Is there a link between conduct disorder (CD) and oppositional defiant disorder (ODD)? What influences do gender and age have on ODD? Are there any patterns relating to comorbidity with other disorders (e.g., ADHD, anxiety disorders and depression)? These questions are difficult to answer, but are important in determining the needs of children with these antisocial disorders and in developing effective services and treatment options.
CD and ODD, both classified as child and adolescent disruptive behavior disorders, are typified by a constellation of antisocial behaviors. In general, CD symptoms include aggressive acts (e.g., fighting), non-aggressive acts (e.g., lying or stealing) and status violations (e.g., truancy or running away from home). Children with ODD exhibit a pattern of hostile and defiant behavior and are often argumentative and resentful toward adult authority figures.
It is known that these disruptive behavior disorders are highly comborbid with attention-deficit/hyperactivity disorder (ADHD) - experts estimate that about 50% of children with ADHD are comorbid for ODD and/or CD, while almost all children under 12 years of age with these disruptive behaviors meet the criteria for ADHD. CD appears to be more prevalent in boys than in girls and may change in presentation with increasing age. Information concerning trends of ODD is less clear; although, because of considerable overlap with CD and a perceived prevalence in younger children, some investigators have suggested that ODD might be a developmental precursor to CD.
Extending the epidemiological evidence
"Although many epidemiologic studies have reported on CD/ODD, we were surprised when we reviewed the literature to find how many issues - including very basic ones, such as the pattern of age trends in these disorders - were still far from clear," Barbara Maughan, Ph.D., of the MRC Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, King's College London, told The Brown University Child and Adolescent Behavior Letter.
In an effort to better define these antisocial disorders in children and adolescents, Maughan and colleagues conducted a study that focused on age trends, gender ratios and patterns of comorbidity. The study, published in the Journal of Child Psychology and Psychiatry, benefited from a relatively large sample size, a broad-age range and methods of analysis that enabled researchers to study trends of individual symptoms for both disorders as well as specific trends related to ODD.
For this study, researchers used cross-sectional data from the 1999 British Child Mental Health Survey (B-CAMHS99), which is based on a nationally representative sample of over 10,000 boys and girls from 5-15 years of age. Over 90% of children sampled were white and most lived with both parents. The children were assessed using the Development and Well-Being Assessment (DAWBA), consisting of a parental interview, a child interview (for children age 11 years and older) and a teacher questionnaire.
DSM-IV diagnoses of CD and ODD were drawn from the DAWBA information. Two additional measures were created specifically for this study. First, a new category - "inclusive ODD" - was created by relaxing the DSM-IV criteria for ODD to allow for ODD to be diagnosed even in the presence of a CD diagnosis. Second, the DSM-IV criterion for each disorder was used to explore trends in individual symptomology. Five symptom scales were formed:
1) Total ODD symptoms
2) Total CD symptoms
3) Aggressive CD symptoms (bullying, fighting, weapon use, cruelty to people/animals, et al.)
4) Status violations (truancy, running away from home)
5) Other non-aggressive CD symptoms (fire setting, vandalism, breaking in, lying, stealing)
Gender and age trends
Similar to previous reports, this study found that CD was significantly more common in boys than in girls. Overall, 0.8% of girls in the sample met the criteria for CD compared to 2.1% of boys. There also appeared to be a steady increase in rates of CD in boys as they got older. Rates of CD in girls remained relatively low until age 12, where they began to increase similarly to the pattern observed with boys.
Trends in CD symptom profiles across several age groups showed that in the older boys (age 13-15), there was a significant rise in status violations and non-aggressive conduct problems and a significant decline in fighting. In girls, rates of non-aggressive behavior were significantly lower in the 13-15 year age group compared to boys, but there were no observed gender differences in levels of status violations. Interestingly, in the 13-15 year old group, rates of aggressive behavior (fighting) were reported equally for both girls and boys.
This study also observed gender differences in ODD prevalence, with ODD diagnosed in significantly more boys than girls (overall, 1.4% of girls met ODD criteria compared to 3.2% of boys). However, this difference appeared to draw from data of teacher reports, as no significant difference was observed with data from parent reports. This highlights one of the complexities associated with these studies and stresses the importance of analyzing data from various reporters.
In both boys and girls, the rates of ODD remained relatively constant until age 10, when it started to decline. However, when the "inclusive ODD" category was used (disregarding overlaps with CD), rates of ODD did not decline with age in either boys or girls. Rather, levels of ODD appeared to persist beyond childhood into adolescence, even showing a trend to be more severe in the older age groups.
"Although rates of DSM-IV defined ODD declined quite markedly with age, rates of 'inclusive' ODD were almost as high in 15 year-olds as they were in 7 year-olds," explained Maughan. "It seemed to us that these findings could be useful in alerting clinicians to the need to assess ODD symptomatology in children and adolescents who present with CD, and to consider whether additional treatment strategies are needed to deal with the oppositional aspects of their difficulties," she said.
