Oppositional defiant disorder in children: the CBPT assessment & treatment protocol
A practitioner’s guide to recognising persistent defiance, anger and argumentativeness in childhood and treating it with Cognitive Behavioral Play Therapy and parent training — under the scientific direction of Maria A. Geraci and Susan M. Knell.
Train in the CBPT protocol for childhood ODDScientific direction: Maria A. Geraci and Susan M. Knell
Five-phase clinical pathway
For child psychotherapists
Behind defiance there is almost always a child who feels misunderstood. Play opens a door that confrontation keeps shut.
— CBPT Research Center
When every interaction becomes a battle
ODD in children is a relational disorder — not wilfulness, not bad character.
Families living with ODD describe constant friction — arguments over small requests, refusal, anger and blame that exhaust everyone. The pattern is relational: coercive cycles between child and caregivers escalate and entrench. The child is often as distressed as the adults, caught in a loop they cannot exit alone.
“Everyone thinks I’m just being bad — but I don’t know how to stop.”
Understanding ODD in children
A clinical overview: what oppositional defiant disorder is, how its symptoms present, when it begins, and the factors that cause and maintain it.
Disruptive, impulse-control and conduct disorder (DSM-5-TR)
Angry/irritable mood, argumentative/defiant behaviour, or vindictiveness lasting ≥6 months
Preschool or early school years
Reflects the number of settings affected (mild, moderate, severe)
ADHD (very common); also anxiety and depression
Risk of escalation toward conduct problems; early intervention improves outcomes
What is ODD? (DSM-5-TR definition)
Oppositional defiant disorder is defined by a pattern of angry/irritable mood, argumentative/defiant behaviour, or vindictiveness lasting at least six months.
According to DSM-5-TR (APA, 2022), ODD is characterised by a persistent pattern of angry or irritable mood, argumentative or defiant behaviour, or vindictiveness, evidenced by at least four symptoms from any of the three symptom clusters, occurring during interaction with at least one non-sibling individual. Severity is specified by the number of settings in which symptoms are present: mild (one setting), moderate (two settings), severe (three or more settings). The behaviour must occur more frequently than is typically observed in individuals of comparable age and developmental level and cause clinically significant impairment. Behaviour that exceeds developmental norms is a key distinguishing criterion.
Symptoms & presentation
ODD symptoms fall across three clusters: angry/irritable mood, argumentative/defiant behaviour, and vindictiveness.
The angry/irritable mood cluster includes: often loses temper, is often touchy or easily annoyed, is often angry and resentful. The argumentative/defiant behaviour cluster includes: often argues with authority figures, often actively defies or refuses to comply with requests from authority figures or rules, often deliberately annoys others, often blames others for mistakes or misbehaviour. The vindictiveness criterion: has been spiteful or vindictive at least twice within the past six months. Behaviours must occur during interaction with at least one non-sibling person and must be distinguished from those occurring during a mood episode, psychotic episode, or substance use.
ODD vs ordinary defiance
Oppositional behaviour is developmentally normal at times; ODD is distinguished by its frequency, persistence and impairment.
Oppositional and defiant behaviour is a normal part of child development at particular ages — toddlers asserting autonomy, adolescents renegotiating authority. The clinical distinction rests on frequency, persistence, breadth across settings and the degree of functional impairment. ODD is frequent, persistent, beyond the developmental norm for age, and causes clinically meaningful impairment in social, school or family functioning. Clinicians should always consider developmental level when evaluating whether the threshold for ODD is met.
Differential diagnosis
ODD is distinguished from other conditions that share overlapping features of irritability, defiance or rule-breaking.
- Conduct disorder: the defining feature is violation of the basic rights of others or major age-appropriate societal norms or rules — a more severe trajectory than ODD.
- ADHD: irritability and non-compliance in ADHD are driven primarily by attention and impulse-regulation difficulties rather than by the relational defiance pattern that characterises ODD; the two commonly co-occur.
- Anxiety or depression: irritability is a common feature of both mood and anxiety disorders in children; differentiation requires assessing whether defiance occurs broadly or only in specific anxiety-provoking contexts.
- Disruptive mood dysregulation disorder (DMDD): characterised by severe, recurrent temper outbursts and persistently irritable mood; differs from ODD in the severity and chronicity of mood dysregulation.
- Adjustment reactions: oppositional behaviours that emerge in direct response to an identified stressor and do not meet the duration or pervasiveness criteria for ODD.
Common comorbidities
ADHD co-occurs with ODD very commonly and should always be assessed alongside it. Anxiety disorders and depression are also frequent comorbidities. Clinically important: ODD can precede and predict conduct problems, making early identification and intervention a priority.
Onset, course & epidemiology
ODD typically emerges in preschool or early school years; early intervention improves outcomes and reduces escalation.
