Psychosocial Treatment of Oppositional Defiant Disorder

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1 Social Work in Mental Health ISSN: (Print) (Online) Journal homepage: Psychosocial Treatment of Oppositional Defiant Disorder Abby Sprague & Bruce A. Thyer To cite this article: Abby Sprague & Bruce A. Thyer (2002) Psychosocial Treatment of Oppositional Defiant Disorder, Social Work in Mental Health, 1:1, 63-72, DOI: / J200v01n01_05 To link to this article: Published online: 20 Oct Submit your article to this journal Article views: 628 View related articles Citing articles: 3 View citing articles Full Terms & Conditions of access and use can be found at Download by: [Florida State University] Date: 26 November 2015, At: 06:53

2 Psychosocial Treatment of Oppositional Defiant Disorder: A Review of Empirical Outcome Studies Abby Sprague Bruce A. Thyer ABSTRACT. Objective: To review and describe empirical outcome studies on the psychosocial treatment of children and adolescents meeting the criteria for Oppositional Defiant Disorder (ODD). Method: To locate these treatment outcome studies, an extensive review of the literature using the PsycINFO database was conducted. Results: Psychosocial treatments designed solely for youth meeting the criteria for ODD are rare. Rather, it seems that most of the intervention studies have involved youth with Conduct Disorder as well as ODD, even though these two disorders have distinct differences. Selected psychosocial interventions, including anger control and stress inoculation training, assertiveness training, multisystemic therapy, and rational emotive therapy, have produced favorable outcomes in the studies conducted and published to date. Conclusions: Social workers serving ODD youth should seek training in these provisionally supported evidence-based practices. Given the scarcity of treatments designed solely for ODD with adolescents, there is Abby Sprague is affiliated with the School of Social Work, University of Georgia. Bruce A. Thyer is affiliated with the School of Social Work & Department of Psychology, University of Georgia; the Department of Psychiatry and Health Behavior, Medical College of Georgia; the School of Human and Health Sciences, University of Huddersfield, UK; and the Department of Social Work, Queen s University of Belfast, Northern Ireland. Address correspondence to: Bruce A. Thyer, School of Social Work, University of Georgia, Athens, GA ( Bthyer@arches.uga.edu). Social Work in Mental Health, Vol. 1(1) by The Haworth Press, Inc. All rights reserved. 63

3 64 SOCIAL WORK IN MENTAL HEALTH a need for more outcome studies on this specific population, and for more studies of social work practice involving such youth. [Article copies available for a fee from The Haworth Document Delivery Service: HAWORTH. address: <getinfo@haworthpressinc.com> Website: < by The Haworth Press, Inc. All rights reserved.] KEYWORDS. Oppositional Defiant Disorder, ODD, psychosocial treatment, evidence-based practice The most common mental health diagnoses observed among child and adolescents seeking treatment are Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD) (Cohen, Kasen, Brook, & Struening, 1991). According to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994), ODD is defined by the following criteria: A recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months and is characterized by the frequent occurrence of at least four of the following behaviors: losing temper, arguing with adults, actively defying or refusing to comply with the requests or rules of adults, deliberately doing things that will annoy other people, blaming others for his or her own mistakes or misbehavior, being touchy or easily annoyed by others, being angry and resentful or being spiteful or vindictive. To quality for Oppositional Defiant Disorder, the behaviors must occur more frequently than is typically observed in individuals of comparable age and developmental level and must lead to significant impairment in social, academic, or occupational functioning. The diagnosis is not made if the disturbance in behavior occurs exclusively during the course of a Psychotic Mood Disorder or if criteria are met for Conduct Disorder or Antisocial Personality Disorder. (p. 92) Oppositional symptoms usually increase with age, and before puberty the disorder is more prevalent in males. However the rates in males and females after puberty are similar. The prevalence of ODD varies from 2% to 16%, depending on the sample studied and method of assessment. One recent large-scale study of over 7200 children found a prevalence rate of about 6% among 1-4th grade students (August,

