Depending on how it is defined and assessed, between 5% and 15% of children have significant difficulties with what might be called “challenging behaviours” – for example, those such as following instructions from adults, verbal or physical aggression, impulsivity, high levels of conflict with peers or siblings, being deceitful, rule breaking and chronic irritability.
Although many private practitioners in Australia choose to not formally diagnose these children with the DSM-5 disorders which have challenging behaviours as some of their primary symptoms (the reasons for this, and the risks and benefits of these diagnoses is outside the scope of this article), there are a number of these disorders which may be useful for us to be aware of when thinking about these children, including the following:
- Oppositional Defiant Disorder (ODD): Characterized by negative, defiant, and hostile behaviors.
- Conduct Disorder (CD): Severe and persistent rule or law-breaking behavior, violating the rights of others and societal norms.
- Intermittent Explosive Disorder (IED): Marked by recurrent outbursts of anger, aggression, and destructive behavior.
- Disruptive Mood Dysregulation Disorder (DMDD): The outbursts listed above (and more of them than required in IED), plus chronic irritability between outbursts.
Attention-Deficit/Hyperactivity Disorder (ADHD) is another disorder to be aware of when working with children with challenging behaviours. Although ADHD is characterized by symptoms of inattention, hyperactivity, and impulsivity – and not by the defiant, angry behaviours or outbursts in the other disorders above, ADHD is the most common comorbidity for ODD.
Whether or not children meet the criteria for one of these disorders, challenging behaviours are the most common symptom experienced by children referred to mental health clinics. As a result, it is important for clinicians to know about the research which has been conducted on treatment approaches for disruptive behaviour disorders (DBDs).
What are the evidence-based treatment approaches for DBDs?
At the broadest level, treatment approaches can be divided into parent/caregiver-focused treatments and child -focused treatments.
Parent/caregiver-focused treatment approaches aim to assist caregivers (often parents but may also be other caregivers who provide the majority of care – for example, grandparents and foster carers) to interact more effectively with their child and support their child in specific ways which are thought to be consistent with improved mental health and reduced challenging behaviours.
Parent/caregiver-focused approaches can be divided into approaches which are either a) more heavily influenced by social/behavioral learning principles – often called Parent Management Training (PMT) or Behavioural Parent Training (BPT) – or b) those which are influenced more by attachment or emotion coaching frameworks or problem solving/mediation frameworks.
Examples of commonly used PMT/BPT programs include the following:
- Parent-Child Interaction Therapy (PCIT): Arguably the most commonly studied PMT approach – it involves live coaching sessions in which the therapist guides parents in using (first stage) communication and relationship strategies and (second stage) specific discipline techniques.
- Incredible Years: A longstanding PMT program usually provided in group format for parents and using role play/video focuses on coaching “positive” parenting and correction strategies, as well as strengthening parent-child relationships.
- Triple P (Positive Parenting Program): Another extensively studied program (provided in both group and individual formats) and offers different levels of intervention based on the severity of the child’s behaviors, and the content very similar to other PMT/BPT programs.
- Parent Management Training- Oregon Model: The content of PMTO is similar to the other PMT/BPT’s above. However, this approach was developed out of Patterns cycle of coercive control (child behaviour – parent response – child escalation – parent retreat) and therefore emphasizes social relationships/the type of parent responding which specifically avoids this cycle.
- Kazdin Method: A PMT/BPT program which primarily focuses on positive reinforcement and planned ignoring.
Examples of commonly used attachment, emotion coaching frameworks or problem solving/mediation frameworks (which are slightly heterogenous in nature compared to the relative homogeneity of above PMT/BPT programs) include the following:
- Circle of Security: Usually run as a group program and often focused on parents/caregivers of younger children – aims to promote secure parent-child relationships and enhance parent/caregiver reflection of parent needs (and their own parenting experiences).
- Attachment and Biobehavioral Catch Up: A home visiting program for parents/caregivers and their infants/toddlers to help enhance parent/child relationships.
