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This is an intermediate level course. After completing this course, mental health professionals will be able to:
This course is largely adapted from Dr. Barkley’s book, Defiant Children: A Clinician’s Manual for Assessment and Parent Training. New York: Guilford Press, 2013 (3rd ed.) It has been adapted with permission of the publisher.
The materials in this course are based on the most accurate information available to the author at the time of writing. The scientific literature on childhood defiant behavior and ODD grows daily, and new information may emerge that supersedes these course materials. This course material will equip clinicians to have a basic understanding of the nature, assessment, and treatment of ODD in children. Readers are directed to the book for detailed information on how to implement Dr. Barkley's parent training program for the management of ODD in children.
The term “noncompliance” as used here will refer to three categories of child behavior, these being the following:
The term “noncompliance,” however, may convey the notion of passive avoidance of completing parental commands and requests or following previously stated household rules. Thus, the term “defiance” can also be used for many instances of noncompliant behavior where the child not only fails to obey a directive or rule, but also displays active verbal or physical resistance to complying with such parental directives. This is an active resistance to direction rather than a passive one as might be conveyed by the term noncompliance. For instance, as when a child engages in verbal refusal, temper outbursts, and even physically aggressing against a parent when the parent attempts to impose compliance with a directive on the child. Examples of noncompliant behavior are:
Yells |
Steals |
Fails to complete chores |
Whines |
Lies |
Destroys property |
Complains |
Argues |
Physically fights |
Defies |
Humiliates/Annoys |
Fails to do school homework |
Cries or holds breath |
Teases |
Disrupts others activities |
Tantrums or screams |
Ignores requests |
Ignores self-care routines |
Throws objects |
Self-injury |
Runs off |
Argues or sarcastic |
Swears |
Physically resists |
Despite their apparent dissimilarity, all of these behaviors can be construed as belonging to a more general or larger class of behavior that involves noncompliance. This broad band of inter-related forms of behavior has also been termed “externalizing” or “disruptive” behavior disorders and may include oppositional-defiant disorder, hostile-defiant behavior, social aggression, or conduct or other externalizing problems. Some of the behaviors in the list above are in fact direct efforts of the child to escape or avoid the imposition of the command. Hence, all may be treated by a common program that addresses noncompliance. Research has shown that treating noncompliance often results in significant improvements in other behaviors in this general class even though those behaviors were not specifically targeted by the intervention. It is this targeting of noncompliance that distinguishes this parent training program from many others, which may single out one or several types of inappropriate behavior but fail to address the more general class of noncompliance or defiance to which such specific forms of externalizing behavior belong.
Another means of understanding the relationships among various forms of disruptive behavior comes from meta-analytic reviews of the literature that have employed factor analysis to study these relationships. One such review by Paul Frick and colleagues (1993) showed how various forms of oppositional behavior may cluster into a form of overt disruptive behavior that is nondestructive but is related to three other equally, if not more serious, forms of antisocial acts, status violations, and aggression toward and offenses against others. As such, childhood oppositional behavior carries significant concurrent and developmental risks for more serious forms of externalizing disorders, such as conduct disorder (CD), and the co-existence of CD with ODD is itself a strong predictor of concurrent and later antisocial or criminal activity and substance use and abuse. Childhood oppositionality also conveys an increase in risk for later anxiety disorders and depression in addition to its known association with CD. The link between ODD and anxiety may be mediated, in part, by the comorbidity of each with ADHD.
As the foregoing discussion makes apparent, there exists a continuum of oppositionality in the human child population along which degrees of oppositionality, defiant or noncompliant child behavior, can be discerned. Whereas degrees of intellectual deficits may be carved into categories of slow, borderline, mild, moderate, and severe or profound to define mental retardation, no such consensus exists for labeling degrees of noncompliant or defiant behavior, though adapting some of the former categories might be appropriate for a dimension of defiant behavior. On a well-standardized behavior rating scale of this dimension, children whose defiant behavior exceeds the mean by only one standard deviation (+1 SD, 84th percentile) or less are considered normal even though possibly being stubborn or strong-willed. Those children placing above the 84th percentile but below the 93rd percentile (within +1 to +1.5 SD) could be described as having borderline oppositionality or just as being “noncompliant” or “difficult,” provided they do not meet the full clinical diagnostic criteria for ODD in the DSM-5. Those children who place above the 93rd percentile on such rating scales or who meet full clinical criteria for ODD by diagnostic rules would be said to have that disorder, perhaps further qualified as mild, moderate, or severe depending on the severity of their ratings of deviant behavior on the rating scales or the number of ODD symptoms they possess above the minimal number required to meet the diagnostic threshold. Children in most of these categories except the normal one might be appropriate for this parent training program, provided that the criteria for justifying intervention described above were met.
As summarized by McMahon and Frick (2019), studies show that the frequency with which children manifest clinically significant and impairing levels of defiant and noncompliant behavior is greatly determined by the definition used for such disorders when surveying childhood populations. The lifetime prevalence rate of ODD appears to be 10.2% but with ranges being reported from 2.6% to 28%, depending of course on how it is defined and assessed. In large scale studies, the prevalence of ODD in children seems to be around 6%. DSM-IV cited a prevalence ranging between 2 and 16% for ODD. Using parent reports of child behavior problems in a large sample (1,096) of military dependents ages 6 to 17-years-old, one study reported a prevalence of 4.9% for ODD based on diagnostic criteria from the DSM-III-R. Another study using multiple sources of information (parent, child, teacher) for a large sample of 11-year-olds reported a prevalence rate of 5.7% for ODD using DSM-III diagnostic criteria. In the child age group, the male-to-female ratio for ODD can range from 2:1 to 3:1 but by adolescence the sex ratio is nearly equal. There is a decrease in the prevalence of ODD with age with up to half of all cases in childhood not meeting criteria for the disorder in later years.
As noted earlier, childhood ODD is strongly associated with risk for concurrent or eventual childhood CD (see Thapar & Goozen, 2019). Although approximately 20-25% of children with ODD may no longer have the disorder 3 years later, up to 52% will persist in having ODD over this period of time. Of those who persist with ODD, nearly half (25% of the initial total of ODD children) will meet criteria for CD within a 3-year follow-up period. However, among children who have CD, over 80% will have had ODD as a co-existing or even preexisting disorder, making ODD the most common early developmental stage for the co-existence with or later progression into CD. And so, while the majority of ODD children will not progress further into CD, children with persistent ODD are more likely to do so, and the vast majority of children with CD will have ODD. The age of onset of early CD symptoms has been shown repeatedly to be a particularly important predictor of the progression into delinquency and the severity and persistence of such delinquency, with onset of initial symptoms before age 12-years-old being an especially salient threshold in making such predictions.
Beyond its relationship to CD, ODD also carries a high risk for the co-existence or development of other psychiatric disorders, such as ADHD, depression and even anxiety disorders. Nock et al. (2007) found that over 92% of people who have qualified for ODD in their lifetime had at least one other lifetime psychiatric disorder, with risks being 46% for mood disorders, 62% for anxiety disorders, 68% for ADHD or other impulse control disorders, and 47% for substance use disorders.
ADHD shows a strong linkage to ODD; ADHD children are up to 11 times more likely than non-ADHD children to eventually be diagnosed with ODD. ADHD is also linked to the persistence of ODD. ADHD has an earlier average age of onset than ODD with up to 60% or more of children with ADHD eventually developing ODD, often within a few years of the onset of their ADHD. It appears to be the hyperactive-impulsive symptom dimension of ADHD that is most strongly predictive of the eventual development of ODD and especially the head strong, defiant, or social conflict aspects of ODD or oppositionality to be discussed below. In view of the above, it is apparent that early hyperactive-impulsive behavior is a childhood risk factor for the development and persistence of ODD. Yet research has also repeatedly demonstrated that impaired or disrupted parenting along with associated parent psychopathology is among the most influential predictors of which children progress from being ADHD only to developing ODD. The emergence of ODD is then a risk factor for concurrent or later CD, anxiety, and depression. And all three externalizing disorders (ADHD, ODD, and CD) are predictors of later adult criminal behavior and arrest rates.
The substantial body of research that exists on the parent-child relations in families with oppositional children is too voluminous to review here. At the very least, interested readers should begin with a perusal of the texts by Patterson (1982; Patterson et al., 1992) and others (McMahon & Forehand, 2005; Wahler, 1975) for their historical importance and insight into the family interactions of aggressive or defiant children. The texts by Patterson and colleagues in particular set forth one of the most well-established and accepted theories concerning the development and maintenance of oppositionality and aggression in parent-child interactions, known as coercion theory and discussed further below. Coercion theory falls within the larger framework of social learning theory which is a major part of if not the foundation for the development of all behaviorally oriented parent training programs, including this one. This theory simply states that noncompliant, defiant and aggressive child behavior arises from and/or is largely sustained by the family context and especially by the social consequences such behavior receives from others within the family. Thus, to the extent that such behavior is being learned and maintained within families, it can be unlearned, reduced, or returned to a normal state by unlearning, or through the alteration of the contributing contingencies within families. For more contemporary reviews on the nature of oppositionality generally and ODD specifically in children one should read the chapter by Hinshaw and Lee (2012) as well as published reviews or studies by Beauchaine, Hinshaw, and Pang, (2010), Burke et al. (2008), Ellis and Nigg (2009), Loeber et al. (2009), Nock et al., (2007), Rydell (2010), and Harvey et al. (2011). The more consistent and general findings from this body of research are important for clinicians to consider when engaging in the training of these families. I summarize them briefly below.
Without a doubt, research repeatedly demonstrates that the quality or nature of parent-child interactions is strongly and reliably associated with childhood noncompliant, defiant, and aggressive behavior patterns, and the persistence of these behaviors over development, as well as the risk for later adolescent delinquency and conduct disorder. Children with oppositional behavior show a poorer quality of attachment relationships to their parents along with their significantly higher rates of stubbornness, verbal defiance, temper outbursts, arguments, and even physical aggression in their interactions with their parents (and other family members). The parents of such children also provide highly inconsistent, lax, and, at times, even positive consequences to children for their deviant behavior. Such poor attachment, unpredictable use of consequences, and even inadvertent reinforcement of defiant behavior may serve to increase and sustain occurrences of oppositional child behavior in future interactions. When children fail to comply with parental directions and rules, and especially when they refuse to obey, act out, throw temper tantrums, engage in aggression toward parents, or otherwise directly oppose commands, it is surely difficult for parents not to attend to such behavior. Even though such attention is largely negative in nature and involves high rates of expressed hostility and other negative emotions, it may still serve to sustain or increase future oppositional behavior. On other occasions, paternal laxness in discipline may also contribute to child ODD symptoms across development, perhaps signaling to the child that there will be no consequences for oppositional behavior toward either parent. Parents may also provide positive attention or rewards to children in an effort to get them to stop “making a scene,” such as in a store, restaurant, or other public place. Buying a child the candy bar or toy for which he has been throwing a tantrum is but one obvious way in which parents may accelerate the acquisition and maintenance of oppositional child behavior.
Conversely, parents may provide less attention or reinforcement to prosocial or appropriate behaviors of the child. Clinical experience suggests that parents of oppositional children may monitor or survey child behaviors less often than in families of normal children, such that they may not always be aware of ongoing appropriate child behaviors. Even if they are aware that the child is behaving well, they may elect not to attend to the child or praise him for several reasons. One is that many parents report that when they praise or attend to good behavior in their oppositional child it only serves to provoke a burst of negative behavior from the child. This leads the parent to adopt the attitude of “let sleeping dogs lie” when they encounter ongoing acceptable child behavior. Research has not established that this reaction occurs when parents have tried to praise a behavior problem child or, if it does, what the learning history was that established this behavioral pattern. But it is a frequently voiced opinion by parents of these children in my clinical experience. It is possible that parental praise for good behavior in a child prompts the child to misbehave because the child continues to receive parental attention if he/she does so. Had the child continued to behave well, the parent might have terminated the interaction, moving on to do something else. Another reason parents may fail to react positively when a defiant child behaves well is that parents dislike interacting with the oppositional child and will choose to avoid interacting with the child when possible, reducing their contact with this temperamental individual. Parents of chronically defiant children often develop animosity or “grudges” toward the child such that they will elect not to praise him when the child finally behaves well. This may eventually lead to parents spending significantly less leisure and recreational time with the defiant child simply because it is not fun to do so.
