IACAPAP Textbook of Child and Adolescent Mental Health

EXTERNALISING DISORDERS

Chapter

D.2

OPPOSITIONAL DEFIANTDISORDER
Katie Quy & Argyris Stringaris

Katie Quy MSc
Institute of Education, ThomasCoram Research Unit, London,
UK
Conflict of interest: nonereported.

Argyris Stringaris MD, PhD,
MRCPsych
Senior Lecturer, King’s College
London, Institute of Psychiatry,
UK & Consultant Child andAdolescent Psychiatrist, Mood
Disorder Clinic, Maudsley
Hospital, London , UK
Conflict of interest: nonereported.
Acknowledgments: The authors
are grateful Professor Stephen
Scott for his helpful comments.
Dr Stringaris gratefully
acknowledges the support of
the Wellcome Trust.
This publication is intended for professionals training or practising in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Quy K, Stringaris A. Oppositional defiant disorder. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent
Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2012.

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IACAPAP Textbook of Child and Adolescent Mental HealthD

isruptive behaviour disorders are common and are associated with
substantial impairment for both children and their families, and with arange of poorer adjustment outcomes in later development (Ford et al,
2003; Burke et al, 2005; Copeland et al, 2009; Kim-Cohen et al, 2003; Costello
et al, 2003). Disruptive behaviour problems are also associated with increased
cost to society: it is estimated that the costs arising for individuals with antisocial
behaviours in childhood are at least 10 times higher than in non-antisocial
individuals by the time they reach 28 years (Scott et al, 2001a).
The two main classification systems, the Diagnostic and Statistical
Manual of Mental Disorders, 4th Edition (DSM-IV; APA, 1994, 2000) and theInternational Classification of Diseases, 10th Revision (ICD-10; WHO, 1993)
specify oppositional defiant disorder (ODD) as a persistent pattern of defiant,disobedient and antagonistic behaviour toward adults. This disorder is defined by
the absence of the more serious acts of aggression or antisocial behaviour associatedwith conduct disorder.

DIAGNOSISThe DSM-IV criteria for ODD require four or more symptoms to be present
for at least six months. Symptoms must occur at a level greater than in individualsof comparable age or developmental stage and must cause ‘significant’ impairment.
A diagnosis of ODD must exclude conduct disorder. Key features of ODD
highlighted by ICD-10 guidelines include a persistent pattern of provocative,
hostile and non-compliant behaviour, characterised by low temper threshold.

•

EPIDEMIOLOGY•ODD is a relatively common childhood disorder with an estimatedprevalence of 2% to 10% (Maughan et al, 2004; Costello et al, 2003). Prevalence
estimates may, however, vary depending on factors such as informant source (e.g.,parent vs. child) type of report (e.g., concurrent vs. retrospective) and whether or not
children meeting criteria for conduct disorder are included. ODD is significantly
more common in boys than girls. Symptoms are relatively stable between the agesof five and ten, but are thought to decline after that point. ODD is diagnosed
more rarely in older children, partly in order to avoid labelling normative discord
between children and their parents during adolescence. Table D.2.1 summarises
prevalence rates from a number of large studies.

•

Cross-cultural differences in prevalence

DSM-IV ODD
symptoms

•

•
•
•
•

Is often angry andresentful
Often argues withadultsIs often touchy or easily
annoyed by others
Often loses
temperOften deliberately
annoys or irritatesothersOften blames others forhis or her mistakes or
misbehaviour
Often actively defies orrefuses to comply withadult requests or rules
Is often spiteful andvindictive

Data drawn from World Health Organisation and World Mental Healthsurveys indicate that estimates of the prevalence of ODD vary widely acrosscountries. For example, data from a large-scale international survey published by
Kessler et al (2007) demonstrated marked variation in the lifetime prevalence of
impulse control disorders (comprising intermittent explosive disorder, oppositional
defiant disorder, conduct disorder, and attention-deficit/ hyperactivity disorder).
Relationship between ODD and conduct disorder
The extent to which ODD and conduct disorder should be considered as
separate or as a single disorder is the subject of some debate. This is reflected
in existing classification systems: in DSM-IV the diagnosis of conduct disorder

