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Editorials for Clinical Practice


CHADIS Co-Director and President, Dr. Barbara Howard is a regular contributor to the Behavioral Consult column of Pediatric News and an Assistant Professor of Pediatrics at The Johns Hopkins University School of Medicine.


Dr. Howard is a developmental-behavioral pediatrician trained by Dr. T. Berry Brazelton at Harvard University. She is a national speaker on child behavior problems and is a past president of the Society for Developmental and Behavioral Pediatrics. She was a contributing author for Bright Futures™, Diagnostic and Statistical Manual for Primary Care (DSM-PC) and Bright Futures in Practice: Mental Health and has served on national committees of the American Academy of Pediatrics.

Barbara Howard, MD

When to Refer Oppositional Defiant Disorder

LAS VEGAS — Opposition and aggression are part of normal childhood development, but if they are developmentally inappropriate and last long periods of time, they can have serious consequences and may require a referral.


Oppositional defiant disorder (ODD) is a condition occurring in 2%–16% of children. Pediatricians have heard the parental complaints about the oppositional child: The child won't listen, won't obey, and does exactly the opposite of what is asked.


“Sixty percent of the time, preschoolers will do what the parents ask,” said Barbara Howard, M.D., a behavioral pediatrician at Johns Hopkins University, Baltimore. “But the oppositional child will only do what the parent asks about 30% of the time.”


“Pediatricians need to figure out the meaning of the behavior by eliciting specific examples from the parents,” Dr. Howard said at a meeting sponsored by the American Academy of Pediatrics and California Chapter 2 of the AAP.


Remember that ODD begins at home; just because the child is doing okay at school doesn't mean the child does not have ODD, she said.


The condition is defined as developmentally inappropriate hostile or defiant behavior that lasts for more than 6 months. It is characterized by the child's losing his or her temper, arguing with adults, and actively defying compliance with requests. The child deliberately annoys people and blames others for his or her mistakes. He or she often is angry, resentful, and vindictive.

The actions of the oppositional child may be a part of normal development, the result of inappropriate expectations by the parents, sleep deprivation, a stressful environment, attention-deficit hyperactivity disorder, traumatic life events, mood disorders, overly harsh discipline, or overly lax discipline, Dr. Howard said.


Take a detailed history, realizing that aggression and opposition can be a part of normal development, especially in children 18–36 months of age, she said.


Elicit specific examples of what was going on prior to the behavior, the actual behavior, and what resulted for the child and parents. Ask about the frequency, intensity and to what extent the behavior interferes with school and home life.


Then look for health, emotional or learning problems, school attainments, mood disorders, attention-deficit disorders or learning disorders, Dr. Howard said.


“It may be simply that the child is acting badly to elicit negative response due to inadequate attention,” she said. “The doctor needs to question the child about the behavior as well.”

“Remember that young children may not report sadness,” she said. “The normal predominant child mood is cheerful. Depression may present as hyperactivity or irritability.”


But rapid mood swings may be bipolar depression; when an older child has such mood swings, also consider substance abuse, she said.


Explore the manner in which parents discipline the child, then offer advice on adjustments that may improve the child's behavior.


Often parents need to learn the principles of limit setting, she said. “They need to make one request, then move. All the caregivers need to be consistent and need to be flexible to meet the needs of a special occasion.”


“Parents need to respond to aggression promptly as well as giving adequate positive attention to the child,” she said.


Remember that 40% of severe aggression in adults started before they were 8 years of age, she said. “The patterns of interaction start at home then generalize to all authority relationships if untreated or reinforced.”


If the child continues to be entrenched in this behavior, then refer the child for psychological help, she said.


“Early aggression correlates almost 70% of the time with later behavior disorders,” Dr. Howard said.


Dr. Howard’s contribution to this publication is as a paid expert to Frontline Medical Communications. E-mail her at

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