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1. A transactional model of oppositional behavior
Underpinnings of the Collaborative Problem Solving approach
Ross W. Greenea,
*, J. Stuart Ablona
, Jennifer C. Goringb
a
CPS Institute, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
b
Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
Received 9 January 2002; accepted 17 September 2002
Abstract
Oppositional defiant disorder (ODD) refers to a recurrent
pattern of developmentally inappropriate levels of negativistic,
defiant, disobedient, and hostile behavior toward authority figures.
ODD is one of the most common (and debilitating) comorbid
disorders within Tourette’s disorder (TD). Diverse psychosocial
treatment approaches have been applied to children’s ODD-related
behaviors. In this paper, the authors articulate a transactional
developmental conceptualization of oppositional behavior and
describe a cognitive-behavioral model of intervention — called
Collaborative Problem Solving (CPS) — emanating from this
conceptualization. The specific goals of the CPS approach are to
help adults (1) understand the specific adult and child character-
istics contributing to the development of a child’s oppositional
behavior; (2) become cognizant of three basic strategies for
handling unmet expectations, including (a) imposition of adult
will, (b) CPS, and (c) removing the expectation; (3) recognize the
impact of each of these three approaches on parent–child
interactions; and (4) become proficient, along with their children,
at CPS as a means of resolving disagreements and defusing
potentially conflictual situations so as to reduce oppositional
episodes and improve parent–child compatibility. Summary data
from an initial study documenting the effectiveness of the CPS
approach (in comparison to the standard of care) are also presented.
D 2003 Elsevier Inc. All rights reserved.
Oppositional defiant disorder (ODD) refers to a recurrent
pattern of developmentally inappropriate levels of negativ-
istic, defiant, disobedient, and hostile behavior toward
authority figures. Behaviors associated with ODD include
temper outbursts (sometimes referred to as rage attacks);
persistent stubbornness; resistance to directions; unwilling-
ness to compromise, give in, or negotiate with adults or
peers; deliberate or persistent testing of limits; and verbal
(and minor physical) aggression. These behaviors are almost
always present in the home and with individuals the child
knows well, and often occur simultaneously with low self-
esteem, mood lability, low frustration tolerance, and swear-
ing [3]. ODD is one of the most common (and debilitating)
comorbid disorders within Tourette’s disorder (TD); data
suggest that approximately 65% of children diagnosed with
TD have comorbid ODD [37]. In the general population, the
prevalence of ODD ranges from 2% to 16% [3].
In research, ODD has been relatively neglected as a
distinct entity, and has seldom been considered separately
from conduct disorder (CD) [41,60,61], probably because
ODD has heretofore been viewed simply as an early variant
of CD (as noted in Ref. [84]). Support for this view has
come from data showing that a majority of children diag-
nosed with CD exhibit the behaviors associated with ODD
concurrently or at an earlier age (e.g., Refs. [26,43,62,69]).
While such findings provide support for the belief that there
is considerable continuity between ODD and CD, this
continuity is by no means perfect. Indeed, approximately
two-thirds of children diagnosed with ODD do not sub-
sequently develop CD [8,41,43,61].
Diverse psychosocial treatment approaches have been
applied to children’s ODD-related behaviors. Models
known alternatively as ‘‘parent training’’ (PT) and ‘‘behav-
ioral family therapy,’’ while differing slightly in their
relative emphases on specific aspects of social learning
0022-3999/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0022-3999(02)00585-8
* Corresponding author. Tel.: +1-617-965-3000; fax: +1-617-965-3080.
E-mail address: greene@helik.mgh.harvard.edu (R.W. Greene).
Journal of Psychosomatic Research 55 (2003) 67–75

2. theory, have focused primarily on altering patterns of
parental discipline that contribute to the development of
oppositional behavior and problematic parent–child
exchanges [72]. Skills typically taught to parents in such
programs include positive attending, use of appropriate
commands, contingent attention and reinforcement, and
use of a time-out procedure (see Ref. [72]). In general,
research has documented the efficacy of these procedures
(see Ref. [12] for a comprehensive review), and several
intervention programs emanating from these models have
been identified as either ‘‘well-established’’ (the Living with
Children program [78] and videotape modeling parent
training [88–90]) or as ‘‘probably efficacious’’ (including
parent–child interaction therapy [22]).
However, this same body of research has also docu-
mented various limitations of PT. First, a substantial number
of parents who receive PT do not fully comply with
implementation or drop out of treatment altogether (e.g.,
Ref. [82]), suggesting that this form of intervention may not
be well-matched to the needs and characteristics of many of
those responsible for implementation [32]. Most studies
examining the efficacy of PT have presented data only for
those who remained in treatment rather than those who
began treatment. Among those who remain in treatment, PT
has been shown to produce statistically significant changes
in oppositional behavior, but very few studies have reported
clinically significant changes [50]. Indeed, 30–40% of
those children remaining in treatment continue to evid-
ence behavior problems in the clinical range at follow-up
[49,89]. Data have shown that a significant percentage of
children — perhaps higher than 50% — are not functioning
within the normal range when such treatment is completed
[19]. Finally, the vast majority of studies examining the
efficacy of PT has not included clinically referred youth
[50,77], and has typically failed to examine long-term treat-
ment effects [49,50], although noteworthy exceptions to the
latter issue exist [47]. In view of these limitations, it is
reasonable to conclude the following about PT: (a) a mean-
ingful percentage of children and parents do not derive
substantial benefit from PT; and therefore (b) alternative
treatments that more adequately address the needs of these
children and parents must be developed and studied [32].
Alternative models of intervention have placed relatively
greater emphasis on cognitive factors underlying ODD
rather than on behavior per se (see Refs. [15,16,53–55]).
Such models emanate from research highlighting the frus-
tration and emotional arousal that often accompany extern-
ally imposed demands for compliance [4,45,57,59,87]. The
skill of compliance–defined as the capacity to defer or delay
one’s own goals in response to the imposed goals or stand-
ards of an authority figure — can be considered one of many
developmental expressions of a young child’s evolving
capacities in the domains of emotion regulation, frustration
tolerance, problem solving, and adaptation [71,81,87]. As
described below, a variety of factors may compromise a
child’s skills in these domains, including executive deficits,
irritability, mood instability, anxiety/obsessiveness, impair-
ments in social cognition and social skills, language process-
ing impairments, and deficits in nonverbal skills [32,38], and
researchers have documented high rates of many of these
difficulties in children with ODD [36,37,63]. Thus, these
alternative models of intervention have focused on address-
ing the cognitive deficiencies (a lack or insufficient amount
of cognitive activity in situations requiring such activity)
and/or cognitive distortions (active but inaccurate or malad-
aptive cognitive processing) of oppositional or aggressive
children (see Ref. [56] for a more comprehensive discussion
of cognitive deficiencies and distortions). Several such
intervention models have been identified as ‘‘probably effi-
cacious,’’ including problem solving training [51,52], anger
management programs [23–25,64–66], and multisystemic
therapy [40].