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Table D.2.1

Estimates of the prevalence ODD
Age range

Boys (%)

Girls (%)

5-10 years

4.8

2.1

11-15 years

2.8

1.3

The Great Smoky Mountains Study (Costello et al, 2003) – threemonth prevalence

9-16 years

3.1

2.1

The Bergen Child Study (Munkvold et al, 2009)

7-9 years

2.0

0.9

British Child and Adolescent Mental Health Survey (Meltzer et al,
2000; Ford et al, 2003)

can include all of the features of ODD and it is treated as a precursor to conductdisorder. In ICD-10, ODD is thought to only be a milder form of conductdisorder, so the two are considered as a unique category, as they sometimes are in
empirical research studies (Kim-Cohen et al, 2003). However, while ODD and
conduct disorder have been found to have high levels of comorbidity, the majorityof children diagnosed with ODD do not go on to develop conduct disorder (Roweet al, 2002), and the two disorders are distinguishable by a range of different
correlates (Dick et al, 2005; Nock et al, 2007).
Relationship between ODD and other disorders (co-morbidity andheterotypic continuity)
ODD is characteristically comorbid, in that it occurs together with or
before a wide range of other disorders (Costello et al, 2003) including anxiety anddepressive disorders (girls), conduct disorder and substance use disorders. Children
with ADHD often go on to develop ODD. The wide range of associations between
ODD and other disorders is depicted in Figure D.2.2.
ODD has consistently been found to predict later depression (Copeland
et al, 2009; Burke et al, 2010; Burke et al, 2005) and anxiety (Maughan et al,2004). Most strikingly, Copeland et al (2009) found that childhood oppositional
defiant disorder predicted young adult depression; young adult depression and
Figure D.2.1

Lifetime prevalence of impulse control disorders (Kessler et al, 2007)

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Figure D.2.2: The relationship between ODD and other disorders (modified from Burke et al,
2005)

TIME
ODD: oppositional defiant disorder; CD: conduct disorder; ADHD: attention deficit/hyperactivity disorder (common precursor to
ODD)

anxiety disorders were often preceded by adolescent ODD, but not CD. The
relationship between ODD and emotional problems is particularly puzzling –it has been suggested that it may be the affective aspects of ODD that predict
emotional disorders such as anxiety and depression (Burke et al, 2005; Stringaris& Goodman, 2009b)
In an attempt to explain the heterogeneity of the associations between
childhood ODD and adult disorders, Stringaris and Goodman (2009a, 2009b)
proposed that the DSM-IV ODD criteria consist of three a priori specified
dimensions described as “irritability,” “headstrong and “hurtful” behaviour.
Others (Rowe et al, 2010) have identified only two dimensions – irritability andheadstrong, while others have suggested slightly different partition of symptoms(Burke et al, 2010). The findings suggest that “irritable” mood is more strongly
predictive of later emotional disorder (Stringaris et al, 2009), while “headstrong”
and “hurtful” behaviours are more predictive of conduct problems. The clinicalutility of these distinctions has yet to be established (Rowe et al, 2010; Burke et al,
2010; Aebi et al, 2010).
AETIOLOGY AND RISK FACTORS
While no single cause of ODD has been identified, a number of risk factors
and markers have been found to be associated with oppositional behaviour.
Genetics
Genetic effects contribute significantly to the development of ODDsymptoms with heritability estimates exceeding 50%, with genetic factors
accounting more than 70% of the variability in individual measures based onparent reports (Eaves et al, 1997). While some have suggested that ODD shares
substantial genetic overlap with conduct disorder (Eaves et al, 2000), other studies
have indicated unique effects for each (Rowe et al, 2008, Dick et al, 2005). In

