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Counseling outcomes for youth with oppositional behavior: a meta-analysis.

Oppositional defiant disorder (ODD) involves patterns of negativistic, defiant, disobedient, and hostile behavior toward authority figures that last for at least 6 months (American Psychiatric Association [APA], 2013). ODD is among the most prevalent and resource-demanding mental health problems for children and adolescents (Loeber, Burke, Lahey, Winters, & Zera, 2000), with 5% to 10% of children ages 8 to 16 years having notable ODD behavior problems (Fraser & Wray, 2008). Characteristics of ODD include persistent stubbornness and refusal to comply with instructions, unwillingness to compromise with adults or peers, persistently and deliberately testing limits, failing to accept responsibility for one's own actions and blaming others for one's own mistakes, deliberately annoying others, and frequently losing one's temper (APA, 2013). ODD has also been associated with excessive arguing, cognitive and social deficits, and significantly problematic adult-child and child-peer interactions (Greene et al., 2002). According to Finger et al. (2011), youth with ODD demonstrate high rates of aggressive and antisocial behaviors, with a subset displaying callousness and psychopathic traits, including a lack of guilt, empathy, and remorse.

It is sometimes difficult to determine whether a child truly meets the criteria for having an ODD diagnosis because many of the behavioral qualifications are commonly seen among youth in early childhood and adolescence (Fraser & Wray, 2008). If a child's behaviors consistently cause distress to the family system and have an effect on his or her social and educational functioning, further evaluation is warranted. ODD has been linked to many other comorbid disorders, such as anxiety; depression; and, most commonly, attention-deficit/ hyperactivity disorder (ADHD; Biederman, Newcorn, & Feldman, 2007). Jensen et al. (2001) found that ODD occurred in 30% to 60% of children diagnosed with ADHD.

ODD has historically been considered a male problem (Loeberet al., 2000), and the developmental factors that accounted for symptoms in girls were only partly understood (Hipwell et al., 2002; Messer, Goodman, Rowe, Meltzer, & Maughan, 2006). One study (Munkvold, Lundervold, & Manger, 2011) found that the impact of symptoms and the prevalence of ODD were higher in boys than in girls. Fraser and Wray (2008) found that girls were more likely to demonstrate symptoms after the onset of puberty, during the adolescent years, whereas boys more frequently showed symptoms in early childhood. The manifestation of ODD in boys also differed from the manifestation of ODD in girls in that boys were more likely to demonstrate physical aggression or threaten others (overt aggression), whereas girls were more likely to harm or disrupt relationships with others (Crick & Grotpeter, 1995), better known today as relational aggression. Individuals diagnosed with early-onset ODD were more likely to have been abused by their parents, drop out of school, engage in serious crimes, and have greater long-term involvement with the mental health system.

Because ODD is such a serious and common disorder and is comorbid with other disorders, it is important to determine whether counseling and psychotherapy reduce symptoms in individuals diagnosed with ODD. Primary counseling strategies discussed in the literature include family interventions and individual and group counseling approaches with children and adolescents. Family interventions, especially parent training programs, have been empirically supported as efficacious (Lonigan, Elbert, & Johnson, 1998). Brestan and Eyberg's (1998) research indicated that families completing a parent training program achieved both short- and long-term treatment goals. In addition to their known effect on child conduct problems, parenting group interventions promoted both child and family competencies (Borden, Schultz, Herman, & Brooks, 2010). Participants in a study of self-administered videotape parent training reported significantly fewer child behavior problems, reduced levels of stress, and less use of physical punishment (Webster-Stratton, 1990). The self-administered videotape parent training was effective in altering parent-child behaviors and attitudes. According to Webster-Stratton and Hammond (1997), interventions that involved parent training were superior to other treatments in terms of behavior improvement, parent behavior, and consumer satisfaction.

Likewise, parent-child interaction therapy produced significant improvements in child behavior, so much so that many participant children no longer met criteria for ODD (Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998). Owens et al. (2005) reported an evidence-based behavioral treatment package to target symptoms associated with oppositional behavior, defiance, and aggression, as well as academic and social functioning, but cautioned that the results may not readily generalize to other situations because of practical challenges that may interfere with treatment and compliance (e.g., demands on teachers, parent attendance).

Research also supports the use of individual and group counseling approaches in treating ODD (Nitkowski, Petermann, Buttner, Krause-Leipoldt, & Petermann, 2009). Youth with ODD who engaged in individual and group counseling showed a decline in social and conduct problems (Nitkowski et al., 2009) and an increase in prosocial, positive behavior (Nelson-Gray et al., 2006). A study that used social-cognitive interventions yielded significant results in the reduction of behavior problems and an increase of social-cognitive skills in children with ODD as compared with those in a wait-list control condition (Muffs, Meesters, Vincken, & Eijkelenboom, 2005). The findings showed a moderate treatment result, but treatment effects were modest with a weak negative association between improved social cognition and a decline in behavior problems (Muffs et al., 2005).

Luk et al. (2001) demonstrated a significant reduction in oppositional symptoms for children who engaged in counseling. Although the reduction in symptoms was apparent, most of the children still scored within the clinical range. Similarly, Erford's (1999) study, which used a modified time-out procedure with a contingency delay, noted that children with extremely defiant, out-of-control behaviors may be inappropriate candidates for this intervention, even though the intervention resulted in significant reductions in noncompliant episodes for nearly all other participants. In summary, numerous studies using family, individual, and group counseling approaches resulted in significant effects of treatment at termination, although not to the same degree of effectiveness.

