Developmental pathways in oppositional defiant disorder and conduct disorder

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994) specifies a developmental relationship between oppositional defiant disorder (ODD) and conduct disorder (CD). Evidence for this link is mixed, however, and recent studies suggest that different symptom dimensions in ODD may have different outcomes. The authors examined links between ODD, CD, and their young adult outcomes in the Great Smoky Mountains Study (E. J. Costello et al., 1996), a longitudinal data set with over 8,000 observations of 1,420 individuals (56% male) covering ages 9-21 years. ODD was a significant predictor of later CD in boys but not in girls after control for comorbid CD and subthreshold CD symptomatology. Transitions between ODD and CD were less common than anticipated, however, particularly during adolescence. The authors examined characteristics and outcomes of children with pure ODD, pure CD, and combined CD/ODD. Alongside many similarities in childhood and adolescent correlates, key differences were also identified: CD largely predicted behavioral outcomes, whereas ODD showed stronger prediction to emotional disorders in early adult life. Factor analysis identified irritable and headstrong dimensions in ODD symptoms that showed differential prediction to later behavioral and emotional disorders. Overall, the results underscore the utility of retaining separate ODD and CD diagnoses in DSM-V.     

Building an evidence base for DSM-5 conceptualizations of oppositional defiant disorder and conduct disorder: introduction to the special section

The DSM-5 ADHD and Disruptive Behavior Disorders Work Group recently outlined a research agenda designed to support possible revisions to the diagnostic criteria for oppositional defiant disorder (ODD) and conduct disorder (CD). Some of the areas in need of further investigation include (a) examining the clinical utility of the current diagnostic system in girls, (b) further clarifying the developmental progression from ODD to CD, (c) determining whether facets of ODD symptoms can help explain heterotypic continuity and enhance predictive validity, (d) evaluating the clinical utility of a new subtyping scheme for CD on the basis of the presence of callous-unemotional traits, and (e) comparing the clinical utility of dimensional versus categorical conceptualizations of ODD and CD. This special section was organized in an attempt to provide data on these issues using a diverse array of longitudinal data sets consisting of both epidemiological and clinic-based samples that collectively cover a large developmental span ranging from childhood through early adulthood.     

Evidence for developmentally based diagnoses of oppositional defiant disorder and conduct disorder

This paper compares the validity of DSM-III-R diagnoses of oppositional defiant disorder (ODD) and conduct disorder (CD) and an alternative option which is subdivided into three levels according to developmental sequence and severity: modified oppositional disorder (MODD), intermediate CD (ICD), and advanced CD (ACD). Using a sample of 177 boys followed over 3 years, both the DSM-III-R and the alternative diagnostic constructs are evaluated on three criteria: symptom discriminative validity, and diagnostic external and predictive validity. Most DSM-III-R ODD and CD symptoms discriminated between ODD and CD, but exceptions are noted. Additional analyses demonstrated considerable overlap among DSM-III-R oppositional symptoms. The majority of the symptoms proposed for the alternative option could be assigned to a specific level based on acceptable symptom discrimination. External validity lent support to the distinctions between DSM-III-R ODD and CD, and between MODD, ICD, and ACD. MODD was a better predictor than ODD of which boys received a later diagnosis of CD. Suggestions are made for the inclusion and exclusion of symptoms for developmentally based diagnoses of oppositional and conduct disorders.This research was supported by a grant from the John D. and Catherine R. MacArthur Foundation to the American Psychiatric Association, and grant 1-RO1-MH42529-04 from the National Institute of Mental Health. The authors are indebted to Paul Frick for his advice with some of the statistical analyses, and particularly to Ms. Judith Navratil for her expert help in data collection.     

Interrelationships and Continuities in Symptoms of Oppositional Defiant and Conduct Disorders from Age 4 to 10 in the Community

