DOI: 10.31038/PSYJ.2025771

Abstract

This commentary critically evaluates the empirical study An Empirical Study of Integration Models and Mechanisms for Maternity Care in Innovative Vocational Education Systems, which addresses maternal health disparities in underserved China through an integrated vocational training model. Using a mixed-methods design combining PLS-SEM and NVivo analysis, the study reveals both the promise and limitations of integrating simulation-based learning, structured supervision, and early clinical immersion. Key findings include significant improvements in patient satisfaction but no measurable impact on student engagement or maternal complications, highlighting systemic barriers to translating training into clinical outcomes. This commentary discusses the study’s methodological innovations, practical implications for vocational education reform and health policy, and identifies future research directions to enhance the model’s effectiveness.

Introduction: Background and Core Issues

Maternal health disparities persist in underserved regions of China, complication rates remain significantly higher than the national average [1]. A critical underlying factor is the fragmentation of vocational education for maternal care, characterized by three key pain points: (1) a disconnect between theoretical instruction and clinical practice, with delayed exposure to real-world scenarios; (2) fragmented simulation training, often limited to video observations rather than hands-on practice; and (3) inadequate structured supervision, leading to passive student engagement [2]. These gaps contribute to poor emergency response skills among graduates and inconsistent care delivery, exacerbating maternal health risks. Against this backdrop, the empirical study (hereafter referred to as the Study) aims to evaluate an integrated training model combining simulation-based learning, structured clinical supervision, and early clinical immersion. This commentary analyzes the Study’s contributions, limitations, and implications for addressing maternal care challenges in underserved settings.

Innovative Methodology: Mixed-Methods Design

The Study’s strength lies in its rigorous mixed-methods approach, which overcomes the limitations of single-method research:

Quantitative Analysis

Partial Least Squares Structural Equation Modeling (PLS-SEM) was used to analyze data from 300 participants (students, nurses, patients, instructors) across experimental (integrated training) and control (traditional training) groups. This allowed the assessment of causal relationships between constructs (e.g., Staff Training → Patient Satisfaction) and multi-group comparisons to identify intervention effects.

Qualitative Analysis

Thematic analysis using NVivo 14 was applied to 14 semi-structured interviews, exploring implementation barriers and stakeholder experiences. This provided contextual depth to explain quantitative findings.

Triangulation

Convergent validation of quantitative results (e.g., patient satisfaction improvements) with qualitative insights (e.g., staff communication quality) enhanced the credibility of conclusions.

This mixed-methods design is innovative in the Chinese vocational education context, as it links training inputs to both patient-centered outcomes and institutional implementation mechanisms (Luo, 2025).

Key Findings: Promise and Limitations

The Study’s findings reveal a nuanced picture of the integrated model’s effectiveness:

Quantitative Insights

The integrated training significantly predicted higher patient satisfaction (β = 0.863, R² = 0.743), aligning with Kolb’s Experiential Learning Theory. However, no significant relationships were found between student interaction and patient satisfaction, or between patient satisfaction and maternal complications. Critically, the Staff Training construct exhibited weak psychometric validity (Composite Reliability [CR] = 0.337; Average Variance Extracted [AVE] = 0.126), indicating fragmented implementation of training components.

Qualitative Insights

Interviews highlighted key barriers: inconsistent use of simulation tools (e.g., control group students only watched videos), unclear student roles in clinical settings (“We just stood back and watched; we never practiced ourselves”), and systemic constraints like emergency delays and staffing shortages. These insights explain why patient satisfaction improvements did not translate into reduced maternal complications—perceived care quality does not address structural gaps in healthcare delivery.

Together, these findings suggest that while integrated training enhances patient perceptions, it fails to improve clinical outcomes due to poor implementation fidelity and institutional readiness.

Practical and Policy Implications

The Study offers actionable insights for vocational education reform and health policy:

Vocational Education Reform

Standardize simulation training: Mandate high-fidelity simulation实操 with structured checklists to ensure consistent implementation.

Clarify student roles: Develop guidelines for student engagement in clinical care (e.g., assisting with routine tasks under supervision) to reduce role ambiguity.

Strengthen supervision: Allocate dedicated supervisory hours and implement real-time feedback mechanisms to enhance student learning.

Health Policy

Resource allocation: Prioritize funding for simulation equipment and staff training in underserved regions to address resource scarcity.

Cross-sector collaboration: Foster partnerships between education and health sectors to align training curricula with clinical needs (e.g., joint development of maternal care training standards).

Accreditation and audit: Include implementation fidelity metrics (e.g., simulation usage rates, supervision quality) in vocational college accreditation to ensure model adherence.

These measures can bridge the gap between training inputs and clinical outcomes, enhancing maternal care quality in underserved areas.

Limitations and Future Directions

The Study has several limitations that future research should address:

Construct Measurement

The Staff Training construct requires refinement (e.g., splitting into sub-dimensions like simulation quality and supervision intensity) to improve validity.

Outcome Measurement

Maternal complication data were self-reported; future studies should use electronic medical records (EMR) to obtain objective clinical outcomes (e.g., postpartum hemorrhage rates).

Generalizability

The single-institution sample limits external validity; multi-site randomized controlled trials (RCTs) are needed to test the model’s scalability.

Longitudinal Design

A longitudinal approach can track the long-term impact of integrated training on student competence and maternal health outcomes over time.

Addressing these limitations will strengthen the evidence base for integrated vocational education models in maternal care.

Conclusion

The Study provides valuable insights into the potential of integrated vocational education to improve maternal care in underserved China. While the model enhances patient satisfaction, its clinical impact is constrained by implementation gaps and systemic barriers. To realize its full potential, reforms must focus on standardizing training, clarifying student roles, and addressing structural healthcare deficits. Future research should build on these findings to develop more robust, context-adapted models that translate training into tangible improvements in maternal health outcomes. This commentary underscores the importance of rigorous mixed-methods research in evaluating vocational education interventions and the need for systemic collaboration between education and health sectors to advance maternal health equity.

References

1. LI Y, Zhang Y, Yuan B, Wang H (2023) Analysis and thoughts on the settings of sub-campus of public hospitals directly under the National Health Commission of China. Chinese Journal of Hospital Administration, 399-403.
2. Luo W (2025) An empirical study of integration models and mechanisms for maternity care in innovative vocational education systems.

DOI: 10.31038/PSYJ.2025764

Abstract

This study explored the work-related challenges and adjustment experiences of novice firefighters in Taiwan. Using a qualitative thematic analysis design, we conducted semi-structured, in-depth interviews with four novice firefighters (one woman and three men) aged 27–33 years (M = 29.75) who had 2–3.5 years of work experience. The findings revealed several salient challenge-related themes, including perceived unfairness and oppression in the workplace, ethical dilemmas in practice, organizational and interpersonal stressors, stress associated with insufficient work resources, and pressure arising from public expectations and commentary. Regarding adjustment and coping, participants expressed substantial concerns about using formal mental health resources and therefore relied primarily on personal resources to manage stress. Implications for practice and directions for future research are discussed.

Keywords

Novice firefighters, Work challenges, Work adjustment, Resilience

Work Challenges and Adjustment among Novice Firefighters in Taiwan

In recent years, global climate anomalies have contributed to increasingly complex and unpredictable disasters. In Taiwan, economic development and population concentration—together with larger, taller, and more diverse building structures—have expanded firefighters’ operational demands and increased exposure to hazardous labor conditions [1]. To address workforce shortages, the National Fire Agency launched the “Firefighting Workforce Enhancement Initiative” in 2018 and added 3,100 firefighting personnel [2]. Under these conditions, the training and development of novice firefighters becomes especially critical. Without resilience- building opportunities and a health-supportive work environment, novice personnel may experience excessive stress and maladaptation that ultimately contribute to early exit from the profession. Despite the practical significance of this issue, research on novice firefighters’ work challenges and psychological adjustment in Taiwan remains limited. Novice firefighters may face structural, systemic, and hierarchical constraints; high job demands may intensify perceived stress, while access to organizational resources may be restricted. Over time, an imbalance between excessive demands and insufficient resources may contribute to anxiety, depression, and stress-related symptoms, increasing the risk of physical and psychological burnout. Accordingly, this study aims to describe (a) the work-related challenges novice firefighters in Taiwan encounter and (b) their experiences of adjustment and coping.

