Cognitive Behavioural Therapy: Oppositional Defiant Disorder
Evidence-Based Intervention for ODD- EDPS 674 Alicia Marchini, Sarah Sarah Juchnos!i " #indsa$ Birchall
A%enda & & & & & & &
Descri'tion of the Intervention - Alicia (evie of (esearch Basis - Alicia Overvie of the )heoretical Basis - Sarah *eneral A''lication - #indsa$ +o%nitive +han%e +ha n%e )a )as!s - #indsa$ Behavioural +han%e )as!s )as!s - Sarah +ritical )hou%ht of Practical A''lication - Sarah " #indsa$
Descri'tion of the Intervention
Descri'tion of the Intervention -
+B) for child conduct 'roles as develo'ed ith the notion that children dis'la$ disru'tive ehavior ecause of
.a/ learned co%nitive distortions ./ co%nitive deficiencies .c/ a related tendenc$ to res'ond i'ulsivel$ to oth e0ternal and internal stiuli
Descri'tion of the Intervention )ar%et Areas1 - )o reduce a%%ressive ehaviour - )o increase 'rosocial interactions - )o correct the co%nitive deficits, distortions and inaccurate self-'erce'tions - )o reduce eotional outursts, i'ulsivit$, and e0'losiveness, e0'losive ness, and ultiatel$ enalin% the child to e ore reflective and considerate of ho est to res'ond
Descri'tion of the Intervention A%e (an%e1 -
Initiall$ used ith school-a%e children .2-3 $ears old/
- Adults -
More recentl$ used ith 'reschool children
Deliver$ 5orat " Acco'an$in% +osts1 -
One-on-One -
-
eteen 38 and 28 for sessions that are 28 inutes or lon%er
*rou' -
eteen 38 and 378 for sessions that are hour to an hour and a half lon%
Descri'tion of the Intervention )rainin% )rainin % (e9uireents1 )he thera'ist ust e ade9uatel$ trained in::: -
co%nitive ehavioural thera'$
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co%nitive restructurin%
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various thera'$ techni9ues to e0'lore 'ersonal issues that i%ht e contriutin% to the child;s defiant ehaviour
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counication s!ills
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'role solvin% s!ills
(evie of (esearch Basis
(evie of (esearch Basis -
Meta-anal$tic studies sho ediu to lar%e effect si
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+B) has 'roven to e ore effective than co'arison %rou's
-
)$'icall$, those ho had +B) are ore li!el$ to e in the noral functionin% ran%e after the thera'$ co'ared to those in other conditions
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#iitation of Studies1 Often relied solel$ on 'arent and teacher re'ort
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>endall and Brasell .3=?/1 +o'ared +B), ehavioural ehavioural treatent, and an attention control condition -
found that +B) and ehavioural treatent ere su'erior to the control condition and that +B) as sli%htl$ ore effective
(evie of (esearch Basis -
+B) leads to an increase in 'role-solvin% s!ills and self-control, and a decrease in co%nitive distortions and hostile attriutions -
@$'othesi
-
@oever, no studies have shon that these chan%es are co'letel$ @oever, accounted for $ the +B) treatent t reatent
(evie of (esearch Basis -
+hildren of older a%e .33-3 $ears old/ and ith %reater co%nitive ailit$ are ore li!el$ to enefit fro +B) than $oun%er children .2-7 $ears old/ and less co%nitivel$ develo'ed children
-
+hild is less li!el$ to res'ond to +B) if1 -
she has a hi%her nuer of conduct disorder s$'tos
-
'arent has hi%her levels of 'arentin% stress, de'ression, or detriental child-rearin% 'ractices
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the child lives in a sin%le-'arent hoe or is of lo socio-econoic status
(evie of (esearch Basis -
o relationshi' eteen the len%th of the treatent and the thera'eutic outcoe for children ith conduct 'role
-