Childhood oppositional defiant disorder (ODD) has commonly been thought to increase the risk of conduct disorder (CD) in late childhood and adolescence. However, symptoms of CD may also emerge during preschool and middle childhood. The few studies that have examined whether ODD increases the risk of such early onset CD have produced equivocal results, potentially due to methodological issues. In this study, a community sample of Norwegian 4-year-olds (n = 1042, 49.9 % males) was examined bi-annually over four waves of data collection. Symptoms of ODD, CD, attention-deficit/hyperactivity disorder (ADHD), anxiety and depressive disorders were measured through interviews with parents and children using the Preschool Age Psychiatric Assessment and the Child and Adolescent Psychiatric Assessment. The results showed that at all ages, more symptoms of ODD predicted more symptoms of CD at the next age of examination even after adjusting for previous CD and comorbid conditions. The effect of previous ODD on CD two years later did not differ according to gender, SES, or parental cohabitating status at any point in time. There was modest homotypical continuity in symptoms of CD and moderate homotypical continuity in symptoms of ODD. Symptoms of ODD increased from age 4 to 8 and declined to age 10. In conclusion, symptoms of ODD increase the risk of early onset symptoms of CD. The continuity in symptoms of ODD, and to some extent CD, combined with an increased risk of early symptoms of CD forecasted by symptoms of ODD, underscore the importance of detection, prevention and treatment of behavioral disorders already in early childhood.     

Unintentional Injury Risk in Children with Externalizing Behavior Disorders at Summer Camp

Children with externalizing behavior disorders such as attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) have greatly increased risk of unintentional injury, but it is unclear what mechanisms are responsible for that increased risk. This study followed 22 children participating in a summer camp for children with ADHD. Injury incidents were recorded daily and a set of primary symptoms of behavioral disorders were recorded at 15-min intervals over the course of the 6-week summer camp experience (roughly 300 h of observing each child). We predicted symptoms of ODD and CD would be more strongly related to injury incidence than symptoms of ADHD. Results from univariate Poisson regression models confirmed our prediction. Symptoms of ODD and CD—violations and intentional aggression in particular—were related to injury incidence but symptoms of ADHD were not. This finding is consistent with a growing body of evidence that oppositional, noncompliant, and aggressive behavior patterns might be primarily responsible for increased risk for injury among children with externalizing behavior disorders. Thanks to Sylvie Mrug, Peter Winslett, and the other staff members of the STP camp for their cooperation.     

Sources of covariation among attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder: the importance of shared environment.

Research has documented high levels of covariation among childhood externalizing disorders, but the etiology of this covariation is unclear. To unravel the sources of covariation among attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD), the authors studied 11-year-old twins (N = 1,506) from the Minnesota Twin Family Study. Symptom counts for each of these disorders were obtained from interviews administered to the twins and their mothers. A model was fit that allowed the parsing of genetic, shared environmental (factors that make family members similar to each other), and nonshared environmental (factors that make family members different from each other) contributions to covariation. The results revealed that although each disorder was influenced by genetic and environmental factors, a single shared environmental factor made the largest contribution to the covariation among ADHD, ODD, and CD.     

Mind the gap: assessing impairment among children affected by proposed revisions to the diagnostic criteria for oppositional defiant disorder

The Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) workgroup for disruptive behavior disorders is considering adopting a frequency threshold for symptoms of oppositional defiant disorder (ODD). In the present study, the impact of substituting the term "often" with a specific age-based frequency on impairment and prognosis among preschool children was tested in a longitudinal design. Mutually exclusive groups were created to identify children who met criteria for ODD based on a symptom threshold of "often," as in Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-4), and those that met criteria for ODD based on a threshold of "1-2 times per day," which approximated the proposal for DSM-5. Comparisons of these groups to each other and to nondiagnosed peers determined the impact of changing the symptom threshold on impairment and prognosis. Close to one-third of children who met DSM-4 criteria for ODD did not meet criteria under the alternative diagnosis; African American children were overrepresented in this group. Preschoolers who met DSM-4, but not the alternative criteria, had higher rates of ODD, conduct disorder (CD), and were more impaired than their nondiagnosed peers at baseline and follow-up. Preschoolers meeting DSM-4 criteria were less impaired than children meeting the alternative ODD criteria at baseline according to parent, but not according to teacher report. No differences could be detected between those meeting DSM-4 and those meeting the alternative criteria in rate of ODD, CD, or impairment at follow-up. Among clinically referred preschool children, changing the symptom threshold for ODD could result in a sizable group of children who would no longer meet diagnostic criteria, despite demonstrating significant morbidity concurrently and prospectively.     

