1. Oppositional Defiant Disorder: Empirically Supported Treatments Rachel J. Valleley, Ph.D. Assistant Professor Munroe-Meyer Institute Nebraska Medical Center

2. Oppositional Defiant Disorder  Enduring pattern of uncooperative, defiant, and hostile behavior toward authority figures that does not involve major antisocial violations.  Frequently gets confused with ADHD. Can have both.

3. Oppositional Defiant Disorder: DSM-IV Criteria  Loses temper  Argues with adults  Actively defiant or refuses to comply with adults’ requests or rules  Deliberately annoys people  Blames others for his or her mistakes or misbehavior  Touchy or easily annoyed by others  Angry and resentful  Spiteful or vindictive

4. Oppositional Defiant Disorder  Most common diagnosis given in our clinics in pediatric practices.  Often setting specific  Occurring more with parents or other caregiver  Difficulties with sleeping, eating, and toileting.  Increased risk for other problems  Coercive Family Process

5. Oppositional Defiant Disorder  Misconception that “He’ll grow out of it”.  Often leads to Conduct Disorders or antisocial personality disorder.  Effective early intervention leads to long- term positive outcomes  No medication that will effectively work

6. Oppositional Defiant Disorder In Short: Disruptive and defiant behaviors have paid off Disruptive and defiant behaviors have paid off Attention/ReactionAttention/Reaction Removal of demandRemoval of demand Often test limits Often test limits Have not learned prerequisite skill of complying to authority Have not learned prerequisite skill of complying to authority

7. Oppositional Defiant Disorder  Treatment: Parent Training: Forehand & McMahon Parent Training: Forehand & McMahon Parent-Child Interaction Therapy: Hembree- Kigin & McNeil Parent-Child Interaction Therapy: Hembree- Kigin & McNeil

8. Treatment for ODD: Parent Training 1. Encourage/increase appropriate behavior  Differential Attention  Child’s Game  Sticker Charts/Grab Bag Prizes

9. Treatment for ODD: Parent Training  Differential attention Attend to average behavior Attend to average behavior Praise exceptional behavior Praise exceptional behavior

10. Treatment for ODD: Parent Training  The Child’s Game: A relationship-building activity that makes children want to earn your POSITIVE attention.

11. Treatment for ODD: Parent Training  DO Describe Describe Reflect Reflect Imitate Imitate Praise Praise Touch Touch  DON’T Command Reprimand Question

12. Treatment for ODD: Parent Training  Sticker Charts/Grab Bag Prizes: Bedtime routine, morning routine Bedtime routine, morning routine Daily for overall behavior Daily for overall behavior Magic circle chart Magic circle chart Dot-to-dot’s Dot-to-dot’s Grab Bag Prizes Grab Bag Prizes

13. Treatment for ODD: Parent Training  Effective Commands: Simple Simple Direct Direct One at a time One at a time Start small Start small “Do” commands “Do” commands

14. Treatment for ODD: Parent Training  Bad Commands “Don’t jump on the bed” “Don’t jump on the bed” “Bring your shoes to the bedroom, put your clothes in the hamper, make your bed, and take all the dishes to the sink.” “Bring your shoes to the bedroom, put your clothes in the hamper, make your bed, and take all the dishes to the sink.” “Could you please turn off the T.V.” “Could you please turn off the T.V.” “Watch out” “Watch out” “I need you to pick up the toys because grandma is coming over.” “I need you to pick up the toys because grandma is coming over.”

15. Treatment for ODD: Parent Training 2. Decrease inappropriate behavior  Time out  Job Card Grounding

16. Treatment for ODD: Parent Training  What is time out? Time out is the removal of attention, tangibles, or anything interesting to the child for a brief amount of time. Time out is the removal of attention, tangibles, or anything interesting to the child for a brief amount of time.

17. Treatment for ODD: Parent Training  Misconceptions and mistakes with time out Not the chair Not the chair Have to sit quietly before time starts Have to sit quietly before time starts 1 minute per year 1 minute per year Think about what did wrong and feel sorry Think about what did wrong and feel sorry Talking to child in time out Talking to child in time out Not expecting extinction burst Not expecting extinction burst

18. Treatment for ODD: Parent Training  How to do Time Out: Stop talking once told “Time Out” Stop talking once told “Time Out” Get to chair/spot with minimal guidance Get to chair/spot with minimal guidance Do not attend to anything in time out Do not attend to anything in time out Stay close enough to monitor but be aloof Stay close enough to monitor but be aloof Child serves 2-3 minutes Child serves 2-3 minutes Let child out Let child out Follow up with expecting appropriate behavior Follow up with expecting appropriate behavior

19. Treatment for ODD: Parent Training  Common problems with Time Out My child won’t go/stay in time out My child won’t go/stay in time out My child does not seem to care that they are in time out My child does not seem to care that they are in time out My child will not be quiet in time out My child will not be quiet in time out My child won’t get out of time out My child won’t get out of time out

20. Treatment for ODD: Parent Training  Common uses for time-out Noncompliance Noncompliance Aggression Aggression Rule infractions Rule infractions Tantrums Tantrums

21. Treatment for ODD: Parent Training  Compliance training  Give command, wait 5-10 seconds. If comply, praise. If not comply, give time out warning. If comply, praise. If still does not comply, time out. After time out, go back to original command and repeat until followed.

22. Treatment for ODD: Parent Training  Time out for aggression and rule infractions Do not use warning Do not use warning Look for positive behavior immediately following time out to praise. Create contrast!! Look for positive behavior immediately following time out to praise. Create contrast!!

23. Treatment for ODD: Parent Training What is job card grounding?  Discipline program which requires children to earn their way off grounding, rather than simply waiting for time to pass.

24. Treatment for ODD: Parent Training  Common uses of job card grounding Arguing Arguing Noncompliance Noncompliance Rule infractions Rule infractions

25. Treatment for ODD: Parent Training  Set up for Job Card Grounding Develop house rules Develop house rules Do what you are toldDo what you are told Be respectfulBe respectful Develop list of jobs Develop list of jobs Develop list of rewards Develop list of rewards Set criteria for earning reward Set criteria for earning reward

26. Treatment for ODD: Parent Training  Rule infraction earns job card  Grounded from all privileges until job is complete  Once job is done, no more discussion of misbehavior  Reward for following rules

27. Treatment for ODD: Parent Training  Trouble Shooting Job Card Grounding What if child argues when given job card? What if child argues when given job card? What if grounding seems to be lasting an excessively long time? What if grounding seems to be lasting an excessively long time? What do you do regarding extracurricular activities? What do you do regarding extracurricular activities?

28. Summary of Treatment for ODD  Just as important to increase appropriate behaviors as it is to decrease inappropriate behaviors