Treatment of Oppositional/Defiant Behavior, and Aggression

Treating Oppositional
Defiant Disorder, Conduct
Disorder, and Aggression
Center for Assessment and Treatment
A New Jersey Nonprofit Corp.
Roseann Bennett
Marriage and Family Therapist

Agenda
• Introduction to the epidemiology, prevalence, course
diagnostic criteria, and comorbidity to Oppositional
Defiant Disorder, Conduct Disorder, and other
aggressive symptomology
• Tests and measures for assessing
• An overview of empirically supported treatment
approaches
• Parent Management Training, an in-depth exploration
• Conclusion and questions

Oppositional Defiant Disorder
• “A pattern of negativistic. hostile, and defiant behavior lasting at least 6 months, during which
four (or more) of the following are present:
• often loses temper
• often argues with adults
• often actively defies or refuses to comply with adults' requests or rules
• often deliberately annoys people
• often blames others for his or her mistakes or misbehavior
• is often touchy or easily annoyed by others
• is often angry and resentful
• is often spiteful or vindictive”

Culture, Age, and Gender
Features
• Because transient oppositional behavior is very
common in preschool children and in adolescents,
caution should be exercised in making the
diagnosis of ODD. Rates are equal to males and
females after puberty, before more common in
males. Males have more confrontational patterns.

Prevalence
• Rats of ODD are reported from 2%-16%,
depending on the nature of the population sample
and methods of ascertainment.

Course
• ODD usually becomes evident before age 8 and
usually not later than early adolescence. Sx often
emerge in the home setting. Onset is usually
gradual. In a significant proportion of cases, ODD
is developmental antecedent to Conduct Disorder.

Comorbidity
• Those who have ODD tend to have problematic
temperaments or high motor activity. There may
be a low or inflated self esteem. Frequent
conflicts with parents, teachers, and peers. There
may be a vicious cycle in which the parent and
child bring out the worst in each other.
• DSMIVTR, 2000

Conduct Disorder
“A repetitive and persistent pattern of behavior in which the basic rights of others or
major age-appropriate societal norms or rules are violated, as manifested by the
presence of three (or more) of the following criteria in the past 12 months with at
least one criterion present in the past 6 months:
Aggression to people or animals
Often bullies, threatens, or intimidates others
Often initiates physical fights
Has used a weapon that can cause serious physical harm to others
Has been physically cruel to people
Has been physically cruel to animals
Has stolen while confronting a victim
Has forced someone into sexual activity

Conduct Disorder
Destruction of property
Has deliberately engaged in fire setting with the intention of causing serious damage
Has deliberately destroyed other’s property
Deceitfulness or theft
Has broken into someone else’s house, car, etc…
Often lies to obtain goods or to avoid obligations
Has stolen item's of nontrivial value without confronting a victim
Serious violation of rules
Often stays out at night despite parental prohibitions, beginning before age 13
Has run away from home overnight at least twice while living in parental home
Is often truant from school”
DSM-IVTR, 2000, p 98-99.

Onset Type and Specifier
• Childhood-Onset Type: Onset of at least one criterion
characteristic prior to age 10. May have had ODD during early
childhood. More likely to develop adult Antisocial Personality
Disorder. These individuals are typically male.
• Adolescent-Onset Type: Absence of any criteria prior to age
10. Compared to Childhood-Onset Type, these individuals are
less likely to display physical aggression
• Mild: Few if any in excess of what is required to make a
diagnosis, relatively minor harm to others
• Moderate: Number of conduct problems is intermediate
• Severe: In excess of what is required, conduct problems cause
considerable harm to others

Culture, Age, and Gender
Features
• Do not diagnosis if pattern of behavior is
protective
• Less severe behaviors tend to emerge first with
the most severe emerging last
• More common in males
• Males tend to exhibit more fighting, stealing,
vandalism, and school discipline problems
whereas females exhibit more lying, truancy,
running away, and prostitution. Males use more
confrontational aggression and females are
nonconfrontational.

Prevalence
• Reports range from less than 1% to more than
10% of the general population meeting criteria for
this diagnosis. One of the most frequently
diagnosed conditions in outpatient and inpatient
mental health facilities for children.

