Clinical presentation and treatment outcome for children with comorbid externalizing and internalizing symptoms

This study examined the effects of comorbid separation anxiety disorder (SAD) on the expression of externalizing symptoms in children presenting with oppositional defiant disorder (ODD) as well as the treatment effects on anxiety and internalizing symptoms. Participants were 64 children with ODD seen in parent-child interaction therapy (PCIT), including 15 children with comorbid SAD. Children with ODD+SAD did not differ from children with ODD only in disruptive behavior severity at pre-treatment assessment, and children with ODD+SAD showed significant decreases in SAD symptoms at post-treatment. Additionally, children with clinical levels of internalizing behavior demonstrated significant reductions in these symptoms, along with reduction of externalizing symptoms targeted in treatment. We discuss the possibility that treatments focusing on parent-child interactions and certain parenting skills may generalize across specific child symptom constellations.     

Attention-deficit/hyperactivity disorder and comorbid oppositional defiant disorder or conduct disorder

Comorbid oppositional defiant disorder (ODD) and conduct disorder (CD) are common in clinically referred children and adolescents with attention-deficit/hyperactivity disorder (ADHD). Early recognition and treatment of co-occurring ADHD and ODD and/or CD is important because comorbidity influences symptom severity, prognosis, and treatment. Research on treatment supports the importance of behavior therapies for ODD and multimodal psychosocial interventions delivered simultaneously and intensively for CD with adjunctive medication for ADHD symptoms. Clinical trials are beginning to show that stimulants and atomoxetine are effective for ADHD and ODD symptoms when the disorders occur together. It is presently unclear if ODD in the absence of ADHD responds to pharmacotherapy. More research is needed examining the effects of commonly prescribed ADHD medications on CD symptoms. Research suggests a high prevalence of lifetime comorbidity with ODD in clinically referred patients with ADHD.     

Source-specific oppositional defiant disorder: comorbidity and risk factors in referred elementary schoolboys

OBJECTIVE: To examine differences in risk factors and comorbid conditions for oppositional defiant disorder (ODD) symptom groups in a sample of 248 elementary schoolboys (ages 6-10) recruited from 1994 to 1996. METHOD: The boys and their mothers received multiple assessments of cognitive, behavioral, academic, and family functioning, including a clinic-based evaluation in Stony Brook, NY. ODD was defined using four different strategies for aggregating data from mother and teacher reports of DSM-IV symptoms. RESULTS: Source-specific ODD symptom groups had better internal validity and were more differentiated than groups defined using the other strategies. The mother-defined ODD symptom group (ODD/M) had higher levels of maternal detachment than the teacher-defined symptom group (ODD/T), and the ODD/T group had more social problems than the ODD/M group. The classification agreement group (ODD/M + T) evidenced higher levels of sensation-seeking, maternal control, and comorbid symptoms than the ODD/M and ODD/T groups. Controlling for co-occurring attention-deficit/hyperactivity disorder and conduct disorder symptoms altered some of the relationships among ODD, comorbid symptoms, and psychosocial correlates. CONCLUSIONS: Patterns of co-occurring psychiatric symptoms and psychosocial correlates of ODD symptom groups varied depending on the rater(s) used to determine group membership. Results support continued research into source specificity for conceptualizing ODD.     

Oppositional Defiant Disorder as a Clinical Phenotype in Children with Autism Spectrum Disorder

To examine the validity of oppositional defiant disorder (ODD) as a clinical phenotype distinct from attention-deficit hyperactivity disorder (ADHD), parents and teachers completed a DSM-IV-referenced rating scale and a background questionnaire for 608 children (ages 3-12 years) with autism spectrum disorder (ASD). The ASD sample was separated into four groups: ODD, ADHD, ODD + ADHD, and neither (NONE). Comparison samples were non-ASD clinic (n = 326) and community (n > 800) controls. In the ASD sample, all three ODD/ADHD groups were clearly differentiated from the NONE group, and the ODD + ADHD group had the most severe co-occurring symptoms, medication use, and environmental disadvantage. There were few differences between ASD + ODD and ASD + ADHD groups. Findings for ASD and control samples were similar, supporting overlapping mechanisms in the pathogenesis of ODD.     

