This programme is a treatment manual written for mental health professionals. It assumes clinical training, experience of working with children and families, and access to supervision. It replaces neither your clinical judgement nor your professional responsibility. The diagnostic criteria here are reformulated in our own words and never reproduced: consult the original manuals for the letter of the text.
1. The programme at a glance
Indication. Oppositional defiant disorder in children aged 6 to 12: angry and irritable mood, argumentative and defiant behaviour, sometimes vindictiveness, present for at least six months, more frequent than expected for the age, and affecting family, school or peers.
Reference model. Parent management training, recommended first line in pre-adolescent children by the British guidance (National Institute for Health and Care Excellence, 2013, updated 2017) and by most syntheses. It rests on Patterson's coercive model, on functional analysis of behaviour, and on the evaluated protocols of Forehand and McMahon, of Barkley, of Webster-Stratton, of Eyberg and of Kazdin.
Format. Twelve sessions with the parents, of 50 minutes, weekly then spaced out; six sessions with the child, interleaved from the sixth parent session onwards; two booster sessions at one month and then at three months. Twelve parent sessions is the upper end of the evaluated dose: the trials use eight to sixteen sessions, and what counts is not their number but the amount of practice actually done in session.
Mechanism targeted. Not obedience, but four changes: bringing the family out of the coercive cycle, making parental attention contingent on the wanted behaviour rather than the troublesome one, making instructions predictable and executable, and giving the child back a place where they obtain something other than through conflict.
| Session |
Object |
Product of the session |
| P1 |
Gathering, differential, screening for violence |
Functional analysis begun |
| P2 |
The coercive cycle, and special time |
Special time set up |
| P3 |
Differential attention |
Three behaviours to spot |
| P4 |
Effective instructions |
Instructions rewritten and practised |
| P5 |
Predictable consequences |
Two consequences chosen |
| P6 |
Withdrawal of attention and time-out |
Procedure written and rehearsed |
| P7 |
The points chart |
Chart built with the child |
| P8 |
High-risk moments |
One moment handled end to end |
| P9 |
Outside, and in front of others |
Written outing plan |
| P10 |
Siblings and the parental couple |
Written parental agreement |
| P11 |
School |
Liaison sheet in place |
| P12 |
Review, plan, relapse prevention |
Plan written by the parents |
What the family takes away. Seven printable worksheets, listed in section 37 and downloadable from this page: my record, our special time, what I notice, my instructions, what follows, the points chart, our plan.
What distinguishes this programme from general parenting guidance. Advice on child-rearing does not shift an established oppositional disorder: it is structured training, practice in session with one's own child, and the numbered record between sessions that produce the effect. A programme limited to explaining to parents what they ought to do is a pleasant consultation with no result.
2. Before you begin
Who this programme is for
This text is written for psychologists, psychiatrists, child psychiatrists, psychotherapists, specialist nurses and doctors trained in cognitive behavioural therapy with children. It assumes that you can conduct a diagnostic interview with a child and their parents, that you know the developmental presentations that must be ruled out, and that you can recognise and report a situation of danger.
It is not written for parents. It contains the procedures, the thresholds, the criteria for non-response and the precautions, and a parent would mostly read in it a list of things they do not do — which is exactly the opposite of the effect sought in session.
The prior question: is this really oppositional defiant disorder?
This is the most important decision in this manual, and it is taken in session P1.
This programme treats oppositional defiant disorder, that is, a lasting pattern of tantrums, refusals and provocations that goes beyond what is expected for the age and that affects the child's life.
It does not treat age-appropriate opposition. A six-year-old who argues, tests and refuses at times is doing the work of a six-year-old. Section 3 gives the landmarks, and it is not a preamble: it is a sorting tool.
It does not treat situated opposition. A child who is oppositional only at school, or only with one adult, or only over homework, should prompt a search for something else: a learning disorder, a specific conflict, bullying, a particular relationship. Oppositional disorder is rarely confined to a single context, but when it is, that points somewhere.
It does not treat the four presentations that must be ruled out first: attention deficit hyperactivity disorder, language disorder, autism spectrum disorder, and the consequences of a context of maltreatment or violence. These four are frequent, present with the same complaint, and three of them get worse if a discipline programme is applied to them unrecognised. Sections 8 and 9 are devoted to them, and they are not optional.
It does not treat established conduct disorder. Theft, cruelty, fire-setting, serious assault, repeated running away: the picture changes, the prognosis changes, and management goes beyond this manual. See section 8.
