Oppositional defiant disorder: characteristics and treatment approaches

Self-Efficacy and Oppositional Defiant Disorder

Oppositional Defiant Disorder

The challenges of adolescence have always loomed large for young people and for families -- for as long as adolescence has been a recognized stage in human development. A constellation of skills is needed by young people to bridge the transition from childhood dependency to adult independency (Smith, Cowie, & Blades, 1998). For some young people, the transition is especially difficult and skill development does not progress smoothly or without incidence. One of the areas in which adolescents may particularly experience difficulties is that of originating, developing, and directing purposeful goal-directed action (Zimmerman & Cleary, 2006). The umbrella term that covers these behaviors is personal agency (Zimmerman & Cleary, 2006). When these behaviors result in positive outcomes in line with an individual's intention, the behavior is deemed effective (Zimmerman & Cleary, 2006). Having confidence in one's ability to achieve according to one's desires and abilities is referred to as self-efficacy (Zimmerman & Cleary, 2006).

As with most belief systems, self-efficacy is not static -- belief in one's self-efficacy can swing wildly depending on life circumstances, available resources, and how broadly a person can extend their sphere of control (Zimmerman & Cleary, 2006). A belief in the ability to influence the world external to the self holds within it a belief in the ability to influence how one interacts with the external world (Zimmerman & Cleary, 2006). For everyone, not just adolescents, these beliefs in oneself are nested, one within the other (Zimmerman & Cleary, 2006). For most adults, however, there exists some history of personal efficacious behavior from which to draw when faced with challenges and doubts (Zimmerman & Cleary, 2006). Adolescents generally do not have this springboard from which they can propel themselves forward with a reasonable level of confidence that they will figure things out (Zimmerman & Cleary, 2006). Further, adolescents are not afforded the same options as adults regarding choices of life activities (Zimmerman & Cleary, 2006). Most adolescents have to attend schools -- a milieu that imposes a swath of social and intellectual challenges that can be as punishing as they are rewarding (Zimmerman & Cleary, 2006).

For young people who behave in a manner that indicates the presences of some disordering of the natural responses to the challenges of adolescence, a decidedly discouraging and self-fulfilling downward spiral can occur. The behaviors that are associated with oppositional defiant behavior -- and its frequently co-morbid condition conduct disorder -- are not tolerated well by social systems, and particularly not by schools. Counselors who provide therapeutic support for these adolescents draw on a number of theoretical bases. This paper will examine the occurrence of oppositional defiance disorder in the adolescent experience, and consider and discuss therapeutic approaches to the adolescents who exhibit behaviors associated with this disorder.

The first section of the paper presents a brief discussion of oppositional defiant disorder and its relation to co-morbid conditions. A discussion follows of self-efficacy as the bridge to behaviors and actions that tend to increase the probability of positive outcomes for adolescents. The second section explores the relation between self-efficacy and the self-regulatory behaviors of self-directed learners. This discussion considers explores the linkages between self-efficacy beliefs, self-regulatory behaviors, and the expression of empowerment and capability that drives further increases in self-efficacy. The relation of oppositional defiant disorder to perceived self-efficacy is discussed in this section and connects with the counseling and therapeutic approaches. In the final section, the strategies and approaches available to counselors and therapists who treat adolescents with oppositional defiant disorder are explored.

Oppositional Defiant Disorder

Oppositional Defiant Disorder, as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and as reported in several large community-based studies, occurs in approximately three percent of children in the population (Hamilton & Armando, 2008; ). However, considerable variance exists across the studies with regard to age at diagnosis, the number of informants interviewed, the exact criteria applied in assessment, such that, the prevalence estimates range from one percent to 16% (Hamilton & Armando, 2008).

The disorder is more common in girls than in boys, but there is some inconsistency in reported data, particularly since rates of incidence appear to even out in adolescence (Hamilton & Armando, 2008). Behavioral differences are apparent and there is some consideration in the field about using different criteria for assessing girls over boys (Hamilton & Armando, 2008). Aggression in girls is evidenced differently and exhibited more covertly than in boys (Hamilton & Armando, 2008). Verbal attacks, exclusion of others, and spreading rumor about other children are all more common expressions of aggression in girls and appear to typically supplant the physical aggression that is typical of boys with this disorder (Hamilton & Armando, 2008). Interestingly, the prevalence of oppositional defiant disorder is greater among children from low socio-economic backgrounds (Hamilton & Armando, 2008). Although symptoms typically appear two to three years prior to diagnosis, formal diagnosis of the disorder most often occurs in the later years of preschool or in the early years of elementary school (Hamilton & Armando, 2008). As children age, according to cross-sectional epidemiologic research studies, the prevalence of oppositional defiant disorder gradually increases (Hamilton & Armando, 2008).