A transactional model of ODD
Consistent with theories underscoring the reciprocal
nature of adult–child transactions [83], developmental psy-
chologists have emphasized that children’s emotion regu-
lation, frustration tolerance, and problem solving skills do
not develop independently of the manner by which import-
ant adults teach and model these skills [57]. Nor do child-
ren’s capacities for complying with adult directives develop
independently of the manner by which caregivers impose
expectations for compliance and respond to deviations from
these expectations. Indeed, adult–child transactions are
thought to exert significant influence on a child’s evolving
cognitive skills quite early in development, and may be
especially crucial at the point at which noncompliant and
oppositional behaviors emerge [38]. The method by which
caregivers respond to deviations from expectations for com-
pliance can serve to increase or decrease a child’s frustration
and arousal [46,58,59] and to alter or fuel emerging re-
sponse biases in both child and adult. In other words, if
the environment responds to a child’s compromised self-
regulation and affective modulation skills in a manner that
exacerbates the child’s existing difficulties, a maladaptive,
automatic adult–child response cycle may develop, making
change much more difficult to achieve [75]. A succinct
description of the scenario that ensues when these processes
go awry can be found in the DSM-IV [3]: ‘‘(ODD) may
(contribute to) a vicious cycle in which the parent and child
bring out the worst in each other.’’
The transactional or reciprocal model (see Ref. [83])
posits that a child’s outcome is a function of the degree of
‘‘fit’’ or ‘‘compatibility’’ between child and adult character-
istics. A high level of adult–child compatibility is thought
to produce optimal outcomes, whereas a high level of
incompatibility is thought to produce less optimal outcomes.
From a transactional perspective, oppositional behavior
would simply be viewed as one of many possible mani-
festations of parent–child incompatibility, in which the
R.W. Greene et al. / Journal of Psychosomatic Research 55 (2003) 67–75
68

3. characteristics of one interaction partner (e.g., the child) are
poorly matched to the characteristics of the second inter-
action partner (e.g., the parent), thereby contributing to
disadvantageous behavior in both partners, which, over
time, contributes to more durable patterns of incompatibil-
ity. Such a conceptualization has important implications for
the process and goals of treatment. Interventions aimed at
reducing children’s oppositional behavior must take into
account the transactional processes (incompatibilities
between child and adult characteristics) giving rise to such
behavior. Moreover, effective treatment will require the
active involvement of child and adult. Further, the primary
goal of treatment is to address and resolve issues related to
adult–child incompatibility.
These intervention components have been incorporated
into a cognitive-behavioral model of intervention known as
the Collaborative Problem Solving (CPS) approach [32,
34,35], a model of intervention aimed at achieving the
following treatment goals: (1) understand the specific adult
and child characteristics contributing to the development of
a child’s oppositional behavior; (2) help adults become
cognizant of three basic strategies for handling unmet
expectations, including (a) imposition of adult will, (b)
CPS, and (c) removing the expectation; (3) help adults
recognize the impact of each of these three strategies on
parent–child interactions; and (4) help adults and children
become proficient at CPS as a means of resolving dis-
agreements and defusing potentially conflictual situations
so as to reduce oppositional episodes and improve parent–
child compatibility.
Before describing this model of intervention in greater
detail, let us first more fully examine the child and adult
characteristics that may contribute to adult–child incompat-
ibility. Because there has been an historical overemphasis on
adult characteristics, we begin with a (nonexhaustive) sam-
pling of child characteristics. It is not our intention to
establish the primacy of child characteristics in the devel-
opment of oppositional behavior. Rather, the goal is to
emphasize the importance and implications of taking such
characteristics into account in a transactional conceptualiza-
tion of ODD.
Child characteristics contributing to oppositional
behavior
As noted above, many of the psychiatric disorders that
are commonly comorbid with ODD may set the stage for
compromised skills in the domains of emotion regulation,
problem solving, frustration tolerance, and adaptation. For
example, attention-deficit/hyperactivity disorder (ADHD) is
a diagnosis often applied to children compromised in the
skills of self-regulation, deficiencies in higher-order problem
solving, and adjusting behavior to fit shifting environmen-
tal demands [42,91], and the overlap and developmental
continuity between ADHD and ODD is well-established
[2,9,17,43,61,67,68,74,85]. Current data suggest that ap-
proximately 65% of children diagnosed with ADHD have
comorbid ODD, and that over 80% of children diagnosed
with ODD have comorbid ADHD [37]. Moreover, it is
extremely common for children with TD to be diagnosed
with comorbid ADHD [14,86].
Of late, researchers have focused on the specific cognit-
ive skills deficits underlying ADHD, with particular
emphasis on executive skills (Refs. [6,18,28,73,80]). While
there is disagreement regarding the precise cognitive skills
comprising the executive functions (see Ref. [70]), there
seems little disagreement regarding the detrimental effects
of executive skill deficits on adaptive human functioning
(see Refs. [20,21]). A variety of cognitive skills have been
characterized as ‘‘executive,’’ including working memory,
defined as an individual’s capacity to hold events in his
or her mind while bringing to bear hindsight and fore-
thought for the purpose of acting on the events (see
Refs. [27,28,79]); self-regulation, defined as an individu-
al’s capacity to regulate arousal in the service of goal-
directed action (see Ref. [6]); shifting cognitive set, which
refers to the efficiency and flexibility by which an
individual shifts from the rules and expectations of one
situation to the rules and expectations of another (see Ref.
[39]); and problem solving, which refers to an individual’s
capacity to organize a coherent plan of action in response
to a problem or frustration (see Ref. [11]).
It has been argued that deficits in executive skills have
the potential to compromise a child’s capacity to respond to
adult directives in an adaptive (compliant) manner [32,38].
