collaborative problem solving odd

MARGARET RILEY, MD, SANA AHMED, MD, AND AMY LOCKE, MD

Am Fam Physician. 2016;93(7):586-591

Patient information : A handout on this topic is available at https://familydoctor.org/familydoctor/en/diseases-conditions/oppositional-defiant-disorder.html .

Author disclosure: No relevant financial affiliations.

Oppositional defiant disorder (ODD) is a disruptive behavior disorder characterized by a pattern of angry or irritable mood, argumentative or defiant behavior, or vindictiveness lasting for at least six months. Children and adolescents with ODD may have trouble controlling their temper and are often disobedient and defiant toward others. There are no tools specifically designed for diagnosing ODD, but multiple questionnaires can aid in diagnosis while assessing for other psychiatric conditions. ODD is often comorbid with attention-deficit/hyperactivity disorder, conduct disorder, and mood disorders, including anxiety and depression. Behavioral therapy for the child and family members improves symptoms of ODD. Medications are not recommended as first-line treatment for ODD; however, treatment of comorbid mental health conditions with medications often improves ODD symptoms. Adults and adolescents with a history of ODD have a greater than 90% chance of being diagnosed with another mental illness in their lifetime. They are at high risk of developing social and emotional problems as adults, including suicide and substance use disorders. Early intervention seeks to prevent the development of conduct disorder, substance abuse, and delinquency that can cause lifelong social, occupational, and academic impairments.

Oppositional defiant disorder (ODD) is a disruptive behavior disorder characterized by a pattern of angry or irritable mood, argumentative or defiant behavior, or vindictiveness lasting for at least six months ( Table 1 ) . 1 Children and adolescents with ODD may have trouble controlling their temper and are often disobedient and defiant toward others. ODD usually manifests in children by late preschool or early elementary school, although it can also begin in adolescence. 2 , 3

A systematic review found that the prevalence of ODD is approximately 3.3% across multiple cultures; other reports listed a prevalence of 1% to 16%. 3 , 4 ODD is more common in children who live in poverty, and before adolescence it is slightly more prevalent in boys, although this difference resolves in adolescence. 1 , 4 , 5 Concern about ODD is among the most common reasons children are referred for mental health services. 4

Family physicians are uniquely positioned to help assess children at risk of ODD and refer their families to community programs and resources. Once a child has begun displaying symptoms, prompt diagnosis and referral to local mental health professionals with experience in treating ODD are essential.

What Causes ODD?

The etiology of ODD is not clearly defined. Most experts think it is caused by the cumulative effect of multiple risk factors that stem from biologic, psychological, and social issues. Social support is a protective factor .

EVIDENCE SUMMARY

The etiology of ODD is multifactorial with a cumulative nature. Biologic factors associated with ODD may include nicotine use by parents, prenatal nutritional deficiencies, and developmental delay. 6 – 9 Familial clustering suggests an underlying genetic component, but hereditary connections are variable. Psychological factors associated with ODD may include insecure attachment and unresponsive parents. 6 Parental psychopathology, including maternal aggression, is associated with ODD; abuse, harsh punishment, and inconsistent discipline are common correlates. 10 Newer studies confirm that parental behavior is likely causal rather than a response to the child's symptoms. 11 Additional social factors that may contribute to ODD include poverty, lack of structure, peer rejection, and community violence. 6 Protective factors are less clear but include social support, such as peer acceptance and time spent in supportive environments. 10

What Are the Diagnostic Criteria?

To meet the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., (DSM-5) diagnostic criteria for ODD, the child must have at least four symptoms of angry/irritable mood, argumentative/defiant behavior, or vindictiveness. Symptoms must be present for at least six months and have a negative impact on social, educational, or occupational functioning .

A number of changes in the diagnostic criteria for ODD were made in the DSM-5. Symptoms are now grouped by mood, behaviors, and vindictiveness, and the exclusion criterion for conduct disorder has been removed. Because many oppositional behaviors are a normal part of early childhood and adolescence, the DSM-5 now provides guidance on when these behaviors are a departure from normal development. For example, the DSM-5 notes that temper outbursts for preschool-aged children are common, but they may be abnormal if they occur on most days and are associated with significant impairment, such as being asked to leave school. 1

The DSM-5 also provides severity criteria depending on the number of settings in which symptoms are present. In contrast with attention-deficit/hyperactivity disorder (ADHD), in which impairment must be pervasive across multiple settings, ODD symptoms must be present in only one setting to make the diagnosis. 1 This means that a child who has no behavioral problems in school may be diagnosed with ODD as a result of oppositional issues at home. However, ODD more commonly causes impairment in multiple settings, and pervasiveness across settings indicates a more severe disorder. 12 Children with ODD who have symptoms in only one setting may still have significant problems with current and future adjustment, and warrant further evaluation and treatment.

Are There Tools for Diagnosing ODD?

No questionnaires are specifically designed for diagnosing ODD, but multiple tools can aid in diagnosis while assessing for other psychiatric conditions .

Diagnostic tools for ADHD, such as the Vanderbilt ADHD Diagnostic Parent Rating Scale and the Conners 3 scales, have comorbidity screening scales that can help identify ODD. 6 , 13 One study of the Vanderbilt scale found that affirmative answers (“often” or “very often”) to the items “Actively disobeys or refuses to follow adults' requests or rules” and “Is angry or bitter” had good sensitivity (55% to 88%) and specificity (85% to 94%) for diagnosing ODD. 13 Table 2 provides information on these and other tools for identifying behavior disorders; Table 3 lists the differential diagnosis of ODD. 1

What Are Common Comorbidities with ODD?

ODD is often comorbid with other mental health conditions. The most common are ADHD and conduct disorder, although mood disorders are also common. Substance use and other behavioral problems may also coexist with ODD .

ADHD is one of the most common comorbid conditions with ODD, occurring in 14% to 40% of children with the disorder. 14 , 15 Symptoms of ADHD may precede those of ODD. Children with more predominant defiant and headstrong symptoms of ODD are more likely to have comorbid ADHD. 2 , 16 Older studies suggested that conduct disorder may be a more severe, age-related progression of ODD, although more recent evidence suggests that they are distinct disorders. 2 , 12 , 14 Retrospective studies estimate that conduct disorder is comorbid in up to 42% of persons with ODD. 4 , 14 Those with comorbid ADHD and ODD or conduct disorder and ODD tend to have more severe and persistent behavioral problems and are more likely to have additional comorbid mood disorders. 6 , 17 They are also at higher risk of substance use and abuse. 17

Anxiety and depression are commonly associated with ODD, developing as early as preschool age. 2 , 5 , 14 One study found that up to 14% of persons with ODD also have anxiety, and 9% have a depressive disorder. 15 A more recent study found even higher rates; at least 50% of participants with ODD had comorbid anxiety or depression. 14 Those with angry and irritable symptoms of ODD are at higher risk of comorbid mood disorders, whereas those with argumentative, defiant, and vindictive symptoms are at higher risk of conduct disorder. 16

Which Behavioral Treatments Are Effective?

Individualized treatment plans by mental health professionals for both the child and family are the most effective. Behavioral parenting interventions are first-line therapy in younger children. In adolescence, individual therapy takes a more prominent role, but outcomes are better when parents are involved. Early intervention may help prevent other disorders, such as conduct disorder, substance abuse, and delinquency .

Child-based therapy often focuses on problem-solving skills, whereas parent training (parent management therapy) focuses on how to respond to the child's behavior. Parent management therapy aims to help parents manage disruptive behavior by decreasing unintentional positive reinforcement of disruptive behaviors, to help them understand appropriate consequences and punishments for disruptive behaviors, and to help them make their response timely, predictable, and appropriate. Overall, the goal is for parents to be more positive and less harsh. 6 A 2012 Cochrane review found that group parenting interventions based on behavioral therapy and cognitive behavior therapy (CBT) are effective and cost-effective for improving child conduct problems, parental mental health, and parenting skills in the short term. 18 Group CBT for children has also been found to decrease aggressive behaviors. 19

Collaborative problem solving, in which parents and children work together, is another effective technique for treating ODD. 20 A 2015 trial found collaborative problem solving to be as effective as parent management therapy. 21 In both treatment arms, 50% of children no longer met criteria for ODD after six months.

Can Pharmacologic Treatment Help?

Medications are not recommended as first-line treatment for ODD, but they may be helpful in some situations when used in conjunction with behavioral interventions. Treatment of comorbid conditions often improves symptoms of ODD . 6 Mood stabilizers and atypical antipsychotics may be helpful for aggressive behaviors, but have limited data for ODD .

Stimulants can help improve oppositional symptoms in persons with comorbid ADHD, whereas atomoxetine (Strattera) has mixed evidence for reduction of ODD symptoms. 22 , 23 Clonidine has also proved effective in managing concomitant ADHD and ODD. 24

Antidepressant therapy in persons with concomitant depression and ODD can help both disorders. One study found that fluoxetine (Prozac), with or without CBT, improves comorbid ODD. 25 Fluoxetine plus CBT was superior to CBT alone, but ODD symptoms improved in all treated groups.

The broader literature on conduct disorder suggests that mood stabilizers and atypical antipsychotics may be helpful for managing aggressive behavior. A 2012 Cochrane review found limited evidence that atypical antipsychotics help with aggression and conduct problems in children five to 18 years of age. 26 The evidence was strongest for risperidone (Risperdal), and there was no evidence to support the use of quetiapine (Seroquel) in this population.

What Is the Natural History of ODD?

ODD does not have a consistent course. Symptoms often resolve by early adulthood, although other mental health problems, such as mood disorders and social impairment, may persist or develop .

The normal course of ODD is not well defined. One study showed that 70% of persons with ODD had symptom resolution by 18 years of age. 14 However, ODD can persist into adulthood, and earlier onset of symptoms and male sex predict more severe psychopathology. 6 , 14

Environmental factors such as family instability, low may increase the risk of conduct disorder in persons with ODD. 2 , 4 Because antisocial personality disorder is considered a more severe adult form of conduct disorder, children with ODD and comorbid conduct disorder are at risk of developing antisocial personality disorder. 6

Adults and adolescents with a history of ODD have a greater than 90% chance of being diagnosed with another mental illness in their lifetime. 14 They are at high risk of social and emotional problems as adults, including suicide. They also have a higher risk of mood disorders, such as anxiety, depression, and bipolar disorder, and high rates of substance use disorders. 2 , 17 , 27 , 28 Early intervention is aimed at preventing the development of conduct disorder, substance abuse, and delinquency that can cause lifelong social, occupational, and academic impairments.

Can ODD Be Prevented?

Programs that improve social skills, conflict resolution, and anger management in preschool-aged children to adolescents can reduce the risk of ODD. These programs are often embedded in existing community programs that serve high-risk youth, such as Head Start, or in elementary or secondary school curricula .