Negative Halo Effects in Parent Ratings of ADHD,ODD, and CD

Attention-deficit/hyperactivity disorder (ADHD), Oppositional Defiant Disorder (ODD), and Conduct Disorder (CD) are highly comorbid, with symptoms that share some similarities. The evidence-based diagnostic process for these disorders includes ratings from adults in the child’s life to assess behavior across settings, so it is important to understand how these raters think about potentially overlapping symptoms. Researchers have identified negative halo effects in ratings of ADHD and ODD symptoms, but ratings of CD have not been examined in these prior studies. Thus, the current study extended past research to examine negative halo effects in parent ratings of the predominantly hyperactive-impulsive presentation of ADHD (i.e., ADHD/HI), ODD, and CD. Parent participants read one of four vignettes that portrayed an 11-year-old boy displaying symptoms of ADHD/HI, ODD, CD, or typical development, and then completed a disruptive behavior scale. The general trend we found was that the presence of a relatively more severe disorder (i.e., CD) artificially inflated ratings of - or showed a negative halo effect for - the relatively less severe disorder (i.e., ADHD/HI), but with some nuance as discussed in the paper. These findings explain and validate how important it is that clinicians conduct evidence-based psychological assessments to decrease the chance of misdiagnosis.

     

Waxing and waning in concert: dynamic comorbidity of conduct disorder with other disruptive and emotional problems over 7 years among clinic-referred boys

Six waves of structured diagnostic assessments were conducted of 168 clinic-referred 7- to 12-year-olds, over 7 years. Wave-to-wave changes in the number of conduct disorder (CD) behaviors were paralleled by correlated changes in the numbers of symptoms of oppositional defiant disorder (ODD), attention-deficit/hyperactivity disorder (ADHD), depression, and anxiety. In addition, CD in Wave 1 predicted levels of ODD, ADHD, depression, and anxiety in later waves when initial levels of those symptoms were controlled, but only ODD in Wave 1 predicted CD in later waves when initial CD levels were controlled. These findings indicate a striking degree of dynamic comorbidity between CD and other types of psychopathology and provide an initial empirical framework for needed developmental models of comorbidity.     

Mother-Teacher Agreement on Preschoolers’ Symptoms of ODD and CD: Does Context matter?

The aims of this study were to examine mother-teacher agreement on oppositional defiant disorder (ODD) and conduct disorder (CD) symptoms and diagnoses in preschool children; to determine if context is a source of disagreement; and to explore if sex, referral status, and age moderated agreement rates. Participants included 158 male and 139 female 3- to 5-year old preschool children, their mothers, and teachers. A structured interview, the Kiddie-Disruptive Behavior Disorder Schedule was used for maternal report and teachers completed the Early Childhood Inventory. Results indicated that mothers reported more symptoms and diagnoses of ODD and CD than teachers, and mother-teacher agreement on both ODD and CD symptoms and diagnoses was low. Level of mother-teacher agreement increased when reporting on behavior in the same context; however, the rates remain modest. Referral status increased the likelihood of mother and teacher agreement on several ODD and CD symptoms, as well as ODD and CD diagnosis. These data suggest that context plays a role in mother-teacher agreement in the assessment of young children's ODD and CD symptoms.     

Problem of item overlap between the psychopathy screening device and attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder rating scales

Content validity requires a clear definition of the construct of interest and the delineation of the construct from similar constructs. Content validity also requires that the items be representative of the construct as well as specific to the construct. An examination of the items on the Psychopathy Screening Device (PSD), a parent- and teacher-rating scale of childhood psychopathy, indicates significant overlap with the symptoms and associated features of attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD). The failure of the PSD to have unique items results in poor discriminant validity with ADHD, ODD, and CD rating scales. More careful attention to content validation guidelines is required to develop a more useful measure of childhood psychopathy.     

A Systematic Review and Meta-analysis of Neuroimaging in Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) Taking Attention-Deficit Hyperactivity Disorder (ADHD) Into Account

