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Program Written Summary
Audio-Digest Pediatrics
Volume 59, Issue 31
August 21, 2013

Diagnostic criteria; Differential diagnosis; Comorbid conditions; Interviewing strategies; Standardized assessment tools – Barbara J. Howard, MD
From The North Pacific Pediatric Society 186th Scientific Conference, Presented By The Npps And Seattle Children’s Hospital
Digital Media $24.99
Audio CD $27.99

The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program.

Pediatrics Program Info  Accreditation InfoCultural & Linguistic Competency Resources

 Oppositional Behavior in Preschool-Age Children, Part 1: 

Diagnostic Tools and Techniques

From the North Pacific Pediatric Society 186th Scientific Conference, presented by the NPPS and Seattle Children’s Hospital

Barbara J. Howard, MD, Assistant Professor of Pediatrics, the Johns Hopkins University School of Medicine, and Developmental-Behavioral Pediatrician, Baltimore, MD; Senior Scientist, Medstar Health Research Institute, Hyattsville, MD

Educational Objectives

The goal of this program is to improve the diagnosis of oppositional behavior in preschool-age children. After hearing and assimilating this program, the clinician will be better able to:

1. Describe the differential diagnosis of oppositional behavior.

2. Identify signs and symptoms of oppositional defiant disorder.

3. Recognize signs and symptoms of comorbid conditions that may be contributing to oppositional behavior, including attention-deficit/hyperactivity disorder.

4. Choose appropriate questionnaires and interviewing techniques to elicit relevant family dynamics surrounding oppositional behavior.

5. Counsel parents on initial management of oppositional behavior.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Howard is president of Total Child Health, Inc. The planning committee reported nothing to disclose. In her lecture, Dr. Howard presents information related to the off-label or investigational use of a therapy, product, or device.

Overview of normal development: children need to learn how to be assertive without being aggressive; oppositional behavior problematic only when it causes significant dysfunction

Oppositional defiant disorder (ODD): occurs in 2% to 16% of children; problem more common in boys until puberty; usual onset <8 yr of age; definition of ODD (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Primary Care Version [DSM-IV-PC]) — “persistent pattern of angry and irritable mood, with defiant and vindictive behavior, as evidenced by 4 or more symptoms displayed with 1 person other than sibling”; mood — losing temper; “touchy” or easily annoyed by others; angry and resentful; behaviors — headstrong (arguing with adults, actively defying or refusing to comply); deliberately annoying or blaming others; spiteful or vindictive 2 times in last 6 mo (of prognostic features, vindictiveness most worrisome); DSM-5 — children of mental age <5 yr must have symptoms most days for 6 mo; sex and culture relevant (“some cultures expect [and experience] better behavior”); diagnosis requires clinically significant impairment in only one setting (social, educational, or vocational)

Anger and aggression: anger defined as strong feeling of displeasure or hostility (aggression requires intrusive actions or acts intended to hurt others); frustration-aggression hypothesis — frustration and helplessness lead to anger and aggression; children who fail to master early regulatory tasks, including ability to manage angry emotions, more likely to develop conduct, social, and academic problems; epidemiology — 15% to 30% of preschool children have significant behavior problems (usually significant because of aggression); normally, aggression peaks before mental age of 3 yr (unmitigated aggression at >3 yr of age important sign that child not developing normal ability to manage emotions); predisposing factors — environment of anger; painful feelings; thwarting of needs

Environment of anger: angry child often product of angry parents; sources of parental stress include poverty, housing problems, immigration, legal struggles, discrimination, lack of social support, marital discord, domestic or neighborhood violence; 30% to 50% of mothers of children <5 yr of age have significant symptoms of depression or other mental health problem (eg, attention-deficit/hyperactivity disorder [ADHD]); health problems; substance abuse (6% of children have 1 alcoholic parent); exhaustion or lack of sleep; struggling parent may not be able to respond to suggestions for dealing with child’s behavior

Sources of painful feelings in child: physical pain; hunger; fatigue; side effects of medication; failure to “master one’s world” leads to low self-esteem and anger; child who does not manage well socially may feel lonely or isolated; anxiety about situations over which child has no control; sensory overload; not feeling supported by parent; children of any age can have depression; in United States, 8% of children undernourished; sources of physical pain — sickle cell disease; arthritis; eczema; inflammatory bowel disease; celiac disease; constipation; head injuries and/or chronic headache; child abuse; adverse effects of physical punishment — if parents acting impulsively, punishment poorly modulated and delivered inconsistently; disrespectful to child and lowers self-esteem; increases aggression through modeling and raised tension; tends to replace other forms of management; not useful in older children (generates fear and anger, and inhibits more positive behaviors); long-term use associated with — higher rates of depression; alcoholism; drug abuse; lower school and job achievement; less stable marriages; increased spousal and child abuse