Firefighters and Their Work

Firefighters’ work encompasses a broad range of duties. In Taiwan, novice firefighters commonly perform two major categories of frontline tasks: (1) disaster response and life-saving rescue, including fire suppression, rescue operations across disaster types, and the management and deployment of rescue resources; and (2) emergency medical services (EMS), including the planning, supervision, and delivery of prehospital emergency care, as well as communication and coordination with medical institutions. In this study, we use the term fire and emergency service work experience to denote frontline operational experience spanning disaster response/rescue, life-saving or technical rescue, and EMS. Firefighting is widely recognized as a high-risk occupation characterized by substantial physical demands, heavy psychological load, and high task complexity. As disaster responders, firefighters are required to enter and operate at hazardous scenes; even under life-threatening and terrifying conditions, professional responsibility typically precludes avoiding the scene or refusing assigned duties. Firefighting work is dangerous, unpredictable, and time-sensitive. Prolonged exposure to heavy workloads, shift-related strain, and traumatic events places firefighters at elevated risk for exhaustion and compromised physical and mental health [3]. Firefighters often must remain in a continuous “combat- ready” state, making firefighting a particularly high-stress occupation [4]. Long-term on-call shift systems can disrupt sleep and interfere with normal physical and psychological recovery processes [5]. Kuo [6] further noted that, driven by a sense of mission and responsibility, firefighters must meet public expectations; at disaster scenes, they may suppress physical discomfort and psychological distress in order to execute tasks calmly and courageously. When such reactions accumulate without adequate processing, firefighters may develop PTSD-related symptoms (e.g., hypervigilance, insomnia, exaggerated startle responses, irritability, and concentration difficulties). If psychological trauma is not addressed in a timely manner, symptoms may intensify over time.

Operational conditions also constrain emotional processing. During missions, firefighters often lack the time and space to process emotions and may temporarily set aside personal feelings until tasks are completed, at which point they begin to experience and interpret the impact of the event. Frequent exposure to disaster incidents may require firefighters to re-enter distressing rescue contexts before psychological equilibrium is restored, thereby accumulating negative emotions and traumatic experiences [7]. In addition, firefighters face public pressure through media coverage and public praise or criticism, which may further intensify occupational stress [8].

Novice Firefighters

Novice firefighters are commonly defined as those with 2–4 years of service [9]. They are expected to learn and perform core duties such as fire suppression and emergency medical response while adapting to the realities of frontline work. In Taiwan, however, empirical research on novice firefighters remains limited. Existing literature has primarily examined safety and training effectiveness, the influence of overall health on performance, the effects of stress, and the development of professional knowledge [10]. Because novice firefighters often serve as frontline personnel, they may experience substantial pressure associated with disaster response. Prior evidence suggests that shorter tenure is associated with stronger stress responses among firefighters [11,12]. Novice firefighters may also report higher stress than senior firefighters [13]. Moreover, they require an adjustment period to manage challenges such as the gap between training and real-world practice and the complexity of diverse duty types [14]. At the same time, they must learn to navigate bureaucratic features of the firefighting system and pressures related to obedience and hierarchical authority [15].

Job Demands and Resource Provision

Work environments shape employees’ health, well-being, and performance [16]. The Job Demands–Resources Model (JDRM) provides a useful framework for understanding how occupational conditions influence stress and adjustment [17]. Job demands refer to aspects of a job that require sustained physical and/or psychological effort and include negative factors at physical, psychological, social, or organizational levels; such demands entail specific physiological and/ or psychological costs. Examples include workload, time pressure, emotional load, and role conflict. Although moderate job demands may stimulate motivation and alertness, chronically excessive demands can initiate a health-impairment process that depletes resources and increases burnout risk, physical and mental health problems, and performance decrements.

In contrast, job resources refer to positive job characteristics at physical, psychological, social, or organizational levels. Job resources support goal attainment, reduce job demands and their associated costs, and promote personal growth, learning, and development. Resources may operate at the task level (e.g., autonomy), organizational level (e.g., career development opportunities), interpersonal level (e.g., supervisor and coworker support), and job design level (e.g., performance feedback). Adequate resources activate a motivational process, enhance engagement, and are associated with positive outcomes such as safety behaviors, job performance, and organizational commitment.

Safety-Oriented JDRM

Building on the JDRM, scholars have proposed a safety-oriented JDRM that foregrounds safety-relevant job demands and safety- relevant resources [18]. For firefighting, this model highlights four demand dimensions: (1) Workload, referring to the speed and volume of task completion under time constraints and pressure; high time pressure has been linked to increased firefighter fatality rates. (2) Physical demands, including high-intensity biomechanical activities such as running, carrying, and ladder climbing; excessive exertion contributes to fatigue that can undermine reaction time and adherence to safety procedures. (3) Emotional demands, referring to the psychological effort required to manage emotions and cope with affective reactions (e.g., fear, suppression); sustained emotional labor may deplete energy reserves and contribute to emotional exhaustion. (4) Complexity, involving cognitive demands associated with handling multiple difficult tasks, maintaining situational awareness, making rapid decisions, and conducting risk assessments—particularly in life- threatening contexts.

Structural Insufficiency of Resources

Fire service organizations may also face structural shortages of resources. Insufficient resources have been identified as a key factor undermining firefighters’ psychological health [19]. In addition, interpersonal conflict, discrimination, harassment, and negative perceptions of organizational justice can weaken resilience and are associated with anxiety, depression, and physical illness [20]. In particular, perceptions of organizational and systemic unfairness increase mental health risks and are closely tied to hierarchical stress. In such contexts, employees may engage in proactive behaviors that reshape their work conditions. These include job crafting (actively modifying one’s job or available resources) and self- undermining (stress-related mistakes that inadvertently increase one’s own job demands). Novice personnel may adjust their work behaviors in response to hierarchical pressure, or they may reduce engagement due to fear of making mistakes. When social support is limited, interpersonal resources become scarce and fragile, and this vulnerability is closely linked to trauma-related stress symptoms, depression, and emotional exhaustion [21]. Moreover, negative views of organizational systems (e.g., unfair policies or promotion practices) may further elevate mental health risks. Interpersonal conflict can also obstruct help-seeking and support access, producing a “double hit” of resource loss. Under conditions of high hindrance, high demands, and systemic resource deficiencies, job demands may substantially exceed resource provision, creating a structural imbalance that undermines job performance directly or indirectly through psychological distress.

The Buffering Effects of Resources

The JDRM also emphasizes personal resources, defined as individuals’ beliefs about their ability to control and influence their environment. Job resources can buffer strain associated with job demands and mitigate the negative effects of work stressors. This buffering function suggests that resources may be especially protective under high-demand conditions, supporting both well-being and work performance. Common personal resources include self-efficacy, optimism, and resilience. Such resources predict work engagement by strengthening confidence in one’s capacity to manage challenges and sustain involvement. Personal resources may also operate similarly to job resources by buffering the adverse effects of job demands on stress. In sum, when employees face high demands (e.g., heavy workload or emotional load), greater resources (e.g., autonomy, social support, performance feedback, and professional development opportunities) are generally associated with lower burnout and emotional exhaustion.

Organizational Culture

Organizational culture is another critical influence on firefighters’ well-being and help-seeking. A traditional culture emphasizing “toughness, silence, and self-sacrifice,” along with emotional taboo, may inhibit seeking psychological support [22]. In contrast, framing professional psychological help-seeking as a constructive form of self- care may facilitate a healthier organizational climate [23].

Resource adequacy in the fire service also matters. The quality, quantity, and suitability of personal protective equipment are central to firefighters’ sense of safety. Station facilities, vehicles, staffing, and occupational health and safety measures represent foundational resources that directly shape the safety and comfort of the work environment. Supervisor support is likewise influential: when perceived support from managers, family, or friends decreases, depressive symptoms tend to increase. Supervisors’ support, trust, and care may strengthen subordinates’ resilience. Leadership practices— such as reward and punishment systems, internal management, duty scheduling, performance evaluation, discipline, and performance demands—may function either as resources or as stressors, depending on how they are enacted and experienced.

