Evaluating underlying psychosocial factors.
Although biological vulnerabilities may underlie certain disruptive symptoms (eg, aggression, impulsivity), there is currently no evidence for a unifying, valid biological explanation of the origin of oppositional and defiant behaviors.¹¹ This reality underscores the importance of a careful investigation of the psycho- social factors that underlie oppositional behavior (Table 5), as exemplified in the cases presented here.

The developmental aspects of separation-individuation are often awry in patients with ODD. The 2 periods when developmentally appropriate interpersonal antagonism is most commonly seen are the toddler years and early adolescence. An assessment must thus consider the question of whether, in some patients who present with the chief complaint of oppositionality and defiance, the behavior represents normal development. The diagnosis of ODD rests on the clinician's determination of impairment and his or her own perception of how developmentally deviant the behavior has become.

To test or not to test?
Although the clinical interview is at the core of an evaluation for disruptive behavior, psychological testing is a valuable supplement that is designed to support clinical judgment.¹² Psychological testing can be helpful in sorting out diagnoses.

The most commonly used psychological measures in the primary care outpatient setting are rating scales. These are filled out by older patients, patients' parents, and patients' teachers. The Conners Rating Scales and Vanderbilt Rating Scales, which are used to evaluate for ADHD, also assess oppositional and conduct-related difficulties. The scales can be scored quickly and help with sifting through the differential diagnosis.

Further assessment is typically done when requested by a clinician having difficulty in distinguishing between multiple conditions, especially if learning difficulties are involved. When making a request for psychological testing, it is important to be specific about the nature and purpose of the assessment being sought. For example, asking for help with the differential diagnosis is different from asking, "Can you assist with evaluating for the presence of a reading disorder in this child, who has ADHD, combined type?"

Helpful components of a psychological assessment of a child with a disruptive behavior disorder may include the child behavior checklist, a learning evaluation, and projective tests (eg, Rorschach test, thematic apperception test) to evaluate for sources of oppositional behavior.

TREATING ADHD WITH COMORBID ODD
After a thorough assessment establishes the presence of ODD as a comorbid diagnosis in a child with ADHD, the next questions are "what to do?"and "what to treat first?"

Treatment of ADHD.
Recommendations for the treatment of ADHD clearly involve medication treatment, usually starting with the psychostimulants.⁴ There are also nonstimulants that can be used, such as the FDA-approved atomoxetine(Drug information on atomoxetine), as well as off-label uses of a2-agonists (guanfacine, clonidine(Drug information on clonidine)), tricyclic antidepressants (eg, imipramine(Drug information on imipramine)), and bupropion.

Whatever the initial choice, there is usually appropriate apprehension on the part of parents and some physicians about using psychoactive agents in children. There has been increasing scrutiny of the true value of medication in childhood psychiatric disorders.¹³ However, the NIMH Multimodal Treatment Study of Children with ADHD (MTA) provided strong reinforcement of the need for medication to adequately treat ADHD.

It is with this realization that clinicians treat ADHD with medication while at the same time enlisting psychosocial therapies to address a patient's oppositional-defiant behavior. The MTA established that combining psychostimulant treatment with psychosocial interventions (ie, behavioral therapy) was helpful when treating ADHD with comorbid disorders.⁴ The combination of medication treatment and behavior therapy may have led to less decompensation when medication was not taken, as well as contributing to the use of lower doses of psychostimulants.¹⁴ Although oppositional and defiant behaviors may improve as a child's ADHD responds to medication, the expectation that "just"medication can be used to treat the majority of children with ADHD does not acknowledge the common co-occurrence of psychosocially mediated symptoms that require psychosocial treatments.

Treatment of comorbid ODD.
When addressing the additional concerns of disruptive behavior, it is important to look beyond medication. When ADHD and ODD co-occur in the same child, a biopsychosocial etiology is implied, necessitating a multimodal treatment approach.

The primary care pediatrician plays a critical role in the inauguration of psychotherapeutic interventions. Referring a child for psychiatric consultation and/or psychotherapy invariably taps into the family's attitudes about mental health issues. The pediatrician's attitudes and beliefs can be powerful contributors to the perception that patients and their parents have regarding mental health care.