Integrating behavioral programs for preventing conduct problems into existing programs such as Head Start has had a positive impact. One example, the Incredible Years program ( http://www.incredibleyears.com ), has been found to improve social competence and emotional self-regulation and decrease conduct issues. This program has content for parents, children, educators, and clinicians. 29 , 30 Other programs for adolescents concentrate on CBT-based interventions, skills training, vocational training, and academic preparation. A comprehensive list of programs and resources is available on the American Academy of Child and Adolescent Psychiatry's website ( https://www.aacap.org/aacap/Families_and_Youth/Resource_Centers/Oppositional_Defiant_Disorder_Resource_Center/Home.aspx ). 6 , 31

Data Sources : A PubMed search was completed in Clinical Queries using the key term oppositional defiant disorder. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. A search was also performed using Essential Evidence Plus. Search dates: January 2015 through December 2015.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders . 5th ed. Washington, DC: American Psychiatric Association; 2013.

Rowe R, Costello EJ, Angold A, Copeland WE, Maughan B. Developmental pathways in oppositional defiant disorder and conduct disorder. J Abnorm Psychol. 2010;119(4):726-738.

Canino G, Polanczyk G, Bauermeister JJ, Rohde LA, Frick PJ. Does the prevalence of CD and ODD vary across cultures?. Soc Psychiatry Psychiatr Epidemiol. 2010;45(7):695-704.

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.

Boylan K, Vaillancourt T, Boyle M, Szatmari P. Comorbidity of internalizing disorders in children with oppositional defiant disorder. Eur Child Adolesc Psychiatry. 2007;16(8):484-494.

Steiner H, Remsing L 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.

Tiesler CM, Heinrich J. Prenatal nicotine exposure and child behavioural problems. Eur Child Adolesc Psychiatry. 2014;23(10):913-929.

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.

Speltz ML, Coy K, DeKlyen M, Smith C, Jones K, Greenberg MT. Early-onset oppositional defiant disorder: what factors predict its course?. Semin Clin Neuropsychiatry. 1998;3(4):302-319.

Tung I, Lee SS. Negative parenting behavior and childhood oppositional defiant disorder: differential moderation by positive and negative peer regard. Aggress Behav. 2014;40(1):79-90.

Smith JD, Dishion TJ, Shaw DS, Wilson MN, Winter CC, Patterson GR. Coercive family process and early-onset conduct problems from age 2 to school entry. Dev Psychopathol. 2014;26(4 pt 1):917-932.

Frick PJ, Nigg JT. Current issues in the diagnosis of attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder. Annu Rev Clin Psychol. 2012;8:77-107.

Becker SP, Langberg JM, Vaughn AJ, Epstein JN. Clinical utility of the Vanderbilt ADHD diagnostic parent rating scale comorbidity screening scales. J Dev Behav Pediatr. 2012;33(3):221-228.

Nock MK, Kazdin AE, Hiripi E, Kessler RC. Lifetime prevalence, correlates, and persistence of oppositional defiant disorder: results from the National Comorbidity Survey Replication. J Child Psychol Psychiatry. 2007;48(7):703-713.

Angold A, Costello EJ, Erkanli A. Comorbidity. J Child Psychol Psychiatry. 1999;40(1):57-87.

Stringaris A, Goodman R. Longitudinal outcome of youth oppositionality: irritable, headstrong, and hurtful behaviors have distinctive predictions. J Am Acad Child Adolesc Psychiatry. 2009;48(4):404-412.

Connor DF, Steeber J, McBurnett K. A review of attention-deficit/hyperactivity disorder complicated by symptoms of oppositional defiant disorder or conduct disorder. J Dev Behav Pediatr. 2010;31(5):427-440.

Furlong M, McGilloway S, Bywater T, Hutchings J, Smith SM, Donnelly M. Behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years. Cochrane Database Syst Rev. 2012(2):CD008225.

Goertz-Dorten A, Benesch C, Hautmann C, et al. Efficacy of an individualized social competence training for children with oppositional defiant disorders/conduct disorders. Psychother Res. 2015:1-12.

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.

Ollendick TH, Greene RW, Austin KE, et al. Parent management training and collaborative & proactive solutions: a randomized control trial for oppositional youth. J Clin Child Adolesc Psychol. 2015:1-14.

Blader JC, Pliszka SR, Jensen PS, Schooler NR, Kafantaris V. Stimulant-responsive and stimulant-refractory aggressive behavior among children with ADHD. Pediatrics. 2010;126(4):e796-e806.

Dittmann RW, Schacht A, Helsberg K, et al. Atomoxetine versus placebo in children and adolescents with attention-deficit/hyperactivity disorder and comorbid oppositional defiant disorder: a double-blind, randomized, multicenter trial in Germany. J Child Adolesc Psychopharmacol. 2011;21(2):97-110.

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.

Jacobs RH, Becker-Weidman EG, Reinecke MA, et al. Treating depression and oppositional behavior in adolescents. J Clin Child Adolesc Psychol. 2010;39(4):559-567.

Loy JH, Merry SN, Hetrick SE, Stasiak K. Atypical antipsychotics for disruptive behaviour disorders in children and youths. Cochrane Database Syst Rev. 2012;9:CD008559.

Copeland WE, Shanahan L, Costello EJ, Angold A. Childhood and adolescent psychiatric disorders as predictors of young adult disorders. Arch Gen Psychiatry. 2009;66(7):764-772.

Harpold T, Biederman J, Gignac M, et al. Is oppositional defiant disorder a meaningful diagnosis in adults? Results from a large sample of adults with ADHD. J Nerv Ment Dis. 2007;195(7):601-605.

Webster-Stratton C, Reid MJ, Hammond M. Preventing conduct problems, promoting social competence: a parent and teacher training partnership in head start. J Clin Child Psychol. 2001;30(3):283-302.

Webster-Stratton C, Jamila Reid M, Stoolmiller M. Preventing conduct problems and improving school readiness: evaluation of the Incredible Years Teacher and Child Training Programs in high-risk schools. J Child Psychol Psychiatry. 2008;49(5):471-488.

American Academy of Child and Adolescent Psychiatry. Oppositional defiant disorder resource center. https://www.aacap.org/aacap/Families_and_Youth/Resource_Centers/Oppositional_Defiant_Disorder_Resource_Center/Home.aspx . Accessed September 9, 2015.

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• Patient Care & Health Information
• Diseases & Conditions
• 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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“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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Download or Stream the Podcast Audio

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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• Collaborative Problem Solving® »

Collaborative Problem Solving® (CPS)

At Think:Kids, we recognize that kids with challenging behavior don’t lack the will  to behave well. They lack the  skills  to behave well.

Our Collaborative Problem Solving (CPS) approach is proven to reduce challenging behavior, teach kids the skills they lack, and build relationships with the adults in their lives.

Anyone can learn Collaborative Problem Solving, and we’re here to help.

What is Collaborative Problem Solving?

Kids with challenging behavior are tragically misunderstood and mistreated. Rewards and punishments don’t work and often make things worse. Thankfully, there’s another way. But it requires a big shift in mindset.

Helping kids with challenging behavior requires understanding why they struggle in the first place. But what if everything we thought was true about challenging behavior was actually wrong? Our Collaborative Problem Solving approach recognizes what research has pointed to for years – that kids with challenging behavior are already trying hard. They don’t lack the will to behave well. They lack the skills to behave well.

Learn More About the CPS Approach

Kids do well if they can.

CPS helps adults shift to a more accurate and compassionate mindset and embrace the truth that kids do well if they can – rather than the more common belief that kids would do well if they simply wanted to.

Flowing from this simple but powerful philosophy, CPS focuses on building skills like flexibility, frustration tolerance and problem solving, rather than simply motivating kids to behave better. The process begins with identifying triggers to a child’s challenging behavior and the specific skills they need help developing.  The next step involves partnering with the child to build those skills and develop lasting solutions to problems that work for everyone.

The CPS approach was developed at Massachusetts General Hospital a top-ranked Department of Psychiatry in the United States.  It is proven to reduce challenging behavior, teach kids the skills they lack, and build relationships with the adults in their lives. If you’re looking for a more accurate, compassionate, and effective approach, you’ve come to the right place. Fortunately, anyone can learn CPS. Let’s get started!

Bring CPS to Your Organization

Attend a cps training.

6 out of 10 teachers report reduced stress.

Significant reductions in parents’ stress.

74% average reduction in use of seclusion.

73% reduction in oppositional behaviors during school.

Parents report improvements in parent-child interactions.

71% fewer self-inflicted injuries.

reduction in school office referrals.

Significant improvements in children’s executive functioning skills.

60% of children exhibited improved behavior 

Privacy overview.

The California Evidence-Based Clearinghouse for Child Welfare

• Contact the CEBC
• Sign up for The CEBC Connection
• Topic Areas
• Rating Scales
• Implementation-Specific Tools & Resources
• Implementation Guide
• Implementation Examples

Collaborative & Proactive Solutions (CPS)

About this program.

Target Population: Children ages 4-14 who experience oppositional episodes and their parents

For children/adolescents ages: 4 – 14

For parents/caregivers of children ages: 4 – 14

Program Overview

CPS is a treatment model that is designed to help parents/caregivers and children learn to collaboratively and proactively solve the problems that contribute to the children's challenging behaviors, with the goal of improving family communication, cohesion, and relationships. It is made up of four modules that teach parents: (a) to identify lagging skills and unsolved problems that contribute to oppositional episodes; (b) to prioritize which unsolved problems to focus on first; (c) about the Plans framework—the three potential responses to solving problems: Plan A (solving a problem unilaterally, by imposing the adult will), Plan B (solving a problem collaboratively and proactively), and Plan C (setting aside the problem for now); and (d) how to implement Plan B with their child by gathering information from the child to get a clear understanding of their concern or perspective, defining the adult concern on the same unsolved problem, and finally having the child and adult brainstorm solutions to arrive at a plan of action that is both realistic and mutually satisfactory. The clinician actively guides the initial problem-solving process, however, the goal of treatment is to help the child and parents become independent in solving problems together. In general, parent(s) and child are in attendance at all of the sessions, although there are times when a clinician may feel that it would be beneficial to discuss certain issues with the child or parent(s) individually.

Program Goals

The goal of Collaborative & Proactive Solutions (CPS) is:

• Identify and solve unsolved problems that contribute to oppositional episodes

Logic Model

The program representative did not provide information about a Logic Model for Collaborative & Proactive Solutions (CPS) .