One stud$ found that a lon%er +B) 'ro%ra .3? sessions/ as associated ith si%nificantl$ i'roved ehaviour in co'arison to a shorter version of the sae 'ro%ra .3 sessions/
-
Most of the a''roaches that are e0ained in studies are t$'icall$ ithin a short tie frae .? and 38 ee!l$ sessions/ that are t$'icall$ an hour lon%
(evie of (esearch Basis -
o difference eteen the outcoe of individual and %rou' thera'$ forats of +B) and fail$ thera'$ a''roaches -
-
tie and cost advanta%es of %rou' treatent C i%ht e favoured over individual treatent
+ontradictor$ Evidence1 *rou' treatent ith children and adolescents ith conduct 'roles a$ actuall$ cause the 'roles to ecoe orse
(evie of (esearch Basis -
Man$ of the studies include children ho are referred $ teachers, 'arents, or 'eers, or have onl$ ild, undia%nosed ehaviour 'roles
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+B) for ild child conduct 'roles can or!, ut it has een ar%ued that the$ don;t actuall$ 'rovide evidence that it does or! ith actual clients
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Su%%ested that the nature, severit$, and and nuer of ehaviour 'roles of children ho are in an$ of these studies st udies are not si%nificantl$ different fro those seen in clinical sa'les
(evie of (esearch Basis -
+B) has deonstrated eneficial effects ith children fro out'atient and in'atient clinical 'o'ulations, ho have ulti'le dia%noses and are fro diverse ethnic and socioeconoic ac!%rounds, in various settin%s
-
Positive effects ere aintained u' to a $ear after the treatent as co'leted
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)his level of %eneralit$ has not een 'roven ith the an$ different !inds of +B) treatent a''roaches
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Evidence for lon%-ter effects . one $ear after treatent/ is liited
(evie of (esearch Basis -
(esearch su''orts the efficac$ of +B) for children ith conduct disorders
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Influences on +B)1
-
-
child;s otivation
-
adherence to treatent
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level of !noled%e
-
counication s!ills
-
thera'ists; arth and li!eailit$
ot $et clear hich as'ects of +B) are effective a%ents of chan%e and
Overvie of the )heoretical Basis
@istor$ Behaviourism: Precedes the 3=881 Pavlov, S!inner, #ittle Alert: 5ocuses on
current, e'hasi
thou%hts, eliefs, assu'tions, attitudes, eories and fantasies in to thera'$: Bandura .3=6=/ develo'ed the social learnin% theor$, connected our environent and conse9uences ith co%nitive 'rocesses: Alert Ellis .3=28/ derived fro (ational Eotive )hera'$, thou%hts ediate our ehaviour: CBT: Aaron Bec! .3=68/ develo'ed develo'ed +B) incor'oratin% incor'oratin% oth co%nitive and ehavioral co'onents: Bec! 'ut %reat i'ortance into one;s internal dialogue.
(ationale and +han%e Process Behaviourism:
F F F F
5ollos scientific ethod, Belief that ehaviour is oservale, easurale and easil$ evaluated, )al! is not valuale +han%e coes throu%h stiulus control and reinforceent
Cognitive:
F F F F
Ge a!e sense of our situations throu%h t hrou%h thou%hts, hich affects ho e ehave and feel D$sfunctional thin!in% causes d$sfunctional ehaviour B$ identif$in% ne a$s of thin!in% +han%e coes throu%h anal$
+o%nitive Behavioural )hera'$ F F F F F
+oinations of +o%nitive and Behavioural thera'$ +o%nition, eotion, ehaviour, and 'h$siolo%$ all interact to%ether ith the environent B$ e0ainin% all these as'ects $ou can in turn develo' the est treatent 'lan +B) is d$naic and all-enco'assin% Man$ chan%e tas!s under +B) a!es it the ost 'o'ular and e'iricall$ researched ode of 's$chothera'$:
A''lication
S$'to (evie ★ ★ ★
Angry/Irritable Mood Angry/Irritable Argumentative/Defiant Argumen tative/Defiant Behaviour Vinditiveness