Be especially careful not to blame the families dealing with the disruptive behaviors. Focusing on the interventions instead may improve the likelihood of their following through with a referral. To achieve this nonblaming attitude, it is helpful to keep in mind that the problematic behaviors are interactional in nature: "problematic parenting can be elicited by a 'difficult' child and, at the same time, can create problems for a child."¹⁵

Given this interactional model, it is not surprising that the 2 types of evidence-based treatments for patients with ODD are individual therapy with a cognitive behavioral focus on problem-solving skills and parental intervention in the form of parent management training (PMT).

Establishing a relationship with a child and adolescent psychiatrist can facilitate treatment planning. Such a person can direct the pediatrician to therapists who are versed in both family and individual therapies.

Parent management training.
While the chief goal in working with disruptive children is to enhance their own self-confidence in their ability to manage impulses and negative emotions, this can seldom be achieved without working with the child's family. The first step therapists typically take in working with the families of children with disruptive behavior who have been referred to them is to pursue PMT. PMT is one of the most substantiated interventions in child mental health.^8,16,17 As psychopharmacological interventions are to ADHD, so PMT is to ODD. The goal of PMT is to help parents establish a more focused approach to consistency and predictability, which promotes pro- social behavior in their child. Without a positive relationship with or attachment to the child, it becomes very difficult to establish lasting change in negative behavior. PMT teaches ways to reward children (eg, surprise rewards after desired behavior, anticipated rewards). Parents learn to value praise and their relationship with their child as powerful tools for managing disruptive behavior. Finding opportunities for the parent and child to interact in healthier ways can inject much needed positive energy into a relationship that probably has been composed solely of negative interactions.

Parents are taught about limit setting, active ignoring, consequences, and communication, as well as uses of  "time outs."

Webster-Stratton and Hancock state that "consistent limit setting and predictable responses from parents help give children a sense of stability and security . . . children who feel a sense of security regarding the limits of their environment have less need to constantly test it."¹⁸ It is important to remind parents that all children test parents' rules and that, by upholding the rules, parents play a significant role in helping their child develop self-regulation. Parents should be reminded that much of effective limit setting is simply a matter of acquiring and practicing skills, a process not so different from that of learning a sport or a musical instrument.

It is important to discuss with parents the need for appropriate expectations regarding the timeline of their child's response (weeks to months). Parents also need to be aware that symptoms of disruptive behavior tend to increase when the family system is changing. For example, as parents change their approach to handling inappropriate behavior, the child may become defiant to test their resolve. Preparing parents for these new stressors and helping them to view them as predictable and part of the therapeutic process is critical in maintaining their commitment to change. Some parents benefit from recommendations for adjunctive educational materials. Television shows, such as Supernanny, or parenting books, such as 1,2,3 Magic, can reinforce the skills learned in therapy.

Individual therapy for ODD. Individual work with patients with ODD is usually most effective in children of school age and older. The older the child, the more likely he will be to benefit from problem-solving skills training and social competency training. Therapy usually begins with alliance building—a challenge with children with ODD. The next step is usually to introduce a skill, to model and role-play the skill, and then to try to connect the skill to the patient's day-to-day challenges. Patients typically are given homework assignments, such as "stop, think, and act"instructions for younger children and practice in thought monitoring for older children and adolescents.¹⁹

When PMT and individual therapy are not effective. Despite efforts to provide appropriate avenues of treatment for disruptive behavior, some families and children struggle to respond to PMT, social skills training, and problem-solving training. In such situations, a higher level of care is needed. Josephson and Serrano²⁰—and other researchers²¹—have found that when parents do not effectively use parent management techniques, it is often because of complex individual and marital dynamics—and even diagnosable disorders. In such cases, it may be necessary for the primary care clinician to refer the family to a larger mental health system (eg, an academic center or a community mental health center).

What about using medication to treat ODD? When disruptive behavior is associated with other principal diagnoses, it is clear that medication can help.⁴ However, when disruptive behavior is clearly a manifestation of ODD, medication plays no role in definitive treatment. When severe and persistent ODD develops into CD, then psychopharmacological interventions to assist with severe mood dysregulation and severe aggression may be warranted, along with referrals for higher levels of care (partial programs, inpatient treatment, and residential care).