ARTICLE

Oppositional Defiant Disorder: Clinical

Considerations and When to Worry
Juan David Lopez, MD,* Whitney Daniels, MD,† Shashank V. Joshi, MD†
*San Francisco Department of Public Health, Children, Youth and Families, San Francisco, CA
†
Division of Child and Adolescent Psychiatry and Child Development, Department of Psychiatry and Behavioral Sciences, Stanford University School of
Medicine, Stanford, CA

PRACTICE GAP

Since the COVID-19 pandemic, there has been a significant increase in

pediatric mental health disorders, with increasing wait times to access
specialized behavioral health services. There is an opportunity for pediatricians
to improve their ability to provide mental health assessments in diagnosing
oppositional defiant disorder and recommending treatments.

OBJECTIVES After completing this article, readers should be able to:

1. Describe the differences between oppositional defiant disorder and

conduct disorder and the overlap of attention-deficit/hyperactivity disorder
in children and teenagers.
2. Develop awareness of potential biases of diagnosing aggressive behaviors.
3. List the types of support and resources that are helpful for a child who
displays disruptive or aggressive behaviors.

CASE VIGNETTE
Miguel is a 10-year-old Hispanic bilingual boy of Mexican ancestry who presents for
a new patient health supervision visit. His parents request to speak with you privately AUTHOR DISCLOSURES: Drs Lopez,
Daniels, and Joshi have disclosed no
before you see him because they have concerns about his behaviors during the past
financial relationships relevant to this
2 years. Since starting the 4th grade, teachers at his public school have mentioned article. This commentary does not
that he will not follow the rules, talks back often, and is overall quite disruptive to the contain a discussion of an unapproved/
investigative use of a commercial
classroom learning environment because he cannot sit still and has a tendency to de- product/device.
liberately annoy others. He has been placed in detention multiple times, with no im-
provement in these behavioral issues. He is doing poorly in multiple subjects, and
ABBREVIATIONS
there have been suggestions at the parent-teacher conferences that his behavior needs
ACE adverse childhood experience
to improve otherwise he is at risk for being held back or possibly transferred to a ADHD attention-deficit/hyperactivity
more structured classroom setting. His parents also share that he has been quite irri- disorder
table at home (disobeying their requests to clean his messy room), is “very active,” CD conduct disorder
DSM Diagnostic and Statistical Manual
and often blames his younger sister for his misbehaviors. The parents are over- of Mental Disorders
whelmed and do not know what to do. ODD oppositional defiant disorder