Professional counselors who seek to treat youth with ODD should be concerned with the efficacy and lasting effects of these therapeutic approaches beyond termination of treatment. Parent training programs were reported to have lasting effects, with one study showing that those children diagnosed with ODD before treatment no longer received that diagnosis 5 to 6 years after treatment (Drugli, Larsson, Fossum, & Morch, 2010). A study by Webster-Stratton (1992), which was con ducted using videotape parent training, reported not only that the treatment was effective but also that the positive effects were maintained at least 1 year later and, in some cases, continued to improve. Another study of parent training by Webster-Stratton and Hammond (1997) indicated that the significant changes seen posttreatment were maintained over time, and problems with conduct lessened over time. At 1-year follow-up, Webster-Stratton and Hammond found that all significant findings were still maintained. Larsson et al. (2009) reported similar outcomes in which maintenance of achieved improvement in child conduct problems was found after 1 year. Thus, many of the studies reported a lasting effect of at least 1 year (Drugli & Larsson, 2006; Hautmann et al., 2009).

With regard to the long-term effects of individual counseling, Luk et al. (2001) found a reduction in oppositional symptoms reported 6 months after initial clinical contact, although the majority of the group still scored within the clinical range. Luk et al.'s study did show a decrease in oppositional behavior but reported that long-term intervention lacked a corresponding control group for comparison.

Most but not all family, individual, and group counseling interventions had long-term staying power. Individual and group counseling interventions were effective, but the longevity of these interventions did not seem as long as that of the family training programs. Many of the individual and group intervention studies did not report the lasting effects of the intervention, or if staying power was reported, it was in the 3- to 6-month range (Luk et al., 2001; Muris et al., 2005), whereas the family training programs reported lasting effects anywhere from 1 year to 5-6 years (Brestan & Eyberg, 1998; Lonigan et al., 1998). Thus, a cursory review of the extant literature suggests that family training interventions may be most effective when treating youth who display ODD symptoms. However, no meta-analyses have been conducted to date to clarify this debate and directly test the comparison.

Because the priority of a professional counselor is to act in the best interest of the client, counselors should question the differential effectiveness among approaches used to treat clients with ODD. Research indicated that parent training programs, especially those interventions that were behavioral, showed the most promise in helping families with children with ODD (Connell, Sanders, & Markie-Dadds, 1997; Schuhmann et al., 1998). However, it was those behaviorally based parent training programs that were combined with other interventions (i.e., problem-solving skills training, child therapy/training) that displayed the most significant changes in these children (Barkley, Edwards, Laneri, Fletcher, & Metevia, 2001; Drugli & Larsson, 2006; Kazdin, Siegel, & Bass, 1992; Larsson et al., 2009; Webster-Stratton & Hammond, 1997).

The current meta-analytic study explored the following three questions related to the effectiveness of counseling as a treatment for children and adolescents with ODD: (a) Is counseling/psychotherapy effective in reducing symptoms of ODD in school-age youth when compared with various comparison conditions? (b) If so, do the effects of counseling/ psychotherapy last? and (c) Is there a differential effectiveness among the approaches used to treat youth with ODD?

* Method

Inclusion and Exclusion Criteria

Counseling or psychotherapy was defined as any treatment or intervention performed by a mental health practitioner addressing reduction of oppositional symptoms directed at the child or through the child's caregiver. In this meta-analysis, nine criteria were applied for study selection to obtain a sample of moderate to high-quality clinical trials addressing the treatment of oppositional behavior: (a) Studies appeared in print between 1990 and 2009; (b) studies were published in English; (c) the intervention was implemented directly to children or through parents to reduce the symptoms of participants diagnosed with oppositional behavior; (d) treatment involved counseling or psychotherapy delivered through individual, group, or family approaches (drug trials were excluded); (e) symptoms of oppositional behavior were assessed by at least one standardized measurement procedure (e.g., self-report rating scale, frequency count); (f) means and standard deviations for outcome measures were available for computation of mean gain effect sizes or mean difference effect sizes for posttreatment or follow-up data; (g) treatment was directed at child or adolescent participants (ages 2-17 years); (h) studies had a minimum sample size of six participants; and (i) acceptable study designs included clinical trials with a single group or some control or comparison group condition (e.g., wait list [inactive], placebo [active], or treatment as usual [TAU; active comparison]). We eliminated nonexperimental or preexperimental designs and included only quasi-experimental or true experimental clinical trials.

Search Strategies

Included studies were identified through computerized literature searches, a review of clinical trial reference lists, and hand searches of the journals most likely to publish clinical trials on the treatment of oppositional behavior. Computerized searches of PsycINFO, Academic Search Premier, and MEDLINE from 1990 to 2009 were conducted using keywords related to intervention (e.g., counseling, psychotherapy) and condition (e.g., opposition, defian*). Search parameters were delimited to English, age (child and adolescent), peer review, and clinical trials. Identified clinical trial reference lists were searched for additional potential candidate articles. Then, journals yielding high numbers of candidate studies were searched (i.e., Journal of Consulting and Clinical Psychology, Behavior Modification, Clinical Child Psychology and Psychiatry, Journal of Abnormal Child Psychology, and Journal of Clinical Child Psychology). Two independent judges reviewed the title, abstract, and full text (when available) of each candidate study to determine whether the inclusion/ exclusion criteria were met. Disagreements were resolved by consensus, and final selection decisions were confirmed by the first author.

