CLINICAL INQUIRIES

What are effectivetreatments for oppositionaland defiant behaviorsin preadolescents?

• EVIDENCE-BASED ANSWERParent training is effective for treating opposi­tional and defiant behaviors (strength of recom­mendation [SOR]: A, based on systematicreviews). Parent training programs are standard­ized, short-term interventions that teach parentsspecialized strategies-including positive attend­ing, ignoring, the effective use of rewards andpunishments, token economies, and time out-toaddress clinically significant behavior problems.In addition to parent training, other psychosocialinterventions (Table) are efficacious in treatingoppositional and defiant behavior.

To date, no studies have assessed the efficacyof medication in treating children with pure oppo­sitional defiant disorder (ODD). However, studieshave shown amphetamines to be effective forchildren with ODD and comorbid attentiondeficit/hyperactivity disorder (ADHD) (SOR: A,based on a meta-analysis).

• EVIDENCE SUMMARYOppositional and defiant behaviors include non­compliance, temper tantrums, arguing, and mildaggression. Children exhibiting these behaviorsmay have a diagnosis of ODD. Importantly, thisreview does not examine treatments for childrendiagnosed with conduct disorder or thoseexhibiting more deviant behaviors such as seri­ous aggression and delinquency.

Eight well·done systematic reviews exam­ined the effectiveness of parent training pro­grams. Parent training is typically conductedby clinical child psychologists but may also beavailable through certified parenting educa­tors (see the National Parenting Education

162 FEBRUARY Z005 I VOL 54, NO Z • The Jomnal of FIDIIIy PRotice

Network web page for links to state organiza­tions, at www.ces.ncsu.edu/depts/fcs/npenl).Parent training strategies are also described forparents in books such as Your Defiant Child. I

The most rigorous of the reviews looked at 16randomized controlled trials that examined theeffectiveness of training programs for childrenbetween the ages of 3 and 10 years who had"externalizing problems," including tempertantrums, aggression, and noncompliance.z AllstudIes included in the review compared a group­based parent training program with a no·treat­ment wait-list control group and assessed out­comes using a standardized measure of behavior.In studies where sufficient data were provided,effect sizes ranged from 0.6 to 2.9. This indicatesthat, on a standardized child behavioral measure,parental report of children's externalizing prob·lems decreased by 0.6 to 2.9 standard deviationsfrom pre- to posttreatment (an effect size of >0.8is considered large). In the 2 studies that includ­ed independent observations of child behavior, thebenefits reported by parents were confirmed bythese observations.

Although parent training has the strongestevidence as a treatment for oppositional anddefiant behavior, other psychosocial treatmentinterventions have been found by multiple ran­domized controlled trials to be superior to notreatment or wait-list controls (Table).

In treating oppositional behaviors among elill­dren with ADHD and comorbid oppositional defi­ant disorder or conduct disorder, a meta-analysisidentified 28 studies of children age 7 to 15 yearsthat addressed oppositional/aggression-relatedbehaviors within the context of ADHD.8 The analy­sis found that stimulants are efficacious. The over­all weighted effect size (a measure of improve­ment representing the average effects across allreporters) was 0.89. This indicates that raterssaw a change in oppositional behaviors-noncom­pliance, irritability, and temper tantrums-thatcorresponded to a drop in scores of approximately1 standard deviation.

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CLINICAL INQUIRIES

Additional ODD treatments support~d

by randomized controlled trials

Treatment andrepresentative study

Anger Coping Therapt

SOR: B

Problem Solving SkillsTraining4

SOR:B

Dina Dinosaur SocialEmotional and ProblemSolving Child Training/Incredible Years ChildTraininge

SOR: B

Incredible YearsTeacher Training7

SOR: B

Treatment descriptIon

A 12- to 18-session groupcognitive-behavioral and socialproblem-solving traini.ngprogram. Assessedindependently (AC) and witha teacher component (ACTC)

A 20- to 25-sesslonindividual child skills training.Assessed individually(PSST) and with PT

An 18- to 22-session groupskills training program.Assessed as an independenttreatment and with PT

A classroom teachertraining program.Assessed with PT. CTand PT+CT

Outcome

AC and ACTC exhibited reductionsin directly observed disruptive andaggressive classroom behavior (P<.05).No significant differences between ACand ACTC

33% (parent report) to 57% (teacherreport) of the PSST group and 64%--69%of the PSST+PT group were within thenormal range after treatment. Gainsmaintained at 1 year. No control group.

In an inpatient population, PSST showedgreater decreases in externalizing andaggressive behaviors than controls (P<.01)5

PT and PT+CT groups demonstrated.fewer mother-reported behavior problemsat post-test. Effect sizes: PT vs. control =.89(P<.05); PT + CT vs. control =.73 (P<.05)

One-year follow-up: compared with baseline,95% of children in the PT+CT group,74% in the CT group, and 60% in the

. PT group exhibited at least a 30% reductionin home-observed deviant behaviors.The difference between the PT + CT andPT groups was significant (P<.01)

Per parent report, 55% (PT + CT + TT),59% (PT + TT), 47% (CT + TT) and 20%(control group) had a reduction of 20% ormore in behavior problems. The differencebetween the control group was significantfor the PT + CT + IT and PT + IT groups.