- Tuning into Kids: A program (again usually run in groups) based on Gottman’s emotional coaching framework and aims to teach parents emotion coaching skills to help their children develop emotional intelligence and regulate their emotions.
- Collaborative Problem Solving: A program for adults/teachers which teaches adults to use mediation and problem-solving skills with children in an attempt to understand their difficulties as skill gaps – and find mutually acceptable solutions to conflicts.
Although PMT/BPT programs and attachment/emotion focused/family problem solving parent-focused approaches can be considered to be quite different categories of treatment approaches from a theoretical perspective, practically speaking, the content of all of these programs often overlap and most programs include many common components.
What are the core intervention components included in parent-focused treatments for DBDs?
Typically, core elements of parent/caregiver-focused treatment approaches (of either theoretical orientation outlined above) for DBDs include the following core components (note, this is not a comprehensive list – and not all programs use all elements listed below):
Psychoeducation about the causes of disruptive behaviors, developmental norms, effective communication, and relationship building.
Teaching or coaching parents to use skills, such as:
- Sensitivity and awareness of the child’s needs
- Empathy and compassion for child
- Expressions of enjoyment in the child, expressions of love and physical affection
- Child directed play time
- Communication and problem-solving skills to address child/parent conflict
- Emotion coaching skills
- Giving clear instructions and establishing routines
- Helping children identify and express emotions
- Helping children learn social skills
- Mild punishment – time out/response cost interventions
Parent reflection skills, for example:
- Identification of parent emotions which occur in parenting
- Identification of their own experiences of being parenting and their influence
- Identification of parent/family values
Depending on the parent focused approach, varying methods to teach these skills are used, including:
- Including the child to rehearse/role play the skills
- Therapist modelling with the parent or child
- Watching videos
- Discussion, identification of barriers and problem solving (with therapist and/or other parents)
- Structured homework
Programs usually are weekly, 90-120 minutes with homework considered to be integral in most of the programs (often between three 15-minute sessions to daily 15-minute sessions)
Involvement of the child:
Some parent programs (particularly PCIT) also include the child in treatment/sessions. This might include active rehearsal with the child (with therapist feedback) or parallel skills training with child and parent together.
Research on the effectiveness of parent focused treatment approaches for challenging behaviours:
Evidence for PMT/BPT parent focused treatments for children with disruptive behaviours
PMT/BPT approaches have been studied for many years. These studies have consistently shown that these programs are effective (usually as measured by parent report – not child report) in reducing disruptive behaviors in children, with effect sizes typically around 0.4 to 0.5 compared to control groups. For instance, the Incredible Years, Triple P, and Parent-Child Interaction Therapy (PCIT) have all been evaluated compared to no treatment, waiting list, or attention-placebo control, and have consistently demonstrated significantly positive outcomes for reducing disruptive behaviors in children – with treatment effects usually maintained at follow up (usually 12 months) – and often with children with more severe behaviour problems improving the most.
As a result, PMT/BPT programs (whether conducted in group or individual settings) have been classified as “well-established treatments” by various literature reviews and national treatment guidelines systems (e.g., NICE, Aus Psych Association, American Acad. Of Paeds, etc.)
However, it is important to note that research also suggests there are limitations of these treatments. For example, we know there is likely to be a high dropout rate – one review of 262 PMT studies found that 51% of parents didn’t complete treatment. Even for those who do complete a treatment program, not all benefit – most reviews of PMT programs conclude that around 25%-30 (and in one review, even up to 50%) of families are non-responders. For those who both complete the program and experience benefits – many of these children still show challenging behaviours which are improved but still at above average levels. And finally, follow up research is rarely done after 2 years, so we are not sure whether treatment effects last beyond this time.
To be fair, it should be noted that all of the above limitations are common to almost all psychotherapy interventions. Therefore, despite the limitations of these treatments, most reviewers and treatment classification systems still refer to BPT/PMT programs as the “gold standard” for children with challenging behaviours.