Firefighters’ Adjustment and Coping

Carver et al. [24] developed a coping strategies inventory that categorizes coping behaviors into problem-focused coping, cognitive restructuring coping, emotional support coping, and avoidance coping. Chung and Chiou [25] suggested that firefighters who predominantly use problem-focused coping tend to recover gradually, whereas reliance on avoidance coping may increase risk for psychological disorders. Prior research indicates that firefighters often rely on individual coping strategies to manage work stress. Lee [26] and Chen [27] found that after exposure to death or major critical incidents, firefighters often cope privately; when adjustment is insufficient or support is unavailable, some may request transfer or resign. Some firefighters manage occupational stress through a passive stance (e.g., “you get used to it over time”) [28], whereas others use strategies such as active reflection for improvement or emotional detachment [29]. Firefighters may also cope by maintaining task focus and calm during operations [30] or by adopting passive coping patterns, allowing emotions to fade over time through emotional numbing, suppression, or self-isolation. Although these strategies may stabilize functioning in the short term, they may carry negative long-term consequences.

Resilience also shapes adjustment. Firefighters with higher resilience are more likely to appraise stress as a challenge rather than a threat [31]. Firefighters commonly report using conversation, exercise, leisure activities, and faith practices to reduce stress. Professional competence also increases with accumulated experience and knowledge, which can strengthen coping capacity. Individuals with stronger self-efficacy tend to believe they can control and change situations, thereby moderating the impact of perceived stress on burnout.

Peer support functions as an important buffer by enabling emotional exchange, experience sharing, mutual reminders, and opportunities for emotional ventilation. Colleagues’ competence, knowledge, and experience can enhance individual safety, and camaraderie is a strong predictor of firefighters’ mental health. Firefighters often reduce distress through peer dialogue—talking through tasks and coping approaches—and through experiential transfer from senior peers. Everyday conversations and informal gatherings may also help relieve emotional strain. In Taiwan, fire agencies have established counseling and guidance systems and offer courses and lectures. They may provide psychiatric services, psychological counseling, and consultation, sometimes combined with medication to improve sleep conditions [32]. Overall, building a comprehensive mental health support system—including accessible psychological services, effective communication channels, regular health check-ups, financial and emotional support, and health- and law-related information—may strengthen organizational support and enhance firefighters’ resilience.

Method

This study employed thematic analysis to examine the occupational experiences of novice firefighters in Taiwan. The analytic focus was directed toward describing both the substantive content and the processes embedded in their work, thereby highlighting the complexity of frontline practice and the trajectories through which participants adapted and coped.

Participants

A purposive sampling strategy was adopted. Four frontline novice firefighters were recruited through professional networks by the first author. The sample comprised one woman and three men, aged 27–33 years (M = 29.75), with work tenure ranging from 2 to 3.5 years— consistent with the career stage of novice firefighters (defined as within four years of service). Participants were drawn from brigades located in diverse service contexts: an eastern rural area, a central semi-urban area, a central rural area, and a northern metropolitan area. Two participants held certification as Emergency Medical Technicians–Paramedic (EMT-P), and one participant held Rescue Technician certification.

Data Collection

Data were generated through semi-structured, in-depth interviews. The first author conducted one individual interview with each participant, lasting approximately 60–90 minutes. Participants were invited to narrate their occupational challenges and their experiences of adaptation and coping. The interview guide encompassed questions on: motivations and expectations for entering the fire service; job tasks and sources of stress; interpersonal interactions; utilization of organizational resources; coping strategies; and perceived impacts of work on physical and mental health. Interviews were conducted in quiet, convenient locations selected by the first author. Prior to each interview, participants were informed of the study’s purpose and procedures, potential benefits and risks, and their rights. Ethical principles were observed throughout, including respect for autonomy and confidentiality. Written informed consent was obtained before interviews commenced. All interviews were audio-recorded and subsequently transcribed verbatim by the first author.

Data Analysis

Thematic analysis was conducted following Braun and Clarke’s [33] framework. The first and second authors conducted the analysis using Braun and Clarke’s thematic analysis. They engaged in repeated reading of transcripts, open coding, identification of cross-case patterns, and iterative refinement of thematic coherence. Themes were subsequently defined, named, and integrated into the analytic report. Throughout the process, the researchers maintained an open and reflexive stance, engaging in ongoing dialogue to ensure rigor. Particular attention was devoted to issues raised by participants concerning tenure, hierarchical power relations, the novice role, and work-related challenges, including organizational and structural barriers, resource utilization, and coping/adaptation processes.

Trustworthiness and Ethics

To enhance trustworthiness, multiple strategies were employed, including triangulation, reflexivity, thick description, and cross- checking. These measures ensured coherence between themes and textual evidence, strengthened descriptive appropriateness, and enhanced credibility. Ethical standards were rigorously observed: all participants signed informed consent forms and were informed of the study’s purpose, rights, and procedures for voluntary participation and withdrawal. Audio files and transcripts were de-identified and presented using pseudonyms to ensure anonymity. All study materials were securely stored by the first author, and data were used exclusively for academic purposes.

Results

Seven themes emerged from the thematic analysis. Themes are illustrated with representative participant narratives.

Unfairness and Oppression at Work

Novice firefighters characterized their work as highly complex, unpredictable, and psychologically demanding. One participant described each dispatch as opening a “mystery box,” because incidents could involve life-threatening conditions such as earthquakes, rockfalls, or fires. This uncertainty not only tested physical limits but also created substantial psychological burden.

Beyond the inherent danger of the job, participants emphasized that risk exposure was distributed unevenly across ranks. They reported that novices were frequently assigned the most hazardous roles during operations. For example, one participant noted that junior firefighters were expected to be the first to force entry into unknown environments. He also described death-related incidents in which novices could be tasked with handling particularly distressing duties (e.g., carrying severed body parts). He described this as an unspoken rule: “the most junior firefighter is expected to face unknown risks first or bear the greatest known risks.” Such expectations reflected a power imbalance between senior and novice firefighters and contributed to participants’ perceptions of unfairness and oppressive treatment.

Ethical Dilemmas in Practice

In addition to operational danger, participants reported repeated exposure to ethical and moral shocks, especially during emergency medical work. In out-of-hospital cardiac arrest (OHCA) cases, they often faced dilemmas about whether resuscitation was clinically meaningful—particularly when family members insisted on continuing resuscitation even when firefighters perceived it as futile. In these moments, participants described feeling ethically conflicted and powerless. One participant reflected: No intubation, no defibrillation… and then when we arrived at the hospital, the doctor said there was no chance—just stop resuscitation… I kept wondering… Was my CPR and oxygen meaningful?”Participants also described moral conflict from the opposite direction: even when resuscitation was successful, severe post-resuscitation outcomes could raise questions about long- term suffering and family burden. One participant stated: “Even though I brought him back—breathing, pulse—he would only survive with those machines. Sometimes I struggle inside… Should I save him or not?” Overall, participants emphasized that firefighters often confront ethically fraught situations without clear ethical guidance or standardized norms. For novices in particular, real-world emergency care required enduring ongoing tension among professional obligations, personal values, and ethical considerations.

Systemic Organizational and Interpersonal Pressures

Participants described hierarchical pressure and workplace bullying as major sources of stress. Some supervisors were portrayed as hostile toward newcomers (described as “newcomer killers”), frequently scolding, intimidating, or imposing punitive controls. One participant recalled that during the first six months he was reprimanded almost daily and received leave restrictions for minor issues: “For about the first six months, I was getting scolded almost all day… For small things—five minutes late, missing a signature—I was banned from taking leave for two months… he wrote it down and kept scolding me.” Another participant described feeling constantly monitored and scrutinized by supervisors and senior colleagues, which made his work experience “miserable.” He gave an example of being questioned for not attending activities that occurred on his scheduled days off: “There were two activities… both fell on my days off, and then I was called in and asked, ‘Why didn’t you participate?’”

Participants further reported that some senior firefighters undermined novices’ confidence through disparaging remarks. One participant described being mocked while studying for professional exams: “A senior saw me studying… and said, ‘You won’t pass,’… those sarcastic, belittling things.” They also noted that minor station-related issues (e.g., a gym not being tidied immediately or trash temporarily left) could trigger scolding, and supervisory pressure sometimes extended into rest time. Participants reported being unable to relax even during breaks; using a phone could invite suspicion, and taking leave could lead to criticism for “not helping the team” with dispatch duties. Accumulated pressure affected both physical and psychological functioning. One participant described missing a dispatch alarm due to a malfunctioning bell near his bed; fear of being reprimanded increased stress and contributed to sleep disturbance.