Substantially impaired relationships with peers, parents, and teachers are the primary indicator for oppositional defiant disorder (Green, et al., 2002; Hamilton & Armando, 2008). In comparisons with same-age, same-sex peers, children and adolescents with oppositional defiant disorder score more than two standard deviations below the mean when assessed using scales for social adjustment (Green, et al., 2002; Hamilton & Armando, 2008). Their social impairment is considered to be greater than it is for children who have bipolar disorder, various anxiety disorders, and major depression (Green, et al. 2002; Hamilton & Armando, 2008). Conduct disorder and pervasive developmental disorder show a similar degree of difference -- though it is not statistically significant -- in social adjustment in comparison with oppositional defiant disorder (Green, et al., 2002; Hamilton & Armando, 2008).

Etiology. There does not appear to be a single greatest risk factor or a single cause for oppositional defiant disorder (Hamilton & Armando, 2008). The predominant theory is presented within the context of a biopsychological model (Hamilton & Armando, 2008). According to this theory, biology and environment combine to influence the likelihood that the disorder will develop (Hamilton & Armando, 2008). A child with oppositional defiant disorder will have certain biological protective factors and biological vulnerabilities that interact in complex ways with the protective aspects and the harmful aspects of the child's environment (Hamilton & Armando, 2008).

Contemporary theories point to deficits in discrete sets of skills that result in behavior that is seen as defiant or oppositional (Hamilton & Armando, 2008). Immature cognitive or emotional development may result in immature responses from children with oppositional defiant disorder (Hamilton & Armando, 2008). For instance, self-regulation skills such as affective modulation, may not be well developed such that a child with oppositional defiant disorder generally overreacts emotionally and physically, temporarily shutting off their capacity (child-like and immature to begin with) to reason or be reasoned with (Hamilton & Armando, 2008). Other theories point to deficits in executive cognitive functioning, such as the ability to shift focus and change tasks, to organize for problem solving, or to effectively tap working memory (Hamilton & Armando, 2008). In fact, some of these deficits have been demonstrated in children with pervasive developmental disorder and autism (Hamilton & Armando, 2008). Deficits of this order can undermine a child's effort to comply with the demands of adults and the challenges of interacting with peers (Hamilton & Armando, 2008). These skill deficits are central to the transactional theories of oppositional defiant disorder that examines the context of the problem behaviors and the interactions between the parents and the children (Hamilton & Armando, 2008). This transactional conceptualization of oppositional defiant disorder highlights the predictability of behavioral meltdowns by the child according to certain contexts, such as transitions to dinnertime, bath time, and bedtime (Hamilton & Armando, 2008). Functional behavioral assessments show that characteristic transactions between parents and children occur at these transitional times that tend to exacerbate problem behavior and increase the probability that it will occur (Hamilton & Armando, 2008).

Conditions co-morbid with oppositional defiant disorder. Various neurobiological theories have been put forward regarding the aggression that occurs in children with oppositional defiant disorder (Hamilton & Armando, 2008). No single neurotransmitter or neurological pathway has been found to be the root cause of oppositional defiant disorder (Hamilton & Armando, 2008). There is a clear familial relation but the role of genetics is not yet clear and studies have produced inconsistent results (Hamilton & Armando, 2008). The natural history of oppositional defiant disorder is not well understood, however, the majority of people who are diagnosed with the disorder as children will exhibit the disorder along with a co-existing condition (Hamilton & Armando, 2008). Typically, disorders co-morbid with oppositional defiant disorder in adults include an affective disorder and attention deficit hyperactivity disorder (ADHD) (Hamilton & Armando, 2008). Commonly, children who receive diagnoses of oppositional defiant disorder in preschool or early elementary school transition to a diagnosis of one of three major categories of disorder: depression, anxiety, or ADHD (Hamilton & Armando, 2008). Then, too, a goodly number of children do not develop co-existing conditions (Hamilton & Armando, 2008). Many children with oppositional defiant disorder continue to exhibit a stable pattern of the disorder as adults (Hamilton & Armando, 2008). In general, the more severe the oppositional defiant disorder is in childhood and the earlier symptoms were recognized or diagnosis occurred, the poorer the prognosis over the life-span (Hamilton & Armando, 2008).

