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• Oppositional defiant disorder (ODD)

To determine whether your child has oppositional defiant disorder, a mental health provider does a thorough psychological exam. ODD often occurs along with other behavioral or mental health problems. So it may be difficult to tell which symptoms are from ODD and which ones are linked to other problems.

Your child's exam will likely include an assessment of:

• Overall health.
• How often the behaviors occur and how severe they are.
• Emotions and behavior in different settings and relationships.
• Family situations and interactions.
• Strategies that have been helpful ― or not helpful ― in managing problem behaviors.
• Issues experienced by the child and the family due to the problem behaviors.
• Other possible mental health, learning or communication problems.

Treatment for oppositional defiant disorder primarily involves family-based interventions. But treatment may include other types of talk therapy and training for your child — as well as for parents. Treatment often lasts several months or longer. It's important to also treat any other problems, such as a mental health condition or learning disorder, because they can cause or worsen ODD symptoms if left untreated.

Medicines alone generally aren't used for ODD unless your child also has another mental health condition. If your child also has other conditions, such as ADHD , anxiety disorders or depression, medicines may help improve these symptoms.

Treatment for ODD usually includes:

• Parenting skills training. A mental health professional with experience treating ODD can help you develop parenting skills that are more consistent, positive and less frustrating for you and your child. In some cases, your child may join you in this training, so everyone in your family develops a consistent approach and shared goals for how to handle problems. Involving other authority figures, such as teachers, in the training may be an important part of treatment.
• Parent-child interaction therapy (PCIT). During PCIT , a therapist coaches you while you interact with your child. In one approach, the therapist sits behind a one-way mirror. Using an "ear bug" audio device, the therapist guides you through strategies that reinforce your child's positive behavior. As a result, you can learn more-effective parenting techniques, improve the quality of your relationship with your child and reduce problem behaviors.
• Individual and family therapy. Individual therapy for your child may help them learn to manage anger and express feelings in a healthier way. Family therapy may help improve your communication and relationships and help your family members learn how to work together.
• Problem-solving training. Cognitive problem-solving therapy can help your child identify and change thought patterns that lead to behavior problems. In a type of therapy called collaborative problem-solving, you and your child work together to come up with solutions that work for both of you.
• Social skills training. Your child also may benefit from therapy that will help them be more flexible and learn how to interact in a more positive and effective way with peers.

As part of parent training, you may learn how to manage your child's behavior by:

• Giving clear instructions and following through with appropriate consequences when needed.
• Recognizing and praising your child's good behaviors and positive traits to encourage desired behaviors.

Although some parenting techniques may seem like common sense, learning to use them consistently in the face of opposition isn't easy. It's especially hard if there are other stressors at home. Learning these skills requires routine practice and patience.

Most importantly, during treatment, show consistent, unconditional love and acceptance of your child — even during difficult and disruptive situations. Don't be too hard on yourself. This process can be tough for even the most patient parents.

Lifestyle and home remedies

At home, you can work on improving problem behaviors of oppositional defiant disorder by practicing these strategies:

• Recognize and praise your child's positive behaviors as close to the time you see them as possible. Be as specific as possible. For example, "I really liked the way you helped pick up your toys tonight." Providing rewards for positive behavior also may help, especially with younger children.
• Model the behavior you want your child to have. Watching you interact well with others can help your child improve social skills.
• Pick your battles and avoid power struggles. Almost everything can turn into a power struggle if you let it.
• Set limits by giving clear instructions and using consistent reasonable consequences. Discuss setting these limits during times when you're not arguing with each other.
• Set up a routine by developing a regular daily schedule for your child. Ask your child to help develop that routine.
• Build in time together by planning a weekly schedule that includes you and your child doing things together.
• Work together with your partner or others in your household to ensure consistent and appropriate discipline procedures. Also ask for support from teachers, coaches and other adults who spend time with your child.
• Assign a household chore that's needed and that won't get done unless your child does it. At first, it's important to set your child up for success with tasks that are fairly easy to do well. Gradually blend in more-important and challenging jobs. Give clear, easy-to-follow instructions. Use this as an opportunity to reinforce positive behavior.
• Be prepared for challenges early on. At first, your child probably won't cooperate or appreciate your changed response to their behavior. Expect behavior to worsen at first after you tell them the new things you now expect. At this early stage, staying consistent even if the problem behavior worsens, is the key to success.

With regular and consistent effort, using these methods can result in improved behavior and relationships.

Coping and support

It's challenging to be the parent of a child with oppositional defiant disorder. Ask questions and tell your treatment team about your concerns and needs. Consider getting counseling for yourself and your family to learn coping strategies to help manage your own needs. Also seek and build supportive relationships and learn stress management skills to help get through difficult times.

Learning coping and support strategies can lead to better outcomes for you and your child because you'll be more prepared to deal with problem behaviors.

Preparing for your appointment

You may start by seeing your child's health care provider. Or you may choose to make an appointment directly with a mental health provider. A mental health provider can make a diagnosis and create a treatment plan that meets your child's needs.

When possible, both parents or caregivers should be present with the child. Or take a trusted family member or friend along to support you and help you remember information.

What you can do

Before your appointment, make a list of:

• Symptoms your child has been experiencing, and for how long.
• Key family information, including factors that you think may be linked to changes in your child's behavior. Include any stressors and changes in the family, such as parents' separation or divorce and differences in parenting styles, including what's expected from your child.
• Your child's school performance, including grades and areas where your child does well or poorly in school. Include any learning disorder assessments and any special education services.
• Issues that you, your family and your child have been experiencing because of the problem behavior.
• Your child's key medical information, including other physical or mental health conditions your child may have.
• Any medicines, vitamins, herbal products and other supplements your child is taking, including the doses.
• Questions to ask your health care provider or mental health provider to make the most of your appointment.

Some questions to ask your child's mental health provider include:

• What do you believe is causing my child's symptoms?
• Are there any other possible causes, such as other mental health conditions?
• Is this condition likely temporary or long lasting?
• What issues do you think might be contributing to my child's problem?
• What treatment approach do you recommend?
• Is my child at increased risk of any long-term complications from this condition?
• What changes do you suggest at home or school to improve my child's behavior?
• Should I tell my child's teachers about this diagnosis?
• What else can my family and I do to help my child?
• Do you recommend family therapy?

Feel free to ask other questions during your appointment.

What to expect from your doctor

Here are examples of questions that your mental health provider may ask.

• What are your concerns about your child's behavior?
• When did you first notice these problems?
• Have your child's teachers or other caregivers reported problem behaviors in your child?
• About how often over the last six months has your child had an angry and irritable mood, argued with or defied people in authority, or purposely hurt others' feelings?
• In what settings does your child show these behaviors?
• Do any specific situations seem to trigger problem behavior in your child?
• How have you been handling your child's problem behavior?
• How do you usually discipline your child?
• How would you describe your child's home and family life?
• What kinds of stress has your family been dealing with?
• Does your child have any other medical or mental health conditions?

Be ready to answer your mental health provider's questions. That way you'll have more time to go over any other information that's important to you.

• Oppositional defiant disorder. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5-TR. 5th ed. American Psychiatric Association; 2022. https://dsm.psychiatryonline.org. Accessed Oct. 11, 2022.
• Oppositional defiant disorder. American Academy of Child and Adolescent Psychiatry. https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Children-With-Oppositional-Defiant-Disorder-072.aspx. Accessed Oct. 12, 2022.
• Oppositional defiant disorder (ODD). Merck Manual Professional Version. https://www.merckmanuals.com/professional/pediatrics/mental-disorders-in-children-and-adolescents/oppositional-defiant-disorder-odd. Accessed Oct. 12, 2022.
• Ferri FF. Oppositional defiant disorder (ODD). In: Ferri's Clinical Advisor 2023. Elsevier; 2023. https://www.clinicalkey.com. Accessed Oct. 12, 2022.
• Kliegman RM, et al. Disruptive, impulse control, and conduct disorders. In: Nelson Textbook of Pediatrics. 21st ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Oct. 12, 2022.
• Oppositional defiant disorder. American Association for Marriage and Family Therapy. https://www.aamft.org/Consumer_Updates/Oppositional_Defiant_Disorder.aspx. Accessed Oct. 12, 2022.
• Dulcan MK, ed. Oppositional defiant disorder and conduct disorder. In: Dulcan's Textbook of Child and Adolescent Psychiatry. 3rd ed. American Psychiatric Association Publishing; 2021. https://psychiatryonline.org. Accessed Oct. 12, 2022.
• Kaur M, et al. Oppositional defiant disorder: Evidence-based review of behavioral treatment programs. Annals of Clinical Psychiatry. 2022; doi:10.12788/acp.0056.
• Sawchuk CN (expert opinion). Mayo Clinic. Nov. 25, 2022.
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• ODD / Oppositional and Defiant Behavior

Oppositional Defiant Disorder Treatment

People with ODD face a higher risk of other mental health diagnoses, especially those that affect behavior, including:

• Conduct disorder
• Attention-deficit hyperactivity (ADHD)
• Antisocial personality

ODD increases the risk of substance abuse, legal difficulties, relationship problems, and workplace issues in both adolescence and adulthood. It can disrupt classrooms, be a chronic source of family stress, and leave those diagnosed with ODD feeling bewildered, frustrated, and angry.

ODD is treatable. Prompt ODD treatment greatly reduces the risk of later psychological and social issues. The right therapist can help a person with ODD control their impulses, understand their emotions, and nurture productive and rewarding relationships. Search for a therapist who specializes in ODD .

ODD Diagnosis

Odd strategies, odd medication, therapy for odd, case examples of therapy for odd.

Proper ODD treatment depends on an accurate diagnosis. ODD can superficially resemble a number of other conditions. Like people with ADHD, people with ODD struggle with impulse control. ODD features some of the same behavioral difficulties as a conduct disorder. Secondary symptoms of ODD, such as substance abuse, may mask the underlying condition.

A doctor or mental health professional can diagnose ODD. The best person from whom to seek a diagnosis is someone experienced in the diagnosis and treatment of childhood mental health and behavioral issues. An expert in ODD is better equipped to distinguish symptoms of ODD from those of other conditions.

To ensure an accurate diagnosis, ask about the diagnostic criteria the clinician uses. Evidence-based diagnosis relies on objective standards. According to the DSM-5 , a person must display at least four of the following symptoms for six months or longer to qualify for a diagnosis:

• Frequent loss of temper.
• Frequently resentful or angry.
• Easily annoyed or excessively sensitive.
• Frequently argues with authority figures such as parents or employers.
• Refuses to comply with reasonable requests from authority figures, or frequently defies rules.
• Deliberately irritates or annoys others.
• Has difficulty taking responsibility for behavior and blames others for their mistakes.
• Has done something spiteful or vindictive at least twice in the past six months.

Each of the above behaviors must go beyond that which is developmentally typical or understandable in context. For instance, a child abuse survivor who distrusts parents or other authority figures is likely reacting to their circumstances. Likewise, a toddler who is often angry or prone to tantrums is testing limits in a way that is likely developmentally normal.

Parents can do a lot to help children with ODD manage the condition. Potentially effective strategies include:

• Proactively teaching children creative problem-solving. Encourage them to talk about conflicts with friends or family and weigh options for responding. Generating a list of potential strategies can help children see that they don’t have to respond with anger or aggression.
• Modeling effective communication and creative problem-solving. Children who see their parents effectively resolving conflicts learn that conflicts don’t have to be harmful.
• Using consistent, evidence-based discipline. A chaotic family environment, inconsistent enforcement of rules, and excessively harsh discipline can make ODD worse.
• Protecting children from trauma. Children exposed to abuse and violence are more likely to develop ODD.

People with ODD can manage their symptoms by:

• Improving social skills. ODD can compromise social skills, making it difficult for people to empathize and effectively solve problems. Social skills training can help.
• Practicing positive ways of responding to stressful situations.
• Working on communication skills. Responding to frustration with defiance or aggression may escalate the situation. Communicating with empathy can defuse tensions.
• Understanding the connection between their emotions, thoughts, and feelings. Cognitive behavioral techniques such as those taught in cognitive behavioral therapy (CBT) may prove especially helpful.

Research does not support the use of medication alone to treat ODD. Instead, ODD should be treated as a complex emotional and behavior challenge that requires therapy, changes in a person’s environment, and support to develop better social skills.

No drugs are approved specifically for the treatment of ODD. However, some medications may help ease symptoms of ODD, especially when those medications are used along with therapy. Antidepressants, for example, may help some children with ODD better manage their emotions.

Children with ODD are often also diagnosed with ADHD. Stimulant medications such as Adderall and Ritalin can help with ADHD. Some children with ADHD also take antidepressants.

A doctor who specializes in the treatment of ODD can help families decide on the right combination of medication, therapy, and other interventions.

ODD is linked to the later development of a conduct disorder. Children with a conduct disorder routinely hurt or violate the rights of other people and animals. They may break the law, start fires, attack peers, sexually abuse friends and family, or destroy property. Some children diagnosed with a conduct disorder develop antisocial personality disorder in adulthood.

Therapy can help children and adults with ODD better manage their emotions and control their behavior. This can improve their relationships, help them succeed at school, and decrease the likelihood they will have serious mental health issues in adulthood.

A trusting alliance with a therapist is a major predictor of how successful therapy will be. People who feel understood and heard—not judged or stigmatized—by their therapist are more likely to remain in therapy and work toward mutually defined goals. So, finding a therapist who can effectively connect with clients is key to effective treatment.

Some therapeutic approaches that can be helpful for managing ODD include:

• Anger management therapy : Children who struggle with emotional regulation also tend to have trouble controlling their anger. Anger management can teach relaxation techniques, goal-setting, effective problem-solving, trigger identification, and recognition of consequences.
• Play therapy : Although adults can have ODD, ODD is more commonly diagnosed in children. Young children may struggle to understand or express their emotions. Play therapy offers an alternative outlet. Through play, children can work through their emotions, understand their behavior, and master new coping skills.
• Family therapy : ODD can disrupt an entire family. Family therapy teaches family members better coping and communication skills. A type of therapy called parent-child interaction therapy helps parents and children communicate more effectively while fostering positive parenting skills. Some research suggests it can improve family life in children with ODD. Another approach, called collaborative problem-solving, can help children and parents work together to solve the problems that ODD presents.
• Social skills training : People with ODD have more trouble devising solutions to social challenges, such as a fight with a friend, than do people without ODD. Approaches that teach social skills and foster creative problem-solving can support healthier relationships and prevent problems at school and work.
• Art and play therapy for an oppositional foster child:  Gerald, 12, is brought to therapy by a foster parent. He is sweet and cooperative some of the time, but he frequently talks back to adults rudely, purposefully breaks rules, sneaks out of the house, speaks angrily to those around him, and refuses to take responsibility for his chores. His foster mother reports that Gerald was neglected by his mother and that he has been in several foster homes. His current foster family would like to adopt him, but they worry that they will not be able to manage his behavior, which seems to be getting worse. The therapist begins by engaging in play with Gerald—art projects, games, and toy army battles. As the therapist develops a relationship with Gerald, the foster parents are brought into some of the sessions, where Gerald is encouraged to write, draw, and talk about his experiences in other foster homes and to communicate these experiences through various means of performance—puppet shows, a play involving everyone in the room, a story with the army soldiers. After several therapy sessions, Gerald begins to show trust for his foster parents, and his anger becomes more manageable.
• Wild high school senior:  Alice, 17, is staying out past her curfew, cutting class, refusing to eat meals with her family, and using drugs. She shouts and swears at her parents when they try to speak to her about her behavior, which has gone on for all eight months of her senior year of high school. The parents seek a therapist, but Alice will not go. The therapist talks to the parents about their options, and while they do not wish to emancipate her, they are not sure how much longer they can try to help her if her behavior continues in the same manner. The therapist explores the couple’s relationship, history, and parenting style and continues to work with the parents, helping them to manage their own stress and address some long-standing intimacy issues. After several weeks, Alice's parents report to the therapist that some of Alice's oppositional behavior has improved, and that she has agreed to enter therapy. During conversations in therapy, Alice's parents become aware of the many ways they have sent mixed messages to her. Alice feels more understood, and her behavior begins to steadily improve.

