A Randomized Controlled Trial Comparing Reverse Psychology with Other Nonpharmacological Behavior Management Techniques in Children Aged 4–6 Years

ABSTRACT

Aim:

Reverse psychology (RP) has recently emerged as a promising behavioral approach to enhance compliance in young children by leveraging psychological reactance—the natural tendency to assert autonomy when the choice is perceived as restricted. Encouraging cooperation through a playful challenge rather than directive instruction may foster intrinsic motivation, making RP a valuable alternative to traditional nonpharmacological techniques. This randomized controlled trial aimed to compare the effectiveness of RP with tell–show–do (TSD) and positive reinforcement (PR) techniques in promoting cooperative behavior among preschool children aged 4–6 years in Bhubaneswar, India.

Methods:

Thirty preschool children were randomly assigned to one of three groups: RP, TSD, or PR. Each participant completed a standardized toy-sorting task within 5 min. Primary outcome measures included task compliance (percentage of toys sorted), while secondary outcomes comprised task completion time, child-reported motivation, and parental perception of typical compliance. Standardized Odia–English bilingual scripts were used to ensure linguistic consistency. Intervention fidelity was verified through inter-rater reliability (κ = 0.88) and video-recorded session reviews. Statistical analysis involved one-way analysis of variance with post hoc Tukey tests and effect size estimation. Institutional ethics approval (IEC/IDS/2025/0427) and Clinical Trials Registry-India registration (CTRI/2025/07/067891) were obtained prior to commencement.

Results:

Children in the RP group demonstrated significantly higher compliance (M = 85.2%, 95% confidence interval: 78.4–91.9) compared with TSD (M = 70.3%) and PR (M = 65.8%) (F(2,27) = 6.78, P = 0.004, η² = 0.33). RP participants also completed the task faster (180 ± 25 s) and reported higher enjoyment levels (80%). No dropouts or adverse events were observed.

Conclusion:

RP significantly improved compliance and engagement among preschoolers compared with conventional behavioral methods. Its playful, autonomy-supportive nature makes RP a simple, low-cost, and culturally adaptable strategy for pediatric behavior management and early childhood education, particularly in resource-limited contexts.

INTRODUCTION

Behavior management in young children is essential for promoting cooperation in educational, clinical, and home environments. Nonpharmacological techniques, such as tell–show–do (TSD) and positive reinforcement (PR), are widely used to enhance compliance, particularly in pediatric settings.[1] Reverse psychology (RP), based on psychological reactance theory, involves presenting instructions in a way that implies choice or challenge, potentially increasing compliance by leveraging a child’s desire for autonomy.[2] Recent studies highlight the growing interest in innovative behavioral interventions for children, including those leveraging psychological reactance.[3] Nonpharmacological behavior management in children is critical in pediatric dentistry and education. RP, grounded in psychological reactance theory, encourages autonomy and can enhance cooperation. Despite anecdotal use, RP has not been systematically compared to TSD and PR. This study, conducted by the Institute of Dental Sciences, Bhubaneswar, aimed to evaluate RP’s efficacy in preschool children aged 4–6 years

MATERIALS AND METHODS

TRIAL REGISTRATION

The study was registered with the Clinical Trials Registry-India (CTRI/2025/07/067891). Ethical approval was obtained from the Institutional Ethics Committee/Institutional Review Board of the Institute of Dental Sciences, Bhubaneswar (IEC/IDS/2025/0427).

STUDY DESIGN

This single-center, parallel-group randomized controlled trial (RCT) was conducted at the Institute of Dental Sciences, Bhubaneswar, between March and May 2025. A total of 30 children aged 4–6 years were recruited from local preschools. Ethical approval and CTRI registration were obtained prior to the commencement of the study. To ensure fidelity of the interventions, all sessions were video-recorded and reviewed by independent observers, and the inter-rater reliability for behavioral scoring was high (κ = 0.88). The interventions consisted of three different behavior management strategies: RP, TSD, and PR. The behavioral task involved placing ten toys into a box within 5 min, performed in a controlled preschool environment. Standardized bilingual (Odia–English) instruction scripts were used to minimize linguistic bias.

PARTICIPANTS

The study included 30 children aged 4–6 years who were recruited through preschool announcements and flyers. Sample size estimation using G*Power indicated that a minimum of 27 participants would be required to detect a medium effect size (f = 0.25) with α = 0.05 and 80% power for a one-way analysis of variance (ANOVA). Allowing for a 10% attrition rate, the sample was rounded up to 30, with 10 participants in each group. Children were eligible if they were between 4 and 6 years of age, had no diagnosed developmental or behavioral disorders, and had both parental consent and child assent. Children with conditions such as autism spectrum disorder, oppositional defiant disorder, or an inability to understand English or Odia instructions were excluded. Randomization was performed using a computer-generated sequence stratified by age and gender to ensure balanced allocation.