Long-acting methylphenidate has an effect on aggressive behavior in children with attention-deficit/hyperactivity disorder

INTRODUCTION: Aggression is frequently observed in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). The aim of this study was to assess the efficacy with regard to oppositional and aggressive behavior of a new long-acting methylphenidate preparation (Medikinet retard, MPH-MR), with equal portions of the immediate-release and the sustained-release active substance, and especially to look at correlations between either teacher or parent assessment of aggression and ADHD sub-symptomatology. METHODS: Eighty five children and adolescents (6-16 years) were investigated in a double-blind, randomized, clinical trial over 5 weeks under a treatment with MPH-MR using symptom checklists for ADHD, oppositional-defiant and conduct disorder according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). RESULTS: A total of 64.9% of the children showed oppositional defiant disorder/conduct disorder (ODD/CD) symptoms. A statistically significant effect was found in the group treated with MPH (verum-group). On the basis of Cohen's criteria, high effects were found for aggressive symptoms in school (d = 1.0), but not in the afternoon (d = 0.4). There were also lower effect sizes for more severe aggressive symptoms. We found characteristic correlations between ODD/CD symptoms and the ADHD subscale hyperactivity/impulsivity compared to the subscale inattention. CONCLUSIONS: Long-acting MPH is effective in the treatment of oppositional-defiant and aggressive behavior, especially concerning milder symptoms. The expected correlation between impulsivity and aggressiveness could be confirmed.     

Influence of Disruptive Behavior Disorders on Academic Performance and School Functions of Youths with Attention-Deficit/Hyperactivity Disorder

Childhood attention-deficit/hyperactivity disorder (ADHD) and comorbid oppositional defiant disorder/conduct disorder (ODD/CD) are associated with negative school outcomes. The study aimed to examine the impact of ADHD and ODD/CD on various school functions. 395 youths with ADHD (244 with ADHD?+?ODD/CD and 151 with ADHD only) and 156 controls received semi-structured psychiatric interviews. School functions were assessed and compared between each group with a multiple-level model. The results showed that youths with ADHD had poorer performance across different domains of school functioning. Youths with ADHD?+?ODD/CD had more behavioral problems but similar academic performance than those with ADHD only. The multiple linear regression models revealed that ADHD impaired academic performance while ODD/CD aggravated behavioral problems. Our findings imply that comorbid ODD/CD may specifically contribute to social difficulties in youths with ADHD. Measures of early detection and intervention for ODD/CD should be conducted to prevent adverse outcomes.     

Gender differences in ADHD subtype comorbidity

OBJECTIVE: To examine gender differences in attention-deficit/hyperactivity disorder ("ADHD") symptom comorbidity with "oppositional defiant disorder", "conduct disorder", "separation anxiety disorder", "generalized anxiety disorder", speech therapy, and remedial reading in children. METHOD: From 1994 to 1995, data from a large sample (N = 4,371) of twins and siblings studied in the Australian Twin ADHD Project were obtained by mailed DSM-IV-based questionnaires, investigating patterns of comorbidity in the three subtypes of "ADHD": "inattentive", "hyperactive/impulsive", and "combined". A total of 1,550 questionnaires were returned (87%) over the next 12 to 18 months. RESULTS: Analysis of variance showed significant between-group differences in males and females for inattention and hyperactive/impulsive symptom counts with higher rates of "oppositional defiant disorder" and "conduct disorder" in males, and higher rates of "separation anxiety disorder" in females indicating internalizing disorders are more common in females and externalizing disorders are occurring more often in males. Differences were found between the "ADHD" subtypes and the no ADHD category for all comorbid conditions, for both males and females. Children without ADHD consistently had fewer symptoms, while children with the combined subtype showed consistently more comorbid symptoms indicating a strong relationship between high rates of externalizing symptoms and high rates of internalizing symptoms. Gender differences in speech therapy were significant only for the children without ADHD. The rates of "separation anxiety disorder" were higher in females with the "inattention" subtype and the rate of "generalized anxiety disorder" higher for females with the "combined" subtype, indicating that the subtypes of ADHD were associated with these internalizing disorders in different ways. CONCLUSIONS: Although comorbidity differs among ADHD subtypes, there were no significant gender differences in comorbidity for externalizing disorders. Inattentive girls may present with anxiety. Clinical approaches for both males and females should be sensitive to possible language and reading problems.     