Coding Procedure

Coding was undertaken for 25 characteristics, including for participants (e.g., sample size, age, sex, ethnicity), method (e.g., blind assessment, treatment manual, individual or group method, number of sessions, duration of sessions), and design (e.g., randomization, recruitment method, setting of treatment, type of treatment, type of comparison group). Coding facilitated potential subsequent moderator-mediator analysis, should the combined effect size estimates lack homogeneity. Each article was independently coded by the second, third, and fifth authors, who completed a rigorous training session and subsequent supervision by the first author. Full text versions of each selected article were obtained, and any discrepancies among coder ratings were adjudicated by the first author.

Outcome Measures

Outcome measures were direct assessments of the dependent variable, oppositional behavior. Within the 31 selected articles, nearly all outcome measures used were standardized observer-report measures provided by a parent, or sometimes by a teacher. The Child Behavior Checklist or the Teacher's Report Form from the Achenbach System of Empirically Based Assessment (Achenbach & Rescorla, 2001) was used in 58% of the trials, the Eyberg Child Behavior Inventory (Eyberg, 1990) was used in 35% of the trials, and some direct observation of oppositional symptoms or compliance with parent or teacher commands was used in 32% of the trials. About 10 other observer-report instruments were used in various clinical trials, but nine were used in only one trial, and the other was used in just two trials.

Statistical Methods

When combined effect size estimates are analyzed, Erford, Savin-Murphy, and Butler (2010) specified that similar effect size estimates (i.e., mean difference or mean gain effect size) should be combined only from similar study designs (e.g., wait-list designs combined with wait-list designs, single-group designs combined with single-group designs) to ensure that comparable effect size estimates are analyzed. All effect sizes from the 31 trials included in this meta-analysis were independent. In addition, post-treatment effects were analyzed by combining effect sizes from the immediate conclusion of the treatment, whereas follow-up effects used the final (i.e., most conservative) follow-up effect size collected. The pooled variance formula of Cohen's d was used to compute standardized mean difference effect sizes for wait-list and TAU comparison group studies (separately); a positive effect of treatment is indicated by a positive effect size. No placebo group trials were located during the current study's search.

We used Lipsey and Wilson's (2001) formula to compute standardized mean gain effect sizes for single-group samples ([d.sub.sg]) and used a conservative reliability estimate of.80 when sample reliabilities were not reported. Effect size estimates (d) were corrected for sample bias (Erford et al., 2010), and subsequent unbiased estimates (d') were again corrected using an inverse weighting procedure (Erford et al., 2010; Lipsey & Wilson, 2001), producing the corrected effect size (d+). At this juncture, estimates of corrected effect size from similar study designs (e.g., wait list, single group) were combined and averaged for hypothesis and homogeneity testing using Cochran's Q and [I.sup.2] (see Erford et al., 2010) using a random effects model (Hedges & Olkin, 1985). Theoretically, if p < .05 for the Q statistic, the null hypothesis of homogeneity was rejected and potential mediation or moderation explored. Regarding [I.sup.2], Higgins, Thompson, Decks, and Altman (2003) recommended [I.sup.2] interpretations of 0% indicating total homogeneity, 25% low, 50% moderate, 75% high, and 100% total heterogeneity. Analysis of mediator-moderator variables was conducted if [I.sup.2] > 50%. Computation of 95% confidence intervals (CIs; Erford et al., 2010; Lipsey & Wilson, 2001) was undertaken to facilitate hypothesis testing of d+ > 0. The null hypothesis was rejected when the entire CI range was greater than zero.

Finally, power is a substantial concern in the current meta-analysis, because meta-analyses with k < 20 studies may be underpowered (Cornwell, 1993; Cornwell & Ladd, 1993), making them prone to Type II errors. In the current meta-analysis, the wait-list k = 21, TAU k = 3, and single-group k = 20 for the posttreatment analyses, whereas the follow-up studies had only one wait-list study and seven single-group studies.

Publication Bias

Unpublished manuscripts, including dissertations and theses, were not included in this meta-analysis. Beretvas (2010) recommended that multiple methods be undertaken to assess for publication bias. To determine the potential for publication bias, we conducted three procedures, including funnel plot analyses, trim-and-fill method, and computation of Rosenthal's (1979) fail-safe N procedure on each effect size set. We did not conduct regression analyses because of limited statistical power (Beretvas, 2010) and because funnel plot analyses and trim-and-fill procedures were within normal limits. Few outliers were noted, and expected graphical configurations were observed. Duval and Tweedie's (2000; see also Richardson, Abraham, & Bond, 2012) trim-and-fill procedure was <.05 in all analyses, indicating no significant effect of bias.

* Results

Figure 1 outlines the article selection decision-making process. Of relevant articles, 473 were identified through computerized search procedures and seven through reference list and hand searches, yielding a total of 480 relevant articles. Of these 480 articles, 434 articles violated at least one of the inclusion criteria, and 15 more articles were excluded after review of the full text. Therefore, 31 articles made up the final set of selected studies. The selection agreement rate was 98.0% ([kappa] = .94). A single asterisk in the reference list indicates the articles that were included in the recta-analysis.

[FIGURE 1 OMITTED]

Study Characteristics

Of the final 31 articles advanced to the coding process, 15 were single-group pretest-posttest designs (21 samples), 13 used wait-list controls (20 comparisons), and three used a TAU comparison group design (three comparisons). Each of the 16 comparison group studies used random assignment procedures. Summary characteristics of these 31 studies are provided in Table 1, including purpose, sample size, mean age, percentage of male participants in the sample, percentage of White participants in the sample, control/ comparison group type, and outcome measure(s) used. The total number of participants was 2,386. Twenty-five of the studies (81%) used a parent training or family-based approach treatment approach.