Course
• May occur as early as preschool years but the first
significant symptoms emerge during the period from
middle childhood through middle adolescence. Onset
after age 16 is rate. In the majority of individuals the
disorder remits by adulthood. However a substantial
portion continue to show behaviors into adulthood and
meet criteria for Antisocial Personality Disorder. Early
onset predicts a worse diagnosis. Individuals with
Conduct Disorder are at risk later for Mood Disorders,
Anxiety Disorders, Somatoform Disorders, and
Substance Related Disorders

Comorbidity
• Often associated with early onset of sexual behavior,
drinking, smoking, use of illegal substances, and risk
taking acts. Suicidal ideation, attempts, and
completed suicide occur at a higher than expected
rate. May be associated with lower than average IQ,
especially verbal IQ. ADHD is common. May also be
associated with Learning Disorders, Anxiety Disorders,
Mood Disorders, and Substance-related Disorders.
The following factors may predispose the individual to
CD: Parental rejection and neglect, difficult infant
temperament, inconsistent child rearing practices with
harsh discipline, physical or sexual abuse, lack of
supervision, delinquent peer group, peer rejection, and
familial psychopathology (Antisocial Personality
Disorder).

Assessment Tools
• Behavioral Assessment Scale for Children,
Second Edition (BASC-2)
• Beck Youth Inventory, Second Edition (BYI-II)
• The Hare Psychopathy Checklist: Youth Version
(PCL:YV)
• Millon Pre-Adolescent Clinical Inventory (M-PACI)
• Clinical Interview/Behavioral Observations in
multiple environments

Treatment Overview
• According to Division 53, behavior therapy currently has the
most empirical evidence for the treatment of disruptive
behavior problems in young people. Specifically they report
the following:

Empirically supported
treatment approaches
Well Established Probably Efficacious Possibly Efficacious
Behavior Therapy: Parent
Management Training
CBT: Anger Control Training
Rational-emotive mental health
program
CBT: Group Anger control
Training
Behavior Therapy: Helping the
noncompliant child (manual)
Reaching Educators, Children,
and Parents (RECAP)
Triple P (Manual)-Positive
Parenting, Standard Individual
Treatment, enhanced
Incredible Years (Manual)
Behavior Therapy: Triple P
(Manual) Standard Group
Treatment
First Step to Success Program
Parent Child Interaction Therapy Self-administered treatment plus
Signal Seat
Problem Solving Skills Training
(Standard, plus Practice, plus
Parent Management Training)
Association for Behavioral and Cognitive Therapies and the Society of Clinical Child and Adolescent Psychology, 2010

Parent Management Training
• Parent Management Training is defined as “An
intervention in which parents are taught social learning
techniques to change the behavior of their children and
adolescents…The treatment is distinguished by a
conceptual view about how to change social,
emotional, and behavioral problems…development of
specific skills through practice, role play, and other
active methods….Integration of assessment and
evaluation” (Kazdin, 2005, p. 378).
• Studied in children ages 2-14

• Uses learning principles of operant conditioning
• Contingencies of reinforcement- the relationship
between behaviors and environmental events
• Follows ABC Model
• (Kazdin, 2005)

Presenting reinforcement to
parents, core of interventions
• “Reinforcement of positive opposites”
• Part of the treatment is reorient parents to focus on
positive pro-social behavior even though above quote
isn’t always necessarily accurate- gives framework
• Often have frustrating ineffective histories
• Kazdin, 2005, p. 86

Empirical Findings
• Kling and others (2010) examined the effectiveness of
parent management training for parents of children ages 3-
10. N=159 children. Parents were refereed to practitioner-
assisted group sessions or a self administration of the
training material, or a waitlist control. Both groups shows
improvement in parent competence and reduced child
conduct problems compared to waitlist at posttest. Both
groups showed further significant improvement at 6 month
follow up. Practitioner-assisted group was superior to the
self administered group on measures of child conduct
problems at posttest.
• Note: 3 year follow up showed no differences between
intervention conditions! Only two of the five outcome
measures favored practitioner over self administered at 6
month follow up.