Evidence for parent-focused treatments based on attachment/emotion coaching/family problem solving:
There have also been many studies evaluating attachment/emotion coaching/family problem solving parent programs (such as the Circle of Security, Tuning into Kids, and Collaborative Problem Solving) and these studies typically also show significant reductions in child disruptive behaviours. Studies on these programs are more likely to measure impacts on parent self-efficacy and parent stress, and typically show improvements in these areas too.
Although these programs are more heterogenous, some reviewers/classifiers of treatment programs have grouped these programs together, and these reviews typically concluded these programs are likely to be effective (e.g., classified as “probably efficacious”).
Many of the same limitations which exist for BPT (i.e., drop out, partial responding, lack of follow up studies) have been shown to also exist for attachment/emotional coaching/family problem solving treatments.
Which type of parent intervention works better for children with disruptive behaviours?
In terms of comparing the two types of parent programs, it should be first noted that there are far fewer studies on attachment/emotion coaching/family problem solving approaches than there are studies on the behaviourally orientated programs. This is why many reviewers of the literature conclude that parent focused treatments based on attachment/emotion coaching/family problem solving approaches were “probably efficacious” treatments as compared to being “well established” treatments (PMT).
With regard to direct “head-to-head” research, there have only been a handful of studies which compare more behaviourally orientated programs to attachment focused programs. Some of these studies find “no difference” but some studies have found programs that included behavioural components were more effective.
It should be noted however that there is some research to indicate that there is a significant number of both parents and professionals who do not like or feel comfortable with some components of behaviourally orientated programs (most commonly the use of time out or negative consequences) suggesting that attachment orientated/emotion focused/family problem solving programs may have a broader acceptance base than PMT programs.
What specific components might work best in parent-focused treatments?
There have been several meta-analyses which have explored the specific components of parent focused treatments which might be most effective.
The studies analysed by these meta-analyses mostly include PMT programs, although some include attachment orientated programs. Although conclusions are still tentative, it seems that including the following components in a parent intervention may be associated with greater effectiveness: increasing positive interactions with the child, teaching parents the use of time-outs (this is of interest, given that this component may cause some families to drop out/not engage with the program), a focus on consistent responding to the child’s behavior, a focus on the parents practicing skills with their child at home, the treatment including practicing with the child during treatment and programs which have a strong focus on the encouragement of homework completion.
Research on the impact of program length remains unclear, but there is some evidence that suggests shorter programs can be just as effective as longer ones.
Evidence on the value of including children (for example, having them present, or having a parallel treatment for the child) in parent-focused approaches is mixed and mostly involves evaluation of the PCIT program compared to other BPT programs. Some reviews suggest the evidence for parent-focused programs which also include the child is stronger, and other reviews suggesting including the child does not add to the effectiveness of the parent-focused treatment program.
Finally, it is important to note that most research on parent focused programs includes mothers only – some reviews suggest that when fathers are included, effectiveness tends to increase.
In contrast to parent-focused approaches, child-focused treatment approaches are those which work directly with the child with disruptive behaviour problems, to try to reduce challenging behaviors via increasing the child’s skills, motivation for change and emotional regulation abilities.
Some writers have divided child-focused treatments for challenging behaviours into three types: social skill programs (SS), cognitive-behavioral programs (CBT), and play-based therapy programs.
Social skill programs provide training in specific social skills (e.g., conflict management, social problem solving), Cognitive-Behavioral Programs focus on identifying and managing distressing or problematic thoughts and emotions related to disruptive behaviours, and play-based therapy programs focus on providing a child-directed space for the child to explore their thoughts, feelings and experiences in a supportive environment with a therapist. In practice, there is a great deal of overlap between SS and CBT programs and so these will be considered next and together.
What are some examples of CBT or SS based programs for children?
Some ‘brand name’ therapies for children with DBD include the following: Anger Coping Therapy / Coping Power Program, Anger Control Training, Assertiveness Training, Problem-Solving Skills Training, Dina Dinosaur Program, PATHS program, etc. Other CBT/SS programs which are commonly run in Australia (although not the focus of very much, if any, empirical research that I am aware of) include Kool Kids, Stop Think Do, Friends Program, What’s the Buzz, etc.
What do these programs involve?
