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Program Written Summary
Audio-Digest Pediatrics
Volume 59, Issue 33
September 7, 2013

Contributing factors; Education of child and parent; Treatment of underlying conditions; Bypass strategies; Behavior modification for dysfunctional patterns; Indications for referral – Barbara J. Howard, MD
From The 186th Scientific Conference, Presented By The North Pacific Pediatric Society And Seattle Children’s Hospital
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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 2:
Steps in Management

From the 186th Scientific Conference, presented by the
North Pacific Pediatric Society 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 goals of this program are to improve the primary care management of oppositional behavior in preschoolage children. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize factors that may contribute to oppositional behavior in young children, including comorbid conditions (eg, attention-deficit/hyperactivity disorder).

2. Educate parents about effective ways to teach self-regulation skills to children with oppositional behavior.

3. Choose appropriate medical therapy for managing oppositional behavior.

4. Explain the importance of positive attention in parenting children with oppositional behavior.

5. Promote the effective use of timeout to manage 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 that is related to the off-label or investigational use of a therapy, product, or device.

Clarify meaning of problem: children may act badly for attention, or feelings of guilt about real or imagined offense; may misbehave only in emotionally conflicted relationships; ask patient who child “takes after” to elicit description of temperament and parental projections; ask, “how is it for you?” (to reveal, eg, parental despair, mood disorders, domestic violence), and “what do you think things will be like in 10 yr?”; emphasize keeping problem in perspective

Address need for state regulation: encourage parents to be responsive to child from early age; help them understand that child responding to environment; encourage routines, expression of affection, and positive attention for positive behaviors; ensure that meals and snacks provided regularly; teach parents to talk softly to their children; decrease television time; increase sleep time, if needed; watch out for exposure to sexually explicit media (eg, X-rated movies); have parent “drop in” at child care center to monitor quality; keep diary of stresses and effects; consider possibility of attention-deficit/hyperactivity disorder (ADHD)

Educate parent and child: if behavior only occurring with one parent, he or she may be source of pain for child (investigate and improve); suggest “special time” (10 min of undivided attention); if parenting style intrusive, consider “sportscasting” (parent “reports” on play without interfering with it); help parent to understand child’s individuality and avoid common triggers for conflict (eg, working with scissors); if school cannot accommodate child’s needs, consider transfer or homeschooling; if child feels guilty (or self-identifies as “bad person”) about, eg, troubles in family, state directly, “it is not your fault,” and coach parents to do same (if problem persists, consider child therapy)

Executive dysfunction in ADHD: signs include difficulty with judging and managing time, being organized, transitioning between tasks, and sustaining effort until job complete; executive functioning managed mostly by frontal lobes; clarify problem for parents; suggest that parent help child break task into smaller parts and aid in initiation of task

General principles for oppositional children: provide consistent structure to reduce anxiety by, eg, providing support, clear rules and discipline, and keeping schedule; model admitting mistakes and apologizing for them; teaching self-regulation skills — in “cool-off time,” child given time to calm herself away from activity and allowed to return whenever she feels ready (in contrast with timeout, in which duration set by parent); help parents look for triggers for anxiety; encourage talking, instead of acting on feelings, and finding ways to calm down; avoid overstimulation; provide outlets for energy; provide reinforcement for — any improvement in behavior; reminding self of good and bad consequences of behavior; learning to talk about complaints; finding acceptable ways to experience pleasure (for some children, being defiant and confrontational is exhilarating)

Treatment for underlying ADHD: according to American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry, behavior management should be primary and initial approach to ADHD in preschool children; components of behavior management — understand underlying weaknesses; establish environment for success; help child develop coping mechanisms (praise even small improvements); avoid negative generalizations and labels; consistent consequences for undesired behavior more necessary in youngest children (less so for older children); identify and promote strengths

Stimulant medication (Preschool ADHD Treatment Study [PATS]): start with low dose and increase slowly (window for effective dose small; exceeding effective dose can worsen behavior); methylphenidate (eg, Concerta, Metadate, Ritalin) and dextroamphetamine available as liquids (approved for children starting at 6 and 3 yr of age, respectively); speaker finds liquid methylphenidate less irritating; in study, dose of methylphenidate increased from 2.5 mg, to 5 mg, then to 7.5 mg, 3 times daily; reduction of symptoms significant; effect sizes smaller than for school-age children (only 21% normalized); at 10-mo follow-up, total dose 20 mg (in 3 doses); new formulation of methylphenidate (Quillivant XR) — fruit-flavored; long-acting

