Psychosocial problems in attention-deficit hyperactivity disorder with oppositional defiant disorder

Psychiatry and Clinical Neurosciences (2002), 56, 365 369 Regular Article Psychosocial problems in attention-deficit hyperactivity disorder with oppositional defiant disorder YUZURU HARADA, md, phd, 1 TOHRU YAMAZAKI, md, phd 2 AND KAZUHIKO SAITOH, md, phd 3 1 Department of Psychiatry, Shinshu University School of Medicine, Matsumoto, Nagano, 2 Department of Psychiatry, Shizuoka Prefectual Mental Care and Rehabilitation Center, Shizuoka and 3 Department of Child and Adolescent Psychiatry, Kohnodai Hospital, National Center of Neurology and Psychiatry, Ichikawa, Chiba, Japan Abstract The purpose of this study is to clarify psychosocial characteristics of the comorbidity of attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) in comparison with ADHD or ODD alone. Thirty-one patients with ADHD comorbid with ODD were compared with 23 ADHD alone and 10 with ODD alone, in terms of various examination items including objective assessment scales. The comorbid group demonstrated higher Children Depression Inventory score and State-Trait Anxiety Inventory for Children (state-anxiety) score than the ADHD or the ODD group, possessing more problems in the relationship with teachers than the ADHD group, with friends more than the ADHD or the ODD group, and with their mothers more than the ADHD group and less than the ODD group. School refusal occurred more frequently in the comorbid group than the ADHD group and less than the ODD group. The comorbid group had more psychosocial problems than the ADHD group and the ODD group. These problems could be classified into three types: (i) those derived from ODD, problems in the relationship with teachers; (ii) those derived from ODD but reduced by the coexistence of ADHD, problems in the relationship with their mothers; and (iii) those resulting from the comorbidity of ADHD and ODD, problems in the relationship with friends and anxious and depressive tendency. The difficulties in the relationship with teachers and friends observed in the comorbid group may lead to school refusal. Key words attention-deficit hyperactivity disorder, oppositional defiant disorder, comorbidity, psychosocial problems, school refusal. INTRODUCTION Correspondence address: Yuzuru Harada, Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390 8621 Nagano, Japan. Email: y-harada@hsp.md.shinshu-u.ac.jp Received 28 February 2001; revised 26 November 2001; accepted 2 December 2001. Previous studies on oppositional defiant disorder (ODD) have mainly discussed its validity as a disorder. 1 3 However, studies by multiple factor analysis 4 6 and prospective studies 7,8 have suggested that ODD can be classified as a category reflecting an oppositional-aggressive psychological dimension that differs from the criminal dimension. 9 Some epidemiological studies 10 12 have shown a high incidence of attention-deficit hyperactivity disorder (ADHD) comorbid with ODD. Of patients with ADHD, 30 45% also have ODD. Of patients diagnosed as having ODD, 61 67% have ADHD. There have been only a few studies that have distinguished ODD from conduct disorder (CD), and evaluated the characteristics of patients with ADHD comorbid with ODD. 13 In addition, because these studies did not compare the comorbid group with a group with ODD alone, it cannot be determined whether the observed characteristics were derived from ODD or a new pathologic condition induced by the comorbidity of the two disorders. In order to clarify the psychosocial characteristics of the comorbidity of ADHD and ODD, we compared patients

366 Y. Harada et al. with ADHD comorbid with ODD and those with ADHD or ODD alone. METHODS Subjects Of patients aged 15 years who visited the National Center of Neurology and Psychiatry, Kohnodai Hospital, Chiba, or the Shinshu University Hospital, Nagano, Japan, between April 1994 and March 1998, all children who fulfilled the criteria of both ADHD and ODD simultaneously, according to DSM-IV, 14 were evaluated (comorbid group). Patients who showed an intelligence quotient 70, who were being treated with drugs, or who had neurological complications such as convulsions or schizophrenic complications such as delusion were excluded. The comorbid group consisted of 27 males and four females aged 7 14 years. In addition, of the patients diagnosed as having ADHD or ODD alone according to DSM-IV, those matched with the comorbid patients for age and sex were selected as controls (ADHD group and ODD group, respectively). The ADHD group consisted of 20 males and three females, and the ODD group consisted of nine males and one female. Evaluation items In principle, the following investigation was carried out at the time of the first consultation. The subjects and their mothers were interviewed by child psychiatrists, and individual records on DSM-IV axes I and II diagnoses, present illness, and adaptation states at home and school were produced. Coexisting psychiatric disorders were also diagnosed according to DSM-IV. School refusal was defined as absence from school for 30 days/year that was not due to physical disorders. Intelligence tests Wechsler Intelligence Scale for Children-Revised and Illinois Test of Psycholinguistic Abilities were performed by experienced clinical child psychologists. Children with markedly low reading or calculating ability compared with other examination items were diagnosed as having learning disorder. Subjects were also examined by the Japanese versions of the Children Depression Inventory (CDI) 15 and State-Trait Anxiety Inventory for Children (STAIC). 