4 Abby Sprague and Bruce A. Thyer 65 Realmuto, MacDonald, & Nugent, 1996). Lehmann and Dangel (1998) say that when dual diagnoses overlap, such as in the case of ODD and CD, it is unlikely that the true prevalence rates will ever be known (p. 93). Evidence of ODD is usually seen before age 8 and not later than early adolescence. ODD is not rare. Social workers serving children and youth will frequently encounter clients meeting the criteria for ODD. There is often confusion between the diagnostic criteria for Conduct Disorder versus ODD. The DSM attempts to clarify this by explaining that individuals with ODD exhibit less severe disruptive behaviors than individuals with CD. The ODD behaviors generally do not include aggression toward animals or people, a pattern of deceit or theft, or destruction of property. If the criteria for CD are met, ODD is not diagnosed because the features of ODD are subsumed by those for CD. School social workers and other social work clinicians are in a good position to provide direct services to these students. Social workers can play a part in creating therapeutic schools where each teacher and administrator fosters ownership for the mental health of students. To do this, social workers can educate school professionals in certain areas. This education can serve as one intervention towards aiding those students with the most frequently diagnosed disorders, one of which is Oppositional Defiant Disorder. REVIEW OF TREATMENT STUDIES The PsycINFO database was searched, using as key words oppositional, defiant, disorder, children, and adolescents. The features and results of empirical outcome studies of psychosocial treatments for youth meeting the criteria for ODD are reviewed. We also made use of Brestan and Eyberg (1998) recent review of similar studies, wherein they described a number of interventions as probably efficacious, meaning there are at least two published journal studies demonstrating that the treatment is more effective than wait-list controls, or two studies that otherwise satisfy criteria for a well-established treatment but are administered by the same research team or investigator. A second standard that defines a probably efficacious treatment is a display of efficacy in a study that meets all standards for a well-established treatment except an independent research team s replication.

5 66 SOCIAL WORK IN MENTAL HEALTH Anger Control and Stress Inoculation Training One very promising set of treatments for youth with ODD are anger control and stress inoculation training, defined as: a coping skills therapy that aims to provide the client with the cognitive and behavioral resources for dealing with stressful situations and for regulating personal stress reactions... the therapeutic approach hypothetically works by first developing coping skills and then exposing the client to manageable doses of a stressor; doses that arouse, but do not overwhelm, the client s defenses. (Novaco, 1985, p. 1) Feindler, Marriot, and Iwata (1984) evaluated on an Anger Control Training program that was administered in a group format for biweekly sessions at a junior high school. There were 10 biweekly 50-minute training sessions. Thirty-six adolescents from a sample of students in a behavior modification program for multisuspended delinquents were chosen based on their high rates of classroom and/or community disruptions. The youth were randomly assigned to two conditions, anger control training versus no-treatment. Pre and post-treatment measures were obtained on school suspensions, classroom fines for disruptive behavior, and scores on standardized measures of problem-solving, locus-ofcontrol, and teacher ratings of student-self-control. The treatment program lasted about 4.5 weeks. The youth were taught common self-control strategies, as well as specific strategies related to aggressive/disruptive events. This intervention targeted occurrences of aggression, social problem-solving skills, and self-control. Group participation, as well as completion of homework, earned participants a Coke and snack immediately following each group. Also effective in gaining cooperation and establishing commitment were in-group reinforcers, including being taught to operate the video equipment, being assigned roles as actors or directors in role-playing situations, being allowed to leave early, and being given free time. Treatment initially focused on suppressing verbal and nonverbal aggressive responding. Students were taught to examine the parts of the provocation cycle such as anger cues, aggressive responses, and consequent events. They recorded this information in a behavioral log. This helped the students see changes in their responses to provoking stimuli. Following this was instruction in two time-out responses. Clients were taught to put in a time delay between the provoking stimuli

6 Abby Sprague and Bruce A. Thyer 67 and the automatic response and to ignore the stimuli for a few seconds. Other techniques were also used to gain control over anger-provoking situations. Verbal and nonverbal assertive responses were taught as alternatives to previous aggression. The more aggressive responses of demands, disagreeable tones, menacing gestures, and staring were replaced during behavior rehearsals of conflict scenes. The aggressive responses were supplanted by practices such as requests for another s behavior change, moderate tone of voice, direct eye contact, and suitable gestures. Also used in the training were the verbal assertive techniques of broken record, fogging, and minimal effective response. Problem-solving was also taught. In the problem-solving area, problem stipulation, itemization of response alternatives, cataloguing consequences of every response, practicing alternatives, and assessing results were taught. The participants were given the opportunity to rehearse these skills, with usual school and home conflict scenarios. Four approaches were used to teach the adolescent alternative responses to provocations. The first method was self-instruction. The student might tell himself to ignore the aggressor and keep cool. The second technique was covert modification of the participant s understanding of the aggression-causing conditions. The participant might tell himself that the aggressor is just envious of his academic performance. Third was self-evaluation of behavior during a conflict and of efficient goal accomplishment. The participant might ask, How did I handle myself? Fourth was a cognitive control technique called thinking ahead that centers on the faulty thinking skills of many troubled adolescents. The participant was instructed in methods of choosing appropriate behaviors and using them to foster self-control. To boost attention to the parameters of the reinforcing or punishing stimulus, imagery training was incorporated. The youth assigned to Anger Control Training displayed significantly fewer school suspensions and in-class fines, compared to the no-treatment control group, as well as more improved problem-solving abilities and self-control. Schlicter and Horan (1981) studied 38 institutionalized male delinquents showing verbal and physical aggression in response to anger provocations, using a pre and posttest design, and random assignment to three conditions: stress inoculation training (SIT), conventional therapy not including SIT, and no treatment. Treatment consisted of 10 one hour-long sessions, and the SIT involved three phases. In Phase One youth were educated about anger and aggression, including the causes, consequences, and alternative control methods. Other educational elements included providing a definition of anger, the analysis of recent