The Multimodal Treatment Study of Children with ADHD is the most comprehensive study of children with a diagnosis of ADHD (Hamilton & Armando, 2008). The study found that 40% of the children identified as having ADHD were also found to meet the diagnostic criteria for oppositional defiant disorder even if they had not been diagnosed with the disorder (Hamilton & Armando, 2008). In general, children who have both disorders are associated with less positive outcomes (Hamilton & Armando, 2008). For instance, children with a dual diagnosis tend to have more persistent behavioral problems and exhibit more aggression, experience more peer rejection, and also show more severe academic underachievement (Hamilton & Armando, 2008). With regard to co-morbidity, one study found that children with oppositional defiant disorder were twice as likely than a reference group to have severe bipolar disorder or severe major depression (Hamilton & Armando, 2008). In a community-based study, the breakdown of co-morbid conditions with oppositional defiant disorder was 14% with ADHD, 14% with anxiety, and 9% with a depressive disorder (Hamilton & Armando, 2008). Although there is no hard data, experts generally agree that oppositional defiant disorder frequently occurs in conjunction with language disorders and learning disabilities (Hamilton & Armando, 2008).

Conduct disorder and oppositional defiant disorder. Many experts have considered oppositional defiant disorder to be a precursor and subset of conduct disorder, as children with conduct disorder nearly always have a history of having exhibited the symptoms of oppositional defiant disorder (Hamilton & Armando, 2008; Maughan, 2004). In fact, roughly 33% of the children with oppositional defiant disorder eventually develop conduct disorder, and 40% of the 33% will show symptoms of antisocial personality disorder when they reach adulthood (Hamilton & Armando, 2008; Maughan, 2004). Those children who have ADHD and oppositional defiant disorder as comorbid conditions are the most likely to develop conduct disorder (Hamilton & Armando, 2008; Maughan, 2004).

According to the DSM-IV criteria and stipulations, a child cannot be diagnosed with both conduct disorder and oppositional defiant disorder at the same time (Hamilton & Armando, 2008). When a child with oppositional defiant disorder exhibits behaviors severe enough to meet the criteria for conduct disorder (such as theft or destruction of property belonging to others, aggression toward others and toward animals, and a general disregard for the rights of other people), then the diagnosis of oppositional defiant disorder must be dropped in favor of the diagnosis of conduct disorder (Hamilton & Armando, 2008). Conceptualizations of the relation between conduct disorder and oppositional defiant disorder ranges from treating them as two completely distinct disorders to considering them both to on a continuum, differing primarily in terms of the severity of the disruptive problem behavior (Hamilton & Armando, 2008). Regardless, conduct disorder is considered as a more serious disorder and an unhappy and poor outcome for some children who were previously diagnosed as having oppositional defiant disorder (Hamilton & Armando, 2008).

The Self-Efficacy Bridge

A number of expectancy-related constructs are associated with and often confused with self-efficacy by laypersons (Zimmerman & Cleary, 2006). These expectancy-related constructs pertain to an individual's outcome expectations, locus of control, self-esteem, and self-concept (Zimmerman & Cleary, 2006). Each of these constructs is distinct though certainly they are related (Zimmerman & Cleary, 2006). To strengthen the understanding about self-efficacy for the purposes of this discussion, it is important to clarify how these constructs are alike and how they are different. The following section addresses a definitional and descriptive discussion of the expectancy-related constructs.

Self-concept. A more generalized and less context-specific assessment of the self, self-concept incorporates general beliefs about one's competence, intelligence, social abilities, talents, and feelings of self-worth. Here, self-efficacy differs in its reference to context with self-judgments based on personal ability to establish a direction or aim, to organize resources and energies, and to take action along that course in order to attain a specific objective or goal (Zimmerman & Cleary, 2006). It can be seen that where self-concept is a more global assessment of the self, the focus of self-efficacy is narrower and tacks specifically toward particular activities or tasks that an individual perceives as manageable in relation to their capacity (Zimmerman & Cleary, 2006). As a more global assessment, aspects of self-efficacy can be found in self-concept, along with measures pertaining to self-esteem and a holistic sense of competence constructed by the self (Zimmerman & Cleary, 2006). Pajares and Miller (1994) found that academic performance is enhanced directly by a belief in self-efficacy, and indirectly thorough its action on self-concept.