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IACAPAP Textbook of Child and Adolescent Mental Healthaddition, it seems that genetic effects underlie the association between ODD and
ADHD (Hewitt et al, 1997) as well as between ODD and depressive disorder(Rowe et al, 2008). In a twin study of adolescents, self-reported irritability
symptoms of ODD shared genetic effects with depressive symptoms, whereas“headstrong/hurtful” symptoms of ODD shared genetic risk with delinquent
symptoms (Stringaris et al, 2012).
Gene-environment interplay
The notion that the effects of exposure to an environmental factor (e.g.
childhood maltreatment) on a child’s behaviour is conditional upon that child’s
genetic make-up has face validity and biological plausibility (Rutter, 2006). In oneof the pioneering studies in the field (Caspi et al, 2002), a functional polymorphismin the promoter region of the gene that codes for the neurotransmitter-metabolizing
enzyme monoamine oxidase A (MAO-A) was found to moderate the effect ofchild maltreatment on future conduct and antisocial problems, although several
later studies did not find such an interaction. Maltreated children with a genotype
that leads to low levels of MAOA activity more often displayed conduct disorderand antisocial behaviours at follow up, than children with a high-activity MAOA
genotype (Caspi et al, 2002). This will be discussed further in the chapter on
conduct disorder (Chapter D.3).
Age of onset
The age of onset of antisocial symptoms (Moffitt, 1993) seems to be a goodpredictor of later outcome. Moffitt (1993) distinguishes between children whose
symptoms first emerge in childhood and persist into adolescence (childhood
onset persistent) compared to those whose symptoms first occurr in adolescence.
Individuals in the childhood onset persistent group have been found to have poorer
adult outcomes when compared with non-disordered and adolescent-onset peers(Moffitt, 2003; Moffitt, 2006; Moffitt et al, 2002; Odgers et al, 2007; Farrington
et al, 2006). Age of onset as a predictor of later outcomes is discussed further in
Chapter D.3.
Temperament
Temperamental factors in toddlerhood, such as irritability, impulsivity,and intensity of reactions to negative stimuli, may contribute to the developmentof a pattern of oppositional and defiant behaviour. It is possible that ODD isarrived at through different temperamental routes that could serve to explain its
comorbidity. Stringaris et al (2010) showed that the comorbidity between ODD
and internalizing disorders was more strongly associated with early temperamental
emotionality, whereas the comorbidity between ODD and ADDH was better
predicted by temperamental over activity.
Peer influences
Children who display oppositional behaviour are more inclined to experience
disrupted or problematic peer relationships. Such children are commonly rejectedby non-deviant peers, and tend instead to associate with other children who
exhibit problem behaviour. It would appear likely that the relationship between
peer rejection and childhood ODD symptoms is a bi-directional one, as is nicely
illustrated in a series of studies about bullying (summarised in Arseneault et al,2010).

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IACAPAP Textbook of Child and Adolescent Mental HealthCallous and unemotional traits
The concept of psychopathy has been extended to young people in recent
years (Frick et al, 1994) with a focus on callous and unemotional traits. While not
all children diagnosed with conduct disorder have callous and unemotional traits(Frick et al, 2000), the presence of such traits appears to distinguish a subgroup ofchildren with more serious conduct problems. Callous and unemotional traits seemto be highly heritable (Viding et al, 2005) and characterised by poor recognitionof emotion (particularly fear) in facial expression (Blair et al, 2006; Dadds et al,2006). The importance of callous and unemotional traits is discussed further in
Chapter D.3.
Neighbourhoods
The broader environment surrounding the child may also be a risk factor.
Disruptive behaviour has consistently been associated with social and economic
disadvantage and neighbourhood violence (Guerra et al, 1995; Rowe et al, 2002).
Family factors
The importance of the interplay between genes and family-level
environmental factors has become increasingly clear in the aetiology of children’s
disruptive behaviour problems (Moffitt, 2005). Evidence from adoption studies(O'Connor et al, 1998; Ge et al, 1996) shows that children at high genetic risk
for antisocial behaviour were more likely to receive negative parenting from theadoptive parents than were children with low genetic risk for antisocial behaviour.
Conversely, it is known from studies using a monozygotic twin design that familylevel effects contribute to children’s risk for externalising problems over and above
children genetic effects (Jaffee et al, 2003; Caspi et al, 2004). In other words,
parental behaviour towards children can be a true environmental risk.
Models of family influences
Patterson (1982) proposed a model about how parental behaviour may
exacerbate children’s negative behaviour and result in what he designated as“coercive family processes”. His work has shown that parents of children with
disruptive behaviour problems are more likely to be inconsistent in how they apply
rules, and give commands that are either unclear or the result of their own current
emotional state rather than contingent upon the child’s behaviour. A typicalmutually coercive process would arise when a parent responds in an unduly harsh
way to a child’s mildly disruptive behaviour, upon which the child may further
escalate its oppositional behaviour. This in turn leads to yet harsher responses by
the parent with further escalation. The result is that the parent may in the end
give in, reinforcing the child’s negative behaviours. This paradoxical “reward” of achild’s negative behaviour may both increase and maintain oppositional behaviours
and is the specific target of therapeutic interventions (see below).