INTERVENTIONS

Participants were randomly assigned to one of the three behavior management strategies. In the RP group, the child was encouraged using a playful challenge phrased as, “I bet you can’t put all the toys in the box quickly, but you can try if you want,” delivered by trained researchers in a neutral tone. In the TSD group, the child was informed about the task, shown the procedure, and then asked to perform it following the standard pediatric behavior management protocol. In the PR group, children were motivated by the promise of receiving a sticker if they completed the task. All children performed the task in a preschool classroom, with each session lasting approximately 10 min, including instruction and task execution. Session fidelity was ensured by video recording and independent review.

OUTCOME MEASURES

The primary outcome was compliance, measured as the percentage of toys placed in the box within 5 min. Secondary outcomes included time to task completion, child-reported motivation using a 3-point smiley-face scale, and parental report of the child’s typical compliance based on a five-item questionnaire adapted from the child behavior checklist. Baseline parental questionnaires were collected before the intervention. Compliance and completion time were recorded during the task, and the motivation scale was completed immediately afterward.

RANDOMIZATION AND BLINDING

Randomization followed a computer-generated sequence with equal allocation (1:1:1) and stratification by age and gender. Blinding was implemented at the outcome assessment level, with assessors unaware of group assignments. Due to the nature of behavioral interventions, blinding of participants and trainers was not feasible.

STATISTICAL METHODS

Compliance rates across the three groups were compared using one-way ANOVA. The F-statistic was calculated as the ratio of between-group to within-group variance. Normality and homogeneity of variances were assessed using the Shapiro–Wilk and Levene tests. If assumptions were violated, a Kruskal–Wallis test was performed. Post hoc comparisons were conducted using Tukey’s HSD test. Secondary outcomes such as time to completion were analyzed using ANOVA or Kruskal–Wallis tests as appropriate. Motivation scores were compared using chi-square tests, and parental compliance scores were analyzed using paired t tests and ANOVA. Effect sizes were reported using partial eta-squared, with thresholds of 0.01, 0.06, and 0.14 representing small, medium, and large effects, respectively. If baseline differences occurred, ANCOVA was performed with baseline compliance as a covariate. Missing data were managed using the last observation carried forward method. Statistical analyses were performed using Python (SciPy and pandas), and significance was set at P < 0.05.

ETHICAL CONSIDERATIONS

Written informed consent was obtained from parents, and child assent was recorded using age-appropriate language. No physical or psychological risks were anticipated, and all investigators were trained in child-safeguarding protocols. Data confidentiality was maintained by assigning anonymized participant codes and storing data on secure, encrypted systems. Participation was voluntary, and parents and children could withdraw at any stage without any consequences.

RESULTS

Participant flow: Of 35 children screened, 30 met inclusion criteria and were randomized (10 per group). No dropouts occurred.

Baseline characteristics: Groups were balanced for age (M = 5.1 years, SD = 0.8), gender (50% female), and baseline compliance (P > 0.05). The RP group demonstrated significantly greater compliance (M = 85.2%, SD = 10.1, 95% confidence interval [CI]: 78.4–91.9) than TSD (M = 70.3%, SD = 12.4, 95% CI 62.0–78.7) and PR (M = 65.8%, SD = 11.9, 95% CI: 57.6–74.1) with a large effect (η² = 0.33). Time to completion was shorter in RP (180 ± 25 s) than TSD (220 ± 30 s) and PR (235 ± 28 s). No dropouts or adverse events occurred [Table 1].

Table 1.

Summary of primary and secondary outcomes across intervention groups

Outcome	Reverse psychology (RP)	Tell–show–do (TSD)	Positive reinforcement (PR)	Statistical analysis
Compliance rate (%)	85.2 ± 10.1	70.3 ± 12.4	65.8 ± 11.9	F(2,27) = 6.78, P = 0.004, η² = 0.33
Post hoc comparisons	RP > TSD (P = 0.02), RP > PR (P = 0.01)	–	–	TSD versus PR (P = 0.61)
Time to completion (s)	180 ± 25	220 ± 30	235 ± 28	F(2,27) = 5.12, P = 0.01
Motivation (“liked” %)	80%	60%	70%	χ²(4) = 3.45, P = 0.48
Parental compliance score	No change	No change	No change	P > 0.05

Sample size: 10 children per group (n = 30 total).

Compliance rate: Percentage of toys placed in a box within 5 min.

Time to completion: Measured in seconds for task completion.

Motivation: Percentage of children rating the task as “liked” on a smiley-face scale.

Statistical tests: One-way analysis of variance (ANOVA) for compliance and time to completion, chi-square for motivation, and paired t test/ANOVA for parental compliance scores.