16 Concerning the adaptation states at school and home, the mothers were asked about the presence or absence of problems. When there were problems, they were asked to write down the details of the problems, which were classified as discussed below. Statistical analysis Stat View J-4.5 (Abacus Concepts, Inc., Berkley, USA) was used for statistical analysis. Categorical data in individual records were compared by the c 2 test. Numerical data on individual records and CDI and STAIC scores were compared by Kruskal Wallis test. Mann Whitney U-test was performed on significant findings. P < 0.05 was regarded as significant. RESULTS IQ and psychopathology in three groups The full IQ score did not significantly differ between the comorbid group (99.3 ± 15.4) and the ADHD group (90.5 ± 19.6). Statistical analysis could not be performed in the ODD group because only a few patients underwent intelligence tests. The number of ADHD symptoms according to DSM-IV did not significantly differ between the comorbid group (10.8 ± 2.3) and the ADHD group (9.7 ± 1.7). The number of ODD symptoms did not significantly differ between the comorbid group (6.6 ± 1.4) and the ODD group (6.7 ± 1.3). As coexisting disorders, the incidence of anxiety disorder, mood disorder, somatoform disorder, tic disorder, or learning disorder was nearly the same between the comorbid group and the control groups. The CDI score in the comorbid group (21.7 ± 7.1) was significantly higher (H-value = 11.5, P = 0.003) than that in the ADHD group (15.9 ± 6.0) or that in the ODD group (16.6 ± 5.4). The state-anxiety score of STAIC in the comorbid group (34.3 ± 8.9) was significantly higher (H-value = 13.5, P = 0.006) than that in the ADHD group (28.8 ± 8.8) or that in the ODD group (28.0 ± 4.1). The trait-anxiety score did not significantly differ among the ADHD group (38.2 ± 9.0), comorbid group (40.6 ± 7.9), and the ODD group (36.0 ± 4.5). School problems The presence or absence of school refusal, the relationship with teachers, relationship with friends, and problems in learning were evaluated. School refusal was observed in four patients (17%) in the ADHD group, 13 (42%) in the comorbid group, and eight (80%) in the ODD group. The percentage in the comorbid group was significantly higher than that in the ADHD group, but significantly lower than that in the ODD group (c 2 = 11.7, P = 0.003). Problems in the relationship with teachers and friends were showed in Table 1. Problems in relationships with teachers were more frequently observed in

ADHD with ODD 367 Table 1. Problems in the relationship with teachers, friends and their mothers ADHD group Comorbid group ODD group (n = 23) (n = 31) (n = 10) No. % No. % No. % Problems in the relationship with teachers 5 22 18 a 58 6 60 Distrust/dissatisfaction 2 9 9 29 2 20 Opposition 1 4 7 23 4 40 Others 2 9 2 6 0 0 Problems in the relationship with friends 18 78 30 a,e 97 6 60 Isolation 9 39 6 19 3 30 Impulsive reaction 6 26 10 32 1 10 Being bullied 3 13 7 23 1 10 Egocentric behavior 0 0 4 13 0 0 Others 2 9 6 19 1 10 Problems in the relationship with mother 3 13 21 c,d 68 10 100 Marked ambivalence 2 9 11 35 3 30 Opposition 0 0 10 b 32 2 20 Violence 0 0 4 13 4 40 Others 1 4 0 0 1 10 More than one answer was accepted. a P < 0.05 vs ADHD group; b P < 0.001 vs ADHD group; c P < 0.001 vs ADHD group; d P < 0.05 vs ODD group; e P < 0.01 vs ODD group. the comorbid group than in the ADHD group (c 2 = 8.1, P = 0.018). Their problems were classified into strong distrust/dissatisfaction without obvious opposition, opposition in both speech and action, and others. According to each category, there was no significant difference among the three groups. Problems in the relationship with friends were observed in 30 patients (97%) in the comorbid group, 18 (74%) in the ADHD group, and six (57%) in the ODD group. Problems were more frequently observed in the comorbid group than in the ADHD group or in the ODD group (c 2 = 8.8, P = 0.012). Their problems were classified into isolation from friends, impulsive reactions to friends, being bullied, egocentric behavior, and others. According to each category, no significant difference was observed among the three groups. Poor school achievement was noted in 62% of the comorbid group, 73% of the ADHD group, and 42% of the ODD group. There were no significant differences among the three groups. Relationship with family members The relationship between the patients and their fathers, mothers, and siblings were assessed. Ten patients (38%) in the comorbid group, six (29%) in the ADHD group, and seven (70%) in the ODD group had trouble with their fathers. No significant differences were observed among the three groups. The nature of the problems were classified into being timid with their fathers, having little contact with their fathers, experiencing opposition in both speech and action, and violence towards their fathers. According to each category, no significant difference was also observed among the three groups. Problems in relationships with mothers are also showed in Table 1. These were observed in 21 patients (68%) in the comorbid group, three (13%) in the ADHD group, and all the 10 in the ODD group. The percentage in the comorbid group was significantly higher than that in the ADHD group, but significantly lower than that in the ODD group (c 2 = 26.3, P < 0.001). The nature of the problems were classified into marked ambivalence toward their mothers, opposition in both speech and action, violence towards their mothers, and other problems. The percentage of patients showing opposition were significantly higher in the comorbid group than in the ADHD group (c 2 = 9.0, P = 0.011). Nineteen patients in the comorbid group, 16 in the ADHD group, and nine in the ODD group had siblings. Problems in the relationship with siblings were observed in 16 patients (84%) in the comorbid group, seven (44%) in the ADHD group, and seven (78%) in the ODD group. The percentage in the comorbid

