Studies of Childhood
Disruptive Behavior Disorders
The evidence base for nonresidential interventions for
disruptive behavior disorders is presented in table 3. It excludes interventions
that require an out-of-home placement (e.g., therapeutic foster care,
group homes, residential treatment centers, or hospitalization).
Interventions must be applicable to school age preadolescent
youth (defined as approximately 6–12). Studies were included if
they covered this age range, but also included youth who were younger
or older. Interventions that are designed exclusively for adolescents
were not included. The review includes prevention and treatment studies.
Therefore, programs that identify youth who are "at risk"
for developing conduct problems are included. Studies in which ADHD
was the primary diagnostic label were excluded (and are included in
the ADHD section of this report). Studies could be included if they
focused on youth with a definable psychiatric diagnosis (e.g., conduct
disorder, oppositional defiant disorder) or on youth with externalizing
behaviors that may contribute to these types of disorders. The review
includes a number of interventions designed to be delivered via
schools. However, we did not search the education literature for education-specific
interventions (e.g., special education).
Searches were conducted in PsycINFO and Medline electronic
databases, beginning with key words "behavior disorders,"
"conduct disorder," or "disruptive." The query was
limited to (1) refereed journal articles, (2) English language, (3)
1985-1999, (4) school age (6–12), and (5) empirical studies. This
net was intended to be broad to prevent omission of relevant articles.
This search resulted in 314 articles. The final set was selected by
reading abstracts or articles. Articles were excluded if they: had a
total sample size of less than 30; did not include a comparison group;
did not include youth younger than 13; were focused on program descriptions
or epidemiologic topics; or had insufficient data to examine outcomes
at the completion of intervention. In addition to this search, we also
included older citations from the frequently cited review by Brestan
and Eyberg (1998) of the literature on treating disruptive disorders.
This resulted in a total of 30 included articles.
Brestan and Eyberg’s review summarized research through
1995. This review has been cited extensively in many recent publications
related to treatment for disruptive behaviors. The current review extends,
rather than duplicates, the Brestan and Eyberg article.
Results from the present review are discussed within five
heuristic categories: parent training; community-based interventions;
clinic-based treatments; prevention programs; and psychopharmacological
treatments. These categories were developed to provide structure in
a field with quite diverse approaches to intervention. In contrast to
the research literature for other disorders in this review, adjunctive
studies examining combined psychosocial and pharmacological interventions
were not found.
Parent training is highlighted because it is a generic
heading that captures both of the "well established" treatments
identified by Brestan and Eyberg. Support seems to be particularly strong
for Webster-Stratton’s Parents and Children Series. Most of the
research on this intervention has been conducted with parents of youth
in the preschool and early school years.
Community-based interventions primarily include treatments
that are delivered in the child and family’s natural ecology and
that focus on meeting the individualized needs of youth and their families.
Multisystemic therapy (MST) has the strongest evidence base within this
section. However, most studies of MST have focused on adolescents, rather
than youth under the age of 13. Various approaches to case management
appear to have positive effects, particularly on treatment-related outcomes
but large direct effects on symptoms have not been found.
Clinic-based interventions included a heterogeneous set
of individual and family-based interventions. Overall, this set of interventions
showed improvements over time for youth. However, differential improvement
between groups was not always significant. This section provides findings
that suggest possible effectiveness of several interventions (e.g.,
day treatment, Problem Solving combined with Parent Management Training,
Family Effectiveness Training). However, the research base is not particularly
strong.
Preventive interventions are unique within this review.
This is in part because the risk factors for disruptive disorders have
been consistently determined, and therefore, prevention programs have
been developed to reduce the probability of later problems in at-risk
youth. All interventions in this section include a multifaceted intervention
that targets the multiple risk factors for the development of disruptive
disorders. An intervention conducted by Tremblay, Vitaro, and colleagues
has the longest followup data, and results look promising into early
adolescence and beyond. Two of the projects included here are recent
additions (e.g., Fast Track, LIFT). Initial outcomes from these projects
look promising, but more time is needed to assess their long-term effects.