What this programme is not
It is not a method for obedience. The objective is not a child who obeys everything, it is a family that comes out of a way of working in which each person gets what they want by going higher than the other.
It is not a therapy of the child alone. In pre-adolescent children, parent-centred programmes do better than those centred on the child alone, and the combination does a little better still. Six sessions with the child are included here, and they come afterwards.
It is not a drug treatment, and it does not call for one. There is no medication for oppositional defiant disorder: see section 35.
It is not work on the parents' past. Their history counts, it often explains their reactions, and it may justify work of its own — but it is not the lever of this programme, and installing it here costs the child time.
How to use it
Read the whole before the first session, in particular sections 5, 9, 30 and 31: the coercive cycle, screening for violence, the conduct of in-session practice, and the conduct of time-out. These are the four places where things go wrong.
Each session is described according to the same frame: the objective, the step-by-step run-through, what you say, the frequent errors, and the criterion for moving on.
A warning specific to this treatment. Behaviours often get worse for one to two weeks when parents stop giving in: that is the extinction burst, it is expected, and it makes families give up when they have not seen it coming. Warning them is not a courtesy here, it is a component of the treatment.
3. What is normal, by age
The first task is not to treat, it is to know whether to treat. Tantrums, refusals and negotiation belong to development, and a proportion of consultations for opposition concern children who are fine and parents who are exhausted.
From three to five years
Tantrums are frequent, daily in many children, and they last a few minutes. Refusal is massive and barely argued. The child tests limits repetitively, because that is how they learn where they are.
What is not age-appropriate: tantrums lasting more than twenty minutes, several times a day, with destruction or assault, or a child who never settles.
From six to eight years
The frequency of tantrums drops markedly. The child argues more, reasons, finds the loophole — and that is cognitive progress, not deterioration. They contest rules they judge unfair, especially between siblings.
What is not age-appropriate: daily tantrums that do not give way, systematic refusal of ordinary requests, physical aggression towards adults, or a child who seems to seek out conflict.
From nine to twelve years
Opposition becomes verbal and selective: it targets one parent rather than the other, particular areas, particular moments. The child can negotiate and tolerates refusal better. Provocations exist, and they are often tests of the adult's consistency.
What is not age-appropriate: lasting resentment, the repeated search for someone else's fault, revenge, assault, and the constant idea of being treated unfairly.
The four questions that sort things out
Frequency. How many times a day, how many days a week? A disorder is counted, not recounted.
Intensity and duration. How long does a tantrum last, and how does it end? Is there damage, are there blows, are there injuries?
The number of contexts. At home, at school, at other people's homes, in activities? A behaviour present everywhere does not have the same meaning as a behaviour present in a single place.
The impact. Does the child have friends? Are they excluded from activities? Does the family turn down invitations? Do the parents argue about it? Is someone suffering — and who?
What the answer changes
Three outcomes, and you must choose in session P1.
Age-appropriate opposition, in an exhausted family. Two to four guidance sessions are often enough: explain, reassure, adjust two or three things, and review. Launching twelve sessions here would be an error — it turns an ordinary child into a problem child.
A characterised oppositional disorder. The programme starts.
Something else in the foreground. See sections 8 and 9.
4. The clinical picture
What the parents describe
They describe a day. Waking, dressing, breakfast, leaving the house, and already three conflicts. Then coming back from school, homework, the screen, the meal, bedtime. They say "everything is a battle", and it is often literally true.
They also describe what surprises them: the child is charming with other people, the school reports nothing, the grandmother has no trouble at all. This discordance makes them doubt themselves, and it is the first thing to explain — see section 5.
The phrases that recur: "he does it on purpose", "he knows perfectly well what he is doing", "with me it is worse than with his father", "I have no patience left", and "I cannot stand him any more" — this last one said with shame, and to be received without comment.
What the child says
Little, often. And when they speak, they describe an injustice: they are always the one blamed, their brother is never punished, their parents shout all the time. They almost never describe themselves as oppositional; they describe themselves as reacting.
This must be heard seriously, for two reasons. The first is clinical: their description of how it unfolds is often accurate, and it informs the functional analysis. The second is strategic: a child who thinks they are being brought in to be corrected will not take part.
The three dimensions of the disorder
Angry and irritable mood. The child gets cross quickly, is touchy, is easily annoyed. This is the dimension most linked to progression towards anxiety and depression, and it is the one that gets underestimated when you look at behaviour.
Argumentative and defiant behaviour. Argues with adults, refuses to comply, deliberately annoys, blames others for their own mistakes. This is the most visible dimension and the one most linked to progression towards conduct disorder.