ODD typically emerges in the preschool period or early school years, though it can first become apparent later. Course varies considerably across individuals: some children show resolution of symptoms over time, while in others symptoms persist or evolve toward conduct disorder, particularly when comorbidities are untreated and family interaction patterns remain coercive. Early recognition and intervention — targeting both the child’s emotion regulation and the family interaction cycle — is associated with better long-term outcomes and reduced risk of escalation.
Causes & maintaining factors (CBPT conceptualization)
Temperament and coercive family interaction patterns combine to establish and maintain ODD; CBPT targets both levers.
ODD arises from the interaction of child temperamental factors — particularly negative emotionality and low frustration tolerance — and coercive family interaction patterns. The coercive cycle (Patterson, 1982) describes how a child’s escalating defiance is inadvertently reinforced when caregivers back down under pressure (negative reinforcement), which strengthens non-compliance; simultaneously, caregiver harsh or inconsistent responses further dysregulate the child. Environmental stressors, family discord and inconsistent discipline maintain the cycle.
In the CBPT conceptualization, intervention must operate at two levels simultaneously. With the child: building emotion regulation, frustration tolerance, social problem-solving and flexible thinking through play-based cognitive-behavioral techniques. With the family: parent training reshapes the interaction cycle by teaching calm, consistent contingency management and communication strategies that break the coercive pattern. Both tracks are essential; neither alone is sufficient.
The CBPT treatment protocol
A structured, brief and goal-oriented pathway for delivering cognitive behavioral therapy for ODD through play: from shared therapeutic goals, through the child’s five-phase work on emotion regulation and social cognition, to the parallel parent-training track and the change clinicians can expect to see.
Therapeutic goals
CBPT is well suited to ODD treatment because it works on emotion regulation and relationship patterns through a non-confrontational play frame.
In CBPT, goal-setting is shared with the child and family. The aim is to teach skills that help the child understand, think about, interpret and respond effectively to events — replacing the negative emotional and behavioural patterns that drive ODD. In the context of oppositional defiant disorder, the protocol generally pursues:
- developing emotion-regulation capacities;
- building frustration tolerance and flexible thinking;
- developing social problem-solving skills;
- psychoeducation for both parents and child.
Crucially, both parents and child should start from the awareness that the child is not responsible for the disorder, that symptoms are separate from who the child is, and that all stakeholders — parents, teachers and therapists — share responsibility for addressing the current struggles.
Working with the child — phase by phase
The intervention is organised into five sequential phases, from orientation to follow-up.
Orientation Phase
The initial phase of CBPT places significant emphasis on preparing both the child and the parents. An initial meeting between therapist and parents — without the child — reviews the child’s history and background in detail and lets parents share their perception of the problem. The therapist helps parents prepare the child for the first session and explains the ongoing role of parents and other significant adults across assessment and treatment. Although attention is focused on the child, the therapist continues to interact regularly with parents to offer support and evaluate progress toward therapeutic goals. For ODD, this phase prioritises building a non-coercive alliance; the child is helped to experience being understood, not corrected.
Assessment Phase
This phase collects the information needed to establish shared, goal-oriented therapy targets. Beyond interviews with parents, structured observation of the child’s play is a key element. Tools include questionnaires administered to parents, assessment of the child’s play, assessment of family play, a puppet sentence-completion task that lets the child reveal thoughts and feelings indirectly, and other measures personalised by the therapist. For ODD, the clinician observes triggers, frustration tolerance and control struggles in play; a baseline of conflict episodes and multi-setting input (home, school) feed directly into case conceptualisation.
Case Conceptualization Phase
CBPT analyses the data gathered during assessment to plan effective treatment and provide a logical structure for developing and achieving goals. It begins by explaining ODD and analysing individual, relational and environmental factors related to the parents’ concerns, examining the child’s emotions, thoughts, physical sensations and coping strategies, alongside the protective, risk and maintaining factors. For ODD, the key task is to map the coercive cycle — the sequence of demand, escalation and caregiver response — specific to this dyad, to guide targeted intervention.
Intervention Phase
This phase uses CBT techniques to help the child with ODD develop more adaptive responses to problems, situations and stressors, emphasising adaptive thoughts and behaviours. Methods include modeling, role-playing, bibliotherapy, generalization and relapse prevention; traditional cognitive techniques are adapted through play tools such as drawing and expressive arts, therapeutic storytelling and puppets that face similar situations, with explicit work on generalising learned behaviours to other contexts. The focus for ODD is on emotion regulation, frustration tolerance, social problem-solving and flexibility skills delivered through play; parent training simultaneously works on calm, consistent contingencies to reshape the interaction cycle. Regular parent meetings continue to monitor progress.