368 Y. Harada et al. group did not significantly differ from that in the control groups. The nature of the problems were quarrels, fights, and bullying in almost all patients. DISCUSSION As described above, there have been only a few studies on the characteristics of the comorbidity of ADHD and ODD. Biederman et al. compared 140 patients with ADHD and 120 control patients and observed a significantly higher complication rates of depression and anxiety disorder in the comorbid group than the ADHD group. 17 Kuhne et al. compared 33 patients with ADHD, 46 with ADHD comorbid with ODD and 12 with ADHD comorbid with CD in terms of intelligence quotient, the severity of ADHD, aggressiveness, anxiety, emotional function, school achievement, self-esteem, social adaptation, and the psychopathology of their parents. 18 The patients with ADHD comorbid with ODD or CD showed severe ADHD symptoms and social adaptation failure compared with those with ADHD alone. In addition, social withdrawal and good school achievement were correlated with ADHD comorbid with ODD. However, these two studies did not compare ADHD comorbid with ODD and ODD alone. Therefore, it is unclear whether the characteristics they observed were derived from ODD or the comorbidity of the two disorders. In the present study, we tried to make this point clear by comparing ADHD comorbid with ODD to not only ADHD but ODD alone. The characteristics in the comorbid group that showed significant differences from the ADHD group but not from the ODD group were problems with teachers. The nature of the problems with teachers were mostly distrust/ dissatisfaction and oppositional attitudes. These appear to be the characteristics derived from ODD, which is defined as oppositional and defiant modes of behavior. The incidence of problems with mothers was significantly more frequent in the comorbid group than in the ADHD group but significantly less frequent in the comorbid group than in the ODD group. These appear to be derived from ODD, however, the coexistence of ADHD may have rather reduced these ODD-derived characteristics to some degree. The nature of the problems were most frequently marked ambivalent feelings toward their mothers, followed by opposition and violence. Irrespective of the cause, when children demonstrate oppositional attitudes or show violence towards their mothers, whom they depend on, they have two opposed feelings; that of love and hate. Marked ambivalent feelings towards their mothers, including those accompanied by direct opposition or violence, are basic feelings in children who have trouble with their mothers. Although some patients in the comorbid group demonstrated oppositional attitudes or were violent to their fathers, the percentage of these patients did not significantly differ from that in the control groups. Because Japanese fathers are less directly involved in childcare than mothers, the relationship between children and fathers may be weaker, inducing fewer conflicts. The items showing differences from both control groups can be considered to be the characteristics of the comorbidity. High CDI and STAIC (state-anxiety) scores were characteristic. This suggests that the comorbid group, despite their oppositional attitudes, tends to become anxious in responding to situations and tends to be depressed. These results were consistent with those reported by Biederman et al. Another characteristic was difficulty in the relationship with friends in the same generation. They impulsively react, behave egocentrically and are bullied and isolated. It is of interest that the comorbid group had more problems in personal relationships with others in the same generation, even more than the ODD group who are also defiant towards adults. The synergistic effect of ADHD symptoms and ODD symptoms may produce such a characteristic. These characteristics may influence school refusal as 42% of the comorbid group showed this. It differs from truancy but is similar to social withdrawal of children in other countries. Children with school refusal generally believe that they should go to school but cannot help feeling reluctant to go to school and they suffer from this conflict. We consider that school refusal is a child s failure to adapt to school. Based on this speculation, the difficulties in the relationship with teachers and friends observed in the comorbid group may readily lead them to school refusal in Japan. The frequent development of school refusal observed in the present study was consistent with the results of the study by Kuhne et al. ACKNOWLEDGMENTS We thank Professor Dr Naoji Amano at the Department of Psychiatry, Shinshu University School of Medicine, and Dr Yuko Miyake at the Institute of Mental Health, National Center of Neurology and Psychiatry for their comments. This study was paid by the Research Grant (5B-5) for Nervous and Mental Disorders from the Japanese Ministry of Health and Welfare.

