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.     

EEG coherence in children with attention-deficit/hyperactivity disorder and comorbid oppositional defiant disorder.

OBJECTIVES: This study is the first to investigate EEG coherence differences between two groups of children with attention-deficit/hyperactivity disorder combined type (AD/HD), with or without comorbid oppositional defiant disorder (ODD), and normal control subjects. METHODS: Each group consisted of 20 males. All subjects were between the ages of 8 and 12 years, and groups were matched on age. EEG was recorded during an eyes-closed resting condition from 21 monopolar derivations. Wave-shape coherence was calculated for 8 intrahemispheric electrode pairs (4 in each hemisphere), and 8 interhemispheric electrode pairs, within each of the delta, theta, alpha, and beta bands. RESULTS: Children with comorbid AD/HD and ODD had intrahemispheric coherences at shorter inter-electrode distances significantly reduced from those apparent in children with AD/HD without comorbid ODD. Such reduced coherences in the comorbid group appeared to wash out coherence elevations previously noted in AD/HD studies. CONCLUSIONS: The present results suggest that, rather than suffering an additional deficit, children with AD/HD and comorbid ODD show significantly less CNS impairment than AD/HD patients without comorbid ODD. SIGNIFICANCE: These results have treatment implications, suggesting that behavioural training, perhaps using family-based cognitive behavioural therapy, could be useful for those children with AD/HD and comorbid ODD. This should focus on the ODD symptoms, in association with a medication regime focussed on the AD/HD symptoms.     

Atomoxetine treatment in children and adolescents with attention-deficit/hyperactivity disorder and comorbid oppositional defiant disorder

OBJECTIVE: To examine (1) moderating effects of oppositional defiant disorder (ODD) on attention-deficit/hyperactivity disorder (ADHD) treatment response and (2) responses of ODD symptoms to atomoxetine. METHOD: Children and adolescents (ages 8-18) with ADHD were treated for approximately 8 weeks with placebo or atomoxetine (fixed dosing: 0.5, 1.2, or 1.8 mg/kg/day, b.i.d.) under randomized, double-blind conditions. Among patients with lifetime diagnostic information (n = 293), 39% were diagnosed with comorbid ODD and 61% were not. Treatment-group differences and differences between patients with and without comorbid ODD were examined post hoc for changes on the Attention-Deficit/Hyperactivity Disorder Rating Scale IV-Parent version, investigator-administered and -scored; Conners' Parent Rating Scale-Revised Short Form; Clinical Global Impressions Severity of ADHD Scale; and the parent-rated Child Health Questionnaire. RESULTS: Youths with ADHD and comorbid ODD showed statistically significant improvement in ADHD, ODD, and quality-of-life measures. Treatment response was similar in youths with and without ODD, except that the comorbid group showed improvement compared with placebo at 1.8 mg/kg/day but not 1.2 mg/kg/day. In contrast, youths without ODD showed improvement at 1.2 mg/kg/day and no incremental benefit at 1.8 mg/kg/day. CONCLUSIONS: Atomoxetine treatment improves ADHD and ODD symptoms in youths with ADHD and ODD, although the comorbid group may require higher doses.     

Children with attention-deficit/hyperactivity disorder and comorbid oppositional defiant disorder: an EEG analysis

This study investigated EEG differences between two groups of children with attention-deficit/hyperactivity disorder combined type (ADHD), with or without comorbid oppositional defiant disorder (ODD), and normal control subjects. Each group consisted of 20 males. All subjects were between the ages of 8 and 12 years, and groups were matched on age. EEG was recorded during an eyes-closed resting condition from 21 monopolar derivations, which were clustered into nine regions for analysis. The EEGs were Fourier transformed to provide absolute and relative power estimates for the delta, theta, alpha and beta bands. Values were also calculated for the theta/alpha and theta/beta ratios. The ADHD groups had more absolute and relative theta than the control group. Regionally, the ADHD groups had less relative alpha and more relative delta in posterior regions, and less relative beta in the frontal regions, than the control group. These differences were also apparent in both ratio measures. Only two significant topographic differences were found between the ADHD groups, with both of these being less deviant from normality in the ADHD+ODD group than the ADHD group. These results indicate that EEG correlates of ADHD are not clouded by the presence of comorbid ODD, which suggests possible applications in clinical practice.     