Empirical Findings
• Hautmann and others (2011), examined 159
families and found that those children with the
most significant pathology had the most to gain
from parent management training, showed the
most improvement.
• Limitations included high drop out rate, analysis
based solely on mother reports, did not include a
parallel control group

Sessions: An Overview
A. Pretreatment Introduction and
Orientation
1 Defining, Observing, and Recording
Behavior
2 Positive Reinforcement: Point
incentive, chart, and praise
3. Time Out from Reinforcement
4. Attending and Planned Ignoring
5. Shaping and School Program
6. Review and Problem Solving
7. Family Meeting
8. Low-Rate Behaviors
9. Reprimands
10/11 Compromising
12. Skill Review, Practice, and
Termination

Structure of the Sessions
• A review of the previous week and how the
program is working at home
• Presentation of principle or theme and how it
translates concretely into what to do at home
• Practice and role playing with the therapist
• Addition of some assignment or changes in the
program that will be implemented in the next week

Pretreatment Introduction
and Orientation
• Objectives: To provide the therapist and parent an opportunity to get acquainted
• To provide the parent with an opportunity to discuss problems and stressors openly
• To introduce parent to treatment and clinical procedures
• According to Kazdin (2005) you should say in part, “….Research has shown a more
effective way of treating children’s problems is to teach parents new ways of
understanding why their child behaves the way he or she does. The focus of this
treatment is to teach parents special skills for changing their child’s behavior…” (p.
260)
• Use basic interviewing skills, be specific, empathetic
• “One thing that distinguishes this program from others is the relationship between the
parent and the therapist. In the beginning, I will teach and demonstrate various
techniques. Later however I will assume the role of the coach to work with you and
give suggestions. By the end you will be successful on your own…” (p. 260).
• Try to get complete picture
• Discuss importance of attendance

Defining, Observing, and
Recording Behavior
• Objective: Teach parents to do the above.
• Teach them what defines a behavior
• Describe handout, if the parent identifies a nonbehavior as a behavior, the therapist should
say “What do you see or hear that makes _____a behavior? (Chart I) (p. 264).
• “Before using any of the techniques you will learn throughout this program you want to start
with clearly defining the problem and the positive behavior you would like to increase…. To
change any behavior it is crucial to increase the positive opposite rather than punish the
negative behavior.” (Chart II) (p.264).
• Prompting: “Pick up your toys (good)….Pick up your toys and put them in the toy box
(better).” (Chart III) (p. 266)
• Discuss the benefits of Reinforcement (Chart IV).
• (Kazdin, 2005)

Positive Reinforcement:
Point incentive, chart, and
praise (Session II)
• Objectives: To review with the parent the elements
of positive reinforcement
• To design a point incentive program to change the
child’s behavior at home
• To teach the parent how to praise the child for
positive behavior

praise (Session II)
• Program review: “Before we start with today’s material, lets review the weekly
observation sheet I gave you last week.” Praise the parent for any evident effort.
Identify specifically the behaviors that are being praised.
• Therapist presentation: “Today we will focus on what positive reinforcement is
and how to use it….”
• Give points and praise as soon as your child does the behaviors on the chart
• Encourage your child to buy at least two rewards each week
• When praising and giving points always :
• Be specific
• Be enthusiastic
• Touch your child
• Be close to you child
• Give points and praise immediately

praise (Session II)
• Chart I
• Reviews types of reinforcers
• Material
• Privilege
• Social
• Token
• Rules for selecting reinforcers (Chart II)
• The reinforcer increases the strength of the positive behavior—if not
you may need to select something else
• Reinforcer should occur immediately after the positive behavior
• Your child must perform the desire behavior before receiving the
reinforcer
• For new behaviors to occur the reinforcer should immediately follow

praise (Session II)
• Hints to make the point chart work:
• Praise and give points immediately after desired behavior
• Review the chart with the child at the end of each day. This
gives you a chance to praise the number of points
accumulated that day and review all the positive things your
child has done to earn the points. When few points have
been earned, it gives the parents an opportunity to neutrally
and encourage your child to earn more the next day
• Have some of the rewards available each day
• Give rewards as agreed. Once the points have been earned
your child gets the reward regardless of what else happens
that day.
• Encourage your child to buy rewards each time
• Bring point chart to sessions each week
• (Kazdin, 2005, p. 276)

praise (Session II)
• How to make your praise most effective: (Chart
IV)
• Deliver praise when you are near the child. When
you are close to your child, you can be sure that the
behavior you are praising is taking place.
• Use sincere, enthusiastic tone of voice.
• Use nonverbal reinforcers by smiling, winking, and
touching. Hug your child, high five him, or pat him
on the back
• Be specific, say exactly what you are approving

praise (Session II)
• Role playing explaining the chart
• Start with the rewards
• Parent should let the child know how much each
reward costs in terms of points, suggest that rewards
will be easy to get by earning points
• Should explain specifically what each behavior is,
what the child has to do, and how many points each
behavior is worth

