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What are effective treatments for oppositional and defiant behaviors in preadolescents?
Parent training is effective for treating oppositional and defiant behaviors (strength of recommendation [SOR]: A, based on systematic reviews). Parent training programs are standardized, short-term interventions that teach parents specialized strategies—including positive attending, ignoring, the effective use of rewards and punishments, token economies, and time out—to address clinically significant behavior problems. In addition to parent training, other psychosocial interventions (Table) are efficacious in treating oppositional and defiant behavior.
To date, no studies have assessed the efficacy of medication in treating children with pure oppositional defiant disorder (ODD). However, studies have shown amphetamines to be effective for children with ODD and comorbid attention deficit/hyperactivity disorder (ADHD) (SOR: A, based on a meta-analysis).
Evidence summary
Oppositional and defiant behaviors include noncompliance, temper tantrums, arguing, and mild aggression. Children exhibiting these behaviors may have a diagnosis of ODD. Importantly, this review does not examine treatments for children diagnosed with conduct disorder or those exhibiting more deviant behaviors such as serious aggression and delinquency.
Eight well-done systematic reviews examined the effectiveness of parent training programs. Parent training is typically conducted by clinical child psychologists but may also be available through certified parenting educators (see the National Parenting Education Network web page for links to state organizations, at www.ces.ncsu.edu/depts/fcs/npen/). Parent training strategies are also described for parents in books such as Your Defiant Child.1
The most rigorous of the reviews looked at 16 randomized controlled trials that examined the effectiveness of training programs for children between the ages of 3 and 10 years who had “externalizing problems,” including temper tantrums, aggression, and noncompliance.2 All studies included in the review compared a group-based parent training program with a no-treatment wait-list control group and assessed outcomes using a standardized measure of behavior. In studies where sufficient data were provided, effect sizes ranged from 0.6 to 2.9. This indicates that, on a standardized child behavioral measure, parental report of children’s externalizing problems decreased by 0.6 to 2.9 standard deviations from pre- to posttreatment (an effect size of >0.8 is considered large). In the 2 studies that included independent observations of child behavior, the benefits reported by parents were confirmed by these observations.
Although parent training has the strongest evidence as a treatment for oppositional and defiant behavior, other psychosocial treatment interventions have been found by multiple randomized controlled trials to be superior to no treatment or wait-list controls (Table).
In treating oppositional behaviors among children with ADHD and comorbid oppositional defiant disorder or conduct disorder, a meta-analysis identified 28 studies of children age 7 to 15 years that addressed oppositional/aggression-related behaviors within the context of ADHD.8 The analysis found that stimulants are efficacious. The overall weighted effect size (a measure of improvement representing the average effects across all reporters) was 0.89. This indicates that raters saw a change in oppositional behaviors—noncompliance, irritability, and temper tantrums—that corresponded to a drop in scores of approximately 1 standard deviation.
TABLE
Additional ODD treatments supported by randomized controlled trials
| Treatment and representative study | Treatment description | Outcome |
|---|---|---|
| Anger Coping Therapy3 | A 12- to 18-session group cognitive-behavioral and social problem-solving training program. Assessed independently (AC) and with a teacher component (ACTC) | AC and ACTC exhibited reductions in directly observed disruptive and aggressive classroom behavior (P.<.05). |
| SOR: B | No significant differences between AC and ACTC | |
| Problem Solving Skills Training4 | A 20- to 25-session individual child skills training. | 33% (parent report) to 57% (teacher report) of the PSST group and 64%–69% Assessed individually of the PSST+PT |
| group were within the SOR: B | (PSST) and with PT | normal range after treatment. Gains maintained at 1 year. No control group. |
| In an inpatient population, PSST showed greater decreases in externalizing and aggressive behaviors than controls (P.<.01)5 | ||
| Dina Dinosaur Social Emotional and Problem Solving Child Training/ Incredible Years Child Training6 | An 18- to 22-session group skills training program. | PT and PT+CT groups demonstrated fewer mother-reported behavior problems at post-test. Effect sizes: PT vs. control = .89 (P.<.05); PT + CT vs. control = .73 (P.<.05) |
| SOR: B | Assessed as an independent treatment and with PT | One-year follow-up: compared with baseline, 95% of children in the PT+CT group, 74% in the CT group, and 60% in the PT group exhibited at least a 30% reduction in home-observed deviant behaviors. The difference between the PT + CT and PT groups was significant (P.<.01) |
| Incredible Years Teacher Training7 | A classroom teacher training program. | Per parent report, 55% (PT + CT + TT), 59% (PT + TT), 47% (CT + TT) and 20% (control group) had a reduction of 20% or and PT+CT more in behavior problems. The difference between the control group was significant for the PT + CT + TT and PT + TT groups. |
| SOR: B | Assessed with PT, CT | Two-year follow-up: 75% of treated children were within the normal range per parent and teacher reports. No control group. |
| AC = Anger coping therapy; ACTC = Anger coping therapy with teacher consultation; | ||
| CT = Child Training; PSST = Problem Solving Skills Training; | ||
Recommendations from others
Two parent training interventions meet the American Psychological Association’s criteria for well-established treatments.9 These include programs based on Patterson and Gullion’s Living with Children, a short-term, behavioral parent training program, and programs based on WebsterStratton’s Videotape Modeling parent training program. Two additional treatments, Anger Coping Therapy and Problem Solving Skills Training, meet the criteria for “probably efficacious.”