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

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.     

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.     

Neuroanatomical correlates of attention‐deficit–hyperactivity disorder accounting for comorbid oppositional defiant disorder and conduct disorder

Aim: An increasing number of neuroimaging studies have been conducted to uncover the pathophysiology of attention‐deficit–hyperactivity disorder (ADHD). The findings are inconsistent, however, at least partially due to methodological differences. In the present study voxel‐based morphometry (VBM) was used to evaluate brain morphology in ADHD subjects after taking into account the confounding effect of oppositional defiant disorder (ODD) and conduct disorder (CD) comorbidity. Methods: Eighteen children with ADHD and 17 age‐ and gender‐matched typically developing subjects underwent high‐spatial resolution magnetic resonance imaging. The regional gray matter volume differences between the children with ADHD and controls were examined with and without accounting for comorbid ODD and CD in a voxel‐by‐voxel manner throughout the entire brain. Results: The VBM indicated significantly smaller regional gray matter volume in regions including the bilateral temporal polar and occipital cortices and the left amygdala in subjects with ADHD compared with controls. Significantly smaller regional gray matter volumes were demonstrated in more extensive regions including the bilateral temporal polar cortices, bilateral amygdala, right occipital cortex, right superior temporal sulcus, and left middle frontal gyrus after controlling for the confounding effect of comorbid ODD and CD. Conclusion: Morphological abnormalities in ADHD were seen not only in the regions associated with executive functioning but also in the regions associated with social cognition. When the effect of comorbid CD and ODD was taken into account, there were more extensive regions with significantly smaller volume in ADHD compared to controls.     

Altered brain morphology in boys with attention deficit hyperactivity disorder with and without comorbid conduct disorder/oppositional defiant disorder

About 50% of attention deficit hyperactivity disorder (ADHD) patients suffer from comorbidity with oppositional defiant disorder/conduct disorder (ODD/CD). Most previous studies on structural morphology did not differentiate between pure (ADHD‐only) and comorbid ADHD (ADHD+ODD/CD). Therefore, we aimed to investigate the structural profile of ADHD‐only versus ADHD+ODD/CD spanning the indices subcortical and cortical volume, cortical thickness, and surface area. We predicted a reduced total gray matter, striatal, and cerebellar volume in both patient groups and a reduced amygdalar and hippocampal volume for ADHD+ODD/CD. We also explored alterations in prefrontal volume, thickness, and surface area. We acquired structural images from an adolescent sample ranging from 11 to 17 years, matched with regard to age, pubertal status, and IQ—including 36 boys with ADHD‐only, 26 boys with ADHD+ODD/CD, and 30 typically developing (TD) boys. We analyzed structural data with FreeSurfer. We found reductions in total gray matter and total surface area for both patient groups. Boys with ADHD+ODD/CD had a thicker cortex than the other groups in a right rostral middle frontal cluster, which was related to stronger ODD/CD symptoms, even when controlling for ADHD symptoms. No group differences in local cortical volume or surface area emerged. We demonstrate the necessity to carefully differentiate between ADHD and ADHD+ODD/CD. The increased rostral middle frontal thickness might hint at a delayed adolescent cortical thinning in ADHD+ODD/CD. Patients with the double burden ADHD and ODD or CD seem to be even more affected than patients with pure ADHD.     

Executive functioning deficits in attention-deficit/hyperactivity disorder are independent of oppositional defiant or reading disorder.

OBJECTIVE: To evaluate deficits of executive functions in children with attention-deficit/hyperactivity disorder (ADHD) classified by type (combined [CT] or predominantly inattentive [IT]) and comorbidity with oppositional defiant disorder (ODD) and reading disorder (RD). METHOD: The Wisconsin Card Sorting Test (WCST) and Tower of Hanoi (TOH) were administered to 28 community volunteers and 359 children (7.5-13.5 years old) divided into ADHD types, RD, and ODD. RESULTS: ADHD/CT children solved fewer puzzles and violated more rules on the TOH than ADHD/IT or non-ADHD subjects. On the WCST there were no differences between diagnostic samples in perseverativeness, but ADHD/CT patients made more nonperseverative errors than ADHD/IT children. ODD was associated with moderately better TOH performance and RD with excessive rule breaks. CONCLUSIONS: Executive functioning deficits were found for only ADHD/CT children and were independent of comorbidity with RD or ODD.     