Pharmacological interventions are relatively rare with
disruptive disorders (except for youth with comorbid ADHD). Recent studies
suggest potentially positive effects of lithium and methylphenidate
hydrochloride. In both cases, the evidence is not yet extensive.
Overall, interventions for disruptive disorders tend to
focus on the child’s behavior and significant others (particularly
parents). There is some evidence for the effectiveness of a variety
of approaches. There is also growing evidence for the effectiveness
of multifaceted prevention programs to prevent development of disorder
in at-risk youth. In the treatment of disruptive disorders, 6- to 12-year-olds
are a relatively understudied population. More attention has been given
to youth who are younger (e.g., preschoolers) or older (e.g., adolescents).
There is a tremendous need for additional research to build upon the
positive interventions listed here and to examine long-term effectiveness.
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| Table 3.1 Review of Childhood Disruptive
Behavior Disorders Studies |
| Study
Citation(s) |
Study
Design/
Description |
Target
Population |
Demographic
Characteristics |
Outcomes |
Notes |
| Brestan & Eyberg,
1998 |
Review of 82 studies
conducted across 29 years (1966-1995)
Included studies based on previous meta-analyses
plus additional search for studies during 1993-95; criteria
for inclusion: prospective design, peer-reviewed journals; 99%
of included studies used a comparison group, 75% used random
assignment
|
Youth with symptoms of
ODD or CD; included comorbid cases |
Not reported in all studies;
typical subject was 9 years old, white, lower-middle income |
Identified 2 well-established
treatments, and 10 probably efficacious treatments; well-established
are both Parent Training (Patterson & Gullion’s Living
with Children; Webster-Stratton’s videotape Parent Training
series); probably efficacious include anger control, assertiveness
training, parent-child interaction, parent training, problem solving,
rational-emotive therapy, delinquency prevention, and multisystemic
therapy |
Not a primary research
article, but included here because it forms the basis for many
contemporary overviews of the state of the field; outcomes appear
to be better with younger children (e.g., preadolescence) |
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| Table 3.2 Parent Training Studies of Childhood
Disruptive Behavior Disorders |
| Study
Citation(s) |
Study
Design/Description |
Target
Population |
Demographic
Characteristics |
Outcomes |
Notes |
| Taylor, Schmidt, Peeler,
& Hodgins, 1998 |
RCT; Webster-Stratton’s
Parents and Children Series (PACS; n = 46) vs.
eclectic atypical treatment (n = 46) vs. wait-list
control (n = 18) |
Families of 3- to 8-year-olds
with behavior problems |
Age: 3 – 8
Gender:
73% boys
27% girls
Race/Ethnicity: DK (92% of mothers born in Canada)
|
PACS and eclectic treatment
showed improvements compared to wait-list controls (total problems);
PACS showed more pronounced effects in intensity of problems and
CBCL total problems score; eclectic showed more pronounced effects
in attentional difficulties |
Sample collected from
families who contacted a public mental health clinic for assistance
related to behavior problems or parenting issues for child with
behavior problems |
| Webster-Stratton &
Hammond, 1997 |
Quasi-experimental design;
child training vs. parent training vs. child training
plus parent training vs. wait-list control (n =
97) |
Families of children with
early-onset conduct problems; children met criteria for ODD or
CD to be included |
Age: 4 – 7
Gender:
74% boys
26% girls
Race/Ethnicity:
86% White
14% Other
|
Assessments at baseline,
2 months' posttreatment and 1 year; all three treatments showed
improvements compared to controls; child training plus parent
training produced most significant improvements at 1-year followup |
|
| Webster-Stratton, Kolpacoff,
& Hollinsworth, 1988 |
RCT; individually administered
videotaped modeling vs. group discussion videotape modeling
treatment vs. group discussion treatment vs. wait
list control (n = 114) |
Families with a child
with conduct problems |
Age: 3 – 8
Gender:
69% boys
31% girls
Race/Ethnicity: DK
|
Significant changes, relative
to controls, for families in all treatment groups; few differences
among three interventions, but consistent trend for better outcomes
associated with group discussion videotape modeling |
|
| Wiltz & Patterson,
1974 |
Quasi-experimental design;
parent training vs. Living with Children curriculum vs.