References:

• Elia, J. (2017, February). Oppositional defiant disorder (ODD). Retrieved from https://www.merckmanuals.com/professional/pediatrics/mental-disorders-in-children-and-adolescents/oppositional-defiant-disorder-odd
• Greene, R. W., Ablon, J. S., Goring, J. C., Raezer-Blakely, L., Markey, J., Monuteaux, M. C., & Rabbitt, S. (2004). Effectiveness of collaborative problem solving in affectively dysregulated children with oppositional defiant disorder: Initial findings.  Journal of Consulting and Clinical Psychology,   72 (6), 1157-1164. Retrieved from http://psycnet.apa.org/buy/2004-21587-026
• Mishra, A., Garg, S. P., & Desai, S. N. (2014). Prevalence of oppositional defiant disorder and conduct disorder in primary school children.  Journal of Indian Academy of Forensic Medicine,   6 (3). Retrieved from http://medind.nic.in/jal/t14/i3/jalt14i3p246.pdf
• Myers, M. G., Stewart, D. G., & Brown, S. A. (1998). Progression from conduct disorder to antisocial personality disorder following treatment for adolescent substance abuse.  American Journal of Psychiatry,   155 (4), 479-485. Retrieved from https://ajp.psychiatryonline.org/doi/pdf/10.1176/ajp.155.4.479
• Nixon, R. D., Sweeney, L., Erickson, D. B., & Touyz, S. W. (2003). Parent-child interaction therapy: A comparison of standard and abbreviated treatments for oppositional defiant preschoolers.  Journal of Consulting and Clinical Psychology,   71 (2), 251-260. Retrieved from http://psycnet.apa.org/buy/2003-02091-005
• ODD: A guide for families  [PDF]. (2009). American Academy of Child and Adolescent Psychiatry. Retrieved from https://www.aacap.org/App_Themes/AACAP/docs/resource_centers/odd/odd_resource_center_odd_guide.pdf
• Reynolds, C. R., & Kamphaus, R. W. (2013).  Oppositional defiant disorder  [PDF]. Pearson. Retrieved from https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_OppositionalDefiantDisorder.pdf

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Effectiveness of collaborative problem solving in affectively dysregulated children with oppositional-defiant disorder: initial findings

Affiliation.

• 1 Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA. [email protected]
• PMID: 15612861
• DOI: 10.1037/0022-006X.72.6.1157

Oppositional-defiant disorder (ODD) refers to a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures. Research has shown that children with ODD and comorbid mood disorders may be at particular risk for long-term adverse outcomes, including conduct disorder. In this study, the authors examined the effectiveness of a cognitive-behavioral model of intervention--called collaborative problem solving (CPS)--in comparison with parent training (PT) in 47 affectively dysregulated children with ODD. Results indicate that CPS produced significant improvements across multiple domains of functioning at posttreatment and at 4-month follow-up. These improvements were in all instances equivalent, and in many instances superior, to the improvements produced by PT. Implications of these findings for further research on and treatment selection in children with ODD are discussed.

Copyright 2004 APA.

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Collaborative Problem Solving® (CPS)

About this program.

Target Population: Children and adolescents (ages 3-21) with a variety of behavioral challenges, including both externalizing (e.g., aggression, defiance, tantrums) and internalizing (e.g., implosions, shutdowns, withdrawal) who may carry a variety of related psychiatric diagnoses, and their parents/caregivers, unless not age appropriate (e.g. young adult or transition age youth)

For children/adolescents ages: 3 – 21

For parents/caregivers of children ages: 3 – 21

Program Overview

Collaborative Problem Solving® (CPS) is an approach to understanding and helping children with behavioral challenges who may carry a variety of psychiatric diagnoses, including oppositional defiant disorder, conduct disorder, attention-deficit/hyperactivity disorder, mood disorders, bipolar disorder, autism spectrum disorders, posttraumatic stress disorder, etc. CPS uses a structured problem solving process to help adults pursue their expectations while reducing challenging behavior and building helping relationships and thinking skills. Specifically, the CPS approach focuses on teaching the neurocognitive skills that challenging kids lack related to problem solving, flexibility, and frustration tolerance. Unlike traditional models of discipline, this approach avoids the use of power, control, and motivational procedures and instead focuses on teaching at-risk kids the skills they need to succeed. CPS provides a common philosophy, language and process with clear guideposts that can be used across settings. In addition, CPS operationalizes principles of trauma-informed care.

Program Goals

The goals of Collaborative Problem Solving® (CPS) are:

• Reduction in externalizing and internalizing behaviors
• Reduction in use of restrictive interventions (restraint, seclusion)
• Reduction in caregiver/teacher stress
• Increase in neurocognitive skills in youth and caregivers
• Increase in family involvement
• Increase in parent-child relationships
• Increase in program cost savings

Logic Model

View the Logic Model for Collaborative Problem Solving® (CPS) .

Essential Components

The essential components of Collaborative Problem Solving® (CPS) include:

• Three different types of intervention delivery to parents and/or children/adolescents depending on the personal situation:
• Family therapy sessions (conducted both with and without the youth) which typically take place weekly for approximately 10-12 weeks
• 4- and 8-week parent training curricula that teach the basics of the model to parents in a group format (maximum group size = 12 participants)
• Direct delivery to youth in treatment or educational settings in planned sessions or in a milieu
• In the family sessions or parent training sessions, parents receive:
• An overarching philosophy to guide the practice of the approach ("kids do well if they can")
• A specific assessment process and measures to identify challenging behaviors, predictable precipitants, and specific thinking skill deficits. Lagging thinking skills are identified in five primary domains:
• Language and Communication Skills
• Attention and Working Memory Skills
• Emotion and Self-Regulation Skills
• Cognitive Flexibility Skills
• Social Thinking Skills
• A specific planning process that helps adults prioritize behavioral goals and decide how to respond to predictable difficulties using 3 simple options based upon the goals they are trying to pursue:
• Plan A – Imposition of adult will
• Plan B – Solve the problem collaboratively
• Plan C – Drop the expectation (for now, at least)
• A specific problem solving process (operationalizing "Plan B") with three core ingredients that is used to collaborate with the youth to solve problems durably, pursue adult expectations, reduce challenging behaviors, teach skills, and create or restore a helping relationship.
• When directly working with the youth in treatment or education settings, providers engage youth with:

Program Delivery

Child/adolescent services.

Collaborative Problem Solving® (CPS) directly provides services to children/adolescents and addresses the following:

• A range of internalizing and externalizing behaviors, including (but not limited to) physical and verbal aggression, destruction of property, self-harm, substance abuse, tantrums, meltdowns, explosions, implosive behaviors (shutting down), crying, pouting, whining, withdrawal, defiance, and oppositionality

Parent/Caregiver Services

Collaborative Problem Solving® (CPS) directly provides services to parents/caregivers and addresses the following:

• Child with internalizing and/or externalizing behaviors, difficulty effectively problem solving with their child

Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: Any caregivers, educators, and other supports are essential to the success of the approach. Caregivers, teachers and other adult supporters are taught to use the approach with the child outside the context of the clinical setting. School and clinical staff typically learn the model via single or multi-day workshops and through follow-up training and coaching.

Recommended Intensity:

Typically family therapy (in which the youth is the identified patient, but the parents are heavily involved in the sessions so that they can get better at using the approach with their child on their own) occurs once per week for approximately 1 hour. The approach can also be delivered in the home with greater frequency/intensity, such as twice a week for 90 minutes. Parent training group sessions occur once a week for 90 minutes over the course of 4 or 8 weeks. The approach can also be delivered by direct care staff in a treatment setting and/or educators in a school system, in which case delivery is not limited to scheduled sessions, but occurs in the context of regular contact in a residence or classroom.

Recommended Duration:

Family therapy: 8-12 weeks; In-home therapy: 8-12 weeks; Parent training groups: 4-8 weeks

Delivery Settings

This program is typically conducted in a(n):

• Adoptive Home
• Birth Family Home
• Foster / Kinship Care
• Outpatient Clinic
• Community-based Agency / Organization / Provider
• Group or Residential Care
• Justice Setting (Juvenile Detention, Jail, Prison, Courtroom, etc.)
• School Setting (Including: Day Care, Day Treatment Programs, etc.)

Collaborative Problem Solving® (CPS) includes a homework component:

Identifying specific precipitants, prioritizing behavioral goals, and practicing the problem solving process are expected to be completed by the caregiver and youth between sessions.

Collaborative Problem Solving® (CPS) has materials available in languages other than English :

Chinese, French, Spanish

For information on which materials are available in these languages, please check on the program's website or contact the program representative ( contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

Trained personnel. If being delivered as parent group training, it requires a room big enough to hold the number of families (anywhere from a couple of parents up to 12 participants), as well as A/V equipment or printed materials for delivery of material in training curriculum.

Manuals and Training

Prerequisite/minimum provider qualifications.

Service providers and supervisors must be certified in CPS . There is no minimum educational level required before certification process can begin.

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Treatment Manual: Greene, R. W., & Ablon, J. S. (2005). Treating explosive kids: The Collaborative Problem Solving approach . Guilford Press.

Training Information

There is training available for this program.

Training Contact:

• Think: Kids at Massachusetts General Hospital [email protected] phone: (617) 643-6030

Training Type/Location:

Training can be obtained onsite, at Massachusetts General Hospital in Boston, at trainings hosted in other locations, online (introductory training only), or via video/phone training and coaching.

Number of days/hours:

Ranges from a 2-hour exposure training to more intensive (2.5 day) advanced sessions as well as hourly coaching:

• Exposure/Introductory training: These in-person and online trainings typically last from 2–6 hours and provide a general overview exposure of the model including the overarching philosophy, the assessment , planning and intervention process. Training can accommodate an unlimited number of participants.
• Two-and-a-half day intensive trainings that provide participants in-depth exposure to all aspects of the model using didactic training, video demonstration, role play and breakout group practice. Tier 1 training is limited to 150 participants. Tier 2 training is limited to 75 participants.
• Coaching sessions for up to 12 participants that provide ongoing support and troubleshooting in the model

Additional Resources:

There currently are additional qualified resources for training:

There are many certified trainers throughout North America who teach the model as well as well as systems that use the approach. The list is available at https://thinkkids.org/our-communities

Implementation Information

Pre-implementation materials.

There are pre-implementation materials to measure organizational or provider readiness for Collaborative Problem Solving® (CPS) as listed below:

A CPS Organizational Readiness Assessment measure has been developed that is available for systems interested in implementing the model. It can be obtained by contacting the Director of Research and Evaluation, Dr. Alisha Pollastri, at [email protected].

Formal Support for Implementation

There is formal support available for implementation of Collaborative Problem Solving® (CPS) as listed below:

For organization-wide implementation , Think:Kids offers formal implementation support, including ongoing coaching of staff to maximize practice fidelity , implementation consultation to the organization’s leader(s) or implementation team, and implementation /outcome monitoring and reporting. Organizations that opt for implementation support are matched with a Think:Kids Project Manager who helps coordinate the various training and implementation activities. There is a Manager of Implementation at Think:Kids who oversees these implementation supports.

Fidelity Measures

There are fidelity measures for Collaborative Problem Solving® (CPS) as listed below:

Self-Study of CPS Sustainability, Updated 06/2019 : A guide for systems to assess the degree to which they have put the structures in place to implement CPS with fidelity .

CPS Manualized Expert-Rated Integrity Coding System (CPS-MEtRICS) and Practice Integrity Form (CPS-PIF) : Fidelity tools to help measure the degree to which CPS is being practiced with fidelity in a specific encounter.

Both of the above can be obtained by contacting the Director of Research and Evaluation, Dr. Alisha Pollastri, at [email protected]

Established Psychometrics:

Pollastri, A. R., Wang, L., Raftery-Helmer, J. N., Hurley, S., Eddy, C. J., Sisson, J., Thompson, N., & Ablon, J. S. (2022). Development and evaluation of an audio coding system for assessing providers’ integrity to Collaborative Problem Solving in youth-service settings. Professional Psychology: Research and Practice, 53 (6), 640–650. https://doi.org/10.1037/pro0000476

Wang, L., Stoll, S. J., Eddy, C. J., Hurley, S., Sisson, J., Thompson, N., Raftery-Helmer, J., Ablon, J. S., & Pollastri, A. R. (2023). Pragmatic fidelity measurement in youth service settings. Implementation Research and Practice . Advanced online publication. https://doi.org/10.1177/26334895231185380

Implementation Guides or Manuals

There are implementation guides or manuals for Collaborative Problem Solving® (CPS) as listed below:

Clinician Session Guide : Guides the clinician in all aspects of the treatment, from initial assessment to ongoing work. Can be obtained by contacting the Director of Research and Evaluation, Dr. Alisha Pollastri, at [email protected].

CPS Coaching Guide : A guide specifically geared towards trainer individuals who are helping caregivers to implement the model over time. Available to certified trainers.

CPS Implementation Manual : Provides detailed implementation guideposts and instructions for those implementing CPS system-wide. Available to organizations opting for CPS implementation support from Think:Kids. More information available from the Manager of Implementation , Hallie Carpenter, at [email protected]

Implementation Cost

There are no studies of the costs of Collaborative Problem Solving® (CPS) .

Research on How to Implement the Program

Research has been conducted on how to implement Collaborative Problem Solving® (CPS) as listed below:

Ercole-Fricke, E., Fritz, P., Hill, L. E., & Snelders, J. (2016). Effects of a Collaborative Problem Solving approach on an inpatient adolescent psychiatric unit. Journal of Child and Adolescent Psychiatric Nursing, 29 (3), 127–134. https://doi.org/10.1111/jcap.12149

Pollastri, A. R., Boldt, S., Lieberman, R., & Ablon, J. S. (2016). Minimizing seclusion and restraint in youth residential and day treatment through site-wide implementation of Collaborative Problem Solving. Residential Treatment for Children & Youth, 33 (3-4), 186–205. https://doi.org/10.1080/0886571X.2016.1188340

Pollastri, A. R., Ablon, J. S., & Hone, M. J. (Eds.). (2019). Collaborative Problem Solving: An evidence-based approach to implementation and practice. Springer.

Pollastri, A. R., Wang, L., Youn, S. J., Ablon, J. S., & Marques, L. (2020). The value of implementation frameworks: Using the active implementation frameworks to guide system-wide implementation of Collaborative Problem Solving. Journal of Community Psychology , 48 (4), 1114–1131. https://doi.org/10.1002/jcop.22325

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

Greene, R. W., Ablon J. S., Goring, J. C., Raezer-Blakely, L., Markey, J., Monuteaux, M. C., Henin, A, Edwards, G., & Rabbitt, S. (2004). Effectiveness of Collaborative Problem Solving in affectively dysregulated children with oppositional defiant disorder: Initial findings. Journal of Consulting and Clinical Psychology, 72 (6), 1157–1164. https://doi.org/10.1037/0022-006X.72.6.1157

Type of Study: Randomized controlled trial Number of Participants: 47

Population:

• Age — 4–12 years
• Race/Ethnicity — Not specified
• Gender — 32 Male and 15 Female
• Status — Participants were parents and their children with oppositional defiant disorder (ODD).

Location/Institution: Massachusetts

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to examine the efficacy of Collaborative Problem Solving (CPS) in affectively dysregulated children with oppositional defiant disorder (ODD). Participants were randomized to either the parent training version of CPS or parent training (PT). Measures utilized include the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children—Epidemiologic version (K-SADS–E), the Wechsler Intelligence Scale for Children—Revised, the Parent–Child Relationship Inventory (PCRI), the Parenting Stress Index (PSI), the Oppositional Defiant Disorder Rating Scale (ODDRS), and the Clinical Global Impression–Improvement (CGI-I) . Results indicate that CPS produced significant improvements across multiple domains of functioning at posttreatment and at 4-month follow-up. Limitations include small sample size and length of follow-up.

Length of controlled postintervention follow-up: 4 months.

Pollastri, A. R., Boldt, S., Lieberman, R., & Ablon, J. S. (2016). Pollastri, A. R., Boldt, S., Lieberman, R., & Ablon, J. S. (2016). Minimizing seclusion and restraint in youth residential and day treatment through site-wide implementation of Collaborative Problem Solving. Residential Treatment for Children & Youth. 33 (3–4), 186–205. https://doi.org/10.1080/0886571X.2016.1188340

Type of Study: Pretest–posttest study with a nonequivalent control group (Quasi-experimental) Number of Participants: Not specified

• Age — Not specified
• Gender — Not specified
• Status — Participants were in residential and day treatment and included youth in foster care and child welfare.

Location/Institution: Oregon

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to describe the results of one agency’s experience implementing the Collaborative Problem Solving (CPS) approach organization-wide and its effect on reducing seclusion and restraint (S/R) rates. Participants were grouped into the CPS intervention at a residential or day treatment facility. Measures utilized include the Child and Adolescent Functional Assessment Scale (CAFAS) and the Child and Adolescent Needs Assessment (CANS) . Results indicate that during the time studied, frequency of restrictive events in the residential facility decreased from an average of 25.5 per week to 2.5 per week, and restrictive events in the day treatment facility decreased from an average of 2.8 per week to 7 per year. Limitations include lack of randomization of participants, and lack of follow-up.

Length of controlled postintervention follow-up: None.

Additional References

Greene, R. W., & Ablon, J. S. (2005). Treating explosive kids: The Collaborative Problem Solving approach . Guilford Press.

Greene, R. W., Ablon, J. S., Goring, J. C., Fazio, V., & Morse, L. R. (2003). Treatment of oppositional defiant disorder in children and adolescents. In P. Barrett & T. H. Ollendick (Eds.), Handbook of Interventions that work with children and adolescents: Prevention and treatment. John Wiley & Sons.

Pollastri, A. R., Epstein, L. D., Heath, G. H., & Ablon, J. S. (2013). The Collaborative Problem Solving approach: Outcomes across settings. Harvard Review of Psychiatry, 21 (4), 188–199. https://pubmed.ncbi.nlm.nih.gov/24651507/

Contact Information

Date Research Evidence Last Reviewed by CEBC: July 2023

Date Program Content Last Reviewed by Program Staff: December 2023

Date Program Originally Loaded onto CEBC: May 2017

Glossary | Sitemap | Limitations & Disclosures

The CEBC is funded by the California Department of Social Services’ (CDSS’) Office of Child Abuse Prevention and is one of their targeted efforts to improve the lives of children and families served within child welfare system.