Intercoder agreement across the 25 coded variables ranged from 72% to 100%, with a median percentage agreement of 97%. Related kappas ranged from .49 to 1.00 with a median kappa of .92. Landis and Koch (1977) indicated that kappas in the range of .41-.60 were moderate and ordinarily sufficed for research purposes, whereas kappas of .61-.80 were considered substantial and kappas of .81-1.00 were almost perfect. Because effect size averages across different study conditions are not equivalent (Thompson, 2002, 2006), effect sizes are homogeneously grouped and presented.

Is Counseling/Psychotherapy Effective for School-Age Youth With ODD?

The effectiveness of counseling or psychotherapy at termination (posttest) was evaluated using single-group (k = 21), wait-list (k = 20), and TAU (k = 3) comparison group studies. Mean difference and mean gain effect sizes are interpreted as follows (Lipsey & Wilson, 2001): 0 indicates no effect of treatment; [less than or equal to] .30 indicates a small effect, .50 indicates a medium effect, and [greater than or equal to] .67 indicates a large effect. Alternatively, because mean difference and mean gain effect sizes conform to a z-score distribution, effect sizes for the treatment conditions can be transformed into percentile ranks and interpreted as a percentage of the population distribution in comparison with the control condition. Therefore, a percentile rank of 50 indicates no effect of treatment, a percentile rank greater than 50 indicates increasing degrees of effectiveness, and a percentile rank lower than 50 indicates increasingly harmful effects of treatment. For example, a "small" effect size of.30 means the average person in the treatment group performed better than 62% of comparison group participants, whereas a "medium" effect size of .60 means the average person in the treatment group performed better than 73% of comparison group participants.

Single-group studies. Twenty-one groups across 15 studies (n = 1,251) combined for an average corrected effect size (d+) of .63, 95% CI [.47, .79]. Because the entire 95% CI range is greater than zero, the null hypothesis of d+ = 0 can be rejected and one can conclude that d+ is greater than zero, meaning that counseling/psychotherapy at termination is significantly more effective than baseline measurement for school-age children with ODD in these 21 single-group comparisons. A d+ of.63 is a medium to large effect, meaning that the average participant at termination scored at the 74th percentile of the pretest score distribution. A d+ of .63 in a 21-study analysis has a fail-safe N of 1,325, meaning that one would need to locate 1,325 additional single-group studies with an effect size of zero to mitigate this study's result and reduce the d+ of .63 down to a nonsignificant d+ of.01. The funnel plot analysis showed only one outlying effect size (i.e., Hautmann et al., 2009). These funnel plot and fail-safe N analyses indicate a low probability of publication bias. In tests for homogeneity of the set of effect sizes from these 21 studies, Cochran's Q was 20.58. With 20 degrees of freedom, this Q-statistic value resulted in p > .05, meaning that the null hypothesis of homogeneity was retained and the set of 21 effect sizes are consistent and homogeneous. To corroborate this analysis, we computed F to be 0%, also indicating homogeneity (i.e., [I.sup.2] < 50%). Because the distribution of effect sizes was homogeneous, there was no need to conduct moderator or mediator analyses.

Wait-list comparison groups. Across 13 studies, 20 comparison groups (n = 926) reported wait-list comparisons for an average d+ = .68, 95% CI [.50, .86]. This d+ is greater than zero and has a fail-safe N of 1,409 studies and funnel plot analysis with no outliers, so this is a quite robust result. The homogeneity analysis indicated that Q(19) = 21.00, p > .05, which was corroborated by [I.sup.2] = 5.0%, indicating substantial homogeneity. A d+ of.68 is a medium to large effect and indicates that the average treatment group participant was less oppositional than 74% of the wait-list control participants at termination.

TAU comparison groups. The mean difference comparisons for three studies reporting TAU comparisons (n = 136) combined for a d+ equal to .36, 95% CI [-.02, .75], which was not significantly higher than zero, thus allowing retention of the null hypothesis. Analysis resulted in a fail-safe N of 106 studies and a funnel plot analysis with no outliers. Thus, the average participant in the treatment condition, which all involved parent training interventions (Powers & Roberts, 1995, Scahill et al., 2006; Scott et al., 2010), performed at the 65th percentile of the TAU comparison group distribution, a small effect of treatment. Again, the distribution of effect sizes was very homogeneous: Q(2) = 2.13,p > .05, and [I.sup.2] = 6%.

Thus, two of these three conditions (single group and wait list) yielded average weighted effect sizes (d+) that were significantly higher than zero at termination, meaning that the treatments for defiance were effective, and all tests of homogeneity (Cochran's Q and F) indicated significant homogeneity and no effects of moderating or mediating variables. Only the TAU condition did not indicate a significant effect of treatment, but only three TAU controlled trials were located so the analysis was significantly underpowered. Table 2 provides a summary of these effect size statistics.

Do the Effects of Counseling/Psychotherapy Last for School-Age Youth With ODD?

The effectiveness of counseling and psychotherapy at longest follow-up was evaluated using single-group studies and wait list clinical trials. No TAU comparison group studies reported follow-up results. Again, we analyzed each of these effect size groupings separately to determine the likely staying power of therapeutic treatment effects on ODD in the months or years after termination.