Time-out from Reinforcement
(Session III)
• Objective: Teach parents the elements of time out
• Therapist teaches the following:
• Correct explanation and use of time out
• Proper room selection for time out
• Role playing time out with the child before using it
• Using time out immediately
• Using time out rather than threatening its use
• Telling the child what was done wrong before sending them to time out
• Praising the child for going to time out without having a tantrum
• Informing the child that he will lose privileges if he does not go to timeout
• Correcting or cleaning up things broken or messed up on the way to time out
or while in time out
• Giving positive reinforcement for desire behavior

(Session III)
• Time out presentation:
• “An example of an effective punishment technique is
time out. When used consistently time out has proven
to be extremely effective in decreasing the problem
behavior. It is a mild procedure that involves removing
the child from the opportunity to receive attention or
other rewards when he engages in undesired behavior.
The child is sent to a boring or non-reinforcing place
for a brief period of time immediately after a problem
behavior occurs. Some rules will need to apply to
maximize effectiveness.” (Kazdin, 2005, p. 282).

(Session III)
• Damaging side effects of physical, verbal, or
prolonged punishment (chart 1)
• Leads to only short term success, but negative
behavior will likely increase
• Can cause fear
• Child likely to avoid parent , relationship deteriorates
• Increase aggression
• Does not teach how to solve problems

(Session III)
• Punishment Guidelines
• Remain calm
• Use time out immediately
• If you need to take a privilege away, take it away for
a short period of time, such as a TV or phone for an
afternoon or an evening. How immediate and
consistent the punishment is more important than
how big the loss is or how upset the child becomes
• Praise and reinforce your child’s positive behaviors
(positive opposites)
(e.g. temper tantrums v. handling problems calmly)

(Session III)
• Time out Rules
• Be sure you can observe the behavior you want to stop
• Select a room that is away from people and without anything
interesting to do. Do not lock the door!
• Stay calm
• Before using time out, explain and role-play going to time out
• Don’t threaten time out.
• Don’t debate or argue. Tell them what they did wrong and calmly tell
him to go to time out.
• If the child goes without having a tantrum, give praise and tell them
why you’re giving praise
• If they won’t go, the time it takes your child to get there is added to
the original 5 minutes
• Time out starts when they are quiet

(Session III)
• Time out Rules continued
• If the child refuses to go to time out then use back up
procedures such as restrictions, loss of privileges or
restrictions should occur. Make sure you let the
child know ahead of time what will happen if he does
not go to time out. “you will lose_____if you don’t go
to time out.
• If the child breaks something in time out, he needs to
fix it. If child makes a mess he needs to clean it up.
• Be sure to continue to praise appropriate behavior.
(p. 284-285)

(Session III)
• Identify and define the problem behavior
• Identify and define positive opposite
• Role play use of time out
• The therapist should role play how the parents should
respond when:
• The child goes to time out immediately
• The child takes excessive time to get to time out (add time)
• The child is noisy in time out
• The child refuses to go to timeout (let the child know that he
will lose privileges or will get extra chores if he does not go to
timeout

(Session III)
• Various of time out:
• If out of the house:
• Clearly explain before an outing how you want the child to behave
• At another person’s home send the child to an uninteresting place
• At a store, require the child to sit or stand in a remote corner or aisle
or take the child to the car for time out
• At a mall, use the bench
• Restaurant, nearby unoccupied table
• In the car, remain outside the car or sit in the front and ignore the child
• Time out from toys, remove the toy for 15 minutes, explain the reason
• Time out from the parent- useful when the child’s verbal of physical
behavior are escalating- separate from the child, wait about 5 minutes,
praise the child for regaining calm behavior, if calm enough to discuss
problem then approach it

Attending and Planned
Ignoring (session IV)
• Objectives: The purpose of this session is to
instruct parents how to manage various minor
problems (such as whining, complaining, failing to
entertain oneself, and crying) by using attending
and planned ignoring. These behaviors may
upset or irritate the parent but generally do not
warrant time out or other serious consequences in
the parent consistently used attending and
ignoring with them.