The Family Psychosocial Characteristics of Children with Attention-Deficit Hyperactivity Disorder with or Without Oppositional or Conduct Problems in Japan

We investigated whether the correlates of family psychosocial characteristics among Japanese children with attention-deficit hyperactivity disorder (ADHD) differ according to the comorbid condition of oppositional defiant disorder (ODD) or conduct disorder (CD). Three groups of children (12 ADHD, 15 ADHD + ODD/ CD, and 14 control) were compared on family psychosocial variables. Findings indicated that the interpersonal relationships in ADHD + ODD/ CD children's family were more conflictive and less organized than those of the control. Mental health among mothers of ADHD + ODD/CD children was worse than those of ADHD and control children. Childhood ADHD symptoms of parents were the most severe among parents of ADHD + ODD/CD children. These results support the nosological distinction between ADHD comorbid with ODD and CD. The need for specific clinical intervention according to the comorbid condition is stressed.     

Home-based parent training for school-aged children with attention-deficit/hyperactivity disorder and behavior problems with remaining impairing disruptive behaviors after routine treatment: a randomized controlled trial

The objective is to investigate the effectiveness of home-based behavioral parent training for school-aged children with attention-deficit/hyperactivity disorder (ADHD) and behavior problems with remaining impairing disruptive behaviors after routinely offered treatments in clinical practice. In a randomized controlled study including 73 referred children with ADHD and impairing disruptive symptoms after routine clinical pharmacotherapy and/or clinic-based parent training had been tried or, at least, offered, home-based behavioral parent training (n?=?26) was compared to a waiting list (n?=?23) and a care-as-usual home-based treatment (n?=?24). It was unknown to families which of the home-based treatments that they received. Using mixed models for repeated measures, we examined the effectiveness on the primary outcome measure of children’s severity of disruptive behaviors and on a number of secondary outcome measures [the degree to which parents experienced the disruptive behaviors as troublesome, ADHD symptoms, oppositional-defiant disorder (ODD) symptoms, and internalizing problems]. Compared to the waiting list, children receiving home-based parent training improved significantly more regarding severity of disruptive behaviors (ES?=?0.75), ADHD symptoms (ES?=?0.89), ODD symptoms (ES?=?0.65), and internalizing problems (ES?=?0.60). Compared to care-as-usual, home-based parent training was more effective in reducing disruptive behaviors (ES?=?0.57), ADHD symptoms (ES?=?0.89), and ODD symptoms (ES?=?0.88). Significantly more reduction of children’s internalizing problems was not found. In conclusion, children with ADHD and residual behavioral problems after routine treatment may benefit from home-based behavioral parent training.

     

Biological and psychosocial environmental risk factors influence symptom severity and psychiatric comorbidity in children with ADHD

Attention-deficit/hyperactivity disorder (ADHD) is a genetically as well as environmentally determined disorder with a high rate of psychiatric comorbidity. In this study, non-genetic biological and psychosocial risk factors for ADHD symptom severity and comorbid disorders were assessed in 275 children with ADHD, aged 5–13 years, mean age 9.7 (SD 1.9). Pre-/perinatal biological and lifetime psychosocial risk factors as well as data on parental ADHD were obtained. A different pattern of risk factors emerged for inattentive and hyperactive-impulsive ADHD symptoms. Inattentive symptoms were strongly influenced by psychosocial risk factors, whereas for hyperactive-impulsive symptoms, predominantly biological risk factors emerged. Hyperactive-impulsive symptoms also were a strong risk factor for comorbid oppositional defiant (ODD) and conduct disorder (CD). Smoking during pregnancy was a risk factor for comorbid CD but not ODD and further differential risk factors were observed for ODD and CD. Comorbid anxiety disorder (AnxD) was not related to ADHD symptoms and additional biological and psychosocial risk factors were observed. This study adds to the body of evidence that non-genetic biological and psychosocial risk factors have an impact on ADHD symptom severity and differentially influence comorbid disorders in ADHD. The findings are relevant to the prevention and treatment of ADHD with or without comorbid disorders.     

Executive functioning and emotion recognition in youth with oppositional defiant disorder and/or conduct disorder

Abstract

Objectives: Executive functioning and emotion recognition may be impaired in disruptive youth, yet findings in oppositional defiant disorder (ODD) and conduct disorder (CD) are inconsistent. We examined these functions related to ODD and CD, accounting for comorbid attention-deficit/hyperactivity disorder (ADHD) and internalising symptoms.