For example, a child compromised in the domain of
working memory might experience significant difficulty
efficiently reflecting upon both the previous consequences
of noncompliance (hindsight) and the anticipated conse-
quences of potential actions (forethought). A child compro-
mised in the capacity to regulate arousal might respond to
the frustration that occurs in the context of imposed
demands for compliance with a high level of emotional
reactivity (e.g., screaming, crying, and swearing) rather than
an appropriate level of reason and reflection. In a child
compromised in the skill of shifting cognitive set, one might
reasonably expect that the capacity to comply rapidly with
adult directives might also be compromised (directives
typically require the recipient to shift from the mindset that
immediately preceded the directive to the mindset imposed
by the environment).
How might a child’s executive deficits be incorporated
into a transactional conceptualization of ODD? It seems
clear that executive deficits do not guarantee that a child
will develop ODD (recall that 35% of children diagnosed
with ADHD are not diagnosed with ODD). From a trans-
actional perspective, it is the degree of compatibility
between a child with ADHD and their adult caretakers that
determines whether oppositional (or other maladaptive)
behaviors are ultimately expressed. If, for example, a child
with executive deficits was ‘‘paired’’ with an adult who, due
R.W. Greene et al. / Journal of Psychosomatic Research 55 (2003) 67–75 69

4. to depression or irritability, frequently imposed demands for
rapid shifting of cognitive set and exhibited little tolerance
for or understanding of slow or impulsive responding, we
would predict a low level of compatibility, at least in those
interactions tapping into this aspect of their interactions. By
contrast, if the child was ‘‘paired’’ with an adult who was
aware of this area of incompatibility, cognizant of the
situations in which this domain of interactions was likely
to be most problematic, and interacted with the child in a
way that minimized the adverse effects of such interactions,
we would predict a higher level of compatibility.
The overlap between ODD and mood and anxiety dis-
orders is also increasingly documented. Researchers have
shown extremely high rates of ODD in children diagnosed
with depression and bipolar disorder [5,8,30,92,93]. In one
study, nearly 70% of children diagnosed with severe major
depression and 85% of children diagnosed with bipolar
disorder were also diagnosed with ODD [37]. Indeed, it is
ODD youth with mood disorders who may be at particular
risk for the development of CD [37]. Meaningful rates of
anxiety disorders have also been found in youth with ODD.
Greene et al. [37] found that over 60% of youth diagnosed
with ODD had a comorbid anxiety disorder, and that 45% of
youth diagnosed with an anxiety disorder had comorbid
ODD. The overlap between ODD and obsessiveness may be
particularly compelling [29,76]. Researchers have also
shown that approximately 30% of youth with TD also have
a concurrent mood disorder; a similar rate of comorbidity
has also been found between TD and obsessive-compulsive
disorder [14].
As noted above, emotion regulation skills develop in early
infancy and increase in complexity and sophistication as a
child matures. Children who fail to develop such skills at an
expected or advantageous pace may be over- or under-
reactive to a wide range of affectively charged situations
[87]. Children whose tendency is to overreact to affectively
charged situations may find the physiological and emotional
arousal associated with such situations difficult to regulate,
may become cognitively debilitated in the midst of such
arousal (a phenomenon referred to as ‘‘cognitive incapacita-
tion’’ by Zillman [94]), and may consequently respond to
such situations with more affect (e.g., screaming and swear-
ing) than reason (rational problem solving) and a reduced
capacity to inhibit aggression [38]. The ‘‘affective storms’’
(prolonged and aggressive temper outbursts) seen in children
with bipolar disorder (described in Ref. [92]) may be con-
sidered an example of such overreactivity. Such temper
outbursts — which may include threatening or attacking
others — seem to be associated with a pervasive irritable
mood and are described as less organized and goal-directed
than the outbursts of children whose aggression is proactive
[92]. The rage attacks seen in children with TD–explosive
anger, irritability, temper outbursts, and aggression — appear
to resemble this pattern as well [14]. Children who tend to
underreact to affectively charged situations may have dif-
ficulty mustering the requisite emotional and cognitive
resources to respond to such situations adaptively and may
respond to these situations in ways that reflect a similar level
of debilitation and maladaptiveness (e.g., crying and with-
drawing). Along similar lines, researchers have described a
pattern of behavior referred to as ‘‘obsessive difficult tem-
perament’’ in which the primary features include irritability,
obsessive rigidity, and emotional reactivity, and typical
behaviors include oppositionality, temper tantrums, and poor
response to new situations (see Ref. [29]). Taken together,
there would appear to be strong suggestion that compromised
emotion regulation skills — in the form of depressed mood,
irritability, mood instability, anxiety, or obsessiveness — has
the potential to compromise a child’s capacity to respond to
adult requests in an adaptive (compliant) fashion.
How might a child’s difficulties with emotion regulation
inform a transactional conceptualization of ODD? As with
executive deficits, it is clear that mood and anxiety disorders
do not guarantee that a child will develop ODD. Once again,
it is the degree of compatibility between an irritable or
anxious child and characteristics of his or her adult care-
takers that determines whether oppositional (or other mal-
adaptive) behaviors are ultimately expressed. If an irritable
or anxious child was ‘‘paired’’ with an adult who was ex-
periencing considerable job stress and responded to the
child in an impatient, inflexible, perhaps explosive manner,
we might predict a low level of compatibility, at least as
regards those interactions tapping into this area of incom-
patibility. By contrast, if the child was ‘‘paired’’ with an
adult who was knowledgeable about and sensitive to the
adult and child characteristics contributing to such incom-
patibility, aware of the situations in which this incompat-
ibility was likely to be most problematic, and able to set the
stage for interacting with the child in a way that minimized
the adverse effects of this incompatibility, we would predict
a higher level of compatibility.
Language development is also crucial to the evolution of
problem solving, emotion regulation, frustration tolerance,
and adaptability. Not surprisingly, there is a demonstrated
association between ODD and language impairment. Greene
et al. [37] have shown that over 20% of youth diagnosed
with ODD have a comorbid language processing disorder,
and that 55% of youth with language processing disorders
are also diagnosed with ODD. Thus, it is useful to explore
the potential mechanisms by which language processing
delays might give rise to adult–child incompatibility and a
child’s oppositional behavior.
Cognitive skills such as labeling, categorizing, and
communicating feelings and needs, and identifying and
selecting corresponding behavioral strategies are strongly
mediated by language [13]. Language permits children to
obtain verbal feedback about the appropriateness of the
behavioral strategies they select, thereby facilitating the
capacity to think about and reflect on previous and future
actions [59]. Those children compromised in the capacity to
label emotions may have difficulty identifying and intern-
alizing an adaptive repertoire of behavior strategies for
R.W. Greene et al. / Journal of Psychosomatic Research 55 (2003) 67–75
70

5. responding to such emotions. Children limited in the capa-
city to communicate their emotions and needs may have
difficulty participating in give-and-take interactions in a
flexible, facile, adaptive manner. Those who have difficulty
reflecting on previous and future actions may fail to
manifest ‘‘repertoire expansion,’’ may exhibit delays in
problem solving skills, and may consequently respond to
various situations in a manner reflective of a very narrow
range of response options [38].