The distribution of symptoms of attention-deficit/hyperactivity disorder and oppositional defiant disorder in school age children in Turkey

Abstract Objective The aim of this study was to determine the prevalence of attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) in school age children in Sivas province centre and to examine the distribution of symptoms according to subtypes. Method The study population was made up of 1425 children between the ages of 6 and 15 from eight primary schools selected by random sampling method in Sivas province centre. All students were given a questionnaire prepared according to DSMIV criteria that was completed by their parents or teachers. This form includes 18 symptoms of ADHD and eight symptoms of ODD. Students t-test and variance analysis were used for statistical evaluation. Results A prevalence of 8.1% was found for ADHD in our study. According to subtypes, 32.2% of these were inattentive, 40% were hyperactive and 27.8% were combined type. A prevalence of 11.5% was found for ODD. The boy/girl ratio was > 1 for both ADHD and ODD, and 52.2% of those with ADHD were established as having ODD at the same time. Conclusions The prevalence of ADHD and ODD in primary school children was not considered to be small. Studies concerning the distribution of symptoms in different societies, cultures, and viewpoints and identification of children with this type of problem are beneficial for early diagnosis and prophylactic treatment.     

Treating children with attention-deficit/hyperactivity disorder and comorbid epilepsy

Attention-deficit/hyperactivity disorder (ADHD) is one of common neurodevelopmental disorder often comorbid with epilepsy. There are no existing guidelines on how to manage these two conditions when they are comorbid. To identify relationship between epilepsy and ADHD and to know role of antiepileptics and safety of stimulant like methylphenidate in such conditions from existing literature, we searched articles published in clinical journals available online between 1990-2010, with these key words in medline:children, epilepsy, seizure, comorbid, ADHD, treatment. Relevant abstracts were further selected for their focus on current topic. Cross references were extracted. Finally relevant articles that included original research articles, reviews and abstracts of non-english literature were used. Children with epilepsy may manifest with symptoms of ADHD. Children with ADHD may develop epilepsy. Some antiepileptics like phenobarbitone, gabapentin, topiramate may not be helpful in controlling behavioral symptoms of ADHD. Stimulants are the main stay of pharmacotherapy for ADHD but there is risk of decreasing seizure threshold in children with comorbid epilepsy especially when their epilepsy is not well controlled. Existing evidence is not in favor of screening children with ADHD for EEG abnormality before starting stimulant therapy.     

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.     

Gene-environment interplay in oppositional defiant and conduct disorder

Oppositional defiant and conduct disorder is a disturbance in behavior that is characterized by aggressive and antisocial acts. At present, genetic research on conduct disorder has raised more questions than it has answered, and basic questions such as the heritability of childhood antisocial behavior cannot yet be answered with certainty. Current research, however, has consistently highlighted the importance of gene-environment interplay in antisocial behavior.     

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.     

Differential stimulant response on attention in children with comorbid anxiety and oppositional defiant disorder

Attention-deficit hyperactivity disorder (ADHD) affects 3% to 7% of school-age children. Approximately 30% of the children with ADHD also have comorbid anxiety or oppositional defiant disorder. Methylphenidate is the drug of choice for the medical treatment of such cases. When compared with children with ADHD alone, children with comorbid anxiety or oppositional defiant disorder may show worsening of the global attention score in response to methylphenidate and not only a "reduced response," as reported in previous studies. This study included 1122 children diagnosed as ADHD, of which 174 were diagnosed with comorbid anxiety and 141 with comorbid oppositional defiant disorder. All patients performed the Test of Variables of Attention before and after methylphenidate administration. A normal distribution (Gaussian distribution) of reaction to methylphenidate, as measured by the global ADHD score in children diagnosed as pure ADHD, was found. These findings were in contrast to children with ADHD and comorbid anxiety or oppositional defiant disorder who showed a bimodal distribution and hence represent a distinct population. In both groups with comorbid disorders, there was a larger subgroup in which significant worsening of global ADHD score occurred after methylphenidate administration (P < .05). Children with ADHD and comorbid anxiety or oppositional defiant disorder might represent clinically distinct populations in which inattention is secondary to those disorders; therefore, methylphenidate may be an inappropriate treatment for such children.     