Diagnostic overlap and comorbidity
There was substantial diagnostic overlap of these two disorders in this sample. Overall, 56% of girls and 62% of boys with CD also met the ODD "inclusive" criteria. From the other perspective, fewer children with ODD also met the criteria for CD, although there was a nonsignificant tendency for the overlap percentage to increase with age. Maughan commented "this is another example of the quite widely observed phenomenon that children with comorbid disorders also tend to have more severe patterns of symptomatology."
As for the link between ODD and CD, Maughan thinks the jury is still out. "Like all previous reports, our study confirmed the strong overlap between these two disorders - but as a cross-sectional study, it could not of course directly address develop mental issues," she said. However, based on their experience with other samples as well as findings from other investigators, Maughan and colleagues think that a developmental progression from ODD to CD may be involved for boys (this may differ for girls, but current evidence is limited).
"Many younger boys with ODD go on to develop CD, and many conduct disordered teenagers have shown oppositional behaviors earlier in development," Maughan said. However, she cautioned that the picture is more complex - some boys with ODD to not develop CD, and some cases of adolescent CD emerge relatively de novo.
These investigators also examined comorbidity with other non-antisocial disorders, finding that levels were broadly similar for both ODD and CD (see Table 1). Thirty-six percent of girls and 46% of boys diagnosed with ODD met criteria for at least one other disorder, as did 39% of girls and 46% of boys diagnosed with CD. As previous studies have shown, comorbidity was especially strong with ADHD for both ODD and CD.
Table 1: Comorbid disorders with ODD and CD
 |
ADHD(%) |
Depression(%) |
Anxiety (%) |
| Diagnosis |
Girls |
Boys |
Girls |
Boys |
Girls |
Boys |
| CD |
16.4 |
30.8 |
11.9 |
13.6 |
16.4 |
9.6 |
| ODD(full) |
16.7 |
29.5 |
4.4 |
2.4 |
22.2 |
16.4 |
| None |
0.5 |
2.1 |
0.8 |
0.5 |
3.7 |
3.0 |
(Adapted from Table 3; Maughan et al., 2004)
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When the data were re-analyzed to consider ODD only, CD only or ODD/CD combined, it was found that rates of comorbidity with any other DSM-IV disorder were significantly higher for children diagnosed with ODD (alone or combined with CD) than for those with CD alone (p=0.006). "Our findings suggest that 'oppositional' features often relate more closely to impulsive, hyperactive behaviors than do 'delinquent' ones," said Maughan. Also, children diagnosed with ODD alone were significantly more likely to have comorbid anxiety disorders compared to those with CD alone (p=0.03).
Treatment
The complex interactions of these disorders and their high comorbidity with other disorders (especially ADHD) offer several challenges to choosing the best treatment option. According to a recent international consensus statement concerning the treatment of disruptive behavior disorder
and ADHD - discussed in detail in the February 2004 issue of The Brown University Child and Adolescent Behavior Letter - the optimal approach to treating these children is to target symptoms with a combination of psychosocial intervention and pharmacotherapy (when indicated). Also, it is recommended that when possible, children be treated by a specialist familiar with these disorders.
After full assessment, initial treatment options suggested in the consensus statement for a child with a disruptive disorder involve psychosocial interventions (e.g., parent training, classroom intervention, family therapy, social skills therapy and cognitive behavior therapy [CBT]). The most effective use of these interventions targets specific symptoms. For example, parent training and school intervention is utilized to address oppositionality; social skills programs and/or CBT are most effective for aggression/impulsivity.
An accurate diagnosis is critical before treatment with a pharmacological agent, and depending on the presence or absence of comorbid disorders (especially ADHD), options differ substantially. For children diagnosed with CD only, the atypical antipsychotic risperidone (Risperdal) can be initiated to treat aggression if symptoms were not reduced by previous interventions. For ODD, these experts state the pharmacological treatment should not be considered except in cases where aggression is a significant problem. The consensus statement cautions against use of psychostimulants in children with primary CD due to the high risk of abuse in this population. However, in children with both CD and ADHD, psychostimulant medication can be used to treat the core symptoms of ADHD.
Future directions
Research on these disorders continues to uncover information regarding patterns and trends. Maughan and colleagues recently explored whether we are experiencing an actual increase in prevalence of ODD and/or CD in a paper to be published in the ,Journal of Child Psychology and Psychiatry. Whether or not there has been a rise in prevalence, these behavioral disturbances need to be accurately identified and diagnosed in order for children to find effective treatment and services.
For example, determining whether ODD is a factor in older children, as demonstrated in the study by Maughan et al., could impact the course of treatment and the development of services. "In practice, current evidence- based treatments for ODD (such as parent training) are primarily designed for younger children; we hope that our findings encourage investigators to explore strategies that can be equally effective in treating oppositionality at older ages," said Maughan.
References:
Maughan B, Rowe R, Messer J, et al.: Conduct disorder and oppositional defiant disorder in a national sample: developmental epidemiology. J Child Psychol Psychiatry 2004; 45(3): 609-621.
Kutcher S, Aman M, Brooks SJ, et al.: International consensus statement on attentiondeficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs): clinical implications and treatment practice suggestions. Eur Neuropsychopharmacol 2004;14(1):11-28.
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