• When pooled, multicomponent (parent or teacher plus child) psychosocial interventions were better than usual care or waitlist in reducing parent-reported disruptive behavior measures in preschool and school-age children when assessed immediately post-treatment (strength of evidence [SOE]: Moderate).
• Parent-only psychosocial interventions were better than usual care or waitlist in reducing disruptive behavior in preschool (SOE: Moderate) and school-age children (SOE: Low) when assessed immediately post-treatment.
• Evidence for multicomponent interventions and child-only psychosocial interventions versus usual care or waitlist was mixed in adolescents; likewise, comparisons of psychosocial interventions also yielded mixed results in adolescents. (SOE: Low to Insufficient)
• We were unable to determine whether multicomponent, parent-only, or child-only interventions are most effective in reducing disruptive behaviors (SOE: Insufficient).
• Evidence for some psychosocial interventions and for longer-term treatment effects was limited (SOE: Low to Insufficient).
• We were unable to determine whether psychosocial, pharmacological, or a combination of psychological and pharmacological interventions are more effective in reducing disruptive behaviors in children and adolescents (SOE: Insufficient).
• Stimulant plus add-on risperidone therapy and nonstimulant therapy was associated with reduced disruptive behaviors in some children compared with placebo, but pharmacotherapy was associated with a small increase in the risk of experiencing any adverse event (SOE: Low).
• Evidence for differential benefit and harms of interventions based on patient, clinical, and treatment characteristics and treatment history was inconsistent or insufficient.

Objectives. To determine the most effective treatments for disruptive behavior disorders in children and adolescents.

Data sources. Ovid® MEDLINE®, the Cochrane Library, PsycINFO®, and Embase® databases were searched from 2014 to March 7, 2023. Additionally, we reviewed all studies included in the prior 2015 Agency for Healthcare Research and Quality review.

Review methods. We dual reviewed abstracts and full-text articles; data extraction was checked by a second reviewer; risk of bias and strength of evidence were assessed by two reviewers; and disagreements were resolved by consensus.

Results. For this review, 152 studies in 179 publications (145 randomized controlled trials [RCTs] and 7 nonrandomized studies) met inclusion criteria.

Psychosocial interventions: Multicomponent interventions (parent or teacher plus child) substantially reduced parent-reported disruptive behavior more than usual care or waitlist in preschool children (10 RCTs, N=784, standard mean difference [SMD] -0.96, 95% confidence interval [CI] -1.39 to -0.60) and moderately reduced disruptive behavior in school-age children (9 RCTs, N=524, SMD -0.61, 95% CI -1.05 to -0.10). Similarly, interventions that involved the parent only and not the child also moderately reduced parent-reported disruptive behavior in preschool children (13 RCTs, N=1,222, SMD -0.61, 95% CI -0.99 to -0.31) and slightly reduced disruptive behavior in school-age children (6 RCTs, N=842, SMD -0.39, 95% CI -0.63 to -0.19). Comparisons between psychosocial interventions generally showed only minor differences in disruptive behaviors in preschool and school-age children. Findings in adolescents for multicomponent and child-only interventions versus usual care and waitlist and versus another intervention were mixed. Through pairwise, indirect, and network meta-analyses, we were not able to determine whether multicomponent, parent-only, or child-only interventions are superior overall, though there was less evidence in child-only interventions and interventions in adolescents.

Pharmacologic interventions: There was limited evidence to support the use of stimulants and/or antipsychotics for disruptive behavior disorders in selected children. Treatment response was more likely with stimulant treatment alone (2 RCTs) or with add-on risperidone (2 RCTs) compared to placebo. Study withdrawal due to adverse events was higher with any pharmacotherapy relative to placebo (6 RCTs, N=911, RR 3.44, 95% CI 1.35 to 8.75)

Evidence was insufficient to determine whether psychosocial, pharmacological, or a combination of psychological and pharmacological interventions are more effective in reducing disruptive behaviors in children and adolescents. Evidence was also inconsistent or insufficient to determine if benefits and harms of treatment interventions varied based on patient, clinical, or treatment characteristics, or treatment history.

Conclusions. Multicomponent psychosocial interventions (parent or teacher plus child) and parent-only psychosocial interventions were better than treatment as usual or waitlist at reducing parent report of child disruptive behaviors for preschool and school-age children immediately post-treatment. In these children, direct and indirect comparisons of multicomponent, parent-only, and child-only interventions generally found no or only minor differences in reducing disruptive behaviors, although effectiveness differed by specific psychosocial intervention. Results of multicomponent interventions and child-only interventions were mixed in adolescents and studies in adolescents were few. Pharmacotherapy may be helpful in reducing disruptive behaviors in some children who have inadequate response to psychosocial interventions, but use was also associated with an increased risk of experiencing any adverse event. For all age groups, evidence for some psychosocial interventions and all pharmacological interventions was limited, as was reporting of long-term outcomes. Additional research is needed to aid the clinician in selecting the intervention most likely to be effective in reducing disruptive behaviors well beyond treatment completion.