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.     

Affective Decision-Making and Externalizing Behaviors: The Role of Autonomic Activity

We tested a conceptual model involving the inter-relations among affective decision-making (indexed by a gambling task), autonomic nervous system (ANS) activity, and attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) symptoms in a largely impoverished, inner city sample of first through third grade children (N=63, 54% male). The present study hypothesized that impaired affective decision-making and decreased sympathetic and parasympathetic activation would be associated with higher levels of ADHD and ODD symptoms, and that low sympathetic and parasympathetic activation during an emotion-inducing task would mediate the relation between affective decision-making and child externalizing symptoms. In support of our model, disadvantageous decision-making on a gambling task was associated with ADHD hyperactivity/impulsivity symptoms among boys, and attenuated sympathetic activation during an emotion-inducing task mediated this relation. Support for the model was not found among girls.     

An evaluation of the response modulation hypothesis in relation to attention-deficit/hyperactivity disorder

Several hypotheses related to Newman's (e.g., Patterson & Newman, 1993) response modulation hypothesis were examined among adolescents with attention-deficit/hyperactivity disorder (ADHD; n=18) and normal controls (n=23). Consistent with predictions, youth with ADHD committed more passive avoidance errors (PAEs) than controls during the latter trials of a computerized go/no go task with mixed incentives, and this effect remained significant or marginally significant even after common variance associated with variables that covary with ADHD (i.e., IQ, oppositional-defiant/conduct disorder [ODD/CD] symptoms, anxious/depressed mood) was removed. While a moderate inverse association was observed between PAE frequency and the amount of time spent viewing response feedback following punishment, both categorical (diagnostic) and dimensional analyses of ADHD symptomatology indicated that ADHD and reflection on punishment feedback are uniquely associated with PAE commission. Findings from this study are discussed in relation to models of disinhibition applicable to youth with ADHD.     

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.     

Specificity of Reward Sensitivity and Parasympathetic-Based Regulation among Children with Attention-Deficit/Hyperactivity and Disruptive Behavior Disorders

Attention-deficit/hyperactivity disorder (ADHD) is associated with disruptionsin reward sensitivity and regulatory processes. However, it is unclear whether thesedisruptions are better explained by comorbid disruptive behavior disorder (DBD)symptomology. This study sought to examine this question using multiple levels ofanalysis (i.e., behavior, autonomic reactivity). One hundred seventeen children (aged 6 to 12 years; 72.6% male; 69 with ADHD) completed theBalloon-Analogue Risk Task (BART) to assess external reward sensitivity behaviorally.Sympathetic-based internal reward sensitivity and parasympathetic-based regulationwere indexed via cardiac pre-ejection period (PEP) and respiratory sinus arrhythmia(RSA), respectively. Children with ADHD exhibited reduced internal reward sensitivity (i.e.,lengthened PEP; F(1,112)=4.01, p=0.047) compared to healthy controls and werecharacterized by greater parasympathetic-based dysregulation (i.e., reduced RSAaugmentation F(1,112)=10.12, p=0.002). However, follow-up analyses indicated theADHD effect was better accounted for by comorbid DBD diagnoses; that is, childrenwith ADHD and comorbid ODD were characterized by reduced internal rewardsensitivity (i.e., lengthened PEP; t=2.47, p=0.046) and by parasympathetic-baseddysregulation (i.e., reduced RSA augmentation; t=3.51, p=0.002) in response to rewardwhen compared to typically developing youth. Furthermore, children with ADHD and comorbid CD exhibited greater behaviorally-based external reward sensitivity (i.e.,more total pops; F(3,110)= 5.96, p=0.001) compared to children with ADHD only (t=3.87, p=0.001) and children with ADHD and ODD (t=3.56, p=0.003). Results suggest that disruptions in sensitivity to reward may be betteraccounted for, in part, by comorbid DBD.Key Words: attention-deficit/hyperactivity disorder, autonomic nervous system,disruptive behavior disorders, reward sensitivityPowered     

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.     

