735 432245 31
aHigher scores on the adaptive scales are desirable.
BASC–2 ? Behavior Assessment System for Children—Version 2 (Reynolds & Kamphaus, 2004). Case 2 presents an average score for both
bT scores in the clinical range.
cT scores in the at-risk range.
SMITH, HANDLER, AND NASH
real time (e.g., Kazdin, 2007). Although the current study did not
specifically address mediators and mechanisms of change, time-series
methodology can reveal the ebb and flow of clinical improvement
during intervention and allows us to test how well our theories of
change measure up against what we observe.
Despite the advantages of this methodology, there are also some
limitations. For example, the family and the clinician were not blind
to the hypothesis of the study (i.e., the family would benefit from
treatment), and the family members were the sole reporters of the data
used to assess improvement. Thus, demand characteristics and other
potentially biasing factors could have influenced their reports. How-
ever, it is important to understand what is measured and reflected in
the finding of a treatment efficacy study. TA aims to help parents
develop more cohesive, accurate, compassionate, and empathic sto-
ries about their child (Finn, 2007; Tharinger et al., 2007), suggesting
that self-report measures are appropriate because they likely reflect a
changing perspective. The individualized nature of the time-series
design employed in this study poses a challenge for replicated single-
case designs. With the intent of tailoring both the treatment and the
research design to each specific family, we developed individualized
variables to be measured daily that would capture the particular
only two dimensions shared by each family in the time-series aspect
of the study, making direct comparisons of symptomatic change
difficult. One way in which this issue was addressed was to combine
the dependent variables for each case, which came at the cost of
examining changes in specific symptoms across cases. Again, the
inclusion of the BASC–2 provided a shared measure, but the time-
series measures are the essence of this study. Perhaps it is almost of
greater importance to enact change in areas the family reports as their
greatest concern, rather than measuring domains the family did not
report as problematic.
This study was intended to test the efficacy of the TA model with
a common childhood problem and with patients already seeking
psychological services. The clients were diverse in terms of racial
background, socioeconomic status, and family structure. The need to
test TA under stringently controlled conditions still remains. In addi-
tion to larger sample sizes, future studies might examine the effec-
tiveness of TA for ODD in younger and older children, given evi-
dence of age-related differences (Maughan et al., 2004); lengthen the
family system as a whole, as opposed to the identified child client.
Burke, Pardini, and Loeber (2008) found that ODD affects parenting
approaches and familial communication, suggesting these would be
possible areas to target in future study.
Randomized controlled trials will likely continue to be the predom-
inant paradigm for assessing treatment efficacy. However, not only
are these studies costly but the findings arguably obscure the pro-
cesses of change (Skinner, 1938) and arguably don’t translate to
real-world clinical practice (e.g., Jacobsen & Christensen, 1996; Mor-
rison et al., 2003; Westen & Morrison, 2001). Experimental single-
case designs may provide a comparably inexpensive yet scientifically
valid method to bridge the gap between the laboratory and clinical
1992, 2008). The current study provides evidence of the knowledge
that can be attained from this methodology, both individually and
between cases, while also demonstrating the efficacy of a promising
intervention for children with ODD.
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Received January 7, 2010
Revision received March 9, 2010
Accepted March 9, 2010 ?
SMITH, HANDLER, AND NASH