Two-year follow-up: 75% of treated childrenwere within the normal range per parentand teacher reports. No control group.

AC = Anger coping therapy; ACTC = Anger coping therapy with teacher consultation;CT =Child Training; PSST =Problem Solving Skills Training;PT =Parent training; TT = Teacher training.

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164 FEBRUARY 2005 I VOL 54, NO 2 ' The Jounl&1 01 Family Practico

CLINICAL INQUIRIES

IAn important role for the FPis to convince parents that theirparticipation is critical to treatment

• RECOMMENDATIONS FROM OTHERS'!\vo parent training interventions meet theAmerican Psychological Association's criteria forwell-established treatments.9 These include pro­grams based on Patterson and Gullion's Livingwith Children, a short-tenn, behavioral parenttraining program, and programs based on Webster­Stratton's Videotape Modeling parent training pro­gram. Two additional treatments, Anger CopingTherapy and Problem Solving Skills lraining,meet the criteria for "probably efficacious."

According to the International ConsensusStatement on ADHD and Disruptive BehaviorDisorders, "pharmacological treatment of pure ODDshould not be considered except in cases whereaggression is a significant, persistent problem."IO

Suzanne E, Farley, MA, Jennifer S. Adams, MA,Psychology Department, University ojNorth Carolina .atGreensboro; Michelle E. Lutton, PsyD,Moses Cone Family Medicine Residency Program, Greensboro;Caryn Scoville, MLS, J Otto Lottes Health SciencesLibrary, University oj Missouri-Columbia

REFERENCES1. Barkley RA, Benton CM. Your Defiant Child: Eight Steps to

Better Behavior. New York: Guilford Press; 1998.2. Barlow J, Stewart·Brown S. Behavior problems and group­

based parent education programs. J Dev Behav Pediatr2000; 21:356-370.

3. Lochman JE. Lampron LB, Gemmer TC, Hams SR.Wyckoff GM. Teacher consultation and cognitive·behav­ioral interventions with aggressive boys. Psychol Schools1989; 26:179-188.

4. Kazdin AE, Siegel Te, Bass D. Cognitive problem solvingskills training and parent management training in thetreatment of antisocial behavior in children.J Consult ClinPsychol 1992; 60:733-747.

5. Kazdin AE, Esveldt-Dawson K, French HR, Unis AS.Problem·solving skills training and relationship therapy inthe treatment of antisocial child behavior. J Consult ClinPsychol 1987; 55:76-85.

6. Webster-Stratton C, Reid MJ. 'Ireating conduct problemsand strengthening social and emotional competence inyoung children: the dina dinosaur treatment program.J Emot Behav Disord 2003; 11:130-143.

7. Reid MJ, Webster-Stratton C, Hammond M. Follow-up ofchildren who received the incredible years intervention for

oppositional-defiant disorder: maintenance and predictionof 2-year outcome. Behav Ther ZOO3; 34:471-491. .

8. Connor DF, Glatt SJ, Lopez ID, Jackson D, Melloni RH Jr.Psychopharmacology and aggression. I: A meta-analysisof stimulant effects on overt/covert aggression-relatedbehaviors in ADHD. J Am Acad Child Adolesc Psychiatry2002; 41:Z53-261.

9. Brestan Ev, Eyberg SM. Effective psychosocial treatments ofconduct-disordered children and adolescents: 29 years, 82studies, and 5,272 kids,JClin ChildPsychol 1998; 27:180-189.

10. Kutcher S, Aman M, Brooks 5J, et aI. International con·sensus statement on attention-deficit/hyperactivity disor­der (ADHD) and disruptive behaviour disorders (DBDs):clinical implications and treatment practice suggestions.Eur Neuropsychopharmacol 2004; 14:11-28.

• CLINICAL COMMENTARYPsychological interventions for parentand child are essentialOppositional and defiant behaviors are a familyproblem requiring a family solution. Frustratedparents often request a Nquick fix," so this lit­erature review is helpful in defining when med­ications are not indicated. Psychological inter­ventions for the parents and for the child areessential. An important role for the familyphysician is to convince parents that their par­ticipation is critical in treating this problem. Inaddition to encouraging referrals to psycholog­ical resources in the commwlity and occasion·ally prescribing medication, another role forthe physician is to model parenting skills. Thephysician can demonstrate the "Tough Love"philosophy of holding the child responsible forunacceptable behavior without rejecting thechild or blaming other people. An additionalrole could be to schedule brief checkup/coun­seling sessions with the family and child.These roles can be time consuming withoutnecessarily having the assurance that all ofthem are evidence-based. However, the value ofhaving multiple role options is that familyphysicians can develop an individualizedapproach for helping each family, as long as theemphasis remains on parental involvement.

Richard C. Fulkerson, MD, Anita R. Webb, PhD,John Peter Smith Family Medicine Residency Program,Fort Worth, Thx

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FEBRUARY 2005 I VOL 54, NO 2 • Tho 10um&1 or Family Practice 165

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