Methods: We compared executive functioning (visual working memory, visual attention, inhibitory control) and emotion recognition between youth (8–18?years old, 123 boys, 55 girls) with ODD (n?=?44) or CD (with/without ODD, n?=?48), and healthy controls (n?=?86). We also related ODD, CD, and ADHD symptom counts and internalising symptomatology to all outcome measures, as well as executive functioning to emotion recognition.

Results: Visual working memory and inhibitory control were impaired in the ODD and CD groups versus healthy controls. Anger, disgust, fear, happiness, and sadness recognition were impaired in the CD group; only anger recognition was impaired in the ODD group. Deficits were not explained by comorbid ADHD or internalising symptoms. Visual working memory was associated with recognition of all basic emotions.

Conclusions: Our findings challenge the view that neuropsychological impairments in youth with ODD/CD are driven by comorbid ADHD and suggest possible distinct neurocognitive mechanisms in CD versus ODD.     

Psychopathology and substance abuse in parents of young children with attention-deficit/hyperactivity disorder

OBJECTIVE: To compare the prevalence of psychological disorders in parents of young children with and without attention-deficit/hyperactivity disorder (ADHD) and comorbid disruptive behavior disorders (DBD). METHOD: Subjects included 98 three- to seven-year-old children with DSM-IV ADHD (68 with ADHD and comorbid oppositional defiant or conduct disorder [ADHD+ODD/CD]) and 116 non-ADHD comparison children recruited in 1995-96 during the first wave of a longitudinal study. Biological mothers were administered interviews to assess ADHD and DBD in their children and mood, anxiety, and substance use disorders in themselves. In addition, they were queried about symptoms of childhood ADHD and DBD, and antisocial personality disorder in themselves and their children's biological fathers. RESULTS: Child ADHD was associated with increased rates of maternal and paternal childhood ADHD relative to comparison children. Child ADHD+ODD/CD was associated with maternal mood disorders, anxiety disorders, and stimulant/cocaine dependence, and paternal childhood DBD. Mothers of children with ADHD+ODD/CD also reported increased drinking problems in their children's fathers. CONCLUSIONS: These findings indicate that many young children with ADHD, particularly those with comorbid ODD/CD, require comprehensive services to address both their ADHD and the mental health needs of their parents.     

Clinical precursors of adolescent conduct disorder in children with attention-deficit/hyperactivity disorder

OBJECTIVE: To examine precursors of adolescent conduct disorder (CD) in children with attention-deficit/hyperactivity disorder (ADHD), investigating the significance of childhood oppositional defiant disorder (ODD) and ADHD. METHOD: A total of 151 children with ADHD recruited from child psychiatric and pediatric clinics were assessed through standardized diagnostic interviews at ages 6 to 13 years and in adolescence 5 years later. Using multiple regression analysis, we assessed baseline ODD diagnosis and ODD, CD, and ADHD symptom scores as clinical predictors of adolescent CD diagnosis and symptom scores. RESULTS: Childhood ODD (diagnosis and severity) was significantly associated with adolescent CD (diagnosis and severity), independent of childhood ADHD severity and childhood CD. Children with a diagnosis of ODD were almost three times more likely to develop CD in adolescence (odds ratio = 2.79, 95% CI 1.16-6.70, p = .02). Childhood ADHD severity predicted adolescent CD scores but not diagnosis of CD (although there was a trend toward association). The presence of at least one CD symptom in childhood predicted adolescent CD severity. CONCLUSIONS: ODD is a significant precursor of adolescent CD in children with ADHD independent of ADHD severity. Considering the negative prognosis of ADHD with comorbid CD, it is imperative that clinicians pay specific attention to the presence of childhood ODD behaviors.     

The development of a rating scale to screen social and emotional detachment in children and adolescents

Rating scales to assess psychopathic characteristics in children and adolescents show a considerable item overlap with rating scales to assess attention deficit hyperactivity disorder (ADHD), oppositional-defiant disorder (ODD) and conduct disorder (CD) symptoms. The aim of this study is to preliminary test a short questionnaire clinicians can use to screen the unique characteristics of psychopathy. Parental ratings of psychopathic characteristics and symptoms of ADHD, ODD and CD were gathered in a community sample of 2535 4-18-year-old Dutch children. The dimensionality of the ratings was determined by factor analysis and related to ADHD, ODD and CD. Two factors emerged covering egocentric-narcissistic and callous-unemotional characteristics. To avoid unnecessary stigmatization of youngsters the first factor is referred to as the "social detachment dimension" and the second as the "emotional detachment dimension". Parental ratings were reliable across all age and gender groups, and correlated moderately with ODD and CD, but not with ADHD. Preliminary findings support a two-dimensional syndrome depicting respectively narcissistic and unemotional characteristics. The syndrome is associated with ODD and CD symptoms and possibly depicts a subtype of the ODD/CD childhood disorder.     