Single-group studies. Eleven groups across seven studies (n = 440) combined to yield an average corrected effect size (d+) of .62, 95% CI [.39, .85], which indicates a treatment effect greater than zero. Lapsed time between treatment termination and longest follow-up ranged from 2 to 36 months. This average d+ is a medium to large effect and indicates that the average participant at follow-up performed at the 74th percentile of the pretest distribution mean score. The fail-safe N for this analysis was 683 studies, meaning that 683 unpublished or unfound studies with d' = 0 would need to be located to reduce the d+ of .62 down to an insignificant effect size of .01, an unlikely occurrence. In addition, funnel plot analysis indicated a single outlier effect size, again stemming from the study conducted by Hautmann et al. (2009). The distribution of 11 effect sizes was homogeneous: Q(10) = 9.70, p > .05, and [I.sup.2] = 0%; therefore, no moderator analysis was justified. While these results must be viewed with caution because of the small sample sizes and numbers of studies, some evidence exists that treatment gains were maintained up to 1 year after termination (see Table 3); that is, the posttest d+ = .63 (k = 15), 1-4-month follow-up d+ = .62 (k = 5), half-year follow-up d+ = .36 (k = 1), 1-year follow-up d+ = .47 (k = 4), and 3-year follow-up d+ = 1.14 (k = 1) progression was observed for the 11 studies reporting follow-up effect sizes.

Wait-list comparison group studies. The effect of counseling and psychotherapy at longest follow-up for the two samples from the single wait-list study providing follow-up data (Drugli & Larsson, 2006; 12-month follow-up; total N = 127) resulted in d+ = .37, 95% CI [-.06, .80]. Thus, the follow-up mean d+ was not greater than zero, and the null hypothesis was retained. The fail-safe N was 75 studies, and the funnel plot analysis indicated no outliers. A d+ of .37 is a small effect and means that the average participant in the treatment condition remained less oppositional than about 65% of the wait-list control participants after termination. This distribution of two effect sizes was homogeneous: Q(1) = 0.06, p > .05, and [I.sup.2] = 0%; therefore, no analysis for moderator or mediator variables was conducted. Thus, although positive effect sizes were observed, the small number of samples and subsequent low power of the analysis mitigate a conclusion of significant maintenance in effect of treatment for oppositionality in school-age youth after termination when compared with wait-list conditions. Again, these results should be interpreted with caution because of the small number of studies involved.

Thus, only the single-group conditions resulted in an average weighted effect size (d+) that was significantly higher than zero at follow-up intervals. And all tests of homogeneity (Cochran's Q and [I.sup.2]) indicated significant homogeneity and no effects of moderating or mediating variables. The wait-list condition did not indicate a significant effect of treatment on follow-up, but that analysis contained only two comparisons within a single study. Table 3 provides a summary of these follow-up effect size statistics.

Is There a Differential Effectiveness Among the Approaches Used to Treat Youth With ODD?

The absence of heterogeneity in all analyses pointed to the absence of potential mediator and moderator variables. This means that no significant differences were evident between or among any of the coded variables. Therefore, no differences were evident among the various approaches to counseling interventions with children displaying oppositional behavior. Thus, individual, small-group, family, and parent training approaches demonstrated equivalent effectiveness.

Discussion

This meta-analysis suggests that counseling/psychotherapy is moderately effective in the treatment of oppositional behavior, resulting in medium to large average weighted effect sizes (d+) for single-group and wait-list post-treatment analyses and a small effect size for the TAU post-treatment analysis. Only the TAU condition was not significantly greater than zero, and that probably was due to a sample of only three studies and 136 participants, which resulted in an analysis with substantially low power. A single additional TAU study with an effect size of .36 or higher would have yielded a significant result.

Mixed results emerged from follow-up studies of treatment efficacy. In follow-up analysis, single-group mean effect sizes were again medium to large, whereas wait-list control results dropped to a small to moderate effect size of .37. Only one wait-list follow-up study was located, and the result was not significant, although a single additional study of equal size and magnitude would have led to a significant result. No TAU follow-up studies were located in the literature. Significant homogeneity and no effects of moderating or mediating variables were indicated by all tests of homogeneity (Cochran's Q and [I.sup.2]), meaning that no treatment approach or other study characteristic demonstrated an advantage.

Thus, it can be concluded that counseling/psychotherapy is effective in producing short-term positive therapeutic changes in children with oppositional behaviors, but more follow-up studies are needed to determine whether this treatment is long-lasting and resistant to relapse. This is the first meta-analysis to assess the short- and long-term effects of counseling on oppositional behavior in children and adolescents, and the preliminary results are promising. However, it is possible that most analyses were underpowered because of the small numbers of studies evident in the extant literature. The current meta-analysis also probably yielded conservative estimates of effect size averages because we used a random effects model.

It is interesting to note that the absence of mediator or moderator variables means that no therapeutic approach was demonstrated as superior to any other and that individual, group, and systemic family or parent training approaches appeared equivalent. This is not surprising given the hypothesis-testing advantages inherent in meta-analyses, which generally yield lower, more conservative estimates when combining studies than do qualitative syntheses or reports of individual studies from the literature. Thus, in contrast to several clinical trials reviewing a limited number of earlier studies (Barkley et al., 2001; Connell et al., 1997; Drugli & Larsson, 2006; Kazdin et al., 1992; Webster-Stratton & Hammond, 1997), behaviorally based parent training programs that were combined with other interventions were no more effective than other approaches.