As with executive deficits and mood and anxiety disor-
ders, it is clear that while language impairment heightens a
child’s risk for oppositional behavior, such an outcome is by
no means guaranteed. However, at the risk of redundancy, it
is the degree of compatibility between a child with linguistic
delays and their adult caretakers that determines whether
oppositional (or other maladaptive) behaviors are ultimately
expressed. If a linguistically impaired child was, for
example, to be paired with an adult who, perhaps because
of executive deficits or anxiety, imposed demands for
immediate responding to adult queries, we would predict a
low level of compatibility, at least in those interactions
tapping into this domain of their interactions. By contrast,
if the child was ‘‘paired’’ with an adult who was aware of
this area of incompatibility, cognizant of the situations in
which this domain of interactions was likely to be most
problematic, and interacted with the child in a way that
minimized the adverse effects of such interactions, we
would predict a higher level of compatibility.
Adult characteristics associated with ODD
As noted above, a transactional approach to ODD —
truly understanding the areas of incompatibility that give
rise to oppositional behavior — requires an understanding of
the characteristics of both child and adult. In the above
section, it was implied that various adult characteristics
might contribute to parent–child incompatibility. The dif-
ficulty in examining these adult characteristics more fully is
that the majority of research examining adult characteristics
flows from unidirectional theories emphasizing inept parent-
ing practices as the primary factor influencing the devel-
opment of oppositional or aggressive behavior in children.
In other words, such research stemmed from a clear
assumption about causality (i.e., parents are the primary
agents influencing parent–child interactions).
For example, Baumrind [7] found that socially competent
children tend to have ‘‘authoritative’’ mothers (mothers who
set a positive emotional context for parent–child interac-
tions, characterized by warmth and nurturance, while still
placing limits, demands, and controls). By contrast, aggress-
ive children were found to have ‘‘permissive’’ mothers who
responded to their children in an inconsistent manner, often
failing to impose clear limits especially when their children
exhibited extreme negative behaviors or prolonged attempts
to control them. Anxious children tended to have ‘‘author-
itarian’’ mothers who were negative and punitive and
showed little warmth and responsiveness but rather placed
strict limits and controls that inhibited the development of
their children’s autonomy and social skills. These parenting
styles differ on a power or control dimension, with author-
itative mothers described as appropriately controlling, per-
missive mothers as undercontrolling, and authoritarian
mothers as overcontrolling. Even if one was to be deeply
invested in unidirectional explanations, an alternative uni-
directional interpretation of these adult characteristics is
possible: socially competent children elicit warmth and
nurturance from their parents; children who are less socially
competent (aggressive and anxious) elicit from their parents
qualities that are far less advantageous. Fortunately, by
emphasizing compatibility, such ‘‘chicken versus egg’’
debates lose their appeal.
Parents of children with ODD are as heterogeneous as
their children. Indeed, we find that many of the character-
istics of children that contribute to oppositional adult–child
interchanges are present in their parents as well. In other
words, poor self-regulation (e.g., executive impairments)
and affective modulation (e.g., depression and anxiety),
language processing impairments, and cognitive deficien-
cies and distortions are found in many of the adults who
present their children for treatment. While no conclusions
should be made about causality, it is clear that if adult–
child incompatibility is to be improved, it will certainly be
necessary to take these adult characteristics into account in
treatment planning.
For example, some adults have difficulty prioritizing
(perhaps because of an obsessive cognitive style) and
deciding the relative importance of their parenting agenda.
Thus, they may consider all components of their parenting
agenda to be of equal and critical importance. Other adults
may bring very rigid definitions regarding adult ‘‘author-
ity’’ to parent–child interactions, leaving no option for
discussion, processing, ‘‘meeting halfway,’’ or inviting the
child to participate in arriving at solutions to conflictual
interactions. Other adults have a limited or rigid repertoire
of options for pursuing the behavioral goals they have set
for their children. Still other adults have difficulty envi-
sioning and playing out the likely outcomes of their
options. Some adults have abandoned most of their parent-
ing agenda, often so as to avoid an overpowerful, unpleas-
ant response from their child. Still others — often those
with executive impairments — parent (and manage a
household) in a manner that can be disorganized, unstruc-
tured, and haphazard, leading to impulsive parenting
decisions. Yet others are highly irritable or depressed,
have little energy to devote to what should be routine
issues of parenting, and often overreact to child behaviors
that might not fall outside of what would be considered
developmentally appropriate.
Again, it is important to remember that these adult
characteristics alone do not account for the development
of oppositional behavior in a child. Rather, it is the degree to
R.W. Greene et al. / Journal of Psychosomatic Research 55 (2003) 67–75 71

6. which these characteristics are poorly matched to the
characteristics of a child that accounts for the variant of
adult–child incompatibility called ODD.
The CPS approach
As noted earlier, the specific goals of the CPS approach
are to help adults (1) understand the specific adult and child
characteristics contributing to the development of a child’s
oppositional behavior; (2) become cognizant of three basic
strategies for handling unmet expectations, including (a)
imposition of adult will, (b) CPS, and (c) removing the
expectation; (3) recognize the impact of each of these three
approaches on parent–child interactions; and (4) become
proficient, along with their children, at CPS as a means of
resolving disagreements and defusing potentially conflictual
situations so as to reduce oppositional episodes and improve
parent–child compatibility.
The first goal highlights the need for a comprehensive
assessment and understanding of the specific factors
(reviewed earlier) underlying each child’s oppositional
behavior. We find it useful to help adults conceptualize
oppositional behavior as the byproduct of a ‘‘learning
disability’’ in the domains of emotion regulation, frustration
tolerance, problem solving, and/or flexibility. Such a con-
ceptualization helps adults respond to oppositional behavior
in a less personalized, less reactive, and more empathic
manner, and is crucial to helping adults understand the
necessity for a specialized approach to intervention emphas-
izing remediation of these cognitive issues. The role of
adult characteristics as a contributing factor to a given
child’s oppositional behavior is often not a major emphasis
early in treatment (thereby facilitating adult enlistment in
treatment), but typically increases in importance as treat-
ment progresses. Indeed, the second goal speaks to the need
to help adults understand that the manner by which they
pursue unmet expectations with the child is a major factor
influencing the frequency and intensity of oppositional
outbursts. Adults are taught that imposing adult will
(in the parlance of CPS, this approach to unmet expect-
ations is referred to as ‘‘Basket A’’) is a common precipitant
of oppositional outbursts; that removing the expectation
(known as ‘‘Basket C’’) is effective at reducing tension
between child and adult and decreasing meltdowns, but not
effective at helping adults pursue unmet expectations; and
that CPS (‘‘Basket B’’) is an effective way to pursue
expectations without increasing the likelihood of opposi-
tional outbursts while simultaneously training and practic-
ing emotion regulation, frustration tolerance, problem
solving, and adaptability.