H Develo'entall$ ina''ro'riate H onco'liance, defiant and disru'tive ehaviours H Activel$ refusin% to to co'l$ ith adult adult re9uests and rules H O''ositionalit$ O''ositionalit$-disoedient -disoedient ehaviours toard authorit$ H e%ativistic and hostile ehaviours H A%%ression .veral threats and 'h$sical 'h$sical acts/ H E0cessive ar%uin% ith adults H Poor Eotional re%ulation H Delieratel$ tr$in% to anno$ others or u'set others, or ein% easil$ anno$ed $ others H Blain% others for $our ista!es H Bein% s'iteful and see!in% reven%e H Searin% and usin% oscene lan%ua%e-sa$in% ean or hateful thin%s hen u'set H Pro'ert$ destruction .APA, 83 @ailton, 88? Steiner " (esin%, 887 eed:co/
I'lications of S$'tos &
& & & & & & & & &
Individuals t$'icall$ do not reco%nise s$'tos in theselves H instead the$ ustif$ their ehaviours as a res'onse to unreasonale circustances or deands Si%nificant disturance in social, acadeic or occu'ational functionin% Proleatic relationshi's and interactions ith others H Circular Causality of of d$sfunctional interactions D$sfunctional fail$ interactions Difficult$ a!in% and !ee'in% friends-'eer reection Difficult$ at or! ith su'ervisors and authorit$ fi%ures Poor school or! and 'erforance - school s chool dro'out Antisocial ehaviours ehaviours Suicide, an0iet$, de'ression, de'ression, sustance use I'ulse control 'roles
.APA, 83 @ailton, 88? Steiner " (esin%, 887 eed:co/
Etiolo%$ & Sin%le cause is un!non and unli!el$ & S$'tos increase ith a%e & )he %radual stac!in% of factors contriutes to the develo'ent of ODD
(is! 5actors1 SES, culture, 'renatal .so!in%, to0in e0'osure, 'oor nutrition, ne%lect/, failial cluster of disru'tive ehaviour disorders, unres'onsive 'arentin% 'ractices, attachent related, 'arents li!el$ to have siilar difficulties ith self-control, eotional re%ulation, ood stailit$ stailit$,, one 'arent dia%nosed ith 's$chiatric disorder, arital difficulties/
.Steiner " (esin%, 887/
Earl$ Intervention " Prevention &
Earl$ Intervention1 the earlier the intervention 'rocess can e%in, the ore li!el$ it is to succeed
&
Possile 'revention of ore 'roleatic ehaviours and the t$'ical 'ro%ression of ODD .e:%: later develo'ed +D/
&
Earl$ interventions can inii
&
More intensive treatent is necessar$ if the onset is earl$ and the severit$ is %reat
.Steiner " (esin%, 887 Ba!er " Scarth, 88/
Individuali
+o%nitive-+han%e +o%nitive-+han%e )as!s Identif$in% and )estin% Autoatic )hou%hts Decatastro'hi
+o%nitive +han%e Processes Aareness of client;s client;s co%nitive content content or strea of thou%ht in their reaction to an u'settin% event ie thou%hts as h$'othesis-rather than facts-so clients can reco%ni
+B) " ODD !ous on
& & & &
+ounication Prole Solvin% S!ills I'ulse +ontrol An%er Mana%eent Mana%eent
Main "#ills
& Prole Solvin% & +o%nitive (estructurin%
★
+hildren often have co%nitive s!ill %a's and co%nitive distortions affectin% these areas .Ba!er " Scarth, 88/
Prole Solvin% & Ma$ e ollaborative1 involvin% others ho the challen%in% ehaviour arise ith .'arents, 'eers, teachers/ & Ma$ e group1 students 'resentin% ith siilar s$'tos and difficulties in siilar areas & Ma$ e individual .Bieran, Miller, " Sta, 3=?7 5re$, 5re$, @irschstein, " *u<
*rou' Prole Solvin%1Second Ste' "eond "tep problem "olving Model
3: Identif$ the 'role : Brainstor solutions : Evaluate solutions $ as!in%, LIs it safe Is it fair @o i%ht 'eo'le feel Gill it or!N 4: Select, 'lan, and tr$ the solution 2: Evaluate if the solution or!ed and hat to do ne0t
& & & &
& & & &
"oial $earning Theory % Modeling M odeling
Ideal for 'racticin% social 'role solvin% in school settin%s Students 'ractice 'role solvin% odel usin% h$'othetical situations (ole Pla$s, Draas " +oedic scenes1 offers eotional distance H ideo cli's H Pu''ets, character 'la$ .$oun%er children/ Ideal si
