hyperactivity disorder?

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Comprehensive Psychiatry 51 (2010) 412 – 418 www.elsevier.com/locate/comppsych

Does oppositional defiant disorder have temperament and psychopathological profiles independent of attention deficit/hyperactivity disorder? Hyo-Won Kima , Soo-Churl Chob , Boong-Nyun Kimb,⁎, Jae-Won Kimb , Min-Sup Shinb , Jin-Young Yeoc a

b

Department of Neurosychiatry, Dongguk University College of Medicine, Kyeonggi 410-773, Korea Division of Child and Adolescent Psychiatry, Department of Neuropsychiatry, Seoul National University College of Medicine, Seoul 110-769, Korea c Didim Psychiatric Clinic, Seoul 138-170, Korea

Abstract Background: Most studies on temperamental and behavioral/emotional characteristics of oppositional defiant disorder (ODD) did not rule out the effect of comorbid attention-deficit/hyperactivity disorder (ADHD). The main objective of this study was to identify the temperamental and psychopathological patterns of ODD independent of comorbid ADHD. We also aimed to compare the patterns of temperament and psychopathology between ODD with and without ADHD. Method: Parents of 2673 students, randomly selected from 19 representative schools in Seoul, Korea, completed the Diagnostic Interview Schedule for Children Version IV. Among 118 children and adolescents with ODD diagnosed by the Diagnostic Interview Schedule for Children Version IV, the parents of 94 subjects (mean age, 10.4 ± 3.0 years) and the parents of a random sample of 94 age- and gendermatched non-ODD/non-ADHD children and adolescents completed the parent's version of the Child Behavior Checklist (CBCL) and the Junior Temperament and Character Inventory. Results: Subjects with ODD showed temperament and character profiles of high Novelty Seeking, low Self-directedness, and low Cooperativeness, a distinct pattern on the CBCL, and were at increased risk for anxiety and mood disorders compared to the controls after controlling for the effect of comorbid ADHD. The children and adolescents with both ODD and ADHD showed decreased levels of Persistence and Self-directedness and higher scores on 4 subscales of the CBCL (Anxious/Depressed, Attention Problems, Delinquent Behaviors, and Aggressive Behaviors) compared to those with ODD only. Conclusions: Oppositional defiant disorder is associated with specific temperamental and behavioral/emotional characteristics, independent of ADHD. Moreover, the results of this study support that co-occurring ADHD and ODD have differentially higher levels of behavioral and emotional difficulties. © 2010 Elsevier Inc. All rights reserved.

1. Introduction Oppositional defiant disorder (ODD) is one of the most common psychiatric disorders of childhood and adolescence, affecting about 3% to 6% of children and adolescents

The results of this study were presented in the 55th annual meeting of the American Academy of Child and Adolescent Psychiatry. This study was supported by a Seoul Child and Adolescent Mental Health Center Grant (07-2005-013-02). ⁎ Corresponding author. Tel.: +822 2072 3647; fax: +822 744 5774. E-mail address: [email protected] (B.N. Kim). 0010-440X/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.comppsych.2009.09.002

worldwide [1,2]. Oppositional defiant disorder typically occurs in early childhood and is characterized by a recurrent pattern of developmentally inappropriate negativistic, defiant, disobedient, and hostile behaviors toward authority figures [3]. Children with ODD are known to experience disturbances in peer and family relationships, as well as poor academic achievement [1]. Disruptive behavior disorders including ODD and conduct disorder (CD) have been reported to have temperamental patterns including high Novelty Seeking [4], high Emotionality/low Persistence [5], and Disinhibition [6]. Conduct disorder was also associated with high Novelty