Gerald R Patterson, founderof the Oregon Social
Learning Centre, described
the so called “coercive family
processes” and their rolein the development andmaintenance of behaviour
problems.

ASSESSMENT
Measurement instruments
It is feasible to assess oppositional problems in children as young as 5 yearsof age (Kim-Cohen et al, 2005). A wide range of instruments is available tomeasure ODD symptoms and to assist in the diagnostic process and monitoring.
Clinicians should always bear in mind that diagnosis is based on their judgment

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Table D.2.2

Assessment tools commonly used to identify ODD (symptoms or the disorder).

Type

Questionnaires

Semistructured
interviews

Structured
interviews

Observational
instruments

Name

Availability•

The Eyberg Child Behavior Inventory (ECBI: Eyberg &Ross, 1978; Eyberg & Robinson, 1983)

Can be purchased from PAR•

The Child Behaviour Checklist (Achenbach &Edelbrock, 1983)

Can be purchased from ASEBA•

The Behaviour Assessment for Children (BASC-2:
Reynolds & Kamphaus, 2004)

Can be purchased from Pearson•

Conners Child Behaviour Checklist (Conners &Barkley, 1985)

Can be purchased from MHS•

Strengths and Difficulties Questionnaire (SDQ:
Goodman, 1997)

Available free of charge from SDQ
website subject to conditions.

•

The Child and Adolescent Psychiatric Assessment(Angold & Costello, 2000)

Available free of charge fom Duke
University, subject to copyrightapproval from the author.

The Development and Well-Being Assessment (DAWBA:
Goodman et al, 2000) combines questionnaires andinterviews (with both structured and semi structured
elements)

Available free of charge from theDAWBA website, for non-commercial
purposes.

•

The Diagnostic Interview Schedule for Children (DISC:
Shaffer et al, 1993; Schwab-Stone et al, 1993; Shaffer
et al, 2000; Shaffer et al, 2004)

Available by emailing disc@worldnet.
att.net (administration charge forpaper copies)•

The Disruptive Behaviour Diagnostic Observation
Schedule (Wakschlag et al, 2008b, Wakschlag et al,
2008a)and integration of the information gathered by interviews, clinical examination,
scales and other means (summarised in Table D.2.2).
Useful principles for assessing children with ODD include: a) try to obtain
information from as many different sources (parent, child, teacher) as possible;b) assess comorbid psychiatric problems, particularly ADHD; c) assess otherrisk factors at family, school and neighbourhood level. Children with disruptive
behaviour problems often come from deprived backgrounds. It is important
to identify factors (such as bullying or peer deviance) that maintain or increase
oppositional behaviours. The same applies to performance at school: a child withreading difficulties or hyperactivity may be more likely to manifest oppositional
behaviours at school.
Differential diagnosis
Oppositionality can be seen in many childhood conditions. It is important
for the clinician to recognise those cases where other disorders may have givenrise to it. For example, it is not uncommon for children who develop a specificphobia or other anxiety disorders (such as OCD) to become oppositional anduncooperative, particularly in situations in which they expect to be exposed to
the feared situation. Clinicians treating children with OCD whose rituals are
disrupted know this phenomenon all too well. In these cases, assigning a diagnosis