Self-esteem. An affective reaction about how one feels about their own self, self-esteem is a judgment of self-worth (Zimmerman & Cleary, 2006). Self-esteem differs from self-efficacy as the one is an affective response and the other is a cognitive judgment about personal capabilities (Pintrich & Schunk, 2002). Self-concept -- as the global perception of the self -- can contribute to self-esteem, but so can any number of other attributes that are variously considered of value or not by society (Bandura, 1997). Mone, Baker, and Jeffries (1995) studied self-esteem and self-efficacy with regard to the validity of the constructs for predicting the performance and goal attainment of college students. Almost half of the variance in the prediction of goal attainment was accounted for by self-efficacy, and up to 14% of the variance in the prediction of academic performance was accounted for by self-efficacy, while self-esteem was not predictive of either goal attainment or academic performance. The work of Mone, et al. (1995) informs the literature on self-efficacy as a predictor of academic outcomes, and makes salient the idea that as task-specificity increases, the predictive ability of self-perception measures also increases.

Outcome expectations. Beliefs about self-efficacy have been shown to be more predictive of the behavior of individuals than outcome expectations (Schunk & Miller, 2002). Regardless, outcome expectations are important to the understanding of behavior (Bandura, 1997). Shell, Murphy, and Bruning (1989) explored the relative predictive power of outcome expectations and self-efficacy on achievement in reading and writing. In this study by Shell, et al. (1989) outcome expectations were associated with social endeavors, family life, education, and employment, while self-efficacy was measured by the perceptions held by students regarding their abilities to perform writing and reading tasks. Self-efficacy accounted for 25% of the variance in reading achievement while outcome expectations accounted for only 4% of the variability (Shell, et al., 1989).

Perceived control. The work of Rotter (1966) on locus of control forms the basis for the research on the construct of perceived control, which holds that personal outcomes are the result of one's own behavior or external events (Zimmerman & Cleary, 2006). An internal locus of control is seen as fostering self-directed behavior while an external locus of control tends to act as an inhibitor on the skills and abilities associated with personal agency (Zimmerman & Cleary, 2006). People with higher levels of self-efficacy and a perceived internal locus of control tend to exhibit more self-directed behaviors than people with lower levels of self-efficacy and a perceived external locus of control (Zimmerman & Cleary, 2006). However, perceived control does not necessarily factor in levels of confidence about performing certain tasks and activities in particular contexts and, as Bandura suggested (1986, 1997), there may be very little value in de-contextualizing people's perceptions of control. Smith (1989) reported that locus of control has no predictive value for improvement in academic performance, nor did it contribute to a reduction in anxiety levels of student who had been engaged in training for coping skills. However, self-efficacy did demonstrate predictive value in the improvement of academic performance, and this capacity is attributed largely to the focus of self-efficacy beliefs on task-specific and context-specific performance and the relation to an individual's perceptions about their capability (Smith, 1989).

Zimmerman and Cleary (2006) assert that the perceptions adolescents have of their efficacy has a substantive influence on their transition to adulthood. The literature on ecological contexts in which the beliefs adolescents hold about their self-efficacy are challenged has illustrated the complexity of the development of these beliefs (Zimmerman & Cleary, 2006). Self-efficacy beliefs are shaped by a dynamic and complex mesh of interconnected forces that exhibit a dyadic nature -- these beliefs are both the cause and the effect of adolescent functioning (Zimmerman & Cleary, 2006). An adolescent's beliefs about his social and intellectual abilities impact his expression of these beliefs in the form of basic levels of functioning (Zimmerman & Cleary, 2006). In other words, the conventional wisdom is that mind over matter really makes a difference. With adolescents experiencing self-efficacy issues, strongly held beliefs have the potential to impact day-to-day functioning and choices that will have long-reaching impact, such as academic coursework that facilitates future choices of occupation (Zimmerman & Cleary, 2006).

Bandura (1997) held that self-efficacy could strongly interact with factors that act as determinants of academic functioning regardless of whether these determinants were seen as contextual, personal, or behavioral. The literature point to the importance of self-efficacy measures that are specific with regard to task, condition, and context, and that are sensitive to changes that are reflective of fluctuations in functioning levels.

The magnitude with which self-efficacy can have impact on an adolescent's life is reflective of their capacity to self-regulate the way they function in and across environments. Backward-mapping from successful academic functioning, a number of self-regulatory functions indicate the capacity to have a substantial impact on the development of self-efficacy beliefs. These academic self-regulatory functions include: goal setting, accurate self-monitoring, self-evaluation against appropriate standards, using effective strategies, and "attributing causation to adaptable processes" (Zimmerman & Cleary, 2006).