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 INTRODUCTION preschoolers to have weekly tantrums). Although opposi-
As early as the 19th century, a developmental perspective tional behavior toward authority figures is a normal part of
describing disruptive behavior disorders began its evolu- childhood development, openly hostile or uncooperative be-
tion with the international child-saving movement. (1). haviors rise to a level of concern when these behaviors are
“Child savers” were reformer women who worked to allevi- so frequent and consistent that they seriously interfere with
ate child delinquency and change the treatment of juveniles a child’s day-to-day functioning across multiple settings.
in the justice system. Child savers emphasized the value of Children with ODD have ongoing patterns of being un-
prevention and redemption of problem behaviors through cooperative, defiant, and hostile toward authority figures.
early identification and interventions such as education and These behaviors last at least 6 months and include at least
training. The juvenile justice system was established at the 4 of the following (7): frequent temper tantrums, often
urge of those leading the child-saving movement. In the touchy or easily annoyed, often angry and resentful, often
1920s and 1930s, thought leaders such as Jane Addams and argue with authority figures, often actively defy or refuse
August Aichhorn helped further evolve a foundational devel- to comply with rules, often deliberately annoy others, often
opmental perspective for disruptive behavior disorders, which blame others for their mistakes, and have been spiteful or
would eventually lead to formal classification in the Diagnostic vindictive at least twice in the past 6 months.
and Statistical Manual of Mental Disorders (DSM). Opposi- Spite is the desire to deliberately hurt others, and with
tional defiant disorder (ODD) falls under this classification. ODD, spite can show as physical or emotional bullying of
Pediatric patients with ODD can be emotionally taxing other children. Vindictiveness is the desire to hurt others
for pediatricians, their administrative staff, and other pa- who we perceive to have wronged us and is seen in chil-
tients and families in the clinic. Since the COVID-19 pan- dren who hold grudges and build cases against others to
demic, there has been a substantial increase in mental justify vengeful acts. ODD is further broken down by sever-
health issues in children and adolescents, with increased ity, with mild denoting symptoms confined to only 1 setting,
wait times to get connected with a behavioral health specialist. moderate indicating symptoms present in at least 2 settings,
(2)(3)(4) Pediatricians are well-positioned to detect and inter- and severe being associated with symptoms in 3 or more set-
vene on behavioral disturbances early on. To avoid unhelpful tings. The diagnosis is not given if the symptoms appear
approaches and instead improve the physician-patient rela- only in the context of a mood or psychotic disorder.
tionship, pediatricians should be aware of the clinical pre- An accurate assessment of a child who exhibits disruptive
sentation, contributing factors, and potential biases when
or aggressive behavior requires a thorough and thoughtful
diagnosing ODD. This awareness will inform approaches to
evaluation of the frequency, intensity, and chronicity of
treatment that should prompt referral to a developmental-
the behavior in the context of that child’s developmental
behavioral pediatrician or child and adolescent psychiatrist.
stage (Table 1). Such an evaluation requires knowledge of
This review article provides an overview of ODD with some
normal child development and inquiry of the temperaments of
of its most common presenting characteristics, treatments,
the child’s parents and siblings. It is also important to be
and clinical features, including those features that should
aware of sex differences with respect to aggression. In early de-
prompt referral.
velopment, girls may manifest aggression in ways that are less
DIAGNOSIS overt and more covert, especially regarding relationships. (8)
Indirect, verbal, and relational expressions of aggression may
The diagnosis of ODD was first suggested in 1966 by the
be more representative of girls’ oppositional behaviors. (9)
Group for the Advancement of Psychiatry and appeared for
In addition, an accurate diagnosis relies on obtaining
the first time in DSM-III, which was published in 1980. (5)
The diagnosing of antisocial, aggressive, and socially disrup- information from multiple sources. Similarly to diagnos-
tive conduct has long been controversial. However, there ing attention-deficit/hyperactivity disorder (ADHD), it is
seems to be significant coherence of ODD behaviors con- critical to incorporate the parents’, teachers’, and child’s
tained in the diagnostic criteria of the DSM. (6) perspectives into the assessment process.
All children are oppositional from time to time, especially The use of specific questionnaires and rating scales
during periods of hunger, stress, sleep disruption, and fa- may be helpful in evaluating children for ODD and for
tigue, which can make their emotions run high. Children tracking progress. (5) A range of instruments and inter-
may argue, talk back, disobey, and defy parents, teachers, views have been developed to measure oppositional behav-
and even their own pediatricians. (It is not unusual for ior and aggression in childhood across settings. (9)(10)

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 Table 1. General Definitions of Mental Disorders
Mood disorders are highlighted by emotional disturbances with the presence of sad, empty, or irritable mood accompanied by somatic
and cognitive changes that significantly affect one’s capacity to function. Examples include major depression, bipolar disorder, and
disruptive mood dysregulation disorder. (7)
Neurodevelopmental disorders are conditions with an onset in early development that produce impairments in personal, social,
academic, or occupational functioning. Examples include autism spectrum disorder, attention-deficit/hyperactivity disorder, and
learning differences. (7)
Personality disorders are defined by having an enduring pattern of inner experience and behavior that deviates significantly from the
expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time,
and leads to distress or impairment. Examples include borderline personality disorder, histrionic personality disorder, and narcissistic
personality disorder. (7)
Psychotic disorders are considered when an individual experiences delusions, hallucinations, disorganized thinking and speech,
abnormal motor functioning (including catatonia), and negative symptoms such as diminished emotional expression. Examples include
schizophrenia, schizotypal personality disorder, and substance/medication-induced psychotic disorder. (7)
Disruptive, impulse-control, and conduct disorders are conditions where the individual struggles with self-control of emotions and
behaviors. Although other mental health disorders also involve problems in emotional and/or behavioral regulation, these disorders
are unique in that their problems manifest in behaviors that violate the rights of others and that bring the individual into significant
conflict with societal norms and authority figures. Examples include oppositional defiant disorder, conduct disorder, and antisocial
personality disorder. (7)