Needs of children: need for state regulation, mastery, positive emotional tone, and assistance with regulating negative affect; need to be taught prosocial behavior; need for fair treatment

Types of dysfunctional parenting (from Zero to Three National Center): overregulation; underregulation; inappropriate regulation (eg, using recommended techniques, but with wrong age group); chaotic regulation; affective mismatch

Underregulation: no efforts made to correct misbehavior; parent may be distracted or inattentive to child’s needs; parents who work long hours may feel guilty and become permissive (some parents “just too relaxed”); “vulnerable child syndrome” (if child born with special needs, parent may respond by setting fewer limits); some parents consciously avoid harsh parenting suffered during their own childhood, but have no alternative models for day-to-day parenting; parent may be depressed, intoxicated, or distracted by marital discord

Overregulation: sources — parents anxious or have high performance standards; cultural standard; vulnerable child; signs — constant negative attention for even minor behaviors; ignoring positive behavior; corporal punishment; adverse effects — excessively harsh parenting associated with development of conduct disorder; anger or opposition; low self-esteem

Need for state regulation: eg, awake vs asleep, aroused vs calm; routines (for, eg, getting up, having breakfast, going to bed) and consistent responsiveness from parent stabilize mood and reduce resistance to required behaviors; avoiding overstimulation (noise levels in home directly correlated with misbehavior, and inversely correlated with language development); parental risk factors — allowing child to stay up until he or she falls asleep; exposure to sexually explicit or overstimulating media; child risk factors — due to temperament, child may be irregular in habits or inadaptable; neurologic damage due to lead poisoning, prenatal substance exposure, or neurologic difference; 60% of children with ODD have ADHD; other risk factors — families in social chaos or “too busy”; caregivers with poor communication skills; medication used for ADHD may make matters worse

Oppositional behavior and ADHD: most children with ADHD diagnosable at 3 to 4 yr of age; American Academy of Pediatrics — ADHD treatable in primary care from age of 4 yr; DSM-V — symptoms must appear by 12 yr of age; controversy — at 3 yr of age, most typical children have symptoms of ADHD; preschoolers more sensitive to environment (eg, tension in household) than older children (10-yr-old more able to rationalize it); diagnostic caveats for preschoolers — symptoms must be present for 9 mo, with dysfunction in home and 1 other setting; consider medication if dysfunction has not responded adequately to behavioral therapy; Preschool ADHD Treatment Study (PATS) — of 300 preschoolers with moderate to severe ADHD, 70% had comorbid disorders; Harvard study — 86% of children seeking psychiatric care had ADHD; symptoms more likely to persist with onset earlier in life and family history of ADHD; the more comorbidities present, the less likely that ADHD will respond to medication

Need for mastery: children need opportunity to exercise abilities; thwarting of needs can be source of frustration, anger, and oppositional behavior; 10% to 15% of children not adapted to current day care (child may express “bad day” at day care by acting up at home); parent may be overly strict, overprotective, or inconsistent in setting adequate limits (so child not helped with mastery); when child defiant, consider whether child will not vs cannot comply (due to, eg, developmental delay); consider use of standardized screening tests to detect autism, low cognitive functioning or learning disabilities, speech and language delays, or trouble with social learning (sensory factors may play role); good quality day care provides adequate number of caregivers, positive attention for positive behaviors, anticipation of misbehavior and redirection, adequately stimulating curriculum, space and toys for small-group play, and nonphysical discipline; parents can monitor quality of care by making unscheduled visit

Need for positive emotional tone: positive tone and stable attachments promote resilience under stress; hostility in family raises tension for child, models aggression, and can induce fear, suspicion, and depression; hostile bias attribution — anxious children overinfer negative thoughts of others, which may lead to bullying (thinking someone “is out to get you” makes you more likely to strike first); may be caused by insecure attachment relationship with parent (ie, child more anxious about whether people have good intent); can be addressed with cognitive behavioral therapy (ie, identifying and counteracting negative thoughts); traumatic life events — much television programming too stressful for young children; if parent dies, or gets divorced, children (even those 3 or 4 yr of age) may think they caused it and deserve to be punished; if onset of oppositional behavior sudden, consider possibility of child abuse; criticize behavior, not child; offer specific language for parents to use

Need for assistance regulating negative affect: help with regulation of emotion occurs through jollying, distracting, modeling, acknowledging and verbalizing feelings of upset, and compromising; when parents cannot tolerate negative feelings, they may covertly encourage negative behavior through passive acceptance or attribution to, eg, other parent (to elicit this, ask “who does child take after?”); parent may need to separate from prejudice against child to improve management

Need to be taught prosocial behavior and empathy: empathy partly inherent, but partly taught through interaction with parents and teachers; social skills include trading, taking turns, waiting, asking for things, taking other’s point of view, seeing effects of own actions, thanking, recognizing feelings of others; obstacles — large family size; low income; single parenthood