According to the International Consensus Statement on ADHD and Disruptive Behavior Disorders, “pharmacological treatment of pure ODD should not be considered except in cases where aggression is a significant, persistent problem.”10
Psychological interventions for parent and child are essential
Richard C. Fulkerson, MD
Anita R. Webb, PhD
John Peter Smith Family Medicine Residency Program, Fort Worth, Tex
Oppositional and defiant behaviors are a family problem requiring a family solution. Frustrated parents often request a “quick fix,” so this literature review is helpful in defining when medications are not indicated. Psychological interventions for the parents and for the child are essential. An important role for the family physician is to convince parents that their participation is critical in treating this problem. In addition to encouraging referrals to psychological resources in the community and occasionally prescribing medication, another role for the physician is to model parenting skills. The physician can demonstrate the “Tough Love” philosophy of holding the child responsible for unacceptable behavior without rejecting the child or blaming other people. An additional role could be to schedule brief checkup/counseling sessions with the family and child. These roles can be time consuming without necessarily having the assurance that all of them are evidence-based. However, the value of having multiple role options is that family physicians can develop an individualized approach for helping each family, as long as the emphasis remains on parental involvement.
1. Barkley RA, Benton CM. Your Defiant Child: Eight Steps to Better Behavior. New York: Guilford Press; 1998.
2. Barlow J, Stewart-Brown S. Behavior problems and groupbased parent education programs. J Dev Behav Pediatr 2000;21:356-370.
3. Lochman JE, Lampron LB, Gemmer TC, Harris SR, Wyckoff GM. Teacher consultation and cognitive-behavioral interventions with aggressive boys. Psychol Schools 1989;26:179-188.
4. Kazdin AE, Siegel TC, Bass D. Cognitive problem solving skills training and parent management training in the treatment of antisocial behavior in children. J Consult Clin Psychol 1992;60:733-747.
5. Kazdin AE, Esveldt-Dawson K, French NH, Unis AS. Problem-solving skills training and relationship therapy in the treatment of antisocial child behavior. J Consult Clin Psychol 1987;55:76-85.
6. Webster-Stratton C, Reid MJ. Treating conduct problems and strengthening social and emotional competence in young children: the dina dinosaur treatment program. J Emot Behav Disord 2003;11:130-143.
7. Reid MJ, Webster-Stratton C, Hammond M. Follow-up of children who received the incredible years intervention for oppositional-defiant disorder: maintenance and prediction of 2-year outcome. Behav Ther 2003;34:471-491.
8. Connor DF, Glatt SJ, Lopez ID, Jackson D, Melloni RH Jr. Psychopharmacology and aggression. I: A meta-analysis of stimulant effects on overt/covert aggression-related behaviors in ADHD. J Am Acad Child Adolesc Psychiatry 2002;41:253-261.
9. Brestan EV, Eyberg SM. Effective psychosocial treatments of conduct-disordered children and adolescents: 29 years, 82 studies, and 5,272 kids. J Clin Child Psychol 1998;27:180-189.
10. Kutcher S, Aman M, Brooks SJ, et al. International consensus statement on attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs): clinical implications and treatment practice suggestions. Eur Neuropsychopharmacol 2004;14:11-28.
Parent training is effective for treating oppositional and defiant behaviors (strength of recommendation [SOR]: A, based on systematic reviews). Parent training programs are standardized, short-term interventions that teach parents specialized strategies—including positive attending, ignoring, the effective use of rewards and punishments, token economies, and time out—to address clinically significant behavior problems. In addition to parent training, other psychosocial interventions (Table) are efficacious in treating oppositional and defiant behavior.
To date, no studies have assessed the efficacy of medication in treating children with pure oppositional defiant disorder (ODD). However, studies have shown amphetamines to be effective for children with ODD and comorbid attention deficit/hyperactivity disorder (ADHD) (SOR: A, based on a meta-analysis).
Evidence summary
Oppositional and defiant behaviors include noncompliance, temper tantrums, arguing, and mild aggression. Children exhibiting these behaviors may have a diagnosis of ODD. Importantly, this review does not examine treatments for children diagnosed with conduct disorder or those exhibiting more deviant behaviors such as serious aggression and delinquency.
Eight well-done systematic reviews examined the effectiveness of parent training programs. Parent training is typically conducted by clinical child psychologists but may also be available through certified parenting educators (see the National Parenting Education Network web page for links to state organizations, at www.ces.ncsu.edu/depts/fcs/npen/). Parent training strategies are also described for parents in books such as Your Defiant Child.1
The most rigorous of the reviews looked at 16 randomized controlled trials that examined the effectiveness of training programs for children between the ages of 3 and 10 years who had “externalizing problems,” including temper tantrums, aggression, and noncompliance.2 All studies included in the review compared a group-based parent training program with a no-treatment wait-list control group and assessed outcomes using a standardized measure of behavior. In studies where sufficient data were provided, effect sizes ranged from 0.6 to 2.9. This indicates that, on a standardized child behavioral measure, parental report of children’s externalizing problems decreased by 0.6 to 2.9 standard deviations from pre- to posttreatment (an effect size of >0.8 is considered large). In the 2 studies that included independent observations of child behavior, the benefits reported by parents were confirmed by these observations.
Although parent training has the strongest evidence as a treatment for oppositional and defiant behavior, other psychosocial treatment interventions have been found by multiple randomized controlled trials to be superior to no treatment or wait-list controls (Table).
In treating oppositional behaviors among children with ADHD and comorbid oppositional defiant disorder or conduct disorder, a meta-analysis identified 28 studies of children age 7 to 15 years that addressed oppositional/aggression-related behaviors within the context of ADHD.8 The analysis found that stimulants are efficacious. The overall weighted effect size (a measure of improvement representing the average effects across all reporters) was 0.89. This indicates that raters saw a change in oppositional behaviors—noncompliance, irritability, and temper tantrums—that corresponded to a drop in scores of approximately 1 standard deviation.