• The Conners’ Parent Rating Scale and the Conners’ PREVALENCE, DEVELOPMENT, COURSE OF
Teacher Rating Scale have multiple formats with excel- DISORDER, AND POTENTIAL CONSEQUENCES
lent psychometrics for ADHD and ODD and is validated Nationally, ODD is found in 1% to 11% of youth, with
across childhood into adolescence. (11) These scales have averages estimated to be approximately 3.3%. (15) It is
been translated into various languages. The most cur- more prevalent in boys than in girls (1.59:1) before adoles-
rent 4th edition requires purchase.
cence, but by adolescence, ODD is equally prevalent in
• The Vanderbilt ADHD Diagnostic Rating Scale is a well-
boys and girls. (16)
validated tool for children ages 6 to 12 years that assists
ODD symptoms normally appear during the preschool
with diagnosing ADHD and screening for ODD, con-
years, and it is rare to have it first manifest beyond early
duct disorder (CD), anxiety, and depression. (12) There
adolescence. Approximately 30% of children with early-
are parent and teacher forms, with the 3rd edition being
onset ODD will go on to develop CD, and 10% of those
modified for DSM-5 criteria and requiring purchase.
diagnosed as having ODD go on to develop antisocial per-
• The Disruptive Behavior Disorders Rating Scale is a free
sonality disorder and other personality disorders. (8)(9)(17)
and widely used tool for assessing ADHD, ODD, and CD
Promisingly, although the diagnosis of ODD is relatively
and has strong psychometrics for children ages 5 to
stable over time, approximately 67% of children will no
12 years. The Disruptive Behavior Disorders Rating Scale
longer meet the criteria for the diagnosis after 3-year
has recently been evaluated to be in accordance with the
follow-up. (9)
latest DSM-5 criteria. (13)(14)
There is a significantly increased risk of anxiety and
DIFFERENTIAL DIAGNOSIS (TABLE 2) major depression for those who have ODD, especially in
children who present with anger and irritability. ADHD is
• ADHD
often found as a comorbid condition that contributes to
• CD
• Intermittent explosive disorder the symptoms of ODD and can add to the complexity of
• Adjustment disorder diagnosis. Conditions associated with ODD include ele-
• Posttraumatic stress disorder vated risks of substance use disorders and attempting sui-
• Disruptive mood dysregulation disorder cide. (18)
• Major depressive disorder When ODD is persistent throughout the childhood
• Bipolar disorder years, individuals with the disorder experience frequent
• Anxiety conflicts with parents, teachers, health-care providers,
• Learning differences peers, and even their romantic partners. These interper-
• Intellectual developmental disorders (intellectual disability) sonal conflicts can result in profound impairments in
• Speech-language disorders the young person’s emotional, psychological, social, aca-
• Normal development demic, and occupational adjustment. (19)(20)

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 Table 2. Comparing Oppositional Defiant Disorder versus Disruptive Mood Dysregulation Disorder versus
Conduct Disorder
OPPOSITIONAL DEFIANT DISRUPTIVE MOOD
VARIABLE DISORDER DYSREGULATION DISORDER CONDUCT DISORDER
Onset Preschool years Elementary school years Middle childhood through middle
adolescence
Symptoms Trouble with authority Frequent and severe temper tantrums Bullying and being physically aggressive
Defies and breaks rules Physical aggression toward others toward others
Difficulty following directionsa Persistent irritability or anger Cruelty toward animals
Irritabilitya Difficulty regulating emotionsa Destruction of property
Difficulty regulating emotionsa Poor school performancea Theft
Argumentative Setting fires
Easily annoyed Serious violations of rules (eg, truant from
Deliberately annoys others school, running away from home)
Frequent temper tantrumsa Poor school performancea
Poor school performancea
Duration $6 mo $12 mo $3 incidents in the past 12 mo with
$1 in the past 6 mo
a
A shared symptom with attention-deficit/hyperactivity disorder.

RISK FACTORS AND PROGNOSTIC INDICATORS Environmental

As one might expect, the development of ODD involves mul- ACEs such as poverty, food insecurity, child neglect and
tiple contributing factors, some of which are highlighted in abuse, lead exposure, interpersonal and systemic racism,
the following subsections. vicarious traumas such as observing domestic violence,
and experiencing harsh parenting styles are all implicated
as a part of increased risk for ODD. (6)(7)(25) Children
Temperamental
High levels of emotional reactivity and low frustration tol- with ODD are at higher risk for being bullied and of bully-
erance for a child are predictive of ODD. This is especially ing peers. (26)
important when there is a mismatch between a child’s
temperament and a parent/guardian’s parenting style. Pa- Biological/Genetic
rental use of physical discipline can lead to future aggres- There is notable overlap between the genetic influences
sive behaviors because it provides that child with a model for major depression and generalized anxiety and the irri-
for using aggressive behaviors as a solution to conflict. (7) tability and anger symptoms of ODD. Youth with lower
In contrast, nurturing relationships with significant adults resting heart rates and abnormalities in the prefrontal cor-
promotes resilience in children. Resilience is a strong fac- tex and amygdala; altered functioning of the serotonergic,
tor in helping children thrive and can mitigate the effects noradrenergic, and dopaminergic systems; low cortisol lev-
of adverse childhood experiences (ACEs). (21) els; and elevated testosterone levels are at higher risk for
ODD. (7)(27)