Essential Components

The essential components of Collaborative & Proactive Solutions (CPS) include:

• How to identify lagging skills and unsolved problems that contribute to oppositional episodes
• How to prioritize which unsolved problems to focus on first
• Understanding the Plans frameworks–the three potential responses to solving problems:
• Plan A (solving a problem unilaterally, by imposing the adult will)
• Plan B (solving a problem collaboratively and proactively)
• Plan C (setting aside the problem for now)
• How to use Plan B Including:
• Gathering information about and achieving a clear understanding of the child's concern or perspective on the unsolved problem
• Sharing the concern of the second party (often the adult)
• Generating solutions that are realistic (meaning both parties can do what they are agreeing to) and mutually satisfactory (meaning the solution truly addresses the concerns of both parties)
• Trouble shooting interfering factors (factors interfering with caregivers' capacity to implement Plan B such as disorganization, time, family dysfunction and dynamics, marital issues, and so forth)
• Helping caregivers prepare for the sustained use of Plan B

Program Delivery

Child/adolescent services.

Collaborative & Proactive Solutions (CPS) directly provides services to children/adolescents and addresses the following:

• The problems that are contributing to oppositional behaviors

Parent/Caregiver Services

Collaborative & Proactive Solutions (CPS) directly provides services to parents/caregivers and addresses the following:

• Parents or caregivers of children who have oppositional episodes and may have issues that interfere with effective parenting such as disorganization, lack of time, family dysfuntion and dynamics, or marital issues

Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: Caregivers in other settings may be involved in the problem-solving process if there are oppositional episodes in those settings.

Recommended Intensity:

Typically provided in a flexible, individualized manner during 60-minute weekly sessions

Recommended Duration:

Typically ranges between 7 and 16 weeks with an average length of 11 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 & Proactive Solutions (CPS) includes a homework component:

Families are encouraged to practice solving problems collaboratively independently at home between sessions.

Collaborative & Proactive Solutions (CPS) has materials available in languages other than English :

Bulgarian, Chinese, Danish, Dutch, Finnish, French, German, Hebrew, Italian, Japanese, Korean, Norwegian, Polish, Romanian, Russian, Spanish, Swedish, Turkish, Vietnamese

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:

Meeting space to permit family therapy

Manuals and Training

Prerequisite/minimum provider qualifications.

There is no minimum educational requirement to become a provider. For a clinician or educator to become certified in the CPS model, they must participate in a 24-week CPS training program.

Manual Information

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

Training Information

There is training available for this program.

Training Contact:

• Dr. Ross Greene [email protected]

Training Type/Location:

Much training is provided by teleconference, but also through webinars and onsite training.

Number of days/hours:

Variable, depending on the type of training

Implementation Information

Pre-implementation materials.

There are no pre-implementation materials to measure organizational or provider readiness for Collaborative & Proactive Solutions (CPS) .

Formal Support for Implementation

There is formal support available for implementation of Collaborative & Proactive Solutions (CPS) as listed below:

There are several dozen certified trainers who support implementation of the model in schools and facilities throughout the world. These trainers provide initial training as well as ongoing consultation.

Fidelity Measures

There are no fidelity measures for Collaborative & Proactive Solutions (CPS) .

Implementation Guides or Manuals

There are implementation guides or manuals for Collaborative & Proactive Solutions (CPS) as listed below:

The CPS model is described in the following publications:

Greene, R. W. (2014). The explosive child: A new approach for understanding and parenting easily frustrated, chronically inflexible children . HarperCollins World.

Greene, R. W. (2016). Lost and found . Jossey-Bass.

Greene, R. W. (2014). Lost at school: Why our kids with behavioral challenges are falling through the cracks and how we can help them . Scribner.

• Videos and other supporting materials for implementing CPS are available on the Lives in the Balance website: http://www.livesinthebalance.org/

Research on How to Implement the Program

Research has been conducted on how to implement Collaborative & Proactive Solutions (CPS) as listed below:

• Greene, R. W., Ablon, J. S., Monuteaux, M., Goring, J., Henin, A., Raezer, L., & 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 (6), 1157-1164. https://doi.org/10.1037/0022-006X.72.6.1157
• 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. https://doi.org/10.1176/appi.ps.57.5.610
• 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. https://doi.org/10.1176/appi.ps.59.12.1406
• Ollendick, T. H., Greene, R. W., Austin, K. E., Fraire, M. G., Halldorsdottir, T., Allen, K. B., Jarrett, M. A., Lewis, K. M., Smith, M. W., Cunningham, N. R., Noguchi, R. J. P., Canavera, K., & Wolff, J. C. (2016). Parent Management Training (PMT) and Collaborative & Proactive Solutions: A randomized control trial for oppositional youth. Journal of Clinical Child and Adolescent Psychology 45 (5), 591-604. https://doi.org/10.1080/15374416.2015.1004681

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 youth 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 [now called Collaborative & Proactive Solutions (CPS) ] in affectively dysregulated children with oppositional defiant disorder (ODD). Participants were randomized to 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.

Ollendick, T. H., Greene, R. W., Austin, K. E., Fraire, M. G., Halldorsdottir, T., Allen, K. B., Jarrett, M. A., Lewis, K. M., Whitmore Smith, M., Cunningham, N. R., Noguchi, R. J., Canavera, K., & Wolff, J. C. (2015). Parent Management Training and Collaborative & Proactive Solutions: A randomized control trial for oppositional youth. Journal of Clinical Child & Adolescent Psychology, 45 (5), 591–604. https://doi.org/10.1080/15374416.2015.1004681

Type of Study: Randomized controlled trial Number of Participants: 134

• Age — 7–14 years
• Race/Ethnicity — 84% White
• Gender — 62% Male and 38% Female
• Status — Participants were families with adolescents with oppositional defiant disorder (ODD).

Location/Institution: Rural Southwest Virginia

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to examine the efficacy of Collaborative & Proactive Solutions (CPS) in treating oppositional defiant disorder (ODD) in youth. Participants were randomized to CPS , Parent Management Training (PMT), or a 6-week waitlist control (WLC) group. 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. Measures utilized include the Peabody Picture Vocabulary Test, 4th Edition, the Expressive Vocabulary Test, 2nd Edition, the Anxiety Disorders Interview Schedule for DSM-IV, Child and Parent Versions (ADIS-C/P), the Clinical Global Impression-Severity (CGI-S), the Disruptive Behavior Disorders Rating Scale (DBDRS), the Behavior Assessment System for Children-Second Edition (BASC), the Parent Consumer Satisfaction Questionnaire, and the Clinical Global Impression-Improvement (CGI-I) . Results indicate that both treatment conditions were superior to the WLC condition but did not differ from one another in either 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 posttreatment, 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. Limitations include high attrition rate, lack of generalizability due to sample of largely middle-class Caucasian families, and decision was made to drop the WLC condition because none of the 11 families improved during the wait period.

Length of controlled postintervention follow-up: 6 months.

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 (5), 1623–1633. https://doi.org/10.1007/s10826-015-0323-3

Type of Study: Randomized controlled trial Number of Participants: 123

• Age — 7–14 years (Mean=9.56 years)
• Gender — 76 Male and 47 Female
• Status — Participants were children who met full diagnostic criteria for oppositional defiant disorder (ODD).

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations) The study used a subsample of Ollendick et al. (2015). The purpose of the study was to examine the moderating influence of parent-child relationship quality (as viewed by the child) on associations between conduct problems and treatment responses for children with oppositional defiant disorder (ODD). Participants were randomized to one of two psychosocial treatments: Parent Management Training or Collaborative & Proactive Solutions (CPS) . Measures utilized include the Behavior Assessment System for Children-2nd Edition (BASC-2), the Disruptive Behavior Disorders Rating Scale (DBDRS), the child version of the BASC, and the Anxiety Disorders Interview Schedule, Child and Parent Versions (ADIS-C/P). Results indicate that elevated reports of children’s conduct problems were associated with attenuated reductions in both ODD symptoms and their severity. Perceived relationship quality with parents moderated the ties between conduct problems and outcomes in ODD severity but not the number of symptoms. Mother reports of elevated conduct problems predicted attenuated treatment response only when children viewed relationship quality with their parents as poorer. When children viewed the relationship as higher quality, they did not show an attenuated treatment response, regardless of reported conduct problems. Limitations include the correlation al nature of the study precludes making causal inferences; the extent of family dropout during treatment or before the posttreatment assessment ; considering only the perspective of the child concerning the quality of the parent-child relationship is limiting; a largely middle-class, Caucasian sample of children; and the lack of long-term follow-up on intervention effects.

Length of controlled postintervention follow-up: None.

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 (6), 1880–1888. https://doi.org/10.1007/s10826-015-0356-7

Type of Study: Randomized controlled trial Number of Participants: 75

• Age — 7–12 years (Mean=9.66 years)
• Race/Ethnicity — Families: 80% Caucasian, 9% African American, 5% Hispanic, 3% Asian, and 3% Other
• Gender — 46 Male
• Status — Participants were children who received treatment for oppositional defiant disorder (ODD) and their parents.

Summary: (To include basic study design, measures, results, and notable limitations) The study used a subsample of Ollendick et al. (2015). The purpose of the study was to examine parent–child synchrony, the inverse of parent–child incompatibility as a predictor of children’s emotional lability, aggression, and overall functioning following psychosocial treatment. Participants received one of two empirically supported treatments for oppositional defiant disorder (ODD), Parent Management Training or Collaborative and Proactive Solutions (CPS) . Measures utilized include the Anxiety Disorder Interview Schedule, Fourth Edition (ADIS-IV), the Emotion Talk Task, and the Behavior Assessment System for Children, Second Edition (BASC-2) . Results indicate that pretreatment parent–child synchrony was associated with decreased emotional lability and aggression following both treatments, as well as improvement in overall functioning, irrespective of treatment condition. Limitations include lack of follow-up, an abundance of missing data, a mostly Caucasian sample, and did not measure the effects of treatment in school settings.

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 , 27 (8), 2552–2561. https://doi.org/10.1007/s10826-018-1089-1

• Gender — 38% Female
• Status — Participants were children with oppositional defiant disorder (ODD) and their parents.

Summary: (To include basic study design, measures, results, and notable limitations) The study used the same sample as Ollendick et al. (2015). The purpose of the study was to predict change in maternal stress over the course of a randomized clinical trial comparing the efficacy of two interventions for oppositional defiant disorder (ODD): Parent Management Training and Collaborative & Proactive Solutions (CPS) . Participants were randomized to CPS , Parent Management Training (PMT), or a 6-week waitlist control (WLC) group. Measures utilized include the Anxiety Disorders Interview Schedule for DSM-IV-Child and Parent Versions (ADIS-IV-C/P), the Behavior Assessment System for Children, Second Edition (BASC-2), and the Parenting Stress Index-Short Form (PSI-SF) . Results indicate that hypothesized indirect effects were supported such that children’s reports of positive views toward parents uniquely predicted reductions in ODD severity over time, which in turn uniquely predicted reductions in maternal stress. Limitations include limited diversity in family ethnicity and socioeconomic status, considerable family drop-out at follow up periods, and reports of parenting stress were limited to mothers and restricted to self-reports.

Length of controlled postintervention follow-up: 1 week and 6 months.