TABLE
Additional ODD treatments supported by randomized controlled trials
| Treatment and representative study | Treatment description | Outcome |
|---|---|---|
| Anger Coping Therapy3 | A 12- to 18-session group cognitive-behavioral and social problem-solving training program. Assessed independently (AC) and with a teacher component (ACTC) | AC and ACTC exhibited reductions in directly observed disruptive and aggressive classroom behavior (P.<.05). |
| SOR: B | No significant differences between AC and ACTC | |
| Problem Solving Skills Training4 | A 20- to 25-session individual child skills training. | 33% (parent report) to 57% (teacher report) of the PSST group and 64%–69% Assessed individually of the PSST+PT |
| group were within the SOR: B | (PSST) and with PT | normal range after treatment. Gains maintained at 1 year. No control group. |
| In an inpatient population, PSST showed greater decreases in externalizing and aggressive behaviors than controls (P.<.01)5 | ||
| Dina Dinosaur Social Emotional and Problem Solving Child Training/ Incredible Years Child Training6 | An 18- to 22-session group skills training program. | PT and PT+CT groups demonstrated fewer mother-reported behavior problems at post-test. Effect sizes: PT vs. control = .89 (P.<.05); PT + CT vs. control = .73 (P.<.05) |
| SOR: B | Assessed as an independent treatment and with PT | One-year follow-up: compared with baseline, 95% of children in the PT+CT group, 74% in the CT group, and 60% in the PT group exhibited at least a 30% reduction in home-observed deviant behaviors. The difference between the PT + CT and PT groups was significant (P.<.01) |
| Incredible Years Teacher Training7 | A classroom teacher training program. | Per parent report, 55% (PT + CT + TT), 59% (PT + TT), 47% (CT + TT) and 20% (control group) had a reduction of 20% or and PT+CT more in behavior problems. The difference between the control group was significant for the PT + CT + TT and PT + TT groups. |
| SOR: B | Assessed with PT, CT | Two-year follow-up: 75% of treated children were within the normal range per parent and teacher reports. No control group. |
| AC = Anger coping therapy; ACTC = Anger coping therapy with teacher consultation; | ||
| CT = Child Training; PSST = Problem Solving Skills Training; | ||
Recommendations from others
Two parent training interventions meet the American Psychological Association’s criteria for well-established treatments.9 These include programs based on Patterson and Gullion’s Living with Children, a short-term, behavioral parent training program, and programs based on WebsterStratton’s Videotape Modeling parent training program. Two additional treatments, Anger Coping Therapy and Problem Solving Skills Training, meet the criteria for “probably efficacious.”
According to the International Consensus Statement on ADHD and Disruptive Behavior Disorders, “pharmacological treatment of pure ODD should not be considered except in cases where aggression is a significant, persistent problem.”10
Psychological interventions for parent and child are essential
Richard C. Fulkerson, MD
Anita R. Webb, PhD
John Peter Smith Family Medicine Residency Program, Fort Worth, Tex
Oppositional and defiant behaviors are a family problem requiring a family solution. Frustrated parents often request a “quick fix,” so this literature review is helpful in defining when medications are not indicated. Psychological interventions for the parents and for the child are essential. An important role for the family physician is to convince parents that their participation is critical in treating this problem. In addition to encouraging referrals to psychological resources in the community and occasionally prescribing medication, another role for the physician is to model parenting skills. The physician can demonstrate the “Tough Love” philosophy of holding the child responsible for unacceptable behavior without rejecting the child or blaming other people. An additional role could be to schedule brief checkup/counseling sessions with the family and child. These roles can be time consuming without necessarily having the assurance that all of them are evidence-based. However, the value of having multiple role options is that family physicians can develop an individualized approach for helping each family, as long as the emphasis remains on parental involvement.
Parent training is effective for treating oppositional and defiant behaviors (strength of recommendation [SOR]: A, based on systematic reviews). Parent training programs are standardized, short-term interventions that teach parents specialized strategies—including positive attending, ignoring, the effective use of rewards and punishments, token economies, and time out—to address clinically significant behavior problems. In addition to parent training, other psychosocial interventions (Table) are efficacious in treating oppositional and defiant behavior.
To date, no studies have assessed the efficacy of medication in treating children with pure oppositional defiant disorder (ODD). However, studies have shown amphetamines to be effective for children with ODD and comorbid attention deficit/hyperactivity disorder (ADHD) (SOR: A, based on a meta-analysis).
Evidence summary
Oppositional and defiant behaviors include noncompliance, temper tantrums, arguing, and mild aggression. Children exhibiting these behaviors may have a diagnosis of ODD. Importantly, this review does not examine treatments for children diagnosed with conduct disorder or those exhibiting more deviant behaviors such as serious aggression and delinquency.
Eight well-done systematic reviews examined the effectiveness of parent training programs. Parent training is typically conducted by clinical child psychologists but may also be available through certified parenting educators (see the National Parenting Education Network web page for links to state organizations, at www.ces.ncsu.edu/depts/fcs/npen/). Parent training strategies are also described for parents in books such as Your Defiant Child.1
The most rigorous of the reviews looked at 16 randomized controlled trials that examined the effectiveness of training programs for children between the ages of 3 and 10 years who had “externalizing problems,” including temper tantrums, aggression, and noncompliance.2 All studies included in the review compared a group-based parent training program with a no-treatment wait-list control group and assessed outcomes using a standardized measure of behavior. In studies where sufficient data were provided, effect sizes ranged from 0.6 to 2.9. This indicates that, on a standardized child behavioral measure, parental report of children’s externalizing problems decreased by 0.6 to 2.9 standard deviations from pre- to posttreatment (an effect size of >0.8 is considered large). In the 2 studies that included independent observations of child behavior, the benefits reported by parents were confirmed by these observations.
Although parent training has the strongest evidence as a treatment for oppositional and defiant behavior, other psychosocial treatment interventions have been found by multiple randomized controlled trials to be superior to no treatment or wait-list controls (Table).