Psychological
Attachment theorists have shown parallels between in- POTENTIAL BIASES AND CONCERNS IN
secure attachment behaviors and disruptive behavioral DIAGNOSIS
disorders, whereby the oppositional behavior may be Even when controlling for confounding variables such as
considered a special signal to a parent who is unrespon- ACEs, socioeconomic background, genetics, and previous
sive. (22) Children with comorbid ADHD and ODD ex- juvenile offenses, ethnic and racial minority youth are more
perience multiple individual and contextual risk factors likely to receive a diagnosis of ODD and are less likely to be
beginning in infancy that can lead to adverse personality diagnosed as having ADHD compared with non-Hispanic
formation into adulthood. (17)(23) Aggressive children white youth. (28) In addition, many studies document the
have been found to underuse pertinent social cues, misat- disproportionate psychiatric diagnosis of African Americans
tribute hostile intent in others, generate fewer solutions to and Latinx Americans compared with Euro-Americans. (29)
problems, and expect to be rewarded for aggressive re- However, first-generation immigrants and refugees have
sponses. (24) been shown to have a decreased risk of ODD. (30)

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 There is growing evidence and concern that uncon- 1. Parent management training. Parent management train-
scious biases by clinicians and health systems may play a ing is a specialized time-limited (10–16 sessions) therapy
role in the overdiagnosing or overemphasizing of ODD in that emphasizes teaching parents the techniques and
minoritized youth. It is of particular importance to be strategies to alter their children’s problem behavior and
aware of diagnosing only ODD without considering other change the consequences of that behavior. Positive rein-
important diagnoses. For instance, recall that ODD and forcement, such as social praise, tokens, or points, can
ADHD are highly comorbid. Undiagnosed ADHD may re- be given for desired behaviors. The therapy is adapted to
sult in inadequate treatment, support, and resources in a the unique culture of the family and takes advantage of
young person with ODD. (28) inherent strengths and skills found in each family sys-
ODD as a diagnosis can also feel quite stigmatizing for tem. There are various parent management training
both the public and the medical community. The diagnosis packages, such as The Incredible Years, being tailored to
may be regarded as a label of judgment, akin to calling the children, parents, and teachers. Their emphasis is on
child “bad” or the family “broken.” However, children with empowering parents to help their child in the following
ODD are not bad, and usually their parents are also strug- ways:
gling and have not yet learned the most effective ways to • Focus on the positives right away. The child is given
address these problem behaviors. In addition, parents may lots of praise and positive reinforcement when the
also need treatment to support their own mental health, child cooperates or shows flexibility with behaviors.
and pediatricians are well positioned to screen parents for The goal is to build up a robust foundation of positive
their mental health needs. reinforcement before introducing negative consequen-
To consider the important factor of stigma, ask this ces, such as punishment. Without this foundation,
question: Why am I diagnosing this child with ODD and most punishment methods lose their effectiveness. By
what impact will the diagnosis have on the child and the pa- starting with small positive behaviors, parents can build
rents? It can often be helpful to take an agnostic stance and shape larger positive behaviors by linking them
about “why” these behaviors are occurring and to instead with smaller positive behaviors.
remind oneself that the purpose of diagnosing ODD is to • Prioritize the things parents want the child to do. Using
help them bring about change by providing the patient the concept of differential attention, parents are taught to
and family with access to resources and evidence-based attend to desired or positive behaviors while actively ig-
interventions. noring mild inappropriate behaviors. This practice helps
to teach children that they will stop receiving attention
TREATMENTS (positive reinforcement) when engaging in problem be-
Management of children with ODD symptoms can be very haviors. When appropriate, parents can give children
challenging, and even defeating, for parents. As such, pa- more decisional control by offering behavioral choices
rents benefit greatly from a pediatrician’s support as well that are acceptable to the parents.
as when the entire clinical team can inspire hope that the • Avoid a never-ending tug of war scenario. Children with
child can get better. It is imperative that parents receive ODD have difficulty avoiding power struggles, and pa-
education from the outset, that children with ODD often rents can get overwhelmed and exhausted battling differ-
improve in an incremental fashion, and that some of the ent issues. Parents should take time-outs for themselves
most effective treatments will be learning and implement- if they suspect that they are going to make the conflict
ing parenting skills that are specific to helping the child. worse. Taking time-out promotes healthy modeling by
The following subsections highlight evidence-based strate- showing when to step away before overreacting. Children
gies that address disruptive behaviors. should also be supported when they decide to take an ap-
propriate time-out.
Parent Behavior Therapy • Set reasonable, consistently enforced, age-appropriate limits
Based on social learning principles, parent behavior therapy and consequences. Overly harsh consequences or inconsis-
teaches parents to be more effective behavioral reinforcers. tency are ineffective means for reducing oppositional be-
It can be delivered in groups, to parents individually with haviors. In 2-parent households, parents are encouraged
or without a child present, or via self-directed methods to function as “1 person” so that they both set the same
such as bibliotherapy or computer-assisted interventions. limits and consequences. Parents can also support one
(31) There are 2 subtypes: another by taking turns managing the misbehaviors,