In addition, it is possible that parents of oppositional children, especially those children at risk for later delinquency, may monitor their children’s activities less often and attend less to unacceptable behavior so as to avoid further confrontations with the child. As in the saying “out of sight, out of mind,” parents may eventually reduce the amount of effort they expend monitoring a child’s ongoing behavior within the home so as not to have to confront any minor unacceptable behavior that may be occurring. By overlooking the problem behavior, they do not have to face the aversive nature of dealing with this difficult child or otherwise engage in yet another negative, coercive exchange with the child about the matter. This may explain the frequent clinical observation that some parents seem to be oblivious to ongoing negative behavior occurring in their presence – behavior other parents would normally react to in a corrective fashion. For various reasons to be explored further below, some parents of oppositional children are simply not as invested in serving in parental roles to these children, possibly because of their own frequently younger-than-normal age when becoming parents, single motherhood status, their social immaturity or limited intelligence, and even their own psychological or psychiatric disorders. Regardless of its origins, such a decline in parental monitoring and management of a child’s activities generally is associated with the development of some of the most serious forms of CD, which involve both covert antisocial behavior – such as lying, stealing, destruction of community property, and so forth – as well as overt antisocial acts, such as physical aggression toward others.
Parents may also be observed actually to punish prosocial or appropriate behavior at times, again because of possible resentment that may have developed over years of negative interactions with the child. Parents may often give “back-handed compliments” to a child for finally doing something correctly, as when they sarcastically remark, “It’s about time you cleaned your room; why couldn’t you do that yesterday?” For all of these reasons, parents are simply not providing appropriate, consistent, or even contingent consequences for ongoing child behavior that would be expected to manage or control it effectively.
This inconsistent, over-reactive, sometimes timid or lax, and often unpredictable use of consequences is a hallmark of parents who have highly oppositional children. It is characterized by both punishing both prosocial and antisocial child behavior as well as intermittently and unpredictably rewarding both classes of child behavior. Termed “indiscriminant” parenting, the oppositional children in these interactions are damned if they do and damned if they don’t comply. Dumas and Wahler (1985) have hypothesized that this form of indiscriminant use of consequences by parents creates a great deal of social unpredictability within families and especially in the parent-child relationship. Such environments are experienced by both humans and animals as inherently aversive. Any response by the child in such a situation that may be instrumental in reducing unpredictability (increasing predictability) will be negatively reinforced for doing so and thereby increase in frequency. Thus, according to this theory, children may emit various forms of defiant and aggressive behavior toward parents, based on which of these forms increases predictability in the course of parent-child interactions.
Even more evidence exists for the role of negative reinforcement in these interactions, as explained in the highly influential coercion theory developed by Patterson (1976, 1982) and colleagues. This research group has argued that both parents and children in families with defiant or aggressive children are negatively reinforced for behaving in aggressive and coercive ways toward each other, and that such negative reinforcement serves to sustain their highly conflicted and hostile interactions with each other. Substantial research supports this argument.
To understand this theory, it is first necessary to remember that negative reinforcement is not the same as punishment – a mistake often made by those less experienced in behavioral terminology. Negative reinforcement occurs when a particular behavior serves to reduce or terminate an unwanted or aversive interaction or situation. This reduction in unpleasantness or in the aversive nature of the situation is reinforcing and serves to increase the probability that the person will employ that same behavior in the next encounter with that or a related aversive situation.
In this theory, the negative or aversive behavior of one member of the parent-child dyad serves to terminate the ongoing negative behavior of the other, thereby negatively reinforcing the first member’s “coercive” behavior. The use of angry, hostile, defiant, or aggressive behavior by one party serves to coerce the other party to reduce or terminate the conflicted interaction, hence the term coercion theory. Important to appreciate here is that both parties are using such coercive tactics with each other (though not necessarily intentionally) and so both are subject to the operation of negative reinforcement that serves to sustain this reciprocal chain of negative interactions. On some occasions one person’s coercion succeeds in the withdrawal of the other from the interaction or at least in a reduction in the aversive nature of the interaction. Yet on other occasions the other person’s negative behavior succeeds, and so both participants are involved in a partial reinforcement schedule. Such schedules are known to generate some of the most persistent behavior, in this case of negative or hostile conduct thereby explaining the persistence of such conflict-ridden family interactions. Over time, each party learns that it takes an ever higher level of hostility, aggression, or generally aversive behavior to cause the other party to reduce or terminate the interaction. This presumably explains why parents and children, once having begun a negative interaction with each other, will escalate their negative behavior toward each other very quickly to intense levels of anger, hostility, aggression or general coercion. Furthermore, the likelihood that such forms of interaction will occur again is greatly increased as a result.
As an example, consider what may ensue when the parent of an oppositional child attempts to impose the command of getting ready for bed while the child is watching a favorite television program. Like many children, this child often finds this imposition to be aversive, unpleasant, or otherwise unwanted. The child may oppose, resist, or otherwise escape from the parental demand through defiant, aggressive, or other coercive behavior. The parent withdraws from the interaction, at least temporarily, and so that behavior by the child may serve to delay having to get ready for bed and allows the child to continue to remain up and watching television. The child’s success at escaping from the command, even if only temporarily, negatively reinforces his/her oppositional behavior. The next time the parent asks the child to get ready for bed, the likelihood of the child resisting the command has increased. The more a parent persists at repeating the request, the more intense the child’s resistance may become due to this previous success at escaping or avoiding the activity specified in the command. As already noted above, many parents may eventually acquiesce to this type of coercive child behavior. Parents need not acquiesce to every command for a child to acquire resistant behavior; only to some of them.
Parents may also acquire aggressive or coercive behavior toward their defiant child by much the same process. In this case, the parent may have been successful on occasion at getting a child to cease whining, refusing, or throwing a tantrum and to comply with a command through the parent’s use of yelling, screaming, or even physical aggression against the child. The parent may also have discovered that rapidly increasing the intensity of his/her negative behavior toward the child is more successful at getting the child to capitulate and obey, especially if the child initially opposes the command. Hence, in subsequent situations the parent may escalate very quickly to intense yelling, use of threats, and other negative behavior toward a child due to a previous history of its success at terminating oppositional child behavior by this means. The parent need not be successful with this strategy every time or even the majority of times the parent confronts oppositional behavior in order to maintain this type of parental hostile behavior across most command-compliance encounters with the defiant child. Only occasional success with coercive behavior is needed to sustain this type of behavior in parents.
Viewed from this perspective, both parent and child have a prior history of periodic but only partial success at escaping or avoiding each other’s escalating aversive or coercive behavior. Each can be considered both the victim and the architect of this coercive family process. As a result, each will continue to employ it with the other in most command-compliance interactions. Over time, each learns that when a command-compliance situation arises, the faster each escalates his/her own negative emotional intensity and coerciveness, the more likely the other is to acquiesce to his/her demands. As a result, over months of experience with each other, confrontational interactions between parent and child may escalate quickly to quite intense, emotional, and even aggressive confrontations. On some occasions these may end with physical abuse of the child by the parent, destruction of property by the child, assault by the child against the parent, or even self-injury by some children.
This view also implies that much oppositional child behavior is not sustained by positive attention or reinforcement from the parent but by negative reinforcement. Accordingly, when a clinician tells such a parent to ignore negative child behavior, it may only worsen the problem as it is likely to be viewed by the child as acquiescence. In many cases, parents cannot ignore the child because in so doing the child escapes from performing the command given by the parent. Parents in such a situation will have to continue interacting with the child if they wish to get the task accomplished. Many experienced clinicians have noted this problem in training parents of behavior problem children – ignoring defiant behavior is not always successful or even possible. Instead, a great deal of negative child behavior is developed, not through positive parental attention, but through escape/avoidance learning (negative reinforcement). It is maintained because of its success in avoiding unpleasant or aversive activities often invoked by parents. As Patterson suggests, and as this program teaches, the parent training program must incorporate mild and consistent punishment (usually time out from reinforcement), as well as prevention of the child from escaping the parental command, if the program is to be successful at diminishing child noncompliance developed through such a process of negative reinforcement.
Patterson has also noted that parents are likely, once trained, to rely predominantly on the punishment methods taught in the program and to diminish their use of positive reinforcement methods over time. Therapists must anticipate this parental drift and regression and address it during the last few sessions of parent training as well as during follow-up booster sessions. Parents must be instructed that most punishment methods lose their effectiveness when relied on as the primary management technique with children. Without sufficient positive reinforcement methods being provided for the alternative, appropriate behavior desired from the child, such desirable behavior is unlikely to be maintained.
The factors that contribute to oppositionality can be nicely summarized in a model comprising four factors. Each of these factors will now be discussed in some detail.
As discussed above, and shown in Figure 1, below, one of the major if not greatest proximal contributors to noncompliance, defiance, and social aggression repeatedly identified in research studies is disrupted parenting. By this is meant ineffective, inconsistent, indiscriminant and lax or even timid child management methods being employed by parents, often but not always combined with high rates of expressed hostile emotions and at times including unusually harsh (abusive) but inconsistent disciplinary methods. In the case of ODD children who develop CD as well, one also finds low parental warmth and poor parental monitoring of the child activities both in and especially outside the home. As a result of even partial success and employing emotional coercion, noncompliance and defiance by children become very effective methods for escaping or avoiding unpleasant, boring, or effortful tasks. This partial success of mutual, reciprocal coercion is more than enough to sustain the persistent use of aversive, hostile, and aggressive behavior by each party toward the other. The child’s use of coercion may also serve to increase the predictability of consequences in parent-child exchanges (no matter how negative), and on some occasions even obtaining rewards by the child for doing so (e.g., candy for the tantrum in the store). Thus, mutual coercion is a major pathway through which oppositionality in children and heightened parent-child conflict can arise. But it would be erroneous to conclude from this that all defiant behavior is simply learned out of the parent-child relationship. Social learning theory can only get us so far in understanding the development and evolution of oppositionality and social aggression in children (or their parents).
Figure 1
Whereas the exact form, nature, or topography of the noncompliant and defiant responses and even their severity in a child probably have much to do with the child’s learning history within a family, the probability of acquiring or emitting oppositional or noncompliant behavior and some of its severity is also affected by at least three other domains of influence. Combined with disrupted child and family management practices (first factor), these three other causal influences make up a Four-Factor Model of oppositional behavior in children.
Are some children more likely than others to initiate disruptive, oppositional, or noncompliant behavior more than others? Unequivocally, yes. The second factor in the model acknowledges this fact. It is founded on abundant evidence that children having certain temperaments, psychological traits, and other personal characteristics are far more prone to emit coercive-aggressive behavior and acquire defiant or oppositional conduct than are other children.
Research has demonstrated that child oppositionality consists of at least a two or even three factor structure each of which can, themselves, be traced back in development to at least two earlier predisposing characteristics of the child. Let us start with the two factor structure of oppositionality. Contrary to its representation in the DSM-IV and even on some child behavior rating scales, oppositionality in children (or ODD) is not a unitary dimension of symptoms but constitutes two (or even three) distinct yet inter-related dimensions worth differentiating.
The first of these is an emotional dimension consisting of impatience, irritability, quickness to frustrate or be annoyed, anger, and hostility. It may also include a reduced fear of and diminished sensitivity to punishment, though these seem more likely to be an aspect of childhood psychopathy than of this dimension of ODD. This factor is shown in Figure 2, below.