Side effects: more likely in preschool children than in older children; decreased appetite — consider fourth meal at bedtime; abdominal pain — uncommon; disappears in 3 wk; rule out constipation; headaches — also abate within 3 wk; consider 7 days/wk dosing, instead of 5 days/wk, to avoid fluctuations; growth reduction — small even when high doses given long-term (ie, 1 cm in adult height, 2 lb in adult weight); tics — mostly comorbid or transient; in some children, stimulant medication decreases tics; if problem persists, try lower dose; irritability — less common with methylphenidate than with dextroamphetamine (if significant, consider another first-line medication; dexmethylphenidate [Focalin] has fewer side effects overall than methylphenidate, but comes as sprinkle, rather than liquid)

More about medication: no medication approved for managing oppositional defiant disorder (ODD) without ADHD in children (consider consultation for off-label use of medication); α-agonists — include guanfacine (Tenex, Intuniv); latter long-acting, but dose difficult to modulate; long-acting clonidine (Kapvay) delivered through patch that can be cut into pieces; α-agonists safe for use in primary care, but can affect heart function and blood pressure; risperidone (Risperdal) — atypical antipsychotic medication; reduces symptoms of ODD; approved for managing autism spectrum disorders (ASD), but side-effect profile very worrisome (includes, eg, significant weight gain, diabetes, neuroleptic malignant syndrome); anticonvulsants — include carbamazepine (eg, Carbatrol, Epitol, Tegretol); antidepressants — only fluoxetine (Prozac, Rapiflux, Sarafem) approved for use in young children; available as liquid; can worsen symptoms

Treat underlying developmental differences: “if they can’t do it, they won’t do it” (inability of young children to perform tasks may be expressed as unwillingness); 504 plan — all children with health impairment diagnosed by physician eligible; physician can suggest accommodations (eg, lower level or volume of work, grouping with younger children) without doing psychologic testing; speech and language disorders — most common developmental disabilities in children, and most treatable (refer for evaluation and treatment); while skills developing, children need to be shown, not just told, how to complete tasks, and should be given alternative ways to present their ideas (eg, pictures, drawings); social learning disability — teach in small groups or group with favorite peers; for ASD, provide social skills training and/or applied behavior analysis (ABA); build alternative strengths

Techniques to achieve increased compliance: increase positive attention to positive behavior; giving marks — for each positive behavior, take child’s hand, make eye contact, thank him for specified behavior, then place small mark on back of hand with pen (aim for 6-10 marks per hour); child receives prize for “bunch” of marks (reward always given); reducing distractionseg, turn off television before giving instruction; giving effective commands — watch for natural pause in child’s activity, get her attention, and maintain focus on child; components of effective command (eg, “I want you to pick up the book now”); then, keep eye contact, but stop talking (“act don’t yak”); “make one request, then move” (grasp child while you and/or she completes task); counsel parents to reduce overall number of requests; start by requesting action that child already wants to do; deal with behavior without interference from another adult (“whoever starts, finishes”); discuss any disagreement later (outside of child’s presence); implement timeout for noncompliance, but child must comply afterward; practice at home first, next in public place with low risk (eg, fast-food restaurant across town)

More on positive attention: special time — undivided attention for 10 to 15 min/day; echoing — teaches children vocabulary for feelings; eg, “I hear you saying _____,” or “you seem to feel _____”; match body posture, tone, and speed of child’s expression; “lightening up” — also referred to as jollying or distracting; provides people with welcome assistance in modifying their moods and responses, and teaches children use of humor; redirection allows child to “save face,” avoids unnecessary confrontations, and conveys lack of hostility from parent; it provides practice for children in calming themselves, and alternative strategy for managing feeling of upset