CBT and SS programs for children with challenging behaviours typically include the following components:
Supporting children to:
- improve their awareness of emotions
- increase their skills to communicate emotions
- physiological arousal management (awareness and reduction)
- identification of problematic thoughts (or beliefs)
- increasing positive (or self-compassionate) self-statements
- improving perspective-taking
- improving skills in problem-solving (especially social problem-solving) skills
- improving conflict resolution
- attention redirection skills
These components are typically taught using methods such as psychoeducation, role-playing, drawing/games, feedback, videos, homework, and (when group programs) group discussions.
Evidence for CBT/SS Programs for Children:
According to a 2017 review, CBT/SS programs for children with DBD’s are considered “probably efficacious.” It should be noted that most published research for CBT/SS programs consists of either non-randomized trials or RCTs but only with a wait list comparison. The effect sizes for these programs range from small to medium (around 0.23 to 0.5). Some studies have found them to be more effective for older children compared to primary-aged children. Some studies have found that SS programs are more effective when they have a CBT orientation.
As stated above, play therapy or non-directive therapy programs for children are quite diverse in their scope and aim, but generally have a focus on using the medium of play in a safe therapeutic space, to help a child express and uncover their thoughts and feelings using play.
There are far fewer studies on the effectiveness of play therapy compared to CBT/SS programs for children with challenging behaviours, and those studies have yielded mixed results. Some have found significant effects compared to control groups, others have not found such effects. One review suggested that individual child-centered play therapy was “unclassifiable” due to insufficient evidence.
Comparing Parent-Focused vs. Child-Focused Approaches: Which is better for children with disruptive behaviours?
There have been several reviews and meta-analyses trying to determine whether it is more effective for children with disruptive behaviour disorders to receive a child-focused treatment approach or for their parents/caregivers to receive a parent-focused treatment approach. There are few “head-to-head” comparisons, and so reviews/meta-analyses which try to answer this question usual comparing effect sizes in different studies. Those which have done this have tended to conclude – at least for children under 13 – that parent-focused treatments are associated with slightly larger effect sizes than child-focused treatments and therefore should be considered the first line treatment approach.
What do we do with this information? Conclusions for therapists working with kids with DBDs:
Working with preschool or primary aged children
If we were to be purely guided by the existing RCTs for children with DBD’s, then effectively treating disruptive behavior disorders with preschool or primary aged children would probably involve working directly with their parents/caregivers for twelve to twenty-four weekly 90–120-minute sessions, and ensuring these caregivers are doing 15 minutes of therapy homework at least three times per week with their child. We may or may not be having the child present for these sessions (to facilitate practice opportunities for the parent and provide us with examples and information about the child to more specifically fine tune our parent interventions to make them more helpful). As an alternative, if we had to – we might provide child-focused treatments, and use a 12 weekly session CBT/SS orientated program (more justifiable from the research literature if we are working with older children perhaps), but if we are thinking about gold standard approach to treatment, the previously described parent/caregiver interventions would be our first choice.
In contrast, there is nothing in the research which compellingly suggests that the best approach for most children would be 6 to 10 primarily play or game-based therapy sessions (say every fortnight or 3 weeks) with the child on their own and in which our primary focus is on them – and in which we only interact with the caregiver through an update about what we are doing at the beginning of sessions.
I’m pointing out the lack of research for this particular example of a therapy approach because unfortunately and uncomfortably this approach is often precisely what caregivers expect from mental health providers (possibly understandably given what TV/media tell us about therapy), and what our funding models might suggest we do.
This *huge gap* between what the research might suggest we do and what we are pressured to provide is a big problem for child mental health providers in Australia.
(A side note – it seems this problem is not always one faced by therapists in other countries. I recently read a review on treatment of disruptive behaviours in children which was funded by a “managed care” (health insurance) organisation in the US. The goal of this research review stated in the first paragraph was to examine whether or not it was “worth” involving children themselves in treatment. The suggestion was they should only be funding parent only work and were disputing the need to see children!)
However, unless we turn children away from our clinics, we have to find a way to apply the research in the best way we can to try to work effectively with families in the funding models we have available to us.