Figure 2
Part of oppositionality is a mood disturbance and that mood is irritability or quickness to anger. It is largely an inherent characteristic of the child and can be traced back into early childhood by its connection to negative or irritable child temperament. Negative child temperament has been repeatedly linked to childhood oppositionality. And although parental psychopathology and poor marital and family functioning may further exacerbate the risks of such children for greater defiance and aggression, negative temperamental features of the child are among the strongest influences in this process and may be sufficient in themselves to create these risks. The effects of early childhood temperament may be gender specific: More negative temperament in infant and toddler boys may be predictive of higher risk for later oppositional behavior; in contrast, for toddler girls early negative temperament may predict a decrease in the risk for later aggressive behavior but possibly an increase in later risk for internalizing disorders.
Whether or not it arises from a further developmental blossoming of an inherent negative irritable infant/child temperament in particular cases, this emotional dimension of ODD can also arise from the presence of a psychiatric disorder in the child that disrupts normal emotion regulation. The two, in fact, often co-exist (irritable temperament and early emotional dysregulation). Disorders such as childhood onset bipolar disorder, depression, and ADHD, among others, are all predisposing factors to the development of comorbid ODD and the pathway for doing so is in part their impact on emotion regulation.
For instance, ADHD is known to be associated with impulsive emotions and deficits in executive functioning one dimension of which is emotional self-regulation. It is therefore associated with significantly higher rates of impatience, verbal aggression, and anger than is typical of the childhood population. Indeed, ADHD shares this dimension of heightened emotionality with ODD specifically and the dimension of externalizing psychopathology in children more generally; a shared risk arising both from shared genetic liability and an environmental liability, such as Factor I above. Disorders like ADHD or mood disorders that create increased emotion, emotional dysregulation, or the impulsive expression and deficient (executive) self-regulation of emotion thereby create a propensity toward ODD through its first or emotional dimension – irritability, impatience, and quickness to anger.
Going forward in development, this emotional dimension is significantly associated with risk for depression specifically, mood disorders more generally, and even anxiety disorders by adolescence, if not earlier. It may also increase the risk for symptoms of autistic spectrum disorders and even schizophrenia symptoms. This risk for mood and thought disorders appears to be the case in both sexes of children, though especially in girls.
The second dimension of ODD is one of defiant behavior or social conflict or a propensity to be head strong. A propensity for rule-breaking, stubbornness, noncompliance or a direct refusal to obey, ignoring the requests of others, such as parents, high rates of exploratory activity (hyperactivity), impulsive, excessive, and even defiant verbal behavior, and physical resistance to the demands of another all comprise this second social conflict or head strong dimension. This dimension of ODD or oppositionality is related to an earlier childhood history of persistent hyperactive-impulsive (HI) behavior more than it is to earlier inattentive symptoms. This explains why high temperamental activity or ADHD (hyperactive or combined types), again, is often a major precursor to ODD through its contribution to the head strong or social conflict dimension of ODD. It should be evident here that pre-existing ADHD or its early infant/child temperament precursors can contribute to ODD through both of its dimensions. The impulsive emotion and poor self-regulation of emotions associated with ADHD can contribute to the emotional dimension of ODD while the HI dimension of ADHD symptoms (that includes the impulsive expression of emotions) can also contribute to the head strong dimension of ADHD and thus its propensity to cause social conflicts with others, initially parents. It is not surprising then that there exists a single shared genetic liability to both the HI dimension of ADHD and to this head strong dimension of ODD and between these two factors and concurrent and later conduct problems or disorder. This may explain why ODD is 11 times more likely to occur in the context of ADHD than in the general population given that ADHD is a contributor to both ODD dimensions and accounts for any genetic (heritable) liability to ODD and even to later CD.
Symptoms of ADHD, such as over-activity, inattention, and impulsivity, are typically considered aspects of early childhood temperament when studied in infants and toddlers, believed to be a harbinger of later personality traits. Should these temperamental traits persist into later preschool years and eventually school age, such symptoms are more likely to create persistent parent-child interaction conflicts and parenting stress. Symptoms of ADHD may prevent a child from finishing assigned activities or otherwise adversely affect their interactions with parents and thus the child may be more likely to elicit increased commands, supervision, and negative reactions from parents. The relationship here may be reciprocal, with the child’s poor attentional control adversely affecting parental responses which may then reciprocally adversely affect the child’s further development of attentional control. Children with higher levels of ADHD symptoms may also be more likely to respond to parental controlling behavior with impulsive negative emotional reactions. If such reactions result in the child’s escaping further demands, according to the above coercion theory of defiance, their use during subsequent commands by parents will be increased and sustained. The co-occurrence of ADHD symptoms, particularly that of poor impulse control, with early oppositionality is particularly virulent, predicting significantly greater family conflicts and worse developmental outcomes, especially in the realm of later antisocial activity, than does either dimension of behavior alone.
Though early HI behavior is a clear contributor to this behavioral dimension of ODD, as just noted social training via earlier and concurrent inconsistent parenting is likely to operate through this dimension of ODD as well. Indeed, it may mediate the relationship of HI symptoms to ODD in that a context of disruptive family routines or inconsistent parenting may determine if HI will increase the risk for ODD. The excessive behavior of the highly HI child results in a greater frequency of rule violations and also brings them into repeated conflict with those trying to manage, supervise, and otherwise rear them. The heightened emotionality of the child further ensures that they will respond to efforts of parental control with a greater propensity for irritability, anger, and hostility. Whether this progresses further to clinical ODD may well depend on the parental response to it and the consistency and predictability of family routines. If this barrage of high rate behavior and emotionality by the child is responded to by inconsistent or over-reactive parenting, high levels of parental expressed emotion, parental timidity in using effective discipline, disrupted or unpredictable family routines, and parental child-rearing disagreements, the training ground for further oppositionality and defiance via the coercive family process described above has now been set in motion.
This involvement of parenting in this dimension of ODD also helps to understand why studies often find that there is a situation specific factor or context to ODD besides its emotional and behavioral/social dimensions. That is to say that ODD can be highly situation and person specific and is most often seen in parent-child interactions. While it can be seen as well in child-peer interactions or child-teacher interactions, the child and family correlates of children engaging in such peer or even teacher conflicts may not be the same as for those seen in parent-targeted ODD. This situation specificity of ODD, however, may simply reflect the stepping stone model first described by Patterson (1982) in which ODD often first appears in the home toward parents but then may, over time, increases in frequency and intensity and spreads to interactions with siblings. From there, it then metastasizes onward or outward to interactions with other children in the neighborhood or school and eventually even to teachers. In sum, there are both child temperamental or psychological as well as parenting/family environmental contributors to child oppositionality or ODD.
The aforementioned role of disrupted parenting in ODD sheds light on understanding why ODD is also just as familial a disorder as ADHD. That is to say that families in which ODD exists in their children are far more likely to have other family members who meet criteria for ODD than families having no psychopathology. ODD can be a family diagnosis and not just a diagnosis of the child member of that family. This would be expected from the high heritability of ADHD traits such as HI and impulsive emotional symptoms and their shared genetic liability with ODD making these traits more likely to be evident in biological relatives as well as from the reciprocal coercive family training taking place across repeated parent-child interactions.
This seems to make it clearer now how this behavioral dimension of ODD is more predictive over development of concurrent and later risk for CD in both males and females, although the emotional dimension of ODD may convey some risk for CD as well. It is the dimension most associated with rule-breaking, defiance of authority, and conflict with others more generally. It also makes it apparent why early HI symptoms may increase the risk for CD indirectly via their contribution to this head strong behavioral dimension of ODD and from there on to CD.
A third smaller dimension of ODD has sometimes been identified by researchers, though not consistently, and typically referred to as hurtful. It consists of the physically aggressive and vindictive symptoms that can co-exist with ODD or child oppositionality. But this dimension of physical aggression may actually be more of a feature of early CD than of ODD. Verbal aggression is more highly associated with ODD while physical aggression is more strongly linked to CD. Even so, early verbal aggression is a significant predictor of the later development of physical aggression accounting for why ODD increases the risk for later CD. It therefore seems best to view any hurtful or physically aggressive dimension of behavior as reflecting CD rather than ODD.
While not considered to be a dimension of ODD, another component of child psychological development related to this broader class of externalizing psychopathology (ADHD, ODD, CD) is important to at least briefly note here given its higher than normal occurrence in some children with ODD and especially some cases of CD. That dimension is the callous-unemotional (CU) traits evident in childhood psychopathy. There is strong evidence for the role of genetics and neurology in the development of CU traits or psychopathy in comparison to a much weaker role for social causes. Such children demonstrate a significant lack of empathy for the misfortunes of others and a lack of guilt, conscience, and remorse for their own transgressions. They may also show a reduced insensitivity to and fear of punishment. Indeed these latter attributes may not be so much a part of the emotional dimension of ODD as first noted above but rather a signal for the presence of these CU traits in such a child. This CU dimension is known to be associated with or predictive of concurrent, more severe and more persistent forms of antisocial behavior in children and adolescents and of risk for antisocial personality disorder in adults even independently of ODD and CD.
To summarize, ODD appears to consist of two separable yet inter-related psychological dimensions. One is comprised of an emotional dimension that may emerge in part from early childhood negative/irritable temperament as well as from the early emergence of symptoms of mood disorders. It is associated with an elevated risk for later mood and anxiety disorders by adolescence if not earlier. The other is a behavioral dimension comprised of defiance, rule breaking, verbal aggression, and otherwise head strong behavior that emerges from or is related to earlier persistent hyperactive-impulsive behavior interacting with coercive family processes that provide reciprocal negative and partial reinforcement to both parent and child for angry, hostile, stubborn, and verbally aggressive interactions. It is associated with an elevated risk of current or later CD. These two dimensions are sometimes joined by a third one comprised of hurtful, vindictive, or otherwise physically aggressive behavior that, while not an inherent part of ODD, can co-exist with it and is more highly related to concurrent or later CD. A fourth dimension may also be apparent in some children that consists of CU traits comprising childhood psychopathy and predictive of even more persistent antisocial behavior and adult antisocial personality disorder.
As in the case of child characteristics above, are some parents more likely than others to engage in coercive parenting practices and to have more defiant children? Again, undoubtedly yes. Noncompliance or oppositionality in children may also increase in probability in children as a result of this third factor; that is, predisposing parental characteristics. For instance, the risk of child disruptive behavior is elevated in families as a function of the earlier age of mothers at the time of child-bearing, and this effect is greatest on second and third born children. This factor is illustrated in Figure 3, below.
Figure 3
ODD children, especially those with comorbid ADHD, are also more likely to have parents with psychiatric disorders, especially ADHD, depression, and antisocial personality disorder, than are children without these disorders. Conversely, immature, inexperienced, impulsive, inattentive, depressed, hostile, rejecting, or otherwise negatively temperamental parents are also more likely to have defiant and aggressive children. It is certainly likely that some of the risk of shared parent and child psychiatric disorders, as in ADHD and depression, and even parent-child hostility is a consequence of shared psychiatric genetics and not because the parental disorder conveys an environmental (parenting) risk for the child’s disorder, such as ODD. Yet research shows that parental disorders like depression and ADHD convey a risk as an environmental liability (disrupted parenting) for the child independent of the risk conveyed genetically for the child’s disorder.