• Rules for attending:
• Define the behavior you want to increase. A good
definition tells who, what, where, and when.
• Decide on the type of attention to use
• Vary the attention and the approval
• Specific praise is most effective when paired with
attention and interest in the child and what they are
doing
• Decide when to use it
• While the behavior is happening or immediately after
• (Kazdin, 2005)

• Rules for ignoring:
• Define the behavior to be ignored
• A good definition tells who what where and when
• Decide what kind of planned ignoring to use when the defined behavior occurs
• Look away
• No facial expression
• Do not talk with your child
• Ignore all requests
• Leave the room
• Decide when to use it. Set an acceptable limit of tolerance for the identified
behavior
• Decide how much of the behavior you will tolerate (e.g. ignoring all whining after you
explain once
• Use ignoring immediately after the limit has been reached
• Use it every time the behavior occurs
• Decide on what positive opposite behavior to attend to
• Planned ignoring will not work unless attending is not used at the same time

Shaping and School Program
(session V)
• Objectives:
• To teach the parents the components of shaping
• To review school-related problems
• To design a shaping program for a school-related
problem

Review and Problem Solving
(Session VI)
• Objectives:
• To review programs and make necessary changes
• To review skills introduced so far in treatment
• To practice applying skills to hypothetical problems

Family Meeting (session VII)
• Objectives:
• To observe how the parents and child interact
• To reinforce parent compliance, consistency, and
positive behavior
• To give the parents feedback on how they’re doing
• To confirm that the program is still being carried out
correctly

Low Rate Behaviors (Session VIII)
• Objectives:
• To prepare parents for occurrences of low-rate
behaviors
• To provide parents with a means of handling these
behaviors, should they occur

Reprimands (session IX)
• Objective:
• Teach parents how to implement reprimands
effectively

Compromising (Session X, XI)
• Objective:
• To teach the parents a strategy for resolving conflicts
within the family
• To guide them through appropriate communication
about one problem area

Skill Review, Practice, and
Termination (Session XII)
• Objectives:
• To complete a final evaluation of all programs
• To practice applying techniques to manage
behavioral problems
• To allow the parent to teach and train the therapist as
part of role reversal
• To summarize parent’s involvement in treatment
• To address any termination issues

Assessment and Evaluation
of Progress
• Review of the programs at the beginning of each
program
• Role play to see what they do
• Phone call contacts to check in
• Have parent and child reenact situations that
occurred at home

Limitations
• Research suggests that adolescents respond less well to
Parent Management Training than children. However this
could be attributable to severity of symptoms (Dishion and
Patterson, 1992).
• Cultural gaps
• According to Kazdin (1996), child and adolescent therapy in
general there is a 40%-60% who terminate early. Successful
implementation of Parent Management Training is limited by
client participation. There is no evidence to suggest that
despite the demands that Parent Management Training places
on the parents that it increases drop out rates.
• Remember comorbidity—the child may still need individual
treatment of a mood or anxiety disorder exists.

References
• American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC: Author.
• Dishion, T. J., & Patterson, G. R. (1992). Age effects in parent training outcome. Behavior Therapy, 23(4), 719-729. doi:10.1016/S0005-
7894(05)80231-X
• Eyberg, S. M., Nelson, M. M., & Boggs, S. R. (2008). Evidence-based psychosocial treatments for children and adolescents with disruptive behavior.
Journal Of Clinical Child And Adolescent Psychology, 37(1), 215-237. doi:10.1080/15374410701820117
• Hautmann, C., Stein, P., Eichelberger, I., Hanisch, C., Plück, J., Walter, D., & Döpfner, M. (2011). The severely impaired do profit most: Differential
effectiveness of a parent management training for children with externalizing behavior problems in a natural setting. Journal Of Child And Family
Studies, 20(4), 424-435. doi:10.1007/s10826-010-9409-0
• Hill, L. G., Coie, J. D., Lochman, J. E., & Greenberg, M. T. (2004). Effectiveness of Early Screening for Externalizing Problems: Issues of Screening
Accuracy and Utility. Journal Of Consulting And Clinical Psychology, 72(5), 809-820. doi:10.1037/0022-006X.72.5.809
• Kazdin, A. (2005). Parent management training: Treatment for oppositional, aggressive, and antisocial behavior in children and adolescents. New
York: Oxford University Press.
• Kazdin, A. E. (1996). Therapies for Children as Conducted in Clinical Practice. Psyccritiques, 41(8), 795-797. doi:10.1037/003049
• Kling, Å., Forster, M., Sundell, K., & Melin, L. (2010). A randomized controlled effectiveness trial of parent management training with varying degrees
of therapist support. Behavior Therapy, 41(4), 530-542. doi:10.1016/j.beth.2010.02.004
• Loeber, R. R., & Dishion, T. T. (1983). Early predictors of male delinquency: A review. Psychological Bulletin, 94(1), 68-99. doi:10.1037/0033-
2909.94.1.68

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