Limitations of This Meta-Analysis

To enhance generalizability across populations, treatment variations, outcome variables, and research designs, we used rigorous methodology in conducting this recta-analysis. Still, limitations exist. For example, some viable studies may have been eliminated because of the rigorous selection criteria aimed at enhancing study quality, perhaps unintentionally leading to publication bias, although funnel plots and trim-and-fill procedures indicated insignificant publication bias probability. Whiston, Tai, Rahardja, and Eder (2011) indicated that although maintaining study quality in a meta-analysis is important, eliminating less rigorous studies sometimes alters the results of a meta-analysis. A significant limitation was the small number of studies available for some comparisons, particularly during analysis of follow-up to treatment. In a meta-analysis, sufficient power generally occurs when 20 or more similar studies are analyzed simultaneously (Cornwell, 1993; Cornwell & Ladd, 1993). In our meta-analysis, the posttreatment single-group and wait-list conditions each had at least 20 samples reported across 15 and 13 studies, respectively, but none of the other categories had more than seven samples. The power of analyses will increase as additional future studies of the treatment of oppositional behavior accumulate, thus minimizing the possibility of Type II errors. This is particularly important for follow-up results to determine the staying power of interventions used to treat oppositional and defiant behaviors, and so the conclusions of this meta-analysis can be reexamined and refined in the context of a larger set of follow-up studies.

Implications for Counseling Practice and Research

This study is the first meta-analytic investigation of the effectiveness of methods used to specifically treat oppositional behavior. Because the study's design produced conservative outcome estimates as a result of using a random effects model, the results have important implications in clinical practice. In practice, counselors can anticipate similar treatment outcomes with clients to those found in this study. This study's results (d+ = .63 for single-group comparisons; d+ = .68 for wait-list comparisons; d+ = .37 for TAU comparisons) suggest that counseling and psychotherapy are associated with a significant decrease in oppositional behavior at termination, which is about one-half standard deviation better than comparison group measures and a significant clinical improvement.

A continuing concern related to the treatment of oppositional behavior among youth is the sparse evidence that treatment has any lasting effect after the conclusion of counseling. Evidence that does exist is favorable in this regard, but only one wait-list study (d+ = .37) out of 13, and only seven single-group studies out of 15 (d+ = .62), conducted a follow-up phase. These long-term results indicate continued improvement in the range of one-half standard deviation better than comparison group measures, which is a substantial clinical improvement realized by children and families. Future research should address the matter of long-term efficacy by using trials with single-group follow-up phases and wait-list and TAU control designs. More important, these short-term and long-term client improvements appear to be independent of theoretical approach or other treatment parameter (e.g., individual, group, or family approach; discipline or training level of the clinician).

Research exploring long-term treatment efficacy in depression (Erford et al., 2011) and bulimia nervosa (Erford et al., 2013) has suggested that follow-up sessions may strengthen long-term treatment efficacy. This idea may also apply to the treatment of oppositional behavior. Clients who are treated for ODD often respond well to treatment but regress toward oppositional behavior after the termination of treatment. This can be frustrating to individuals with ODD and their families, especially after expending significant time and financial resources during treatment. Those with limited financial or medical resources, including third-party reimbursement organizations, may not want to spend these resources on treatment methods that are not enduring. Perhaps periodic "booster sessions" could promote long-term treatment efficacy. Counselors have an ethical responsibility to apply reliable and effective ODD treatment methods and establish dependable ways to help clients maintain the improvements that they have achieved through counseling.

Previous research into treatments of oppositional behavior has yet to investigate the cost-effectiveness of various treatments. Because health care and its costs are prominent concerns and a major source of financial burden for many people, there is a growing need for researchers to examine the costs associated with treatment methods for disorders such as ODD. The development of treatment methods that best use clients' time and financial resources greatly benefits society. This study's findings contribute to the understanding of what is efficacious in treating clients with ODD, but further study is needed of the cost-effectiveness of counseling for treatment of ODD. This is particularly important when one considers the outcome that improved child behavior may have in the classroom on learning outcomes for both the target student with ODD and his or her classmates as a result of an improved classroom climate and learning environment.

In addition to exploring and developing more cost-effective treatment methods, future researchers need to use randomized, clinical trials to measure the effectiveness of treatment for oppositional behavior not only at termination but also at both short-term and long-term follow-up sessions. In particular, more TAU studies would be beneficial in contributing to the development of effective treatment methods and the well-being of clients. Few TAU studies of the treatment of ODD exist in the literature, and those located indicate a small effect at termination (d+ = .36). No follow-up TAU studies were located that met selection criteria. Ethical quandaries that stem from withholding treatment from participants in control groups can be avoided through the use of a TAU design (Erford et al., 2011; Weisz, McCarty, & Valeri, 2006). The use of TAU studies would allow all participants to receive treatment comparable to what they normally receive, as opposed to other research designs that assign participants to a control group that does not receive treatment. Certainly, it is of value to know that a treatment is more effective than no treatment at all, but it is of even greater value to know that a treatment is more effective than some other therapeutic intervention the client is likely to receive in normal clinical practice.

Finally, future research focusing on the efficacy of treatment for oppositional behavior and other disorders must use standardized treatment procedures that ensure that interventions can be duplicated in clinical settings. Although the studies used in this meta-analysis were all published in peer-reviewed journals, the descriptions of the procedures and samples used were not consistently sufficient to be successfully replicated. The inability to replicate previous research prevents advancement and substantiates a need for researchers to be more stringent in reporting methods and sample characteristics. It is also important that journal editors maintain consistency in requiting that sufficient information is included to allow adequate replication of studies.