This is because ADHD, depressed, antisocial or otherwise psychiatrically impaired parents display poor attention and monitoring abilities around their children, inconsistent management strategies, greater use of negative parenting methods, and higher levels of irritability, hostility, and expressed negative emotions toward their children, and provide less positive parenting methods and reinforcement for prosocial behavior. Through such inconsistent, over-reactive, and indiscriminant parenting, then, parents set in motion a reciprocal coercive family process in which children experience periodic success at avoiding demands, further reinforcing the children’s use of oppositional or coercive behavior. Such increases in child coercive behavior may then feed back further to affect detrimentally parent mood, sense of competence, self-esteem, and even marital functioning in a vicious, reciprocal cycle of bidirectional effects. Such parents may also employ coercive behavior with others in the family, providing a model of such behavior for the child to imitate.
Parents of children with externalizing disorders, like ODD, are more likely to have problems empathizing with their child, to have an inappropriate or external locus of control, to demonstrate low frustration tolerance, among other cognitive and attributional disturbances or biases, and to show disrupted synchrony in their parent-child interactions. These cognitive risk factors appear to make their own contribution to the evolution of child behavioral problems independent of their impact on disrupted parenting. Some of these cognitive risk factors are also highly related to likelihood of parental aggression toward their children, accounting for 63% of the variance in parental abuse potential and 55% of the variance in parental inappropriate disciplinary practices.
Where parents have a specific psychiatric disorder, it may further adversely impact parenting. More specifically, the level of parental ADHD, parental depression, and parental antisocial personality disorder, are significantly associated with risk for parenting stress and disrupted parenting. As a consequence, these parental disorders pose an increased risk for their children developing oppositional and aggressive behavior and later CD or delinquency.
The presence of these disorders, particularly parental ADHD, is also a predictor for reduced success or even failure in behavioral parent training programs such as this one. For these reasons and those noted below for contextual factors, parent psychological status must be a formal focus of the evaluation of children referred for defiant behavior. Indeed, parental ADHD or depression may require treatment before involving such parents in training in order to improve their pre-treatment parenting abilities, such as with stimulant medication in the case of adult ADHD, and thus increase parents susceptibility to successful training.
It is virtually self-evident that parental behavior is not only a function of various parent characteristics or attributes that may predispose parents toward using disrupted parenting methods but that parental behavior may also be adversely affected by the surrounding social ecology or family context. A few factors acting within this context have been identified, and this context serves as the fourth factor in the model shown in Figure 4, below.
Figure 4
Certain characteristics of the family context may create or contribute to increased risks for child defiant behavior and aggression as well as later delinquency. As noted earlier, maternal social isolation is one such factor. But so is parental marital status. Single mothers are the most likely to have significantly aggressive children, followed by mothers who live with male partners but are unmarried. Married mothers have the lowest rates of aggressive children, with these associations being moderated somewhat by higher socio-economic status.
Marital discord also has been repeatedly linked to child disruptive and defiant behavior, especially high intensity couple conflict. Apart from marital discord, parental disagreement over child-rearing may make independent contributions to risk for child disruptive behavior. Debate continues over the mechanisms involved in this relationship between inter-parental relations and child disruptive behavior. It may be reciprocal, with marital discord contributing to higher rates of oppositionality in children through its adverse effects on parenting and child oppositionality then feedbacks to worsen marital discord and child-rearing disagreements all of which may hasten divorce.
Also noted earlier, family social disadvantage or social adversity is another factor associated with risks for childhood defiant and aggressive behavior. These stress events or settings appear to act on child misbehavior via their influence on creating inconsistent or indiscriminant parenting practices, inattention, lower rates of positive parenting, and parental irritability or aggression in child management by parents. Such disrupted parental behavior further predisposes children to develop or sustain noncompliance or defiance within family interactions as noted above.
Notice that for some of these circumstances, a reciprocal relationship exists wherein they may contribute to antisocial behavior in a child but such behavior, once developed, contributes to a worsening of these circumstances, such as in marital conflict, divorce, and parent psychiatric disturbances. Research with ADHD children suggests that disruptive and oppositional behavior may also feed back to increase parental alcohol use as well. I illustrate these feedback mechanisms with additional arrows (effects) in the final Figure 5 of the four-factor model, below.
Figure 5. The four factor model of child oppositional defiant behavior. From R. A. Barkley (2013). Defiant Children: A Clinician’s Manual for Assessment and Parent Training (3rd ed.). New York: Guilford Press. Copyright 2013 by the Guilford Press. Reprinted with permission
It is all too common for clinicians to observe that many families referred for treatment of a defiant child have most or all of these predisposing characteristics: temperamental, impulsive, overactive, and inattentive children being raised by immature, temperamental, and impulsive parents within a family experiencing greater marital, financial, health, and personal distress in its members, where management of the child is characterized by inconsistent, harsh, indiscriminant, and coercive parenting often along with reduced parental monitoring of the child’s activities.
Given all of this it is not surprising to discover that interpersonal trauma may be a consequence of ODD severity and may also feedback to exacerbate such symptoms while non-interpersonal trauma might actually precede the development of ODD or at least further exacerbate its severity (Mikolajewski & Sheeringa, 2022). Hence, family violence may be both a background factor preceding the development of ODD but especially an outcome of the irritable emotion regulation component of ODD coupled with parental insularity or alienation (Chen et al., 2020).
Hopefully this explication of the four-factor model of defiant behavior shows why any parent training program cannot simply focus on child noncompliance, defiance, or ODD. Instead, it must target those social processes in the family believed to have helped, at least partially, to develop or sustain the child’s oppositional behavior. These processes were more thoroughly explained above in the section on the “The Nature of Parent-Child Interactions in Defiant Children.” Noncompliance or oppositionality is the most obvious product of these social processes, although there are other significant correlates and outcomes of these processes, such as comorbidity for other disorders in the child, maternal depression, parental stress and low self-esteem, lack of a sense of parental competence, marital discord and divorce, and even sibling hostility and resentment, to name but a few. There are many well-established reasons for choosing noncompliance or oppositionality, and its underlying family processes, as the focus of intervention.
First, noncompliance, or defiance, in various forms appears to be the most frequent complaint of families referring children to child mental health centers, especially for boys. Over half of all referrals to such clinics are for oppositional or aggressive behavior and this figure rises to more than 74% if symptoms of ADHD are included in the analysis. Although these children may receive various diagnoses of ODD, CD, ADHD, Adjustment Reactions, and so forth, a major concern of the parents or teachers referring such a child is his/her inability to comply with directions, commands, rules, or codes of social conduct appropriate to the child’s age group. Parents may complain that the child fails to listen, throws temper tantrums, is aggressive or destructive, is verbally oppositional or resistant to authority, fails to do homework, does not adequately perform chores, cannot play appropriately with neighborhood children, lies or steals frequently, or engages in other forms of inappropriate behavior. However, all of these behaviors are violations of commands, directions, or rules that were either previously stated to the child or are directly stated in the particular situation. Hence, noncompliance, broadly defined, encompasses the majority of acting-out, externalizing, or conduct problem forms of behavior.
Second, noncompliance underlies the majority of negative interactions between family members and the referred child. Research has shown that disruptive or aggressive behavior from children occurs neither continuously nor randomly throughout the day but instead appears in “bursts” or “chunks.” These are high-rate, often intense episodes of oppositional or coercive behaviors by the child that punctuate an otherwise normal stream of behavior. Research early on suggested that one of the most common precipitants of child noncompliance or defiance is parental or teacher commands or requests.
Such negative encounters between adult and child seem to take a certain predictable form. The sequence is initiated by the command given by a parent, typically to have the child engage in a task that is not considered enjoyable or reinforcing by the child, such as to have the child pick up his/her toys, clean up his/her room, or perform school homework. On rare occasions, the behavior disordered child may obey this first request. This usually occurs where the command involves some very brief amount of effort or work from the child (e.g., “Please hand me a Kleenex.”) or involves an activity generally pleasurable to the child or that may promise immediate reinforcement for compliance (e.g., “Get in the car so we can go get some ice cream”). In these instances, child probably complies with the request and the family proceeds into other interactions. This may not seem especially important but what is actually significant here is the fact that rarely is such compliance followed by social reinforcement, such as a positive reaction from the parent that acknowledges appreciation for the compliance. When such compliance goes unnoted by parents, it frequently declines in occurrence over time and may eventually only occur where the activity requested of the child involves something highly intrinsically rewarding and immediately available to the child. In such cases the child obeys not because of being previously reinforced by the parent for doing so but because the specific activity required of the child is itself highly reinforcing. However, it is often only in a minority of instances that behavior disordered children will comply with the first commands or requests of parents.
More often, the pattern of events is that the child has failed to comply with the initial command, which is often followed by the parent simply repeating the command to the child. This is rarely met with compliance from the child and so the command may be repeated again, over and over perhaps as many as 5 to 15 times (or more!) in various forms yet without the child complying with any of them. At some point, parental frustration arises and the emotional intensity of the interaction heightens. The parent may then issue a warning or threat to the child that if compliance does not occur, something unpleasant or punitive will follow. Yet, the child often fails to comply with the threat, in part, perhaps, because the parents frequently repeat it. In so doing, the threats lack credibility and often go unenforced as well. Over time, both parent and child escalate in their level of emotional behavior toward each other, with voices rising in volume and intensity, as well as collateral behavioral displays of anger, defiance, or destructiveness being shown. Ultimately, the interaction sequence ends in one of several ways. Less frequently, the parent disciplines the child, perhaps by sending the child to his/her room, removing a favored privilege from the child, or even hitting the child. Such discipline often fails because it is inconsistently applied and is delayed well past the point where compliance was initially requested. More often, the parent acquiesces and the command is left uncompleted or only partially completed by the child. Even if the task is eventually done, however, the child has succeeded in at least delaying its completion, allowing greater time for play or some other desired activity.
This latter circumstance (eventual child compliance) may prove quite an enigma to parents and therapists alike. That is, parents may believe that they have actually “won,” or succeeded in getting the child to listen, yet they are surprised to find that the child will again attempt to avoid or defy that same command when issued again later. Parents may question the therapist as to why the child continues to misbehave or defy them when he ultimately will be forced to perform the task. The key to understanding this situation, however, is to see it from a child’s point of view rather than an adult’s. Adults tend to look at this situation in its entirety and are able to see that ultimately they will always make the child perform this command (e.g., “Get ready for bed”). Most children, however, will not show this breadth of awareness of the entire interaction sequence, but instead will simply view it as a moment-to-moment interaction with their parents in which their immediate goal is to escape or avoid doing the requested task, even if only for the moment. As a result, every minute the child is able to procrastinate is an additional minute they may continue to do what they were doing prior to the imposition of the command – an activity often more reinforcing to the child than what the parents may wish him/her to do. It is also an additional minute of avoiding the often unpleasant task requested by the parent; avoidance of unpleasant or aversive activities is itself a (negative) reinforcer for behavior.
This may help to explain why parents are often puzzled that the child spends more time avoiding the requested task, as well as arguing or defying the parents, than it would have taken to do it. The moment-by-moment procrastination of the child is doubly reinforcing in this sense, serving to permit continued participation in a desired activity (positive reinforcement) while, for the moment, successfully avoiding the unpleasant task being imposed by the parent (negative reinforcement). The ultimate outcome of the interaction (eventual punishment or forced compliance) is sufficiently delayed so as to have little, if any, influence on the child’s immediate behavior.
Acquiescence occurs when the child fails to accomplish the requested activity. In some instances, the child leaves the situation. He/she may run out of the room or yard without accomplishing the task. Or the parent may storm out of the room in anger or frustration, leaving the child to return to his/her previous activities. In some cases, a parent may in fact complete the command him/herself, as is seen when a parent picks up the toys for the child. Or the parent may assist the child with the task after directing the child to do it alone. In a few instances, the child may not only succeed in escaping from doing the task, but also receive some positive consequence as well. This can be seen in cases where, for example, a mother directs a child to pick up toys, the child refuses, throws him/herself to the floor, and begins hitting his/her head against the floor. The mother may respond to this behavioral display out of fear that the child may injure him/herself, by picking the child up and holding him/her in her lap while trying to soothe the child’s feelings. As a result, the child’s tantrum and self-injurious behavior are not only negatively reinforced by escaping from the unpleasant task initially requested by the mother, but also are positively reinforced by the soothing attention. It is likely that such dual consequences for oppositional behavior rapidly accelerate children’s acquisition and maintenance of such behavior patterns in future similar circumstances. These acquiescent interaction patterns can be found to underlie many of the negative encounters between parents and defiant or noncompliant children. They must be the focus of treatment if the complaints of the family are to be successfully ameliorated.