Vindictiveness. Resentment, revenge. Rare but informative, and often linked to severity.
These three dimensions do not predict the same thing. Note them separately.
Where the disorder shows itself
The important point: severity is measured by the number of contexts. A child who is oppositional only at home calls for family work. A child who is oppositional at home and at school has a heavier picture and a poorer prognosis. A child who is oppositional everywhere and with everyone calls for broader management.
And a remark to make to the parents: that the child behaves elsewhere is not proof that they could behave at home. It means the contingencies are not the same, and that is precisely what is going to be changed.
What maintains the disorder
This is the heart of the model, and it is what the treatment attacks. Five mechanisms, all of them accessible.
The coercive cycle. Described in the next section. It is the main mechanism.
Parental attention become contingent on the problem. Troublesome behaviour obtains immediate attention; ordinary behaviour obtains none. A child who receives thirty interactions a day of which twenty-eight are reproaches learns very well where to find the adult.
Instructions impossible to follow. Too many, framed as questions, given from a distance, stacked up, without a deadline, followed by nothing. A significant part of "refusal" is a problem of instruction, not of obedience.
The inconsistency of consequences. What is forbidden one day is tolerated the next. Inconsistency does not produce less opposition than consistent strictness: it produces more, and more resistant.
The parents' exhaustion. It is a consequence, and it becomes a cause: an exhausted parent gives in faster, shouts faster, and no longer has a pleasant moment with their child. Treating it is part of the treatment.
Epidemiology, in two useful figures
The prevalence of oppositional defiant disorder is around 3 % in children, with estimates varying from 1 to 11 % depending on definitions and populations. It is somewhat more frequent in boys before adolescence, and this difference fades afterwards.
It is the most frequent reason for referral in child psychiatry, and it frequently precedes other disorders: the irritable dimension predicts anxiety and depression, the defiant dimension predicts conduct disorder. Treating early therefore makes sense, and it is an argument to give the parents.
5. The coercive cycle: the model that guides this programme
What Patterson described
The most useful model in this manual, and the one to explain to the parents in session P2, with a drawing. It is the most profitable explanation in the programme, because it makes everything that follows acceptable and comprehensible.
The sequence is always the same. The parent asks for something disagreeable to the child. The child refuses, shouts, resists. The parent insists, raises their voice. The child goes higher still. At some point, one of the two gives in.
If the parent gives in, the child learns that escalating works. If the child gives in after the parent has shouted, the parent learns that shouting works. In both cases, the episode ends in immediate relief, and that relief reinforces what has just happened.
It is learning by negative reinforcement, on both sides. Nobody wanted this. Nobody is at fault. And it is perfectly modifiable.
Why this explanation changes everything
Because parents arrive with a theory: their child is like that, or they are bad parents. Both theories block the treatment — the first because it makes action pointless, the second because it makes action shameful.
The coercive model replaces these two theories with a third, which has the advantage of being accurate: a sequence has set in, it maintains itself, and it comes undone through the same mechanisms that set it up.
Say it in these words, and draw it: "You did not create this problem. You fell into it, as almost everyone falls into it, and we are going to get out of it by changing what happens in the ten seconds after a request."
The four variants you will see
The classic escalation. Request, refusal, insistence, shouting, parent gives in. The most frequent.
Pre-emptive surrender. The parent no longer asks, because they know how it will end. The opposition becomes invisible: it has won before starting. It is the hardest variant to spot, and you have to look for it by asking what the parents no longer ask for.
Escalation up to punishment. The parent escalates to a disproportionate sanction, often unenforceable, sometimes followed by a guilt that cancels it. The child learns that sanctions do not hold.
Alternation between the two parents. One gives in, the other punishes. The child learns whom to approach. See session P10.
What the model implies doing
Making attention non-contingent on conflict. That is the sense of special time (P2) and differential attention (P3).
Making the request executable. That is the sense of effective instructions (P4).
Making what follows predictable. That is the sense of consequences (P5) and of time-out (P6).
Giving a path that pays more than conflict. That is the sense of the points chart (P7).
What the model implies not doing
Do not start with discipline. This is the most frequent error, and it fails: a family given a time-out before a little relationship has been rebuilt will not apply it, or will apply it in anger. The order of the programme is not arbitrary.
Do not look for the deep why before having changed the sequence. There is often something to understand. But the order is the reverse of what one thinks: things are better understood once the house is liveable.
Do not make the child the main patient. In pre-adolescent children, what works goes through the parents. Saying so clearly in P1 avoids a misunderstanding that costs three sessions.