In addition to interpersonal dynamics, participants described institutional unfairness that amplified helplessness. One participant stated that performance evaluations were opaque and highly subjective—dependent on “the supervisor’s mood”—yet directly influenced salary and promotion. When effort was not matched by recognition or reward, participants reported frustration and demoralization. Another participant described being reassigned to another brigade despite holding strong paramedic qualifications, which he experienced as unfair and identity-undermining.

Finally, participants described rigid systems and dysfunctional equipment as chronically depleting. They reported pressure to meet unreasonable key performance indicators and to complete large volumes of administrative tasks despite inadequate staffing and limited experience. Under directives from higher-level leadership, core emergency work was sometimes displaced by unrelated activities (e.g., sports events) and could even become entangled with election- related events—at the expense of essential rescue and EMS duties. Participants also described being constrained by outdated protocols: even after learning improved clinical approaches, they were expected to follow older procedures because regulations had not been updated and senior members insisted on “the old way.” Collectively, these systemic conditions were perceived as obstructing professional development, eroding motivation for learning and innovation, and fostering high pressure, helplessness, diminished self-efficacy, and weakened professional identification.

Scarcity of Job Resources

Participants consistently emphasized that job resources were insufficient relative to the demands they faced. At the basic operational level, one participant reported chronic shortages of essential supplies and incomplete distribution of equipment. For example, ambulance gauze ran out and was not replenished for an extended period; paramedic medication kits were not fully issued, forcing firefighters to purchase supplies themselves or seek support from physicians: “Resources are very limited—equipment, gear, consumables. The gauze on the ambulance ran out… and the whole station had none because it wasn’t issued… The medication kit wasn’t provided, so I bought it myself… This affects how well I can do the job, and it affects my quality of life.”Another participant highlighted chronic understaffing. On some days, only three personnel were on duty, increasing the likelihood of station closure or even single-person dispatch, which substantially elevated operational risk. Resource scarcity also extended to compensation. One participant stated that pay was disproportionate to high risk and long working hours, estimating an hourly wage lower than that of part-time student workers. He also described institutional limits on overtime pay, whereby excess overtime was converted to compensatory leave rather than paid overtime. Additionally, leave taken across months could reduce the salary of a given month, despite leave being largely nonvoluntary in practice. Participants experienced these arrangements as discouraging and demoralizing. Participants further described resource deficits in organizational infrastructure and administrative systems. One participant reported frequent crashes in electronic systems with little improvement. Shared computers lacked internet access and could not support routine administrative tasks; outdated equipment was neither functional nor replaced. These barriers disrupted both administrative operations and professional emergency duties, increasing stress, draining energy, and undermining morale.

Pressure From Public Expectations and Commentary

Participants described substantial pressure arising from public expectations, scrutiny, and online commentary. When rescue or response efforts were perceived as inadequate, participants experienced intense criticism and what they viewed as unreasonable accusations, which increased emotional disturbance and work stress. They noted that even cautious decision-making could be judged negatively, resulting in complaints or online attacks. One participant listed common disputes, such as being criticized for driving “too slowly,” questioned for running red lights during emergency transport, reported for siren noise at night, or asked by bystanders to move hoses during active fire response. He recalled: “Once, during a fire response, I was still dealing with it, and there was a hose on the ground. Someone said he wanted to drive home and asked me to move the hose… I said, ‘I’m still fighting a fire!’”Overall, participants expressed a sense that “whatever we do, the public will criticize.” They reported that minor mistakes could be amplified, leaving them uncertain about how to respond and pressured by constant evaluation. This perceived scrutiny affected their occupational identity and sense of meaning in the work.

Personal Ajustment and Coping

In response to the imbalance between high demands and limited resources, participants described diverse coping strategies that ranged from proactive competence-building to emotional self-protection and cognitive reframing. Proactive learning and competence-building. Some participants demonstrated strong agency. One participant repeatedly volunteered for training opportunities despite low seniority and initial supervisory rejection: “I’m pretty junior, so it wouldn’t be my turn… I recommended myself… he rejected me two or three times before finally letting me go.” Another participant described enrolling in an instructor-training program to rekindle motivation: “Last year… I changed my mindset… I decided to recover my passion… I applied for instructor training, and I got in.”

Participants also described practice-based improvement, especially in EMS. One participant reported reviewing the quality of CPR and airway management after OHCA cases, requesting simulation training, and striving to improve care quality. Another described systematically refining EMS procedures— practicing operational details, adjusting workflows, strengthening competence, and promoting team improvements. He explained how training translated to smoother field performance: “When I arrived on scene, I followed the training model… and the next time, I didn’t waste time… it went smoothly, and I completed the EMS work successfully.” He further described keeping organized records, publicly noting procedural gaps, advocating updated protocols, and optimizing team workflows. These efforts increased accomplishment and self-efficacy; when improved performance was recognized during later dispatches, confidence was reinforced in a positive feedback cycle.

Self-protective Emotional Strategies

In contrast, some coping strategies emphasized denial, minimization, or emotional detachment. One participant described himself as “digesting emotions quickly,” “letting it pass,” and being “forgetful,” noting that positive events could override work-related distress: “I digest (negative emotions) pretty fast… after sleeping a few times, I’m fine… If something happy happens, it covers up the unpleasantness.” Another participant rationalized supervisory harshness by framing militarized management as something men “should” endure, interpreting survival of strict training as evidence of becoming competent.

Compartmentalization and Technical Focus

One participant described being briefly frightened at the scene but switching immediately to professional judgment and action. After returning to the station, he reviewed dispatch footage to evaluate technical execution and team communication, using procedural focus to avoid being absorbed in distress: “Back at the station, I watch the footage again… if there are problems, we discuss and improve next time. That way, I don’t think too much… or get stuck on why it happened.”

Relational Coping and Future-oriented Strategies

Some participants described selectively collaborating with reliable senior firefighters to support smoother teamwork. Others attempted to transform unfair treatment into motivation for self-improvement— strengthening training, obtaining key EMS certifications, and preparing for potential future transfers to other units.

Cognitive Reframing

One participant reduced distress by reframing EMS work as “taxi” service: complete necessary tasks without judging whether patients were misusing EMS resources and without ruminating: “We arrive a hospital and see he (the patient) is actually okay—fine, take measurements, transport him, then happily go back to rest… I imagine my work is like a taxi driver.”

In summary, across accounts, the above strategies reflect novice firefighters’ attempts to preserve functioning, maintain competence, and sustain meaning under chronic stress in work.

Concerns About Using Counseling Resources

Although participants acknowledged that fire agencies provide mental health resources (including on-site counseling), they expressed substantial concerns about using them. One participant noted that counseling appointments required taking personal leave; after exhausting shifts, he preferred to use leave for sleep and rest. Another participant expressed fear of stigma and confidentiality breaches, reporting limited trust in counseling privacy and concern that supervisors might learn about counseling use: “Privacy… If I go talk to a counselor… will my supervisor know and ‘check on’ me?… Work stress is private… Counselors keep records—are they stored somewhere? Would people know?… Would I be labeled as having a mental problem?”

One participant questioned whether counseling could address structural sources of distress—such as authoritarian supervision, unfair treatment, or outdated equipment—given that these conditions would remain unchanged after counseling: “If I’m bullied long-term… would talking to a counselor make me better?… I still have to go back, and the supervisor is the same… So is counseling useful? I have a question mark.”

Overall, participants viewed counseling as potentially providing temporary emotional ventilation but offering limited practical benefit for stressors rooted in persistent organizational and structural conditions. Consequently, they tended to rely more on personal coping resources than on formal psychological services.