untreated control group (n = 16) |
Boys with aggressive behavior |
Age: M =
9.8
Gender:
100% boys
Race/Ethnicity: DK
|
Outcomes available at
end of 5-week treatment; boys in intervention showed decreased
deviant behavior in targeted areas |
Small sample size; short-term
outcomes; included because this is listed as one of Brestan and
Eyberg’s (1998) well established treatments |
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| Table 3.3 Community-Based Studies of Childhood
Disruptive Behavior Disorders |
| Study
Citation(s) |
Study
Design/
Description |
Target
Population |
Demographic
Characteristics |
Outcomes |
Notes |
| Burns, Farmer, Angold,
Costello, & Behar, 1996 |
RCT; treatment team led
by a case manager vs. treatment team without a case manager
(n = 167) |
Youth with SED being served
by community mental health center (77% had diagnosis of externalizing
disorder) |
Age: 8 – 17
Gender:
53% boys
47% girls
Race/Ethnicity:
13% African American
77% White
|
Outcomes available for
1-year period following initiation of treatment; youth with case
manager remained in services longer, received wider array of services,
fewer inpatient days, and more community-based services; symptoms
and functioning did not differ between groups |
Control group also served
by multi-agency treatment teams; both groups receiving some version
of coordinated care |
| Clark, Lee, Range, &
McDonald, 1996 |
RCT; regular foster care
vs. Fostering Individualized Assistance Program (n
= 132) |
Youth in foster care with
externalizing behavior problems |
Age: 7 – 16
Gender: DK
Race/Ethnicity: DK
|
Outcomes approximately
2.5 years after program entry; youth in Fostering Individualized
Assistance Program showed fewer placement changes, less amount
of time spent running away from home, and fewer days incarcerated |
All findings are only
borderline significant; target group focused on foster children
who had behavior problems (this definition is less strictly oriented
toward disruptive disorders than most other interventions) |
| Evans, Armstrong, &
Kuppinger, 1996 |
RCT; Treatment Foster
Care (n = 15) vs. Family-Centered Intensive Case
Management (n = 27); Family-Centered Intensive Case Management
uses a team approach (including a parent advocate) to provide
intensive support to parents of youth with serious emotional disorder |
Children referred for
placement in Family-Based Treatment (e.g., Treatment Foster Care);
69% had diagnosis of a disruptive behavior disorder |
Age: 5 – 12
Gender:
91% boys
9% girls
Race/Ethnicity:
33% White
67% African American
|
Outcomes collected every
6 months and 6 months' postdischarge (duration in services varies,
based on needs); improvements in symptoms across time; trend in
favor of Family-Centered Intensive Case Management group, but
not statistically significant |
Results very preliminary;
many children still in services; suggests that youth referred
for out-of-home placements can be served equally well at home,
with intensive supports for family |
| Fraser & Nelson, 1997 |
Meta-analysis; reviewed
findings on Family Preservation Services |
Youth at risk of out-of-home
placement; includes various subgroups (e.g., abuse/neglect, juvenile
delinquents, family reunification) |
DK |
Outcomes for child welfare
are most relevant in terms of age range (<13); results mixed,
with some evidence (though small) of effects on out-of-home placements;
outcomes for juvenile justice are most relevant in terms of disruptive
disorders; tend to focus on somewhat older youth (13–15);
effect sizes range from moderate to large (.48 –.92) |
Mixed findings with many
methodological caveats; positive findings for juvenile justice
cases come almost exclusively from MST programs |
| Henggeler, Pickrel, &
Brondino, 1999 |
RCT; multisystemic therapy
vs. usual service (n = 118) |
Juvenile offenders with
substance abuse/dependence |
Age: 12 – 17
Gender:
79% boys
21% girls
Race/Ethnicity:
50% African American
47% White
3% Other
|
Outcomes: end of treatment