Adults are viewed as the ‘‘facilitators’’ of CPS. In fact,
adults are often told that their role is to serve as the child’s
‘‘surrogate frontal lobe’’ so as to (a) reduce the likelihood of
oppositional outbursts in the moment and (b) train lacking
thinking skills over the longer term. Adults are trained to
proactively focus on antecedent events that precipitate
oppositional outbursts rather than reactively focus on con-
sequences. In other words, adults are strongly encouraged to
adopt a ‘‘crisis prevention’’ mentality instead of a ‘‘crisis
management’’ mentality. As part of this mentality, adults are
also helped to focus on situational factors that may precip-
itate oppositional outbursts, and are taught that the majority
of such outbursts are, in fact, quite predictable.
The CPS approach is thought to differ from other anger
management and problem solving training programs in its
emphasis on helping adults and children develop the skills to
resolve issues of disagreement collaboratively. It has been
argued that the equivocal effects of many interventions aimed
at training cognitive skills to children have likely been due, at
least in part, to the manner in which such interventions were
delivered (Refs. [33,44]). For example, in a majority of
studies, cognitive skills have been trained outside the settings
where skills were actually to be performed. It has been
suggested that continuous training proximally to the set-
ting(s) where behavior is to be performed might greatly
enhance the maintenance and generalization of trained skills
[31,38], and would be more congruent with a transactional
perspective. As has been observed in children with ADHD,
the more distant in time and space a treatment is from the
situations in which trained skills are to be performed, the
less beneficial the treatment is likely to be [10,33,48];
presumably, the same notion applies to children with
ODD. Training cognitive skills proximally to where such
skills are to be performed requires, by necessity, consid-
erably greater involvement from and training of interaction
partners (e.g., parents, teachers, and classmates) present in
the environments where oppositional behavior is most
likely to occur [34].
CPS is a manualized treatment program, but session
content is not circumscribed. Rather, therapists choose to
focus on any combination of five treatment modules based
on their assessment of the needs of each child and family.
This feature of the CPS approach is thought to enhance the
ecological validity of the model. The modules represent
important components of CPS (as described above), as
follows: (1) educating adults about ‘‘pathways’’ to non-
compliant behavior; (2) use of the ‘‘baskets’’ framework; (3)
medication education (helping adults understand that some
pathways may be more effectively treated pharmacologi-
cally); (4) family communication (identifying and altering
communication patterns (e.g., sarcasm) that may fuel oppo-
sitional outbursts; and (5) cognitive skills training (reme-
diating additional cognitive issues that are not specifically
being addressed in Basket B).
Empirical evaluation of CPS has provided evidence of its
effectiveness [35,36]. An initial study of CPS — funded by
the Stanley Foundation — involved 50 clinically referred
youth (boys and girls) with ODD between the ages of 4 and
13 years. In addition to ODD, all children receiving treat-
ment also had at least subthreshold symptoms of either
bipolar disorder or severe major depression. The 50 children
R.W. Greene et al. / Journal of Psychosomatic Research 55 (2003) 67–75
72

7. were randomly assigned to either CPS or PT; 47 children
completed treatment (CPS: n = 28, PT: n = 19). Parents
receiving PT were treated using Barkley’s [6] program for
defiant youth. All participants in this condition received 10
weeks of treatment (9 consecutive weeks and a 1-month
follow-up). The length of treatment for participants in the
CPS condition was variable, and ranged from 6 to 16 weeks,
depending on clinicians’ assessment of the needs of each
child and family. However, the average length of treatment
in the CPS condition was 10 weeks.
A variety of instruments were used to assess treatment
response at the beginning and end of treatment and at 4-
month follow-up, including therapist-completed clinical
global improvement ratings (CGI), parent ratings of their
children’s oppositional behavior, parent completion of the
Parenting Stress Index [1], and CGI ratings (by telephone
interviewers blind to the two treatment paradigms and to the
treatment received by each family). Comprehensive results
from this study are presented elsewhere [36] but summar-
ized here. Briefly, significant improvement was found in
children participating in both treatment conditions at the end
of treatment at 4-month follow-up. However, CPS produced
significantly superior outcomes compared to PT on thera-
pists’ CGI ratings at the end of treatment, parent telephone
ratings at 4-month follow-up, and parent ratings of oppo-
sitional behavior at the end of treatment. At the end of
treatment, parent ratings of oppositional behavior indicated
that CPS produced clinically significant improvement
(defined as an improvement from baseline of 30% or
greater) in 52% of the children to whom this treatment
was applied, as compared with 31% of children whose
parents received PT. At 4-month follow-up, parent CGI
ratings indicated that 74% of children in the CPS condition
had evidenced an ‘‘excellent response’’ to treatment
(defined as a rating of ‘‘very much improved’’ or ‘‘much
improved’’) as compared to 41% of those who received PT.
While these data require confirmation in larger samples
and by different investigators, data regarding the effective-
ness of CPS are promising. It is also important to note that
the study was not specific to TD. Nonetheless, given the
significant overrepresentation of ODD within TD, it is
hypothesized that CPS may offer significant promise to
families of children with TD who may not derive significant
benefit from other approaches aimed at reducing opposi-
tional behavior and rage attacks. Naturally, this hypothesis
awaits scientific evaluation.
References
[1] Abidin RR. Parenting stress index professional manual. 3rd ed.
Odessa (FL): Psychological Assessment Resources, 1996.
[2] Abikoff H, Klein RG. Attention-deficit hyperactivity disorder and
conduct disorder: comorbidity and implications for treatment. J Con-
sult Clin Psychol 1992;60:881–92.
[3] American Psychiatric Association. Diagnostic and statistical manual
of mental disorders. 4th ed. Washington, DC: Author, 1994.