Need for fair treatment: children sensitive to whether treatment “fair”, especially compared with that received by siblings

Parenting assessment: ask for specific examples of oppositional behavior (listen for family dynamics); “ABCs of parenting” — Antecedents (setting, events); Behavior (what did child do?); Consequence (result for child and parent); eating, sleeping, toileting — ask parent, “tell me about a typical day, starting when she gets up,” or “how are meals?”; meals and bedtime need structure, whereas toileting and eating need freedom (responses indicate whether parent over- or underregulating); child derives emotional security from parent (look for failure to provide that); “how does she do when she has to leave for school?”; “how does he do with friends?”; lack of sleep — destabilizes frontal lobes, which govern executive functioning and mood regulation; 40% of parents can solve sleep problems by using sleep diary; preschooler 4 to 6 yr of age needs 10.75 to 11.5 hr/day (note duration of naps); consider possibility of obstructive sleep apnea; sleep problem good starting point (families highly motivated to improve it); history — get child’s input first (he or she may be inhibited after negative comments from parent)

Physical examination: rule out neurocognitive problems; look for signs of physical abuse (eg, anxiety, refusal to be examined); vision and hearing assessment

Standardized developmental screening tools: Child Behavior Checklist (CBCL) applicable from 18 mo of age; validated screening tools for ADHD in younger children lacking (consider Vanderbilt ADHD Rating Scale)

Laboratory studies: probably not indicated, but consider possibility of lead poisoning, anemia, or other medical problem (eg, sleep study may be indicated)

Steps in management: observe parent and child during visit; form hypothesis about main cause of problem; educate family and propose trial intervention

Speaker’s experience: in children 3 to 6 yr of age, inappropriate expectations and management (often combined with difficult temperament, sleep deprivation, stressful environment, or ADHD) most common reason for oppositional defiant behavior; hearing problems not common source (but consider possibility of chronic serous otitis media); posttraumatic stress disorder or mood disorders also less common; according to PATS, language problems fairly common; low cognitive functioning or learning disability, regulatory problems, and autism all part of differential diagnosis; mood and irritability of celiac disease can precede weight loss or bowel changes

Taking history from child: ask about best friend, and about who lives at home; ask about easiest member of family first (may be youngest child, even family pet); progress to questions about more difficult members; specific questions — “what do your parents do if you do something bad?”; “is there anything bad or scary that has happened to you?”

Family history: find out composition of family; ask about emotional or learning problems, and educational and vocational attainments of relatives (looking for, eg, ADHD, mood problems, juvenile delinquency); specific questions for parents — ask, “what is the hardest part of parenting right now for you?”; “do you agree with your partner on discipline?”; ask about social support (“who can you count on when you need support?”); “how’s your marriage?”; finally, “who does she take after?”

Initial management: formulate hypothesis and negotiate plan with family; ask, “is it okay for us to talk about the methods of discipline that you’re using?” and “would you be interested in some other ideas about it?” (parents more willing to listen if asked permission first)

Follow-up: speaker gives parent small “homework” assignment; if parent seems overwhelmed by circumstances, ask, “what can you do for yourself?” or “what can you do to change how you’re feeling?” (eg, get more sleep); then have parent return to talk (parent feels understood; puts conversation on better footing); if assignment given, record it in chart (at next visit, ask about results); if successful, offer praise; if not successful — remember, “failure is telling of success”; discuss “where did it go wrong?” and “what kinds of problems did you have implementing this?” (answers offer new depth of information); summary — children who feel more loved, accepted, and competent are less angry

More about standardized developmental assessment tools: Ages and Stages Questionnaire: Social Emotional (ASQ:S-E) — extensive; looks at regulatory, hyperactivity, and compliance issues in children 6 mo to 5.5 yr of age; CBCL — applicable from 18 mo of age; Child Health and Development Interactive System (CHADIS) — includes diagnostic criteria for children 0 to 3 yr of age; Eyberg Child Behavior Inventory — starts at 2 yr of age; Behavior Assessment System for Children (BASC) — starts at 2.5 yr of age; Pediatric Symptom Checklist — not intended for young children, but Preschool Pediatric Symptom Checklist (coauthored by Perrin) being tested; Strengths and Difficulties Questionnaire (SDQ) — starts at 4 yr of age


Dr. Howard was recorded at the North Pacific Society 186th Scientific Conference, presented April 26-29, 2013, in Portland, OR, by the North Pacific Pediatric Society and Seattle Children’s Hospital. To attend the NPPS 188th Scientific Conference, to be presented April 25-27, 2014, in Redmond, WA, please visit The Audio-Digest Foundation thanks Dr. Howard, the North Pacific Pediatric Society, and Seattle Children’s Hospital for their cooperation in the production of this program.

Reproduction of this summary in whole or in part in any form or medium without express written permission is prohibited.