7 68 SOCIAL WORK IN MENTAL HEALTH anger incidents, the reviewing of self-monitoring data, and the construction of an individual 6-item anger hierarchy. In Phase Two clients were taught specific coping skills, including self-instructions, relaxation training, backward counting, pleasant imagery, how to assertively (as opposed to aggressively) respond, and self-reinforcement. In Phase Three, the clients initially role-played a provoker role, and therapists the role of the coper. The roles were then reversed. Modeling, practice, and feedback were used until the highest hierarchy item was mastered. Clients were seen individually for an hour twice a week, over a five-week period, and were given $1 each session. Results revealed that SIT, as well as conventional treatment, reduced anger and aggression on three self-report scales, but only SIT lowered verbal aggression in role-played provocations. Assertiveness Training Assertiveness training is an intervention method which is designed to enhance interpersonal skills...onthemostgenerallevel,itreferstothe expression of preferences and opinions (Gambrill, 1985, p. 7). The assumption underlying assertiveness training is that productive relationship skills can be taught, leading individuals to be able to relate to others in terms of understanding and mutual respect. Huey and Rank (1984) examined the effects of group assertive training on African Americans exhibiting aggression, as well as the effectiveness of professional and peer counselors as trainers. Forty-eight male participants, chosen for their aggressive classroom behavior, were randomly assigned to three groups, assertiveness training in groups, group discussions, or to no-treatment. Pre and post-treatment assessments were made of assertiveness, anger, and aggression in the classroom. A response that was forthright and honest without being threatening or abusive was considered an assertive response. Passive responses were those that showed unwillingness to stand up for one s rights. An aggressive response was indicated when the subject used sarcasm, insults, threats, and tried to reach his goals in an abusive way. Youth receiving assertiveness training demonstrated greater improvements on the outcome measures that those assigned to the group discussion or to no-treatment conditions. Multisystemic Therapy Multisystemic therapy emphasizes both the interactional nature of adolescent psychopathology and the role of multiple systems in which

8 Abby Sprague and Bruce A. Thyer 69 the adolescent is embedded, such as the family, school and peer group... The family is viewed as a core focus of the intervention...therapistsintervene at one or more levels as required, and employ a variety of therapy approaches, such as family therapy, school consultation, peer intervention strategies, marital therapy, or individual therapy (McMahon & Wells, 1998, pp ). Henggeler, Rodick, Borduin, Hanson, Watson, and Urey (1986) evaluated multisystemic therapy (MST) with 57 juvenile offenders and their families. Participants received one of three conditions, MST, referral to standard treatment, or to no-treatment. Standardized pre and post-treatment assessments were made of personality, behavior problems, and family relationships. Those youth receiving MST showed appreciably fewer conduct problems and anxious-withdrawn behaviors, less immaturity and affiliation with undesirable peers. Family relations improved and the adolescent took a more active, positive, role within the family. A number of other studies have evaluated MST with delinquent youth. Borduin, Mann, Cone, Henggeler, Fucci, Blaske, and Williams (1995) examined the long-term effects of using multisystemic therapy (MST) versus individual psychotherapy (IT) on preventing criminal behavior and violent offending, with 176 juvenile offenders as participants. Results revealed that MST was more effective than IT in improving key family correlates of antisocial behavior and in ameliorating adjustment problems in individual family members (Borduin et al., 1995, p. 569). MST was also shown, at a four year follow up, to be more effective than IT in preventing future criminal behavior, a remarkably positive finding. Social workers Sutphen, Thyer and Kurtz (1995) used a combination of single-subject designs and a group O-X-O design to evaluate multisystemic treatment provided to 8 juvenile offenders determined to be at high risk for reoffending. The intervention provided these youth with case management services, an educational program, traditional family therapy provided by a social worker, and an additional parent-adolescent nurturing program. Outcome measures included family functioning, a Delinquency Index, recidivism in reoffending, life skills, and school functioning. Improvements were noted through the program and post-treatment on measures of family environment, parent reports of problem behavior, adolescent life skills, school attendance and grades, and reduced delinquent associations. To obtain statistically significant differences with such as small sample size suggests that these improvements were sizable as well as reliable.