© copyright 2006-2024 The California Evidence-Based Clearinghouse for Child Welfare www.cebc4cw.org

Collaborative Problem Solving (CPS)

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Collaborative and Proactive Solutions (CPS)

Introduction

The Collaborative Problem Solving model (CPS) was developed by Dr. Ross Greene and his colleagues at Massachusetts General Hospital’s Department of Psychiatry. The model was created as a reconceptualization of the factors that lead to challenging or oppositional behaviors, and a shift in the targets of intervention for these behaviors. Dr. Greene published the book The Explosive Child in 1998, which was the first detailed description of CPS. Multiple research studies (detailed below) have followed in the time since the book’s publication.

In the subsequent years there was a split between Dr. Greene and Massachusetts General Hospital. Massachusetts General Hospital has continued its work on CPS via the “Think:Kids” program under the direction of Dr. Stuart Ablon, who had previously collaborated with Dr. Greene. Dr. Greene has founded a nonprofit organization called “Lives in the Balance” to further his work on CPS, which...

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Becker, K., Chorpita, D., & Daleiden, B. (2011). Improvement in symptoms versus functioning: How do our best treatments measure up? Administration and Policy in Mental Health and Mental Health Services Research, 38 (6), 440–458.

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Bill of Rights for Behaviorally Challenging Kids. (n.d.). Retrieved from https://www.livesinthebalance.org/bill-rights-behaviorally-challenging-kids

Drilling Cheat Sheet. (n.d.). Retrieved from https://www.livesinthebalance.org/sites/default/files/Drilling%20Cheat%20Sheet%20060417.pdf

Greene, R. (2010). Collaborative problem solving. In Clinical handbook of assessing and treating conduct problems in youth (1st ed., pp. 193–220). New York: Springer.

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Greene, R., & Winkler, J. (2019). Collaborative & Proactive Solutions (CPS): A review of research findings in families, schools, and treatment facilities. Clinical Child and Family Psychology Review, 22 (4), 549–561.

Greene, R. W., Ablon, J. S., Goring, J. C., Raezer-Blakely, L., Markey, J., Monuteaux, M. C., Henin, A., Edwards, G., & Rabbitt, S. (2004). Effectiveness of collaborative problem solving in affectively Dysregulated children with oppositional-defiant disorder: Initial findings. Journal of Consulting and Clinical Psychology, 72 (6), 1157–1164.

Ollendick, T. H., Greene, R. W., Austin, K. E., Fraire, M. G., Halldorsdottir, T., Allen, K. B., Jarret, M. A., Lewis, K. M., Smith, M. W., Cunningham, N. R., Noguchi, R. J. P., Canavera, K., & Wolff, J. (2016). Parent management training and Collaborative & Proactive Solutions: A randomized control trial for oppositional youth. Journal of Clinical Child and Adolescent Psychology, 45 (5), 591–604.

Pollastri, A., Epstein, L., Heath, G., & Ablon, J. (2013). The collaborative problem solving approach: Outcomes across settings. Harvard Review of Psychiatry, 21 (4), 188–199.

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Rosen, B. (2020). Collaborative Problem Solving (CPS). In: Lebow, J., Chambers, A., Breunlin, D.C. (eds) Encyclopedia of Couple and Family Therapy. Springer, Cham. https://doi.org/10.1007/978-3-319-15877-8_1160-1

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S. SUTTON HAMILTON, MD, AND JOHN ARMANDO, LCSW

Am Fam Physician. 2008;78(7):861-866

A more recent article on oppositional defiant disorder is available .

Patient information: See related handout on oppositional defiant disorder , written by the authors of this article.

Author disclosure: Nothing to disclose.

Oppositional defiant disorder is defined by the Diagnostic and Statistical Manual of Mental Disorders , 4th ed., as a recurrent pattern of developmentally inappropriate, negativistic, defiant, and disobedient behavior toward authority figures. This behavior often appears in the preschool years, but initially it can be difficult to distinguish from developmentally appropriate, albeit troublesome, behavior. Children who develop a stable pattern of oppositional behavior during their preschool years are likely to go on to have oppositional defiant disorder during their elementary school years. Children with oppositional defiant disorder have substantially strained relationships with their parents, teachers, and peers, and have high rates of coexisting conditions such as attention-deficit/hyperactivity disorder and mood disorders. Children with oppositional defiant disorder are at greater risk of developing conduct disorder and antisocial personality disorder during adulthood. Psychological intervention with both parents and child can substantially improve short- and long-term outcomes. Research supports the effectiveness of parent training and collaborative problem solving. Collaborative problem solving is a psychological intervention that aims to develop a child's skills in tolerating frustration, being flexible, and avoiding emotional overreaction. When oppositional defiant disorder coexists with attention-deficit/hyperactivity disorder, stimulant therapy can reduce the symptoms of both disorders.

Oppositional defiant disorder is among the most commonly diagnosed mental health conditions in childhood. It is defined by a recurrent pattern of developmentally inappropriate levels of negativistic, defiant, disobedient, and hostile behavior toward authority figures. 1 This behavior must be present for more than six months and must not be caused by psychosis or a mood disorder, and the behavior must negatively impact the child's social, academic, or occupational functioning ( Table 1 ). 1

Several large community-based studies have found that approximately 3 percent of children meet criteria for oppositional defiant disorder as described by the Diagnostic and Statistical Manual of Mental Disorders , 4th ed. (DSM-IV). 2 – 4 However, studies show considerable variance associated with differences in the criteria used, age at assessment, and number of informants used, resulting in prevalence estimates of 1 to 16 percent. 5

Children with oppositional defiant disorder have substantially impaired relationships with parents, teachers, and peers. These children are not only impaired in comparison with their peers, scoring more than two standard deviations below the mean on rating scales for social adjustment, but they also show greater social impairment than do children with bipolar disorder, major depression, and multiple anxiety disorders. 6 When compared with oppositional defiant disorder, only conduct disorder and pervasive developmental disorder had nonstatistical differences in social adjustment. 6

Oppositional defiant disorder is more common in boys than girls, but the data are inconsistent. 7 Some researchers propose that different criteria be used with girls, who tend to exhibit aggression more covertly. 5 Girls may use verbal, rather than physical, aggression, often excluding others or spreading rumors about another child. Oppositional defiant disorder is more common among children in low-income households and is typically diagnosed in late preschool to early elementary school with symptoms often appearing two or three years earlier. Cross-sectional epidemiologic studies show a gradually increasing prevalence of oppositional defiant disorder as children age. 4

Researchers agree there is no single cause or even greatest single risk factor for oppositional defiant disorder. Rather, it is best understood in the context of a biopsychosocial model in which a child's biologic vulnerabilities and protective factors interact complexly with the protective and harmful aspects of his or her environment to determine the likelihood of developing this disorder. 5

Recent theories conceptualize children with oppositional defiant disorder as possessing deficits in a discrete skill set that lead to oppositional behavior. 6 An apparently noncompliant child who “explodes” in response to a parental demand may lack the cognitive or emotional skills required to comply with the adult's request. For example, a child may not have developed the skill of affective modulation, and tends to emotionally overreact, losing his or her capacity to reason. A child may possess deficits in his or her executive cognitive skills (e.g., working memory, ability to change tasks, organized problem solving). These deficits undermine the child's ability to comply with adult demands. Such skill deficits are components of the transactional conceptualization of oppositional defiant disorder, which emphasizes the interaction of the children and parents, and the context of the behavior. An important feature of this model is the relative predictability of the context (e.g., bath time, dinnertime) and the parent and child behaviors that precipitate a child's meltdown.

Neurobiologic theories have been explored in the etiology of aggression. Neurotransmitters such as serotonin, norepinephrine, and dopamine have been investigated in their role with aggression. No single neurotransmitter or neurologic pathway has been identified as the root cause. Oppositional defiant disorder is clearly familial, but research has yet to determine what role genetics play because studies on the genetics of the disorder have produced inconsistent results. 5 Smoking during pregnancy and malnutrition during pregnancy have been associated with the development of oppositional defiant disorder, although causality has not been firmly established. 8

Natural History

The natural history of oppositional defiant disorder is not completely understood. The majority of persons who are diagnosed with the disorder in childhood will later develop a stable pattern of oppositional defiant disorder behavior, an affective disorder, or oppositional defiant disorder with coexisting attention-deficit/hyperactivity disorder (ADHD) or affective disorders. Some children persist with oppositional defiant disorder without coexisting conditions. Children who were diagnosed with oppositional defiant disorder at a young age (e.g., preschool, early elementary school) may later transition to a diagnosis of ADHD, anxiety, or depression. 9 In general, earlier and more severe oppositional defiant disorder is associated with a poorer long-term prognosis. 9

Coexisting Conditions

Coexisting conditions are common in children with oppositional defiant disorder, particularly ADHD and mood disorders. The extent and nature of their coexistence is not precisely defined. The most comprehensive study of children with ADHD is the Multimodal Treatment Study of Children with ADHD. In this study, researchers found that 40 percent of children with ADHD also meet diagnostic criteria for oppositional defiant disorder. 10 Children who have both disorders tend to be more aggressive, have more persistent behavioral problems, experience more rejection from peers, and more severely underachieve academically. 5

In one community study of children with oppositional defiant disorder, 14 percent had coexisting ADHD, 14 percent had anxiety, and 9 percent had a depressive disorder. 7 The authors of another study found that children with oppositional defiant disorder were twice as likely to have severe major depression or bipolar disorder compared with a reference group. 6 , 11 Specific data are lacking, but expert consensus is that learning disabilities and language disorders also commonly coexist with oppositional defiant disorder. 5

Oppositional defiant disorder has commonly been regarded as a subset and precursor of the more serious conduct disorder, in part because most children with conduct disorder have a history of oppositional defiant disorder. Approximately one third of children with oppositional defiant disorder subsequently develop conduct disorder, 40 percent of whom will develop antisocial personality disorder in adulthood. 12 Children with coexisting oppositional defiant disorder and ADHD are particularly likely to develop conduct disorder.

Among other features, aggression toward other people and animals, a disregard for the rights of others, and the theft or destruction of others' property characterize conduct disorder. 1 The DSM-IV precludes diagnosing a child with both oppositional defiant disorder and conduct disorder. When a diagnosis of conduct disorder is made, the diagnosis of oppositional defiant disorder must be dropped if strict adherence to the DSM-IV is sought. Some researchers conceptualize conduct disorder and oppositional defiant disorder less as separate disorders, but rather as differing primarily in the severity of their disruptive behavior. Other researchers consider the two as entirely separate disorders. There is little disagreement that conduct disorder is more serious and is a poor outcome for children previously diagnosed with oppositional defiant disorder.

Lisa is a five-year-old girl whose parents asked their family physician to see her because of their increasing concern about her temper tantrums in the home. The parents indicated that Lisa often becomes enraged and argumentative with them, refusing to follow rules or take direction. In particular, they report difficulty getting her to transition from playing with her toys to coming to the dinner table. After Lisa ignored her parents' repeated prompts, her father became frustrated and told her that she had lost her dessert privilege. Lisa became aggressive and destructive, breaking her toys and smashing food and water from the dinner table into the carpet. Her parents described similar scenarios at bedtime, bath time, and when getting dressed in the morning. They described her as irritable in these situations and they felt she was deliberately ignoring or trying to annoy them.

Tools such as the National Initiative for Children's Healthcare Quality (NICHQ) Vanderbilt Assessment Scale, 13 designed for the primary care evaluation of children with suspected or diagnosed ADHD, contain questions that aid in the identification of oppositional defiant disorder. Use of this or similar instruments, such as the SNAP-IV Teacher and Parent Rating Scale for children with ADHD, 14 may allow enhanced detection of oppositional defiant disorder as well as other psychological concerns. Screening tools such as the Pediatric Symptom Checklist are not specific for oppositional defiant disorder, but can screen for cognitive, emotional, or behavioral problems, thereby identifying children who require additional investigation. 15 Table 2 provides more information on how to access these tools online. 13 – 15

Table 3 provides a differential diagnosis for oppositional defiant disorder. 1 A higher index of suspicion should be maintained in children with known risk factors such as ADHD because approximately 40 percent of children with ADHD have coexisting oppositional defiant disorder. 10 It is useful to recognize the role of established environmental risk factors such as living in a single-parent household and having low socioeconomic status. Chronically obese children are also at increased risk for oppositional defiant disorder. 4 Relevant family history includes that of oppositional defiant disorder, conduct disorder, or antisocial personality disorder. 1

Oppositional defiant disorder is most commonly diagnosed during the elementary school years, although most children with the disorder have a history of significant oppositional behavior in preschool.

The initial step in diagnosis is to determine whether or not the behavior is, in fact, abnormal. A certain amount of oppositional behavior is normal in childhood. Oppositional defiant disorder is only distinguishable by the duration and degree of the behavior. Physicians should carefully explore the possibility that the child's oppositional behavior is caused by physical or sexual abuse, or neglect. Given the wide range of normal oppositional behavior during the preschool years, caution should be exercised in diagnosing this disorder in the preschool-age child. 5 Assessment of the child with a potential diagnosis of oppositional defiant disorder depends on establishing a therapeutic alliance with both the child and family. The assessment should include information gathered from multiple sources (e.g., preschool, teachers) as well as history obtained from the child directly.

To satisfy DSM-IV criteria for oppositional defiant disorder, a child must frequently demonstrate behavior from at least four of nine criteria ( Table 1 ). 1 The behavior must be considerably more frequent than is typically observed in persons of comparable age and developmental level and must cause clinically significant impairment in social, academic, or occupational functioning. 1

When the diagnosis is unclear, patients should be referred to a psychologist or psychiatrist trained in the assessment of children with behavioral disorders. For children in elementary school, a physician's written request should facilitate a school-based evaluation by an appropriate professional. Evaluation of preschool children can most often be prompted by a telephone call to a county's Child Find or similar program. When available, a developmental-behavioral pediatrician can be an ideal beginning point of an assessment. Structured psychological interviews (such as the National Institute of Mental Health's Diagnostic Interview Schedule for Children [DISC] version 2.3), typically administered by a psychologist, can be used for formal diagnosis. When these services are unavailable, physicians may wish to use a brief series of questions that researchers have shown to possess 90 percent sensitivity and 94 percent specificity for identifying oppositional defiant disorder ( Table 4 ). 7

Neuroimaging (e.g., functional magnetic resonance imaging, single-photon emission computed tomography, electroencephalography) has a role in the research of aggressive behavior, but it has no clinical role in the evaluation of children with suspected oppositional defiant disorder.

Nonpharmacologic Treatment

Research supports outpatient psychological interventions for children with oppositional defiant disorder. Studies have demonstrated that parent training is an effective means of reducing disruptive behavior. 16 Parents often come to see their child's behavior as deliberate and under the child's control, intentionally hurtful toward the parent, or as an attribute of a disliked family member (e.g., an abusive partner). 17 The difficult behavior and social disruption caused by children with oppositional defiant disorder can have adverse effects on the mental health of their parents. 18 Parent training teaches parents to be more positive and less harsh in their discipline style. Media-based parent training (e.g., watching a video) has been shown to be effective with results continuing one year after the intervention. 19 In a randomized study, investigators found that applying parent training to both the child and parent is superior to training aimed solely at the parent, supporting the generally agreed-upon principle that therapies are more effective when both parent and child are involved. 20

Multisystemic therapy is a term for a community-based intervention that explicitly attempts to intervene in multiple real-life settings (e.g., home, school). Studies support the evidence behind multisystemic therapy, but there are limitations in the ability to generalize findings. 13

Collaborative problem-solving interventions seek to facilitate joint problem solving, rather than to teach and motivate children to comply with parental demands. This model encourages parents and children to identify issues and to use cognitive approaches to resolve the conflict to the mutual satisfaction of both parties. Collaborative problem solving appears to be at least as effective as parent training. 21

Pharmacologic Treatment

Several studies have found that medicines used in the treatment of ADHD, such as methylphenidate (Ritalin), atomoxetine (Strattera), and amphetamine/dextroamphetamine (Adderall), are effective in the treatment of ADHD with coexisting oppositional defiant disorder. 22 – 24 According to these studies, stimulants reduced the symptoms of both ADHD and oppositional defiant disorder symptoms. There are also two small studies that show the effectiveness of clonidine (Catapres) in treating children with ADHD and oppositional defiant disorder, either as monotherapy or as augmentation to medical therapy. 25 , 26 Studies have not demonstrated that stimulants reduce the symptoms of oppositional defiant disorder when ADHD is absent.