.Bieran, Miller, " Sta, 3=?7 5re$, @irschstein, " *u<
*rou' Prole Solvin%1Second Ste' &
Gatch video cli' H +haracters deonstratin% 'ositive and ne%ative ehaviours & As! %rou' 9uestionsdiscussion H LGhat set the character offN LGhat did $ou see ha''enN LGhat ere the conse9uencesN & Identif$ details1 voice tones, facial e0'ressions, hand %estures, defensiveness, hostile 'osturin%, an%r$ e$e contact & +hildren ith ODD often do not see all the conse9uences of their actions H es'eciall$ ith 'eer relationshi's H or issues of res'ect and trust
*rou' Prole Solvin%1 Second Ste' &se group proess to help in sti#y situations
5or e0a'le1 LGhat do $ou thin! e need to do aout Joe$;s ehavior, %u$sN LGhat do $ou thin! our choices areN LIf Joe$ continues to rea! (ule , our %rou' can;t 'ic! soethin% 'ositive that is 'lanned or a %rou' reard that could e %ivenQ: I; onderin% ho the %rou' can hel'N *ive veral 'raise to the su%%estions that are eneficial, hile tr$in% to i%nore or inii
*rou' Prole Solvin%1 Second Ste' &se humor to defuse negative omments or ations
LGell, 5redd$, 5redd$, 'unchin% Joe$ in the face fac e is an o'tion: @oever,, then, $ou ould e in even ore troule ith @oever the %rou' than Joe$ is: *reat ideaN
.#inseisen, 88?, ':38/
+o%nitive (estructurin% 'edefining a problem: can facilitate chan%e hen our conce'tuali
★ODD
&Individuals often attriute their 'role to the actions of others - )he 'role is out of their control Ma$ teach individuals ith ODD that the 'role can e navi%ated if the$ redefine it-ta!e accountailit$ and res'onsiilit$ for their ehaviours
+o%nitive (estructurin% Automati Thoughts &)hou%hts are accessile, 'oerful and haitual &*ather data on s'ecific thou%hts &)est validit$ and eanin% throu%h direct evidence and lo%ical anal$sis &Identif$ co%nitive distortions &Ma$ uncover lo%ical inconsistencies, contradictions, errors in thin!in%
Thought "topping & &
Part of Autoatic )hou%ht 'rocess Brea!in% a chain of thou%hts that tend to escalate into distress, 'articularl$ an0iet$ & +lient identifies se9uence of thou%hts- then attends to those earl$ in the 'rocess & An0iet$ or frustration frustration 'rovo!in% activit$ activit$ is underta!en, to 'ractice interru'tin% the chain
.)ruscott, 838 Geddin% and +orsini, 834/
+o%nitive (estructurin% ★ODD
& Identif$in% thou%hts that contriute to escalation: Brea!in% a chain of thou%hts usin% thou%ht sto''in%: Sto' an%er, frustration, frustration, an0iet$ that a$ escalate into a%%ressive a%%ressive or hostile ehaviours: Buildin% tolerance throu%h 'ractice: Pair ith redefinin% redefinin% the 'role and ta!in% res'onsiilit$ for one;s actions:
Behavioural - +han%e +han%e )a )as!s @oeor! @$'othesis testin% E0'osure )hera'$Interventions )hera'$Interventions Behavioural (ehearsal(ole Pla$ Diversion )echni9ues Activit$ Schedulin% *raded-)as! *raded-)as! Assi%nent Assi% nent (ela0ation Based Interventions
(es'onse Prevention O'erant Strate%ies Social S!ills )rainin% )ie-Out Successive A''ro0iation A''ro0iation .Sha'in%/ +ontin%enc$ Based .)o!en Econoies/ Modelin%
)o!en Econo$ Econo$ S$stes S$stes To#en (onomy "ystems )T("* F
F F
Individuali
ODD F F F F F F
)$'icall$ used to increase co'liance, disru'tive ehaviour and acadeic )$'icall$ +ontin%ent teacher 'raise or re'riands )o!en econo$ s$stes (es'onse cost )ie )i e out fro 'ositive reinforceent Self-ana%eent
(ela0ation Based Interventions 'ela+ation Interventions
F
)echni9ues include1 reathin%, refocusin% attention, increasin% od$ aareness, aarene ss, e0ercises, editation, 'ro%ressive uscle rela0ation, visual vis ual ia%er$, and variations of these:
ODD
F F F
)$'icall$ used to tar%et )$'icall$ t ar%et an%er and tantru li!e ehaviour Decreases 'h$siolo%ical arousal )echni9ues include rela0ation, distraction and self-instruction