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IACAPAP Textbook of Child and Adolescent Mental HealthJack is 7 years of age. His mother reported that he was “very difficult” and that he had “always” been like that. He would
lose his temper over seemingly trivial matters, such as losing at a video game he played with his best friend: “he gets red
in the face and starts huffing, shouts and cries”. Also he was often grumpy for no apparent reason. His mother describedthat when he did not want to do something “he simply won’t”. He often refused to go to bed; “we have massive rows in theevenings because of this”. Jack sometimes got so angry that he broke his own toys or threw them around.
Jack has had no contact with his father since the age of six months. His mother said that Jack’s father was an “angry andaggressive man”, who often shouted and lost his temper.
His teacher said that Jack was argumentative and refused to do as he was asked in class and constantly annoyed theother children by throwing bits of paper at them and taking their pencils or toys. The other children in the class didn’t like toplay with Jack and this made him angry. Recently, some of the older children had been mocking him and pushing him aroundin the playground. He often came home looking sad and grumpy.
Jack’s mother said that she was “at the end of her tether” and that “You can’t reason with him, you can’t shout at him, it
just doesn’t help – no matter what I do it just doesn’t work”.
Jack and his mother were seen at their local child and adolescent mental health service. On the basis of his symptoms
and level of impairment, Jack was given a diagnosis of ODD and his mother was offered to take part in a parent management
course.
Within only a few weeks of attending the course she found this very helpful in dealing with Jack’s behaviours. At the endof the intervention, Jack no longer displayed significant symptoms of ODD. His tantrums had become very rare and he was,overall, much less defiant. He and his mother were more able to enjoy activities and play together. Jack’s mother reports that
she now finds it easier to identify Jack’s good behaviours and praise them accordingly.

of oppositional defiant disorder and failing to recognise and address the underlying
anxiety disorder is counterproductive. The same applies to children with ADHD
who often develop oppositionality. Indeed, oppositionality might be the main
reason for the referral of such children. It is crucial for the clinician to be able tolook for ADHD as a possible underlying issue of the disturbance, even when theparents’ chief worry is their child’s oppositionality. This has important treatment
implications (see below). Similar situations can arise in children with autism, who
can become particularly oppositional in the face of change of routine or due tosensory sensitivities. Here too, clinicians will want to recognise possible underlying
problems and ensure that these are adequately treated.

TREATMENT
Some general principles apply to the treatment of oppositional problems
as with other psychiatric disorder. Comorbidities should be identified as they arelikely to require treatment in their own right. This is particularly true for ADHD
and to a large extent also for childhood depression and anxiety. Other treatableor modifiable risks (e.g., ongoing bullying or failure at school due to learning
difficulties) should always be assessed and addressed as part of the treatment
package offered to the family.
A number of treatments are available to clinicians, depending on the needs ofthe individual child and family. For example, behaviour occurring predominantlyin either the home or school context may be best managed using a treatment
designed to address context-specific issues. More pervasive problems may call for
more intensive individual work (Moffitt & Scott, 2008).
Parent management training
Parent management training-based on principles of social learning theory isa key feature of treatment in ODD. Problematic parent-child interaction patterns

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IACAPAP Textbook of Child and Adolescent Mental Healthhave been implicated in the development and maintenance of oppositional
behaviour and principles of social learning, particular in relation to operant
conditioning (the role of reinforcement / consequences in altering behaviour),have been found to be useful in modifying behaviour in both parents and children(Feldman & Kazdin, 1995). Parent management training teaches parents to
identify prosocial and problem behaviour and apply punishment and reinforcement
techniques designed to increase the frequency of desired behaviours and decrease
the frequency of undesired ones.
Examples of parenting programmes
Several programmes based on social learning theory have been found to beeffective in addressing early onset antisocial behaviour, namely:•