and 6 months' posttreatment; some decrease in self-reported alcohol/drug
use at end of treatment in favor of multisystemic therapy; difference
not apparent in urine tests or at 6 months' post-treatment; MST
youth experienced fewer days of out-of-home placement |
Many other multisystemic
therapy sites show positive effects; mostly, MST has been conducted
with adolescent populations; smaller effects in this study than
in other MST studies may reflect lower treatment adherence by
clinicians; age range mostly adolescents; included because it
targeted substance use as an outcome |
| Lochman, Burch, Curry,
& Lampron, 1984 |
RCT; 12-week anger-coping
vs. anger-coping plus goal setting vs. goal setting
vs. no treatment (n = 76) |
Boys with aggressive behavior |
Age: 9 – 12
Gender:
100% boys
Race/Ethnicity:
53% African American
17% White
|
Boys in anger coping and
anger coping plus goal setting showed more improvement than other
two groups (including less disruptive and aggressive off-task
behavior, parental reports of aggression, self-esteem); both anger-coping
groups showed improvement, but addition of goal setting improved
outcomes |
Very short-term followup;
reported in a research note, so there is very little information
available on details |
| Lochman, Lampron, Gemmer,
Harris, & Wyckoff, 1989 |
RCT; 18-session anger
coping (n = 11) vs. anger coping plus teacher consultation
(n = 13) vs. no treatment (n = 8) |
Boys with aggressive behavior |
Age: 9 – 13
Gender:
100% boys
Race/Ethnicity:
69% African American
31% White |
Posttreatment differences
in off-task disruptive-aggressive behavior, perceived social competence,
teacher-reported aggressiveness; both intervention groups showed
similar improvements |
Small sample size; consultation
was very minimal (6 hours in small groups) |
| Schoenwald, Ward, Henggeler,
& Rowland (in press); Henggeler, et al., 1999 |
RCT; 4-month multisystemic
therapy vs. hospitalization (n = 113) |
Children presenting for
psychiatric emergency hospitalization; 62% had disruptive disorders,
38% had been involved with juvenile justice system |
Age: 10 – 17
Gender:
65% boys
35% girls
Race/Ethnicity:
64% African American
34% White
|
Outcomes available through
end of multisystemic therapy: 75% of children not hospitalized,
fewer days in any out-of-home placement, decreased in externalizing
symptoms, and improved family functioning |
Outcome data available
only at end of multisystemic therapy treatment; many youth in
study were older than 12 |
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| Table 3.4 Clinic-Based Studies of Childhood
Disruptive Behavior Disorders |
| Study
Citation(s) |
Study
Design/
Description |
Target
Population |
Demographic
Characteristics |
Outcomes |
Notes |
| Fonagy & Target, 1994 |
Chart-review of youth
who received psychoanalysis and psychotherapy at Anna Freud Center;
children with disruptive disorders compared to matched sample
of children with emotional disorder (n = 135) |
Children with disruptive
disorders |
Age: M =
9.0
Gender:
75% boys
25% girls
Race/Ethnicity: DK
|
33% of disruptive youth
not diagnosable at completion of treatment; improvement was higher
for youth with ODD than with CD; overall, youth with disruptive
disorders improved less than youth with emotional disorders |
Treatment most effective
with youth who remained in treatment for full course of psychoanalytic
treatment (e.g., 3 years); 31% terminated treatment within first
year |
| Grizenko, Papineau, &
Sayegh, 1993; Grizenko, 1997 |
Quasi-experimental design;
day treatment vs. wait list (n = 30) |
Youth with disruptive
disorders who are unable to function in home/school |
Age: 5 – 12
Gender:
77% boys
23% girls
Race/Ethnicity: DK
|
At 6-month followup, treatment
group more improved than controls on behavior, self-perception,
and school reintegration |
Small sample size; 5-year
followup shows some deterioration of outcomes, but still improvements
over baseline |
| Kazdin, Siegel, &
Bass, 1992 |
RCT; 6- to 8-month problem-solving
skills training vs. parent management training vs.