Oppositional defiant disorder (ODD) and conduct disorder (CD) are common behavioural disorders in childhood and adolescence and are associated with brain abnormalities. This systematic review and meta-analysis investigates structural (sMRI) and functional MRI (fMRI) findings in individuals with ODD/CD with and without attention-deficit hyperactivity disorder (ADHD). Online databases were searched for controlled studies, resulting in 12 sMRI and 17 fMRI studies. In line with current models on ODD/CD, studies were classified in hot and cool executive functioning (EF). Both the meta-analytic and narrative reviews showed evidence of smaller brain structures and lower brain activity in individuals with ODD/CD in mainly hot EF-related areas: bilateral amygdala, bilateral insula, right striatum, left medial/superior frontal gyrus, and left precuneus. Evidence was present in both structural and functional studies, and irrespective of the presence of ADHD comorbidity. There is strong evidence that abnormalities in the amygdala are specific for ODD/CD as compared to ADHD, and correlational studies further support the association between abnormalities in the amygdala and ODD/CD symptoms. Besides the left precuneus, there was no evidence for abnormalities in typical cool EF related structures, such as the cerebellum and dorsolateral prefrontal cortex. Resulting areas are associated with emotion-processing, error-monitoring, problem-solving and self-control; areas associated with neurocognitive and behavioural deficits implicated in ODD/CD. Our findings confirm the involvement of hot, and to a smaller extent cool, EF associated brain areas in ODD/CD, and support an integrated model for ODD/CD (e.g. Blair, Development and Psychopathology, 17(3), 865-891, 2005).     

Parenting Behavior and Conduct Problems in Children with and Without Attention-Deficit/Hyperactivity Disorder (ADHD): Moderation by Callous-Unemotional Traits

There is evidence that negative parenting positively predicts oppositional defiant disorder (ODD) and conduct disorder (CD) and that children’s callous-unemotional (CU) traits may moderate this association. However, it is largely unknown if CU traits show similar interactive effects with positive parenting for ODD/CD. 208 ethnically diverse (56% Caucasian) 6–9 year-old children with and without attention-deficit/hyperactivity disorder (ADHD) were ascertained using multiple methods and informants for ODD, CD, and CU traits. CU traits, corporal punishment, positive parenting, and each of their interactions with CU traits were unrelated to parent- and teacher-rated ODD. Corporal punishment and CU traits were similarly unrelated to parent- and teacher-rated CD. However, positive parenting inversely predicted parent-reported CD symptoms and it was significantly moderated by CU traits. Positive parenting was negatively associated with CD at low to moderate levels of CU traits, but it was unrelated to CD at high levels of CU traits. Children with elevated levels of CU traits exhibited significantly higher levels of CD symptoms that were largely independent of positive parenting behavior. We discuss these findings within a developmental psychopathology framework to provide further perspectives on reciprocal influences between parenting behavior and CU traits in the development of ODD and CD.     

The role of a lifetime history of oppositional defiant and conduct disorders in adults with ADHD: implications for clinical practice

IntroductionAttention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) are frequently co-occurring disorders in children and adolescents. However, their clinical status among adults is still under discussion. This study analyzes how the current clinical presentation of adult ADHD might be influenced by a lifetime history of CD and ODD. METHODS: We compared three groups of patients: ADHD without history of CD/ODD (n = 178), ADHD + history of ODD (n = 184), and ADHD + history of CD (n = 96). RESULTS: A history of CD (and to a lower extent ODD) is associated with a more severe and externalizing profile.ConclusionPast CD and ODD entail a significant negative mental health impact on persistent ADHD, reinforcing the importance of actively assessing the developmental history of adult ADHD patients.     

Preschoolers at risk for attention-deficit hyperactivity disorder and oppositional defiant disorder: family,parenting, and behavioral correlates

This community study assigned 129 4-year-olds to groups at risk for attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), both ADHD and ODD, or no problems. Mothers of children at risk for ODD reported more family dysfunction, felt less competent as parents, suggested fewer solutions to child behavior problems, demonstrated a less assertive approach to child management, and reported more child internalizing problems than did mothers of children not elevated on ODD symptoms. Mothers of children at risk for ADHD reported higher personal depression scores than did those of the non-ADHD subgroup. Children at risk for ADHD evidenced the most difficulties in school where teachers reported more social behavior, classroom management, and internalizing problems relative to other children not at risk for ADHD. When solving child management problems, mothers of children in all groups suggested twice as many controlling/negative management strategies as positive/preventive strategies. In addition, faced with oppositional and conduct problems, mothers of children in all groups increased controlling/negative suggestions and decreased positive/preventive suggestions. Mothers of girls at risk for ADHD, ODD, and ADHD/ODD gave more rewards per positive behavior than did mothers of boys.     