There is evidence that programs for preschool children (e.g., Head Start) reduce delinquency and, by inference, oppositional defiant disorder. 13 In elementary school-age children, the greatest evidence on prevention supports parent management strategies. Researched programs include the Triple P-Positive Parenting Program and Incredible Years parenting series. Both of these use self-directed, multimedia, parenting and family support strategies to prevent severe behavioral problems in children by enhancing the knowledge, skills, and confidence of parents. These programs are most appropriate for parents whose children appear to be at risk of developing emotional and/or behavioral problems. School-based programs that focus on anti-bullying, antisocial behavior, or peer groups can also be effective prevention approaches. 27

Family physicians should suspect oppositional defiant disorder when parents report an excessively argumentative, defiant, and hostile school-age child. Oppositional defiant disorder is common in children with ADHD, and use of the validated instruments mentioned in this article for the assessment and diagnosis of ADHD can help physicians to identify oppositional defiant disorder. Suspicion for oppositional defiant disorder should be raised when known risk factors (e.g., family history of oppositional defiant disorder/conduct disorder, ADHD, low socioeconomic status) are present. Formal diagnosis may require referral to a children's psychologist or psychiatrist.

Children with oppositional defiant disorder are best served by referral to a professional who is skilled and knowledgeable in evidence-based therapies for these children, although finding such professionals can be challenging. A physician's ability to locate particular resources for a child will depend on the family's insurance, financial resources, and motivation, as well as the availability of such resources in their community. There is no single best way to connect a child to the best services for him or her, and it is often prudent to explore multiple avenues to find the optimal available services. A physician's knowledge of oppositional defiant disorder, its typical symptoms, and best available treatments can allow the physician to serve as a patient advocate, to connect families with services, and to provide families with educational materials and online resources.

Diagnostic and Statistical Manual of Mental Disorders . 4th ed. rev. Washington, DC: American Psychiatric Association; 1994.

Maughan B, Rowe R, Messer J, Goodman R, Meltzer H. Conduct disorder and oppositional defiant disorder in a national sample: developmental epidemiology. J Child Psychol Psychiatry. 2004;45(3):609-621.

Mustillo S, Worthman C, Erkanli A, Keeler G, Angold A, Costello EJ. Obesity and psychiatric disorder: developmental trajectories. Pediatrics. 2003;111(4 pt 1):851-859.

Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry. 2003;60(8):837-844.

Steiner H, Remsing L for the Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(1):126-141.

Greene RW, Biederman J, Zerwas S, Monuteaux MC, Goring JC, Faraone SV. Psychiatric comorbidity, family dysfunction, and social impairment in referred youth with oppositional defiant disorder. Am J Psychiatry. 2002;159(7):1214-1224.

Angold A, Costello EJ. Toward establishing an empirical basis for the diagnosis of oppositional defiant disorder. J Am Acad Child Adolesc Psychiatry. 1996;35(9):1205-1212.

Raine A. Annotation: the role of prefrontal deficits, low autonomic arousal, and early health factors in the development of antisocial and aggressive behavior in children. J Child Psychol Psychiatry. 2002;43(4):417-434.

Lavigne JV, Cicchetti C, Gibbons RD, Binns HJ, Larsen L, DeVito C. Oppositional defiant disorder with onset in preschool years: longitudinal stability and pathways to other disorders. J Am Acad Child Adolesc Psychiatry. 2001;40(12):1393-1400.

The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Multimodal Treatment Study of Children with ADHD. Arch Gen Psychiatry. 1999;56(12):1073-1086.

Kadesjö C, Hägglöf B, Kadesjö B, Gillberg C. Attention-deficit-hyperactivity disorder with and without oppositional defiant disorder in 3- to 7-year-old children. Dev Med Child Neurol. 2003;45(10):693-699.

Loeber R, Burke JD, Lahey BB, Winters A, Zera M. Oppositional defiant and conduct disorder: a review of the past 10 years, part I. J Am Acad Child Adolesc Psychiatry. 2000;39(12):1468-1484.

National Iniatitive for Children's Healthcare Quality. Caring for children with ADHD: a resource toolkit for clinicians. http://www.nichq.org/NICHQ/Topics/ChronicConditions/ADHD/Tools/ADHD.htm. (password required). Accessed November 29, 2007.

Swanson JM. The SNAP-IV teacher and parent rating scale. http://www.adhdcanada.com/pdfs/SNAP-IVTeacherParetnRatingScale.pdf . Accessed November 29, 2007.

Massachusetts General Hospital. Pediatric symptom checklist. http://www.massgeneral.org/allpsych/PediatricSymptomChecklist/psc_english.PDF. Accessed November 29, 2007.

Farmer EM, Compton SN, Bums BJ, Robertson E. Review of the evidence base for treatment of childhood psychopathology: externalizing disorders. J Consult Clin Psychol. 2002;70(6):1267-1302.

Dadds MR, Hawes D. Integrated Family Intervention for Child Conduct Problems: A Behaviour-Attachment-Systems Intervention for Parents . Bowen Hills, Queensland, Australia: Australian Academic Press; 2006:1–10.

Kashdan TB, Jacob RG, Pelham WE, et al. Depression and anxiety in parents of children with ADHD and varying levels of oppositional defiant behaviors: modeling relationships with family functioning. J Clin Child Adolesc Psychol. 2004;33(1):169-181.

Montgomery P, Bjornstad G, Dennis J. Media-based behavioural treatments for behavioural problems in children. Cochrane Database Syst Rev. 2006(1):CD002206.

Webster-Stratton C, Hammond M. Treating children with early-onset conduct problems: a comparison of child and parent training interventions. J Consult Clin Psychol. 1997;65(1):93-109.

Greene RW, Ablon JS, Goring JC, et al. Effectiveness of collaborative problem solving in affectively dysregulated children with oppositional-defiant disorder: initial findings. J Consult Clin Psychol. 2004;72(6):1157-1164.

Swanson JM, Kraemer HC, Hinshaw SP, et al. Clinical relevance of the primary findings of the MTA: success rates based on severity of ADHD and ODD symptoms at the end of treatment. J Am Acad Child Adolesc Psychiatry. 2001;40(2):168-179.

Newcorn JH, Spencer TJ, Biederman J, Milton DR, Michelson D. Atomoxetine treatment in children and adolescents with attention-deficit/hyperactivity disorder and comorbid oppositional defiant disorder. J Am Acad Child Adolesc Psychiatry. 2005;44(3):240-248.

Biederman J, Spencer TJ, Newcorn JH, et al. Effect of comorbid symptoms of oppositional defiant disorder on responses to atomoxetine in children with ADHD: a meta-analysis of controlled clinical trial data. Psychopharmacology (Berl). 2007;190(1):31-41.

Connor DF, Barkley RA, Davis HT. A pilot study of methylphenidate, clonidine, or the combination in ADHD comorbid with aggressive oppositional defiant or conduct disorder. Clin Pediatr (Phila). 2000;39(1):15-25.

Hazell PL, Stuart JE. A randomized controlled trial of clonidine added to psychostimulant medication for hyperactive and aggressive children. J Am Acad Child Adolesc Psychiatry. 2003;42(8):886-894.

Burke JD, Loeber R, Birmaher B. Oppositional defiant disorder and conduct disorder: a review of the past 10 years, part II. J Am Acad Child Adolesc Psychiatry. 2002;41(11):1275-1293.

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“Beyond Rewards & Consequences: A Better Parenting Strategy for Teens with ADHD and ODD” [Video Replay & Episode #220]

In this hour-long webinar-on-demand, learn how dr. greene’s collaborative & proactive solutions model can help you parent teens with odd and adhd..

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Episode Description

Search for parenting advice on Amazon.com , and you’ll see 70,000+ books filled with guidance — much of it contradictory, confusing, and/or ambiguous. These days, it’s tough to know what’s right or wrong, what to let slide, what to prioritize, and how best to respond when your child isn’t meeting expectations. If your teen is diagnosed with ADHD or ODD, the questions are more numerous and the challenges greater.

How can I motivate my teen? How can I make him obey me? These are often the first questions I hear. But they should be your last reaction if you want to have a good relationship with your teen and influence his or her development. Collaboration and problem-solving work a lot better.

In this webinar, you will learn about:

• Dr. Greene’s Collaborative & Proactive Solutions models
• How to influence, not control, your adolescent
• How to stop focusing on your teen’s behavior and start focusing on (and solving) the problems that are causing that behavior
• How to help your teen explore his or her own values and be aware of yours
• Why adult-imposed consequences may be counterproductive
• Why good parenting means “being responsive to the hand you’ve been dealt”
• The three steps that are involved in solving a problem collaboratively

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Enter your email address in the box above labeled “Video Replay + Slide Access” to watch the video replay (closed captions available) and download the slide presentation.

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This ADHD Experts webinar was first broadcast live on June 6, 2018.

Related recommended resources:

• Helping Tweens Succeed
• Free Download: Why Is My Child So Defiant?
• [Self-Test] Oppositional Defiant Disorder (ODD) in Children
• Defiant Child Behavior Strategies for Parents… from Parents

Listener testimonials:

• “Excellent content and well-organized presentation.”
• “This was very informative. I received a lot of valuable information. Thank you.”
• “Insightful way of reframing how we think about ‘discipline.'”
• “Great information and very helpful to me.”

Ross W. Greene, Ph.D., is a member of the ADDitude Medical Review Panel

Meet the Expert Speaker:

Ross W. Greene, Ph.D. is the originator of the innovative, empirically-supported approach now known as Collaborative & Proactive Solutions (CPS), as described in his influential books The Explosive Child , Lost at School , Lost & Found , and the recently released Raising Human Beings . Dr. Greene was on the faculty at Harvard Medical School for over 20 years, and is now Founding Director of the non-profit Lives in the Balance .  He is on the adjunct faculty in the Department of Psychology at Virginia Tech and in the Faculty of Science at the University of Technology in Sydney, Australia. Dr. Greene has worked with several thousand behaviorally challenging kids and their families, and he and his colleagues have overseen implementation and evaluation of the CPS model in hundreds of schools, inpatient psychiatry units, and residential and juvenile detention facilities, with dramatic effect: significant reductions in discipline referrals, detentions, suspensions, and use of restraint procedures and solitary confinement. He has infused the parenting and teaching of all kids with humanity, empathy, and compassion.  Dr. Greene lectures throughout the world and lives with his family in Portland, Maine.

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Effectiveness of Collaborative Problem Solving in Affectively Dysregulated Children With Oppositional-Defiant Disorder: Initial Findings

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• Journal of Consulting and Clinical Psychology 72(6):1157-64
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Collaborative and Proactive Solutions

• Building Relationships, Managing Emotions, and Decision-Making Skills
• Positive Youth Development
• Intervention

How to access this practice/program?

Visit https://cpsconnection.com/workshops-and-training/ to review training options.

What is the practice/program?  

Collaborative and Proactive Solutions (CPS) is an evidence-based, trauma-responsive approach to working with children who are experiencing social, emotional, and behavioral challenges in families, schools, and treatment facilities. CPS helps children and caregivers solve the problems that are causing the concerning behaviors. The problem solving is collaborative, not unilateral, and proactive, not reactive. The model has been shown to be effective at not only solving problems and improving behavior, but also at enhancing skills.  

Who is the practice/program for?  

This approach works with children and adolescents and is most effective with ages 4-14.   

What outcomes does the practice/program produce?  

• Improve relationships  
• Improve communication  
• Improve skills of empathy, appreciating how one’s behavior is affecting others, resolving disagreements in collaborative ways, taking another’s perspective, and honesty  
• Decrease the likelihood of conflict  

What is the evidence?  

Tshida, J.E., Maddox, B.B., Bertollo, J.R., Kuschner, J.S., Miller, J.S., Ollendick, T.H., Greene, R.W., & Yerys, B.E. (2021). Caregiver perspectives on interventions for behavior challenges in autistic children. Research in Autism Spectrum Disorders. 81. https://livesinthebalance.org/wp-content/uploads/2021/06/Autism-Spectrum-Disorders_0.pdf  

Results of this study indicate that caregivers of school-age children with a diagnosis of Autism Spectrum Disorder, a reported IQ equal or greater than 70, and behavioral challenges rated medications and CPS as significantly more helpful at improving behavior challenges. Additionally, medications, CPS, ABA, and “other interventions” were rated as leading to significantly greater maintained improvements.  

Greene, R.W., & Winkler, J. (2019), Collaborative & Proactive Solutions: A review of research findings in families, schools, and treatment facilities. Clinical Child and Family Psychology Review, 22(4), 549-561. https://rdcu.be/bHMLV   

Collaborative & Proactive Solutions (CPS) is a psychosocial treatment model for behaviorally challenging youth, which has been applied in a diverse array of settings, including families, schools, and therapeutic facilities. Numerous studies have documented its effectiveness and examined factors that mediate and moderate the effectiveness of the model. Data have thus far shown that, with regard to behavioral improvements, CPS is at least the equivalent of the standard of care for externalizing youth, Parent Management Training, and that CPS may hold additional benefits as regards parent-child interactions and children’s skill enhancement.   

Greene, R. W., Ablon, J. S., Goring, J. C., Raezer-Blakely, L., Markey, J., Monuteaux, M. C., Henin, A., Edwards, G., & Rabbitt, S. (2004). Effectiveness of Collaborative Problem Solving in Affectively Dysregulated Children With Oppositional-Defiant Disorder: Initial Findings. Journal of Consulting and Clinical Psychology, 72(6), 1157–1164. https://doi.org/10.1037/0022-006X.72.6.1157  

This study compared the effectiveness of the CPS program to that of the parent training (PT) program. 50 children with oppositional-defiant disorder (ODD) between the ages of 4-12 were randomly assigned to either the CPS treatment group or PT group. The students were assessed both pre and post treatment based on parent stress and clinical evaluations. Students in the CPS treatment group saw significant improvement across multiple domains (i.e., ODD related behaviors, mood, communication) at the post assessment and 4-month mark. At the 4-month mark 60% students in the CPS treatment group saw clinically significant improvement compared to 37% in the PT group.  

How is the practice/program implemented?  

In the CPS model, a student’s concerning behaviors are simply the way in which they communicate that there are expectations they are having difficulty meeting. Those “unmet” expectations are called “unsolved problems.” The CPS model focuses on identifying the unsolved problems and then engaging the student in solving them. CPS utilizes the Assessment of Lagging Skills and Unsolved Problems (ALSUP) to identify the student’s lagging skills and “Plan B” to solve the problems. Plan B involves three basic steps: 1) the Empathy step which involves gathering information in order to achieve the clearest understanding of what’s making it difficult for a student to meet a particular expectation; 2) the Define the Problem step which involves figuring out why it is important to the adult that the expectation be met; and 3) the Invitation step which involves having adults and students brainstorm solutions in order to arrive at an action plan that is both realistic and mutually satisfactory.  

Who can implement the practice/program?  

Clinicians, educators, and parents can implement CPS.  

What are the costs and commitments associated with becoming trained in this practice/program?  

Cost and commitment associated with training differs depending on the individual and/or the group. For more information, please click on this link – https://www.cpsconnection.com/workshops-and-training    

What resources are useful for understanding or implementing the practice/program?  

• More information on CPS can be found here: https://www.cpsconnection.com/about
• More information on CPS tools can be found here: https://www.cpsconnection.com/paperwork  
• To find mental health providers and resources in your area visit the Texas School Mental Health Resource Database here: https://schoolmentalhealthtxdatabase.org/  

Rating: Promising  

Secondary components: Grief Informed and Trauma Informed Practices; Positive, Safe, and Supportive School Climate; Positive Behavior Interventions and Supports

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Research Etc.

The Collaborative & Proactive Solutions* model is recognized as an empirically-supported, evidence-based treatment by the  California Evidence-Based Clearinghouse for Child Welfare  (CEBC). The research base supporting the effectiveness of the CPS model continues to grow, and this page is updated continuously.

Published and Submitted Papers:

Greene, R.W., Hall, A., & O’Leary, H. (2023). Reducing Restraints and Seclusions in Schools: Implementation of Collaborative & Proactive Solutions in One School System, under review. CLICK HERE

Wagener, E., & Hyson, D. (2023), Collaborative & Proactive Solutions: Additional impact of practitioner multicultural competency. Poster presented at the 2023 conference of the National Association of School Psychologists. CLICK HERE

Stout, G., & Hyson, D. (2023). Reimagining CICO: Using a Collaborative & Proactive Solutions approach. Poster presented at the 2023 conference of the National Association of School Psychologists. CLICK HERE

Mulraney, M, Sciberras, E, Payne, JM, De Luca, C, Mills, J, Tennant, M, &  Coghill, D. (2022). Collaborative and Proactive Solutions compared with usual care to treat irritability in children and adolescents: a pilot randomized controlled trial. Clinical Psychologist 26(2) : 231 -239. CLICK HERE

Murrihy, R.C.. Drysdale, S.O., Dedousis-Wallace, A., Remond, L., McAloon, J., Ellis, D.M., Halldorsdottir, T., Greene, R.W., & Ollendick, T.H. (2022). Community-delivered Collaborative and Proactive Solutions and Parent Management Training for oppositional youth: A randomized trial. Behavior Therapy. CLICK HERE

Trapp, L., Gershwin, T., & Robinson, J. (2022). Honoring team decision-making during manifestation determination meetings through Collaborative & Proactive Solutions. Intervention in School and Clinic . CLICK HERE

Hinden, K., & Hyson, D. (2022). Influencing Teacher Self-Efficacy: Integrating Coaching in School-Based Behavioral Consultation. Poster presented at the annual conference of the National Association of School Psychologists, Boston, MA. CLICK HERE

Greene, R.W., & Haynes, S. (2021). An alternative to exclusionary discipline. Childhood Education , 97 (5), 72-76. CLICK HERE

Polacek, R., Sarah, K., & Greene, R.W. (under review). Combining Collaborative & Proactive Solutions and Positive Behavior Interventions & Supports: Recommendations for schools engaged in transforming disciplinary practices. CLICK HERE

Greene, R.W., & Winkler, J. (under review). Reducing discipline referrals: Collaborative & Proactive Solutions in four schools. CLICK HERE

Wilmot, B., & Mascio, B. (2021). Returning to school during the pandemic: An opportunity to integrate social-emotional AND academic learning. Albert Shanker Institute. CLICK HERE .