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 thereby allowing the other parent a break to manage role-playing, to teach the child new ways of interacting
their own stress. Over time, parents can include teachers, with others.
coaches, and other caregivers in the behavioral plans to
ensure that the consistency of limits and consequences Teacher Training
extends across settings. Teacher training typically incorporates similar behavioral
• Use tokens or point systems, which can be effective for principles as do parent behavior therapies, with the goal to
older children. This is considered a response or cost sys- help teachers be more effective reinforcers for a child’s be-
tem, whereby the tokens/points are earned for engaging havior in the classroom. (31)
in appropriate or positive behaviors. Similarly, these same
tokens/points can be taken away for problem behaviors. Child-Centered Play Therapy
The tokens/points are accumulated and can be traded in This type of therapy is nonbehavioral and instead open and
for reasonable rewards. Older children benefit from being dynamic, with the therapist working directly with the child
incorporated into the planning aspects of the behavior with the goal to provide a close, supportive relationship. (31)
training because being involved in the planning can help
The assumed mechanism for change is that by providing a
them identify the behaviors being targeted, as well as iden-
nurturing relationship for the child, over time the opposi-
tify the rewards that they would consider to be motivating.
tional behaviors will remit. (31)
• Cultivate and maintain parent-child hobbies and inter-
ests. It is important for parents to recognize that the
Family Psychotherapy
long-term goal is not just managing the misbehaviors
Family therapy can have the intended outcome of helping
but also promoting and deepening healthy relation-
to improve communication and bridge mutual under-
ships between parents and their children.
standing between various members of the family system.
2. Parent-child interaction therapy. Parent-child interaction
Family treatments can also help clarify and emphasize the
therapy is a specialized, time-limited (12–20 sessions)
appropriate roles of each family member and how to help
subtype therapy of parent behavior therapy for younger
stop role confusion. For example, in some families with a
children up to age 8 years that teaches parents how to
child with ODD, siblings may take on the “parent” role to
navigate problem behaviors. Parent-child interaction
try and stop their sibling’s problem behavior. Although
therapy is often conducted with a therapist sitting be-
well-intended, this “parentification” of a sibling can be
hind a 1-way mirror watching a parent and child inter-
problematic because it places age-inappropriate responsi-
act. Equipped with a radio earphone, the therapist will
bilities on a child, leading to distress and developmental
provide guidance and coach the parent regarding how
difficulties. Among the longer-lasting effects of parentifica-
to deal with problem behaviors.
tion is insecure attachment, which can cause difficulty
Child Behavior Therapy trusting others, being overly self-reliant, and automatically
These treatment approaches involve the therapist inter- taking on caregiver roles in relationships.
acting directly with a child to teach the child appropriate Through family psychotherapy, parents can be empow-
social skills. (31) One version is called cognitive problem- ered to “take the reins back” and set appropriate limits and
solving skills training, which is a form of cognitive be- consequences. A version called family problem-solving
havioral therapy. This model explains that aggressive be- training can help teach family members how to identify un-
haviors are not simply reactions to environmental events solved problems contributing to oppositional behavior, how
but rather that the aggressive response occurs due to a to prioritize which problems need to be addressed, and
cognitive perception or misinterpretation of the event. how to collaboratively resolve the problem. (31)
Children with ODD tend to focus more on aggressive
stimuli and can overattribute the hostile intent of others. One-Time or Punitive Treatments
Children with ODD often lack social problem-solving Dramatic approaches such as boot camps or shock incar-
skills and behavioral self-awareness. This step-by-step ceration are considered at best ineffective and at worst in-
training program helps the child solve interpersonal jurious when attempting to treat ODD. (6)(9)(17) Exposing
problems by examining the cognitive distortions that can children and teens to fearful situations may worsen symp-
impact social behavior. Positive reinforcement is used of- toms by heightening a fear-aggression reactive behavioral
ten, along with modeling of appropriate behaviors and process. (9)