The Pharmacological Management of Oppositional Behaviour,Conduct Problems,and Aggression in Children and Adolescents With Attention-Deficit Hyperactivity Disorder,Oppositional Defiant Disorder,and Conduct Disorder: A Systematic Review and Meta-Analysis. Part 1: Psychostimulants,Alpha-2 Agonists,and Atomoxetine

Objective:

Children with attention-deficit hyperactivity disorder (ADHD) may have oppositional behaviour, conduct problems, and aggression. These symptoms vary in severity, and may be related to a comorbid diagnosis of oppositional defiant disorder (ODD) or conduct disorder (CD). Critical evaluation of the efficacy of ADHD medications may guide the clinician regarding the usefulness of medications for these symptoms.

Method:

We performed a systematic review and meta-analysis of psychostimulants, alpha-2 agonists, and atomoxetine for oppositional behaviour, conduct problems, and aggression in youth with ADHD, ODD, and CD. The quality of evidence for medications was rated using the Grading of Recommendations Assessment, Development and Evaluation approach.

Results:

Two systematic reviews and 20 randomized controlled trials were included. There is high-quality evidence that psychostimulants have a moderate-to-large effect on oppositional behaviour, conduct problems, and aggression in youth with ADHD, with and without ODD or CD. There is very-low-quality evidence that clonidine has a small effect on oppositional behaviour and conduct problems in youth with ADHD, with and without ODD or CD. There is moderate-quality evidence that guanfacine has a small-to-moderate effect on oppositional behaviour in youth with ADHD, with and without ODD. There is high-quality evidence that atomoxetine has a small effect on oppositional behaviour in youth with ADHD, with and without ODD or CD.

Conclusions:

Evidence indicates that psychostimulants, alpha-2 agonists, and atomoxetine can be beneficial for disruptive and aggressive behaviours in addition to core ADHD symptoms; however, psychostimulants generally provide the most benefit.     

Deficient social problem-solving in boys with ODD/CD, with ADHD, and with both disorders

OBJECTIVE: To study social problem-solving skills in psychiatrically defined aggressive boys, starting from Dodge's social information-processing model. METHOD: Videotaped stimuli of problematic social situations and questions were presented to elicit responses that indicate boys' social problem-solving skills (encoding and interpretation of social cues, generation of possible responses, evaluation of responses, self-efficacy evaluation, and response selection). Boys aged 7 to 12 years with oppositional defiant or conduct disorder (ODD/CD) (n = 48), attention-deficit hyperactivity disorder (ADHD) (n = 27), and both disorders (ODD/CD + ADHD) (n = 29) were involved as well as a normal control group (n = 37) and a psychiatric control group with internalizing disorders (n = 23). RESULTS: When compared with normal controls, boys with ADHD, with ODD/CD, and with ODD/CD + ADHD encoded fewer social cues and generated fewer responses. Boys with ODD/CD and with ODD/CD + ADHD moreover were more confident in their ability to enact an aggressive response than normal controls. When ODD/CD boys and ODD/CD + ADHD boys were given the opportunity to select a response from various types of responses shown, they selected an aggressive response more often than normal controls. Thus, in ADHD boys social problem-solving was affected only in encoding and in the generation of responses, whereas in ODD/CD and ODD/CD + ADHD boys social problem-solving was affected throughout the process. CONCLUSION: For the further study of social problem-solving in aggressive children, it is essential to differentiate between children with ADHD and children with ODD/CD and ODD/CD + ADHD.     