Tshida, J.E., Maddox, B.B., Bertollo, J.R., Kuschner, J.S., Miller, J.S., Ollendick, T.H., Greene, R.W., & Yerys, B.E. (2021). Caregiver perspectives on interventions for behavior challenges in autistic children. Research in Autism Spectrum Disorders , 81. CLICK HERE

Greene, R.W., & Winkler, J. (2019). Collaborative & Proactive Solutions: A review of research findings in families, schools, and treatment facilities. Clinical Child and Family Psychology Review, 22(4), 549-561. CLICK HERE .

Booker, J., & Ollendick, T.H. (2019). Patterns in the parent-child relationship and clinical outcomes in a randomized control trial. Presented at symposium, Collaborative and Proactive Solutions as an alternative to Parent Management Training for youth with oppositional defiant disorder: A comparison of therapeutic models. World Congress of Behavioral and Cognitive Therapies, Berlin, Germany. CLICK HERE

Ollendick, T.H., Radtke, S.R., & Booker, J. (2019). Psychosocial treatment of the affective and behavioral dimensions of ODD and the potential moderating role of anxiety on treatment outcomes. Presented at symposium, Collaborative and Proactive Solutions as an alternative to Parent Management Training for youth with oppositional defiant disorder: A comparison of therapeutic models. World Congress of Behavioral and Cognitive Therapies, Berlin, Germany. CLICK HERE

Dedousis-Wallace, A., Drysdale, S., Murrihy, R.C., Remond, L., McAloon, J., Greene, R.W., & Ollendick, T.H. (2019). Predictors and moderators of Parent Management Training and Collaborative & Proactive Solutions in the treatment of oppositional defiant disorder in youth. Presented at symposium, Collaborative and Proactive Solutions as an alternative to Parent Management Training for youth with oppositional defiant disorder: A comparison of therapeutic models. World Congress of Behavioral and Cognitive Therapies, Berlin, Germany. CLICK HERE

Booker, J.A., Capriola-Hall, N.N., Greene, R.W., & Ollendick, T.H. (2019). The parent-child relationship and post-treatment child outcomes across two treatments for oppositional defiant disorder. Journal of Clinical Child and Adolescent Psychology.  CLICK HERE .

King, S. (2019). The effect of executive function deficits on treatment response in children with oppositional defiant disorder. Master’s thesis, University of Alabama. CLICK HERE

Maddox, B.B., Cleary, P., Kuschner, E.S., Miller, J.S., Armour, A.C., Kenworthy, L., Schultz, R.T., & Yerys, B.E. (2018). Lagging skills contribute the challenging behavior in children with autism spectrum disorder without intellectual disability.  Autism, 22 (8), 898-906.  CLICK HERE . 

Booker, J.A., Ollendick, T.H., Dunsmore, J.C., Capriola, N., & Greene, R.W. (2018). Change in maternal stress for families in treatment for their children with oppositional defiant disorder. Journal of Child and Family Studies , in press.

Ollendick, T.H., Booker, J.A., Ryan, S., & Greene, R.W. (2018). Testing multiple conceptualizations of oppositional defiant disorder in youth.  Journal of Clinical Child & Adolescent Psychology ,   47:4,   620-633.   CLICK HERE

Sams, D.P., Garrison, D., & Bartlett, J. (2016). Innovative, strength-based care in child and adolescent psychiatry. Journal of Child and Adolescent Psychiatric Nursing , 29 , 110-117. CLICK HERE

Ollendick, T. H. (2016).  Parent Management Training and Collaborative & Proactive Solutions* in the treatment of ODD in youth: Predictors and moderators of change. Presented at Symposium, Advances in conceptualisation and treatment of youth with oppositional defiant disorder: A comparison of two major therapeutic models , Eighth World Congress of Behavioural and Cognitive Therapies, Melbourne, Australia.  CLICK HERE

Murrihy, R., Wallace, A., Ollendick, T.H., Greene, R.W., McAloon, J., Gill, S., Remond, L., Ellis, D.M., & Drysdale, S. (2016). Parent Management Training and Collaborative & Proactive Solutions*: A randomised comparison trial for oppositional youth within an Australian population. Presented at Symposium,  Advances in conceptualisation and treatment of youth with oppositional defiant disorder: A comparison of two major therapeutic models , Eighth World Congress of Behavioural and Cognitive Therapies, Melbourne, Australia. CLICK HERE

Greene, R.W. (2016). Collaborative & Proactive Solutions*: Applications in schools and juvenile detention settings. Presented at symposium,  Advances in conceptualisation and treatment of youth with oppositional defiant disorder: A comparison of two major therapeutic models , Eighth World Congress of Behavioural and Cognitive Therapies, Melbourne, Australia. CLICK HERE

Dedousis-Wallace, A., Murrihy, R.C., Ollendick, T.H., Greene, R.W., McAloon, J., Gill, S., Remond, L., Ellis, D.M., & Drysdale, S. (2016). Moderators and mediators of Parent Management Training and Collaborative & Proactive Solutions* in the treatment of oppositional defiant disorder in children and adolescents. Presented at Symposium,  Advances in conceptualisation and treatment of youth with oppositional defiant disorder: A comparison of two major therapeutic models, Eighth World Congress of Behavioural and Cognitive Therapies, Melbourne, Australia. CLICK HERE

Remond, L. (2016). Collaborative & Proactive Solutions* (CPS): A clinician’s experience. Presented at Symposium,  Advances in conceptualisation and treatment of youth with oppositional defiant disorder: A comparison of two major therapeutic models,  Eighth World Congress of Behavioural and Cognitive Therapies, Melbourne, Australia. CLICK HERE

Booker, J.A., Ollendick, T.H., Dunsmore, J.C., & Greene, R.W. (2016).  Perceived parent-child relations, conduct problems, and clinical improvement following the treatment of oppositional defiant disorder.  Journal of Child and Family Studies,  25, 1623-1633 .  CLICK HERE

Miller-Slough, R.L., Dunsmore, J.C., Ollendick, T.H., & Greene, R.W. (2016).  Parent-child synchrony in children with oppositional defiant disorder: Associations with treatment outcomes,  Journal of Child and Family Studies , 25, 1880-1888.  CLICK HERE .

Ollendick, T.H., Greene, R.W., Fraire, M.G., Austin, K.E., Halldorsdottir, T., Allen, K.B., Jarrett, M.E., Lewis, K.M., Whitmore, M.J., & Wolff, J.C. (2015). Parent Management Training (PMT) and Collaborative & Proactive Solutions* (CPS) in the treatment of oppositional defiant disorder in youth: A randomized control trial. Journal of Clinical Child and Adolescent Psychology.  CLICK HERE

Dunsmore, J.C., Booker, J.A., Ollendick, T.H., & Greene, R.W. (2015). Emotional socialization in the context of risk and psychopathology: Maternal emotion coaching predicts better treatment outcomes for emotionally labile children with oppositional defiant disorder.   Social Development.  CLICK HERE

Dunsmore, J.C., Booker, J.A., Atzaba-Poria, N., Ryan, S., Greene, R.W., & Ollendick, T.H. (2015).  Emotion coaching predicts change in family functioning across treatment for children with oppositional defiant disorder. Poster presented at the biennial meeting of the Society for Research in Child Development, Philadephia, PA.  CLICK HERE

Johnson, M., Ostlund, S., Fransson, G., Landgren, M., Nasic, S., Kadesjo, B., Gillberg, C., and Fernell, E. (2012).  Attention-deficit/hyperactivity disorder (ADHD) with oppositional defiant disorder (ODD) in Swedish children:  An open study of Collaborative Problem Solving*.   Acta Paediactrica , Volume 101, pp. 624-630.  CLICK HERE

Fraire, M., McWhinney, E., & Ollendick, T. (2011). The effect of comorbidity on treatment outcome in an ODD sample. In T. Ollendick (Chair), C omorbidities in children and adolescents: Implications for evidence-based treatment.  Symposia presented at the 41 st  European Association for Behavioral and Cognitive Therapies, Reykjavik, Iceland. CLICK HERE

Halldorsdottir, T., Austin, K. & Ollendick, T. (2011). Comorbid ADHD in children with ODD or specific phobia: Implications for evidence-based treatments. In T. Ollendick (Chair), C omorbidities in children and adolescents: Implications for evidence-based treatment.  Symposia presented at the 41 st  European Association for Behavioral and Cognitive Therapies, Reykjavik, Iceland. CLICK HERE

Epstein, T., & Saltzman-Benaiah, J. (2010). Parenting children with disruptive behaviors: Evaluation of a Collaborative Problem Solving* pilot program. Journal of Clinical Psychology Practice , 27-40. CLICK HERE

Martin, A., Krieg, H., Esposito, F., Stubbe, D., & Cardona, L. (2008). Reduction of restraint and seclusion through Collaborative Problem Solving*: A five-year, prospective inpatient study. Psychiatric Services , 59(12), 1406-1412. CLICK HERE

Greene, R.W., Ablon, S.A., & Martin, A. (2006). Innovations: Child Psychiatry: Use of Collaborative Problem Solving* to reduce seclusion and restraint in child and adolescent inpatient units. Psychiatric Services , 57(5), 610-616. CLICK HERE

Greene, R.W., Ablon, J.S., Monuteaux, M., Goring, J., Henin, A., Raezer, L., Edwards, G., & Markey, J., & Rabbitt, S. (2004). Effectiveness of Collaborative Problem Solving* in affectively dysregulated youth with oppositional defiant disorder: Initial findings. Journal of Consulting and Clinical Psychology , 72, 1157-1164. CLICK HERE

Greene, R.W., Biederman, J., Zerwas, S., Monuteaux, M., Goring, J., Faraone, S.V. (2002). Psychiatric comorbidity, family dysfunction, and social impairment in referred youth with oppositional defiant disorder. American Journal of Psychiatry , 159, 1214-1224. CLICK HERE

Conceptual/Theoretical Underpinnings:

Greene, R.W. (2018) Transforming school discipline: Shifting from power and control to collaboration and problem solving, Childhood Education , 94:4, 22-27.  CLICK HERE

Greene, R.W., Zisser, A.R., Eyberg, SM., & Pavuluri, M (2017).  Frequent tantrums: Oppositional behavior in a young child. In C.A. Galanter and P.S. Jensen (Eds.), DSM-5 Casebook and Treatment Guide for Child Mental Health , American Psychiatric Association Publishing, 231-241.

Greene, R.W. (2011). The aggressive, explosive child. In M. Augustyn, B. Zuckerman, & E. B. Caronna (Eds.), Zuckerman and Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care. (2nd Ed.). Baltimore: Lippincott, Williams, & Wilkins, 282-284.

Greene, R. W. (2010). Collaborative Problem Solving*. In R. Murrihy, A. Kidman, & T. Ollendick (Eds.), A clinician’s handbook of assessing and treating conduct problems in youth. New York: Springer Publishing, 193-220.

Greene, R.W. (2010). Conduct disorder and oppositional defiant disorder. In J. Thomas & M. Hersen (Eds.), Handbook of Clinical Psychology Competencies. New York: Springer Publishing, 1329-1350.

Greene, R. W., & Doyle, A.E. (1999). Toward a transactional conceptualization of oppositional defiant disorder: Implications for treatment and assessment. Clinical Child and Family Psychology Review , 2(3), 129-148.

*Dr. Greene originally referred to his model as Collaborative Problem Solving, but now calls his model Collaborative & Proactive Solutions (CPS). He is unaffiliated with those who are now marketing a product called “Collaborative Problem Solving” and does not endorse their work. He is really sorry for the confusion! Read more here .

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Oppositional Defiant Disorder: Children Learn If They Can

At a glance.

Few people are more qualified than Greene to draw that conclusion. An Associate Clinical Professor in the Department of Psychiatry at Harvard Medical School, Greene has spent the better part of his career studying children who exhibit disruptive behavior, often referred to as Oppositional Defiant Disorder (ODD). Much of his work developing what he terms the Collaborative Problem Solving Approach to helping these children has been distilled into three books, The Explosive Child, Lost At School, and the newly published Raising Human Beings.  

Beyond Behavior

  Greene harbors no illusions about children with ODD. He characterizes them as irritable, inflexible and explosive, yet, he maintains, they do not choose to be that way. Once parents recognize that their oppositional child is not behaving in a purposeful, manipulative way, it allows them to change the way they deal with the behavior. It frees them to figure out what skills their child lacks to respond appropriately, and to provide them with those tools.

“If adults are willing to work with kids on the causes for their maladaptive behavior,” says Greene, “it will change.”

According to Greene, 80% of non-compliant, explosive kids are diagnosed with ADHD . Alternatively, he suggests, a child may be developmentally delayed with regard to flexibility, adaptability and frustration tolerance or lack crucial cognitive and emotional skills. But whatever the problem is, it is not one of motivation. As Greene notes, “I teach skills—not motivation.” The lack of such skills, he says, should appropriately be characterized as a learning disability.

Underlying Problems

Greene identifies a number of “pathways” that may lead to the development of ODD, including problems with executive skills  relating to planning, initiating and carrying out actions; and with language processing skills —a frequently overlooked cause of ODD. Other pathways include problems with emotional regulation, cognitive flexibility, and social skills.

Most of the problem-solving methods Greene proposes involve language. The regulation of emotion to control a child’s irritability, however, is generally accomplished with the use of medication . But, he cautions, starting medication does not make up for the years of schooling and skill development a child may have missed.

As with most behavior problems, Greene emphasizes that there is no quick fix or “cookie cutter” solution to these children’s difficulties. But adults can choose how to respond to children whose meltdowns, he maintains, are highly predictable. Once the triggers are known, ways to avoid them can be implemented.

A child will most often become frustrated as a result of an adult’s command, a change in plans, or a disagreement. Rather than trying to impose their will via a punishment and reward system or simply avoiding confronting the issue (the “drop-it-for-now” approach), Greene advises parents to take a collaborative approach and include the child in solving the problem.

The key, Greene concludes, is to discover the factors that are behind the child’s inflexibility and poor frustration tolerance; that, he adds, may require a comprehensive assessment . Once the underlying issues have been determined, it is important to set priorities for dealing with threatened meltdowns. Is the issue important enough to have a meltdown over? Is it unimportant enough to walk away? Or does it offer an opportunity to train a child in critical problem-solving skills? When adults choose the third option the child will begin to learn how to think and stay calm while frustrated.

Learn more about Greene’s work and the Collaborative Problem Solving Approach at www.livesinthebalance.org .

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“Kids do well if they can.”

—Ross Greene, Ph.D.

Say goodbye to conflict, screaming, spankings, detentions, suspensions, de-escalating, restraint, and seclusion. Say hello to solving problems collaboratively and proactively.

What is collaborative & proactive solutions.

Collaborative & Proactive Solutions (CPS) is an evidence-based model of psychosocial treatment originated and developed by Dr. Ross Greene , and described in his books The Explosive Child , Lost at School , Raising Human Beings , and Lost & Found .

What does CPS do?

Rather than focusing on kids’ concerning behaviors (and modifying them), CPS helps kids and caregivers solve the problems that are causing those behaviors. The problem solving is collaborative (not unilateral) and proactive (not reactive). Research has shown that the model is effective not only at solving problems and improving behavior but also at enhancing skills.

Where has CPS been implemented?

In countless families, general and special education schools, group homes, inpatient psychiatry units, and residential and juvenile detention facilities, the CPS model has been shown to dramatically reduce concerning behavior and dramatically reduce or eliminate discipline referrals, detentions, suspensions, and the use of restraint and seclusion .

How do you get the ball rolling?

This website connects you to vast array of resources, including a variety of learning and training options and over 200 providers in 16 different countries. And you’ll find lots of additional resources—including the research supporting the effectiveness of the model—on the website of the non-profit,  Lives in the Balance .

We are also happy to discuss your specific needs… CONTACT US

Collaborative and Proactive Solutions™

• Research and Studies of Collaborative Problem Solving »

Research and Studies of Collaborative Problem Solving

This is the full list of published studies on Collaborative Problem Solving.