Discussion

The novice firefighters in this study characterized firefighting as an occupation involving high risk, heavy physical demands, substantial psychological load, and high complexity. They also emphasized that the work environment and organizational culture strongly shape mental health and necessitate coping strategies to manage occupational stress. These findings are consistent with Bakker and Demerouti’s argument that the work environment influences employees’ health, well-being, and performance. Taken together, the results suggest that novice firefighters’ early-career adjustment is not determined solely by the inherent dangers of frontline work, but also by organizational arrangements, leadership practices, resource provision, and public scrutiny—factors that jointly produce a structural pattern in which demands often exceed available resources. Participants described having to cope with diverse operational and administrative challenges, as well as bureaucratic features of the firefighting system and hierarchical pressures requiring obedience. Their narratives also highlighted pronounced hierarchical stress, including implicit workplace rules that positioned novices to assume high-risk and high-impact tasks, and supervisory practices experienced as punitive or oppressive. In addition, the findings echo prior evidence that firefighters are exposed to societal expectations and external evaluation—including media coverage and public praise or criticism—which can intensify occupational stress.

Smith and Dyal’s safety-oriented JD–R model is particularly useful for interpreting these results, as it emphasizes both safety- related job demands and safety-related resource provision. The current findings partially converge with this framework and with the four dimensions of firefighting job demands described by Smith and Dyal. Participants repeatedly reported working under stringent time constraints and pressure, which heightened stress. They also described emotional demands, especially in emergency medical and urgent rescue contexts, where fear, shock, and emotional suppression were common. Such emotional demands can deplete psychological energy and contribute to emotional exhaustion. In addition, participants emphasized cognitive complexity: managing multiple difficult tasks in life-threatening contexts required sustained situational awareness, rapid decision-making, risk assessment, and the execution of emergency interventions.

Notably, when these demands were experienced as persistent and cumulative, participants’ accounts suggested a health-impairment process consistent with the JD–R perspective. For example, some participants described wanting only to rest during time off and reported limited capacity for additional activities, including psychological counseling. This pattern underscores that excessive demands may constrain recovery opportunities and gradually erode psychological resources, thereby increasing risks for burnout and compromised functioning over time.

In the safety-oriented JD–R model, resource provision is not a peripheral issue but a central determinant of safety and well- being. Participants in this study described a broad range of resource constraints, including shortages of supplies, malfunctioning or obsolete systems, insufficient infrastructure (e.g., computers and internet access), and understaffing that increased operational risk. They also expressed dissatisfaction with compensation and overtime arrangements that were perceived as disproportionate to workload, risk, and time demands. These findings align with Payne and Kinman’s argument that insufficient resources represent a key factor undermining firefighters’ psychological health, and with research emphasizing that adequate equipment, facilities, staffing, and occupational health and safety measures influence the safety and comfort of firefighters’ work environments.

At the interpersonal and organizational levels, participants described authoritarian supervision, frequent reprimands for minor issues, disparaging remarks, and a sense of constant scrutiny. They also reported unfair or inconsistent evaluation and managerial practices, leaving them uncertain about behavioral standards and concerned that outcomes depended on supervisors’ subjective judgments. These experiences are consistent with prior literature identifying interpersonal conflict and low organizational justice as critical risk factors that erode resilience and increase vulnerability to anxiety, depression, and physical illness. They also reinforce the importance of supervisory support: deficiencies in managerial support have been linked to elevated depressive symptoms, whereas supervisors’ trust, care, and support may strengthen resilience. In the present study, perceived unfairness and hierarchical oppression appeared to operate as chronic “hindrance demands,” increasing stress while simultaneously restricting access to key resources such as psychological safety, guidance, and professional recognition.

A salient contribution of this study is the centrality of ethical dilemmas, particularly in OHCA cases. Participants described moral conflict when family requests for resuscitation diverged from firefighters’ assessment of futility, and they also described ambivalence when resuscitation succeeded but survival implied severe impairment and long-term dependence on life-sustaining equipment. These experiences suggest that novice firefighters may be exposed to moral distress—ethical discomfort arising when one’s professional judgment conflicts with external demands or constrained options—yet they may lack clear norms, ethical guidance, and structured opportunities to process these conflicts. Accordingly, ethical strain should be considered a meaningful component of job demands in EMS-related duties, not merely an emotional byproduct of trauma exposure.

Participants’ coping strategies reflected both active and avoidant patterns. Some described relatively active coping approaches, including cognitive reframing, transforming frustration into motivation for professional development, pursuing training and certifications, and strengthening technical competence. These strategies appeared to enhance self-efficacy, a key personal resource within the JD–R framework, and are consistent with evidence that believing one can control or change situations may mitigate the impact of stress on burnout. Participants also described drawing on interpersonal resources, such as selectively collaborating with supportive senior colleagues, which partially supports the safety-oriented JD–R proposition that social support buffers the psychological impact of high-demand work. At the same time, several participants reported passive or self-protective coping—emotional suppression, compartmentalization, denial, replacement, and self- isolation—used to maintain immediate functioning. These patterns align with prior research suggesting that some firefighters use passive stances or emotional detachment to cope, while others engage in active reflection and improvement. Although avoidant strategies may provide short-term stabilization and enable continued performance, they may carry longer-term risks. Lin similarly noted that passive coping can temporarily stabilize psychological states but may yield adverse long-term consequences for health and work functioning.

Participants also indicated that rescue and EMS work often involves immediate shock, but firefighters must rapidly regain composure to complete tasks according to standard procedures. This aligns with evidence that firefighters cope by focusing on the task and maintaining calm during operations. It also echoes Yeh’s observation that firefighters often lack time and space to process emotions during missions and must temporarily set aside feelings until tasks are completed. However, in the present study, novices did not clearly report structured post-mission emotional processing; instead, they tended to rely on compartmentalization, suppression, or redirection of attention. This suggests that novice firefighters may have limited awareness of cumulative trauma risks and may underestimate the potential harm of unprocessed emotional and psychological impact. If distress is repeatedly ignored, cumulative strain may contribute to psychological depletion, emotional exhaustion, intrusive re- experiencing, and triggered recall, with trauma-related symptoms becoming more pronounced over time.

Although participants were aware that fire agencies provide mental health services (including counseling), they tended to perceive such services as offering only temporary emotional relief and limited practical utility for problem solving. They also reported concerns about privacy and the confidentiality of counseling records, which reduced willingness to seek help. These findings imply that existing governmental and organizational mental health resources may not fully match novice firefighters’ needs. Importantly, participants’ skepticism was not solely attitudinal; it reflected a perception that counseling cannot resolve structural sources of distress (e.g., authoritarian supervision, institutional injustice, and equipment/resource deficits). Thus, improving service uptake likely requires both strengthened confidentiality safeguards and organizational reforms that address upstream stressors and demonstrate institutional accountability.

In summary, the findings indicate that novice firefighters’ job demands arise not only from the inherent danger of frontline tasks, but also from organizational oppression and institutional injustice— manifested as hierarchical pressure, workplace bullying, and opaque managerial practices—combined with structural resource deficits (e.g., shortages of supplies, malfunctioning systems, and insufficient interpersonal support). Under such conditions, personal coping and adaptation may help individuals maintain day-to-day functioning but remain insufficient to compensate for systemic problems. Novice firefighters in this study appeared to operate in a structural imbalance in which demands substantially exceeded available resources, highlighting the need for multi-level interventions that extend beyond individual resilience.

Implications

Fire service organizations should prioritize novice development by ensuring reasonable work allocation and adequate resources, supported by a constructive work environment, healthy organizational culture, and fair performance evaluation systems. Providing sufficient equipment and accessible psychological resources may foster a more supportive workplace and reduce the risk of work-related psychological harm. More specifically, leaders and supervisors should establish transparent and equitable assessment mechanisms, acknowledge and address resource shortages, and ensure stable provision of emergency medical supplies and other essential materials. Institutional protections for novice personnel should be strengthened to prevent unfair or oppressive treatment arising from hierarchical differences. Supervisors should proactively attend to novices’ needs and shift their role from “monitor” to a buffering resource—providing guidance on professional values, emotional support, and tangible resources, and helping novices navigate supports for processing distress and potential trauma-related reactions. Future research may examine the effectiveness of different coping strategies in response to specific challenges (e.g., hierarchical oppression and ethical dilemmas) and investigate how organizational resources and culture shape novice firefighters’ adjustment over time.