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 Pharmacotherapy/Medications For children with ODD and bipolar disorder or severe
Psychotropic medications may be helpful in controlling aggressive behaviors, mood stabilizers such as lamotrigine
more distressing symptoms of ODD and CD, as well as and valproic acid can be helpful. (42) In addition, atypical
coexisting conditions such as ADHD, depression, or anxi- antipsychotic medications such as aripiprazole and risperi-
ety. The primary care provider should consider the role of done can be used. Psychiatrists should normally be pre-
medications with the following suggestions (32): scribing and following children who take these types of
medications given the higher adverse effect burden.
• It is important to clarify the underlying diagnosis and
comorbid issues before initiating any psychotropic CASE VIGNETTE (CONTINUED)
medications. Your visit with Miguel and his parents was quite challeng-
• Pharmacotherapy should be considered only when strictly ing. Miguel had a tantrum in the waiting area when asked
necessary. by his parents to go into the examination room. He
• Pharmacotherapy should never be the sole treatment screamed and demanded to be left alone with his elec-
method but rather should complement psychotherapy tronic device, and each attempt by the parents to encour-
treatments. age him to see you resulted in more shouting (which was
• It is important to identify target behaviors and associ- quite stressful for the other patients in the waiting room).
ated impairments in social and academic functioning so To help de-escalate the situation, you opted to meet with
that changes or improvements can be tracked once a the parents alone. You validated their frustrations and
medication has been introduced. counseled them about your diagnostic concerns about his
behavior and effect on his development. Because of clinic
Medications are thought to help support a child’s time constraints and how problematic the defiant behav-
weakly developed inhibitory capabilities, thereby increas- iors were in your office, you decided to refer Miguel to a
ing the ability to use the cognitive skills a child is learning child and adolescent psychiatrist for an assessment to bet-
in therapy. ter understand the clinical presentation. Miguel was diag-
For children with ODD and ADHD, psychostimulants are nosed as having ODD and had symptoms consistent with
a reasonable option to address impulsivity issues that mani- comorbid ADHD. Miguel revealed to the psychiatrist that
fest with aggressive behaviors. Methylphenidate (immediate- he is angry all the time and that he has been bullied for
release and long-acting) therapy has been shown to be ef- years by his peers for his Spanish accent. The parents
fective in school-age children with ADHD and ODD/CD. meet with the school to report their concerns and come
(33)(34)(35)(36)(37) Furthermore, methylphenidate has been up with a plan to stop the bullying. Miguel is started on
shown to reduce aggression in children with ODD with sub- methylphenidate treatment, with a significant improve-
threshold ADHD symptoms. (32) However, due to the ad- ment in his ADHD symptoms but a continued display of
verse effects of stimulants, especially in younger children oppositional behaviors. The parents enroll into parent
(ie, weight loss, irritability, insomnia), alternatives such as management training with a local therapist and by the
atomoxetine, guanfacine, or clonidine can be considered. end of the first therapy session are empowered to take the
Atomoxetine is effective in reducing ADHD symptoms and lead in supporting Miguel through daily positive reinforce-
leading to some improvement in ODD symptoms. (38)(39) ment, healthy limit setting, and behavioral tracking.
Clonidine seems to be less effective for managing ADHD Three months later, Miguel presents for a follow-up
and ODD, compared with psychostimulants and atomoxe- visit. Although he is initially argumentative about needing
tine, and incurs more sedating adverse effects. (40) Guanfa- to go to the examination room to be seen by you, he does
cine extended-release is a nonstimulant that is approved by so after both parents are equally firm about the need for
the Food and Drug Administration (FDA) for ADHD, and it him to go to the examination room. The parents share, in
can be effective for treating comorbid ODD symptoms as front of Miguel, how proud they are of the improvements
well. (41) they have been seeing in him during the past several
For children with ODD and anxiety and/or depression, months.
selective serotonin reuptake inhibitors are considered first-
line medication treatments. A child and adolescent psychi- WHEN TO WORRY
atrist can consult with the pediatrician if there are con- Urgent concerns should arise whenever CD symptoms or
cerns about managing adverse effects. behaviors begin to manifest. These include but are not

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 limited to bullying, cruelty toward animals, stealing, start-
dation with evidence suggesting that it is
ing fires, and cruelty toward or violating the rights of
probably efficacious. (32)(48)(49)
others. Patients with CD symptoms are at serious risk for
functional impairments such as school expulsions, legal • Teacher training: Weak to moderate recom-
issues (including juvenile hall placement), and subsequent mendation with evidence suggesting that it is
development of antisocial personality disorder in adult- possibly efficacious, with 1 study showing that it
hood. Early intervention with psychiatry involvement is was superior to no treatment. (31)(50)
key to helping these young people improve by getting the • Child-centered play therapy: Moderate recom-
multidisciplinary support and required treatments. mendation with evidence suggesting that it is
probably efficacious because both individual and
DISCUSSION AND TAKEAWAY POINTS group child-centered play therapy were found to
Effective ODD treatment occurs with a multidisciplinary be superior to alternate treatments. (32)(51)(52)
approach, with pediatricians, child and adolescent psychia- • Family problem-solving training: Weak recommen-
trists, developmental-behavioral pediatricians, therapists, dation because not yet tested in a randomized trial.
and teachers working to collaborate with parents to help (32)(53)
the child. The role of the treatment team is to empower
• One-time/shock interventions: Strong recom-
parents and teach them the skills to become experts in
mendation against these practices because
managing these difficult and challenging behaviors. Clini-
they are viewed to be ineffective and likely
cally, it is important to be aware of biases that may impact
harmful. (6)(9)(17)
diagnosis. This is especially important when working with
minoritized and racialized patients because they are at in- • Pharmacotherapy:
creased risk for overdiagnosis and underdiagnosis of vari- When prescribed, medications should always
䊏