9 70 SOCIAL WORK IN MENTAL HEALTH Rational Emotive Therapy Rational emotive therapy is A psychotherapeutic method based on cognitive theory and the ideas of psychologist Albert Ellis, in which the client is encouraged to make distinctions between what is objective fact in the environment and the inaccurate, negative, and self-limiting interpretations made of one s own behavior and life (Barker, 1999, p. 400). Block (1978) examined the effectiveness of a rational-emotive mental health program with Hispanic and African American eleventh and twelfth graders who were at risk of academic failure and were also prone to misconduct. Forty youth were randomly assigned to three conditions, rational emotive therapy (RET) conducted in groups, psychodynamic group therapy, or to no treatment. RET focused on cognitive restructuring through the practice of adjustive rational appraisal, in vivo activity exercises, small-group directed discussion, and psychological homework assignments (Block, 1978, p. 61), and involved much role-playing to aid students in internalizing and applying the given concepts. There were sessions built around predetermined themes. Group leaders took an approach that was task-oriented, as well as extremely active and directive. When doing their homework, as well as in-class assignments, students were asked to give honest expressions of feelings. There were exercises involving direct confrontations and risk-taking. Pre and post-treatment assessments were made of disruptive classroom behavior, cutting classes, and of grades. Students receiving RET made the greatest improvements, compared to the other two groups. DISCUSSION Psychosocial treatments for youth meeting the DSM criteria for Oppositional Defiant Disorder that may be provisionally labeled as evidence-based include anger control and stress inoculation, assertiveness training, multisystemic therapy, and rational emotive therapy. But the overall strength of the evidence for any single approach remains relatively weak. Very few studies have been conducted involving children and youth meeting the criteria only for ODD, unmixed with Conduct Disorder, Attention Deficit Hyperactivity Disorder, and related conditions. This compromises effectiveness studies attempting to build evidence-based knowledge specific to children experiencing ODD. Nevertheless, social workers serving ODD youth and their families should become familiar with those limited numbers of psychosocial

10 Abby Sprague and Bruce A. Thyer 71 treatments that have so far been empirically evaluated and shown to be helpful, as described in this paper. It may be reasonably assumed that the larger body of empirical outcome studies evaluating treatments for youth with Conduct Disorder can be extrapolated to the care of ODD children and adolescents (see Kazdin, 1998; Rapp & Wodarski, 1998), but this should be done cautiously. No formal practice guidelines for the treatment of ODD have yet been published, although there is a rapidly expanding literature on the use of psychotropic medications with this population. This is disturbing given the likelihood that selected psychosocial treatments can be beneficial, treatments which do not suffer from the side-effect profiles and stigmatization associated with medication use among the young. There is also relatively little work authored by social workers with this group of children. Given than clinical social workers are the largest providers of mental health care services in the United States, we agree with the recommendations of Lehmann and Dangel (1998): Given the state of the field, social work has a dual role for the future. First, the profession needs to develop more collaborative models of intervening effectively with ODD. Such an approach may include integrating theoretical models as well as incorporating treatment regimens from professions such as psychology and marriage and family therapy. Finally, [there is an] absence of grounded research from the profession. Empirical studies reflecting a social work perspective are needed. (p. 109) REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. August, G. J., Realmuto, G. M., MacDonald, A., & Nugent, S. M. (1996). Prevalence of ADHD and co-morbid disorders among elementary school children screened for disruptive behavior. Journal of Abnormal Child Psychology, 24, Barker, R. (Ed.) (1999). The social work dictionary (4th edition). Washington, DC: NASW Press. Block, J. (1978). Effects of a rational-emotive mental health program on poorly achieving, disruptive high school students. Journal of Counseling Psychology, 25, Borduin, C.M., Mann, B.J., Cone, L.T., Henggeler, S.W., Fucci, B.R., Blaske, D.M., & Williams, R.A. (1995). Multisystemic treatment of serious juvenile offenders: Long-term prevention of criminality and violence. Journal of Consulting and Clinical Psychology, 63,

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