Internal Validity of the Disruptive Behavior Disorder Symptoms: Implications from Parent Ratings for a Dimensional Approach to Symptom Validity

A dimensional approach was used to evaluate the internal validity of the DSM-III-R ADHD-inattention, ADHD-hyperactivity/impulsivity, oppositional defiant disorder (ODD), and conduct disorder (CD) symptoms (i.e., whether a symptom has a stronger correlation with its own dimension than the other three). Parents rated 4,019 children between the ages of 2 and 19 on these symptoms. The results showed that 5 of the 6 inattention symptoms, 3 of the 4 hyperactivity symptoms, 1 of the 4 impulsivity symptoms, 6 of the 9 oppositional defiant disorder symptoms, and 8 of the 11 CD symptoms had significant internal validity. Confirmatory factor analysis (CFA) found support for inattention, hyperactivity/impulsivity, oppositional defiant, and conduct disorder dimensions. Multiple-group CFA also found support for factor pattern and loading invariance across gender. The implications of these results as well as the merits of the dimensional approach to symptom validity are discussed in the context of the DSM-IV changes in ADHD, ODD, and CD.     

Inhibition and working memory in young preschool children with symptoms of ADHD and/or oppositional-defiant disorder

Background: Early symptoms of attention deficit/hyperactivity disorder (ADHD) and oppositional-defiant disorder (ODD) are associated with deficits in cognitive self-regulatory processes or executive functions (EF)s. However, the hypothesis that neurocognitive deficits underlying the two disorders are already evident during early preschool years still has limited empirical support. The present study investigated associations between symptoms of ADHD and/or ODD and two core EFs, inhibition and working memory, in a large nonclinical sample of 3-year old children. Method: Participants were 1045 children (554 boys, age 37–47 months), recruited from the population based Norwegian Mother and Child Cohort Study (MoBa). Relations between behavioral symptoms and measures of inhibition and working memory were studied both categorically and dimensionally. Results: Children with co-occurring symptoms of ADHD and ODD performed at a significantly lower level than typically developing children in 4 out of 5 EF measures. Symptoms of ADHD, both alone and in combination with ODD, were associated with reduced performance on tests of inhibition in the group comparisons. Dimensional analyses showed that performance within both EF domains contributed to variance primarily in ADHD symptom load. The associations between test results and behavioral symptoms remained significant after gender and verbal skills had been controlled. Conclusion: Young preschoolers show the same pattern of relations between EF and behavioral symptoms of ADHD and/or ODD as previously described in older children diagnosed with ADHD and/or ODD. Effect sizes were generally small, indicating that measures of EF have limited clinical utility at this stage in development.     

Understanding the Covariation Among Childhood Externalizing Symptoms: Genetic and Environmental Influences on Conduct Disorder,Attention Deficit Hyperactivity Disorder,and Oppositional Defiant Disorder Symptoms

Conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD) are common childhood externalizing disorders that frequently co-occur. However, the causes of their comorbidity are not well understood. To address that question, we analyzed data from > 600 Finnish twin pairs, who completed standardized interviews at age 14. Behavior genetic methods were used to examine how genetic/environmental factors contribute to each disorders symptoms and to their covariation. We found significant genetic effects on each disorder with only modest evidence of shared environmental influences. Our data suggest the comorbidity among CD, ADHD, and ODD is primarily explained by shared genetic influences; however, each disorder was also under unique genetic influence, supporting the distinction of each disorder.     

Significance of Childhood Conduct Problems to Later Development of Conduct Disorder Among Children With ADHD: A Prospective Follow-Up Study

This study investigates whether low to moderate levels of childhood oppositional defiant disorder (ODD) and conduct disorder (CD) behaviors contribute to the development of clinically diagnosed CD in adolescence, in children with attention deficit hyperactivity disorder (ADHD). Participants were 207 White boys (ages 6-12) with ADHD free of conduct disorder diagnoses. Parent and teacher ratings were obtained. Participants were assessed at mean age 18 by clinicians blind to childhood status. A non-ADHD group (recruited in adolescence) was also studied. ODD behavior ratings did not predict CD in adolescence, whereas CD behavior ratings did. No single ODD or CD behavior predicted adolescent outcome. ADHD probands with very low ratings (Not at all, Just a little) by parents and teachers on all CD behaviors were still at significantly increased risk for CD in adolescence, compared to non-ADHD controls. The same relationships were found between childhood ODD and CD behaviors, and antisocial personality disorder in adulthood (mean age, 25). We conclude that childhood ADHD is a developmental precursor of later antisocial disorder, even in the absence of comorbid ODD or CD in childhood. However, low levels of CD-type problems are not innocuous, because they predict later CD among children with ADHD without comorbid CD.