Conclusion Phase
Both child and family are actively involved in the final phase. The child addresses feelings related to ending therapy while the therapist highlights the changes achieved and consolidates learning. Final sessions may be spaced from weekly to biweekly or monthly, helping the child perceive their ability to manage life without the therapist. Positive reinforcement is provided for progress between sessions and the separation is normalised. The conclusion phase for ODD consolidates cooperative patterns, generalises skills to everyday settings, and puts a relapse-prevention plan in place. Follow-ups are scheduled at 3, 6, 12 and 24 months to verify the effectiveness of the intervention.
Learn to deliver every phase in session
Master the five-phase clinical sequence with the child — the play-adapted CBT techniques, emotion-regulation and problem-solving work, the in-session sequencing and the assessment battery — under the scientific direction of Maria A. Geraci and Susan M. Knell.
Get the complete in-session protocolThe structured 16-week treatment protocol
For ODD, the protocol is typically organised across roughly 16 weeks, combining child sessions and parent training.
Each session follows a consistent structure: review of the previous week, reaffirmation of goals, presentation of new material, practice of targeted skills, and assignment of between-session activities. A common arrangement integrates child play sessions with parent-training meetings, structured to:
- establish the therapeutic relationship and psychoeducation framework;
- identify triggers, frustration patterns and the coercive cycle for this child and family;
- build emotion-regulation and problem-solving skills through structured play;
- teach parents calm, consistent contingency management and communication strategies;
- generalise skills and consolidate cooperative patterns; relapse prevention and follow-up.
The intervention is reinforced by a Playbook: a family resource of weekly play-based activities, a copy of the treatment plan and the therapeutic agenda, plus worksheets to monitor conflict episodes and behavioural progress. The Playbook becomes the family’s transitional object, carrying therapy skills into everyday life.
Working with the family — parent training
While the child follows the five-phase CBPT protocol, parents follow a parallel five-phase training programme.
A competence-based pathway brings parents into the playroom to shape adaptive behaviours.
Parent Training is a competence-based intervention model that assumes families are capable of managing the problem, that every family has strengths, and that parents can learn new skills. Integrated into CBPT, it brings parents into the playroom to observe and progressively implement interventions that shape adaptive behaviours in the presence of the therapist, aiming to modify relational styles and attitudes that negatively affect children’s behaviour.
Parents are taught to understand the factors contributing to the child’s symptoms, the cues and events that trigger mood changes, and behaviour-management strategies that enhance self-esteem rather than shame the child — alongside the principles of a collaborative problem-solving approach (Greene) that respects both the parent’s and the child’s point of view.
Through this approach, parents have the opportunity to:
- Learn new skills.
- Acquire and practise specific techniques.
- Receive individualised, ongoing feedback from the therapist to increase their awareness.
- Interpret more accurately their children’s emotions, concerns and communication expressed through play.
This program, called PARENT TRAINING CBPT, follows an integrated and innovative approach. Although the primary work is with the child, periodic meetings with parents are essential during both assessment and treatment: this pathway runs parallel to the child’s therapy, emphasising the role parents play in influencing maladaptive behaviours. Parents are encouraged to reinforce adaptive child behaviours so treatment continues outside the therapy setting (using appropriate reinforcement for adaptive behaviours and extinction for maladaptive ones).
The parent-training pathway — five phases
Assessment
The problem is analysed, parenting style is adapted and therapeutic goals are defined. Parents receive information about the causes and consequences of their child’s dysfunctional behaviours and learn to establish clear, consistent rules.
Learning
This phase teaches the new skills needed to support change. Parents learn and practise specific techniques through role-play sessions in which the therapist acts as the child. Key targets include:
- mastery of prerequisites;
- modeling of skills;
- role-playing;
- errorless learning;
- successive approximations (shaping);
- feedback (verbal and social reinforcers, token economy);
- repeated practice.
Practice
Parents carry out play sessions with their own children to apply the skills learned, recognising and preventing situations that trigger difficult behaviours and using consistent problem-solving strategies across contexts. After initial practice with the therapist, parents begin to run individual play sessions under supervision.
Review
Parents discuss at length with the therapist the home play sessions to learn how to generalise what they have learned. Strengths and any problems are reviewed; the therapist helps generalise the interventions and parenting skills acquired. Each week, time is dedicated to applying techniques in everyday life and homework is assigned to practise the strategies.
Conclusion
Reached when therapeutic goals have been met and parents have achieved a satisfactory level of competence in play activities and parenting skills. Therapy is tapered gradually, reducing session frequency to every other week, then monthly, and so on.
Objectives of parent training — specific goals
This program helps parents interact effectively with their child by developing functional behavioural and communicative habits and techniques, removing the conditions that give rise to problem behaviours and replacing them with adaptive, socially desirable conduct.
Understanding behaviour
Increase understanding of the child’s problematic behaviour.
Realistic expectations
Set more realistic expectations.