The Incredible Years (Webster-Stratton, 1981)
One of the best validated is Webster-Stratton’s “Incredible Years”,
a behaviourally-based training programme designed for use with parents(Webster-Stratton & Hammond, 1997; Webster-Stratton, 1982; WebsterStratton, 1981), teachers and children (Webster-Stratton & Hammond,
1997). Scott and colleagues (2001b) carried out a multi-centre controlled
trial of the group parenting version in a sample of 141 (intervention group,
n=90; waiting list control group, n=51) children aged 3 to 8 years who werereferred for antisocial behaviour to their local multidisciplinary child andadolescent mental health service. They used the videotape-based “Basic”
programme (Webster-Stratton & Hancock, 1998). This comprised 13-16
2-hour weekly sessions in which parents were shown video segments withscenes showing right and wrong ways to manage children. The programme
covered play, praise and rewards, limit-setting, and handling misbehaviour.
After watching the videos, parents were encouraged to discuss their own
children’s behaviour and rehearsed different approaches to handling it. Parents
were also given weekly activities to try at home (homework) and progress was
supported by telephone contact. Programme costs were comparable withthe cost of individual treatment. Substantial and statistically significant
decreases in antisocial behaviour compared with controls were found inparents’ ratings of children’s conduct problems as well as hyperactivity;
parent reports of total number of problems per day; conduct problems andtotal deviance as measured by the Strengths and Difficulties Questionnaire(Goodman, 1997); externalising and total problem scores as assessed by theChild Behaviour Checklist (Achenbach & Edelbrock, 1983); parent definedproblems (the three problems parents identified as the ones they most wanted
to see improved); and ICD­10 diagnosis of oppositional defiant disorder.
Parent behaviour was also measured and significant decreases were found inobservations of parents’ inappropriate commands. Two further programmes
have also been developed: the “Advance” programme, designed to manage
parental relationships and the “Partners” programme, designed to support
children’s academic learning and build up parent-teacher relationships.
Integrating the three programmes has been found to achieve the mostsubstantial improvements in behaviour.

•

The Triple P—Positive Parenting Programme
Triple P is an evidence based parenting and family support programme

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9IACAPAP Textbook of Child and Adolescent Mental HealthA group of parents graduate
from a parenting programin South Africa. Source:
Beautifulgate.

designed to prevent and manage behaviour problems in preadolescent children
by enhancing parenting skills and improving parent-child relationships. The
programme comprises multiple levels: universal intervention designed toprovide information on parenting issues for interested parents; provision ofadvice for specific problem behaviours; brief programmes to provide advice
and training parents dealing with minor behaviour problems; and more
intensive programmes comprising training in mood management strategies,
coping skills and partner support skills designed to address more persistentand pervasive behaviour problems. Triple P has been validated in a numberof studies with a range of family types and cultural backgrounds (Graaf et al,
1998, Bor et al, 2002).
Alternative approaches
Strategies have also been put forward to treat behaviour problems infamilies where such programmes have been unsuccessful. Scott and Dadds (2009)
suggest a number of alternative ways of approaching intervention which may
provide a framework to address factors which may limit the efficacy parent training
programmes. They recommend taking account of attachment security and theparent-child relationship in considering intervention strategies, in order to allow
for the impact which disrupted attachment may have on the meaning of expected
reinforcers or punishments. In addition, they emphasise the importance of widersocial contexts which may impact on the child, such as parent relationships,
siblings, extended families and neighbourhoods. Finally, they encourage clinicians
to consider beliefs held by parents about the child (or aspects of parenting) which
may be interfering with treatment.
School-based interventions
1. Teachers may also be provided with additional tools to promote
improvements in classroom behaviour. Social learning theory is also key
in this approach. Moffitt and Scott (2008) identify four primary domainsof functioning to be addressed:Promoting compliance and adherence toclassroom rules and acceptable behaviours
2. Supporting the development of problem solving skills
3. Preventing problem behaviour
4. Avoiding the escalation of oppositional behaviour

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Goals in managing
ODD (from Fraser &Wray, 2008)
For parents•
Improve positiveparenting skills•
Enhance skills inproblem solving,
conflict resolution andcommunication
For the child•
Developmentof effective
communication,
problem-solving andanger management
skillsFor the family•
Family counselling andsupport to deal withthe stresses in theirrelationships and thehome environment
In the classroom•
Encourage the teacher
or school counsellor
to provide social skills
sessions to improve
peer relationship.