Conclusion

Within highly hierarchical fire service organizations, novice firefighters may experience a structural pattern of high demands and low resources, including hierarchical pressure, institutional injustice, resource scarcity, prolonged high-risk work, and compensation perceived as disproportionate to workload and risk. Despite these conditions, novice firefighters strive to adapt and often demonstrate resilience and commitment to professional practice. However, they primarily rely on individual coping strategies—such as emotional suppression, compartmentalization, and attentional redirection— to manage stress and emotional reactions, strategies that may carry hidden risks of long-term psychological depletion and escalation of trauma-related symptoms. Accordingly, supporting novice firefighters’ sustainable adaptation requires coordinated efforts that combine individual- and peer-level supports with organizational reforms in leadership practices, procedural justice, resource provision, and the design and credibility of mental health services.

References

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DOI: 10.31038/PSYJ.2025763

Abstract

Oppositional Defiant Disorder (ODD) is a disruptive behavioral condition characterized by persistent patterns of angry, irritable mood, argumentative behavior, and vindictiveness (APA, 2022). This comprehensive review explores the diagnostic criteria, prevalence, and developmental trajectory of ODD in youth, with a focus on the interplay of risk, protective, and ameliorating factors. The article examines the distinctions between medical and educational diagnoses, including the implications of DSM-5-TR and special education law in the United States (IDEIA). It highlights the disorder’s comorbidity with ADHD, mood disorders, and conduct disorder, and discusses how cultural, gender, and socioeconomic factors influence diagnosis and symptom presentation. The review also delves into dispositional, genetic, cognitive, neurobiological, and environmental risk factors, emphasizing the importance of early intervention and strong familial and peer relationships as protective mechanisms. Evidence-based treatments are presented as effective strategies for managing ODD symptoms. The article underscores the critical role of educators and psychologists in identifying, evaluating, and supporting students with ODD through informed assessment and intervention practices.

Oppositional Defiant Disorder

Oppositional Defiant Disorder (ODD) is a complex externalizing behavioral condition characterized by persistent patterns of angry or irritable mood, argumentative and defiant behavior, and vindictiveness in children and adolescents [1]. Understanding ODD requires a comprehensive, multidisciplinary approach that considers its diagnostic criteria, prevalence, and developmental trajectory, as well as the interplay of dispositional, genetic, cognitive, neurobiological, and environmental risk factors. In clinical settings, psychiatrists and licensed psychologists typically provide a medical diagnosis of ODD, while in educational contexts, school psychologists, particularly those trained in clinical assessment and diagnostic frameworks, are responsible for evaluating students for special education eligibility under the classification of emotional disability (ED) [2]. This review will provide a comprehensive overview of ODD and present the developmental trajectory of risk and protective factors for youth with ODD. The article will also explore the distinctions between medical and educational diagnoses, with particular attention to the implications of DSM-5-TR criteria and special education law in the United States (IDEIA). The article will examine how comorbid conditions such as ADHD, mood disorders, and conduct disorder complicate both identification and intervention. Additionally, it will highlight how cultural, gender, and socioeconomic factors influence symptom presentation and diagnostic outcomes, and provide a review of effective early intervention and evidence-based treatments, such as Parent-Child Interaction Therapy (PCIT) and Teacher-Child Interaction Training (TCIT), in equipping educators and psychologists to support youth with ODD effectively.

Overview of ODD

Diagnostic Features and Criteria

Oppositional Defiant Disorder (ODD) poses distinct challenges across both healthcare and educational systems. In clinical settings, professionals use standardized diagnostic tools to identify and manage the disorder. In contrast, educators must assess whether a student’s behavioral patterns meet the criteria for special education services. It’s important to distinguish between a clinical diagnosis and an educational classification: the DSM-5-TR provides the framework for diagnosing ODD in medical contexts, while eligibility for school- based support is determined by federal legislation such as the Youth with Disabilities Education Improvement Act (IDEIA) and state- specific guidelines like Indiana’s Article 7. Together, these systems help ensure that children with ODD receive comprehensive support that addresses both their behavioral health and academic needs.

DSM-5-TR

According to DSM-5-TR, ODD is characterized by a persistent pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least six months (APA, 2022). Diagnosis requires the presence of at least four symptoms from these categories, exhibited during interactions with at least one individual who is not a sibling). Regarding angry/irritable mood, an individual may experience symptoms where they often lose their temper, are touchy or easily annoyed, and/or are often angry and resentful. An individual may also experience symptoms of argumentative/defiant behavior where they often argue with authority figures, defy or refuse to comply with requests from authority figures or with rules, deliberately annoy others, and/or often blame others for their mistakes or misbehavior. The individual may have also been spiteful or vindictive at least twice within the past six months. The disturbance in behavior must be negatively impacting their social, educational, occupational, or other important areas of functioning, and the behaviors cannot be better explained by other mental health conditions (e.g., psychotic, substance use, depressive, or bipolar disorder). Finally, the DSM-5-TR includes three specifiers: mild (symptoms are confined to one setting); moderate (symptoms are present in at least two settings); and severe (symptoms are present in three or more settings).

IDEIA and State Laws

Youth with ODD, and disruptive behaviors, are often considered for special education services under the classification of Emotional Disorder (ED). IDEIA, the federal law that governs special education in the United States, broadly defines ED as a condition that exhibits at least one of the provided characteristics for a long period of time and to a marked degree that adversely affects a child’s educational performance [3]. Characteristics include: an inability to learn that cannot be explained by intellectual, sensory, or health factors; an inability to build or maintain satisfactory interpersonal relationships with peers and teachers; inappropriate types of behavior or feelings under normal circumstances; a general pervasive mood of unhappiness or depression; and/or a tendency to develop physical symptoms or fears associated with personal or school problems. While IDEIA provides a general overview of ED, it does not provide guidelines for how to evaluate the category.

Although IDEIA outlines the general criteria for ED, it does not provide detailed procedures for how to assess or determine eligibility. Each state in America is responsible for developing its own evaluation standards. For instance, in the state of Indiana, Article 7 serves as the state’s special education framework and builds upon the federal definition by adding further clarification. Indiana’s criteria include episodes of psychosis and emphasize the need for a comprehensive evaluation process. This process must include assessments of academic achievement and emotional functioning, a thorough developmental and social history, a functional behavior assessment, and relevant medical or psychological information. The goal is to ensure that the student’s learning challenges are not better explained by other factors such as cognitive or sensory impairments [4].

Prevalence

While there are limited population- or national-level data on the prevalence of Oppositional Defiant Disorder (ODD) in the United States, current estimates suggest a prevalence rate of approximately 3.3%, with most community samples ranging from 3% to 6% [5]. This variability may be influenced by differences in diagnostic practices, sample demographics, and access to mental health services across regions. Boys are slightly more likely than girls to develop and be diagnosed with ODD during childhood, possibly due to more overt behavioral symptoms that draw attention in educational and clinical settings. However, research indicates that gender differences in prevalence tend to diminish during adolescence and adulthood, with similar rates observed across sexes. These findings highlight the importance of early identification and culturally sensitive assessment practices to ensure accurate diagnosis and appropriate intervention.

Comorbidity

Youth with ODD are at risk of having internalizing and externalizing comorbidity. Youth with ODD have higher rates of comorbidity with attention deficit hyperactivity disorder (ADHD) and mood and anxiety disorders [6,7]. Youth who develop ODD during childhood and adolescence are at an increased risk for developing conduct disorder (CD) and/or antisocial personality disorder (APD). There is also evidence of comorbidity between posttraumatic stress disorder (PTSD) and ODD [8]. Youth with ODD are also more likely to use tobacco, alcohol, and drugs [9].

Factors Associated with ODD

Cultural Factors

Cultural differences in the diagnosis of Oppositional Defiant Disorder (ODD) may stem from misdiagnosis or overdiagnosis among youth from marginalized backgrounds. African American youth, for example, have been reported to exhibit higher rates of defiant behaviors and conduct problems in some research samples [10,11]. In special education settings, Black males are disproportionately identified as having Emotional Disturbance (ED), often due to elevated reports of behavioral concerns compared to their white peers—even when the actual intensity and frequency of behaviors are similar across racial groups. This overrepresentation may reflect systemic biases in behavioral interpretation and referral practices rather than true differences in symptom severity. As a result, culturally responsive assessment and intervention practices are essential to ensure accurate identification and equitable support for students with behavioral challenges.