Received 09/09/12

Revised 12/24/12

Accepted 01/28/13

DOI:10.1002/j.1556-6676.2014.00125.x

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Bradley T. Erford, Lauren E. Paul, and Conor Oncken, Education Specialties Department, Loyola University Maryland; Victoria E. Krese, Department of Counseling and Special Education, Youngstown State University; Matthew R. Erford, Department of Psychology, Susquehanna University. Correspondence concerning this article should be addressed to Bradley T. Erford, Education Specialties Department, Loyola University Maryland, Timonium Graduate Center, 2034 Greenspring Drive, Timonium, MD 21093 (e-mail: berford@loyola.edu).
TABLE 1
Characteristics of Individual Studies Used in the Meta-Analysis

Study                       Summary of Treatment

Barkley et al. (2001)       Problem-solving communication and
                              behavior management training
Bogels et al. (2008)        Mindfulness training
Chase & Eyberg (2008)       Parent-child interaction therapy
Connell et al. (1997)       Behavior family intervention for parents
Costin & Chambers (2007)    Parent management training
Drugli & Larsson (2006)     Parent training and child therapy
Ducharme et al. (2000)      Success-based, noncoercive treatment
Erford (1999)               Regular and modified time-out procedure
Greene et al. (2004)        Collaborative problem solving, parent
                              training
Hastings & Ludlow (2006)    Pleasurable parenting
Hautmann et al. (2009)      Parent management training
Kazdin et al. (1992)        Cognitive problem-solving skills and
                              parent management training
Kazdin & Wassell (2000)     Parent management training,
                            problem-solving skills training
Kazdin & Whitley (2006)     Parent management training,
                              problem-solving skills training
Kolko et al. (2009)         Community and clinic-based modular
                              treatment
Larsson et al. (2009)       Incredible Years parent training program
                              only
Luk et al. (2001)           Unspecified
McNeil et al. (1991)        Parent-child interaction therapy
Muris et al. (2005)         Social-cognitive group intervention
Nelson-Gray et al. (2006)   Modified dialectical behavior therapy
Nicholson & Sanders         Behavior family intervention
  (1999)
Nitkowski et al. (2009)     Behavior modification
Owens et al. (2005)         Parent training and behavior modification
Powers & Roberts (1995)     Simulation vs. parent training
Scahill et al. (2006)       Parent management training
Schuhmann et al. (1998)     Parent-child interaction therapy
Scott et al. (2010)         Parent groups
Webster-Stratton (1990)     Self-administered videotape training
Webster-Stratton (1992)     Individually administered videotape
                              training
Webster-Stratton &          Child and parent training
  Hammond (1997)
Webster-Stratton et al.     Parent training, child training
  (2004)

                                          M Age
Study                           n        (Years)   %Male

Barkley et al. (2001)         35.32       14.6      88

Bogels et al. (2008)          14.12       14.4      57
Chase & Eyberg (2008)           44         4.5      66
Connell et al. (1997)           23         4.3      44
Costin & Chambers (2007)        21         9.1      81
Drugli & Larsson (2006)       59.64        6.6      80
Ducharme et al. (2000)          15         6.9      67
Erford (1999)                 18.18        6.5      100
Greene et al. (2004)          28.19        -8       Dk
Hastings & Ludlow (2006)        65         6.4      60
Hautmann et al. (2009)         210         6.5      79
Kazdin et al. (1992)        25,20, 21     10.3      78
Kazdin & Wassell (2000)        250         7.8      76
Kazdin & Whitley (2006)        183         7.9      77
Kolko et al. (2009)           70.69        8.8      85
Larsson et al. (2009)         95,108       6.6      80
Luk et al. (2001)               29         9.3      83
McNeil et al. (1991)            18         4.6      77
Muris et al. (2005)           31.11       10.3      76
Nelson-Gray et al. (2006)       32        12.6      85
Nicholson & Sanders             42         9.6      64
  (1999)
Nitkowski et al. (2009)         24        10.1      88
Owens et al. (2005)             42         8.5      67
Powers & Roberts (1995)         18         4.0      72
Scahill et al. (2006)           24         8.9      75
Schuhmann et al. (1998)         64         4.9      81
Scott et al. (2010)             96         5.6      70
Webster-Stratton (1990)       35.31        5.1      79
Webster-Stratton (1992)        100         5.0      72
Webster-Stratton &          34, 33, 28     5.7      74
  Hammond (1997)
Webster-Stratton et al.       44.42        5.9      90
  (2004)

                            Control Group
Study                           Type        % White

Barkley et al. (2001)       Single group      86

Bogels et al. (2008)        Single group      Dk
Chase & Eyberg (2008)       Single group      77
Connell et al. (1997)         Wait list       100
Costin & Chambers (2007)    Single group      Dk
Drugli & Larsson (2006)       Wait list       Dk
Ducharme et al. (2000)      Single group      Dk
Erford (1999)                 Wait list       Dk
Greene et al. (2004)        Single group      89
Hastings & Ludlow (2006)    Single group      95
Hautmann et al. (2009)      Single group      Dk
Kazdin et al. (1992)        Single group      69
Kazdin & Wassell (2000)     Single group      74
Kazdin & Whitley (2006)     Single group      73
Kolko et al. (2009)         Single group      48
Larsson et al. (2009)         Wait list       Dk
Luk et al. (2001)           Single group      Dk
McNeil et al. (1991)          Wait list       77
Muris et al. (2005)         Single group      81
Nelson-Gray et al. (2006)   Single group      47
Nicholson & Sanders           Wait list       Dk
  (1999)
Nitkowski et al. (2009)       Wait list       Dk
Owens et al. (2005)           Wait list       Dk
Powers & Roberts (1995)          TAU          Dk
Scahill et al. (2006)            TAU          96
Schuhmann et al. (1998)         Wait          77
Scott et al. (2010)              TAU          62
Webster-Stratton (1990)       Wait list       Dk
Webster-Stratton (1992)       Wait list       Dk
Webster-Stratton &            Wait list       86
  Hammond (1997)
Webster-Stratton et al.       Wait list       79
  (2004)