Setting limits: why parents fail to set limits — too busy; fear of child’s reaction; they feel it places hardship on “special” child; reacting to overly strict limits set by their own parents, or by spouse; setting limit fulfills need (kids push until limit set); principles of limit setting — “pick your fights” (prioritize issues and let go of small matters, especially at first); have all caregivers be consistent (if possible); be flexible to meet needs of “special occasion” before child demands it

More techniques for promoting compliance: “broken record” — for older children; repeat request exactly same way each time (do not add extra information); may be combined with incremental consequences for delays in performance; “beat the clock” — for habitual dawdling, set timer for reasonable period; give no reminders; if task done by time runs out, give reward

Timeout explained: use for no more than 2 to 3 behaviors at one time; works best for correcting dangerous or destructive behaviors that occur at low rate, and are maintained by parental attention; practice before first real use; can be implemented as early as 9 mo of age; give only one warning (no warnings for aggressive behavior); briefly state offense (6 words); put child in uninteresting (not scary) place; use 1 min/yr of age (15 sec shown to be effective); end timeout when child shows evidence of “giving in”; afterward, distract with new activity and do not discuss incident further; praise positive or neutral behavior; if child leaves timeout without permission, restrain (eg, on parent’s lap) or use barrier; barriers to success — excessive use (>1 time/day); continued interaction with child; child too strong to restrain, or location frightening; not enough positive reinforcement

Triage for oppositional behaviors (from R. Greene): A) emergency (needs enforcement); B) important (parent chooses to teach, role play, and/or modify task to match child’s abilities); C) optional (just “drop it”)

Family meetings: discuss family activities and problems; express appreciation for one another; implement solutions that can be tried for 2 to 3 wk (discuss results at later meeting)

Making successful referrals: develop your own formulation of issues; involve all relevant people in referral, if possible, and identify individual concerns; give hope; demystify counseling (liken it to techniques already initiated; emphasize your continuing support); identify appropriate resources; maintain contact with family and therapist

Prognosis of oppositional defiant disorder: if untreated, patterns of oppositional interaction at home generalize to all authority relationships; early aggression has correlation of 0.68 with later expression of behavior disorders; 80% of children with untreated ODD develop conduct disorder (key predictors include spiteful or vindictive behavior); 40% of sociopathic adults displayed behaviors at <8 yr of age

Questions and answers: period immediately following timeout — based on literature, speaker recommends no immediate discussion of transgression; redirect, and be silent or find positive behavior to praise; apologies not recommended because children generally not truly regretful (ie, insisting on apology forces child to lie); adults should model appropriate apologies; discuss or use role playing to address behavior at later point in time (children too fragile in immediate post-timeout period); reassure parents that repeat of behavior does not indicate failure of timeout; parents who lay blame for divorce on child — be sympathetic to parent, but advise him or her that child fares better in long term when not carrying burden of guilt; children treated with overall meanness by parent benefit from long-term interaction with caring individual who models appropriate behavior


Dr. Howard was recorded at the North Pacific Pediatric 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 held April 25-27, 2014, in Redmond, WA, please visit The Audio-Digest Foundation thanks Dr. Howard and the sponsors for their cooperation in the production of this program.

Suggested Reading

Emond SK et al: Management strategies for attention-deficit/hyperactivity disorder: a regional deliberation on the evidence. Postgrad Med 124:58, 2012; McBurnett K, Pfiffner LJ: Treatment of aggressive ADHD in children and adolescents: conceptualization and treatment of comorbid behavior disorders. Postgrad Med 121:158, 2009; McMenamy J et al: Early intervention in pediatrics offices for emerging disruptive behavior in toddlers. J Pediatr Health Care 25:77, 2011; Owens JS et al: Incremental benefits of a daily report card intervention over time for youth with disruptive behavior. Behav Ther 43:848, 2012; Riddle MA et al: The Preschool Attention-Deficit Hyperactivity Treatment Study (PATS) 6-year follow-up. J Am Acad Child Adolesc Psychiatry 52:264, 2013; Ross WJ et al: Pediatrician-psychiatrist collaboration to care for children with attention deficit hyperactivity disorder. Clin Pediatr (Phila) 50:37, 2011; Salmon M: Paying attention to ADHD. Ment Health Today Nov-Dec:8, 2012; Sonuga-Barke EJ et al: Nonpharmacologic interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. Am J Psychiatry 170:275, 2013.

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