Do not set up a discipline programme without having ruled out violence. It is the only error in this manual that can harm the child.
Frequently asked questions
The parents ask for a technique from the first session.
It is the most frequent request, and giving in to it is the main cause of early failure. Give them the record, which is a real action and which occupies them, explain why the order matters, and announce what is coming. A technique given before the functional analysis will be badly applied, judged ineffective, and lost for the rest of the programme.
The parents say the child behaves very well at school and at their grandmother's.
It is frequent, it is informative, and it is good news that should be presented to them as such: it means the child is capable of it, and that what differs is what happens around them. It is neither proof that they do it on purpose, nor proof that the parents are bad parents. The contingencies are not the same; that is exactly what is going to be modified.
One of the two parents refuses to come.
Start with the one who is there, without making the absent one an obstacle. Send them a short document with what is being put in place, offer them a single session, and leave the door open. Many reluctant parents come at the fifth or sixth session, when they see that something is changing at home and that nobody has put them in the dock.
Behaviours have got worse since we started.
That is the extinction burst, it is expected, and it lasts one to two weeks. It occurs precisely because the parents have stopped giving in: the behaviour that used to work no longer works, and the child goes up a notch before giving up. Show them the record, which almost always shows an increase in intensity and a decrease in duration. And remind them that you warned them — that is why one warns.
Is a special time really needed with a child who has just been odious?
Yes, and it is the most transgressed rule of the programme. This time is not a reward: it is the treatment. Removing it on bad days amounts to withdrawing a medicine on the days of fever. Say it with that image, it works. And plan a fixed moment in the day, independent of what happened before.
Time-out, is that not setting the child aside?
It is a legitimate objection and it must be answered seriously, not brushed away. A well-conducted time-out is brief, predictable, announced in the cold, applied without anger, and followed by an immediate return to the relationship. It applies only to two or three behaviours, in a family where positive attention is abundant. Outside that frame, the objection becomes right — and that is why section 31 is so detailed.
The child says the points chart is a baby thing.
Frequent after ten, and easy to deal with: it is the format at fault, not the principle. Replace the stickers with a notebook, a shared account on a phone, a system of levels. Have the child choose it, and give them a role in the counting. A beginning adolescent will accept a written contract where they would refuse a coloured chart.
Is a medication needed?
There is none for oppositional defiant disorder itself. The question arises if there is an associated ADHD, and then it arises for the ADHD — treating it also improves the opposition and makes parent training more effective. In cases of severe resistant aggression, a specialist prescription may be discussed, with monitoring and a limited duration. See section 35.
And if the parents hit their child?
You ask the question directly from the first session, without judgement. If there is danger, you apply your reporting obligations, and you do so without wondering whether it will complicate the therapy. Otherwise, it becomes an immediate treatment target: give an alternative in the same session, and do not put discipline back in place until this point has been worked on. A parent who hits is almost always a parent out of options.
How long before it works?
The rate of compliance with instructions often moves as early as the third or fourth week, and it is the first indicator to show the parents. The frequency of conflicts takes longer. Reckon on eight to twelve weeks for an established result, and announce that timetable from the first session: it is what carries families through the difficult passage.
The parents do not fill in the record.
Make it the subject of the session, without reproach. Without a record there is no measurement, therefore no decision — say it that way. Then look for the real reason: the format is too heavy, the evening is the worst moment, they are ashamed of the figures, or they are too exhausted. Simplify until it is feasible: three tally marks a day are worth more than a detailed chart never filled in.
The child refuses to come to sessions.
It is not blocking: the essential of the work goes through the parents. Do not force them, do not make their coming a condition, and do not comment on their refusal in front of them. Offer a short visit, with a game and without discussion of their behaviour. Most children accept once they have understood that they are not coming to be corrected.
The grandparents undo everything.
Frequent, and rarely resolvable by confrontation. Two principles: ask for the minimum — not undoing what is in place — rather than full application; and give them a short written version of the rules, treating them as allies and not as a problem. And distinguish what really counts from what is an acceptable difference between two households.
Should family therapy be done rather than this programme?
Not first line for this presentation in pre-adolescent children: parent training is better evaluated and faster. Family therapy may be justified afterwards, or when the picture is dominated by a family conflict broader than the child's behaviour. In adolescence, the balance reverses.
Twelve sessions, is that a lot?
It is the upper end of the evaluated dose, and it is adaptable. What counts is not the number of sessions but the amount of practice actually done and the number of procedures actually installed. A family that has set up special time, differential attention and the instructions in six sessions is better treated than a family that has heard about everything in twelve.