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. https://doi.org/10.1080/15374416.2017.1286594

• Status — Participants were clinic-referred youth who met DSM-IV criteria for oppositional defiant disorder (ODD).

Summary: (To include basic study design, measures, results, and notable limitations) The study used the same sample as Ollendick et al. (2015). The purpose of the study was to examine multiple conceptualizations of oppositional defiant disorder (ODD); whether children showed improvements across these ODD dimensions; and whether main and joint effects of ODD dimension improvement predicted clinical outcome. Participants were randomized to receive one of two psychosocial treatments, Parent Management Training or Collaborative & Proactive Solutions (CPS) . Measures utilized include the Anxiety Disorders Interview Schedule for DSM-IV, Child and Parent Versions—(ADIS-C/P), the Clinical Global Impression – Severity and Improvement — (CGI-S and CGI-I), and the Behavior Assessment System for Children-2—(BASC-2) . Results indicate that one- and two-factor conceptualizations were supported, however, the two-factor solution was preferred. With this solution, each dimension significantly and similarly improved across treatment conditions. Improvements across affective and behavioral ODD factors also had significant effects on clinician- and mother-reported clinical outcomes. Limitations include high attrition rate and lack of generalizability due to sample of largely Caucasian families.

Booker J. A., Capriola-Hall N. N., Greene, R. W., & Ollendick, T. H. (2020). The parent–child relationship and posttreatment child outcomes across two treatments for oppositional defiant disorder. Journal of Clinical Child & Adolescent Psychology , 49 (3), 405–419. https://doi.org/10.1080/15374416.2018.1555761

Summary: (To include basic study design, measures, results, and notable limitations) The study used the same sample as Ollendick et al. (2015). The purpose of the study was to examine the degree to which the parent–child relationship uniquely predicted clinical outcomes in externalizing problems and adaptive skills. Participants were randomized to either 1 of 2 treatments: Parent Management Training (PMT) and Collaborative and Proactive Solutions (CPS) . Measures utilized include the Tangram Puzzle Task and the Alabama Parenting Questionnaire at baseline and the Behavior Assessment System For Children, Second Edition (BASC‐2) at baseline, posttreatment, and six months following treatment. Results indicate that four principal components were supported (parental warmth, parental monitoring, family hostility, and family permissiveness). Parental monitoring predicted fewer externalizing problems, whereas family permissiveness predicted more externalizing problems. Parental warmth predicted greatest improvements in children’s adaptive skills among families receiving PMT. Family hostility predicted more externalizing problems and poorer adaptive skills for children, however, families receiving CPS were buffered from the negative effect of family hostility on adaptive skills. Limitations include a reliance on data imputation due to attrition , demographic homogeneity of the sample, as well as using PMT with a sample that extends into early adolescence (13–14 years) may have been problematic.

Murrihy, R. C., Drysdale, S. A. O., Dedousis-Wallace, A., Remond, L., McAloon, J., Ellis, D. M., Halldorsdottir, T., Greene, R. W., & Ollendick, T. H. (2023). Community-delivered Collaborative and Proactive Solutions and Parent Management Training for oppositional youth: A randomized trial. Behavior Therapy, 54 (2), 400–417. https://doi.org/10.1016/j.beth.2022.10.005

Type of Study: Randomized controlled trial Number of Participants: 160

• Age — Youth: 7–14 years; Adults: Not specified
• Race/Ethnicity — Youth: Not specified White; Adults (mother only): 91 Australian, 29 European (Western, Northern, Southern), 10 Asian, 7 African, 7 European (Eastern), 5 Central/South American, 3 NZ/Maori/Pacific Island, and 1 North American
• Gender — Youth: 115 Male, 45 Female; Adults: Not specified
• Status — Participants were youth with oppositional defiant disorder (ODD) and their parents.

Location/Institution: North Sydney, Australia

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to examine the relative effectiveness of Collaborative and Proactive Solutions (CPS) and Parent Management Training (PMT) for youth with oppositional defiant disorder (ODD) in a community setting. Participants were randomized to CPS or PMT for up to 16 weekly sessions. Measures utilized include the Anxiety Disorders Interview Schedule for DSM-IV, Child and Parent Versions (ADIS-IV-C/P), the Disruptive Behavior Disorders Rating Scale (DBDRS), and the Clinical Global Impression Scale (CGI) . Results indicate that both treatments demonstrated similar outcomes, with 45–50% of youth in the nonclinical range after treatment, and 67% considered much improved. No differences were found between groups, and group equivalency was shown on the independent clinician and parent rated measures. Gains were maintained at the 6-month follow-up. Limitations include the omission of a treatment as usual (TAU) group; exclusion of youth with CD, ASD, developmental delay, high suicidality and substance abuse; and an unequal ratio of experienced clinical psychologists across treatment conditions.

Dedousis-Wallace, A., Drysdale, S. A. O., McAloon, J., Murrihy, R. C., Greene, R. W., & Ollendick, T. H. (2022). Predictors and moderators of two treatments of oppositional defiant disorder in children. Journal of Child and Adolescent Psychology. Advance online publication. https://doi.org/10.1080/15374416.2022.2127102

Type of Study: Randomized controlled trial Number of Participants: 145

• Age — 7–14 years (Mean=8.88 years)
• Race/Ethnicity — 56% Australian, 21% European, 6% Asian, 5% African, 4% Central American, 2% New Zealand ,1% North American
• Gender — 103 Male

Summary: (To include basic study design, measures, results, and notable limitations) The study used the same sample as Murrihy et al. (2023). The purpose of the study was to examine predictors and moderators of behavioral improvement in children with oppositional defiant disorder (ODD) following treatment with Parent Management Training (PMT) and Collaborative and Proactive Solutions (CPS) . Participants were randomized to CPS or PMT. Measures utilized include the Anxiety Disorders Interview Schedule for DSM-IV, Child and Parent Versions (ADIS-IV-C/P), the Disruptive Behavior Disorders Rating Scale (DBDRS), the Inconsistent Discipline subscale from the Alabama Parenting Questionnaire – Short Form (APQ-SF), and the Child Responsible Attributions (CRA) 10-item subscale from the Parent Cognition Scale (PCS) . Results indicate that higher pre-treatment levels of conduct problems, lagging skills, and inconsistent discipline predicted poorer behavioral outcomes following both treatments. The only characteristic that moderated treatment outcome was child-responsible attributions – mothers who were more likely to attribute their child’s problematic behaviors to factors in the child had significantly poorer outcomes in PMT than CPS at 6-month follow-up. Limitations include demographic homogeneity of the sample, study could be further strengthened by including a multi-informant method of measuring changes in child conduct problems, and the drop-out rates at post-assessment (19%) and at 6-month follow-up (30%).

Mulraney, M., Sciberras, E., Payne, J. M., 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. https://doi.org/10.1080/13284207.2022.2041983

Type of Study: Randomized controlled trial Number of Participants: 12

• Age — Youth: 9–14 years (Mean=8.88 years); Adults: Mean=42.9–44.2 years
• Gender — Youth: 42 Male; Adults: Not specified
• Status — Participants were youth with exhibited severe and impairing irritability and their parents.

Location/Institution: Child and Adolescent Mental Health Service (CAMHS) at The Royal Children’s Hospital, Melbourne

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to evaluate the acceptability and feasibility of a psychological intervention to manage severe irritability in children and adolescents. Participants were randomized to Collaborative and Proactive Solutions (CPS) or treatment as usual. Measures utilized include the Development and Well-Being Assessment (DAWBA), the Clinical Global Impression – Severity, the Pediatric Quality of Life Inventory 4.0 Generic Core Scales, the Affective Reactivity Index, the Child Health Utility-9D (CHU-9D), the Behavior Rating Inventory of Executive Functioning, the Short Moods and Feelings Questionnaire, the Spence Child Anxiety Scale, the Swan, Nolan and Pelham Parent Rating Scale IV, the McMaster Family Assessment Device, and the Kessler 6 (K6) . Results indicate that compared to usual care, the CPS group had improvements in child irritability, quality of life, executive functioning, and family functioning. Limitations include small sample size and lack of follow-up.

Additional References

Contact information.

Date Research Evidence Last Reviewed by CEBC: June 2023

Date Program Content Last Reviewed by Program Staff: March 2020

Date Program Originally Loaded onto CEBC: May 2017

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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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• Published: 11 January 2023

The effectiveness of collaborative problem solving in promoting students’ critical thinking: A meta-analysis based on empirical literature

• Enwei Xu   ORCID: orcid.org/0000-0001-6424-8169 1 ,
• Wei Wang 1 &
• Qingxia Wang 1  

Humanities and Social Sciences Communications volume  10 , Article number:  16 ( 2023 ) Cite this article

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Collaborative problem-solving has been widely embraced in the classroom instruction of critical thinking, which is regarded as the core of curriculum reform based on key competencies in the field of education as well as a key competence for learners in the 21st century. However, the effectiveness of collaborative problem-solving in promoting students’ critical thinking remains uncertain. This current research presents the major findings of a meta-analysis of 36 pieces of the literature revealed in worldwide educational periodicals during the 21st century to identify the effectiveness of collaborative problem-solving in promoting students’ critical thinking and to determine, based on evidence, whether and to what extent collaborative problem solving can result in a rise or decrease in critical thinking. The findings show that (1) collaborative problem solving is an effective teaching approach to foster students’ critical thinking, with a significant overall effect size (ES = 0.82, z  = 12.78, P  < 0.01, 95% CI [0.69, 0.95]); (2) in respect to the dimensions of critical thinking, collaborative problem solving can significantly and successfully enhance students’ attitudinal tendencies (ES = 1.17, z  = 7.62, P  < 0.01, 95% CI[0.87, 1.47]); nevertheless, it falls short in terms of improving students’ cognitive skills, having only an upper-middle impact (ES = 0.70, z  = 11.55, P  < 0.01, 95% CI[0.58, 0.82]); and (3) the teaching type (chi 2  = 7.20, P  < 0.05), intervention duration (chi 2  = 12.18, P  < 0.01), subject area (chi 2  = 13.36, P  < 0.05), group size (chi 2  = 8.77, P  < 0.05), and learning scaffold (chi 2  = 9.03, P  < 0.01) all have an impact on critical thinking, and they can be viewed as important moderating factors that affect how critical thinking develops. On the basis of these results, recommendations are made for further study and instruction to better support students’ critical thinking in the context of collaborative problem-solving.

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Introduction.