combination
(n = 97) |
7- to 13-year-olds referred
for treatment at a psychiatric facility (outpatient branch) |
Age: 7 – 13
Gender:
78% boys
22% girls
Race/Ethnicity:
31% African American
69% White
|
All groups improved over
time; combination group showed greatest improvement in a variety
of areas, including antisocial and delinquent behavior, depression,
and family functioning |
Changes continued during
the 1-year followup; only parent management training alone showed
no additional gains during followup |
| Luk, Staiger, Mathai,
Field, & Adler, 1998 |
RCT; modified cognitive-behavioral
therapy vs. conjoint family therapy vs. eclectic
therapy (n = 32) |
Outpatient children with
at least three definite conduct symptoms (by parent or teacher
questionnaire) |
Age: M =
8.5 years
Gender:
63% boys
37% girls
Race/Ethnicity: DK (13% from non-English- speaking
families)
|
Outcomes measured 6 months
postintervention; no significant differences between groups; significant
improvements for all groups in parent ratings of internalizing
and externalizing behaviors, irritability, aggressiveness |
Excluded youth who met
criteria for ADHD; small sample size |
| Szapocznik, Santisteban,
Rio, Perez-Vidal, Santisteban, & Kurtines, 1989 |
RCT; 13-session family
effectiveness training vs. minimal contact control (n
= 79) |
Outpatient children with
behavioral or psychological problems |
Age: 6 – 12
Gender:
71% boys
29% girls
Race/Ethnicity:
76% Cuban
24% Other Hispanic
|
End of treatment and 6-month
followup favored family effectiveness training on family functioning,
children's behavior problems, and children’s self-concept |
Intervention designed
to improve family relationships in an effort to strengthen families
and prevent future substance use among youth; designed specifically
for Hispanic families to address intergenerational and intercultural
conflicts |
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| Table 3.5 Prevention Studies of Childhood
Disruptive Behavior Disorders |
| Study
Citation(s) |
Study
Design/
Description |
Target
Population |
Demographic
Characteristics |
Outcomes |
Notes |
| Conduct Problems Prevention
Research Group, 1999 |
Quasi-experimental design;
behaviorally disruptive kindergartners were screened (n
= 891); half of the schools designated as intervention and half
as control; intervention was multifaceted; universal intervention
adapted version of PATHS (Promoting Alternative Thinking Strategies);
selective intervention included: parent groups, child social skills
training, academic tutoring |
Kindergartners with early
disruptive patterns who are at risk for more substantial behavioral
problems |
Age: Kindergartners
Gender:
69% boys
31% girls
Race/Ethnicity:
51% African American
47% White
|
Outcomes during 1st grade:
intervention group showed improvement in reading, positive peer
interaction and peer preference scores, more positive parenting,
and behavioral improvement |
Moderate initial effects
for a broad-based universal and selective prevention program;
effects similar for boys and girls and for different races |
| Reid, Eddy, Fetrow, &
Stoolmiller, 1999 |
RCT; 10-week intervention
focusing on parents and students (playground and classroom behavior)
vs. control; based on variety of previous prevention work,
especially that conducted by Oregon Social Learning Center |
Schools in areas with
above-median rates of juvenile arrests |
Age: 1st and 5th
grades
Gender:
50% boys
50% girls
Race/Ethnicity:
85% White
2% African American
|
Decreases in mother aversive
verbal behavior and child physical aggression behavior in playground
(in 1st graders) |
Initial report on Project
LIFT (Linking the Interests of Families and Teachers); new project,
longer term outcomes not available; attempting to incorporate
a theoretical model of prevention with universal intervention;
not targeted to identified or diagnosed children |
| Vitaro & Tremblay,
1994; McCord, Tremblay, Vitaro, & Desmarais-Garvais, 1994;
Tremblay, Pagani-Kurtz, Masse, Vitaro, & Pihl, 1995 |
RCT; parent, social skills,
and cognitive problem-solving training (n = 46) vs.