• Ashworth, K., Tapsak, S., & Li, S. T. (2012). Collaborative Problem Solving: Is empathy the active ingredient?   Graduate Student Journal of Psychology ,  14 , 83-92.
• Basso, R. V. J. & Graham, J. W. (2016). A longitudinal intervention study to reduce aggression by children ages 4-11 .  Journal of Behavior Therapy and Mental Health, 1(2) :12-23.
• Becker, K. D., Chorpita, B. F., & Daleiden, E. L. (2011). Improvement in symptoms versus functioning: How do our best treatments measure up?   Administration and Policy in Mental Health and Mental Health Services Research ,  38 (6), 440-458.
• Black, V., Bobier, C., Thomas, B., Prest, F., Ansley, C., Loomes, B., Eggleston, G., & Mountford, H. (2020). Reducing seclusion and restraint in a child and adolescent inpatient area: implementation of a collaborative problem-solving approach .  Australasian Psychiatry , 1-7.
• Bonnell, W., Alatishe, Y. A., & Hofner, A. (2014). The effects of a changing culture on a child and adolescent psychiatric inpatient unit .  Journal of the Canadian Academy of Child and Adolescent Psychiatry ,  23 (1), 65.
• Epstein, T., & Saltzman-Benaiah, J. (2010). Parenting children with disruptive behaviors: Evaluation of a Collaborative Problem Solving pilot program .  Journal of Clinical Psychology Practice ,  1 (1), 27-40.
• Ercole‐Fricke, E., Fritz, P., Hill, L. E., & Snelders, J. (2016). Effects of a Collaborative Problem‐Solving approach on an inpatient adolescent psychiatric unit .  Journal of Child and Adolescent Psychiatric Nursing ,  29 (3), 127-134.
• Gathright, M. M., Holmes, K. J., Morris, E. M., & Gatlin, D. A. (2016). An innovative, interdisciplinary model of care for inpatient child psychiatry: An overview .  The journal of behavioral health services & research ,  43 (4), 648-660.
• Greene, R. W., Ablon, J. S., & Goring, J. C. (2003). A transactional model of oppositional behavior: Underpinnings of the Collaborative Problem Solving approach .  Journal of Psychosomatic Research ,  55 (1), 67-75.
• Greene, R. W., Ablon, J. S., Goring, J. C., Raezer-Blakely, L., Markey, J., Monuteaux, M. C., ... & Rabbitt, S. (2004). Effectiveness of Collaborative Problem Solving in affectively dysregulated children with oppositional-defiant disorder: Initial findings .  Journal of consulting and clinical psychology ,  72 (6), 1157.
• Greene, R. W., Ablon, J. S., & Martin, A. (2006). Use of Collaborative Problem Solving to reduce seclusion and restraint in child and adolescent inpatient unit s.  Psychiatric Services ,  57 (5), 610-612.
• Hart, S. C., & DiPerna, J. C. (2017). Teacher beliefs and responses toward student misbehavior: Influence of cognitive skill deficit s.  Journal of applied school psychology ,  33 (1), 1-15.
• Heath, G. H., Fife‐Schaw, C., Wang, L., Eddy, C. J., Hone, M. J., & Pollastri, A. R. (2020). Collaborative Problem Solving reduces children's emotional and behavioral difficulties and parenting stress: Two key mechanisms . Journal of Clinical Psychology.
• Holmes, K. J., Stokes, L. D., & Gathright, M. M. (2014). The use of Collaborative Problem Solving to address challenging behavior among hospitalized children with complex trauma: A case series .  Residential Treatment for Children & Youth ,  31 (1), 41-62.
• Johnson, M., Östlund, S., Fransson, G., Landgren, M., Nasic, S., Kadesjö, B., ... & Fernell, E. (2012). Attention‐deficit/hyperactivity disorder with oppositional defiant disorder in Swedish children–an open study of Collaborative Problem Solving .  Acta Paediatrica ,  101 (6), 624-630.
• Kulkarni, G., Deshmukh, P., & Barzman, D. (2010). Collaborative Problem Solving (CPS) as a primary method of addressing acute pediatric pathological aggression along with other modalities .  Psychiatric quarterly ,  81 (2), 167-175.
• Martin, A., Krieg, H., Esposito, F., Stubbe, D., & Cardona, L. (2008). Reduction of restraint and seclusion through Collaborative Problem Solving: A five-year prospective inpatient study .  Psychiatric Services ,  59 (12), 1406-1412.
• Mohr, W. K., Martin, A., Olson, J. N., Pumariega, A. J., & Branca, N. (2009). Beyond point and level systems: Moving toward child‐centered programming .  American Journal of Orthopsychiatry ,  79 (1), 8-18.
• Open Arms Program of the Cambridge Hospital Child Assessment Unit, Cambridge, Massachusetts. (2003). 2003 APA Gold Award: A more compassionate model for treating children with severe mental disturbances .  Psychiatric Services ,  54 (11), 1529-1531.
• Pollastri, A. R., Epstein, L. D., Heath, G. H., & Ablon, J. S. (2013). The Collaborative Problem Solving approach: Outcomes across settings .  Harvard Review of Psychiatry ,  21 (4), 188-199.
• Pollastri, A. R., Lieberman, R. E., Boldt, S. L., & Ablon, J. S. (2016). Minimizing seclusion and restraint in youth residential and day treatment through site-wide implementation of Collaborative Problem Solving .  Residential Treatment for Children & Youth ,  33 (3-4), 186-205.
• Pollastri, A. R., Rosenbaum, C., & Ablon, J. S. (2019). Disruptive Behavior Disorders . In  The Massachusetts General Hospital Guide to Learning Disabilities  (pp. 207-220). Humana Press, Cham.
• Pollastri, A.R., Wang, L., Eddy C.J., Ablon, J. S. An open trial of Collaborative Problem Solving in a naturalistic outpatient setting . Clinical Child Psychology and Psychiatry 2022; 28(2): 512-524.
• Pollastri, A. R., Wang, L., Raftery-Helmer, J. N., Hurley, S., Eddy, C. J., Sisson, J., Thompson, N., & Ablon, J. S. (2022). Development and evaluation of an audio coding system for assessing providers’ integrity to Collaborative Problem Solving in youth-service settings .  Professional Psychology: Research and Practice , online first.
• Pollastri, A. R., Wang, L., Youn, S. J., Ablon, J. S., & Marques, L. (2020). The value of implementation frameworks: Using the active implementation frameworks to guide system‐wide implementation of Collaborative Problem Solving . Journal of Community Psychology .
• Regan, K. M., Curtin, C., & Vorderer, L. (2006). Paradigm shifts in inpatient psychiatric care of children: approaching child‐and family‐centered care .  Journal of Child and Adolescent Psychiatric Nursing ,  19 (1), 29-40.
• Schaubman, A., Stetson, E., & Plog, A. (2011). Reducing teacher stress by implementing Collaborative Problem Solving in a school setting .  School Social Work Journal ,  35 (2), 72-93.
• Stetson, E. A., & Plog, A. E. (2016).  Collaborative Problem Solving in schools: Results of a year-long consultation project .  School Social Work Journal ,  40 (2), 17-36.
• Stewart, S. L., Rick, J., Currie, M., & Rielly, N. (2009).  Collaborative Problem Solving approach in clinically referred children: A residential program evaluation .  Unpublished manuscript, Department of Applied Research and Education Child and Parent Resource Institute, London, Ontario, Canada .
• Stoll, S. J., Hartman, J. D., Paxton, D., Wang, L., Ablon, J. S., Perry, B. D., & Pollastri, A. R. (2023). De-Implementing a Point and Level System in Youth Residential Care without Increased Safety Risk: A Case Study . Residential Treatment for Children & Youth. Online first.
• Valenkamp, M., Delaney, K., & Verheij, F. (2014). Reducing seclusion and restraint during child and adolescent inpatient treatment: Still an underdeveloped area of research .  Journal of Child and Adolescent Psychiatric Nursing ,  27 (4), 169-174.
• Wang, L., & Pollastri, A. R. (2019).   User’s Guide to the Collaborative Problem Solving Adherence & Impact Measures (CPS-AIMs) . Think:Kids, Massachusetts General Hospital, Harvard Medical School.
• Wang, L., Pollastri, A. R., Vuijk, P. J., Hill, E. N., Lee, B. A., Samkavitz, A., … & Doyle, A. E. (2019). Reliability and Validity of the Thinking Skills Inventory, a Screening Tool for Cross-Diagnostic Skill Deficits Underlying Youth Behavioral Challenges .  Journal of Psychopathology and Behavioral Assessment ,  41 (1), 144-159.
• Wang, L., Stoll, S. J., Eddy, C. J., Hurley, S., Sisson, J., Thompson, N., Raftery-Helmer, J. N., Ablon, J. S., Pollastri, A. R. (2023). Pragmatic fidelity measurement in youth service settings .  Implementation Research and Practice ,  4,  1-13.
• Wang, L., Stoll, S., Hone, M., Ablon, J. S., & Pollastri, A. R. (2022). Effects of a Collaborative Problem Solving parent group on parent and child outcomes . Child & Family Behavior Therapy, 44(4), 241-258.

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Parent Management Training (PMT) and Collaborative & Proactive Solutions (CPS): A Randomized Control Trial for Oppositional Youth

Thomas h. ollendick.

1 Child Study Center, Department of Psychology, Virginia Tech, Blacksburg, VA

Ross W. Greene

Kristin e. austin, maria g. fraire.

2 McLean Hospital/Harvard Medical School, Boston, MA

Thorhildur Halldorsdottir

3 Max Planck Institute for Psychiatry, Munich, Germany

Kristy Benoit Allen

4 Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA

Matthew A. Jarrett

5 Department of Psychology, University of Alabama, Tuscaloosa, AL 35487

Krystal M. Lewis

6 University of Illinois at Chicago, Chicago, IL

Maria J. Whitmore

Natoshia r. cunningham.

7 Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital and Medical Center, Cincinnati, OH

Ryoichi J. P. Noguchi

8 George Mason University, Fairfax, VA

Kristin Canavera

9 Department of Psychology, St. Jude’s Children’s Research Hospital, Memphis, TN

Jennifer C. Wolff

10 Bradley/Hasbro Research Center, Brown University School of Medicine, Providence, RI

Examine the efficacy of Collaborative & Proactive Solutions (CPS) in treating oppositional defiant disorder (ODD) in youth by comparing this novel treatment to Parent Management Training (PMT), a well-established treatment, and a waitlist control (WLC) group.

One hundred and thirty four youth (ages 7 – 14, 61.9% male, 83.6% white) who fulfilled Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for ODD were randomized to either CPS, PMT or WLC groups. ODD was assessed with semi-structured diagnostic interviews, clinical global severity and improvement ratings, and parent report measures. Assessments were completed pre-treatment, post-treatment, and at 6 months following treatment. Responder and remitter analyses were undertaken using intent-to-treat mixed models analyses. Chronological age, gender, and socioeconomic status as well as the presence of comorbid attention deficit/hyperactivity and anxiety disorders were examined as predictors of treatment outcome.

Both treatment conditions were superior to the WLC condition but did not differ from one another in either our responder or remitter analyses. Approximately 50% of youth in both active treatments were diagnosis free and were judged to be much or very much improved at post-treatment, compared to 0% in the waitlist condition. Younger age and presence of an anxiety disorder predicted better treatment outcomes for both PMT and CPS. Treatment gains were maintained at 6-month follow-up.

Conclusions

CPS proved to be equivalent to PMT and can be considered an evidence-based, alternative treatment for youth with ODD and their families.

Oppositional-defiant disorder (ODD) is a childhood disorder characterized by a recurrent pattern of developmentally inappropriate levels of negativistic, defiant, disobedient, and hostile behaviors toward authority figures ( American Psychiatric Association, 1994 , 2013 ). The prevalence rates for ODD in community samples range from 2.6% to 15.6%, and in clinical samples from 28% to 65% ( Boylan, Vaillancourt, Boyle, & Szatmari, 2007 ; Wolff & Ollendick, 2010 ). ODD has also been shown to be highly comorbid with other childhood psychiatric disorders including attention deficit/hyperactivity disorder (ADHD), the depressive disorders, and the anxiety disorders (ADs) ( Greene, Biederman, Zerwas, Monuteaux, Goring, & Faraone, 2002 ; see Cunningham & Ollendick, 2010 for review). There is also a strong association between ODD and conduct disorder (CD), with a significant proportion of youth who develop CD meeting criteria for ODD prior to the onset of CD ( Biederman, Faraone, Milberger, Jetton, Chen, Mick, Greene, & Russell, 1996 ; Hinshaw, Lahey, & Hart, 1993 ).

To date, the predominant approach to the treatment of youth with ODD has been parent management training (PMT; Barkley, 1997 ; Brestan & Eyberg, 1998 ; Eyberg, Nelson, & Boggs, 2008 ; Kazdin, 2005 ; McMahon, Long, & Forehand, 2010). In general, PMT emphasizes ineffective parenting practices in the origins and course of oppositional behavior in youth, and improving compliance is the primary focus of intervention. As such, PMT typically includes interventions aimed at helping parents be more consistent and contingent in their behavior management practices, including use of clear and direct commands, differential attention, contingent reinforcement, response cost, and time-out from reinforcement. An impressive body of research has documented the efficacy of PMT and the evidence is sufficiently compelling to qualify PMT as an empirically supported, well-established treatment (see Brestan & Eyberg, 1998 ; Eyberg et al., 2008 ; and Murrihy, Kidman, & Ollendick, 2010 for reviews). Moreover, PMT interventions have been shown to produce comparable results in both efficacy and effectiveness trials in “real world” clinical settings ( Michelson, Davenport, Dretzke, Barlow, & Day, 2013 ).

However, limitations in PMT outcomes have been noted: treatment effects are not always replicated, treatment often leaves children with deviant behavior still above the range of normative levels, treatment gains often dissipate once the intervention is removed, attrition rates are as high as 50 percent, and there is some evidence to suggest that older, more aggressive youth may not benefit from such treatment ( Frick, 2001 ; Kazdin, 2005 ; Ollendick & Cerny, 1981 ). In addition, Greene and colleagues ( Greene, 1998 , 2010 ; Greene & Doyle, 1999 ) have argued that PMT does not address the reciprocal, adult-child processes giving rise to oppositional behavior in many children. In response, Greene (1998) has proposed an alternative model for the treatment of ODD, now called Collaborative & Proactive Solutions (CPS; previously referred to as Collaborative Problem Solving). The CPS intervention model, based on Greene’s (1998) book, The Explosive Child, emphasizes lagging skills – especially in the domains of flexibility, adaptability, and problem solving – as a major factor contributing to the development of oppositional behavior in youth. In contrast to PMT, CPS focuses primarily on helping parents and children learn to collaboratively and proactively solve the problems that contribute to these challenging behaviors.

Preliminary research has suggested the effectiveness of CPS in a small clinic sample of 47 urban youth from the Boston area with ODD ( Greene et al., 2004 ). This preliminary trial showed that the effects of CPS were commensurate with PMT (based on Barkley’s 1997 program for defiant children) on most measures of treatment outcome both at post treatment and at 4-month follow-up. However, this study was limited by sample size (28 children in CPS, 19 in PMT) and the lack of a waitlist control group; moreover, the follow-up period was only 4 months in duration. Although these initial results are promising, they require replication in a larger sample of children with ODD and in a randomized control trial with a longer follow-up period.

The present study builds upon this early study and uses a randomized control design to test the comparative efficacy of PMT, CPS, and a waitlist control condition (WLC) in a larger sample of youth with ODD. First, we predicted that both treatment conditions would be superior to the WLC condition. Second, given the clear support for PMT as an efficacious treatment for ODD and the emerging support for CPS as an efficacious treatment for ODD, we predicted that the two treatments would be equivalent to one another. Third, we explored predictors of change associated with these treatments. Specifically, we examined chronological age, gender, socioeconomic status, and presence of diagnostic comorbidity as potential predictors of treatment outcome. Although firm support for these predictions is lacking, we tentatively hypothesized that increasing age, male gender, and low socioeconomic status would be associated with less positive treatment outcomes. We also predicted that presence of comorbid ADHD would produce less positive treatment outcomes but the presence of a comorbid anxiety disorder (AD) would produce more positive treatment outcomes. Limited research has shown that ADHD exacerbates the effects of ODD whereas ADs tend to mitigate the effects of ODD (see Drabick, Ollendick, & Bubier, 2010 , for review).

Participants

The clinical trial took place in the United States, in rural Southwest Virginia. Parents of youth with oppositional problems were both referred by mental health professionals, family practice physicians, and school personnel, and recruited through advertisements in local newspapers and television programs announcing the clinical trial. Parents of 275 youth completed a brief telephone screen for ODD, as well as for conditions that would preclude the family’s participation in the trial (see exclusion criteria below). Parents whose children appeared to meet eligibility criteria ( n = 164) were informed of the procedures of the study including the randomization process. Children and their parents provided written informed assent and consent, as approved by our Institutional Review Board. Subsequently, these parents and their children underwent a comprehensive assessment to confirm the ODD diagnosis and determine associated comorbid disorders. Youth were included in the study if they were between 7 and 14 years of age and met full diagnostic criteria for ODD. As can be seen in Table 1 , 64% of the youth had ODD as a primary diagnosis, 30% as a secondary diagnosis, and 6% as a tertiary diagnosis. However, ODD was the principal reason for referral in all instances. Inclusion of youth with primary, secondary, and tertiary diagnoses of ODD was intentional so we could examine the efficacy of our interventions with children who present with varying levels of ODD and comorbid disorders (99% had at least one comorbid disorder and 83% had a second comorbid disorder). The most common comorbid diagnoses were ADHD and an AD (defined as generalized anxiety disorder, social anxiety disorder, or separation anxiety disorder; see Table 1 ). Of the 134 participants, 33 (25%) were on stable doses of ADHD stimulant medication, 11 (8%) on ADHD non-stimulant medication, 5 (4%) on anti-psychotic/bipolar medication, 4 (3%) on anti-depressant medication, 4 (3%) on anti-anxiety medication, and 1 (<1%) on anti-seizure medication (used to treat anxiety). Youth were excluded if they met diagnostic criteria for CD, autism spectrum disorder, a psychotic disorder, intellectual impairment, or current suicidal or homicidal ideation. Overall, 134 youth met inclusion criteria and participated in the trial (see Figure 1 ).

