EVIDENCE-BASED ANSWER
Parent training is effective for treating oppositional and defiant behaviors (strength of recommendation [SOR]: A, based on systematic reviews). Parent training programs are standardized, short-term interventions that teach parents specialized strategies—including positive attending, ignoring, the effective use of rewards and punishments, token economies, and time out—to address clinically significant behavior problems. In addition to parent training, other psychosocial interventions (Table) are efficacious in treating oppositional and defiant behavior.
To date, no studies have assessed the efficacy of medication in treating children with pure oppositional defiant disorder (ODD). However, studies have shown amphetamines to be effective for children with ODD and comorbid attention deficit/hyperactivity disorder (ADHD) (SOR: A, based on a meta-analysis).
Evidence summary
Oppositional and defiant behaviors include noncompliance, temper tantrums, arguing, and mild aggression. Children exhibiting these behaviors may have a diagnosis of ODD. Importantly, this review does not examine treatments for children diagnosed with conduct disorder or those exhibiting 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 conducted by clinical child psychologists but may also be available through certified parenting educators (see the National Parenting Education Network web page for links to state organizations, at www.ces.ncsu.edu/depts/fcs/npen/). Parent training strategies are also described for parents in books such as Your Defiant Child.1
The most rigorous of the reviews looked at 16 randomized controlled trials that examined the effectiveness of training programs for children between the ages of 3 and 10 years who had “externalizing problems,” including temper tantrums, aggression, and noncompliance.2 All studies included in the review compared a group-based 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 indicates that, on a standardized child behavioral measure, parental report of children’s externalizing problems decreased by 0.6 to 2.9 standard deviations from pre- to posttreatment (an effect size of >0.8 is considered large). In the 2 studies that included independent observations of child behavior, the benefits reported by parents were confirmed by these observations.
Although parent training has the strongest evidence as a treatment for oppositional and defiant behavior, other psychosocial treatment interventions have been found by multiple randomized controlled trials to be superior to no treatment or wait-list controls (Table).
In treating oppositional behaviors among children with ADHD and comorbid oppositional defiant disorder or conduct disorder, a meta-analysis identified 28 studies of children age 7 to 15 years that addressed oppositional/aggression-related behaviors 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 all reporters) was 0.89. This indicates that raters saw a change in oppositional behaviors—noncompliance, irritability, and temper tantrums—that corresponded to a drop in scores of approximately 1 standard deviation.
TABLE
Additional ODD treatments supported by randomized controlled trials
| Treatment and representative study | Treatment description | Outcome |
|---|---|---|
| Anger Coping Therapy3 | A 12- to 18-session group cognitive-behavioral and social problem-solving training program. Assessed independently (AC) and with a teacher component (ACTC) | AC and ACTC exhibited reductions in directly observed disruptive and aggressive classroom behavior (P.<.05). |
| SOR: B | No significant differences between AC and ACTC | |
| Problem Solving Skills Training4 | A 20- to 25-session individual child skills training. | 33% (parent report) to 57% (teacher report) of the PSST group and 64%–69% Assessed individually of the PSST+PT |
| group were within the SOR: B | (PSST) and with PT | normal range after treatment. Gains maintained at 1 year. No control group. |
| In an inpatient population, PSST showed greater decreases in externalizing and aggressive behaviors than controls (P.<.01)5 | ||
| Dina Dinosaur Social Emotional and Problem Solving Child Training/ Incredible Years Child Training6 | An 18- to 22-session group skills training program. | PT and PT+CT groups demonstrated fewer mother-reported behavior problems at post-test. Effect sizes: PT vs. control = .89 (P.<.05); PT + CT vs. control = .73 (P.<.05) |
| SOR: B | Assessed as an independent treatment and with PT | 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% reduction in home-observed deviant behaviors. The difference between the PT + CT and PT groups was significant (P.<.01) |
| Incredible Years Teacher Training7 | A classroom teacher training program. | Per parent report, 55% (PT + CT + TT), 59% (PT + TT), 47% (CT + TT) and 20% (control group) had a reduction of 20% or and PT+CT more in behavior problems. The difference between the control group was significant for the PT + CT + TT and PT + TT groups. |
| SOR: B | Assessed with PT, CT | Two-year follow-up: 75% of treated children were within the normal range per parent and teacher reports. No control group. |
| AC = Anger coping therapy; ACTC = Anger coping therapy with teacher consultation; | ||
| CT = Child Training; PSST = Problem Solving Skills Training; | ||