control (n = 58) |
Children with elevated
aggression and risk of later conduct problems; selected on the
basis of teacher report |
Age:
6 (at selection)
8 – 9 at intervention
Gender:
100% boys
Race/Ethnicity:
100% French-speaking,
White, Canadians
|
Outcomes (assessed by
teacher, peer, and self-report) included aggression, delinquency,
and characteristics of friends when students were 10-12 years
old; at age 12, teachers reported less aggressiveness for treatment
group; nonsignificant trends toward less self-reported delinquency
and less disruptive friends |
Eligibility based on scoring
above 70th percentile on the Preschool Behavior Questionnaire
during kindergarten; all parents had less than 15 years of schooling |
| Walker, Kavanagh, Stiller,
Golly, Severson, & Feil, 1998 |
RCT; 3-month First Step
to Success program (n = 46) vs. wait-list controls
(n = 46); intervention screening, school intervention,
and parent/caregiver training |
Kindergartners with early
signs of antisocial behavior patterns |
Age: Kindergartners
Gender:
74% boys
26% girls
Race/Ethnicity:
93% White
7% Minority
|
Outcomes assessed during
1st or 2nd grade showed improved adaptive behavior, less maladaptive
behavior, and less aggression (as measured by teacher report);
results remained fairly constant at longer followup |
Because of delayed intervention
design, true comparison group not reported |
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| Table 3.6 Psychopharmacological Studies
of Childhood Disruptive Behavior Disorders |
| Study
Citation(s) |
Study
Design/Description |
Target
Population |
Demographic
Characteristics |
Outcomes |
Notes |
| Campbell, Adams, Small,
Kafantarix, Silva, Shell, Perry, & Overall, 1995 |
Double-blind, placebo-controlled,
within-subject alternating treatments experimental design; 6-week
lithium vs. 2-week placebo (n = 50); four treatment
cycles |
Hospitalized children
with conduct disorder |
Age: 5 – 12
Gender:
92% boys
8% girls
Race/Ethnicity:
48% Hispanic
38% African American
8% White
6% Other
|
During lithium period,
children showed moderate or marked improvement (68% vs.
40%); other measures of behavior showed nonsignificant trends
in favor of lithium |
Lithium associated with
increases on measures of tension-anxiety and confusion-bewilderment;
short followup period |
| Cueva & Overall, 1996 |
Double-blind, placebo-controlled
RCT; 6-week carbamazepine (n = 22) vs. placebo (n
= 22) included 2-week placebo baseline, randomized assignment
for 6 weeks, 1-week posttreatment placebo |
Children with conduct
disorder |
Age: 5 – 12
Gender:
91% boys
9% girls
Race/Ethnicity:
41% African American
46% Hispanic
9% White
4% Asian
|
Changes in aggressive
behavior did not differ between groups |
Small sample size; short
followup period; noted several side effects of carbamazepine (transient
leukopenia, rash, dizziness, pilopia) |
| Klein, 1998; results also
reported in Klein, Abikoff, Klass, Ganeles, Seese, & Pollack,
1997 |
RCT; 5-week methylphenidate
vs. placebo (n = 84) |
Children with conduct
disorder |
Age: 6 – 15
Gender:
89% boys
11% girls
Race/Ethnicity:
29% African American
65% White
6% Hispanic
|
Improved ratings on a
range of behavioral outcomes by parent and teacher report; significantly
more youth in treatment group rated as improved by all informants |
Two-thirds of children
met criteria for ADHD (in addition to CD); controlling for ADHD
did not affect findings; representativeness of sample is not known |
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References
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