In treating oppositional behaviors among children with ADHD and comorbid oppositional defiant disorder or conduct disorder, a meta-analysis identified 28 studies of children age 7 to 15 years that addressed oppositional/aggression-related behaviors within the context of ADHD.8 The analysis found that stimulants are efficacious. The overall weighted effect size (a measure of improvement representing the average effects across all reporters) was 0.89. This indicates that raters saw a change in oppositional behaviors—noncompliance, irritability, and temper tantrums—that corresponded to a drop in scores of approximately 1 standard deviation.
TABLE
Additional ODD treatments supported by randomized controlled trials
| Treatment and representative study | Treatment description | Outcome |
|---|---|---|
| Anger Coping Therapy3 | A 12- to 18-session group cognitive-behavioral and social problem-solving training program. Assessed independently (AC) and with a teacher component (ACTC) | AC and ACTC exhibited reductions in directly observed disruptive and aggressive classroom behavior (P.<.05). |
| SOR: B | No significant differences between AC and ACTC | |
| Problem Solving Skills Training4 | A 20- to 25-session individual child skills training. | 33% (parent report) to 57% (teacher report) of the PSST group and 64%–69% Assessed individually of the PSST+PT |
| group were within the SOR: B | (PSST) and with PT | normal range after treatment. Gains maintained at 1 year. No control group. |
| In an inpatient population, PSST showed greater decreases in externalizing and aggressive behaviors than controls (P.<.01)5 | ||
| Dina Dinosaur Social Emotional and Problem Solving Child Training/ Incredible Years Child Training6 | An 18- to 22-session group skills training program. | PT and PT+CT groups demonstrated fewer mother-reported behavior problems at post-test. Effect sizes: PT vs. control = .89 (P.<.05); PT + CT vs. control = .73 (P.<.05) |
| SOR: B | Assessed as an independent treatment and with PT | One-year follow-up: compared with baseline, 95% of children in the PT+CT group, 74% in the CT group, and 60% in the PT group exhibited at least a 30% reduction in home-observed deviant behaviors. The difference between the PT + CT and PT groups was significant (P.<.01) |
| Incredible Years Teacher Training7 | A classroom teacher training program. | Per parent report, 55% (PT + CT + TT), 59% (PT + TT), 47% (CT + TT) and 20% (control group) had a reduction of 20% or and PT+CT more in behavior problems. The difference between the control group was significant for the PT + CT + TT and PT + TT groups. |
| SOR: B | Assessed with PT, CT | Two-year follow-up: 75% of treated children were within the normal range per parent and teacher reports. No control group. |
| AC = Anger coping therapy; ACTC = Anger coping therapy with teacher consultation; | ||
| CT = Child Training; PSST = Problem Solving Skills Training; | ||
Recommendations from others
Two parent training interventions meet the American Psychological Association’s criteria for well-established treatments.9 These include programs based on Patterson and Gullion’s Living with Children, a short-term, behavioral parent training program, and programs based on WebsterStratton’s Videotape Modeling parent training program. Two additional treatments, Anger Coping Therapy and Problem Solving Skills Training, meet the criteria for “probably efficacious.”
According to the International Consensus Statement on ADHD and Disruptive Behavior Disorders, “pharmacological treatment of pure ODD should not be considered except in cases where aggression is a significant, persistent problem.”10
Psychological interventions for parent and child are essential
Richard C. Fulkerson, MD
Anita R. Webb, PhD
John Peter Smith Family Medicine Residency Program, Fort Worth, Tex
Oppositional and defiant behaviors are a family problem requiring a family solution. Frustrated parents often request a “quick fix,” so this literature review is helpful in defining when medications are not indicated. Psychological interventions for the parents and for the child are essential. An important role for the family physician is to convince parents that their participation is critical in treating this problem. In addition to encouraging referrals to psychological resources in the community and occasionally prescribing medication, another role for the physician is to model parenting skills. The physician can demonstrate the “Tough Love” philosophy of holding the child responsible for unacceptable behavior without rejecting the child or blaming other people. An additional role could be to schedule brief checkup/counseling sessions with the family and child. These roles can be time consuming without necessarily having the assurance that all of them are evidence-based. However, the value of having multiple role options is that family physicians can develop an individualized approach for helping each family, as long as the emphasis remains on parental involvement.
1. Barkley RA, Benton CM. Your Defiant Child: Eight Steps to Better Behavior. New York: Guilford Press; 1998.
2. Barlow J, Stewart-Brown S. Behavior problems and groupbased parent education programs. J Dev Behav Pediatr 2000;21:356-370.
3. Lochman JE, Lampron LB, Gemmer TC, Harris SR, Wyckoff GM. Teacher consultation and cognitive-behavioral interventions with aggressive boys. Psychol Schools 1989;26:179-188.
4. Kazdin AE, Siegel TC, Bass D. Cognitive problem solving skills training and parent management training in the treatment of antisocial behavior in children. J Consult Clin Psychol 1992;60:733-747.
5. Kazdin AE, Esveldt-Dawson K, French NH, Unis AS. Problem-solving skills training and relationship therapy in the treatment of antisocial child behavior. J Consult Clin Psychol 1987;55:76-85.
6. Webster-Stratton C, Reid MJ. Treating conduct problems and strengthening social and emotional competence in young children: the dina dinosaur treatment program. J Emot Behav Disord 2003;11:130-143.
7. Reid MJ, Webster-Stratton C, Hammond M. Follow-up of children who received the incredible years intervention for oppositional-defiant disorder: maintenance and prediction of 2-year outcome. Behav Ther 2003;34:471-491.
8. Connor DF, Glatt SJ, Lopez ID, Jackson D, Melloni RH Jr. Psychopharmacology and aggression. I: A meta-analysis of stimulant effects on overt/covert aggression-related behaviors in ADHD. J Am Acad Child Adolesc Psychiatry 2002;41:253-261.