Gender Differences

While the prevalence of ODD is similar among boys and girls during adolescence and adulthood, boys and girls may present differently in symptomology, severity, and associated comorbidity [12]. Boys may be found to experience symptoms that include annoying others, blaming others, being aggressive, and they may present with greater functional impairments at school and in the community than girls. Girls may demonstrate less observable oppositional characteristics, including more relational aggression (e.g., refusing to talk to someone, being malicious, avoiding blaming, spreading rumors, attempting to harm someone’s relationships with others, etc.). Additionally, boys may be more likely to have externalizing comorbidity (e.g., ADHD) while girls may be more likely to have internalizing comorbidity due to significantly diminished self-regulation skills compared to boys with ODD (e.g., anxiety, depression, and somatic complaints) [13].

Socioeconomic Differences

Children and adolescents from low-income households are more frequently identified as exhibiting symptoms associated with Oppositional Defiant Disorder (ODD) [14]. Environmental stressors common in economically disadvantaged neighborhoods, such as exposure to community violence, can contribute to the development or intensification of oppositional behaviors. Limited access to mental health resources and safe recreational spaces may further exacerbate these challenges. Additionally, lower levels of parental education are often linked to inconsistent or harsh disciplinary practices, which can influence the emergence of ODD symptoms. Factors such as food insecurity, chronic stress, and reduced access to supportive peer networks also play a role in shaping behavioral outcomes in these populations.

Developmental Pathway of ODD

Overview of Developmental Course

The first symptoms of ODD are typically present as early as preschool but rarely later than early adolescence. If left untreated, the severity of the symptoms could gradually escalate to the development of Conduct Disorder (CD) and even to the severity level of Anti-social Personality Disorder (APD) [15]. A typical developmental progression of disruptive behavior may begin with severe hyperactivity and impulsivity in early childhood, followed by the emergence of ODD symptoms during the preschool years. As the child enters elementary school, these behaviors may intensify and evolve into conduct disorder. During adolescence, the individual may begin to engage in substance- related issues, and if left untreated, these patterns can culminate in antisocial personality disorder in adulthood. Children and adolescents with ODD may experience a variety of problems in adulthood, including relational problems, lower educational attainment, and workplace stress. School psychologists and other providers should be familiar with the risk factors and the developmental trajectory of ODD when evaluating and designing interventions for students with ODD.

Dispositional Risk Factors

Emotional/Temperamental Factors

Numerous emotional risk factors have been associated with the development of ODD. Children who experience difficulties regulating their emotions are more likely to exhibit irritability and vindictiveness [16]. For example, children who have higher levels of emotional reactivity and/or have a low frustration tolerance are at risk for developing ODD. Children and adolescents who have low self-control due to ADHD may also possess issues with emotional regulation making them vulnerable to developing comorbid ODD. Callous-unemotional traits (CU), a cluster of traits of psychopathic youth that include a lack of empathy and indifference toward the feelings of others, have been seen in children and adolescents whose ODD symptoms begin to exacerbate to CD or APD. Youth who have CU traits likely have characteristics of neuroticism that cause them to demonstrate lower levels of fear and anxiety – also increasing the likelihood of their symptoms exacerbating.

Genetic Factors

The heritability estimate for ODD is around 50%. Significant levels of CU traits may be a result of genetic influences (e.g., excess methylation in the OXTR gene predisposes adolescents to CU) [17]. AVPR1A, a gene located on chromosome 2 that plays a significant role in social behavior and interaction, may be associated with aggression in early and middle childhood. Epigenetic research demonstrates that both environmental influences and additive genetic effects, where multiple genes contribute to a single trait, may be involved in the development of Oppositional Defiant Disorder (ODD). Through gene-environment interactions, environmental exposures can either enhance or suppress the expression of genetic predispositions, thereby influencing the likelihood that ODD-related traits will manifest.

Cognitive Vulnerabilities

Youth with ODD may show cognitive deficits in executive functioning (EF) and low verbal intelligence, especially if they possess CU traits. The classification of EF into ‘hot’ and ‘cool’ is a critical element of etiopathological research on externalizing disorders. “Hot” EF involves affective, motivational, and emotional aspects of cognition, whereas “cool” EF focuses on planning, cognitive flexibility, working memory, and inhibition. Children with ODD may have characteristics of greater reward-seeking behaviors and problems with emotional self-control [18]. Regarding “cool” EF, children with ODD have lower behavioral inhibition, which mixed with poor emotional control may exacerbate impulse aggression. School-referred children with disruptive behavior symptoms are associated with poor motivational and cognitive control (also referred to as executive control), and they may be incapable of cognitively processing the negative consequences of their victim’s distress.

Neurobiological Factors

Children with ODD may have neurobiological abnormalities in the amygdala and prefrontal cortex – areas responsible for reasoning, judgment, impulsecontrol, andemotionalprocessing. Morespecifically, reduction in the left amygdala, anterior insula, frontal gyrus, cingulate cortex, and/or medial prefrontal cortex might be associated with ODD. Brain regions such as the amygdala, anterior cingulate cortex, insula, and orbitofrontal cortex are primarily involved in emotional or “hot” executive functions, while the dorsolateral prefrontal cortex and cerebellum are more associated with logical, “cool” executive functions and areas, such as the precuneus, control both types of functioning. Additionally, heart rate, serotonin levels, and basal cortisol levels are often reduced in adolescents with aggressive behaviors.

Environmental Risk Factors

Familial Factors

A variety of family risk factors, including low socioeconomic status (SES), parental separation, and maternal depression, have been associated with the development of ODD. Aside from parental pathology, other family factors that could lead to symptoms of childhood/adolescent-onset of ODD include exposure to poor disciplinary practices (e.g., forms of hostility or aggression), maltreatment and neglect (e.g., sexual, physical, or psychological abuse), single parenthood, and family disharmony (e.g., argumentative parents). A combination of surrounding oneself with deviant peers and having poor parental supervision with low involvement are predictors for adolescents to engage in rebellious and/or defiant behaviors. Children who are exposed to high levels of dysfunctional parenting and maternal depression are also at a higher risk of developing symptoms of defiant and antisocial behaviors. Finally, children who are frequently emotionally dysregulated are at risk of experiencing higher child-parent conflict that could enhance ODD symptomology.

Interpersonal Vulnerabilities

Children and adolescents often face a range of interpersonal challenges, particularly when it comes to initiating and sustaining positive relationships with peers. Those who are consistently rejected by their peers—such as being disliked or excluded—and those who associate with deviant or antisocial peer groups are at increased risk for developing oppositional defiant disorder (ODD). In some cases, youth with ODD may engage in bullying behaviors themselves, contributing to a hostile social environment. However, these individuals may also be targets of bullying, which can intensify symptoms of vindictiveness, especially when they feel compelled to retaliate against those who have harmed them. This cycle of aggression and retaliation can further complicate their social interactions and emotional regulation, reinforcing the behavioral patterns associated with ODD.

Early Adverse Experience

There is a relationship between childhood externalizing problems, including ODD, and exposure to traumatic events. Interpersonal trauma, referring to harmful experiences directly inflicted by another person (e.g., physical abuse, emotional neglect, witnessing domestic violence, etc.), and non-interpersonal trauma, referring to events not involving direct human interaction (e.g., severe accident, natural disaster, loss of a loved one, etc.), are predictive of ODD symptomology in boys, while only interpersonal trauma is a predictor in girls. Children who experience interpersonal trauma are more likely to develop problems with anger, emotional regulation, and disruptive behavior. Children and adolescents who are exposed to community violence in impoverished neighborhoods have an increased risk of developing antisocial attitudes and behaviors.

Protective Factors

There are a variety of protective factors that reduce the likelihood of developing or worsening symptoms of Oppositional Defiant Disorder (ODD). Early intervention is especially important, as it can prevent ODD symptoms from escalating into more severe conditions such as Conduct Disorder (CD) or Antisocial Personality Disorder (APD). One key protective factor is the presence of high-quality relationships, both within the family and among peers. These relationships are often supported by living in safe neighborhoods, having strong family support systems, and being surrounded by prosocial peers who model positive behavior. Additionally, strong executive functioning and emotional regulation skills serve as internal protective mechanisms that help children manage impulses and navigate social challenges more effectively.