Although critical thinking has a long history in research, the concept of critical thinking, which is regarded as an essential competence for learners in the 21st century, has recently attracted more attention from researchers and teaching practitioners (National Research Council, 2012 ). Critical thinking should be the core of curriculum reform based on key competencies in the field of education (Peng and Deng, 2017 ) because students with critical thinking can not only understand the meaning of knowledge but also effectively solve practical problems in real life even after knowledge is forgotten (Kek and Huijser, 2011 ). The definition of critical thinking is not universal (Ennis, 1989 ; Castle, 2009 ; Niu et al., 2013 ). In general, the definition of critical thinking is a self-aware and self-regulated thought process (Facione, 1990 ; Niu et al., 2013 ). It refers to the cognitive skills needed to interpret, analyze, synthesize, reason, and evaluate information as well as the attitudinal tendency to apply these abilities (Halpern, 2001 ). The view that critical thinking can be taught and learned through curriculum teaching has been widely supported by many researchers (e.g., Kuncel, 2011 ; Leng and Lu, 2020 ), leading to educators’ efforts to foster it among students. In the field of teaching practice, there are three types of courses for teaching critical thinking (Ennis, 1989 ). The first is an independent curriculum in which critical thinking is taught and cultivated without involving the knowledge of specific disciplines; the second is an integrated curriculum in which critical thinking is integrated into the teaching of other disciplines as a clear teaching goal; and the third is a mixed curriculum in which critical thinking is taught in parallel to the teaching of other disciplines for mixed teaching training. Furthermore, numerous measuring tools have been developed by researchers and educators to measure critical thinking in the context of teaching practice. These include standardized measurement tools, such as WGCTA, CCTST, CCTT, and CCTDI, which have been verified by repeated experiments and are considered effective and reliable by international scholars (Facione and Facione, 1992 ). In short, descriptions of critical thinking, including its two dimensions of attitudinal tendency and cognitive skills, different types of teaching courses, and standardized measurement tools provide a complex normative framework for understanding, teaching, and evaluating critical thinking.

Cultivating critical thinking in curriculum teaching can start with a problem, and one of the most popular critical thinking instructional approaches is problem-based learning (Liu et al., 2020 ). Duch et al. ( 2001 ) noted that problem-based learning in group collaboration is progressive active learning, which can improve students’ critical thinking and problem-solving skills. Collaborative problem-solving is the organic integration of collaborative learning and problem-based learning, which takes learners as the center of the learning process and uses problems with poor structure in real-world situations as the starting point for the learning process (Liang et al., 2017 ). Students learn the knowledge needed to solve problems in a collaborative group, reach a consensus on problems in the field, and form solutions through social cooperation methods, such as dialogue, interpretation, questioning, debate, negotiation, and reflection, thus promoting the development of learners’ domain knowledge and critical thinking (Cindy, 2004 ; Liang et al., 2017 ).

Collaborative problem-solving has been widely used in the teaching practice of critical thinking, and several studies have attempted to conduct a systematic review and meta-analysis of the empirical literature on critical thinking from various perspectives. However, little attention has been paid to the impact of collaborative problem-solving on critical thinking. Therefore, the best approach for developing and enhancing critical thinking throughout collaborative problem-solving is to examine how to implement critical thinking instruction; however, this issue is still unexplored, which means that many teachers are incapable of better instructing critical thinking (Leng and Lu, 2020 ; Niu et al., 2013 ). For example, Huber ( 2016 ) provided the meta-analysis findings of 71 publications on gaining critical thinking over various time frames in college with the aim of determining whether critical thinking was truly teachable. These authors found that learners significantly improve their critical thinking while in college and that critical thinking differs with factors such as teaching strategies, intervention duration, subject area, and teaching type. The usefulness of collaborative problem-solving in fostering students’ critical thinking, however, was not determined by this study, nor did it reveal whether there existed significant variations among the different elements. A meta-analysis of 31 pieces of educational literature was conducted by Liu et al. ( 2020 ) to assess the impact of problem-solving on college students’ critical thinking. These authors found that problem-solving could promote the development of critical thinking among college students and proposed establishing a reasonable group structure for problem-solving in a follow-up study to improve students’ critical thinking. Additionally, previous empirical studies have reached inconclusive and even contradictory conclusions about whether and to what extent collaborative problem-solving increases or decreases critical thinking levels. As an illustration, Yang et al. ( 2008 ) carried out an experiment on the integrated curriculum teaching of college students based on a web bulletin board with the goal of fostering participants’ critical thinking in the context of collaborative problem-solving. These authors’ research revealed that through sharing, debating, examining, and reflecting on various experiences and ideas, collaborative problem-solving can considerably enhance students’ critical thinking in real-life problem situations. In contrast, collaborative problem-solving had a positive impact on learners’ interaction and could improve learning interest and motivation but could not significantly improve students’ critical thinking when compared to traditional classroom teaching, according to research by Naber and Wyatt ( 2014 ) and Sendag and Odabasi ( 2009 ) on undergraduate and high school students, respectively.

The above studies show that there is inconsistency regarding the effectiveness of collaborative problem-solving in promoting students’ critical thinking. Therefore, it is essential to conduct a thorough and trustworthy review to detect and decide whether and to what degree collaborative problem-solving can result in a rise or decrease in critical thinking. Meta-analysis is a quantitative analysis approach that is utilized to examine quantitative data from various separate studies that are all focused on the same research topic. This approach characterizes the effectiveness of its impact by averaging the effect sizes of numerous qualitative studies in an effort to reduce the uncertainty brought on by independent research and produce more conclusive findings (Lipsey and Wilson, 2001 ).

This paper used a meta-analytic approach and carried out a meta-analysis to examine the effectiveness of collaborative problem-solving in promoting students’ critical thinking in order to make a contribution to both research and practice. The following research questions were addressed by this meta-analysis:

What is the overall effect size of collaborative problem-solving in promoting students’ critical thinking and its impact on the two dimensions of critical thinking (i.e., attitudinal tendency and cognitive skills)?

How are the disparities between the study conclusions impacted by various moderating variables if the impacts of various experimental designs in the included studies are heterogeneous?

This research followed the strict procedures (e.g., database searching, identification, screening, eligibility, merging, duplicate removal, and analysis of included studies) of Cooper’s ( 2010 ) proposed meta-analysis approach for examining quantitative data from various separate studies that are all focused on the same research topic. The relevant empirical research that appeared in worldwide educational periodicals within the 21st century was subjected to this meta-analysis using Rev-Man 5.4. The consistency of the data extracted separately by two researchers was tested using Cohen’s kappa coefficient, and a publication bias test and a heterogeneity test were run on the sample data to ascertain the quality of this meta-analysis.

Data sources and search strategies

There were three stages to the data collection process for this meta-analysis, as shown in Fig. 1 , which shows the number of articles included and eliminated during the selection process based on the statement and study eligibility criteria.

This flowchart shows the number of records identified, included and excluded in the article.

First, the databases used to systematically search for relevant articles were the journal papers of the Web of Science Core Collection and the Chinese Core source journal, as well as the Chinese Social Science Citation Index (CSSCI) source journal papers included in CNKI. These databases were selected because they are credible platforms that are sources of scholarly and peer-reviewed information with advanced search tools and contain literature relevant to the subject of our topic from reliable researchers and experts. The search string with the Boolean operator used in the Web of Science was “TS = (((“critical thinking” or “ct” and “pretest” or “posttest”) or (“critical thinking” or “ct” and “control group” or “quasi experiment” or “experiment”)) and (“collaboration” or “collaborative learning” or “CSCL”) and (“problem solving” or “problem-based learning” or “PBL”))”. The research area was “Education Educational Research”, and the search period was “January 1, 2000, to December 30, 2021”. A total of 412 papers were obtained. The search string with the Boolean operator used in the CNKI was “SU = (‘critical thinking’*‘collaboration’ + ‘critical thinking’*‘collaborative learning’ + ‘critical thinking’*‘CSCL’ + ‘critical thinking’*‘problem solving’ + ‘critical thinking’*‘problem-based learning’ + ‘critical thinking’*‘PBL’ + ‘critical thinking’*‘problem oriented’) AND FT = (‘experiment’ + ‘quasi experiment’ + ‘pretest’ + ‘posttest’ + ‘empirical study’)” (translated into Chinese when searching). A total of 56 studies were found throughout the search period of “January 2000 to December 2021”. From the databases, all duplicates and retractions were eliminated before exporting the references into Endnote, a program for managing bibliographic references. In all, 466 studies were found.

Second, the studies that matched the inclusion and exclusion criteria for the meta-analysis were chosen by two researchers after they had reviewed the abstracts and titles of the gathered articles, yielding a total of 126 studies.

Third, two researchers thoroughly reviewed each included article’s whole text in accordance with the inclusion and exclusion criteria. Meanwhile, a snowball search was performed using the references and citations of the included articles to ensure complete coverage of the articles. Ultimately, 36 articles were kept.

Two researchers worked together to carry out this entire process, and a consensus rate of almost 94.7% was reached after discussion and negotiation to clarify any emerging differences.

Eligibility criteria

Since not all the retrieved studies matched the criteria for this meta-analysis, eligibility criteria for both inclusion and exclusion were developed as follows:

The publication language of the included studies was limited to English and Chinese, and the full text could be obtained. Articles that did not meet the publication language and articles not published between 2000 and 2021 were excluded.

The research design of the included studies must be empirical and quantitative studies that can assess the effect of collaborative problem-solving on the development of critical thinking. Articles that could not identify the causal mechanisms by which collaborative problem-solving affects critical thinking, such as review articles and theoretical articles, were excluded.

The research method of the included studies must feature a randomized control experiment or a quasi-experiment, or a natural experiment, which have a higher degree of internal validity with strong experimental designs and can all plausibly provide evidence that critical thinking and collaborative problem-solving are causally related. Articles with non-experimental research methods, such as purely correlational or observational studies, were excluded.

The participants of the included studies were only students in school, including K-12 students and college students. Articles in which the participants were non-school students, such as social workers or adult learners, were excluded.

The research results of the included studies must mention definite signs that may be utilized to gauge critical thinking’s impact (e.g., sample size, mean value, or standard deviation). Articles that lacked specific measurement indicators for critical thinking and could not calculate the effect size were excluded.

Data coding design

In order to perform a meta-analysis, it is necessary to collect the most important information from the articles, codify that information’s properties, and convert descriptive data into quantitative data. Therefore, this study designed a data coding template (see Table 1 ). Ultimately, 16 coding fields were retained.

The designed data-coding template consisted of three pieces of information. Basic information about the papers was included in the descriptive information: the publishing year, author, serial number, and title of the paper.

The variable information for the experimental design had three variables: the independent variable (instruction method), the dependent variable (critical thinking), and the moderating variable (learning stage, teaching type, intervention duration, learning scaffold, group size, measuring tool, and subject area). Depending on the topic of this study, the intervention strategy, as the independent variable, was coded into collaborative and non-collaborative problem-solving. The dependent variable, critical thinking, was coded as a cognitive skill and an attitudinal tendency. And seven moderating variables were created by grouping and combining the experimental design variables discovered within the 36 studies (see Table 1 ), where learning stages were encoded as higher education, high school, middle school, and primary school or lower; teaching types were encoded as mixed courses, integrated courses, and independent courses; intervention durations were encoded as 0–1 weeks, 1–4 weeks, 4–12 weeks, and more than 12 weeks; group sizes were encoded as 2–3 persons, 4–6 persons, 7–10 persons, and more than 10 persons; learning scaffolds were encoded as teacher-supported learning scaffold, technique-supported learning scaffold, and resource-supported learning scaffold; measuring tools were encoded as standardized measurement tools (e.g., WGCTA, CCTT, CCTST, and CCTDI) and self-adapting measurement tools (e.g., modified or made by researchers); and subject areas were encoded according to the specific subjects used in the 36 included studies.