How exactly we do this is outside the scope of this article, but here are my brief thoughts on what we might consider as psychologists/mental health professionals when working with children who present with challenging behaviours as their “primary symptom” (and I know there is complexity in thinking about this issue too – but I’m putting it aside for now):
1. We should at least tell caregivers about the research-based treatments for children with challenging behaviours and that parent-focused treatments are likely to be best, for most families. We can see whether they are prepared to pay privately or attend a (usually costed) group if available, or find an online option. Explaining this to parents/caregivers requires us to be compassionate, clear and avoiding blame and shame – please see my notes at the end of this article about this.
2. If funding models or parent pressure means we do need to work predominantly with the child present in the therapy room, these types of sessions might still be justifiable from the literature above (and even have some benefits) – providing we still have a strong focus on parent work within those sessions. What these sessions might look like exactly will vary – but it might be having the child involved in rehearsal and role play with the parent/caregiver in our sessions, providing concurrent psycho-education to a child and parent together – or doing skills training with a child but with the clear aim of this skills training being done at least partly in order to help a watching caregiver to know how to do that skills training with the child themselves at home.
3. With regard to the content of specific therapy intervention and sessions – the research suggests that the components we use might include those informed by either attachment and behavioural theoretical orientations depending on our and the parent preferences, but probably is going to be more helpful for most families if it includes at least some behavioural skills which are very specific and practical, as well as a focus on the parent/child relationship. Regardless of the type of components, they are likely to also be most helpful if it includes rehearsal (as above – this might be with the child) or at least role play in session and ideally with us providing feedback to caregivers on skills they are trying to acquire.
4. In terms of frequency and intensity of sessions, the typical 12-24 (sometimes 90 minute) session model of evidence-based treatments is not available under many funding bodies. Even if it was, it is not easily achieved by families (who don’t typically come into therapy expecting this kind of intensity/able to manage schedules/illness to do it) nor provided by therapists under pressure to provide services to many in their community. Unfortunately, more spaced-out sessions, e.g., fortnightly/monthly, inevitably leads to homework not being completed (see next section) and momentum being lost. Therefore, although we might not be able to offer weekly sessions, it may be more effectively to offer a block of intensive sessions – e.g., 6 fortnightly and then a break for another 4 – rather than space them out monthly for 10 months. It is important that we explain the need for this kind of spacing, the fact that the research-based treatments we have are based on even more intensive work, let them know the potential disadvantages of less intensive work/non attendances, collaboratively work with them about what they would like to do, and brain storm options for increasing attendance.
5. The setting of specific homework and focus on completion of that homework is probably going to need to be a significant focus of our attention throughout therapy.
6. We are probably going to want to include both members of a parenting team, and in particularly try hard to involve fathers.
This is just a beginning set of principles however – other areas of psychotherapy outcome research suggest in addition to the above ideals, we want to be using a highly collaborative, individual formulation driven and outcome monitoring approach.
Explaining our approach to parents/caregivers
As stated, one of the barriers for implementing the above conclusions is that parents/caregivers of children with challenging behaviours don’t usually come into therapy with the same ideas, resources or abilities to work in this way parent-centered, homework driven, roleplay/rehearsal focused way.
Furthermore, trying to help them understand these ideas risks shaming or alienating them. This means our education and collaboration with parents has to be done extremely carefully.
How exactly we do this type of non-blaming, supportive and collaborative psychoeducation with parents/caregivers is outside this article’s scope. However, I have written an article for parents/caregivers which you might like to refer to or provide to parents/caregivers. This article provides information and a rationale about us involving them in treatment, the need for active roleplay/rehearsal in sessions, for regular attendance and for therapy homework – and I have attempted to do this in a way which doesn’t shame or blame parents/caregivers. The link to this article is here – feel free to provide it to parents/caregivers you are working with if you think it might be of benefit for any of the families you work with.
All the best in the juggling you might be doing in trying to work with these families – the largest group of children presenting to mental health clinics – while managing demands/pressures which are not always consistent with trying to do this work in an evidence-based way.