Warmth & acceptance
Increase warmth, trust and acceptance toward the child.
The value of play
Recognise the importance of interaction through play.
Effective communication
Communicate more effectively with their children.
Parental confidence
Develop greater confidence and reduce frustrations experienced with their children.
Patience
Cultivate greater patience to create more realistic expectations.
Self-understanding
Discuss personal reactions with the therapist to understand their own feelings and behaviours.
Problem solving
Become effective problem solvers of family conflicts and develop stronger motivation for change.
The course includes the full parent-training pathway
Deliver the integrated parent-training track alongside the child’s protocol — the five parent-track phases, the competence-based model and the Playbook structure that carries change beyond the playroom.
Train in CBPT Clinical Applications — full programWhat change looks like
As emotion-regulation and problem-solving skills grow, the coercive cycle loses its grip and cooperative patterns emerge.
Through play-based emotion-regulation and problem-solving work, the child learns to recognise triggers and respond with greater flexibility rather than escalation. As the coercive interaction cycle is reshaped — with parents supported throughout by parent training — cooperative patterns emerge and consolidate. Progress reaches beyond the therapy room into school and everyday life, with follow-ups confirming that the gains hold.
Train in the full assessment-and-treatment protocol for ODD in children.
Train in the CBPT protocol — Clinical Applications programODD & CBPT: clinical FAQ
How is ODD distinguished from ADHD-related impulsivity?
ODD centres on defiance, anger and vindictiveness in relationships; ADHD centres on attention and impulse-regulation difficulties. They frequently co-occur and should both be assessed. A child with ADHD alone may be non-compliant because of difficulty sustaining effort or following multi-step instructions; a child with ODD actively refuses, argues and blames in a relational pattern that persists across settings and with familiar adults. When both are present, treatment should address both.
Why is parent training emphasised in ODD treatment?
ODD is maintained by coercive interaction cycles in which child non-compliance and caregiver responses escalate each other through negative reinforcement. Changing caregiver contingency management — moving from coercive to calm, consistent, positively structured responses — is one of the most effective levers for reducing ODD symptoms and preventing escalation toward conduct problems. Parent Training CBPT provides the competence-based framework for this parallel work.
What does the child-directed play work add?
Play-based child work builds the emotion-regulation capacity, frustration tolerance and social problem-solving skills that the child lacks — skills that cannot be acquired through instruction alone in a child with ODD, because the confrontational frame of direct teaching triggers the same defiance the therapy aims to address. The non-confrontational, child-directed play frame opens access to the very capacities the intervention needs to develop.
When should conduct disorder be considered?
Conduct disorder should be considered when there is a pattern of violating the basic rights of others or major age-appropriate societal norms or rules — including aggression to people or animals, destruction of property, deceitfulness or theft, and serious rule violations. This represents a different, more severe trajectory than ODD. ODD can precede conduct disorder, making early intervention important; the clinician should assess for both and track whether the picture evolves.
How long is treatment and how is it structured?
Treatment is organised across roughly 16 weeks, though duration is individualised to the child and family. It combines child play sessions and parent-training meetings in a parallel structure, with both tracks following the five-phase CBPT sequence from orientation and assessment through intervention to conclusion and follow-up. The Playbook resource supports generalisation of skills into everyday life between sessions. Follow-ups are scheduled at 3, 6, 12 and 24 months.
Train in the full protocol
Master the complete CBPT assessment-and-treatment protocol for childhood ODD — five clinical phases, play-based emotion-regulation and social problem-solving work, and the parent-training pathway.
Enrol in the CBPT Clinical Applications programBibliography
The clinical framework, assessment battery and phase-by-phase protocol described above are grounded in the CBPT literature and in DSM-5 / DSM-5-TR, under the scientific direction of Maria A. Geraci and Susan M. Knell.
- American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR).
- Geraci M. A. (2022). La play therapy cognitivo-comportamentale. Armando Editore. Roma
- Geraci M. A. (2023). Comprendere il mondo dei bambini giocando. Armando Editore. Roma
- Geraci M. A. (2024). Il mondo della dottoressa Lulù. Collana Amazon - CBPT Books.
- Greene, R. W. (2014). The Explosive Child (collaborative problem-solving approach).
- Knell S. M. (1993). Cognitive Behavioral Play Therapy. J. Aronson.
CBPT Research Center — Training Programme
Professional Training in CBPT for Oppositional Defiant Disorder
The CBPT Research Center develops and delivers evidence-based postgraduate training for psychologists, psychotherapists and clinical specialists. Our certified curriculum includes a dedicated module on the CBPT approach to Oppositional Defiant Disorder, grounded in peer-reviewed research and clinical practice.
View the training curriculumBuild the skill — go further with CBPT
Skills you can use in session, self-paced — under the scientific direction of Susan M. Knell, originator of CBPT.