The data information contained three metrics for measuring critical thinking: sample size, average value, and standard deviation. It is vital to remember that studies with various experimental designs frequently adopt various formulas to determine the effect size. And this paper used Morris’ proposed standardized mean difference (SMD) calculation formula ( 2008 , p. 369; see Supplementary Table S3 ).

Procedure for extracting and coding data

According to the data coding template (see Table 1 ), the 36 papers’ information was retrieved by two researchers, who then entered them into Excel (see Supplementary Table S1 ). The results of each study were extracted separately in the data extraction procedure if an article contained numerous studies on critical thinking, or if a study assessed different critical thinking dimensions. For instance, Tiwari et al. ( 2010 ) used four time points, which were viewed as numerous different studies, to examine the outcomes of critical thinking, and Chen ( 2013 ) included the two outcome variables of attitudinal tendency and cognitive skills, which were regarded as two studies. After discussion and negotiation during data extraction, the two researchers’ consistency test coefficients were roughly 93.27%. Supplementary Table S2 details the key characteristics of the 36 included articles with 79 effect quantities, including descriptive information (e.g., the publishing year, author, serial number, and title of the paper), variable information (e.g., independent variables, dependent variables, and moderating variables), and data information (e.g., mean values, standard deviations, and sample size). Following that, testing for publication bias and heterogeneity was done on the sample data using the Rev-Man 5.4 software, and then the test results were used to conduct a meta-analysis.

Publication bias test

When the sample of studies included in a meta-analysis does not accurately reflect the general status of research on the relevant subject, publication bias is said to be exhibited in this research. The reliability and accuracy of the meta-analysis may be impacted by publication bias. Due to this, the meta-analysis needs to check the sample data for publication bias (Stewart et al., 2006 ). A popular method to check for publication bias is the funnel plot; and it is unlikely that there will be publishing bias when the data are equally dispersed on either side of the average effect size and targeted within the higher region. The data are equally dispersed within the higher portion of the efficient zone, consistent with the funnel plot connected with this analysis (see Fig. 2 ), indicating that publication bias is unlikely in this situation.

This funnel plot shows the result of publication bias of 79 effect quantities across 36 studies.

Heterogeneity test

To select the appropriate effect models for the meta-analysis, one might use the results of a heterogeneity test on the data effect sizes. In a meta-analysis, it is common practice to gauge the degree of data heterogeneity using the I 2 value, and I 2  ≥ 50% is typically understood to denote medium-high heterogeneity, which calls for the adoption of a random effect model; if not, a fixed effect model ought to be applied (Lipsey and Wilson, 2001 ). The findings of the heterogeneity test in this paper (see Table 2 ) revealed that I 2 was 86% and displayed significant heterogeneity ( P  < 0.01). To ensure accuracy and reliability, the overall effect size ought to be calculated utilizing the random effect model.

The analysis of the overall effect size

This meta-analysis utilized a random effect model to examine 79 effect quantities from 36 studies after eliminating heterogeneity. In accordance with Cohen’s criterion (Cohen, 1992 ), it is abundantly clear from the analysis results, which are shown in the forest plot of the overall effect (see Fig. 3 ), that the cumulative impact size of cooperative problem-solving is 0.82, which is statistically significant ( z  = 12.78, P  < 0.01, 95% CI [0.69, 0.95]), and can encourage learners to practice critical thinking.

This forest plot shows the analysis result of the overall effect size across 36 studies.

In addition, this study examined two distinct dimensions of critical thinking to better understand the precise contributions that collaborative problem-solving makes to the growth of critical thinking. The findings (see Table 3 ) indicate that collaborative problem-solving improves cognitive skills (ES = 0.70) and attitudinal tendency (ES = 1.17), with significant intergroup differences (chi 2  = 7.95, P  < 0.01). Although collaborative problem-solving improves both dimensions of critical thinking, it is essential to point out that the improvements in students’ attitudinal tendency are much more pronounced and have a significant comprehensive effect (ES = 1.17, z  = 7.62, P  < 0.01, 95% CI [0.87, 1.47]), whereas gains in learners’ cognitive skill are slightly improved and are just above average. (ES = 0.70, z  = 11.55, P  < 0.01, 95% CI [0.58, 0.82]).

The analysis of moderator effect size

The whole forest plot’s 79 effect quantities underwent a two-tailed test, which revealed significant heterogeneity ( I 2  = 86%, z  = 12.78, P  < 0.01), indicating differences between various effect sizes that may have been influenced by moderating factors other than sampling error. Therefore, exploring possible moderating factors that might produce considerable heterogeneity was done using subgroup analysis, such as the learning stage, learning scaffold, teaching type, group size, duration of the intervention, measuring tool, and the subject area included in the 36 experimental designs, in order to further explore the key factors that influence critical thinking. The findings (see Table 4 ) indicate that various moderating factors have advantageous effects on critical thinking. In this situation, the subject area (chi 2  = 13.36, P  < 0.05), group size (chi 2  = 8.77, P  < 0.05), intervention duration (chi 2  = 12.18, P  < 0.01), learning scaffold (chi 2  = 9.03, P  < 0.01), and teaching type (chi 2  = 7.20, P  < 0.05) are all significant moderators that can be applied to support the cultivation of critical thinking. However, since the learning stage and the measuring tools did not significantly differ among intergroup (chi 2  = 3.15, P  = 0.21 > 0.05, and chi 2  = 0.08, P  = 0.78 > 0.05), we are unable to explain why these two factors are crucial in supporting the cultivation of critical thinking in the context of collaborative problem-solving. These are the precise outcomes, as follows:

Various learning stages influenced critical thinking positively, without significant intergroup differences (chi 2  = 3.15, P  = 0.21 > 0.05). High school was first on the list of effect sizes (ES = 1.36, P  < 0.01), then higher education (ES = 0.78, P  < 0.01), and middle school (ES = 0.73, P  < 0.01). These results show that, despite the learning stage’s beneficial influence on cultivating learners’ critical thinking, we are unable to explain why it is essential for cultivating critical thinking in the context of collaborative problem-solving.

Different teaching types had varying degrees of positive impact on critical thinking, with significant intergroup differences (chi 2  = 7.20, P  < 0.05). The effect size was ranked as follows: mixed courses (ES = 1.34, P  < 0.01), integrated courses (ES = 0.81, P  < 0.01), and independent courses (ES = 0.27, P  < 0.01). These results indicate that the most effective approach to cultivate critical thinking utilizing collaborative problem solving is through the teaching type of mixed courses.

Various intervention durations significantly improved critical thinking, and there were significant intergroup differences (chi 2  = 12.18, P  < 0.01). The effect sizes related to this variable showed a tendency to increase with longer intervention durations. The improvement in critical thinking reached a significant level (ES = 0.85, P  < 0.01) after more than 12 weeks of training. These findings indicate that the intervention duration and critical thinking’s impact are positively correlated, with a longer intervention duration having a greater effect.

Different learning scaffolds influenced critical thinking positively, with significant intergroup differences (chi 2  = 9.03, P  < 0.01). The resource-supported learning scaffold (ES = 0.69, P  < 0.01) acquired a medium-to-higher level of impact, the technique-supported learning scaffold (ES = 0.63, P  < 0.01) also attained a medium-to-higher level of impact, and the teacher-supported learning scaffold (ES = 0.92, P  < 0.01) displayed a high level of significant impact. These results show that the learning scaffold with teacher support has the greatest impact on cultivating critical thinking.

Various group sizes influenced critical thinking positively, and the intergroup differences were statistically significant (chi 2  = 8.77, P  < 0.05). Critical thinking showed a general declining trend with increasing group size. The overall effect size of 2–3 people in this situation was the biggest (ES = 0.99, P  < 0.01), and when the group size was greater than 7 people, the improvement in critical thinking was at the lower-middle level (ES < 0.5, P  < 0.01). These results show that the impact on critical thinking is positively connected with group size, and as group size grows, so does the overall impact.

Various measuring tools influenced critical thinking positively, with significant intergroup differences (chi 2  = 0.08, P  = 0.78 > 0.05). In this situation, the self-adapting measurement tools obtained an upper-medium level of effect (ES = 0.78), whereas the complete effect size of the standardized measurement tools was the largest, achieving a significant level of effect (ES = 0.84, P  < 0.01). These results show that, despite the beneficial influence of the measuring tool on cultivating critical thinking, we are unable to explain why it is crucial in fostering the growth of critical thinking by utilizing the approach of collaborative problem-solving.

Different subject areas had a greater impact on critical thinking, and the intergroup differences were statistically significant (chi 2  = 13.36, P  < 0.05). Mathematics had the greatest overall impact, achieving a significant level of effect (ES = 1.68, P  < 0.01), followed by science (ES = 1.25, P  < 0.01) and medical science (ES = 0.87, P  < 0.01), both of which also achieved a significant level of effect. Programming technology was the least effective (ES = 0.39, P  < 0.01), only having a medium-low degree of effect compared to education (ES = 0.72, P  < 0.01) and other fields (such as language, art, and social sciences) (ES = 0.58, P  < 0.01). These results suggest that scientific fields (e.g., mathematics, science) may be the most effective subject areas for cultivating critical thinking utilizing the approach of collaborative problem-solving.

The effectiveness of collaborative problem solving with regard to teaching critical thinking

According to this meta-analysis, using collaborative problem-solving as an intervention strategy in critical thinking teaching has a considerable amount of impact on cultivating learners’ critical thinking as a whole and has a favorable promotional effect on the two dimensions of critical thinking. According to certain studies, collaborative problem solving, the most frequently used critical thinking teaching strategy in curriculum instruction can considerably enhance students’ critical thinking (e.g., Liang et al., 2017 ; Liu et al., 2020 ; Cindy, 2004 ). This meta-analysis provides convergent data support for the above research views. Thus, the findings of this meta-analysis not only effectively address the first research query regarding the overall effect of cultivating critical thinking and its impact on the two dimensions of critical thinking (i.e., attitudinal tendency and cognitive skills) utilizing the approach of collaborative problem-solving, but also enhance our confidence in cultivating critical thinking by using collaborative problem-solving intervention approach in the context of classroom teaching.