Behavioural +han%e Processes
(einforceent Pro'tin% Stiulus +ontrol Settin% Events
+ritical )hou%ht1 Practical A''lication
A%e of A''lication oun%er clients F
Ma$ need ore concentration on ehavioural techni9ues F Do not have as rich lan%ua%e F Develo'entall$ E%ocentric .troule ta!in% other;s 'ers'ectives/ F #ac! of insi%ht
Older +lients F F F
Ma$ need ore concentration on co%nitive techni9ues @ave ore co%nitive ailities for veral techni9ues Ma$ not u$ into ehaviour techni9ues
+o%nitive and #an%ua%e Issues F
+B) assues the client has stron% understandin% of lan%ua%e: l an%ua%e: +lients ust e ale to anal$
F
#in!s eteen ehaviours and feelin%s are ore easil$ reco%ni
F
F
+B) is feasile in soe of these circustances EU/ for individuals ith co%nitive i'airents ith s'ecific odifications: Such odifications a$ include1 drain%s, visuals, re'etition, sloin% don sessions, over teachin% and an increase in e0'licit teachin%:
+ultural Issues As'ects to consider1 F Socio-econoic status F Ethnic %rou's F 5ail$ d$naics
#ac! of Insi%ht Blame game
F F F F F F
Do not hold theselves accountale acc ountale Blae others for their circustance e0/ )he$ MADE e ad: Believe their actions are arranted ased on hat the$ see as unrealistic e0'ectations )heor$ of ind difficult$ Often ani'ulative, 9uic! to e0'loit others Stron% need to %ain 'oer, therefore 'oer is the ultiate reinforcer
+o-Moridities
.@ailton, 88? APA, 83 ':466/
ODD is highly omorbid ,ith other disorders:
& Attention-deficith$'eractivit$ Attention-deficith$'eractivit$ disorder .AD@D/ .AD@D/ & Mood Disorders H De'ression H An0iet$ & +onduct Disorder & Sustance use 'roles & S'ecific #earnin% Disorders
★ ★ ★
★
S$'tos of ODD can e difficult to distin%uish fro other 'roles )reatin% other ental health conditions a$ hel' i'rove ODD s$'tos It a$ e ore difficult to treat ODD if these other conditions are not evaluated and treated a''ro'riatel$ .a$ orsen ODD s$'tos/ +B) strate%ies should fit individual s$'tos .e:%: i'ulse control, attention/
on +o'liance .#inseisen, 88?/ & & &
Interventions that increase co'liance are i'erative H lead to decreased disru'tive ehaviours LBotto ste' on the ladderN Githout co'liance, otivation and illin% 'artici'ation $ou ill not e ale to or! on hel'ful chan%e tas!s, no atter ho evidence ased the$ are
+onsiderations1 & & & &
+hildren that are non co'liant and o''ositional a$ Lsaota%eN $our efforts to hel' the If the$ are forced to en%a%e in the intervention 'rocess, their 'artici'ation ill e lo If the$ do not elieve their ehaviour is a 'role, their 'artici'ation ill e lo +hildren ith ODD often crave and thrive on ne%ativit$ and conflict H O''ositional ehaviours a$ e reinforced $ adult and 'eer attention, contriutin% to non-co'liance
+o'liance Buildin% .#inseisen, 88?/ & & & & & &
& &
*ive coands and 'rovide conse9uences effectivel$ Deliver$ of re9uests usin% a fir ut 9uiet tone of voice, usin% stateent for .not 9uestion for/ (e9uests should e s'ecific and delivered ithin ft of the student Estalish e$e contact efore a!in% re9uests Post 4 or 2 'ositivel$ ehaviourall$ ehaviourall$ stated rules for the student )ea eacher cher oveent in the classroo 'rovides ore su'ervision in the classroo H 'rootes detection of 'role ehaviours earlier H Increased 'otential for reardin% 'ositive ehaviours ore fre9uentl$ Kse of M$ster$ Motivators as 'ositive reinforcers in the classroo (eco%ni
(elationshi' Buildin% &
(elationshi' uildin% is i'erative H )hera'ist ust uild an alliance ith the child H Buildin% a relationshi' ith $outh ith ODD can ta!e tie and re9uire %reat 'atience
&
Often $outh are disli!ed and disre%arded $ adults H Identified as L'roleaticN or LdefiantN ithin the s$ste )he older the $outh, the ore challen%in%
