Behavioural management of defiance and oppositional behaviours — formative SAQs

SAQ 1 — Formulation and first-line plan (10 marks)

A 7-year-old boy is brought because “he never listens.” For 18 months he has argued daily, lost his temper over small demands, blamed siblings, and been spiteful after consequences. Home and school are both affected. Teachers report incomplete work and frequent talking back, but no stealing, fire-setting or animal cruelty. Mother says time-out “makes it worse” and she often gives up the demand. Father is less involved. The child is otherwise growing well. Hearing screen last year was normal. [4] [9]

Questions

1. Distinguish normative noncompliance, an ODD-range pattern and conduct disorder using this stem. (3 marks) [4]
2. Explain the coercive family cycle likely operating here and why punishment-only strategies fail. (3 marks) [9]
3. Outline a first-line management plan for the next 8 weeks, including school actions and what you would specifically assess for comorbidity. (4 marks) [5] [11] [18]

Model answer

1. Banding (3)

• Not merely normative: duration ~18 months, multi-setting impairment, angry/defiant/vindictive cluster. [4]
• Fits ODD-range pattern rather than isolated toddler limit-testing. [4]
• Not CD on current information: no aggression-to-animals, property destruction, deceit/theft or serious rule-violation criteria described. [4]

2. Coercive cycle (3)

• Demand → child escalates → parent withdraws demand (escape reinforcement for child) or explodes (models aggression). [9]
• Short-term peace is bought; long-term noncompliance strengthens. [9]
• Punishment-only plans without positive engagement and consistent follow-through intensify coercion and do not teach replacement skills. [11]

3. First-line plan (4)

• Behavioural parent training with coached practice (group or individual; Oregon/Incredible Years/PCIT-type components: positive interaction, consistent discipline, practice with child). [5] [11]
• School plan: calm specific commands, contingent praise, planned response to noncompliance, reduce public power struggles; shared goals with teacher. [4]
• Comorbidity screen: ADHD (history + school function), learning/language, sleep, mood/anxiety/trauma. Treat ADHD if present per paediatric ADHD pathway. [18]
• Safety and follow-up metrics: injuries, office referrals, morning routine success, strategy fidelity; step up to specialist care if severe aggression or no functional gain. [4] [5]

SAQ 2 — Medication boundaries and dimensions (10 marks)

A registrar proposes starting risperidone for an 8-year-old with ODD-range arguing and no severe aggression, “because parent training has a six-month wait.” The same child has untreated ADHD features. Another examiner asks how Stringaris dimensions change follow-up. [6] [2] [18]

Questions

1. Critique the risperidone proposal using evidence-based pharmacotherapy principles for disruptive behaviour. (4 marks) [6]
2. State the preferred sequencing when ADHD coexists with oppositional symptoms. (3 marks) [18] [6]
3. Name Stringaris’s three dimensions of oppositionality and one longitudinal implication of the irritable dimension. (3 marks) [2]

Model answer

1. Risperidone critique (4)

• Medication is not first-line for core ODD defiance; psychosocial care comes first. [6]
• Waitlists do not convert mild arguing into an antipsychotic indication; interim parent coaching/school plan and advocacy for access are required. [6] [5]
• Risperidone evidence is strongest in specialist contexts for severe aggression/disruptive behaviour (including subaverage IQ populations), not mild multi-setting arguing alone. [6]
• If ever used later for severe aggression after psychosocial failure, specialist oversight and metabolic/EPS/prolactin monitoring are mandatory; avoid benzos as behaviour management. [6]

2. ADHD sequencing (3)

• Assess and treat ADHD when comorbid; do not wait until “behaviour is fixed.” [18]
• ADHD treatment often reduces secondary oppositional symptoms driven by impulsivity. [18] [6]
• Continue parent training for residual coercive cycles even if ADHD improves. [5]

3. Stringaris dimensions (3)

• Irritable, headstrong, hurtful. [2]
• Irritability longitudinally tracks more toward internalising outcomes (mood/anxiety pathways) than pure conduct alone — so monitor mood, not only office referrals. [2]