A third rationale for selecting noncompliance as the target of intervention is its relatively greater pervasiveness across settings compared to other behavioral problems seen in children. Research suggests that children who display noncompliance or coercive behavior in one situation are highly likely to employ it eventually elsewhere, with other commands or instructions, and with other adults or children. Improving child compliance may therefore have more widespread effects across many situations and individuals than would be seen had a behavioral problem specific to only one situation been selected as the focus of therapy.
Fourth, noncompliant behavior by the child may have indirect effects on family functioning that may, in a reciprocal fashion, come back to have further detrimental effects on the psychological adjustment of the defiant child. The outcomes of impaired family management can be seen in Figure 6, as initially demonstrated in the long-term program of research on aggressive children by Gerald Patterson (1982) and subsequently supported through abundant research on the outcomes of oppositional children (ODD). These outcomes are displayed in Figure 6, below.
Figure 6. The potential outcomes of child defiant behavior, disrupted parenting, and the coercive family process. From R. A. Barkley (2013). Defiant Children: A Clinician’s Manual for Assessment and Parent Training (3rd ed.). New York: Guilford Press. Copyright 2013 by the Guilford Press. Reprinted with permission.
As noted already, out of this impaired family management process, the child rapidly acquires a set of coercive behaviors to use against the parent and other family members or even peers when the child is instructed to do something he/she does not like to do. Parents may also come to acquire a set of rapidly escalating coercive behaviors to use with the child because of those rare occasions where yelling, threatening, or punishing the child has eventually led to compliance by the child. Furthermore, over time parents may request progressively fewer commands of the child, knowing in advance they will be met with resistant, oppositional behavior by the child. Parents instead may assume more of the child’s chores and responsibilities or assign them to a more compliant sibling. The latter situation may then lead not only to declines in the child’s overall level of successful adaptive functioning (i.e., independence, self-care, degree of responsible conduct, etc.) and the child’s capacity to be socialized into the larger community and society. Siblings may develop hostility and resentment toward the defiant child because that child has comparatively less work to do. In other cases, parents and siblings come to spend progressively less leisure time and initiate fewer shared activities and recreational pursuits with the defiant child so as to avoid any further difficulties with that child. Siblings may also acquire and frequently utilize repertoires of coercive behavior back toward the defiant child as well as toward parents, given that parents may frequently employ similar coercive tactics with other members of the family and not just the clinic-referred defiant child. Thus, the density of aversive social events within the families of defiant children is substantially higher than normal. That such family patterns might have negative effects on one’s self-esteem as a parent, on increasing the parent’s sense of helplessness, on family harmony, on marital harmony should the child oppose one parent more than the other, or on the self-esteem of the defiant child almost goes without saying and has been substantiated in research. And so there is a reciprocal system of effects existing within parent-child relations of defiant children where the behavior of parent and child affect each other bidirectionally while also resulting in broader “spillover” effects into the larger social ecology of the family.
Fifth, noncompliance and defiant behavior in children appears to be highly stable over time, significantly predicting the persistence of this behavior pattern across development. Apart from ADHD with which it is often associated, childhood defiance or aggressiveness, in fact, may be one of the most stable of childhood behavioral disorders across development.
Targeting early defiant behavior for treatment is also important because of its repeated association in research with a variety of later maladjustments during the adolescent and young adult years. This is illustrated in Figure 1.3 as well. That is, defiant and coercive behavior, especially if it is of such magnitude and duration that it leads to referral for mental health services, is also a precursor or link to the development of other, more serious forms of antisocial behavior, criminal activity, and substance abuse. The pattern here is obvious; there is a developmental staging in the relationship of oppositional child behavior to later stages of physical aggression, status offenses, and crimes against property. Childhood oppositional behavior also significantly predicts later problems with academic performance and peer acceptance. The risk for later depression, suicidal ideation, and suicide attempts is also greater in children with defiant or aggressive behavior. Thus, research is coming to show that the presence of oppositional defiant behavior, or social aggression, in children is the most highly stable of childhood psychopathologies over development and is a more significant predictor of a widespread array of negative social and academic risks than are most other forms of deviant child behavior. These developmental risks become even more likely and more adverse when childhood defiant behavior is combined with higher levels of ADHD symptoms, particularly childhood impulsivity. Oppositional behavior is therefore singled out for treatment because of the significant potential it carries for future negative consequences for the child and family if left untreated.
Finally, it would be hard to undertake the treatment of any other presenting problems of a child without first addressing the child’s noncompliance. For example, attempting to toilet train a 3-year-old noncompliant child is not likely to prove successful until the child is taught to comply with requests. Similarly, parental tutoring of a school-age child during homework performance is also likely to fail as a consequence of the child’s reliance on defiant behavior during work-related interactions with the parent. This will also be true of noncompliant children who must adhere to other medical regimens or educational programs in that such programs will likely prove less successful until the child’s compliance with adult instructions is developed.
One obvious implication of the model for assessing defiant children is that clinicians must evaluate each factor represented in the model to fully understand how a child may have come to be defiant, ODD, or socially aggressive and, hopefully, what specific contributors exist within each factor that may require attention and intervention.
The evaluation of defiant children incorporates multiple assessment methods relying on several informants concerning the nature of the children’s difficulties (and strengths!) across multiple situations. To accomplish this, parent, child, and teacher interviews are conducted, parent and teacher rating scales of child behavior and rating scales or surveys of child adaptive functioning should be obtained, and parent self-report measures of relevant psychiatric conditions and of parent and family functioning also should be collected. Some clinicians may wish to collect laboratory measures of ADHD symptoms, if that disorder is present, as well as direct observations of parent-child interactions. And, of course, children in whom intellectual or developmental delays or learning disabilities are suspected should receive psychological testing of these domains if such has not already been performed. For a more detailed discussion of specific methods to use in evaluating oppositional children, see Defiant Children: A Clinician’s Manual for Assessment and Parent Training (Barkley, 2013), and more recently, Treating ADHD in Children and Adolescents: What Every Clinician Needs to Know (2022), which contains forms and rating scales that can be photocopied for use in the owner’s clinical practice.
Clinical interviews provide a good starting point for gaining information on the nature of defiant behavior a child may be demonstrating. But they are not normed and so give no indication of the frequency or severity of such behavior relative to a typically developing peer group of the same age and sex. For that end, clinicians can use a broad band child behavior rating scale, such as the Child Behavior Checklist (Achenbach, 2014) or the Behavioral Assessment System for Children - (Reynolds & Kamphaus, 2015). These scales contain dimensions that evaluate aggressive child behavior, among other dimensions of potential psychopathology. If the clinician wants to examine the DSM-5 symptoms of ODD specifically, then the clinical interview can be used for this purpose and the recommended threshold of 4 of 8 symptoms that occur often can be used as the determining cutoff for the presence of significant ODD symptoms. Defiant behavior can also be evaluated using the Home Situations Questionnaire and School Situations Questionnaire (see Barkley, 2013, 2022), which have normative information for school-age children. Direct observations of child behavior can be obtained in the clinic but these are often not especially indicative of the nature of defiant behavior as it may occur in natural settings in parent-child and teacher-child interactions. This is why interviews and rating scales remain the best means of evaluating such behavior in a clinic referred child.
In general, there are several goals to bear in mind in the evaluation of children for defiant behavior. A major goal of such an assessment is not only the determination of the presence or absence of psychiatric disorders, such as ODD, CD, and/or ADHD, but also the differential diagnosis of ODD from other childhood psychiatric disorders. This requires extensive clinical knowledge of these other psychiatric disorders. In evaluating defiant children, it may be necessary to draw on measures that are normed for the individual’s country of residence that have a representative sampling of the various ethnic backgrounds that exist in that general population, if such instruments are available, so as to preclude the over-diagnosis of minority children when diagnostic criteria developed from white children are extrapolated to them.
Another important purpose of the evaluation is the determination of comorbid conditions and whether or not these may affect prognosis or treatment decision making. For instance, the presence of high levels of physically assaultive behavior by the child may signal that a parent training program such as this may be contraindicated, at least for the time being, because of its likelihood of temporarily increasing child violence toward parents when limits on noncompliance with parental commands are established. Or consider the presence of high levels of anxiety specifically and internalizing symptoms more generally in children with ODD who may have ADHD as well. Research has shown such symptoms to be a predictor of poorer responses to stimulant medication or of a partial response than may be seen in non-anxious children with ADHD. Similarly, the presence of high levels of irritable mood, severely hostile and defiant behavior, and periodic episodes of serious physical aggression and destructive behavior may be early markers for later severe mood dysregulation disorder or, if accompanied with mood swings toward mania, even childhood Bipolar Disorder (manic depression). Oppositional behavior is almost universal in juvenile-onset Bipolar Disorder. Such a disorder will likely require the use of psychiatric medications in conjunction with a parent training program.
A further objective of the evaluation is to identify the pattern of the child’s psychological strengths and weaknesses and to consider how these may affect treatment planning. This may also include gaining an impression of the parents’ own abilities to carry out the treatment program, as well as the family’s social and economic circumstances and the treatment resources that may (or may not) be available within their community and cultural group. Some determination will also need to be made as to the child’s eligibility for special educational services within his/her school district, if eligible disorders, such as developmental delay, learning disabilities, or ADHD, are present.
A final purpose of the evaluation is to begin delineating the types of interventions that will be needed to address the psychiatric disorders and psychological, academic, and social impairments identified in the course of assessment. As noted later, these interventions may include individual counseling, parent training in behavior management, family therapy, classroom behavior modification, psychiatric medications, and formal special educational services, to name just a few.
As the foregoing discussion illustrates, the evaluation of a child for the presence of defiant behavior is but one of many purposes of the clinical evaluation of ODD children.
As the explanation of the four-factor model made evident, disrupted parenting is frequently a major contributor to oppositional behavior and, in concert with the child’s features discussed above, creates the final common pathway for the generation of noncompliant and defiant behavior. Although some rating scales of parenting exist in research articles, they are not normed on a U.S. population and so are not relevant to the clinical evaluation of an individual case. The Home and School Situations Questionnaires noted above (see Barkley, 2013, 2022) can help to evaluate those situations in which a child is displaying uncommon levels of defiant behavior but are not able to capture the nature of the parent’s own part of these interactions. For that purpose, I recommend following up those rating scales (when completed) with an interview with the parents. This interview would involve discussing each of the situations on the left hand side of this table. If parents indicate this situation is a problem, then use the questions on the right hand side to probe for the specific nature of the parent-child interactions in this situation. The clinician is seeking here to identify a pattern of inconsistent, vacillating (harsh vs. lax), emotional, and generally ineffective parenting as described in detail in the model above.
Parental Interview Format for Assessing Child Behavior Problems at Home and in Public |
|
Situation to be discussed |
If a problem, follow-up questions to ask |
Overall parent-child interactions Playing alone Playing with other children Mealtimes Getting dressed/undressed Washing and bathing When parent is on telephone When child is watching television When visitors are in your home When you are visiting someone else’s home In public places (stores, restaurants, church, etc.) When father is in the home When child is asked to do chores When child is asked to do school homework Bedtime When child is riding in the car When child is left with a babysitter Any other problem situations |
1. Is this a problem area? If so, then proceed with questions 2-9. 2. What does the child do in this situation that bothers you? 3. What is your response likely to be? 4. What will the child do in response to you? 5. If the problem continues, what will you do next? 6. What is usually the outcome of this situation? 7. How often do these problems occur in this situation? 8. How do you feel about these problems? 9. On a scale of 1 (no problem) to 9 (severe), how severe is this problem for you? |
From Barkley (1981, p. 98; 1987, 1997a, 2022). Copyright 1981, 1987, 1997 by The Guilford Press. Reprinted by permission.