Methylphenidate in children with oppositional defiant disorder and both comorbid chronic multiple tic disorder and ADHD

Our primary objective was to determine if immediate-release methylphenidate is an effective treatment for oppositional defiant disorder diagnosed from mother's report in children with both chronic multiple tic disorder and attention-deficit hyperactivity disorder (ADHD). Children (n = 31) aged 6 to 12 years received placebo and 3 doses of methylphenidate twice daily for 2 weeks each under double-blind conditions and were assessed with ratings scales and laboratory measures. Results indicated significant improvement in both oppositional and ADHD behaviors with medication; however, the magnitude of treatment effect varied considerably as a function of disorder (ADHD > Oppositional behaviors), informant (teacher > mother), assessment instrument, and specific oppositional behavior (rebellious > disobeys rules). Drug response was comparable with that in children (n = 26) who did not have diagnosed oppositional defiant disorder, but comorbidity appeared to alter the perceived benefits for ADHD according to mother's report. Methylphenidate is an effective short-term treatment for oppositional behavior in children with comorbid ADHD and chronic multiple tic disorder.     

Variability in emotional/behavioral problems in boys with oppositional defiant disorder or conduct disorder: the role of arousal

It is often reported that children with oppositional defiant disorder (ODD) or conduct disorder (CD) are under-aroused. However, the evidence is mixed, with some children with ODD/CD displaying high arousal. This has led to the hypothesis that different profiles of arousal dysfunction may exist within children with ODD/CD. This knowledge could explain variability within children with ODD/CD, both in terms of specific types of aggression as well as comorbid symptoms (e.g., other emotional/behavioral problems). We measured heart rate variability (HRV), heart rate (HR) and skin conductance level (SCL) during rest and stress, and obtained parent and teacher reports of aggression, anxiety, attention problems and autism traits in a sample of 66 ODD/CD and 36 non-clinical boys (aged 8–12 years). The ODD/CD group scored significantly higher on aggression, anxiety, attention problems and autism traits than the controls; boys with ODD/CD also had higher resting HRs than controls, but HR stress, HRV and SCL did not differ. Hierarchical regressions showed different physiological profiles in subgroups of boys with ODD/CD based on their type of aggression; a pattern of high baseline HR and SCL, but low stress HRV was related to reactive aggression, whereas the opposite physiological pattern (low HR, low stress SCL, high stress HRV) was related to proactive aggression. Furthermore, high stress SCL was related to anxiety symptoms, whereas low stress SCL was related to attention problems. These findings are important because they indicate heterogeneity within boys with ODD/CD and highlight the importance of using physiology to differentiate boys with different ODD/CD subtypes.     

Comorbid oppositional defiant disorder and the risk of relapse during 9 months of atomoxetine treatment for attention-deficit/hyperactivity disorder

OBJECTIVE: To examine the influence of comorbid oppositional defiant disorder (ODD) on the relative risk (RR) of relapse during 9 months of treatment with atomoxetine for attention-deficit/hyperactivity disorder (ADHD). METHOD: Four hundred and sixteen children and adolescents with ADHD whose symptoms remitted during initial 10-week, open-label atomoxetine treatment were randomly assigned to continue with atomoxetine or placebo. RESULTS: In all, 43% met criteria for comorbid ODD. A total of 17% of patients with comorbid ODD relapsed (CGI-Severity score >or= 3 and ADHD Rating Scale total score of 90% or more of baseline at study entry on two consecutive visits) during atomoxetine treatment, compared with 26% of patients without comorbid ODD (RR 0.67, 95% CI 0.42-1.06). Mean time to relapse was not significantly different [mean (SE) days to relapse, ADHD/ +ODD: 215 (7.38); ADHD/-ODD: 211 (7.61); log rank p = 0.08]. This finding is placed within the context of atomoxetine affording an overall protection against relapse compared with placebo (RR 0.59, 95% CI 0.43-0.80). CONCLUSIONS: Comorbid ODD does not influence the rate of relapse of patients with ADHD during longer-term treatment with atomoxetine. Atomoxetine protects against the relapse of ADHD symptoms regardless of the presence or absence of comorbid ODD.