Neurocognitive performance of 5- and 6-year-old children who met criteria for attention deficit/hyperactivity disorder at 18 months follow-up: results from a prospective population study

The aim of this prospective study was to examine whether neurocognitive performance of children aged 5–6 years distinguished children who were later diagnosed with attention deficit/hyperactivity disorder (ADHD) or borderline ADHD from children without ADHD after adjustment for behavioral measures and to examine the influence of comorbid psychopathology. Out of a general population of 1,317 children, 366 children were selected on the basis of their scores on the Child Behavior Checklist (CBCL). Eighteen months later, the parents were interviewed using a standardized child psychiatric interview: 33 children were classified as ADHD and 75 children as borderline ADHD, and there were 258 children without ADHD. Children with rated ADHD were significantly impaired on measures of visuomotor ability and working memory compared to children without ADHD after adjustment for CBCL results. The performance of borderline ADHD children was in between that of children with and without ADHD. In addition, 4 groups of children were analyzed: 9 ADHD, 24 ADHD with comorbid oppositional defiant disorder/conduct disorder (ODD/CD), 59 ODD/CD, and 274 controls. Children with rated comorbid ADHD and ODD/CD performed significantly worse on these tasks compared to children with rated ODD/CD and control children while they did not differ from ADHD children. Our results imply that neurocognitive measures can contribute to the early identification of ADHD with and without comorbid ODD/CD.     

Adolescents with attention deficit hyperactivity disorder: Mother-adolescent interactions,family beliefs and conflicts,and maternal psychopathology

A group of 83 adolescents with attention deficit hyperactivity disorder (ADHD) were subdivided into those with ADHD alone (n = 27) and those with ADHD and oppositional defiant disorder (ADHD/ODD, n = 56). They were compared to each other and a community control group (n = 77) on measures of family conflicts, family beliefs, maternal adjustment, and observations of mother-adolescent interactions during both a neutral and conflict discussion. Both ADHD groups had more topics on which there was conflict and more angry conflicts at home than control adolescents on parent reports. Only the ADHD/ODD adolescents reported more such conflicts, endorsed more extreme and unreasonable beliefs about their parent-teen relations, and demonstrated greater negative interactions during a neutral discussion than the control teenagers. Similarly, only mothers of the ADHD/ODD teens displayed greater negative interactions during a neutral discussion, more extreme and unreasonable beliefs about their parent-teen relations, greater personal distress, and less satisfaction in their marriages than the mothers in the control group. Most findings for the ADHD only group were between the control group and the group with mixed ADHD/ODD but did not differ from either group. Results imply that it is the combination of ODD symptoms with those of ADHD that is associated with the greater-than-normal conflicts, anger, poor communications, unreasonable beliefs, and negative interactive styles seen in ADHD adolescents. These same characteristics typify their mothers' interactions as well such that both the adolescents' ODD symptoms and maternal psychological distress (hostility) make unique contributions to the degree of conflict and anger in the parent-teen relations of ADHD adolescents.     

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.     

Childhood predictors of adolescent substance use in a longitudinal study of children with ADHD

Children diagnosed with attention-deficit/hyperactivity disorder (ADHD; n = 142) were prospectively monitored into adolescence (13-18 years old) to evaluate their risk for elevated substance use relative to same-aged adolescents without ADHD (n = 100). Probands reported higher levels of alcohol, tobacco, and illicit drug use than did controls. Group differences were apparent for alcohol symptom scores but not for alcohol or marijuana disorder diagnoses. Within probands, severity of childhood inattention symptoms predicted multiple substance use outcomes: childhood oppositional defiant disorder/conduct disorder (ODD/CD) symptoms predicted illicit drug use and CD symptoms. Persistence of ADHD and adolescent CD were each associated with elevated substance use behaviors relative to controls. Further study of the mediating mechanisms that explain risk for early substance use and abuse in children with ADHD is warranted.     

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.     

A sequential analysis of the mother-adolescent interactions of ADHD,ADHD/ODD,and normal teenagers during neutral and conflict discussions

The sequential interactions of three groups of teenagers conversing with their mothers during both neutral and conflict discussion situations were evaluated. Groups consisted of (1) attention deficit hyperactivity disorder (ADHD) alone (n =21), (2) ADHD with comorbid oppositional defiant disorder (ADHD/ODD; n =40), and (3) a community control group of adolescents (n =49). All groups had been followed concurrently for the past 8 to 10 years before being reevaluated in this study. Results indicated that (1) teens and parents in all groups interacted in a tightly linked manner, with the behavior of each member being significantly related only to the immediate antecedent behavior of the other; (2) mothers in all groups were more likely than teens to initiate positive behaviors; (3) teen interactions could be characterized as tit-for-tat while mothers could be typified as be-nice-and-forgive; (4) mother-teen dyads in the ADHD/ODD group displayed significantly higher rates of conflict behaviors than dyads in the other two groups, who did not differ significantly from each other on most measures; and (5) mothers in the ADHD/ODD group responded in a manner similar to their teens (greater negativity) and less like that of mothers in the other groups. The majority of conflict between ADHD children and their parents seemed due to comorbid ODD and such ODD is a family, not just a teen, characteristic.     