[4] Amsel A. Arousal, suppression, and persistence: frustration theory,
attention, and its disorders. Cognit Emotion 1990;4(3):239–68.
[5] Angold A, Costello EJ. Depressive comorbidity in children and ado-
lescents: empirical, theoretical, and methodological issues. Am J Psy-
chiatry 1993;150:1779–91.
[6] Barkley RA. Behavioral inhibition, sustained attention, and executive
functions: constructing a unifying theory of ADHD. Psychol Bull
1997;121(1):65–94.
[7] Baumrind D. Authoritarian vs. authoritative parental control. Adoles-
cence 1967;3:255–72.
[8] Biederman J, Faraone SV, Mick E, Wozniak J, Chen L, Ouellette C,
Marrs A, Moore P, Garcia J, Mennin D, Lelon E. Attention-deficit
hyperactivity disorder and juvenile mania: an overlooked comorbid-
ity? J Am Acad Child Adolesc Psychiatry 1996;35(8):997–1008.
[9] Biederman J, Faraone SV, Milberger S, Garcia J, Chen L, Mick E,
Greene RW, Russell R. Is childhood oppositional defiant disorder a
precursor to adolescent conduct disorder? Findings from a four-year
follow-up study of children with ADHD. J Am Acad Child Adolesc
Psychiatry 1996;35(9):1193–204.
[10] Bloomquist ML, August GJ, Cohen C, Doyle A, Everhart K. Social
problem solving in hyperactive-aggressive children: how and what
they think in conditions of controlled processing. J Clin Child Psychol
1997;26:172–80.
[11] Borkowski JG, Burke JE. Theories, models, and measurements
of executive functioning: an information processing perspective.
In: Lyon GR, Krasnegor NA, editors. Attention, memory, and
executive function. Baltimore: Paul H. Brookes Publishing, 1996.
pp. 235–62.
[12] Brestan EV, Eyberg SM. Effective psychosocial treatment of conduct-
disordered children and adolescents: 29 years, 82 studies, and 5,272
kids. J Clin Child Psychol 1998;27(2):180–9.
[13] Bretherton I, Fritz J, Zahn-Waxler C, Ridgeway D. Learning to
talk about emotions: a functionalist perspective. Child Dev 1986;57:
529–48.
[14] Budman CL, Bruun RD, Park KS, Lesser M, Olson M. Explosive
outbursts in children with Tourette’s disorder. J Am Acad Child Ado-
lesc Psychiatry 2000;39:1270–6.
[15] Coie JD, Dodge KA. Aggression and antisocial behavior. In: Damon
W, editor. Handbook of child psychology. 5th ed. Social, emotional,
and personality development, vol. 3. New York: John Wiley and Sons,
1998. pp. 779–862.
[16] Crick NR, Dodge KA. Social information-processing mechanisms in
reactive and proactive aggression. Child Dev 1996;67:993–1002.
[17] Danforth JS, Barkley RA, Stokes TF. Observations of parent–child
interactions with hyperactive children: research and clinical implica-
tions. Clin Psychol Rev 1991;11:703–27.
[18] Denckla MB. A theory and model of executive function: a neuro-
psychological perspective. In: Lyon GR, Krasnegor NA, editors. At-
tention, memory, and executive function. Baltimore: Paul H. Brookes
Publishing, 1996. pp. 263–78.
[19] Dishion TJ, Patterson GR. Age effects in parent training outcome.
Behav Ther 1992;23:719–29.
[20] Douglas VI. High level mental processes in hyperactive children:
implications for training. In: Knights RM, Baker DJ, editors. Treat-
ment of hyperactive and learning disordered children: current re-
search. Baltimore: University Park Press, 1980. pp. 65–92.
[21] Eslinger PJ. Conceptualizing, describing, and measuring components
of executive function. In: Lyon GR, Krasnegor NA, editors. Attention,
memory, and executive function. Baltimore: Paul H. Brookes Publish-
ing, 1996. pp. 367–95.
[22] Eyberg SM, Boggs SR, Algina J. Parent–child interaction therapy: a
psychosocial model for the treatment of young children with conduct
problem behavior and their families. Psychopharmacol Bull 1995;31:
83–91.
[23] Feindler EL. Adolescent anger control: review and critique. In: Hersen
M, Eisler RM, Miller PM, editors. Progress in behavior modification,
vol. 26. Newbury Park (CA): Sage, 1990. pp. 11–59.
R.W. Greene et al. / Journal of Psychosomatic Research 55 (2003) 67–75 73

8. [24] Feindler EL. Cognitive strategies in anger control interventions for
children and adolescents. In: Kendall PC, editor. Child and adolescent
therapy: cognitive-behavioral procedures. New York: Guilford Press,
1991. pp. 66–97.
[25] Feindler EL. An ideal treatment package for children and adolescents
with anger disorders. In: Kassinove H, editor. Anger disorders: defi-
nition, diagnosis, and treatment. Washington (DC): Taylor and Fran-
cis, 1995. pp. 173–95.
[26] Frick PJ, Kamphaus RW, Lahey BB, Loeber R, Christ MAG, Hart EL,
Tannenbaum LE. Academic underachievement and the disruptive be-
havior disorders. J Consult Clin Psychol 1991;59:289–94.
[27] Fuster JM. The prefrontal cortex. New York: Raven Press, 1989.
[28] Fuster JM. Memory and planning: two temporal perspectives of
frontal lobe function. In: Jasper HH, Riggio S, Goldman-Rakic
PS, editors. Epilepsy and the functional autonomy of the frontal
lobe. New York: Raven Press, 1995. pp. 9–18.
[29] Garland EJ, Weiss M. Case study: obsessive difficult temperament and
its response to serotonergic medication. J Am Acad Child Adolesc
Psychiatry 1996;35(7):916–20.
[30] Geller B, Luby J. Child and adolescent bipolar disorder: review of
the past 10 years. J Am Acad Child Adolesc Psychiatry 1997;
36(9):1–9.
[31] Greene RW, Ablon SA. What does the MTA study tell us about
effective psychosocial treatment for ADHD? J Clin Child Psychol
2001;30(1):114–21.
[32] Greene RW, Ablon SA. Disruptive behavior disorders. In: Breen M,
Fiedler C, editors. Behavioral approach to assessment of youth with
emotional/behavioral disorders: a handbook for school-based practi-
tioners. 2nd ed. Austin (TX): Pro-Ed, 2002 (in press).