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Individual therapy – anger management
Existing evidence indicates that CBT-based anger management training
may be particularly helpful in treating anger (Beck & Fernandez, 1998; Lochman
et al, 2011). This training uses a coping skills approach involving stress inoculationinterventions comprising three elements: cognitive preparation‚ skill acquisition‚
and application training (Meichenbaum, 1996). In the first phase, cognitive
preparation, the trainer works to establish a relationship with the patient. The
patient is coached to reconceptualise stressors as potentially modifiable problems
which can be managed using coping strategies. In the second phase, skill
acquisition, the patient is taught specific coping strategies, such as emotional
self-regulation, acceptance, problem-solving, and attention diversion procedures;
systems which may be applied to particular problems experienced by the patient
and their family. In the final phase, the patient is taught to apply these strategies
in practice. Stressors are gradually introduced (using for example role playing
techniques), until the patient can employ coping skills in real-life situations.
Medication
There is no evidence that medication is effective for the treatment of ODD.
In children with ADHD, treatment with stimulants is known to improve conductand oppositional symptoms (NICE, 2008); however, there is not much evidence
to support use of stimulants to treat oppositional problems in children without
ADHD. A trial in children with ADHD (Blader et al, 2009) showed that sodium
valproate may be useful for those children whose aggression did not respond to
stimulants. However, these were hospitalized children and the results may not
apply to the children commonly seen in outpatient samples. A trial of Lithiumin children with severe irritability has shown no effects (Dickstein et al, 2009).
It is far from clear that the effects of risperidone on the difficult behaviours ofchildren with autism (McCracken et al, 2002) or developmental disability can beextrapolated to typically developing children. Serotonin reuptake inhibitors are
sometimes used for the treatment of anger in adult populations but evidence forits effectiveness in youth is lacking. The dramatic increase in diagnosis of bipolar
disorder, particularly in the US (Blader & Carlson, 2007; Moreno et al, 2007) overthe last 10-15 years has been associated with an increase in the prescription of antipsychotic drugs for children (Olfson et al, 2006). It has been argued that cases withsymptoms typical of ODD, such as irritability, have been misdiagnosed as sufferingfrom bipolar disorder. There is no good evidence to support such expansion of thediagnostic boundaries of bipolar disorder (Leibenluft, 2011; Stringaris, 2011) and,on current evidence, anti-manic drugs should not be given to children with ODD
alone (for a more detailed discussion of this issue see Chapter E.3). Judicious use of
sedating agents in emergency settings or dopamine antagonists (e.g., risperidone)
used short term for specific symptom control may be considered on a case-to-casebasis. Clinicians using such medications will want to have informed parents andchild fully about the reasons for their use (instead of alternatives) as well as of thepotential side effects. Clear treatment goals (i.e., reduction/change in particularbehaviours or rating scale-scores) should be agreed at the outset within the clinicalteam and with the patients and carers. The effects (and unwanted effects) of thetreatment should be carefully and regularly reviewed.

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There is no evidence that
medication is effective
for the treatment of ODD.
In children with ADHD,
treatment with stimulants is
known to improve conductand oppositional symptoms;
however, there is notmuch evidence to support
use of stimulants to treat
oppositional problems inchildren without ADHD.

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REFERENCES
Achenbach TM, Edelbrock C (1983). Manual for the Child
Behavior Checklist and Revised Child Behavior Profile,
Burlington, VT: Queen City Printers.
Aebi M, Müller UC, Asherson P et al (2010). Predictabilityof oppositional defiant disorder and symptom
dimensions in children and adolescents with ADHD
combined type. Psychological Medicine, 40:2089–2100.
Angold A, Costello E (2000). The Child and Adolescent
Psychiatric Assessment (CAPA). Journal of theAmerican Academy of Child & Adolescent Psychiatry,
39:39–48.
American Psychiatric Association (1994). DSM-IV: The
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