Study                       ODD Outcome Measure

Barkley et al. (2001)       Teen ODD Behavior

Bogels et al. (2008)        CBCL Externalizing; YSR Externalizing
Chase & Eyberg (2008)       ODD symptoms
Connell et al. (1997)       ECBI; Parent Daily Report Checklist
Costin & Chambers (2007)    ECBI; CBCL Aggression
Drugli & Larsson (2006)     TRF Aggression
Ducharme et al. (2000)      CBCL Externalizing; Compliance Probability
                              Checklist
Erford (1999)               Noncompliance episodes
Greene et al. (2004)        ODD Rating Scale
Hastings & Ludlow (2006)    ECBI; Oppositional Defiant Behavior
                              Toward Adults
Hautmann et al. (2009)      CBCL Externalizing; Symptom Checklist ODD
Kazdin et al. (1992)        CBCL Total Problem Behaviors; TRF Total
                              Problem Behaviors; Health Resources
                              Inventory (Following Rules)
Kazdin & Wassell (2000)     CBCL Total Problem Behaviors; Parent Daily
                              Report; Interview for Antisocial
Kazdin & Whitley (2006)     CBCL Total Problem Behaviors; Interview
                              Antisocial Behavior; Parent Daily Report
Kolko et al. (2009)         CBCL Externalizing; Iowa Conners
                              Oppositional Defiant; TRF Externalizing;
                              KSADS ODD Conduct Disorder
Larsson et al. (2009)       ECBI mother and father responses; CBCL
                              Aggressive Behavior mother and father
                              responses
Luk et al. (2001)           ECBI; CBCL Externalizing;
                              TRF Externalizing
McNeil et al. (1991)        Sutter-Eyberg Student Behavior Inventory;
                              percent compliance
Muris et al. (2005)         CBCL Externalizing; TRF Externalizing;
                              YSR Externalizing
Nelson-Gray et al. (2006)   CBCL Aggression; YSR Aggression; DISC-ODD
Nicholson & Sanders         CBCL Total Problem Behaviors; Parent
  (1999)                      Daily Report
Nitkowski et al. (2009)     CBCL Aggressive Behavior; TRF Aggressive
                              Behavior; SDQ-P Conduct Problems
Owens et al. (2005)         Disruptive Behavior Disorders Rating
                              Scale, parent and teacher responses;
                              CBCL DSM ODD; TRF DSM ODD
Powers & Roberts (1995)     Compliance
Scahill et al. (2006)       Disruptive Behavior Rating Scale; Home
                              Situations Questionnaire
Schuhmann et al. (1998)     ECBI
Scott et al. (2010)         ECBI; Teacher ODD symptoms
Webster-Stratton (1990)     ECBI; CBCL Total Problem Behaviors
Webster-Stratton (1992)     ECBI; CBCL Total Problem Behaviors;
                              Timeout; Target Negative
Webster-Stratton &          ECBI; CBCL Total Problem Behaviors
  Hammond (1997)
Webster-Stratton et al.     Child Conduct at Home or School
  (2004)

Note. ODD = oppositional defiant disorder; Dk = don't know;
CBCL = Child Behavior Checklist; YSR =Youth Self-Report;
ECBI = Eyberg Child Behavior Inventory; TRF =Teacher's
Report Form; KSADS = Kiddie Schedule for Affective Disorders
and Schizophrenia; DISC = Diagnostic Interview Schedule for
Children; SDQ-P = Strengths and Difficulties Questionnaire-Parents;
DSM= Diagnostic and Statistical Manual of Mental Disorders;
TAU = treatment as usual.

TABLE 2

Summary of Posttest and Follow-Up Results

                                                       95% CI

Condition                    k      n       d+       Low    High

Termination (posttest)
  results
    Single group             15   1,251   .63 (a)    .47    .79
    Wait list                13     926   .68 (a)    .50    .86
    Treatment as usual        3     136       .36   -.02    .75
Longest interval follow-up
  results
    Single group              7     440   .62 (a)    .39    .85
    Wait list                 1     127       .37   -.06    .80

Note. k= number of studies; d+= mean effect size estimate; 95%
CI = 95% confidence interval.

(a) d+ > 0 (* p < .05).

TABLE 3

Summary of Posttest and Follow-Up Results
by Time Interval

                  Posttest   1-4 Months   6 Months

Condition          d+    k    d+   k       d+     k
Follow-up study
continuum
Single group      .63   15   .62   5      .36     1
Wait list         .68   14

                  12 Months   36 Months

Condition          d+   k     d+     k
Follow-up study
continuum
Single group      .47   4     1.14   1
Wait list         .37   2

Note. d+ = mean effect size estimate; k = number of studies.
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Author:Erford, Bradley T.; Paul, Lauren E.; Oncken, Conor; Kress, Victoria E.; Erford, Matthew R.
Publication:Journal of Counseling and Development
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2014
Words:9463
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