Flow chart of participants through the study.

Primary, secondary, and tertiary diagnoses

Note. Anxiety disorder includes diagnosis of Generalized Anxiety Disorder, Social Phobia, and Separation Anxiety Disorder; other disorders include diagnoses of Obsessive Compulsive Disorder, Post Traumatic Stress Disorder, Panic Disorder, Reactive Attachment Disorder, Enuresis, and Encopresis.

Youth were randomly assigned to one of the two active treatment groups or a 6-week waitlist control (WLC). Following the waiting period, those youth and families in the WLC group who continued to meet criteria for ODD and still desired treatment were randomly reassigned to one of the two treatment groups. Youth and their families were also assessed at post-treatment and at 6-months following treatment. Each family received a stipend of $50 for each assessment completed at pre-treatment, post-treatment, and 6-month follow-up for a total of $150.

At each assessment session, two clinicians were assigned to each family. All clinicians were supervised research assistants, graduate students in clinical psychology in our APA-approved clinical scientist doctoral training program, or postdoctoral fellows associated with our Center, and were trained to requisite levels of competence to help ensure reliability and validity of data procurement. None of the assessment clinicians served as therapists for the families they assessed.

Eligible families, randomly assigned to treatment, participated in PMT or CPS with a highly trained and closely supervised clinician. All treatment clinicians were post-Masters, doctoral students in our APA-approved clinical scientist doctoral psychology training program or postdoctoral fellows associated with our Center.

Participant Characteristic Measures

In addition to chronological age, gender, race/ethnicity, socioeconomic status (defined by parent education level and family income), and family structure (single/divorced parent, married or co-habiting parent) derived from a demographic form, measures of receptive and expressive language ability were obtained. These latter measures were used to more fully describe our sample and because deficits in these abilities are frequently associated with ODD (see Kimonis & Frick, 2010 ).

Peabody Picture Vocabulary Test, Fourth Edition (PPVT-4; Dunn & Dunn, 2007 ) and the Expressive Vocabulary Test, Second Edition (EVT-2; Williams, 2007 )

The PPVT-4 and the EVT-2 are reliable and valid measures of receptive and expressive language abilities, respectively. They were administered only at pre-treatment.

Treatment Response Outcome Measures

Anxiety disorders interview schedule for dsm-iv , child and parent versions (adis-c/p; silverman & albano, 1996 ).

The ADIS-C/P is a semi-structured diagnostic interview designed for the diagnosis of most psychiatric disorders of childhood and adolescence. The clinician assesses symptoms and obtains frequency, intensity, and interference ratings (0–8 scale) which are then used by the clinician to identify diagnostic criteria and to develop a clinician severity rating (CSR). A CSR of 4 or above on a 0 to 8 scale indicates a diagnosis. Recently, the ADIS-C/P has been found to be reliable and valid for the diagnosis of both ODD and ADHD, in addition to the anxiety and affective disorders ( Anderson & Ollendick, 2012 ; Jarrett, Wolff, & Ollendick, 2007 ).

The ADIS-C/P has yielded acceptable to excellent 7 to 14-day test-retest reliability ( Silverman, Saavedra, & Pina, 2001 ) and acceptable inter-rater agreement ( Grills & Ollendick, 2003 ). Trained-to-criterion clinicians conducted the diagnostic interviews. Training consisted of a 3-hour workshop on the ADIS-C/P, two practice interviews with the trainer, two live observations of administration of the ADIS-C/P with a trained clinician, and two interviews conducted with the trainer in the session with the trainee. All interviews were videotaped, and 20% of the pre-treatment diagnostic interviews were reviewed by a second clinician to compute Kappa coefficients. Using Cohen’s Kappa, agreements on diagnoses were .77, .85, and .86 on primary, secondary and tertiary diagnoses. At each time point, consensus diagnoses were determined based on the independent findings of the ADIS-C and ADIS-P. This process occurred in weekly staff meetings with the two ADIS clinicians and the doctoral-level clinical psychologist who supervised diagnostic assessments. Prior to treatment and for the 6-month follow-up assessment, the full ADIS-C/P was administered. At the post treatment assessment, only the ADIS-C/P modules of disorders that were endorsed at pre-treatment were administered.

Clinical Global Impression – Severity (CGI-S; Guy, 1976 )

The CGI-S was completed by the same clinicians who completed the ADIS-IV at the designated assessment intervals. The CGI-S includes a rating, on a 7-point Likert scale, of the child’s current overall impairment (ranging from 1 = normal, not impaired to 7 = very seriously impaired).

Disruptive Behavior Disorders Rating Scale (DBDRS; Barkley, 1997 ; Pelham, Gnagy, Greenslade, & Milich, 1992 )

The DBDRS is comprised of the DSM-IV symptom lists for ADHD, ODD, and CD and uses a 4-point response scale ranging from 0 (not at all) to 3 (very much). There are eight symptoms for ODD; individual symptoms coded as a “2” (much) or “3” (very much) are viewed as meeting criteria for the symptom. Thus, scores can range from 0 – 8, with a score of 4 or above indicating the necessary symptom count for possible ODD. The DBDRS has been shown to have excellent psychometric properties (Cronbach’s α = .90 in the current study; see Pelham et al., 1992 , for normative data). This measure was completed by the parents at each assessment point.

Behavior Assessment System for Children–2nd Edition (BASC; Reynolds & Kamphaus, 1992 )

The BASC evaluates the behaviors, thoughts, and emotions of children and adolescents. For the present study, the Aggression scale of the Parent Rating Scales (PRS) was of primary interest, with T -scores ≥ 70 falling in the clinically significant range and T -scores 60–69 being considered “at risk.” The Aggression Scale of the PRS possesses acceptable internal consistency ( Kamphaus & Frick, 2005 ; Cronbach’s α = .90 in the current study) and test-retest reliability over a 2- to 8-week period (.74–.94; Reynolds & Kamphaus, 1992 ). This measure was administered at pre-treatment, 1-week post-treatment and 6-months post-treatment.

Parent Consumer Satisfaction Questionnaire (PCSQ)

The PCSQ is a parent-report questionnaire rating satisfaction with and efficacy of the PMT and CPS interventions. Designed for this study, it consisted of 7 items each rated on a 7-point scale (rated 0–6) assessing the degree to which the parent was satisfied (ranging from very dissatisfied to very satisfied) with the PMT or CPS treatment and the extent to which they perceived the treatments as helpful for them and their child (ranging from considerably worse to greatly improved). This measure was completed by parents at 1-week post-treatment and at 6-month follow-up.

Treatment Remission Outcome Measures

Clinical global impression – improvement (cgi-i; guy, 1976 ).

The CGI-I was completed by assessment clinicians. The degree to which the child’s symptoms improved since the beginning of treatment was rated on a 7-point Likert scale (very much improved to markedly worse). Symptom improvement for remission was defined as a rating of 1 (very much improved) or 2 (much improved) on the CGI-I. This measure was administered at1-week and 6-months post-treatment.

Diagnostic Status

Diagnostic status was defined as presence or absence of a clinical diagnosis of ODD as determined by consensus diagnosis on the ADIS at the post-treatment assessment and at 6-month follow-up. A CSR < 4 was required for remission of clinical diagnosis.

Interventions

In the PMT condition, 6 therapists (2 males, 4 females) provided treatment based on Barkley’s ( Barkley, 1997 ) training program. This widely-used, structured program provides nine consecutive weekly sessions for parents with one additional session four weeks after the last session to review and consolidate treatment gains. Based on our pilot work with families in our community, we extended the program to 12, 75-minute sessions and implemented the follow-up session two weeks after the last regularly scheduled session, rather than four weeks later. In addition, we modified the program to include the children in each session so that the parents could practice the skills learned prior to implementing them in the home setting. The program includes an explicit description of the goals and content for each session, along with standard handouts. The treatment is manualized and consists of the following components: (a) educating parents about the causes of defiant, non-compliant behavior; (b) instructing parents on positive attending through use of “special time”; (c) training parents to use attending skills to increase compliant behavior; (d) increasing the effectiveness of parental commands; (e) implementing a contingency management program; (f) using the time-out procedure; (g) managing children’s behavior in public places; and (h) using a daily school-home “report-card.” Therapists received a 4-hour training workshop in PMT prior to the beginning of the project and live supervision for 75 minutes each week from Dr. Ollendick.

In the CPS condition, 8 therapists (4 males, 4 females) provided treatment based on Greene’s CPS model ( Greene, 1998 ; 2010 ). CPS is organized into four treatment modules: (1) identification of lagging skills and unsolved problems (typical problems include expectations such as completing homework, doing chores, etc.) that contribute to oppositional episodes, and a discussion of how existing parental responses may be counterproductive; (2) prioritization – helping parents prioritize which unsolved problems will be the focal point of initial problem-solving discussions; (3) introduction of the Plans framework – helping parents understand the three potential responses to solving problems: Plan A (solving a problem unilaterally, through imposition of adult will and often accompanied by adult-imposed consequences); Plan B (solving a problem collaboratively and proactively); and Plan C (setting aside the problem for now); and (4) implementing Plan B – helping parents and children become proficient in the use of Plan B and largely discontinuing the use of Plan A. While the clinician actively guides the problem-solving process initially, the goal of treatment is to help the child and parents become increasingly independent in solving problems together. CPS, implemented in a flexible and individualized manner, was also provided in 12, 75-minute sessions with one follow-up session two weeks following the last regularly scheduled session. As with PMT, the child and parent were present in each session so that the skills learned could be practiced in the session prior to implementing them in the home setting. The therapists received a 4-hour training workshop in CPS prior to the beginning of the project and supervision via teleconferencing for 75 minutes each week from Dr. Greene.

Treatment Adherence

Treatment adherence for both treatments was assessed with a 6-item checklist completed by the supervisors and based on the verbalizations and behaviors of the therapists as observed in the session videotapes and reviewed in supervision. The checklist, completed following each session, included three prescriptive and three proscriptive items for each treatment. Representative items included “Therapists and the parents discussed implementation of a contingency contracting system to monitor specific behaviors and to reinforce and consequate behaviors according to the contracting system” for PMT, and “Therapists instructed parents on three potential response options for dealing with their child’s behaviors and helped them implement Plan B strategies (e.g., how to solve problems collaboratively taking into consideration identifying lagging skills in the child)” for CPS.

Statistical Analyses

Differences between treatment groups (i.e., PMT, CPS, WLC) were compared on key demographic variables at pre-treatment with ANOVAs and chi square statistics. For our main treatment outcomes, intent-to-treat analyses were conducted with all participants who were assessed and randomized to the treatment protocols ( n = 134). For the 6-month follow-up analyses, the WLC condition was omitted since participants in this condition were reassigned randomly to one of the two active treatment conditions. The 6-month analyses included these reassigned participants in the two-group analyses ( n = 134). Due to the nested nature of our data (i.e., time points within participants), longitudinal analyses were conducted using mixed models analyses with full maximum likelihood estimation to deal with missing data. Time (pretreatment = 0, posttreatment = 1 and 6-month follow up = 2) and treatment condition (PMT = 0, CPS = 1) were dummy coded. In all analyses, fixed effects were time, treatment condition and time*treatment condition. The intercept and time were random effects. In the predictor analyses models, indicators for time, treatment condition, candidate predictor, and all two-way interaction terms were included. Any candidate pretreatment variable that had a significant ( p < .05) main effect was considered a predictor.

In order to examine group differences (i.e., PMT, CPS, WLC), traditional null hypothesis significance testing was used. However, equivalence testing was used to explore group comparability of the PMT and CPS conditions ( Rogers, Howard, & Vessey, 1993 ). The equivalence interval was defined as ±10% (90% confidence interval) of the PMT group mean (δ) and considered necessary to demonstrate a meaningful difference. For treatment remission analyses, we applied multiple imputation procedures to account for missing data as these measures were only obtained at post-treatment and 6-month follow-up. We used pooled estimates across 20 imputations in order to reduce bias in estimation for these analyses (see Salim, Mackinnon, Christensen, & Griffiths, 2008 ).

Initially, 63 participants were randomly assigned to the PMT condition, 60 to the CPS condition, and 11 to the WLC condition, for a total of 134 participants. It should be noted that participants were assigned to the WLC condition only during the first year of the 5-year clinical trial. The WLC was discontinued because none of the 11 participants improved during the 6-week wait period and their clinical state was deteriorating. All WLC participants requested treatment and were subsequently reassigned randomly but disproportionately to the two active treatment conditions (2:1, CPS: PMT) so that an equal number of participants would be in each treatment condition ( n = 67). Although the WLC included a very small number of participants, we retained them in our initial analyses to illustrate the relative effects of PMT and CPS to a no-treatment control condition.

Thirteen participants dropped out of PMT (19.4%) and 15 participants dropped out of CPS (22.4%), defined as completing 6 or fewer treatment sessions. The criterion for completer status (7 or more treatment sessions) was used since all treatment strategies were introduced by that time and the remaining sessions were used for refinement of skills learned in the previous sessions. The 106 “completer” families were seen for an average of approximately 12 sessions ( M = 11.80, SD = 1.60, range = 7 – 14; 7 families, 5 PMT and 2 CPS, were seen for 14 sessions). The number of treatment sessions was determined by clinical need, which led to some variation in number of sessions. The 28 youth who dropped out from treatment did not differ from the 106 who completed treatment on pre-treatment measures of parent-rated aggression, disruptive behavior, or on clinician rating of clinical severity of ODD. Furthermore, the 28 youth who dropped out from treatment did not differ from those who completed treatment on gender, race/ethnicity, family structure, family income, or age. However, treatment dropouts did have fewer mothers ( χ 2 (1, N = 134) = 9.87, p < .01) and fathers ( χ 2 (1, N = 134) = 10.31, p < .01) who graduated from college.

Of the 106 participants who completed treatment, 89 were available for post-treatment assessment and 57 for the 6-month follow-up assessment. Reasons for not participating in post-treatment and follow-up assessment included insufficient time on the part of the family to complete assessments, a stated disinterest in the “need” for assessment, our inability to maintain contact with the family despite at least three attempts to do so, and relocation. Pre-treatment difference analyses were conducted for post-treatment assessment completers and 6-month follow-up assessment completers. There were significant differences between post-treatment assessment completers and non-completers on income ( t (1, 112) = −2.18, p < .05), mother education ( χ 2 (1, N = 133) = 8.43, p < .01), and father education ( χ 2 (1, N = 123) = 13.01, p < .001). Those who did not complete the post-treatment assessment had fewer mothers and fathers who graduated from college and lower family income. Regarding 6-month follow-up, there were significant differences between assessment completers and non-completers on family structure ( χ 2 (1, N = 133) = 4.12, p < .05), mother education ( χ 2 (1, N = 133) = 7.23, p < .01), father education ( χ 2 (1, N = 123) = 6.74, p < .01), and income ( t (1, 112) = −3.11, p < .01). Specifically, those who did not complete the 6-month follow-up assessment consisted of more single-parent families, more mothers and fathers who did not complete college, and lower family income compared with those who did complete the 6-month follow-up assessment. As noted, all primary analyses were conducted with the full intent-to-treat sample of 134 participants (67 in PMT and 67 in CPS after waitlist randomization). Attrition did not differ significantly by treatment condition ( χ 2 (1, N = 134) = 0.18, p = .67). See Figure 1 for flow chart of participants.

Sociodemographic and Participant Characteristics

No differences in gender, family structure, maternal education, paternal education, or family income were found among the three treatment conditions. However, significant differences were found for race/ethnicity by treatment condition, with fewer non-Caucasian participants in the CPS condition than in the PMT or WLC conditions, χ 2 (2, N = 134) = 7.88, p = .02. Additionally, there were more older children in the WLC condition than in the PMT or CPS conditions, F (2, 131) = 3.19, p = .04. Frequencies and percentages of all demographic variables are presented in Table 2 . After participants in the WLC condition were re-randomized to PMT or CPS, differences in age were no longer present; however, significant differences remained for race/ethnicity, with fewer non-Caucasian participants in CPS than PMT, χ 2 (1, N = 134) = 7.83, p = .01. Finally, no differences in receptive [ F (1, 128) = 1.06, p =.31] or expressive language [ F (1, 123) = 0.22, p =.64] existed between the two treatment groups.