Bandura cautioned against using narrow measures of personal functioning or self-efficacy when the goal is to assess board developmental issues. Bandura, Barbaranelli, Caprara, & Pastorelli, (1996, 2001), conducted a series of ecological studies that included a broader look at the academic and personal development of adolescents. From Bandura's social cognitive perspective, a number of non-academic school context variable impact academic performance. Consider that a student who exhibits poor self-regulation, who has difficulty forming and maintaining positive social relationships with classmates and other students at school will suffer in terms of academic performance, social connections, and personal perceptions of self. Bandura et al. (1996, 2001) examined several types of beliefs about self-efficacy in the students they studied, as follows: (1) Social functioning, which included the formation and maintenance of relationships with peers; (2) self-regulatory functioning, which was indicated by the ability to resist peer pressure to engage in substance abuse or participate in high risk behaviors; and (3) academic functioning which was viewed as mastering different subject matter and self-regulating learning tasks and activities. In addition to these measures, Bandura et al. (1996, 2001) also measured adolescent functioning such as problem behavior, presence of depression, peer preferences, prosocial behavior, and moral disengagement. Because these studies were ecological in their orientation, parents provided self-efficacy measures that focused on their ability to influence the development of their children, and expressions of academic aspirations that they held for their children. The ecological study (Bandura, 1996) showed that the parental academic aspirations and the prosocial behavior of the adolescents were completely mediated through the families' socioeconomic status. In other words, the higher the family's status, the greater the adolescents' prosocial behavior and the higher the parents' academic aspirations for their children. Bandura, et al. (1996) concluded that all of the forms of self-efficacy influenced the academic performance of the adolescents but different this was accomplished through different paths, as revealed through the path analysis employed by the researchers. The ecological study showed that adolescents who doubt their self-efficacy are likely to reduce their academic aspirations, be more depressed, develop more problem behavior, and engage in less prosocial behavior (Bandura, et al., 1996). The long-range view of this constellation of variables is that as the students' doubts about their intellectual capabilities increase and there is a correlational degradation in academic skills, future occupational choices narrow in response.

In a separate study focused on the career choices of adolescents, Bandura et al. (2001) found that occupational self-efficacy perceptions of the adolescents influenced their choices more than their academic performance. The occupational choices that the adolescents were asked to consider included six career paths, each with a focus in a particular area: agricultural- horticultural, education-medical, literary-art, military-police, science-technology, and social service (Bandera, et al., 2001). Academic achievement did not directly predict the career choices of the adolescents. Instead, the occupational self-efficacy beliefs about what the students thought they would be good at directed their choices, indicating that self-efficacy plays a substantive role in academic pursuits and career development (Zimmerman & Cleary, 2006).

The strength of the role that self-efficacy plays in the aspirations and future outcomes of students with oppositional defiant disorder indicates its importance in therapeutic strategies that have as their basis leaning new skills in order to increase capacity for coping and problem-solving.

Non-pharmacological Treatment of Oppositional Defiant Disorder

The research shows support for non-pharmacological, outpatient treatment interventions for children with oppositional defiant disorder. Generally treatment is family-centered as the research has shown the providing guidance and training to parents is an effective intervention for the reduction of disruptive behavior in children with oppositional defiant disorder. An important reason for including parents in counseling is because of the tendency for others to blame the child with oppositional defiant disorder for their problem behavior. Generally, others in the child's environment project blame based on one or more of three fundamental reasons: (1) The problem behavior is seen as deliberate and within the child's control; (2) the problem behavior is associated with a disliked family member, such as an abusive partner or ex-partner, and (3) the problem behavior is seen as being intentionally hurtful toward one or both of the parents or siblings. Parents of children with oppositional defiant disorder can experience adverse effects on their own health as a result of the chronic difficult behavior and the embarrassing social disruption caused by their children (Kashdan, et al., 2004).

Parental training programs. Parents who receive training in how to interact with their children who has oppositional defiant disorder learn how to observe their child and the context, and practice communicating clearly (Dadds, et al., 2006). In addition, parents are taught and practice techniques for providing positive reinforcement, negotiating skills, and other strategies for managing the behavior of a child with oppositional defiant disorder (Dadds, et al., 2006). With appropriate training, the parents can learn to be more positive in their interactions with their child with oppositional defiant disorder, including using less harsh styles of discipline (Dadds, et al., 2006). The literature, including randomized evidence-based studies, shows that training for both the parents and the child result in more positive change and effective therapy than when the training is directly only at the parent (Dadds, et al., 2006; Webster-Stratton & Hammond, 1997). In general, this finding supports the transactional conceptualization of oppositional defiant disorder -- or at least the notion that transactions and context can exacerbate the problem behavior even if they are not the cause of it (Dadds, et al., 2006). In consideration of training modalities, media-based training, such as watching training videos, has been found have lasting positive treatment effects for parents with the improvements continuing well after one year following the intervention (Montgomery, et al., 2006).