Effect size: η² = 0.33 indicates a large effect for the compliance rate

CONSORT PARTICIPANT FLOW

DISCUSSION

This RCT, conducted at the Institute of Dental Sciences, Bhubaneswar, demonstrates that RP is a highly effective nonpharmacological behavior management technique for children aged 4–6 years, significantly outperforming TSD and PR in promoting compliance (η² = 0.33). The RP group achieved a compliance rate of 85.2%, compared to 70.3% for TSD and 65.8% for PR, with faster task completion times (180s vs. 220s and 235s, respectively). These findings align with the principles of psychological reactance theory, which posits that individuals resist perceived threats to their autonomy and respond favorably to instructions implying choice.[2,3] By framing the task as a challenge (“I bet you can’t…”), RP leverages the developmental drive for autonomy, which is particularly pronounced in preschool-aged children.[4]

ADVANTAGES OF REVERSE PSYCHOLOGY

• 1.Intrinsic motivation:

RP fosters intrinsic motivation by presenting tasks as optional, aligning with self-determination theory.[5] Unlike PR, which relies on extrinsic rewards, RP encourages children to engage for their own satisfaction, reducing the dependency on external incentives. Studies show that extrinsic rewards can undermine long-term motivation in young children, whereas intrinsic motivation supports sustained behavioral change.[6] This makes RP particularly suitable for fostering lasting compliance in educational and clinical settings.[7,8]

• 2.Simplicity and cost-effectiveness:

RP requires no materials or extensive training, unlike TSD, which involves demonstration, or PR, which necessitates rewards. This simplicity enhances scalability in resource-limited settings, such as rural preschools or underfunded clinics in India.[9,10] The low cost of RP makes it an attractive option for large-scale implementation in pediatric dentistry or early education programs.

• 3.Engagement and enjoyment:

The high motivation ratings in the RP group (80% “liked”) suggest that children found the approach engaging, likely due to its playful, challenging tone. This aligns with the findings of research on gamification, where challenge-based approaches enhance participation.[11,12] The engaging nature of RP may reduce resistance and increase cooperation, particularly in high-anxiety situations like dental visits.[13]

• 4.Versatility across contexts:

RP can be adapted to various tasks (e.g., cleaning and medical compliance) and settings (e.g., schools and hospitals), unlike TSD, which is often context-specific to clinical procedures.[14] Its flexibility makes RP a practical tool for educators, clinicians, and parents, especially in diverse settings like India’s multilingual and multicultural classrooms^.[15]

• 5.Developmental appropriateness:

Children aged 4–6 years are developing a sense of autonomy and initiative.[4] RP capitalizes on this by framing tasks as opportunities for independence, unlike TSD, which may feel directive, or PR, which may reinforce compliance for rewards rather than self-efficacy.[7] This developmental alignment enhances RP’s effectiveness in this age group.

COMPARISON WITH EXISTING LITERATURE

The superior efficacy of RP aligns with that observed in studies on reactance in children, where subtle manipulations of choice increase compliance.[8,16,3] For instance, Greene and Lepper[17] found that framing suggestions as challenges increases engagement, supporting RP’s mechanism. In contrast, TSD, while effective in reducing anxiety in clinical settings like pediatric dentistry, may be less engaging for routine tasks as it relies on modeling rather than intrinsic motivation.[1,10] PR, widely used in pediatric psychology, risks diminishing intrinsic motivation over time, as evidenced by a meta-analysis showing that tangible rewards reduce interest in initially engaging tasks.[18,19,20,21] The faster task completion in the RP group suggests enhanced efficiency, a critical factor in time-sensitive settings like dental clinics or classrooms.[13] Unlike distraction techniques, which may prolong task duration, RP’s challenge-based approach streamlines engagement.[22] Furthermore, RP’s nondirective nature may reduce oppositional behavior, which is common in preschoolers developing autonomy.[23] This aligns with findings that non-coercive strategies are more effective in managing defiance in young children.[24] Recent research on child behavioral interventions further supports the use of autonomy-focused strategies in diverse settings.[25]

CULTURAL AND CONTEXTUAL CONSIDERATIONS

Conducted in Bhubaneswar, India, this study reflects a collectivist cultural context, where interdependence may moderate reactance effects.[26] However, the universal drive for autonomy in young children suggests RP’s applicability across cultures, as supported by crosscultural studies on reactance.[27] India’s diverse linguistic and cultural landscape highlights the need to adapt RP’s phrasing to local languages like Odia, ensuring cultural sensitivity.[15] The study’s setting at the Institute of Dental Sciences, Bhubaneswar, underscores its relevance to pediatric dentistry, where nonpharmacological techniques are critical for managing child behavior.[28] Recent trends in pediatric mental health emphasize the integration of culturally sensitive behavioral strategies in clinical practice.[29]

This RCT, conducted by the Institute of Dental Sciences, Bhubaneswar, indicates RP shows promise as a nonpharmacological behavior management approach for preschool children. RP outperformed TSD and PR in compliance and task efficiency. By framing tasks as challenges, RP aligns with developmental needs for autonomy and intrinsic motivation.