9. Brestan EV, Eyberg SM. Effective psychosocial treatments of conduct-disordered children and adolescents: 29 years, 82 studies, and 5,272 kids. J Clin Child Psychol 1998;27:180-189.
10. Kutcher S, Aman M, Brooks SJ, et al. International consensus statement on attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs): clinical implications and treatment practice suggestions. Eur Neuropsychopharmacol 2004;14:11-28.
1. Barkley RA, Benton CM. Your Defiant Child: Eight Steps to Better Behavior. New York: Guilford Press; 1998.
2. Barlow J, Stewart-Brown S. Behavior problems and groupbased parent education programs. J Dev Behav Pediatr 2000;21:356-370.
3. Lochman JE, Lampron LB, Gemmer TC, Harris SR, Wyckoff GM. Teacher consultation and cognitive-behavioral interventions with aggressive boys. Psychol Schools 1989;26:179-188.
4. Kazdin AE, Siegel TC, Bass D. Cognitive problem solving skills training and parent management training in the treatment of antisocial behavior in children. J Consult Clin Psychol 1992;60:733-747.
5. Kazdin AE, Esveldt-Dawson K, French NH, Unis AS. Problem-solving skills training and relationship therapy in the treatment of antisocial child behavior. J Consult Clin Psychol 1987;55:76-85.
6. Webster-Stratton C, Reid MJ. Treating conduct problems and strengthening social and emotional competence in young children: the dina dinosaur treatment program. J Emot Behav Disord 2003;11:130-143.
7. Reid MJ, Webster-Stratton C, Hammond M. Follow-up of children who received the incredible years intervention for oppositional-defiant disorder: maintenance and prediction of 2-year outcome. Behav Ther 2003;34:471-491.
8. Connor DF, Glatt SJ, Lopez ID, Jackson D, Melloni RH Jr. Psychopharmacology and aggression. I: A meta-analysis of stimulant effects on overt/covert aggression-related behaviors in ADHD. J Am Acad Child Adolesc Psychiatry 2002;41:253-261.
9. Brestan EV, Eyberg SM. Effective psychosocial treatments of conduct-disordered children and adolescents: 29 years, 82 studies, and 5,272 kids. J Clin Child Psychol 1998;27:180-189.
10. Kutcher S, Aman M, Brooks SJ, et al. International consensus statement on attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs): clinical implications and treatment practice suggestions. Eur Neuropsychopharmacol 2004;14:11-28.
Evidence-based answers from the Family Physicians Inquiries Network
Does stimulant therapy help adult ADHD?
Central nervous system stimulants improve symptoms of attention deficit–hyperactivity disorder (ADHD) in adults (strength of recommendation: B, based on an older, inconclusive systematic review, a lesser-quality systematic review, and several newer small randomized controlled trials).
Although not the focus of this question, nonstimulant medications (including buproprion, modafinil, and guanfacine) have also been studied in the treatment of ADHD in adults. Recently, atomoxetine became the only nonstimulant medication to receive approval by the US Food and Drug Administration for the treatment of ADHD.
Evidence summary
A well-done systematic review of 12 trials assessing the efficacy of stimulant therapy in the treatment of adult ADHD did not find sufficient evidence that stimulants were effective.1 Significant heterogeneity and poor reporting of methodology was seen among the studies.
The 1 study rated as high-quality was a 7-week randomized controlled trial using a crossover comparison of methylphenidate and placebo.2 There was a favorable response in 78% (18/23) of subjects while takin methylphenidate, in contrast to 4% (1/23) while taking placebo (number needed to treat [NNT]=1.4; P<.0001). A favorable response was assessed by the Clinical Global Impression Scale, a measure of illness severity and improvement, and a >30% reduction in symptoms as measured by the ADHD Rating Scale. A more recent, but less rigorous, systematic review identified 15 studies of stimulant efficacy in adults.3 Researchers concluded that under controlled conditions, stimulants are efficacious in the treatment of ADHD in adults. The rate of response among the studies ranged from 25% to 78%.
One of the better studies in this review was a randomized, double-blind, 3-phase crossover study of dextroamphetamine, modafinil (a drug used to treat narcolepsy), and placebo.4 Each phase was 2 weeks long, with a 4-day washout in between. A favorable response was defined as a reduction of ADHD symptoms by at least 30% on the DSM-IV ADHD Behavior Checklist for Adults. Dextroamphetamine and modafinil showed the same response rate in 10 of 21 patients. Both treatments had a significant improvement over placebo (P<.001). It was unclear from the study what percentage of subjects responded to placebo.
A similar study compared dextroamphetamine, guanfacine (an antihypertensive agent), and placebo in 17 patients.5 On the DSM-IV ADHD Behavior Checklist for Adults, subjects taking dextroamphetamine or guanfacine reported similar decreases in mean ADHD scores compared with placebo (24 vs 22 vs 30; P<.05). They did not report the number of subjects who had a 30% reduction in symptoms. Of note: at the end of the study but prior to unblinding, subjects were asked which medication they preferred. Twelve subjects chose dextroamphetamine, 4 chose guanfacine, and 1 chose placebo. Subjects’ stated reason for choosing dextroamphetamine was the positive effect it had on their motivation.
Another study included in this review was a randomized controlled trial of mixed amphetamine salts. Of the 27 adults who completed the study, 19 (70%) responded favorably to mixed amphetamine salts compared with 2 (7.4%) receiving placebo (NNT=1.6; P<.001).6 Favorable response was defined as more than a 30% reduction of symptoms on the ADHD Rating Scale. Not included in either review was a 7-week randomized controlled trial comparing methylphenidate with sustained-release buproprion.7 Thirty out of 37 subjects completed at least 1 week of the study. The primary indicator of a favorable response was the Clinical Global Impression Scale. The rate of response was 50% for methylphenidate, 64% for sustained-release buproprion, and 27% for placebo (P<.14).