It is apparent from the four-factor model that child defiant behavior and related disorders such as ODD, their level of severity, and their response to interventions are, in part, a function of factors affecting parents. As noted above, several types of psychiatric disorders are likely to occur more often among family members of a child with defiant behavior or ODD than in matched groups of control children. That these problems might further influence the frequency and severity of behavioral problems in defiant children has been demonstrated in numerous studies over the past 20 years. Also noted earlier is the fact that the extent of social isolation in mothers of behaviorally disturbed children influences the severity of the children’s behavioral disorders as well as the outcomes of parent training. Others have also shown parental psychopathology and marital discord separately and interactively contribute to the decision to refer children for clinical assistance, the degree of conflict in parent-child interactions, and child antisocial behavior. The degree of resistance of parents to parent training is also dependent on such factors. Assessing the psychological integrity of parents, therefore, is an essential part of the clinical evaluation of defiant children, the differential diagnosis of their prevailing disorders, and the planning of treatments stemming from such assessments. Thus, the evaluation of children for defiant behavior is often a family assessment rather than one of the child alone. Although space does not permit a thorough discussion of the clinical assessment of adults and their disorders, brief mention will be made of some assessment methods that clinicians have found useful in providing at least a preliminary screening for certain important variables in the treatment of defiant children.
The instruments that assess the parents’ own adjustment, discussed below, can be completed by parents in the waiting room during the time their child is being interviewed. They should not mailed out in advance with the other rating scales, as the clinician will need to introduce the purpose of these self-report scales briefly to the parents so as not to offend them with the request for such sensitive information. Typically, I have indicated to parents that having a complete understanding of a child’s behavior problems requires learning more about both the children and their parents. This includes gaining more information about the parents’ own psychological adjustment and how they view themselves in their role as parents. The rating scales below are then introduced as one means of gaining such information. Few parents refuse to complete these scales after an introduction of this type. To save time, some professionals prefer to send these self-report scales out to parents in advance of their appointment, at the same time as the child behavior questionnaires. If so, be sure to prepare a cover letter that sensitively explains to parents the need for obtaining such information about the parent. For instance, this letter might include the following statement:
“When completing the questionnaires pertaining to yourself and to other aspects of your marriage and family, please keep in mind that we are not trying to evaluate you. Instead, we are trying to learn as much as we can about the home environment in which your child lives. That home environment is very important in helping to understand the nature of the problems a child may be experiencing. Having such information allows us to make careful and well-informed recommendations about how best to help your child become more successful and better adjusted both at home and at school.”
Family studies of the aggregation of psychiatric disorders among the biological relatives of children with ADHD and ODD have clearly demonstrated an increased prevalence of ADHD and ODD among the parents of these children. In general, there seems to be at least a 40-50% chance that one of the two parents of the defiant child with ADHD will also have adult ADHD (15-20% of mothers and 25-30% of fathers). The manner in which ADHD in a parent might influence the behavior of an ADHD child specifically and the family environment more generally has not been well studied. Adults with ADHD have been shown to be more likely to have problems with anxiety, depression, personality disorders, alcohol use and abuse, and marital difficulties; to change their employment and residence more often; and to have less education and lower socioeconomic status than adults without ADHD. Greater diversity and severity of psychopathology among parents is particularly apparent among the subgroup of ADHD children with comorbid ODD or CD. More severe ADHD seems to also be associated with younger age of parents, suggesting that pregnancy during their own teenage or young adult years is more characteristic of parents of ADHD than non-ADHD children. It is not difficult to see that these factors, as well as the primary symptoms of ADHD, could influence the manner in which child behavior is managed within the family and the quality of home life for such children more generally. Research suggests that where the parent has ADHD, the probability that the child with ADHD will also have ODD increases markedly. Other studies indicate that ADHD in a parent may interfere with the ability of that parent to benefit from a typical behavioral parent training program. Treatment of the parent’s ADHD (with medication) may result in greater success in subsequent retraining of the parent. These preliminary findings are suggestive of the importance of determining the presence of ADHD and even ODD in the parents of children undergoing evaluation for these disorders.
Recently, the DSM-IV symptom list for ADHD have been cast in the form of a behavior rating scale, and U.S. norms on more than 1,200 adults, ages 17 to 81-years-old, have been collected. Given that DSM-5 has made no changes to these symptoms, the scale is just as applicable to evaluating parents for a possible DSM-5 diagnosis of ADHD. This rating scale for adults, entitled the Barkley Adult ADHD Rating Scale is completed twice; once for their current behavioral adjustment and a second time for their recall of their childhood behavior between ages 5 to 12-years-old. Norms for both current and childhood recall scores are provided in the manual. Clinically significant scores on these scales do not, by themselves, ensure the diagnosis of ADHD in a parent but should raise suspicion in the clinician’s mind about such a possibility. If so, consideration should be given to referral of the parent for further evaluation and, possibly, treatment of adult ADHD, if necessary.
The use of such scales in the screening of parents of defiant children would be a useful first step in determining if the parents had ADHD. If the child meets diagnostic criteria for ADHD and these screening scales for ADHD in the parents proved positive (clinically significant), then referral of the parents for a more thorough evaluation and differential diagnosis might be in order. At the very least, positive findings from the screening would suggest the need to take them into account in treatment planning and parent training.
Parents of defiant children are frequently more depressed than those of normal children and this may affect their responsiveness to behavioral parent training programs. A scale often used to provide a quick assessment of parental depression is the Beck Depression Inventory (Beck, Steer, & Garbin, 1988). Greater levels of psychopathology generally and psychiatric disorders specifically also have been found in parents of children with ADHD, many of whom also have ADHD. One means of assessing this area of parental difficulties is through the use of the Symptom Checklist 90 – Revised (SCL-90-R; Derogatis, 1994). This instrument not only has a scale assessing depression in adults but also scales measuring other dimensions of adult psychopathology and psychological distress. Whether clinicians use this or some other scale, the assessment of parental psychological distress generally and psychiatric disorders particularly makes sense in view of their likely impact on parenting and child defiant behavior as well as on the course and the implementation of the child’s treatments, typically delivered via the parents.
Certainly, clinical interviews can be used to evaluate possible background stressful or other life events that might have some impact on disrupting parenting and generating child defiant behavior. Unemployment, financial problems, marital difficulties, chronic health problems, tense or conflict-ridden interactions with extended family, and other factors are worth exploring in such an interview to gain some idea of their salience in a specific case. A few rating scales can be useful supplemental methods to this part of the clinical interview.
Parental Stress: Research as early as 25 years ago suggested that parents of behavior problem children, especially those children with comorbid ODD and ADHD, report more stress in their families and their parental role than those of normal or clinic-referred non-ADHD children. One measure frequently used in such research to evaluate this construct has been the Parenting Stress Index (PSI; Abidin, 1995). The current PSI is a 120-item multiple choice questionnaire, which can be scored to yield six scores pertaining to child behavioral characteristics (e.g., distractibility, mood, etc.), eight scores pertaining to maternal characteristics (e.g., depression, sense of competence as a parent, etc.), and two scores pertaining to situational and life stress events. These scores can be summed to yield three domain or summary scores, these being Child Domain, Mother Domain, and Total Stress. A shorter version of this scale is available and clinicians are encouraged to utilize it in evaluating parents of defiant children.
Marital Discord: Many instruments exist for evaluating marital discord between parents. The one most often used in research on childhood disorders has been the Locke-Wallace Marital Adjustment Scale (Locke & Wallace, 1959). As noted above, marital discord, parental separation, and parental divorce are more common in parents of defiant children. Parents with such marital difficulties may have children with more severe defiant and aggressive behavior and such parents may also be less successful in parent training programs. Screening parents for marital problems, therefore, provides important clinical information to therapists contemplating a parent training program for such parents. Clinicians are encouraged to incorporate a screening instrument for marital discord into their assessment battery.
Some minor amounts of noncompliant or defiant behavior is normal for children, particularly those in the preschool age group, and should not be thought of as being pathological or abnormal just because it may occur sporadically. Nor will such typical and occasional defiance justify a clinical treatment program such as this one. In my opinion clinicians must take care to establish at least two of the following three criteria for determining that the noncompliant behavior shown by a child referred to them can be justified as in need of clinical intervention:
1. The child’s behavior is developmentally inappropriate or statistically deviant in that it occurs to a significantly greater degree than is common for children of this age group. This can be established through the use of child behavior rating scales that include this dimension of behavior, often called aggression or conduct problem by scale developers. Suffice it to say that the child’s behavior should be rated as falling at least above the 84th percentile (1 standard deviation [SD] above the mean) or higher on such rating scales in order to establish such deviance. Although this information will typically be obtained through the use of parent reports of the child’s behavior because the home setting is where such behavior is usually at its worst, teacher reports on these rating scales may also be used to establish this criterion of developmental inappropriateness. Alternatively, through clinical interview with the parent one can discover whether the child demonstrates sufficient symptoms of ODD or CD as to meet clinical criteria for either of these diagnoses as established in DSM-5 (American Psychiatric Association, 2013).
2. The child’s behavior is resulting in an appreciable degree of impairment. That is, the behavior pattern is interfering with the child’s capacity to function effectively in various domains of major life activities. This means that the child does not meet appropriate developmental expectations for adaptive behavior, such as self-care, or for appropriate social interaction with family members and peers, acceptance of age-appropriate responsibilities as in chore and homework performance, school functioning, and the capacity to be trusted to adhere to rules in the absence of immediate caregiver (typically parental) supervision, among other domains. Such levels of impairment can be established to a limited degree using some child behavior rating scales completed by parents and teachers that have questions dealing with adaptive behavior in major domains of life, such as the Child Behavior Checklist or Behavior Assessment System for Children - 2 or through interviews and inventories with parents that explicitly assess adaptive functioning, such as the Vineland Adaptive Behavior Scale, the Normative Adaptive Behavior Scale, or other such instruments. More specifically, clinicians may wish to use the Barkley Functional Impairment Scale - Children and Adolescents (Barkley, 2012a) that covers parent reports of child impairment in more domains of major life activities (15) than other child behavior rating scales and has current nationally representative norms for children ages 6-17 years. For our purposes, establishing that a defiant child is impaired means that they place at or below the 7th-10th percentile for his/her age on one of these well-normed rating scales of impairment.
3. The child’s behavior is resulting in a significant degree of emotional distress or harm, either for the child or, more likely, for the parents. Child distress may be established through the use of child self-report measures of emotional adjustment, such as ratings of or interviews about anxiety or depression, that convey an impression of the child’s unhappiness with the current state of affairs in the family specifically or their social adjustment more generally. Parent distress may be readily established most directly through the use of parent self-report instruments designed to measure this domain, such as the Short Form of the Parenting Stress Index (Abidin, 1991).