Participant characteristics for PMT, CPS, and WLC groups

Note . PMT = Parent Management Training; CPS = Collaborative & Proactive Solutions; WLC = waitlist control; missing data in family structure for PMT ( n = 1), in mother education for PMT ( n = 1), in father education for PMT ( n = 7), CPS ( n = 3), WLC ( n = 1).

Treatment adherence was determined by aggregate ratings obtained from the PMT and CPS supervisors on the three prescriptive and three proscriptive items from the 6-item adherence rating checklist. Collapsed across the three prescriptive items, the mean number of items checked was 2.94 for PMT and 2.92 for CPS (maximum score = 3), indicating that the therapists focused on the prescribed treatment elements for their respective treatments much or most of the time. For the three proscriptive items, the means were 0.3 and 0.2 (maximum score = 3), respectively, indicating that PMT therapists were not using CPS treatment elements and CPS therapists were not using PMT treatment elements. Thus, both treatments were delivered as specified and there was limited crossover in the therapeutic strategies used.

Treatment Response

Table 3 presents the means and standard errors for the treatment response outcome measures at pretreatment, post-treatment, and 6-month follow-up. 1 One-way analyses of covariance (ANCOVAs) were used to assess treatment group differences at pretreatment, controlling for age and race/ethnicity. No differences were found on any of the outcome measures across treatment conditions at pre-treatment.

Estimated marginal means and standard errors of measures of treatment response controlling for age and race/ethnicity broken down by treatment condition at each time point

Note . PMT = Parent Management Training; CPS = Collaborative & Proactive Solutions; WLC = waitlist control; ADIS-CSR = Anxiety Disorders Interview Schedule clinician severity rating; DBDRS ODD = Disruptive Behavior Disorders Rating Scale, oppositional defiant disorder; CGI-S = clinical global impression – severity (higher scores indicate more severe impairment); BASC = Behavior Assessment Schedule for Children.

At post-treatment, with the 3 groups, mixed models analyses revealed significant time ( F (1, 114) = 50.47, p < .001), treatment ( F (2, 130) = 7.94, p = .001), and treatment-by-time interaction ( F (2, 119) = 5.65, p < .01) effects while controlling for age and race/ethnicity. Participants in the PMT ( p < .001, Cohen’s d = 1.39) and CPS ( p < .001, Cohen’s d = 1.35) conditions experienced greater reduction in ODD CSRs compared to the WLC condition. effect size for CPS was 1.13. At the 6-month follow-up, with the 2-group analyses, there was a significant time effect ( F (2, 201) = 88.48, p < .001), whereas the treatment ( F (1, 176) = 0.17, p = .68) and treatment-by-time ( F (2, 202) = 0.06, p = .95) effects were nonsignificant. The findings indicate comparable reductions in ODD CSRs between the two treatment conditions at the 6-month follow-up ( p = .96). Means are presented in Table 3 . Equivalence testing indicated that the PMT and CPS groups were comparable at each time point (see Table 5 ).

Equivalence testing between the PMT and CPS groups

Note . PMT = Parent Management Training; CPS = Collaborative & Proactive Solutions; EI = equivalence intervals; ADIS-CSR = Anxiety Disorders Interview Schedule clinician severity rating; DBDRS ODD = Disruptive Behavior Disorders Rating Scale, oppositional defiant disorder; CGI-S = clinical global impression – severity (higher scores indicate more severe impairment); BASC = Behavior Assessment Schedule for Children.

Similarly, results of the CGI-S mixed models mixed models analyses revealed significant time ( F (1, 85) = 23.59, p < .001), treatment ( F (2, 111) = 3.89, p = .02) and treatment-by-time interaction ( F (2, 89) = 6.81, p < .01) effects for the 3 groups when controlling for age and race/ethnicity. The CPS ( p < .001, Cohen’s d = 1.06) and PMT ( p < .001, Cohen’s d = 1.21) groups displayed a greater reduction in clinical severity than the WLC group, whereas there was no difference between the two active treatment conditions at post-treatment ( p = .83; see Table 3 for means). The within group effect size (Cohen’s d ) for PMT from pre to post-treatment was .74 and the effect size for CPS was .63. At the 6-month follow-up for the 2-group analyses, the main effect for time remained significant ( F (2, 160) = 46.83, p < .001), whereas treatment ( F (1, 133) = 0.93, p = .34) and treatment-by-time interaction ( F (2, 160) = 0.66, p = .52) effects were once again not significant. That is, treatment gains were maintained at the 6-month follow-up for both PMT and CPS ( p = .18). Equivalence testing indicated that the PMT and CPS groups were comparable (see Table 5 ).

When controlling for age and race/ethnicity, results for the mixed models DBDRS analyses demonstrated significant time ( F (1, 80) = 37.47, p < .001), treatment ( F (2, 104) = 6.69, p < .01) and treatment-by-time interaction ( F (2, 85) = 6.62, p < .01) effects for the 3 groups. Compared to the WLC condition, the CPS ( p < .001, Cohen’s d = .96) and PMT ( p < .001, Cohen’s d = 1.29) conditions displayed significantly greater reduction in ODD symptoms as measured by the DBDRS, yet no differences were found between the two active conditions ( p = .47). The within group effect size (Cohen’s d ) for PMT from pre to post-treatment was .87 and the effect size for CPS was .72. Likewise, at the 6-month follow-up with the 2-group analyses revealed a significant time effect ( F (2, 119) = 54.68, p < .001) whereas the treatment ( F (1, 117) = 1.96, p = .16) and treatment-by-time interaction ( F (2, 119) = .053, p =.95) effects were nonsignificant. The findings suggest that the reductions in ODD symptoms were maintained in PMT and CPS at the 6-month follow-up; however, no difference was found between the two treatment conditions ( p = .38). Means of the DBDRS broken down by treatment condition and time are displayed in Table 3 . Equivalence testing findings for the DBDRS indicated that the PMT and CPS groups were equivalent across time points (see Table 5 ).

When controlling for age and race/ethnicity, results for the mixed models analyses for the aggression measure revealed a significant main effect for time ( F (1, 73) = 40.89, p < .001) and the treatment-by-time interaction ( F (2, 75) = 9.35, p < .001); however, the main effect for treatment was only marginally significant ( F (2, 127) = 2.76, p = .07). The significant treatment-by-time interaction demonstrated that aggression (as measured by the BASC at post-treatment) decreased significantly in the two active treatment conditions, while aggression did not decrease significantly in the WLC condition (PMT vs. WLC p < .001, Cohen’s d = 1.81 and CPS vs. WLC p = .001, Cohen’s d = .92). Means at each time point are displayed in Table 3 . The within group effect size (Cohen’s d ) for PMT from pre to post-treatment was 1.11 and the effect size for CPS was .75. At the 6-month follow-up for the 2-group analyses, the main effect for time remained significant ( F (2, 113) = 74.09, p < .001), while treatment ( F (1, 145) = 0.62, p = .43) and time-by-treatment ( F (2, 113) = 0.74, p = .48) effects were nonsignificant. The findings suggest that CPS and PMT maintained comparable treatment gains at the 6-month follow-up ( p = .38; see Table 3 for means). Equivalence testing indicated that the PMT and CPS groups yielded comparable aggression scores at each time point (see Table 5 ).

Consumer satisfaction

At post-treatment, families in the PMT and CPS conditions did not differ on their satisfaction with the program [ F (1, 69) = 0.45, p = .51]. Overall, families in both PMT ( M = 33.20 SD = 5.51) and CPS ( M = 33.08 SD = 7.06) reported being satisfied (ranging between slightly satisfied to highly satisfied) with the program. Similarly, parents in the two treatment conditions (PMT: M = 32.47 SD = 7.09; CPS: M = 34.11 SD = 5.49) did not differ on their satisfaction with the program at 6-month follow-up [ F (1, 36) = 2.50, p = .12].

Treatment Remission

Treatment remission was determined at both post-treatment and at 6-month follow-up on clinician rated measures: diagnostic status (CSR < 4) and a rating of 1 or 2 on the CGI-I (much or very much improved). At post-treatment, 48.8% of youth in the PMT condition were diagnosis free compared to 48.0% of youth in the CPS condition. Similarly, 46.3% of youth in PMT were viewed as much or very much improved following treatment compared to 46.7% of youth in CPS. These differences between treatments were not significant; the effects were largely maintained at 6-month follow-up although some deterioration was noted in both groups (see Table 4 ).

Treatment remission measures by treatment condition at post and 6-month follow-up

Note . PMT = Parent Management Training; CPS = Collaborative & Proactive Solutions; WLC = waitlist control; CGI-I = clinical global impression – improvement (rated as a 1 or 2); percentages are based on pooled estimates from imputed data at each time point.

Predictor Analyses

Presence of an AD and chronological age predicted outcomes; gender, race/ethnicity, socioeconomic status, and presence of ADHD did not.

For the presence of an AD, there was a significant effect for the AD by time interaction for both CSRs ( F (2, 200) = 3.38, p = .04) and CGI-S ( F (2, 153) = 7.63, p = .001), revealing that the presence of an AD predicted better treatment outcomes for both PMT and CPS across our two clinician-rated measures. However, such interaction effects were not observed for our parent-rated measures, although trends in the same direction were observed (DBDRS: ( F (2, 122) = 2.44, p = .09) and BASC-Aggression: ( F (2, 110) = 2.38, p = .10).

For chronological age, there was a significant effect for age by time interaction for both clinician CSRs ( F (14, 181) = 2.19, p = .01) and parent DBDRS ratings ( F (13, 126) = 2.14, p = .02), revealing that older children did not improve as much as younger children across the two treatments over time on these measures.

The present study compared an evidence-based, well-established treatment (PMT; Barkley, 1997 ; Eyberg et al., 2008 ; Weisz et al., 2012 ) to a less researched but promising treatment (CPS; Greene, 1998 , 2010 ) and a waitlist control (WLC) group in a sample of children and adolescents diagnosed with ODD.

Our primary hypotheses were confirmed. First, PMT and CPS produced better outcomes than the small WLC group on all four of our treatment response outcome measures: lower CSRs on the ADIS C/P, lower severity ratings on the CGI-S, lower scores on the DBDRS, and lower scores on the aggression subscale of the BASC. None of the youth in the WLC group were rated as better following the waitlist period: all continued to meet criteria for ODD and all requested re-assignment to an active treatment.

Second, consistent with our primary hypotheses, both treatments were shown to be equivalent to one another, affirming preliminary findings reported by Greene et al. (2004) and lending support to CPS as an evidence-based intervention. In addition, equivalent results were obtained for both treatments in our remission analyses: nearly 50% of youth in both treatment conditions were diagnosis free at post treatment and were viewed as much or very much improved by raters masked to treatment conditions. Treatment gains were largely maintained at follow-up. The rates for both groups compare favorably to those obtained in other studies in youth with ODD ( Fabiano et al., 2009 ; Kazdin & Whitley, 2006 ; Weisz et al, 2012 ).

Third, regarding predictors of treatment outcomes, we found that our treatments were more effective for younger children than older children, a finding consistent with prior research (cf, Fabiano et al., 2009 ). We also found that presence of an AD was associated with better outcomes across treatments for our ODD youth. This finding is similar to earlier findings by Walker, Lahey, Russo, Frick, Christ, McBurnett, et al. (1991) and Ollendick, Seligman, and Butcher (1999) and more recent findings by Jarrett, Siddiqui, Lochman, and Qu (2014) who showed that internalizing problems like anxiety and depression can serve to mitigate the behavioral expression of conduct problems in youth. If these findings are replicated in additional studies, it will be important to study the exact mechanisms through which their beneficial effects occur (see Drabick et al., 2010 ).

In as much as our two treatments were equivalent and we were unable to explore moderators of change due to our small sample sizes ( Kraemer, Wilson, Fairburn, & Agras, 2002 ), we are not able to comment on “for whom” these two treatments work best. As described earlier, PMT focuses primarily on improving children’s compliance with adult directives by modifying faulty parental disciplinary practices ( Kazdin, 2005 ; McMahon et al., 2011 ) whereas CPS focuses primarily on helping parents and children collaboratively and proactively solve the problems that are contributing to challenging behaviors ( Greene, 1998 , 2010 ). Given these differences in approach, it is likely that moderators exist. Although speculative, they may well include factors such as family preferences, therapist preferences, the therapeutic alliance, and other family-therapist characteristics that signal the “goodness-of-fit” between therapists, treatments, and families. These variables will be the focus of further, more refined analyses with this data set and in subsequent studies. In terms of other future directions, exploring mediators of treatment outcomes may prove fruitful as the mechanisms through which gains are conferred will likely differ between the treatment conditions.

The current study possesses both strengths and weaknesses. The strengths are related to randomization of the sample to the two treatment conditions, use of psychometrically sound assessment measures, thorough operationalization of the treatments via treatment manuals, carefully trained assessors and therapists as well as supervision of these assessors and therapists by experts in the two treatments, and analysis of the intent-to-treat data via mixed models analyses and equivalence testing.

Weaknesses are also present. The number of participants in our WLC condition was very small ( n = 11) and participants were randomized to this condition only during the first year of this 5-year clinical trial. As noted, the decision was made to drop the WLC condition since none of the 11 families improved during the wait period. For clinical and ethical reasons, we discontinued randomization to this condition. Still, it is important to note that these families did not differ on our main outcome variables at pre-treatment and that all WLC families sought and accepted randomization to one of the active treatments. We are cognizant of the shortcomings of this decision but believe it was clinically-responsive and ethically-defensible.

A second major weakness is related to the number of families who dropped out of treatment and/or failed to return for assessment at post-treatment and 6-month follow-up. As noted, these families also differed from families who completed treatment (less education) and who were available for post-treatment assessment and follow-up assessment (less education, lower income, and single parent family status). Although the failure of families with these characteristics to return for assessment is a significant shortcoming, we did employ mixed models analyses which also use maximum likelihood to address missing data. As noted by Salim et al. (2008) and others ( Young, Weckman, & Holland, 2011 ), this approach is generally acceptable even when dropout rates are “substantial” as they were in this study. Furthermore, the current guidelines of the Consolidated Standards of Reporting Trials (CONSORT) recommend use of data imputation and mixed models analyses when outcome data are missing ( Moher, Hopewell, Schulz, Montori, Gotzsche et al., 2010 ).

A third major weakness is a lack of established treatment adherence and competency measures. Here, we reported only on treatment adherence as determined by the supervisors who provided weekly 75-minute supervisory sessions to our clinicians. Such supervisory sessions included review of ongoing video-tapes and careful monitoring to ensure that PMT and CPS were implemented as specified in their respective conditions and that, conversely, elements of these treatments were not used in the alternative treatment. Ratings by the supervisors indicated that treatment was delivered as intended and that little to no crossover in the therapeutic strategies was evident. Still, we did not obtain measures of how competently the clinicians implemented our treatments. We are presently obtaining such competency ratings as well as ratings of the therapeutic alliance for our two treatment conditions.

Other weaknesses include our sample of largely middle class, Caucasian families and conducting the study in a university setting with carefully trained and supervised clinicians (which may not be reflective of other community samples and treatment conditions). Given the characteristics of the sample, particularly in the CPS group, there are limitations to generalizability. The efficacy of CPS and its equivalence to PMT may only be in educated Caucasian samples and further research is needed to implement and evaluate CPS in more racial/ethnic and socioeconomically diverse samples. We also lack longer-term follow-up data on the effects of our intervention. In addition, not all of our youth had a primary diagnosis of ODD. Still, ODD was the principal reason for referral for all youth and all youth did have a diagnosis of ODD as one of their top three diagnoses in this highly comorbid sample. However, we suggest that not limiting the sample to a primary diagnosis of ODD may better reflect “real-world” applicability of these treatments.

Clinical Significance of Findings

In this study, CPS was shown to be equivalent to PMT, and both treatments evidenced large effect sizes in comparison to the WLC and over time within each treatment. This was shown to be the case with youth varying in chronological age, gender, receptive and expressive verbal ability, and presence of co-occurring ADHD and AD. As such, CPS may be a useful, evidence-based option for families seeking alternative and/or additional interventions. Given some of the limitations of PMT described earlier in this paper, the existence of a comparably efficacious but different psychosocial treatment is a positive development in the treatment of youth with ODD and their families. Both patient and therapist preferences might be realized with such equivalent treatments; however, such possibilities await further study and evaluation.

Acknowledgments

Funding was provided by R01 MH76141 from NIMH and by the Institute for Society, Culture, and Environment at Virginia Tech. We wish to express appreciation to graduate student colleagues and research scientists who assisted us with various aspects of this project, including assistance with data reduction, assessment and treatment of the youth: Kaushal Amatya, Scott Anderson, Jordan Booker, Lisa Buonomono, Natalie Costa, and Marshaun Glover. We also wish to extend thanks to the many undergraduate students at Virginia Tech who assisted with data coding, entry, and verification. Finally, we are grateful to the youth and families who participated in this clinical research trial.

1 “Completer” analyses ( n = 106) were also conducted and results were similar to intent-to-treat analyses; therefore, “completer” results are not reported but are available upon request.

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