Recommendations from others
The American Academy of Child and Adolescent Psychiatry8 concluded that stimulant medication can be used to treat adults who have been carefully evaluated. They recommend starting methylphenidate, dextroamphetamine, or mixed amphetamine salts according to patient and clinician preference (Table). They do not recommend the use of pemoline due to the potential for hepatic failure.
TABLE
Stimulants used to treat ADHD in adults
| Drug | Starting dose | Maximum daily dose |
|---|---|---|
| Methylphenidate | ||
| Ritalin, Methylin | 5 mg twice daily | 65 mg* |
| Ritalin-SR, Methylin ER, Metadate ER, Metadate CR | 20 mg every morning | 65 mg* |
| Concerta | 18 mg every morning | 54 mg |
| Dextroamphetamine sulfate | ||
| Dexedrine | 2.5 mg twice daily | 45 mg* |
| Dexedrine spansules | 5 mg every morning | 45 mg* |
| Mixed amphetamine salts | ||
| Adderall | 5 mg | 40 mg |
| Adderall XR | 10 mg every morning | 30 mg |
| *American Academy of Child and Adolescent Psychiatry Practice Parameter | ||
Medication can help even well-adapted adults with ADHD
Daniel Triezenberg, MD
Family Practice Residency, Saint Joseph Regional Medical Center, South Bend, Ind
Stimulant therapy benefits many adult patients with ADHD. While some adults need scheduled dosing, others do well with as-needed dosing.
Adults with ADHD often have made behavioral adaptations that allow success without medication. Drugs help these patients when focused attention is critical for specific tasks. A salesman doing a month-end report may find the improvement in attention helpful, but not needed for most daily tasks. A college student may need medication only for a specific class or project. Physicians can help patients with ADHD through anticipatory guidance in choosing a program of study or career goal and then collaborating in choosing appropriate behavioral and medication therapies.
1. Jadad AR, Boyle M, Cunningham C, Kim M, Schachar R. Treatment of attention-deficit/hyperactivity disorder. Evid Rep Technol Assess (Summ) 1999;11:i-viii,1-341.
2. Spencer T, Wilens T, Biederman J, Faraone S, Ablon S, Lapey K. A double-blind, crossover comparison of methylphenidate and placebo in adults with childhoodonset attention-deficit hyperactivity disorder. Arch Gen Psychiatry 1995;52:434-443.
3. Wilens T, Spencer J, Biederman J. A review of the pharmacotherapy of adults with attention-deficit/hyperactivity disorder. J Atten Disord 2002;5:189-202.
4. Taylor F, Russo J. Efficacy of modafinil compared to dextroamphetamine for the treatment of attention deficit hyperactivity disorder in adults. J Child Adolesc Psychopharmacol 2000;10:311-320.
5. Taylor F, Russo J. Comparing guanfacine and dextroamphetamine for the treatment of adult attention-deficit/hyperactivity disorder. J Clin Psychopharmacol 2001;21:223-228.
6. Spencer T, Biederman J, Wilens T, et al. Efficacy of mixed amphetamine salts compound in adults with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 2001;58:775-782.
7. Kuperman S, Perry P, Gaffney G, et al. Buproprion SR vs. methylphenidate vs. placebo for attention deficit hyperactivity disorder in adults. Ann Clin Psychiatry 2001;13:129-134.
8. American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of stimulant medications in the treatment of children, adolescents and adults. J Am Acad Chil Adolesc Psychiatry 2001;41:26S-49S.
Central nervous system stimulants improve symptoms of attention deficit–hyperactivity disorder (ADHD) in adults (strength of recommendation: B, based on an older, inconclusive systematic review, a lesser-quality systematic review, and several newer small randomized controlled trials).
Although not the focus of this question, nonstimulant medications (including buproprion, modafinil, and guanfacine) have also been studied in the treatment of ADHD in adults. Recently, atomoxetine became the only nonstimulant medication to receive approval by the US Food and Drug Administration for the treatment of ADHD.
Evidence summary
A well-done systematic review of 12 trials assessing the efficacy of stimulant therapy in the treatment of adult ADHD did not find sufficient evidence that stimulants were effective.1 Significant heterogeneity and poor reporting of methodology was seen among the studies.
The 1 study rated as high-quality was a 7-week randomized controlled trial using a crossover comparison of methylphenidate and placebo.2 There was a favorable response in 78% (18/23) of subjects while takin methylphenidate, in contrast to 4% (1/23) while taking placebo (number needed to treat [NNT]=1.4; P<.0001). A favorable response was assessed by the Clinical Global Impression Scale, a measure of illness severity and improvement, and a >30% reduction in symptoms as measured by the ADHD Rating Scale. A more recent, but less rigorous, systematic review identified 15 studies of stimulant efficacy in adults.3 Researchers concluded that under controlled conditions, stimulants are efficacious in the treatment of ADHD in adults. The rate of response among the studies ranged from 25% to 78%.
One of the better studies in this review was a randomized, double-blind, 3-phase crossover study of dextroamphetamine, modafinil (a drug used to treat narcolepsy), and placebo.4 Each phase was 2 weeks long, with a 4-day washout in between. A favorable response was defined as a reduction of ADHD symptoms by at least 30% on the DSM-IV ADHD Behavior Checklist for Adults. Dextroamphetamine and modafinil showed the same response rate in 10 of 21 patients. Both treatments had a significant improvement over placebo (P<.001). It was unclear from the study what percentage of subjects responded to placebo.