The Early Risers Preventive Intervention: Testing for Six-year Outcomes and Mediational Processes

We examined effects of the Early Risers “Skills for Success” early-age-targeted prevention program on serious conduct problems following 5 years of continuous intervention and one year of follow-up. We also examined if intervention effects on proximally-targeted variables found after 3 years mediated intervention effects on conduct problems found after 6 years. Participants included 151 at-risk children (106 males and 45 females) followed from first through sixth-grade, from 23 semi-rural schools in Minnesota. After 6 years, program children showed fewer oppositional defiant disorder (ODD) symptoms than control children. Program children did not significantly differ from controls on number of conduct disorder (CD) symptoms, DSM-IV diagnoses of ODD and CD, or drug use involvement. Results of the mediation analysis indicated that fewer ODD symptoms among program youth after 6 years were partially mediated by social skills and effective discipline. The study provides support for the early-starter model of conduct problems development that provides the framework for the Early Risers intervention. The study’s implications for prevention and limitations are discussed.     

Physiological Emotion Regulation in Children with ADHD with and without Comorbid Internalizing Disorders: a Preliminary Study

Children with Attention-Deficit/Hyperactivity Disorder (ADHD) experience deficits in emotion regulation that can be measured physiologically under environmental stress conditions by examining respiratory sinus arrhythmia (RSA), a marker of parasympathetic nervous system (PNS) withdrawal. The current pilot study examined the impact of comorbid internalizing disorders and comorbid Oppositional Defiant Disorder (ODD) on emotion regulation in children with ADHD by measuring RSA as an indicator of dysregulated emotional reactivity. Twenty-four 7–10 year old children with ADHD participated in the current study. Children completed a 5-min resting attending baseline while electrocardiogram data (ECG) were recorded to examine baseline RSA. Children then completed a stress inducing, blocked goal, Card Sorting Task to measure RSA reactivity to stress. Results revealed a significant effect of internalizing disorder status on RSA difference score, F (1, 18)?=?5.83, p?=?.03, η² = .25. Children in the comorbid internalizing disorder group had a significantly greater decrease in RSA from the baseline time period to the card sorting task. There was no significant effect of ODD diagnostic status on RSA difference score, p?>?.05. The results of this preliminary study suggest that among children with ADHD, the presence of a comorbid internalizing disorder predicts greater withdrawal of the PNS. These findings represent an important step in understanding autonomic functioning of children with ADHD and comorbid disorders.     

Conners’ continuous performance test (CCPT-II) in children with ADHD,ODD, or a combined ADHD/ODD diagnosis

The current study investigated if results on the Conners’ Continuous Performance Test (CCPT-II) could discriminate between children with ADHD (n = 59), ODD (n = 10), ADHD+ODD (n = 15), and normal controls (n =160), and how the results are associated with and explained by the intellectual function of the child. The sample was derived from the Bergen Child Study (BCS), a longitudinal, ongoing, population-based study of children’s development and mental health. CCPT-II performance did not differentiate between the three diagnostic groups (i.e., ADHD, ODD, and ADHD+ODD). Children with ODD (with or without comorbid ADHD) did not differ from children in the control group on any CCPT-II parameters. Children with ADHD made statistically significant more errors of omissions and showed a more variable response time to targets than the control group. The correlations between CCPT-II measures and IQ were mild to moderate, and there was a statistically significant group difference in IQ: Children with ADHD, and children with ADHD+ODD, obtained lower IQ scores than normal controls. A hierarchical multiple regression analysis showed that IQ, but not diagnostic group status, was significant predictors of CCPT-II performance. CCPT-II performance should be interpreted with caution when assessing ADHD and/or ODD in children.     