Gestational and postnatal tobacco smoke exposure as predictor of ADHD, comorbid ODD/CD, and treatment response in the MTA

Objective: To examine relationships among early smoke exposure (ESE), attention-deficit/hyperactivity disorder (ADHD), oppositional-defiant or conduct disorder (ODD/CD), and whether ESE affects symptom severity, comorbidity, and later treatment response. Study design: The Multimodal Treatment Study of Children with ADHD (MTA) had 468 children with ADHD and 279 others from the same classrooms (local normative comparison group, LNCG) with smoke-exposure data. We compared ESE as ‘gestational’ or ‘postnatal’ (ambient house smoke only, without gestational) between ADHD and LNCG, and tested its association with ADHD severity, comorbid ODD/CD, methylphenidate response, and differential treatment response to four randomly assigned treatments. Results: About 1/3 more ADHD than LNCG children had ESE (both types), but association with gestational smoke attenuated from P=0.024 to 0.094 when subjects with comorbid ODD/CD were excluded, although total smoke exposure retained significance (P=0.006). In the MTA/ADHD participants, comorbid ODD/CD, and parent/teacher-rated ADHD and ODD symptom severity were not associated with gestational smoking, but severity of ODD was associated with postnatal smoke, and for boys only, ADHD severity at 14 months associated with postnatal smoke. When ODD and CD were ‘unbundled’, CD was associated (P=0.005) with gestational smoke. Neither ESE moderated response to methylphenidate, optimal dose, 2-year growth slowing, or differential ODD symptom response to 14-months of 4 randomly assigned treatments. However, for ADHD symptoms, postnatal smoke moderated (P=0.008) the 14-month advantage of behavioral treatment (Beh) over community-treated comparison (CC): postnatally exposed boys benefited relatively more from Beh (d>0.5). ADHD symptom improvement also showed significant interaction of sex with gestational (P=0.015) and postnatal (P=0.044) smoke moderator effect for the contrast of MTA medication algorithm vs. Beh and CC: smoke-exposed girls did not show the usual algorithm superiority. Conclusions: These findings suggest possible moderating effects of postnatal ESE on the advantage of intensive behavioral treatment and sex-differential moderating effects of ESE on the advantage of intensive medication over behavioral treatment. This exploratory result requires replication. The findings do not convincingly support the hypothesis that the association of gestational smoking with offspring ADHD is accounted for by comorbid ODD/CD.     

The influence of comorbid oppositional defiant disorder on white matter microstructure in attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) are highly comorbid disorders. ADHD has been associated with altered white matter (WM) microstructure, though the literature is inconsistent, which may be due to differences in the in- or exclusion of participants with comorbid ODD. WM abnormalities in ODD are still poorly understood, and it is unclear whether comorbid ODD in ADHD may have confounded the current ADHD literature. Diffusion Tensor Imaging (DTI) was used to compare fractional anisotropy (FA) and mean diffusivity (MD) between ADHD patients with (n = 42) and without (n = 117) comorbid ODD. All participants were between 8–25 years and groups did not differ in mean age or gender. Follow-up analyses were conducted to examine the role of antisocial behaviour (conduct problems) on FA and MD values in both groups. Comorbid ODD in ADHD was associated with lower FA in left frontotemporal WM, which appeared independent of ADHD symptoms. FA was negatively associated with antisocial behaviour in ADHD + ODD, but not in ADHD-only. Comorbid ODD is associated with WM abnormalities in individuals with ADHD, which appears to be independent of ADHD symptoms. Altered WM microstructure in comorbid ODD may play a role in inconsistencies in the current DTI literature in ADHD. Altered development of these tracts may contribute to social-emotional and cognitive problems in children with oppositional and antisocial behaviour.     

Age-related differences in the prevalence and correlates of anxiety in youth with autism spectrum disorders

Age-related differences in the prevalence and correlates of anxiety were cross-sectionally examined in 1316 children and adolescents with autism spectrum disorder (ASD) who presented for initial evaluation at 14 outpatient autism centers around the country and in Canada. The prevalence of clinical and subclinical anxiety as well as the correlates of anxiety were examined in three age groups of children: preschool, school age and adolescents. Findings showed that the prevalence of anxiety in each age group exceeded the prevalence of anxiety in the general population. Adolescents and school age children had the highest prevalence of clinical (40%) and subclinical anxiety (26%), respectively. Higher IQ and less ASD severity were each weakly correlated with more anxiety in preschool and school age children. Affective symptoms were strongly associated with anxiety in each age group. Age specific psychiatric comorbidities were also present. Anxiety was associated with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) symptoms in the preschool group, ODD and somatic symptoms in the school age children, and ADHD symptoms in adolescents. These data underscore the need for prevention and treatment of anxiety as well as research examining the characteristics of anxiety in children with ASD using a developmental framework.