Regardless of the specific methods used to evaluate these intervention criteria, the clinician must make some effort to demonstrate that the child’s defiant behavior pattern is outside the bounds of normally appropriate child conduct and that it is impairing the child’s adjustment in some way or is creating distress for the child, the caregiver, or others and thus is in need of clinical intervention. Statistical deviance of a child’s behavior alone may not justify either clinical diagnosis or clinical intervention. It may be helpful here to consider the related issue of what defines a behavior pattern as a mental disorder, out of which may come some guidance concerning the issue of when to treat. As discussed by Wakefield (1992), the clinician is attempting to establish that a “harmful dysfunction” exists and is deserving of a label of mental disorder and/or clinical treatment. Wakefield (1992) goes further and requires that an aberration in an internal, normal psychological or cognitive mechanism must also be present to define a “harmful dysfunction”; this must be shown before a diagnosis of mental disorder is rendered. Some defiant or antisocial children may show no evidence of aberrant cognitive mechanisms, although many do particularly in the domain of emotional self-regulation, and their deviant behavior may arise as a result of external mechanisms, such as disrupted, disadvantaged, or even criminogenic environments. Such children without evidence of a deficient cognitive or psychological mechanism may not be viewed as having mental disorders by Wakefield’s definition. Others disagree with Wakefield’s criterion of an aberrant cognitive mechanism (Lilienfeld & Marino, 1995), however, and argue that “fuzzy” boundaries will invariably exist between normality and abnormality by virtue of the dimensional nature of individual psychological characteristics and behaviors and because one must make arbitrary choices about “where to carve nature at her joints” to define abnormality along any dimension. Also, I am not sure that a criterion of an aberrant internal mechanism or even a diagnosis of mental disorder is needed to justify the use of psychosocial treatment for the child and his/her parent. Some relatively socially benign interventions, such as parent training in child management, may be justifiable even though some children whose parents undergo such training do not meet diagnostic thresholds for a mental disorder or Wakefield’s complete criteria for a “harmful dysfunction.” The implementation of treatment, in other words, may not necessarily depend on a diagnosis of a mental disorder, although often it does, but should instead be focused on the reduction of impairment or harm even if no cognitive dysfunction is evident.
In the end, what all of this means is that the clinician must stay alert to the occasional possibility that some children and their families do not need training in specific child management skills. This may result from the fact that some parents, by dint of their own psychological or psychiatric disorders, are significantly distressed by even normal, garden-variety child misbehavior or noncompliance. In such cases, the parents may need intervention for changing their own distress (and developmental expectations of children) or addressing their own psychological disorder rather than the child’s behavior needing clinical treatment. Milder instances of this phenomenon, where parents manifest no serious psychological disorders, may simply reflect an excess of parental concern about their children’s adjustment and their own competence as parents. In these cases, the clinician may only need to offer simple reassurance that all seems well with the child and that the parent seems to be doing a reasonable job of parenting. Likewise, some children may show higher than normal levels of oppositional behavior that do not achieve clinically significant levels of deviance, result in no distress for the parent or child, or are not associated with significant impairment in major life activities. Such children may be viewed as more stubborn, “pig-headed,” strong-willed, temperamental, rigid, or opinionated but such personality descriptors alone would not justify clinical intervention. And there certainly exist those rare cases of children who may be distressed by their own social conduct, even though not clinically deviant in their noncompliance, not distressing to their parents, or/and not impairing of a major domain of life activity, as in the case of social phobia, major depressive disorder, dysthymic disorder, or even obsessive-compulsive disorder. Such children may well be in need of clinical treatment for their own psychological distress but not specifically in need of a parent training program aimed at noncompliant child behavior management as that described here. But the presence of at least two of the three criteria set forth above is likely to indicate that a child’s behavior is placing him/her at significant risk for current and later maladjustment or risk for other disorders, social and academic failure, antisocial activities, and other significant negative developmental outcomes. This establishes that a “harmful dysfunction” exists (even if not associated with an aberrant cognitive mechanism) and that such risks justify clinical intervention.
Through the evaluation, the clinician has gained some indication of what pre-existing childhood characteristics exist that might be contributing to defiant behavior and parent-child conflict. Among these, the most common is likely to be ADHD, although major depression, bipolar disorder, disruptive mood dysregulation disorder, psychopathic personality, among other disorders may also be contributing factors. Treatments for these disorders, including psychiatric medication, may be needed apart from any program of parent training that is going to be implemented. Indeed, failure to address these disorders may well contribute to subsequent failure of such a training program.
This course has shown you that there are several important aspects of the parent-child interactions of oppositional children that have implications for the training of such parents in effective child management procedures. The most important are that parents must be trained to:
(1) increase the value of their attention generally, and its particular worth in motivating and reinforcing their child’s positive behavior;
(2) increase the positive attention and incentives they provide for compliance while decreasing the inadvertent punishment they provide for occasional compliance;
(3) decrease the amount of inadvertent positive attention they provide to negative child behavior;
(4) increase the use of immediate and consistent mild punishment for occurrences of child noncompliance;
(5) ensure that escape from the activity being imposed upon the child does not occur (i.e., the command is eventually complied with by the child);
(6) reduce the frequency of repeat commands parents employ so as to avoid delays to consequences (act, don’t yak);
(7) recognize and rapidly terminate escalating and confrontational negative interactions with the child; and
(8) ensure that the parents do not regress to a predominantly punitive child management strategy once training has been completed.
All of this, then, should serve to reduce the unpredictability involved in indiscriminant or inconsistent parenting while ensuring that child’s coercive oppositional behaviors are unsuccessful in their function to escape or avoid parental requests, demands, and commands.
Just as with Factor I, the clinician may need to recommend various treatments for any parent psychological and psychiatric disorders detected in the evaluation. In ODD children, especially where ADHD is a comorbidity, parental ADHD, among other disorders, is likely to be found in a substantial minority of parents. As noted above, substance use disorders, depression, or anxiety disorders may also be more likely. Hence parents may require interventions for their own disorders prior to or concomitant with any parent training program so as to maximize the likelihood of also reducing parent-child conflict and child defiant behavior. Also, to the extent that various family stress events may exist, referral for social services assistance, medical evaluation and treatment, marital therapy, or other interventions may be called for in dealing with particular stress events identified during the evaluation.
There are numerous well-studied Behavioral Parent Training programs (BPT) available through commercial sources, and their respective clinical manuals or the books written for a parent audience are quite adequate for teaching the techniques. The most commonly used programs having some evidence for their effectiveness are:
Many of these programs have been around for decades. The programs by Webster-Stratton, Thompson, and Harvey are targeted mainly at preschool children. The others encompass a wider age range up to adolescence. There has been little innovation in these methods over that time except for two programs. One was the development of the program explicitly intended for preschool children with ADHD called the New Forest Program by Thompson and colleagues in Europe and a different program for that age group by Harvey in the United States. Those programs focus to some extent on ADHD-specific symptoms, such as inattention, and with preschool children, but they also convey general behavior management strategies as do traditional BPT programs. The other programs are for conduct or behavioral problem children and can be used up until adolescence. They focus more on parent-child conflict, compliance, and improving parental consistency of consequences as described below.
The program by Green and Ablon does not focus so much on contingency management following traditional operant conditioning principles. Instead, it teaches parents collaborative problem solving in which the child is actively invited into brainstorming possible ways of resolving parent-child conflicts so as to reach agreement with parents on a resolution of the problem. Only two studies to date by the developer have been published, both from the same single project. They showed little or no advantage of this approach over traditional BPT (my program specifically) for improving child conduct problems although some parents reported greater acceptability of the problem-solving methods being taught.
To these programs, some developers add other parent exercises focused on building up a better relationship with the child or more positive attachment. This is often done through nondirective play periods several times per week in which parents simply comment positively or otherwise attend to ongoing positive child play behavior, as in my program. Research has shown such relationship building is not necessary for families who seek assistance with problem behaviors in primary care, school, or other community service settings that are not specifically mental health or psychiatric clinics. That is because the child’s problems usually have not reached such an extreme stage that the parent-child relationship is primarily negative. But by the time parents may seek assistance from secondary or tertiary level mental health settings, which are the settings in which I usually practiced, these relationship-focused exercises were important and effective to teach as the parent-child relationship had grown quite conflicted and negative.
All of the eight important issues described above in which parents require training are addressed in my program, Defiant Children. It consists of 10 steps, with 1 to 2 hour weekly training sessions provided either to individual families or in groups. Each step is described in detail in the clinical manual (see References). Assessment tools and parent handouts are also provided in the manual and can be photocopied for use in the owner’s clinical practice. The program is briefly presented below:
1. Review of Information on ADHD (if necessary)
In the first session, the therapist provides a succinct overview of the nature, developmental course, prognosis, and etiologies of ADHD. Providing the parents with additional reading materials, such as an accompanying trade book for parents (Your Defiant Child), can be a useful addition to this session. Professional DVDs are also available that present such an overview and can be loaned to parents for review at home and sharing with relatives or teachers, as needed. Such a session is essential in parent training to dispel a number of misconceptions parents often have about ADHD in children. Research suggests that just this provision of information can result not only in improved knowledge of parents about ADHD but also in improved parental perceptions of the degree of deviance of their child’s behavioral difficulties.
2. The Causes of Oppositional/Defiant Behavior
Next, parents are provided with an in-depth discussion of those factors identified in past research as contributing to the development of defiant behavior in children. Essentially, four major contributors are discussed, these being: (a) Child characteristics, such as health, developmental disabilities, and temperament; (b) Parent characteristics similar to those described for the child; (c) Situational consequences for oppositional and coercive behavior; and (d) Stressful family events. Parents are taught that where problems exist in (a), (b), and (d), they increase the probability of children displaying bouts of coercive, defiant behavior. However, the consequences for such defiance, (c) above, seem to determine whether that behavior will be maintained or even increased in subsequent situations where commands and rules are given. Such behavior appears to primarily function as escape/avoidance learning in which oppositional behavior results in the child escaping from aversive parent interactions and task demands, negatively reinforcing the child's coercion. As in the first session, this content is covered so as to correct possible misconceptions that parents have about defiance (e.g., it is primarily attention-getting in nature). This session can be augmented by the use of two of my professional DVDs on the nature of oppositional defiant behavior and its management (Understanding-the-Defiant-Child; Managing-the-Defiant-Child).
3. Developing and Enhancing Parental Attention
Gerald Patterson suggested that the value of verbal praise and social reinforcement to oppositional or hyperactive children is greatly reduced, making it weak as a reinforcer for compliance. In this session, parents are trained in more effective ways of attending to child behavior so as to enhance the value of their attention to their children. The technique consists of verbal narration and occasional positive statements to the child with attention being strategically deployed only when appropriate behavior is displayed by the child. Parents are taught to reduce the amount of attention to inappropriate behaviors, including ignoring as much negative behavior as possible, while greatly increasing their attention to ongoing prosocial and compliant child behaviors. This is a critical step because many parenting programs result in reductions of rates of negative behavior without corresponding increases in rates of positive behavior. One of the most effective results of parent training is to increase rates of positive behaviors that are incompatible with the negative behaviors the parents wish to terminate.
4. Attending to Child Compliance and Independent Play
This session extends the techniques developed in Session 3 to instances when parents issue direct commands to children. Parents are trained in methods of giving effective commands, such as reducing question-like commands (e.g., Why don't you pick-up your toys now?), increasing imperatives, eliminating sitting activities which compete with task performance (e.g., television), and reducing task complexity. Parents are then encouraged to begin using a more effective commanding style and to pay immediate positive attention when compliance is initiated by the child. As part of this assignment, parents are asked to increase the frequency with which they give brief commands to their child this week and to reinforce each command obeyed. Research suggests that these brief commands are more likely to be obeyed thereby providing excellent training opportunities for attending to compliance. In this session, parents are also trained to provide more positive attention frequently and systematically when their children are engaged in nondisruptive activities while parents must be occupied with some other work or activity. Essentially, the method taught here amounts to a shaping procedure in which parents provide frequent praise and attention for progressively longer periods of child nondisruptive activities.
5. Establishing a Home Token Economy
As noted above in discussing the theoretical model of ADHD, children with the disorder may require more frequent, immediate, and salient consequences for appropriate behavior and compliance in order to maintain it. If this is correct, then instituting a home token economy is critical to addressing these difficulties with intrinsically generated and represented motivation, by bringing more salient external consequences, more immediately, and more frequently to bear on child compliance than is typically the case. In establishing this program, the parents list most of the children's home responsibilities and privileges and then assign values of points or chips to each. The parents are encouraged to have at least 12 to 15 reinforcers on the menu so as to maintain the motivating properties of the program. Generally, plastic chips are used with children 8 or younger as they seem to value the tangible features of the token. For 9 year olds or older, points recorded in a notebook seem sufficient.