Treatment of ODD

Clinical Treatment

Because parental factors are highly associated with ODD, clinical treatments should consider strengthening the relationships between caregivers and their children. Parent-Child Interaction Therapy (PCIT) is an evidence-based therapeutic technique originally developed for children with disruptive behaviors that focuses on strengthening familial relationships by altering parent-child interactions [19]. PCIT involves having a parent and child together in a playroom while a therapist remains on the other side of a one-sided mirror where they coach the parent (by talking to them through a headset of some form) on how to positively interact and build a healthy rapport with their child. This verbal rapport is typically developed through praise, positive reinforcement, and overall parental involvement by the parent. If implemented with fidelity, PCIT is an effective treatment for decreasing ODD symptoms and preventing the development of CD by helping parents quit certain behaviors (e.g., unhealthy discipline responses) while starting other behaviors (e.g., more parental involvement) [20].

School Intervention

Similarly, school psychologists who possess the appropriate training should consider facilitating Teacher-Child Interaction Training (TCIT) with the teacher and student. In general, TCIT is a “classroom-based program designed to provide teachers with behavior management skills that foster positive teacher-student relations and to improve student behavior by creating a more constructive classroom environment” [21]. In general, there are teaching sessions that encompass learning about positive reinforcement through praise, modeling, and various classroom management strategies to decrease disruptive behaviors [22,23]. These sessions typically involve the clinician, teacher, and child, and it may also require the teacher to practice their skills in small and large group settings.

Conclusion

This review article explored Oppositional Defiant Disorder (ODD) in youth, emphasizing its diagnostic criteria, prevalence, developmental trajectory, and associated risk and protective factors. The article distinguishes between clinical and educational diagnoses in the United States, highlighting the roles of DSM-5- TR and IDEIA in shaping assessment and intervention practices. It identifies a range of dispositional, genetic, cognitive, neurobiological, and environmental risk factors that contribute to the onset and progression of ODD, while also underscoring the importance of early intervention and facilitating strong interpersonal relationships as protective mechanisms. Evidence-based treatments such as Parent- Child Interaction Therapy (PCIT) and Teacher-Child Interaction Training (TCIT) are presented as effective strategies for managing symptoms and preventing escalation into more severe disorders like Conduct Disorder (CD) or Antisocial Personality Disorder (APD). Psychologists, therapists, and educators should possess a deep understanding of the psychopathology underlying Oppositional Defiant Disorder (ODD) and be equipped with evidence-based strategies to support affected students. This includes conducting informed evaluations, implementing targeted interventions, and fostering collaborative efforts among school staff and families to address behavioral and emotional challenges effectively.

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DOI: 10.31038/PSYJ.2025762

As digital communication becomes ever more embedded in the daily lives of young adults, the dynamics of intimate relationships are increasingly shaped—and strained—by technology. While digital platforms offer constant connection, they also create new contexts in which control, surveillance, coercion, and aggression can emerge [1]. The publication “College Students Perceptions of Digital Dating Abuse: Insights From Gender Schema Theory” advances the field by examining how college students judge the abusiveness of digital dating abuse (DDA) behaviors, how these judgments differ based on gender, and how personal histories of victimization and perpetration influence these views [2]. Although researchers have clearly defined several digital behaviors as abusive, through the increasing norms of online communication and engagement, it is unclear how college students view these behaviors. Situated within the framework of gender schema theory, this publication provides vital insight into how young adults make sense of digital dating behaviors in their relational lives, and why some forms of DDA remain under-recognized despite their documented harm.

Gender as a Lens for Interpreting DDA

A central contribution of the publication is its clear demonstration that gender strongly shapes how college students interpret DDA. Across all behaviors, male-to-female DDA was viewed as more abusive than female-to-male DDA, reflecting longstanding evidence that violence by men against women is perceived as more harmful and threatening [3,4]. Even in digital contexts without physical contact, cultural scripts linking men with physical power and women with vulnerability shape how students assess potential harm and escalation.Women also consistently rated digital sexual coercion and digital monitoring/control as more abusive than men, aligning with research showing that men are generally more tolerant of aggression and less likely to label behaviors as abusive [5,6]. Gender schema theory [7] offers a useful explanation: cultural expectations that associate masculinity with dominance and femininity with nurturance guide how individuals recognize and evaluate relational harm. Women’s heightened perceptions may also stem from their disproportionate exposure to the emotional, psychological, and sexual consequences of DDA [8-10], including fear of escalation, reputational harm, and coercive control [11,12]. Men, by contrast, may normalize persistent messaging or monitoring due to socialization that minimizes relational intrusion and discourages acknowledging vulnerability.A particularly noteworthy nuance is that women also viewed female-to-male digital monitoring/control as more abusive than men did. Female-perpetrated aggression violates cultural stereotypes positioning women as passive or emotionally compliant [13], making such behavior appear more deviant—and therefore more abusive—to female respondents. Men’s lower ratings in these scenarios may reflect norms that downplay male victimization, reinforce emotional invulnerability, and obscure harm when the perpetrator does not match stereotypical images of an aggressor [14]. As a result, male victims may be less visible to peers, less likely to receive support, and less likely to identify their experiences as abuse [15].

Hierarchies of Harm: Why Monitoring Is Under-Recognized

One of the publication’s strongest contributions is its systematic comparison of how different types of DDA are ranked in severity. Students consistently viewed digital direct aggression as most abusive, followed by digital sexual coercion, and finally by digital monitoring/control. This hierarchy parallels findings from broader intimate partner violence research, where overt threats or sexual aggression are more easily recognized as abusive than psychological or controlling behaviors [16,17]. But digital monitoring/control might present unique risks precisely because it is so easily normalized among young adults.

Research shows that a majority of college students engage in at least one digital monitoring/control behavior—such as checking a partner’s social media or sending excessive messages—without labeling these actions as abusive [18]. Adolescents and young adults often view digital access, shared passwords, or location tracking as signs of trust, intimacy, or commitment [19]. In this context, the publication’s results reflect a broader cultural shift in which persistent digital connection is expected and surveillance becomes routine.

Yet digital monitoring/control is not benign. Studies demonstrate strong associations between monitoring behaviors and poor mental health outcomes, attachment anxiety, and eventual escalation to offline aggression [20,21]. The publication’s findings that students consistently under-recognize this category of harm reinforce the need for educational programs that clearly differentiate between healthy connectedness and intrusive control.

Experience Shapes Perception: Minimization Among Victims and Perpetrators

A significant theoretical insight from the publication is the identification of what might be termed a desensitization effect: individuals with prior experiences of DDA—either as victims or perpetrators—rate abusive behaviors as less harmful than those without such histories. This aligns with research on cognitive dissonance, self-justification, and normalization processes in intimate partner violence.

Victims who remain in or return to unhealthy relationships may reinterpret or downplay DDA behaviors to maintain relational coherence. Perpetrators, meanwhile, may minimize the negativity of their actions, especially when DDA behaviors feel mundane or common among their peers. However, the asymmetry noted by the authors, in which perpetrators minimized digital monitoring/control but not necessarily digital direct aggression or digital sexual coercion, might signal a deeper structural issue: digital monitoring/control is so culturally embedded that even those who commit it may not recognize its harm potential.

This has profound implications for prevention programming. Traditional interventions often assume that individuals can identify unhealthy behaviors but struggle with behavioral change. However, if young adults do not interpret their own actions—or their partner’s actions—as abusive, generative dialogue about harm and relational boundaries becomes more challenging. Prevention efforts must therefore address both recognition and reinterpretation: helping students recalibrate their internal thresholds for what constitutes harmful digital conduct.

Conclusion

The publication “College Students Perceptions of Digital Dating Abuse: Insights From Gender Schema Theory” provides an important and much-needed contribution to the evolving discourse on DDA. By grounding its investigation in gender schema theory and foregrounding the diverse and often contradictory ways college students interpret digital behaviors, it illuminates the perceptual landscape that shapes young adults’ responses to DDA. The findings reveal that DDA is not simply a technological phenomenon but a deeply social one—embedded in gendered expectations, cultural narratives, and personal histories. As institutions, educators, and scholars seek to reduce DDA and foster healthier digital relationships, this study offers a foundation for designing prevention efforts that are evidence-based, culturally attuned, and responsive to the realities of young adults. Its insights serve not only as an academic contribution but as a call for more intentional, nuanced, and inclusive strategies to confront the normalization of digital harm in intimate relationships.

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