A similar study compared dextroamphetamine, guanfacine (an antihypertensive agent), and placebo in 17 patients.5 On the DSM-IV ADHD Behavior Checklist for Adults, subjects taking dextroamphetamine or guanfacine reported similar decreases in mean ADHD scores compared with placebo (24 vs 22 vs 30; P<.05). They did not report the number of subjects who had a 30% reduction in symptoms. Of note: at the end of the study but prior to unblinding, subjects were asked which medication they preferred. Twelve subjects chose dextroamphetamine, 4 chose guanfacine, and 1 chose placebo. Subjects’ stated reason for choosing dextroamphetamine was the positive effect it had on their motivation.
Another study included in this review was a randomized controlled trial of mixed amphetamine salts. Of the 27 adults who completed the study, 19 (70%) responded favorably to mixed amphetamine salts compared with 2 (7.4%) receiving placebo (NNT=1.6; P<.001).6 Favorable response was defined as more than a 30% reduction of symptoms on the ADHD Rating Scale. Not included in either review was a 7-week randomized controlled trial comparing methylphenidate with sustained-release buproprion.7 Thirty out of 37 subjects completed at least 1 week of the study. The primary indicator of a favorable response was the Clinical Global Impression Scale. The rate of response was 50% for methylphenidate, 64% for sustained-release buproprion, and 27% for placebo (P<.14).
Recommendations from others
The American Academy of Child and Adolescent Psychiatry8 concluded that stimulant medication can be used to treat adults who have been carefully evaluated. They recommend starting methylphenidate, dextroamphetamine, or mixed amphetamine salts according to patient and clinician preference (Table). They do not recommend the use of pemoline due to the potential for hepatic failure.
TABLE
Stimulants used to treat ADHD in adults
| Drug | Starting dose | Maximum daily dose |
|---|---|---|
| Methylphenidate | ||
| Ritalin, Methylin | 5 mg twice daily | 65 mg* |
| Ritalin-SR, Methylin ER, Metadate ER, Metadate CR | 20 mg every morning | 65 mg* |
| Concerta | 18 mg every morning | 54 mg |
| Dextroamphetamine sulfate | ||
| Dexedrine | 2.5 mg twice daily | 45 mg* |
| Dexedrine spansules | 5 mg every morning | 45 mg* |
| Mixed amphetamine salts | ||
| Adderall | 5 mg | 40 mg |
| Adderall XR | 10 mg every morning | 30 mg |
| *American Academy of Child and Adolescent Psychiatry Practice Parameter | ||
Medication can help even well-adapted adults with ADHD
Daniel Triezenberg, MD
Family Practice Residency, Saint Joseph Regional Medical Center, South Bend, Ind
Stimulant therapy benefits many adult patients with ADHD. While some adults need scheduled dosing, others do well with as-needed dosing.
Adults with ADHD often have made behavioral adaptations that allow success without medication. Drugs help these patients when focused attention is critical for specific tasks. A salesman doing a month-end report may find the improvement in attention helpful, but not needed for most daily tasks. A college student may need medication only for a specific class or project. Physicians can help patients with ADHD through anticipatory guidance in choosing a program of study or career goal and then collaborating in choosing appropriate behavioral and medication therapies.
Central nervous system stimulants improve symptoms of attention deficit–hyperactivity disorder (ADHD) in adults (strength of recommendation: B, based on an older, inconclusive systematic review, a lesser-quality systematic review, and several newer small randomized controlled trials).
Although not the focus of this question, nonstimulant medications (including buproprion, modafinil, and guanfacine) have also been studied in the treatment of ADHD in adults. Recently, atomoxetine became the only nonstimulant medication to receive approval by the US Food and Drug Administration for the treatment of ADHD.
Evidence summary
A well-done systematic review of 12 trials assessing the efficacy of stimulant therapy in the treatment of adult ADHD did not find sufficient evidence that stimulants were effective.1 Significant heterogeneity and poor reporting of methodology was seen among the studies.
The 1 study rated as high-quality was a 7-week randomized controlled trial using a crossover comparison of methylphenidate and placebo.2 There was a favorable response in 78% (18/23) of subjects while takin methylphenidate, in contrast to 4% (1/23) while taking placebo (number needed to treat [NNT]=1.4; P<.0001). A favorable response was assessed by the Clinical Global Impression Scale, a measure of illness severity and improvement, and a >30% reduction in symptoms as measured by the ADHD Rating Scale. A more recent, but less rigorous, systematic review identified 15 studies of stimulant efficacy in adults.3 Researchers concluded that under controlled conditions, stimulants are efficacious in the treatment of ADHD in adults. The rate of response among the studies ranged from 25% to 78%.
One of the better studies in this review was a randomized, double-blind, 3-phase crossover study of dextroamphetamine, modafinil (a drug used to treat narcolepsy), and placebo.4 Each phase was 2 weeks long, with a 4-day washout in between. A favorable response was defined as a reduction of ADHD symptoms by at least 30% on the DSM-IV ADHD Behavior Checklist for Adults. Dextroamphetamine and modafinil showed the same response rate in 10 of 21 patients. Both treatments had a significant improvement over placebo (P<.001). It was unclear from the study what percentage of subjects responded to placebo.
A similar study compared dextroamphetamine, guanfacine (an antihypertensive agent), and placebo in 17 patients.5 On the DSM-IV ADHD Behavior Checklist for Adults, subjects taking dextroamphetamine or guanfacine reported similar decreases in mean ADHD scores compared with placebo (24 vs 22 vs 30; P<.05). They did not report the number of subjects who had a 30% reduction in symptoms. Of note: at the end of the study but prior to unblinding, subjects were asked which medication they preferred. Twelve subjects chose dextroamphetamine, 4 chose guanfacine, and 1 chose placebo. Subjects’ stated reason for choosing dextroamphetamine was the positive effect it had on their motivation.