ADHD with ODD 369 REFERENCES 1. Rutter M, Shaffer D. DSM III: a step forward or back in terms of classification of child psychiatric disorders. J. Am. Acad. Child Adolesc. Psychiatry 1980; 19: 371 394. 2. Werry JS, Elkind GS, Reeves JC. Attention deficit, conduct, oppositional, and anxiety disorders in children: I. J. Am. Acad. Child Adolesc. Psychiatry 1987; 26: 133 143. 3. Rey JM, Bashir MR, Schwarz M et al. OppositionaI disorder: fact or fiction? J. Am. Acad. Child Adolesc. Psychiatry 1988; 27: 157 162. 4. Achenbach TM, Conners CK, Quay HC et al. Replication of empirically derived syndromes as a basis for taxonomy of child/adolescent psychopathology. J. Abnorm. Child Psychol. 1989; 17: 299 320. 5. Frick PJ, Lahey BB, Loeber R et al. Oppositional defiant disorder and conduct disorder in boys: patterns of behavioral covariation. J. Clin. Child Psychol. 1991; 20: 202 208. 6. Loeber R, Lahey BB, Thomas C. Diagnostic conundrum of oppositional defiant disorder and conduct disorder. J. Abnorm. Psychol. 1991; 100: 379 390. 7. Lahey BB, Loeber R, Quay HC et al. Oppositional defiant and conduct disorders: issues to be resolved by DSM-IV. J. Am. Acad. Child Adolesc. Psychiatry 1992; 31: 539 546. 8. Loeber R, Keenan K, Lahey BB et al. Evidence for developmentally based diagnoses of oppositional defiant disorder and conduct disorder. J. Abnorm. Child Psychol. 1993; 21: 377 410. 9. Rey JM. Oppositional defiant disorder. Am. J. Psychiatry 1993; 150: 1769 1778. 10. Cohen P, Velez N, Kohn M et al. Child psychiatric diagnosis by computer algorithm. J. Am. Acad. Child Adolesc. Psychiatry 1987; 26: 631 638. 11. Spitzer RL, Davies M, Barkley RA. The DSM-III-R. field trial of disruptive behavior disorders. J. Am. Acad. Child Adolesc Psychiatry 1990; 29: 690 697. 12. Pelham WE, Gnagy EM, Greenslade KE et al. Teacher ratings of DSM-III-R. symptoms for the disruptive behavior disorders. J. Am. Acad. Child Adolesc. Psychiatry 1992; 31: 210 218. 13. Schachar R, Wachsmuth R. Oppositional disorder in children: a validation study comparing conduct disorder, oppositional disorder and normal control children. J. Child Psychol. Psychiatry 1990; 31: 1089 1102. 14. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. American Psychiatric Association. Washington, DC, 1994. 15. Kovacs M. Rating scale to assess depression in schoolaged children. Acta Paedopsychiatrica 1981; 46: 305 315. 16. Spielberger CD, Edward CD, Lushene RE et al. Preliminary Manual for the State-Trait Anxiety Inventory for Children (How I Feel Questionnaire). Consulting Psychological Press, California, 1973. 17. Biederman J, Faraone SV, Milberger S et al. Is childhood oppositional defiant disorder a precursor to adolescent conduct disorder? Findings from a four-year follow-up study of children with ADHD. J. Am. Acad. Child Adolesc Psychiatry 1996; 35: 1193 1204. 18. Kuhne M, Shachar R, Tannock R. Impact of comorbid oppositional or conduct problems on Attention-Deficit Hyperactivity Disorder. J. Am. Acad. Child Adolesc. Psychiatry 1997; 36: 1715 1725.