& &
Ge need to eet $outh here the$ are at H ithout 'ushin% to a!e chan%es in their ehaviour or to connect ith the or!er faster or ore intiatel$ than the $outh can ana%e H B$ or!in% ith the $outh at their on 'ace the or!er can %ain trust and 'roote securit$ and stailit$ in the relationshi': & After a relationshi' is estalished1 estalished1 or! on s!ills
Parent Partici'ation +onsiderations1 & Parents of children ith ODD a$ e contriutin% to the 'role ehaviours .'arental ental health issues, d$sfunctional fail$ d$naics, sustance use 'roles, inconsistent disci'line, lac! of su'ervision, harsh disci'line, 'oor eotional re%ulation, n e%lect, ause, etc:/
& &
+hildren ith ODD are relentless and relationshi's ith 'arents are strained Interventions should involve 'ositive fail$ interactions
& Adherence to recoendations a$ a$ e lo1 consider consider +B) odels includin% hoeor! &
Parents ill li!el$ need on%oin% su''orts to aintain their ental health1 +ounsellin%, Parent )rainin%, su''ort %rou's
.a$oclinic#inseisen, 88? @ailton, 88? Steiner "
Parent )r )rainin% ainin% Should Include1 & Mental @ealth 'rovider e0'erienced in treatin% ODD & Parent-+hild Interaction )hera'$ or S$steic 5ail$ )hera'$ & Individual and 5ail$ )hera'$ & Behaviour Modification )hera'$ & +ollaorative " +o%nitive Prole Solvin% )rainin% & Social S!ills )r )rainin% ainin% & Buildin% (esilienc$
.a$oclinic#inseisen, 88? @ailton, 88? Steiner " (esin%, 886/
Possile Behavioural Parent )rainin% )a )as!s & (eco%ni
.a$oclinic#inseisen, .a$oclinic#inseisen, 88? @ailton, 88? Steiner " (esin%, 886/
(eferences Aerican Ps$chiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth E dition : 2th: Arlin%ton, A1 Aerican Ps$chiatric Association 83162-78: Ba!er, #:, #: " Scarth, >: .88/: +o%nitive Behavioural A''roaches to )reatin% +hildren and Adolescents ith +onduct Disorder, +hildren;s Mental @ealth Ontario, retrieved fro1 htt'1:!idsentalhealth:cadocuents+ htt'1 :!idsentalhealth:cadocuents+o%nitiveVBehaviouralV+ o%nitiveVBehaviouralV+onductVDisorder: onductVDisorder:'df 'df Bieran, >: #:, Miller, +: M:, " Sta, S: .3=?7/: I'rovin% the social ehavior and 'eer acce'tance of reected o$s1 Effects of social s!ill trainin% ith instructions and 'rohiitions: Journal of Consulting and Clinical Psychology , 22, 3=4W88: 5re$, >: S:, @irschstein, M, >: " *u<
@ailton, S: S: " Arando, J:, .88?/: O''ositional Defiant Disorder: American Family Physician, 7?.7/1?63-?66, ?67?6? #inseisen, ): .88?/, Effective Interventions for f or outh outh Gith G ith O''ositional Defiant Disorder: In 5ran!lin, +:, @arris, M: B:" Allen-Meares, P: P: .Eds:/, .Eds:/, he School Practitioners Concise Com!anion the Mental "ealth .'':3-32/: O0ford Kniversit$ Press, O0ford Scholarshi' Online1 A'ril 838: doi138:38=ac'rof1oso=7?83=2782?4:883:8883
Ma%%in, D: M:, +hafouleas, S: M:, *oddard, >: M: " Johnson, A: @: .833/: A s$steatic evaluation of to!en econoies as a classroo ana%eent tool t ool for students ith challen%in% ehavior: Journal of School Psychology , 4=12=-224: doi138:3836:s':833 doi138:3836:s':833:82:883 :82:883 a$oclinic:co: O''ositional Defiant Disorder, (etrieved fro1 htt'1:a$oclinic:or%diseas htt'1: a$oclinic:or%diseases-conditionso'' es-conditionso''ositional-defiant-disorde ositional-defiant-disorderasicsdefinitioncon-88 rasicsdefinitioncon-88422= 422= , retrieved
March 32th, 832 O''ositional and Defiant Behavior in +hildren and )eens: )eens: .834/: In #oodhera!y.org : (etrieved March , 832, fro htt'1:%oodthera'$ htt'1 :%oodthera'$:or%thera'$ :or%thera'$-for-o''ositional-and-defiant-disorder: -for-o''ositional-and-defiant-disorder:htl)hera'$X8forX8O''ositionalX8 htl)hera'$X8forX8O''ositionalX8 Behavior
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