Another study included in this review was a randomized controlled trial of mixed amphetamine salts. Of the 27 adults who completed the study, 19 (70%) responded favorably to mixed amphetamine salts compared with 2 (7.4%) receiving placebo (NNT=1.6; P<.001).6 Favorable response was defined as more than a 30% reduction of symptoms on the ADHD Rating Scale. Not included in either review was a 7-week randomized controlled trial comparing methylphenidate with sustained-release buproprion.7 Thirty out of 37 subjects completed at least 1 week of the study. The primary indicator of a favorable response was the Clinical Global Impression Scale. The rate of response was 50% for methylphenidate, 64% for sustained-release buproprion, and 27% for placebo (P<.14).
Recommendations from others
The American Academy of Child and Adolescent Psychiatry8 concluded that stimulant medication can be used to treat adults who have been carefully evaluated. They recommend starting methylphenidate, dextroamphetamine, or mixed amphetamine salts according to patient and clinician preference (Table). They do not recommend the use of pemoline due to the potential for hepatic failure.
TABLE
Stimulants used to treat ADHD in adults
| Drug | Starting dose | Maximum daily dose |
|---|---|---|
| Methylphenidate | ||
| Ritalin, Methylin | 5 mg twice daily | 65 mg* |
| Ritalin-SR, Methylin ER, Metadate ER, Metadate CR | 20 mg every morning | 65 mg* |
| Concerta | 18 mg every morning | 54 mg |
| Dextroamphetamine sulfate | ||
| Dexedrine | 2.5 mg twice daily | 45 mg* |
| Dexedrine spansules | 5 mg every morning | 45 mg* |
| Mixed amphetamine salts | ||
| Adderall | 5 mg | 40 mg |
| Adderall XR | 10 mg every morning | 30 mg |
| *American Academy of Child and Adolescent Psychiatry Practice Parameter | ||
Medication can help even well-adapted adults with ADHD
Daniel Triezenberg, MD
Family Practice Residency, Saint Joseph Regional Medical Center, South Bend, Ind
Stimulant therapy benefits many adult patients with ADHD. While some adults need scheduled dosing, others do well with as-needed dosing.
Adults with ADHD often have made behavioral adaptations that allow success without medication. Drugs help these patients when focused attention is critical for specific tasks. A salesman doing a month-end report may find the improvement in attention helpful, but not needed for most daily tasks. A college student may need medication only for a specific class or project. Physicians can help patients with ADHD through anticipatory guidance in choosing a program of study or career goal and then collaborating in choosing appropriate behavioral and medication therapies.
1. Jadad AR, Boyle M, Cunningham C, Kim M, Schachar R. Treatment of attention-deficit/hyperactivity disorder. Evid Rep Technol Assess (Summ) 1999;11:i-viii,1-341.
2. Spencer T, Wilens T, Biederman J, Faraone S, Ablon S, Lapey K. A double-blind, crossover comparison of methylphenidate and placebo in adults with childhoodonset attention-deficit hyperactivity disorder. Arch Gen Psychiatry 1995;52:434-443.
3. Wilens T, Spencer J, Biederman J. A review of the pharmacotherapy of adults with attention-deficit/hyperactivity disorder. J Atten Disord 2002;5:189-202.
4. Taylor F, Russo J. Efficacy of modafinil compared to dextroamphetamine for the treatment of attention deficit hyperactivity disorder in adults. J Child Adolesc Psychopharmacol 2000;10:311-320.
5. Taylor F, Russo J. Comparing guanfacine and dextroamphetamine for the treatment of adult attention-deficit/hyperactivity disorder. J Clin Psychopharmacol 2001;21:223-228.
6. Spencer T, Biederman J, Wilens T, et al. Efficacy of mixed amphetamine salts compound in adults with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 2001;58:775-782.
7. Kuperman S, Perry P, Gaffney G, et al. Buproprion SR vs. methylphenidate vs. placebo for attention deficit hyperactivity disorder in adults. Ann Clin Psychiatry 2001;13:129-134.
8. American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of stimulant medications in the treatment of children, adolescents and adults. J Am Acad Chil Adolesc Psychiatry 2001;41:26S-49S.
1. Jadad AR, Boyle M, Cunningham C, Kim M, Schachar R. Treatment of attention-deficit/hyperactivity disorder. Evid Rep Technol Assess (Summ) 1999;11:i-viii,1-341.
2. Spencer T, Wilens T, Biederman J, Faraone S, Ablon S, Lapey K. A double-blind, crossover comparison of methylphenidate and placebo in adults with childhoodonset attention-deficit hyperactivity disorder. Arch Gen Psychiatry 1995;52:434-443.
3. Wilens T, Spencer J, Biederman J. A review of the pharmacotherapy of adults with attention-deficit/hyperactivity disorder. J Atten Disord 2002;5:189-202.
4. Taylor F, Russo J. Efficacy of modafinil compared to dextroamphetamine for the treatment of attention deficit hyperactivity disorder in adults. J Child Adolesc Psychopharmacol 2000;10:311-320.
5. Taylor F, Russo J. Comparing guanfacine and dextroamphetamine for the treatment of adult attention-deficit/hyperactivity disorder. J Clin Psychopharmacol 2001;21:223-228.
6. Spencer T, Biederman J, Wilens T, et al. Efficacy of mixed amphetamine salts compound in adults with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 2001;58:775-782.
7. Kuperman S, Perry P, Gaffney G, et al. Buproprion SR vs. methylphenidate vs. placebo for attention deficit hyperactivity disorder in adults. Ann Clin Psychiatry 2001;13:129-134.
8. American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of stimulant medications in the treatment of children, adolescents and adults. J Am Acad Chil Adolesc Psychiatry 2001;41:26S-49S.
Evidence-based answers from the Family Physicians Inquiries Network