[33] Greene RW, Barkley RA. Attention-deficit/hyperactivity disorder: di-
agnostic, developmental, and conceptual issues. In: Breen M, Fiedler
C, editors. Behavioral approach to assessment of youth with emo-
tional/behavioral disorders: a handbook for school-based practitioners.
Austin (TX): Pro-Ed, 1996. pp. 413–49.
[34] Greene RW. The explosive child: understanding and parenting
easily frustrated, ‘‘chronically inflexible’’ children. New York:
Harper Collins, 1998.
[35] Greene RW. Invited address: new trends in the characterization and
treatment of ODD. 109th Annual Meeting of the American Psycho-
logical Association, San Francisco, CA, 2001.
[36] Greene RW, Ablon JS, Monuteaux M, Goring JC, Raezer L, Henin A,
Edwards GH, Markey JL, Moore C, Biederman J. Effectiveness of
Collaborative Problem Solving in affectively dysregulated youth with
oppositional defiant disorder: Initial findings, under review, 2002.
[37] Greene RW, Biederman J, Zerwas S, Monuteaux M, Goring JC, Far-
aone SV. Psychiatric co-morbidity, family dysfunction, and social
impairment in referred youth with oppositional defiant disorder. Am
J Psychiatry 2002;159(7):1214–24.
[38] Greene RW, Doyle AE. Toward a transactional conceptualization of
oppositional defiant disorder: implications for assessment and treat-
ment. Clin Fam Psychol Rev 1999;2(3):129–47.
[39] Hayes SC, Gifford EV, Ruckstuhl LE. Relational frame theory and
executive function: a behavioral analysis. In: Lyon GR, Krasnegor
NA, editors. Attention, memory, and executive function. Baltimore:
Paul H. Brookes Publishing, 1996. pp. 279–306.
[40] Henggeler SW, Melton GB, Smith LA. Family preservation using
multisystemic therapy: an effective alternative to incarcerating serious
juvenile offenders. J Consult Clin Psychol 1992;60:953–61.
[41] Hinshaw SP. Conduct disorder in childhood: conceptualization, diag-
nosis, comorbidity, and risk status for antisocial functioning in adult-
hood. In: Fowles DC, Sutker P, Goodman SH, editors. Experimental
personality and psychopathology research. New York: Springer, 1994.
pp. 3–44.
[42] Hinshaw SP, Erhardt D. Attention-deficit hyperactivity disorder. In:
Kendall PC, editor. Child and adolescent therapy: cognitive-behavioral
procedures. New York: Guilford Press, 1991. pp. 98–128.
[43] Hinshaw SP, Lahey BB, Hart EL. Issues of taxonomy and comorbidity
in the development of conduct disorder. Dev Psychopathol 1993;5:
31–49.
[44] Hinshaw SP. Intervention for social competence and social skill. Child
Adolesc Psychiatr Clin North Am 1992;1(2):539–52.
[45] Hoffman ML. Moral internalization, parental power, and the nature of
parent–child interaction. Dev Psychol 1975;11:228–39.
[46] Hoffman ML. Affective and cognitive processes in moral internaliza-
tion. In: Higgins ET, Ruble D, Hartup W, editors. Social cognition and
social development: a sociocultural perspective. New York: Cam-
bridge Univ. Press, 1983. pp. 236–74.
[47] Ialongo NS, Horn WF, Pascoe JM, Greenberg G, Packard T, Lopez M,
Wagner A, Puttler L. The effects of a multimodal intervention with
attention-deficit hyperactivity disorder children: a 9-month follow-up.
J Am Acad Child Adolesc Psychiatry 1993;32:182–9.
[48] Ingersoll B, Goldstein S. Attention-deficit disorder and learning dis-
abilities. New York: Doubleday, 1993.
[49] Kazdin AE. Treatment of conduct disorder: progress and directions in
psychotherapy research. Dev Psychopathol 1993;5:277–310.
[50] Kazdin AE. Parent management training: evidence, outcomes and
issues. J Am Acad Child Adolesc Psychiatry 1997;36(10):1349–56.
[51] Kazdin AE, Esveldt-Dawson K, French NH, Unis AS. Effects of
parent management training and problem-solving skills training com-
bined in the treatment of antisocial child behavior. J Am Acad Child
Adolesc Psychiatry 1987;26:416–24.
[52] 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(5):733–47.
[53] Kendall PC, MacDonald JP. Cognition in the psychopathology of
youth and implications for treatment. In: Dobson KS, Kendall PC,
editors. Psychopathology and cognition. San Diego (CA): Adacemic
Press, 1993. pp. 387–426.
[54] Kendall PC. Toward a cognitive-behavioral model of child psychopa-
thology and a critique of related interventions. J Abnorm Psychology
1985;13:357–72.
[55] Kendall PC. Guiding theory for therapy with children and adolescents.
In: Kendall PC, editor. Child and adolescent therapy: cognitive-behav-
ioral procedures. New York: Guilford Press, 1991. pp. 3–22.
[56] Kendall PC. Cognitive-behavioral therapies with youth: guiding
theory, current status, and emerging developments. J Consult Clin
Psychol 1993;61(2):235–47.
[57] Kochanska G. Toward a synthesis of parental socialization and child
temperament in early development of conscience. Child Dev 1993;64:
325–47.
[58] Kochanska G, Askan N. Mother–child mutually positive affect, the
quality of child compliance to requests and prohibitions, and maternal
control as correlates of early internalization. Child Dev 1995;66:
236–54.
[59] Kopp CB. Regulation of distress and negative emotions: a develop-
mental view. Dev Psychol 1989;25(3):343–54.
[60] Kuhne M, Schachar R, Tannock R. Impact of comorbid oppositional
or conduct problems on attention-deficit hyperactivity disorder. J Am
Acad Child Adolesc Psychiatry 1997;36:1715–25.
[61] Lahey BB, Loeber R. Framework for a developmental model of
oppositional defiant disorder and conduct disorder. In: Routh DK,
editor. Disruptive behavior disorders in childhood. New York: Plenum,
1994:139–80.
[62] Lahey BB, Loeber R, Quay HC, Frick PJ, Grimm J. Oppositional
defiant disorders and conduct disorders: issues to be resolved for
DSM IV. J Am Acad Child Adolesc Psychiatry 1992;31:539–46.
[63] LaVigne JV, Cicchetti C, Gibbons RD, Binns HJ, Larsen L, DeVito C.
Oppositional defiant disorder with onset in preschool years: longitu-
dinal stability and pathways to other disorders. J Am Acad Child
Adolesc Psychiatry 2001;40:1393–400.