Furthermore, the associated improvements in attitudinal tendency are much stronger, but the corresponding improvements in cognitive skill are only marginally better. According to certain studies, cognitive skill differs from the attitudinal tendency in classroom instruction; the cultivation and development of the former as a key ability is a process of gradual accumulation, while the latter as an attitude is affected by the context of the teaching situation (e.g., a novel and exciting teaching approach, challenging and rewarding tasks) (Halpern, 2001 ; Wei and Hong, 2022 ). Collaborative problem-solving as a teaching approach is exciting and interesting, as well as rewarding and challenging; because it takes the learners as the focus and examines problems with poor structure in real situations, and it can inspire students to fully realize their potential for problem-solving, which will significantly improve their attitudinal tendency toward solving problems (Liu et al., 2020 ). Similar to how collaborative problem-solving influences attitudinal tendency, attitudinal tendency impacts cognitive skill when attempting to solve a problem (Liu et al., 2020 ; Zhang et al., 2022 ), and stronger attitudinal tendencies are associated with improved learning achievement and cognitive ability in students (Sison, 2008 ; Zhang et al., 2022 ). It can be seen that the two specific dimensions of critical thinking as well as critical thinking as a whole are affected by collaborative problem-solving, and this study illuminates the nuanced links between cognitive skills and attitudinal tendencies with regard to these two dimensions of critical thinking. To fully develop students’ capacity for critical thinking, future empirical research should pay closer attention to cognitive skills.

The moderating effects of collaborative problem solving with regard to teaching critical thinking

In order to further explore the key factors that influence critical thinking, exploring possible moderating effects that might produce considerable heterogeneity was done using subgroup analysis. The findings show that the moderating factors, such as the teaching type, learning stage, group size, learning scaffold, duration of the intervention, measuring tool, and the subject area included in the 36 experimental designs, could all support the cultivation of collaborative problem-solving in critical thinking. Among them, the effect size differences between the learning stage and measuring tool are not significant, which does not explain why these two factors are crucial in supporting the cultivation of critical thinking utilizing the approach of collaborative problem-solving.

In terms of the learning stage, various learning stages influenced critical thinking positively without significant intergroup differences, indicating that we are unable to explain why it is crucial in fostering the growth of critical thinking.

Although high education accounts for 70.89% of all empirical studies performed by researchers, high school may be the appropriate learning stage to foster students’ critical thinking by utilizing the approach of collaborative problem-solving since it has the largest overall effect size. This phenomenon may be related to student’s cognitive development, which needs to be further studied in follow-up research.

With regard to teaching type, mixed course teaching may be the best teaching method to cultivate students’ critical thinking. Relevant studies have shown that in the actual teaching process if students are trained in thinking methods alone, the methods they learn are isolated and divorced from subject knowledge, which is not conducive to their transfer of thinking methods; therefore, if students’ thinking is trained only in subject teaching without systematic method training, it is challenging to apply to real-world circumstances (Ruggiero, 2012 ; Hu and Liu, 2015 ). Teaching critical thinking as mixed course teaching in parallel to other subject teachings can achieve the best effect on learners’ critical thinking, and explicit critical thinking instruction is more effective than less explicit critical thinking instruction (Bensley and Spero, 2014 ).

In terms of the intervention duration, with longer intervention times, the overall effect size shows an upward tendency. Thus, the intervention duration and critical thinking’s impact are positively correlated. Critical thinking, as a key competency for students in the 21st century, is difficult to get a meaningful improvement in a brief intervention duration. Instead, it could be developed over a lengthy period of time through consistent teaching and the progressive accumulation of knowledge (Halpern, 2001 ; Hu and Liu, 2015 ). Therefore, future empirical studies ought to take these restrictions into account throughout a longer period of critical thinking instruction.

With regard to group size, a group size of 2–3 persons has the highest effect size, and the comprehensive effect size decreases with increasing group size in general. This outcome is in line with some research findings; as an example, a group composed of two to four members is most appropriate for collaborative learning (Schellens and Valcke, 2006 ). However, the meta-analysis results also indicate that once the group size exceeds 7 people, small groups cannot produce better interaction and performance than large groups. This may be because the learning scaffolds of technique support, resource support, and teacher support improve the frequency and effectiveness of interaction among group members, and a collaborative group with more members may increase the diversity of views, which is helpful to cultivate critical thinking utilizing the approach of collaborative problem-solving.

With regard to the learning scaffold, the three different kinds of learning scaffolds can all enhance critical thinking. Among them, the teacher-supported learning scaffold has the largest overall effect size, demonstrating the interdependence of effective learning scaffolds and collaborative problem-solving. This outcome is in line with some research findings; as an example, a successful strategy is to encourage learners to collaborate, come up with solutions, and develop critical thinking skills by using learning scaffolds (Reiser, 2004 ; Xu et al., 2022 ); learning scaffolds can lower task complexity and unpleasant feelings while also enticing students to engage in learning activities (Wood et al., 2006 ); learning scaffolds are designed to assist students in using learning approaches more successfully to adapt the collaborative problem-solving process, and the teacher-supported learning scaffolds have the greatest influence on critical thinking in this process because they are more targeted, informative, and timely (Xu et al., 2022 ).

With respect to the measuring tool, despite the fact that standardized measurement tools (such as the WGCTA, CCTT, and CCTST) have been acknowledged as trustworthy and effective by worldwide experts, only 54.43% of the research included in this meta-analysis adopted them for assessment, and the results indicated no intergroup differences. These results suggest that not all teaching circumstances are appropriate for measuring critical thinking using standardized measurement tools. “The measuring tools for measuring thinking ability have limits in assessing learners in educational situations and should be adapted appropriately to accurately assess the changes in learners’ critical thinking.”, according to Simpson and Courtney ( 2002 , p. 91). As a result, in order to more fully and precisely gauge how learners’ critical thinking has evolved, we must properly modify standardized measuring tools based on collaborative problem-solving learning contexts.

With regard to the subject area, the comprehensive effect size of science departments (e.g., mathematics, science, medical science) is larger than that of language arts and social sciences. Some recent international education reforms have noted that critical thinking is a basic part of scientific literacy. Students with scientific literacy can prove the rationality of their judgment according to accurate evidence and reasonable standards when they face challenges or poorly structured problems (Kyndt et al., 2013 ), which makes critical thinking crucial for developing scientific understanding and applying this understanding to practical problem solving for problems related to science, technology, and society (Yore et al., 2007 ).

Suggestions for critical thinking teaching

Other than those stated in the discussion above, the following suggestions are offered for critical thinking instruction utilizing the approach of collaborative problem-solving.

First, teachers should put a special emphasis on the two core elements, which are collaboration and problem-solving, to design real problems based on collaborative situations. This meta-analysis provides evidence to support the view that collaborative problem-solving has a strong synergistic effect on promoting students’ critical thinking. Asking questions about real situations and allowing learners to take part in critical discussions on real problems during class instruction are key ways to teach critical thinking rather than simply reading speculative articles without practice (Mulnix, 2012 ). Furthermore, the improvement of students’ critical thinking is realized through cognitive conflict with other learners in the problem situation (Yang et al., 2008 ). Consequently, it is essential for teachers to put a special emphasis on the two core elements, which are collaboration and problem-solving, and design real problems and encourage students to discuss, negotiate, and argue based on collaborative problem-solving situations.

Second, teachers should design and implement mixed courses to cultivate learners’ critical thinking, utilizing the approach of collaborative problem-solving. Critical thinking can be taught through curriculum instruction (Kuncel, 2011 ; Leng and Lu, 2020 ), with the goal of cultivating learners’ critical thinking for flexible transfer and application in real problem-solving situations. This meta-analysis shows that mixed course teaching has a highly substantial impact on the cultivation and promotion of learners’ critical thinking. Therefore, teachers should design and implement mixed course teaching with real collaborative problem-solving situations in combination with the knowledge content of specific disciplines in conventional teaching, teach methods and strategies of critical thinking based on poorly structured problems to help students master critical thinking, and provide practical activities in which students can interact with each other to develop knowledge construction and critical thinking utilizing the approach of collaborative problem-solving.

Third, teachers should be more trained in critical thinking, particularly preservice teachers, and they also should be conscious of the ways in which teachers’ support for learning scaffolds can promote critical thinking. The learning scaffold supported by teachers had the greatest impact on learners’ critical thinking, in addition to being more directive, targeted, and timely (Wood et al., 2006 ). Critical thinking can only be effectively taught when teachers recognize the significance of critical thinking for students’ growth and use the proper approaches while designing instructional activities (Forawi, 2016 ). Therefore, with the intention of enabling teachers to create learning scaffolds to cultivate learners’ critical thinking utilizing the approach of collaborative problem solving, it is essential to concentrate on the teacher-supported learning scaffolds and enhance the instruction for teaching critical thinking to teachers, especially preservice teachers.

Implications and limitations

There are certain limitations in this meta-analysis, but future research can correct them. First, the search languages were restricted to English and Chinese, so it is possible that pertinent studies that were written in other languages were overlooked, resulting in an inadequate number of articles for review. Second, these data provided by the included studies are partially missing, such as whether teachers were trained in the theory and practice of critical thinking, the average age and gender of learners, and the differences in critical thinking among learners of various ages and genders. Third, as is typical for review articles, more studies were released while this meta-analysis was being done; therefore, it had a time limit. With the development of relevant research, future studies focusing on these issues are highly relevant and needed.

Conclusions

The subject of the magnitude of collaborative problem-solving’s impact on fostering students’ critical thinking, which received scant attention from other studies, was successfully addressed by this study. The question of the effectiveness of collaborative problem-solving in promoting students’ critical thinking was addressed in this study, which addressed a topic that had gotten little attention in earlier research. The following conclusions can be made:

Regarding the results obtained, collaborative problem solving is an effective teaching approach to foster learners’ critical thinking, with a significant overall effect size (ES = 0.82, z  = 12.78, P  < 0.01, 95% CI [0.69, 0.95]). With respect to the dimensions of critical thinking, collaborative problem-solving can significantly and effectively improve students’ attitudinal tendency, and the comprehensive effect is significant (ES = 1.17, z  = 7.62, P  < 0.01, 95% CI [0.87, 1.47]); nevertheless, it falls short in terms of improving students’ cognitive skills, having only an upper-middle impact (ES = 0.70, z  = 11.55, P  < 0.01, 95% CI [0.58, 0.82]).

As demonstrated by both the results and the discussion, there are varying degrees of beneficial effects on students’ critical thinking from all seven moderating factors, which were found across 36 studies. In this context, the teaching type (chi 2  = 7.20, P  < 0.05), intervention duration (chi 2  = 12.18, P  < 0.01), subject area (chi 2  = 13.36, P  < 0.05), group size (chi 2  = 8.77, P  < 0.05), and learning scaffold (chi 2  = 9.03, P  < 0.01) all have a positive impact on critical thinking, and they can be viewed as important moderating factors that affect how critical thinking develops. Since the learning stage (chi 2  = 3.15, P  = 0.21 > 0.05) and measuring tools (chi 2  = 0.08, P  = 0.78 > 0.05) did not demonstrate any significant intergroup differences, we are unable to explain why these two factors are crucial in supporting the cultivation of critical thinking in the context of collaborative problem-solving.