Risk Taking and Sensitivity to Punishment in Children with ADHD,ODD, ADHD+ODD,and Controls

We used the Balloon Analog Risk Task (BART) to examine risk taking and sensitivity to punishment, two relevant aspects of behavioral inhibition, in 203 school-age children with attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), ADHD+ODD, and controls. Participants earned points on the BART by pumping 30 separate balloons that exploded at variable intervals. No points were earned on a trial when a balloon exploded. The number of pumps across all balloons estimated risk taking and the reduction in pumps following balloon explosions was interpreted as an indicator of sensitivity to negative punishment. We found that all groups significantly differed from one another on risk taking. The ADHD+ODD group pumped the most, followed by the ODD, ADHD, and the control group, respectively. For sensitivity to negative punishment, all groups performed differently, with the ODD group showing the least sensitivity to an exploded balloon, followed by the ADHD, control, and ADHD+ODD groups, respectively. Children with ADHD+ODD demonstrated significantly different patterns of risk taking and sensitivity to negative punishment than children with either ADHD-only or ODD-only. ADHD youth with comorbid ODD had the greatest levels of risk taking, but they were also the most sensitive to negative punishment. The relationship between ADHD and ODD, as well as the nature of comorbidity in constructs related to risk taking and related behaviors, are discussed.     

The importance of callous-unemotional traits for extending the concept of psychopathy to children

This study focused on the use of callous-unemotional (CU) traits to identify a subgroup of children with both attention deficit/hyperactivity disorder (ADHD) and a conduct problem diagnosis (oppositional defiant disorder [ODD] or conduct disorder [CD] who show characteristics similar to adults with psychopathy. In a clinic-referred sample of children aged 6 to 13 years (N = 154), those with diagnoses of both ADHD and ODD/CD were divided on the basis of teacher ratings of CU traits. Children high on these traits showed features typically associated with psychopathy, such as a lack of fearfulness and a reward-dominant response style. Furthermore, children with CU traits seemed less distressed by their behavior problems. These findings are consistent with research on adults showing that impulsivity and antisocial behavior alone are insufficient to document persons who fit the construct of psychopathy.     

Paired-Associate Learning in Attention-Deficit/Hyperactivity Disorder as a Function of Hyperactivity-Impulsivity and Oppositional Defiant Disorder

A paired-associate learning (PAL) test was administered to 22 community volunteers without disruptive disorders and 197 children (7.5–13.5 years-old) presenting with the inattentive and combined subtypes of attention-deficit/hyperactivity disorder (ADHD) either in combination with or without oppositional defiant disorder (ODD). Participants were screened for learning disorders. In comparison to non-ADHD participants, children with ADHD achieved worse PAL and made errors rated as more acoustically and less semantically similar to the correct paired associates. These deficits were not related to hyperactivity–impulsivity or comorbid ODD. These results suggest that ADHD children are less competent at PAL and use less efficient learning strategies than their non-ADHD peers.     

The structure of childhood disruptive behaviors

Attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) frequently co-occur. Comorbidity of these 2 childhood disruptive behavior domains has not been satisfactorily explained at either a structural or etiological level. The current study evaluated a bifactor model, which allows for a "g" factor in addition to distinct component factors, in relation to other models to improve understanding of the structural relationship between ADHD and ODD. Participants were 548 children (321 boys, 227 girls) between the ages of 6 years and 18 years who participated in a comprehensive diagnostic assessment incorporating parent and teacher ratings of symptoms. Of these 548 children, 153 children were diagnosed with ADHD (without ODD), 114 children were diagnosed with ADHD + ODD, 26 children were diagnosed with ODD (without ADHD), and 239 children were classified as non-ADHD/ODD comparison children (including subthreshold cases). ADHD symptoms were assessed via parent report on a diagnostic interview and via parent and teacher report on the ADHD Rating Scale. ODD symptoms were assessed via teacher report. A bifactor model of disruptive behavior, comprising a "g" factor and the specific factors of ADHD and ODD, exhibited best fit, compared to 1-factor, 2-factor, 3-factor, and 2nd-order factor models of disruptive behaviors. It is concluded that a bifactor model of childhood disruptive behaviors is superior to existing models and may help explain common patterns of comorbidity between ADHD and ODD.