ous disorders. Clinicians may find that reflecting on how be paired with a multimodal behavioral/therapy
and why they provide different care across various patient approach. Strong recommendation from the
populations can help reduce potential negative biases, American Academy of Child and Adolescent
thereby improving patient care. Finally, advocacy at various Psychiatry practice parameters. (5)
levels, such with local school districts, can play an important 䊏
Immediate-release and extended-release methyl-
role in promoting more awareness around oppositional be- phenidate formulations are an appropriate
haviors and for advocating for improved resources for choice for comorbid attention-deficit/hyperactivity
schools and daycare centers. disorder (ADHD) and ODD and should be paired
with a behavioral/therapy treatment. Strong
Summary recommendation with evidence from multiples
studies. (33)(34)(35)(36)(37)
The following points highlight the levels of evidence
for the various oppositional defiant disorder (ODD)
䊏
For patients who cannot tolerate stimulants,
treatments: atomoxetine is a reasonable alternative for
treating comorbid ADHD and ODD and should be
• Parent behavior therapy (including parent man-
paired with a behavioral/therapy treatment. Mod-
agement training and parent-child interaction erate recommendation with less compelling evi-
therapy): Strong recommendation with evidence dence for the use of atomoxetine. (38)(39)
in support of it being well-established. Level of
䊏
Clonidine or guanfacine extended-release are rea-
evidence includes multiple randomized controlled
sonable alternatives to stimulants when treat-
trials and American Academy of Child and
ing combined ADHD and ODD, although with
Adolescent Psychiatry practice parameters.
less effectiveness and a different adverse effect
(5)(32)(43)(44)(45)(46)(47)
profile. Weak to moderate recommen-dation be-
• Child behavior therapy (including cognitive problem- cause these medications are notably less effica-
solving skills training): Moderate recommen- cious than stimulants. (40)(41)

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 RESOURCES 2. Parent Child Interaction Therapy International Thera-
The following resources are intended to be practical starting pist Locator (http://www.pcit.org/find-a-provider.html)
points for pediatricians to enhance their own knowledge as 3. American Psychological Association Psychologist Loca-
well as for sharing with parents of children with ODD. tor (https://locator.apa.org/)
4. American Academy of Child and Adolescent Psychiatry
Child and Adolescent Psychiatrist Finder (https://www.
Videos aacap.org/AACAP/Families_and_Youth/Resources/CAP_
1. What Is Parent Behavior Management Training? (https:// Finder.aspx)
www.youtube.com/watch?v=9PFq8_fJjs8) 5. Association for Behavioral and Cognitive Therapies
2. Parent Management Training for ODD, ADHD, and Find a CBT Therapist (https://services.abct.org/i4a/
Conduct Disorder (https://www.youtube.com/watch?v= memberDirectory/index.cfm?directory_id=3&pageID=
YMl8cKe9DD0) 3282)
3. What Is Parent-Child Interaction Therapy (PCIT)? (https:// 6. American Association for Marriage and Family Thera-
www.youtube.com/watch?v=N3WJwOhnqzM) pist Locator (https://www.aamft.org/Directories/Find_a_
Therapist.aspx)
Book Resources to Consider for Parents 7. The Incredible Years Parent Management Training
1. Your Defiant Child: Eight Steps to Better Behaviors, by Package Information (http://www.incredibleyears.com)
Russell Barkely, PhD, and Christine Benton 8. Triple P: The Positive Parenting Program for Managing
2. The Explosive Child, by Ross Greene, PhD Misbehaviors (https://www.triplep.net/glo-en/home/)
3. The Kazdin Method for Parenting the Defiant Child, by
Alan Kazdin, PhD
Take the quiz! Scan this QR code to take the quiz,
Resources for Clinicians access the references and teaching slides, and
view and save images and tables
1. DSM-5 Casebook and Treatment Guide for Child Mental (available on March 1, 2024).
Health, ed by Cathryn Galanter, MD, and Peter Jensen, MD