Data availability

All data generated or analyzed during this study are included within the article and its supplementary information files, and the supplementary information files are available in the Dataverse repository: https://doi.org/10.7910/DVN/IPFJO6 .

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Acknowledgements

This research was supported by the graduate scientific research and innovation project of Xinjiang Uygur Autonomous Region named “Research on in-depth learning of high school information technology courses for the cultivation of computing thinking” (No. XJ2022G190) and the independent innovation fund project for doctoral students of the College of Educational Science of Xinjiang Normal University named “Research on project-based teaching of high school information technology courses from the perspective of discipline core literacy” (No. XJNUJKYA2003).

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Xu, E., Wang, W. & Wang, Q. The effectiveness of collaborative problem solving in promoting students’ critical thinking: A meta-analysis based on empirical literature. Humanit Soc Sci Commun 10 , 16 (2023). https://doi.org/10.1057/s41599-023-01508-1

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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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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.

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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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Oppositional defiant disorder: Evidence-based review of behavioral treatment programs

Affiliations.

• 1 Cone Behavioral Health Hospital, Greensboro, North Carolina, USA.
• 2 The University of Texas Health Science, Center at San Antonio, San Antonio, Texas, USA.
• 3 Eastern Virginia Medical School, Norfolk, Virginia, USA.
• PMID: 35166664
• DOI: 10.12788/acp.0056

Background: Oppositional defiant disorder (ODD) is a common clinical condition seen among children and adolescents in behavioral health settings. In this article, we review behavioral treatment programs and their clinical use in managing ODD.

Methods: We searched PubMed, PsycInfo, and Scopus from 2000 to 2020 using the terms "oppositional defiant disorder" and "treatment." We found 1,665 articles, including clinical trials, review articles, and case control studies of evidence-based ODD treatments in patients age <18. Articles were screened to identify literature focusing on evidence-based behavioral treatment programs for ODD.

Results: The literature search revealed abundant evidence supporting the role of behavioral treatment programs for managing ODD and other disruptive behavior disorders. In this review, we discuss the most recent findings on established and effective strategies, including Parent Management Training, Parent-Child Interaction Therapy, Collaborative Problem Solving, Incredible Years program, Triple-P Positive Parenting Program, Start Now and Plan program, and Coping Power Program.

Conclusions: ODD can cause significant distress to patients and their caregivers. Familiarity with behavioral treatment programs provides clinicians with tools for managing this condition in clinical settings.

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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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• Functional Behavioral Assessment

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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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Innovations in Teamwork for Health Care

Don’t leave teaming up to chance. Create better teamwork through science.

In this course, experts from Harvard Business School and the T.H. Chan School of Public Health teach learners to implement a strategy for organizational teamwork in health care.

What You'll Learn

Health care is a team effort. From the front desk administrators to the nurses, doctors, insurers, and even the patients and their families, there are many people involved in an individual’s care. To deliver quality care in today’s fast-paced environment, practitioners and caregivers must go beyond medical problem-solving and rely on effective collaboration and communication skills.

While other businesses may organize around a functional area or project, allowing team members to learn each other's working styles and strengths over time, health care workers often find themselves in ad hoc scenarios, coordinating with near-strangers on life and death situations. As a leader, how do you encourage trust and meet shared goals when teams are formed quickly? How do you strengthen flexibility and collaboration even as team membership and structures fluctuate across departments? 

In Innovations in Teamwork for Health Care, leaders in the field of organizational behavior and teamwork, Amy Edmondson, Professor at Harvard Business School, and Michaela Kerrissey, Assistant Professor at the Harvard T.H. Chan School of Public Health, share their latest research and present their concept of "teaming" as it relates to the health care and life science industries.

In this course, you will explore the complexities of collaboration in dynamic cross-functional teams and its impact on quality of care. You will examine the theory of teaming – where individuals join together to lend their expertise – to appreciate what enables effective teamwork and why teamwork fails; articulate the importance of psychological safety and a joint problem-solving orientation; understand the particular needs of time-limited teams; and rethink the role of hierarchy and leadership in the context of teaming.

You’ll hear firsthand from experts with experience inside and outside the health care industry, from CEO and President of the Cleveland Clinic, Tomislav Mihaljevic, to Andres Sougarret, the engineer who led the miraculous rescue of 33 Chilean miners in 2011. 

Ultimately, this course provides you with the tools needed to implement effective teaming strategies for patient-centered care and provides your organization with a framework to empower robust communication, improve efficiency, and elevate patient safety.

The course will be delivered via  HBS Online’s course platform  and immerse learners in real-world examples from experts at industry-leading organizations. By the end of the course, participants will be able to:

• Explore the science of teamwork, focusing on the psychological and sociological aspects of teaming, collaboration, and defining effective outcomes.
• Understand the complexity of building trust in ad hoc teams, including how to define purpose, build trust, and navigate interpersonal risks to reach common goals.
• Apply communication strategies that encourage psychological safety and create a safe space for all to contribute.
• Understand the value in adopting a model of joint problem-solving for patient care.
• Identify the distinct needs of time-limited project teams and how to incorporate effective and transparent feedback loops.
• Ensure accountability and identify leaders, breaking down hierarchy and encouraging the right person to step up at the right time.
• Implement a PDSA (Plan, Do, Study, and Act) framework for your organization.

Continuing Education Credits

In support of improving patient care, Harvard Medical School is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education.

The Harvard Medical School designates this enduring material for a maximum of 20 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Harvard Medical School is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

This activity is approved for 20.00 contact hours. Contact hours are awarded commensurate with participation and completion of the online evaluation and attendance attestation. We suggest claiming your hours within 30 days of the activity date, after this time, the attendance attestation will still be required to claim your hours. 

Groups of 10 or more receive Amy Edmondson's latest book!

A free, hard copy of right kind of wrong: the science of failing well for each participant. .

Your Instructors

Amy C. Edmondson  is the Novartis Professor of Leadership and Management at Harvard Business School, a chair established to support the study of human interactions that lead to the creation of successful enterprises that contribute to the betterment of society. She has pioneered the concept of psychological safety for over 20 years and was recognized in 2021 as #1 on the Thinkers50 global ranking of management thinkers. 

She is the author of Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy (2012), The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth (2018), and Right Kind of Wrong: The Science of Failing Well (2023).

Michaela Kerrissey  is an Assistant Professor of Management at the Harvard T.H. Chan School of Public Health. She conducts research on how teams and organizations innovate, integrate, and perform, with a focus on health care.   Dr. Kerrissey has authored over 30 publications on these topics and has won numerous best-paper awards, such as from the Academy of Management. She designed the Management Science for a New Era course at Harvard’s School of Public Health. In 2023, she was listed on Thinkers50 Radar, a global listing of top management thinkers.

Real World Case Studies

Affiliations are listed for identification purposes only.

Tomislav Mihaljevic, MD

Learn from the President and CEO of the Cleveland Clinic about how to implement joint problem solving in complex care organizations.

Maya Rupert

Hear from a top political strategist and campaign manager about how she leads within a teaming structure.

Trishan Panch, MD, MPH

Learn from Harvard faculty and founder of Wellframe about the importance of team learning.

Available Discounts and Benefits for Groups and Individuals

Experience Harvard Online by utilizing our wide variety of discount programs for individuals and groups. 

Past participant discounts.

Learners who have enrolled in at least one qualifying Harvard Online program hosted on the HBS Online platform are eligible to receive a 30% discount on this course, regardless of completion or certificate status in the first purchased program. Past Participant Discounts are automatically applied to the Program Fee upon time of payment.  Learn more here .

Learners who have earned a verified certificate for a HarvardX course hosted on the  edX platform  are eligible to receive a 30% discount on this course using a discount code. Discounts are not available after you've submitted payment, so if you think you are eligible for a discount on a registration, please check your email for a code or contact us .

Nonprofit, Government, Military, and Education Discounts

For this course we offer a 30% discount for learners who work in the nonprofit, government, military, or education fields. 

Eligibility is determined by a prospective learner’s email address, ending in .org, .gov, .mil, or .edu. Interested learners can apply below for the discount and, if eligible, will receive a promo code to enter when completing payment information to enroll in a Harvard Online program. Click here to apply for these discounts.

Gather your team to experience Innovations in Teamwork for Health Care and other Harvard Online courses to enjoy the benefits of learning together: 

• Single invoicing for groups of 10 or more
• Tiered discounts and pricing available with up to 50% off
• Growth reports on your team's progress
• Flexible course and partnership plans 

Learn more and enroll your team ! 

Course Syllabus

Learning requirements: There are no prerequisites required to enroll in this course. In order to earn a Certificate of Completion from Harvard Online and Harvard Business School Online, participants must thoughtfully complete all 5 modules, including satisfactory completion of the associated assignments, by stated deadlines.

Download Full Syllabus

• Study the Mining Accident Rescue and Cleveland Clinic cases.
• Understand the concept of teaming and how it can be applied to the health care industry.
• Brainstorm how to organize with a team to rescue 33 trapped miners.
• Analyze the problems solved and new challenges created by organizational structures that were implemented to facilitate teamwork at the Cleveland Clinic.
• Outline and analyze an individualized teaming breakdown for your organization. 
• Study the NASA and Google cases on psychological safety.
• Collaborate with team members and leadership to create a space of psychological safety. 
• Identify the indicators of psychological safety in a group. Analyze data from Project Aristotle’s study of teams at Google.
• Consider how past experiences can affect current feelings of psychological safety.
• Study the Cleveland Clinic ,  Boehringer Ingelheim , and  Cincinnati Children’s Hospital Medical Center cases.
• Implement a joint problem-solving orientation in which team members view problems as shared and solutions as requiring collaboration.
• Match different types of diversity in the workplace with the interpersonal boundaries that they imply.
• Articulate what you bring to a team and what you might need from others.
• Walk down the ladder of inference to get to the root of a problem.
• Study the  Virginia Mason Medical Center and  Institute for Healthcare Improvement cases.
• Cultivate an organization where team learning is valued and mobilized for improved performance.  
• Identify different kinds of work on the process knowledge spectrum.
• Brainstorm how a nursing team could learn from an accidental morphine overdose.
• Study the cases of Julio Castro's Presidential Campaign and Wellframe . 
• Practice leadership skills that include coaching, enabling, and ensuring that the right voices are present or represented within the team structure. 
• Build a leadership workshop for your team using the concepts addressed in this course.
• Practice asking meaningful questions as a way to encourage input and express authentic humility.
• Learn the difference between confirmatory and exploratory responses.

Earn Your Certificate

Enroll today in this course.

Still Have Questions?

What are the learning requirements? How do I list my certificate on my resume? Learn the answers to these and more in our FAQs.

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