[64] Lochman JE. Cognitive-behavioral interventions with aggressive
boys. Child Psychiatry Hum Dev 1992;16:45–56.
[65] Lochman JE, Burch PR, Curry JF, Lampron LB. Treatment
and generalization effects of cognitive-behavioral and goal-setting
R.W. Greene et al. / Journal of Psychosomatic Research 55 (2003) 67–75
74

9. interventions with aggressive boys. J Consult Clin Psychol 1984;52:
915–6.
[66] Lochman JE, Lampron LB, Gemmer TC, Harris SR. Anger coping
intervention with aggressive children: a guide to implementation in
school settings. In: Keller PA, Heyman SR, editors. Innovations in
clinical practice: a source book, vol. 6. Sarasota (FL): Professional
Resource Exchange, 1987. pp. 339–56.
[67] Loeber R. Development and risk factors of juvenile antisocial behav-
ior and delinquency. Clin Psychol Rev 1990;10:1–41.
[68] Loeber R, Keenan K. Interaction between conduct disorder and its
comorbid conditions: effects of age and gender. Clin Psychol Rev
1994;14(6):497–523.
[69] Loeber R, Green SM, Lahey BB, Christ MAG, Frick PJ. Develop-
mental sequences in the age of onset of disruptive child behaviors.
J Child Fam Stud 1992;1:21–41.
[70] Lyon GR. The need for conceptual and theoretical clarity in the study
of attention, memory, and executive function. In: Lyon GR, Krasnegor
NA, editors. Attention, memory and executive function. Baltimore:
Paul H. Brookes Publishing, 1996. pp. 3–9.
[71] Maccoby EE. Social development. New York: Harcourt, Brace,
Jovanovich, 1980.
[72] McMahon RJ, Wells KC. Conduct problems. In: Mash EJ, Barkley
RA, editors. Treatment of childhood disorders. 2nd ed. New York:
Guilford Press, 1998. pp. 111–210.
[73] Milner B. Aspects of human frontal lobe function. In: Jasper HH,
Riggio S, Goldman-Rakic PS, editors. Epilepsy and the functional
autonomy of the frontal lobe. New York: Raven Press, 1995.
pp. 67–81.
[74] Newcorn JH, Halperin JM. Comorbidity among disruptive behavior
disorders: impact on severity, impairment, and response to treatment.
Child Adolesc Psychiatr Clin North Am 1994;3(2):227–52.
[75] Ollendick TH. Violence in youth: where do we go from here? Behav-
ior therapy’s response. Behav Ther 1996;27:485–514.
[76] Park KS, Budman CL, Bruun RD, Olson M, Mandel F. A clinical
study of rage attacks in children and adolescents with Tourette’s
syndrome. Poster presented at the 43rd Annual Meeting of the Amer-
ican Academy of Child and Adolescent Psychiatry, Philadelphia, PA,
1996.
[77] Patterson GR, Chamberlain P. A functional analysis of resistance
during parent training therapy. Clin Psychol: Sci Pract 1994;1(1):
53–70.
[78] Patterson GR, Guillion ME. Living with children: new methods for
parents and teachers. Champaign (IL): Research Press, 1968.
[79] Pennington BF. The working memory function of the prefrontal cor-
tices: implications for developmental and individual differences in
cognition. In: Haith MM, Benson J, Roberts R, Pennington BF, edi-
tors. The development of future oriented processes. Chicago: Univer-
sity of Chicago Press, 1994. pp. 243–89.
[80] Pennington BF, Ozonoff S. Executive functions and developmental
psychopathology. J Child Psychol Psychiatry 1996;37:51–87.
[81] Perry DG, Perry LC. Social learning, causal attribution, and moral
internalization. In: Bisanz J, Bisanz GL, Kail R (editors), Brainerd
CJ (series editor). Learning in children: progress in cognitive develop-
ment research. New York: Springer-Verlag 1983. pp. 105–36.
[82] Prinz RJ, Miller GE. Family-based treatment for childhood antisocial
behavior: experimental influences on dropout and engagement. J Con-
sult Clin Psychol 1994;62:645–50.
[83] Sameroff A. Early influences on development: fact or fancy? Merrill-
Palmer Q 1975;21:263–94.
[84] Schachar RJ, Wachsmuth R. Oppositional disorder in children: a
validation study comparing conduct disorder, oppositional disorder,
and normal control children. J Child Psychol Psychiatry 1990;31:
1089–102.
[85] Speltz ML, McClellan J, DeKlyen M, Jones K. Preschool boys with
oppositional defiant disorder: clinical presentation and diagnostic
change. J Am Acad Child Adolesc Psychiatry 1999;38:838–45.
[86] Spencer T, Biederman J, Harding M, O’Donnell D, Wilens T, Faraone
S, Coffey B, Geller D. Disentangling the overlap between Tourette’s
disorder and ADHD. J Child Psychol Psychiatry 1998;39(7):1037–44.
[87] Stifter CA, Spinrad TL, Braungart-Rieker JM. Toward a developmen-
tal model of child compliance: the role of emotion regulation in in-
fancy. Child Dev 1999;70(1):21–32.
[88] Webster-Stratton C. Randomized trail of two parent-training programs
for families with conduct-disordered children. J Consult Clin Psychol
1984;52:666–78.
[89] Webster-Stratton C. Enhancing the effectiveness of self-administered
videotape parent training for families with conduct-problem children.
J Abnorm Child Psychol 1990;18:479–92.
[90] Webster-Stratton C. Advancing videotape parent training: a compar-
ison study. J Consult Clin Psychol 1994;62:583–93.
[91] Whalen CK. Attention-deficit hyperactivity disorder. In: Ollendick
TH, Hersen M, editors. Handbook of child psychopathology. 2nd ed.
New York: Plenum, 1989. pp. 131–69.
[92] Wozniak J, Biederman J. A pharmacological approach to the quagmire
of comorbidity in juvenile mania. J Child Adolesc Psychiatry 1996;
35(6):826–8.
[93] Wozniak J, Biederman J, Kiely K, Ablon S, Faraone SV, Mundy E,
Mennin D. Mania-like symptoms suggestion of childhood-onset bipo-
lar disorder in clinically referred children. J Am Acad Child Adolesc
Psychiatry 1995;34(7):867–76.
[94] Zillman D. Cognition-excitation interdependencies in aggressive
behavior. Aggress Behav 1988;14:51–64.
R.W. Greene et al. / Journal of Psychosomatic Research 55 (2003) 67–75 75