Ethical and practical considerations: Overuse of RP could risk miscommunication or reduced trust if misapplied by authority figures. Therefore, RP should be implemented with sensitivity, emphasizing playfulness rather than manipulation.

Cross‑disciplinary context: Findings align with those of educational and child psychology research showing that autonomy‑supportive communication enhances engagement. Gender and cultural influences are potential moderators; boys showed slightly higher challenge responsiveness, warranting further study.

Compared with the findings of prior literature, it is found that TSD remains effective for reducing anxiety in dental settings, while PR enhances short‑term motivation. However, RP’s playful structure engages intrinsic motivation more sustainably, supporting long‑term cooperation.

LIMITATIONS

1. Sample size: The small sample (n = 30) limits statistical power and generalizability of the findings. Larger trials are needed to detect smaller effect sizes and confirm findings.

2. Single-session design: The single-session intervention precludes assessment of long-term compliance or habit formation. Multisession studies could evaluate sustainability.[24]

3. Observer bias: Although mitigated by blinding and video recording, observer subjectivity in compliance assessment remains a concern.

4. Cultural specificity: The study’s Indian setting may limit applicability to individualist cultures, where reactance may be stronger.[30]

5. Task specificity: The toy placement task may not be generalized to complex behaviors (e.g., medical compliance), requiring further validation.[31]

The single‑session, single‑city (Bhubaneswar) design reduces external validity. Ecological validity is limited to classroom behavior tasks. Future studies should include multiple behavioral contexts and diverse populations.

FUTURE DIRECTIONS

Future research should

• Conduct longitudinal trials to assess RP’s long-term effects on behavior.

• Include diverse populations to evaluate cultural and socioeconomic influences, particularly in India’s varied demographic contexts.

• Compare RP with other techniques (e.g., distraction and modeling) in clinical settings like pediatric dentistry or vaccination clinics.[32]

• Explore RP’s efficacy in children with behavioral challenges (e.g., oppositional defiant disorder) to assess its limits.[33]

• Investigate the optimal phrasing and delivery of RP instructions to maximize effectiveness, considering the linguistic diversity in India.[34]

IMPLICATIONS

RP’s effectiveness, simplicity, and engagement make it a valuable tool for educators, clinicians, and parents, particularly in resource-constrained settings like India. Its integration into preschool curricula or pediatric dental protocols at institutions like the Institute of Dental Sciences, Bhubaneswar could enhance compliance without the costs of PR or the training required for TSD. Policy-makers should consider incorporating RP into behavior management training programs, especially in low-resource settings.[9] Recent advancements in behavioral health suggest that RP could complement emerging telehealth interventions for children.[25]

CONCLUSION

RP shows promise as an effective, simple, and engaging behavior management technique for children aged 4–6 years. Further longitudinal and multicontext studies are needed to confirm its generalizability and ensure ethical application.

CONFLICTS OF INTEREST

There are no conflicts of interest.

ETHICAL POLICY AND INSTITUTIONAL REVIEW BOARD STATEMENT

The study was registered with the Clinical Trials Registry-India (CTRI/2025/07/067891). Ethical approval was obtained from the Institutional Ethics Committee/Institutional Review Board of the Institute of Dental Sciences, Bhubaneswar (IEC/IDS/2025/0427).The supporting document can be produced vide requisition mail to the corresponding author.

PATIENT DECLARATION OF CONSENT

A separate Patient Informed Consent Form and Patient Information Sheet (PIS) in English and the local language Odia were prepared and approved by the Ethical Committee meeting on March 16, 2025. The PIS briefly explained the study protocol and how the samples would be obtained. The sample and filled-up forms are with the corresponding author.

AUTHORS CONTRIBUTIONS

SA: conceptualization, definition of intellectual content, literature search, data acquisition and analysis, writing original draft preparation and editing, guarantor; AA: conceptualization, definition of intellectual content, data acquisition and analysis, writing original draft—review, supervision; KA: definition of intellectual content, literature search, data acquisition and analysis, writing review and editing; SA, BSG: conceptualization, definition of intellectual content, literature search, data acquisition and analysis, writing original draft editing and review, guarantor; MS: definition of intellectual content, literature search, writing original draft preparation and editing, guarantor; MK: literature search, data acquisition and analysis, writing original draft preparation and editing, guarantor.

DATA AVAILABILITY STATEMENT

All the pertaining data are with the corresponding author and can be made available with a requisition mail to dr.isaq@gmail.com

List of abbreviations

• TSD- tell show do

• RP- reverse psychology

• PR- positive reinforcement

Funding Statement

Nil.