140 Pediatrics in Review

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 PIR QUIZ

1. A 9-year-old boy, whose parents are separated and who has a known history
of early physical abuse/neglect, is brought to the clinic by his mother with
concerns that he is not listening in the classroom; refuses to participate and
to follow rules; argues with teachers, classmates, and guardians; and seems
to blame all of his behaviors on others. These complaints have been present
for the past 6 months or more. She thinks that his behavior has been
getting worse. Which one of the following is not considered a necessary
criterion in this patient for meeting the diagnostic criteria for oppositional
defiant disorder (ODD)?
A. A history of adverse childhood events in terms of physical abuse/
neglect. REQUIREMENTS: Learners can
take Pediatrics in Review quizzes
B. Angry and resentful of others. and claim credit online only at:
C. Blames others for his behavior. http://pedsinreview.org.
D. Outward defiance of authority figures.
E. Refusal to follow rules. To successfully complete 2024
Pediatrics in Review articles for
2. An 11-year-old girl is brought to the clinic by her parents for a routine AMA PRA Category 1 Credit™,
health maintenance visit. The parents voiced no concerns but report that learners must demonstrate a
the teachers imply that she is “mean” to other girls in the classroom and on minimum performance level of
60% or higher on this
social media. She sets clear boundaries for who is included in her circle of
assessment. If you score less
friends, and she outwardly appears to cooperate with teachers but then than 60% on the assessment,
does not comply with the agreed expectations. When questioned in the you will be given additional
examination room alone whether she considers herself a happy child, she opportunities to answer
responded “I guess, but I’d be happier if my parents and teachers would just questions until an overall 60%
or greater score is achieved.
leave me alone.” Parents report that she is easily annoyed at home and
argues with them, but they believe that she is just testing her This journal-based CME activity
independence. The clinician explains to the parents that she may be is available through Dec. 31,
exhibiting signs of ODD. Which one of the following is characteristic ODD 2025, however, credit will be
behavior in girls as opposed to boys? recorded in the year in which
the learner completes the quiz.
A. Aggression is typically more covert and relational.
B. Behaviors that are not considered problematic by the parents.
C. Behaviors that are not impairing of social or academic function.
D. Defiance is typically immediate.
E. Expression of aggression is more direct and physical.
3. A developmental-behavioral pediatric physician is discussing with a community 2024 Pediatrics in Review is
approved for a total of 30
interest group the topic of ODD, its risk factors, and how it compares to
Maintenance of Certification
attention-deficit hyperactivity disorder (ADHD). The physician explains that the (MOC) Part 2 credits by the
risk factors for ODD include temperamental, psychological, environmental, social, American Board of Pediatrics
and genetic factors. Based on the available literature, in the presence of similar (ABP) through the AAP MOC
risk factors, children from which one of the following groups may be more likely Portfolio Program. Pediatrics in
Review subscribers can claim up
to be overdiagnosed as having ODD than ADHD?
to 30 ABP MOC Part 2 points
A. Ethnic and racial minorities. upon passing 30 quizzes (and
B. Female sex. claiming full credit for each
quiz) per year. Subscribers can
C. High socioeconomic class.
start claiming MOC credits as
D. High resilience score. early as October 2024. To learn
E. Younger age. how to claim MOC points, go
to: https://publications.aap.org/
journals/pages/moc-credit.

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 4. A 6-year-old boy is brought to the clinic after being suspended from first
grade for a week for continuous disruptive behavior. The parents report that
he is described as being hyperactive in school, he has trouble paying
attention, he is defiant of his teachers, and he fights with other boys in the
school yard. The parents have similar concerns at home as he is not
compliant with commands, is always on the go, has trouble sleeping, and
requires complete supervision to keep him on track with homework. During
the evaluation, the parents complete a Vanderbilt ADHD Diagnostic Rating
Scale, and they are given teacher versions of the same scale. Parent and
teacher versions of the rating scale are consistent with both ADHD and ODD
symptoms. The clinician discusses with the parents the various treatment
options, which include various evidence-based therapy strategies. Which one
of the following therapy types is the most appropriate for this patient at this
time?
A. Family problem-solving training.
B. One-time punitive treatment.
C. Parent behavior therapy.
D. Time-outs.
E. Trauma-focused cognitive behavioral therapy.
5. In vignette 4, given this child’s age, symptom severity, rating scale scores,
and recent suspension, while setting up therapy referral, which one of the
following is the most prudent immediate intervention at this time?
A. Begin a trial of methylphenidate.
B. Begin a trial of selective serotonin re-uptake inhibitors.
C. Refer to a child and adolescent psychiatrist.
D. Refer to the local police department’s “scared straight” program.
E. Watchful waiting and repeat the Vanderbilt rating scale in 3 months.

142 Pediatrics in Review

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