During the first week of this program, the parents are not to fine the child or remove points for misconduct. The program is for rewarding good behavior only. Parents are also asked to be liberal in awarding chips to children for even minor instances of appropriate conduct. However, chips are given only for obeying first requests. If a command must be repeated, it must still be obeyed but the opportunity to earn chips has been forfeited. Parents are also encouraged to give bonus chips for a good attitude or emotional regulation in their children. For instance, if a command is obeyed quickly, without complaint, and with a positive attitude, parents may give the child additional chips beyond those typically given for that job. Where this is used, parents are to expressly note that the awarding of the additional chips is for a positive attitude. Families are encouraged to establish and maintain such programs for at least 6 to 8 weeks to allow for the newly developed interaction patterns spawned by such programs to become habitual patterns in dealing with child compliance.
6. Implementing Time Out for Noncompliance
Parents are now trained to use response cost (removal of points or chips) contingent on noncompliance. In addition, they are trained in an effective time-out-from-reinforcement technique for use with two serious forms of defiance that may continue to be problematic despite the use of the home token economy. These two misbehaviors are selected in consultation with the parents and typically involve a type of command or household rule that the child continues to defy despite parental use of previous treatment strategies. Time out is limited to these two forms of misconduct so as to keep it from being used excessively during the next week.
The time out procedure taught to parents often differs from that commonly used by them. First, the time out is to be implemented shortly after noncompliance by a child begins. Parents often wait until they are very upset with a child before instituting punishment, often repeating their commands frequently to a child in the interim. In this program, parents issue a command, wait 5 seconds, issue a warning, wait another 5 seconds, and then take the child to time out immediately should compliance not have begun to these commands or warnings. Second, children are not given control over the time out interval as they often are in many households. For instance, parents often place a child in time out then say the child can leave time out when they are quiet, ready to do as the parent asked, or when a timer signals the end of the interval. In each of these cases, determination as to when the time out interval ends is no longer under the parent’s control. This program teaches parents to simply tell the child to not leave the time out chair until the parent tells them to. Three conditions must be met by the child before time out ends and these are in a hierarchy: (1) The child must serve a minimum sentence in time out, usually 1 to 2 minutes for each year of their age; (2) the child must then become quiet for a brief period of time so as not to have disruption associated with the parents approaching the time out chair and talking to the child; and (3) the child must then agree to obey the command. Failure of the child to remain in time out until all three conditions are met is dealt with by additional punishment. The consequence is tailored to meet parental wishes but may consist of a fine within the home token system, extension of the time out interval an additional 5 or 10 minutes, or placement of the child in his or her bedroom. In the latter case, toys or other entertaining activities are previously removed from the bedroom and the door to the room may be closed and locked to preclude further escape from the punishment.
7. Extending Time Out to Additional Noncompliant Behaviors
In this session, no new material is taught to parents. Instead, any problems with previously implementing time out are reviewed and corrected. Parents may then extend their use of time out to one or two additional noncompliant behaviors with which the child may still have trouble.
8. Managing Noncompliance in Public Places
Parents are now taught to extrapolate their home management methods to troublesome public places, such as stores, church, restaurants, etc. Using a "think aloud-think ahead" paradigm, parents are taught to stop just before entering a public place, review two or three rules with the child which the child may previously have defied, explain to the child what reinforcers are available for obedience in the place, then explain what punishment may occur for disobedience, and finally assign the child an activity to perform during the outing. Parents then enter the public place and immediately begin attending to and reinforcing ongoing child compliance with the previously stated rules. Time out or response-cost are two methods used immediately for disobedience.
Time out in a public place may require slight modification from its use at home. For instance, parents may be taught to stand the child against the farthest wall from the central aisle of a store to serve as the time out location. If inconvenient, then taking the child to a restroom or having him face the side of a display cabinet may be adequate substitutes. If unavailable, then taking the child outside the building to face the front wall or returning to the car can be used for time out. When none of these locations seem appropriate, parents can be trained to use a delayed punishment contingency. In this case, the parent carries a small spiral notebook to the public place and, before entering the building, indicates that rule violations will be recorded in the book and the child will serve time out for them upon return home from this trip. This author encourages parents to keep a picture of the child sitting in time out at home with this notebook and to show it to the child before entering the public building. This serves as a reminder to the child of what may be in store should a rule be violated. Whenever time out is used in a public place, it need not be for as long an interval as at home. The author suggests that that half of the usual time out interval may be sufficient for public misbehavior given the richly reinforcing activities in public places from which the child has just been removed.
9. Improving Child School Behavior From Home
The Daily School Behavior Report Card: This session was designed to help parents assist their child’s teacher with the management of classroom behavior problems. The session focuses on training parents in the use of a home-based reward program. Children are evaluated on a daily school behavior report card by their teachers. This card serves as the means by which consequences later in the day will be dispensed at home for classroom conduct. The card can be designed to address class behavior, recess or free time behavior, or more specific behavioral or academic targets for any given child. The consequence provided at home typically consists of the rewarding or removal of tokens or points within the home token system as a function of the ratings the child has received from their teachers on this daily behavioral report card. To emphasize the importance of the school to home communication and to avoid escaping consequences if the child “loses” their school behavior report card, it is best to set up a contingency such that “no news is worse than bad news.” Thus, the most austere level in the contingency system should be when the card is incomplete or missing.
10. Managing Future Misconduct
By now, parents should have acquired an effective repertoire of child management techniques. The goal of this session is to get parents to think about how they might be implemented in the future if some other forms of noncompliance developed. The therapist challenges the parents with misbehaviors they have not seen yet and asks them to explain how they might use their recently acquired skills to manage these problems. Behavioral rehearsal (i.e., role plays) surrounding anticipated barriers to implementation of existing parenting plans or making modifications or innovations to deal with new and different behaviors are strongly recommended as a means to prepare for future misconduct.
In what is typically the final session, the concepts taught in earlier sessions are briefly reviewed, problems which have arisen in the last month are discussed, and plans made for their correction. Other sessions may be needed to deal with additional issues that persist but for most families, the previous 10 sessions appear adequate for improving rates of compliant behavior in ADHD children.
The program is intended for children ages 2 to 11 years where oppositional or defiant behavior is an issue. Studies examining the efficacy of this particular BPT with ADHD children have consistently reported significant improvements in child behavior as a function of the parents’ acquisition of these child management skills. Indeed, this was the program that was selected, and modified, for use in the large-scale NIMH Multimodal Treatment of ADHD study (see my other course, ADHD in Children: Diagnosis, Assessment and Management). Results suggest that up to 64 percent of families experience clinically significant change or recovery (normalization) of their child’s disruptive behavior as a consequence of this program. However, improvements in behavior may be more concentrated in the realm of aggressive and defiant child behavior than in inattentive-hyperactive symptoms. All of these studies have relied on clinic-referred families most of whom sought the assistance of mental health professionals for their children.
In contrast to the results of research with such motivated families, I and colleagues found that if such a clinic-based parent training program is offered to parents whose preschool children were identified at kindergarten enrollment as having significant levels of aggressive-hyperactive-impulsive behavior, most do not attend training or do not attend reliably and no treatment effect is evident. Moreover, no significant improvements in child behavior were found even among those who did attend at least some of the training sessions. Studies with disruptive children or those at high risk for externalizing behavior suggest that BPT may be more cost-effective, reach more severely disruptive children and more minority families, and possibly be more effective for them if they are provided as group training classes offered through neighborhood public schools in the evenings using para-professionals as trainers. This might prove to be the case for children specifically having ADHD as well.
Program Effectiveness and Predictors of BPT Success
The effectiveness of BPT declines with age of the child, such that it is most effective in early childhood (65%–75% positive response) and remains at that level through elementary school. But by 12–14 years of age, it declines to about a 25%–35% response rate. That is still better than traditional approaches to family therapy but is just a third of the response rate for young children. Such a fall-off in benefit is not unexpected when one considers that adolescents are psychologically and socially individuating from their parents, parental influence over them declines markedly, peer influence and other out-of-home effects become more prominent in their influence, and genetic differences in personality and especially psychopathology become more prominent as influences on family relationships and teen disruptive behavior.
What factors predict success in these programs?
Side Effects of BPT
When treatments are powerful enough to produce behavior change, it should be no surprise that they can have side effects. Yet even though warnings about their occurrence have been sounded for decades, they have received little notice in clinical practice. It is important, therefore, to be aware of the following sorts of adverse events, common to many psychosocial interventions, among others:
These and other adverse events (AEs) can occur during BPT (see Barkley, 2018, and Allan & Chacko, 2018, in References). Why? Some of these AEs arise due to variability in children’s psychological characteristics, comorbidity, etc., as well in parental fidelity in implementing the methods. Other AEs may arise from lack of clinician training in implementing these methods. About 10%–24% of parents may report a deterioration in the intended targets of treatment, such as a worsening of their child’s ODD symptoms or other conduct problems and of parent-child/teen conflict as a function of BPT. Some of these cases had quite severe ODD (or possibly DMDD) symptoms. Thus, instituting limit setting, discipline, or even contingent use of privileges was enough to spark greater conflict between parents and children or even an escalation to violence by the child. Other children may experience an increase in sadness or depression and decrease in self-worth especially during the use of disciplinary methods.
Care therefore needs to be taken to ask about such adverse events periodically during training and not just naively assume that there is never any worsening of parent-child relations from such programs. And perhaps if the child or teen is already noted to be physically violent, then alternative programs probably need to be used, such as that by Greene on collaborative problem solving. Or clinicians can at least implement only the positive reinforcement aspects of the BPT program.
This course has described the nature of oppositional defiant behavior and stressed the importance of focusing on it as the major target of any parent training program. The processes whereby children may develop, maintain, or increase their rate of oppositional, defiant, or noncompliant behavior were discussed in some detail, and it appears that such behavior is partly if not chiefly sustained by its success at family coercion – terminating parental demands and enabling the child to escape or avoid generally unpleasant, effortful, or boring tasks assigned by parents, while permitting the child to continue in a previous, more desirable activity. It was shown that parents may also come to escalate their own negative behavior toward the child because such behavior occasionally succeeds at terminating ongoing unpleasant child behavior, such as tantrums or defiance, and getting eventual child compliance. Both parents and children may be more predisposed toward such types of coercive behavior by virtue of their particular profile of temperamental patterns and psychological disorders. Larger contextual events such as stress, marital discord, parental social isolation, or events impacting the family from outside may serve to increase the probability of defiant child behavior by virtue of the toll these events take on the consistency of parental management of the child, the positive reinforcement of compliant child behavior, and the general monitoring of child activities by parents.
Specific instructions for how to implement the steps of the author’s parent training program can be found in the text, Defiant Children (Barkley, 2013). Assessment tools are provided in the book for clinicians to use in their treatment to monitor behavior of parents and assess progress. The manual also includes step-by-step instructions to clinicians on how to implement each step as well as parent handouts on the methods they have been instructed to use at each step.
Other parent training programs having some overlap with the author’s program would include Parent-Child Interaction Therapy by Shelia Eyberg, The Incredible Years by Carolyn Webster-Stratton, The Noncompliant Child by Robert McMahon and Rex Forehand, The Community Opportunities for Parent Education (COPE) program by Charles Cunningham, and the Triple P Positive Parenting Program by Matthew Sanders, among others. These are reasonable and scientifically validated alternatives. More about them can be found on the Internet at major online booksellers and by using Google Scholar as a search engine to explore scientific journal publications about them.
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