H.W. Kim et al. / Comprehensive Psychiatry 51 (2010) 412–418

Seeking/low Harm Avoidance [7]. In addition, children and adolescents with disruptive behavior disorders often show high aggression and delinquency and display other psychiatric disorders, including both attention-deficit/hyperactivity disorder (ADHD) and internalizing disorders like anxiety or depression [8]. However, in spite of evidence that ODD is valid as a meaningful clinical disorder independent of CD [9], only a few studies have evaluated the temperamental and behavioral/emotional characteristics of ODD itself. Even in the case of a diagnosis of ODD according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the question of comorbid ADHD symptoms remains an issue of concern. Thus, it is still not clear whether temperamental or behavioral/emotional characteristics observed in ODD are specifically related to the ODD pathology or are due to comorbid ADHD symptoms. A large overlap between ADHD and ODD has been found in diverse epidemiological and clinical samples [10,11], and the relationship between ODD and ADHD is a subject of intense debate and controversy. Several studies have reported that ODD shares cognitive and social deficits and behavioral problems with ADHD [12,13], whereas other studies have indicated that ODD could be differentiated from ADHD in clinical characteristics or psychosocial functioning [14,15]. Furthermore, some researchers suggested that cooccurring ODD and ADHD symptoms result in a clinical entity that is different from what would be predicted from the individual effects of ODD and ADHD symptoms [14]. Nevertheless, only a few studies have evaluated the effect of comorbid ADHD on ODD, especially in terms of temperament. Since there is a vast literature addressing clinical characteristics such as comorbidity and temperament in ADHD (see Refs. 16 and 17 for a review), the effect of comorbid ADHD on ODD could be examined by comparing these two issues between the ODD subjects with and without ADHD. We hypothesized that ODD would have its own temperamental or behavioral/emotional characteristics independent of ADHD and that the subjects who have the 2 disorders might have the combination of temperament traits of both disorders and higher levels of behavioral and emotional difficulties. Thus, the main objective of this study was to identify the temperamental and psychopathological patterns of ODD independent of comorbid ADHD in a Korean community sample. In addition, we aimed to compare the pattern of the temperament and psychopathology between ODD cases with and without ADHD.

2. Methods This study was part of the 2005 Seoul Child and Adolescent Mental Health Survey and was conducted from September through December 2005. The research design in this study has been described in detail previously [18,19]. Seoul was divided into 6 districts based on socioeconomic

413

status (SES), and 19 representative elementary, middle, and high schools were randomly selected. Ten classes were randomly selected from each elementary school, and three classes were randomly selected from each middle and high school. Parents of 2673 students completed the Diagnostic Interview Schedule for Children Version IV (DISC-IV). Among 118 children and adolescents with ODD diagnosed by the DISC-IV, the parents of 94 subjects (mean age, 10.36 ± 3.04 years) and the parents of a random sample of 94 age- and gender-matched non-ODD/non-ADHD children and adolescents completed the parent's version of the Child Behavior Checklist (CBCL) and the Junior Temperament and Character Inventory (JTCI). The biological mother served as the informant in 94.3% of the cases. In-person interviews with parents by trained laypersons were conducted in the schools attended by the children to complete the DISC-IV. All interviewers were college students majoring in psychology or education. All 19 selected schools agreed to participate in the study. The Institutional Review Board of Seoul National University Hospital and the Seoul School Health Promotion Center approved the study. Written informed consent was obtained from parents before each interview. 2.1. Assessment measures 2.1.1. Diagnostic Interview Schedule for Children Version-IV Psychiatric disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition were assessed by the Korean version of the DISC-IV. The interviews were organized into 6 diagnostic sections: Anxiety Disorders, Mood Disorders, Disruptive Behavior Disorders, Substance Use Disorders, Schizophrenia, and Miscellaneous Disorders (Eating, Elimination, and Tic Disorders; Pica; and Trichotillomania). In this study, the DISC-IV scoring algorithms for ascertaining the presence of a diagnosis were derived based on data from parents. Good test-retest reliability of the DISC-IV has been reported [20]. The reliability and validity of the Korean version of the DISC-IV were previously determined [21]. 2.1.2. Child Behavior Checklist The empirically derived CBCL [22] is one of the beststudied instruments evaluating the psychopathology of children and adolescents. The 112 behavioral items are scored by a parent. After generating T scores on scales that assess empirically derived dimensions of psychopathology, a profile of childhood psychological problems can be described on 8 scales and 3 overall dimensions: Internalizing, Externalizing, and Total Behavioral Problems. Numerous studies have confirmed the stability of the instrument's psychometric properties, demonstrating that it shows good reliability and validity in both clinical and nonclinical populations. The stability of the measure's clinical scales was observed over a 4-year period in a clinical sample of youth with ADHD [23]. Furthermore, good convergence

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with structured interviews for psychiatric diagnosis in children with ADHD has been shown [24], and its Attention Problems scale has been found to have a high discriminative power for ADHD [25]. The Korean version of the CBCL was standardized in 1997 [26]. 2.1.3. Junior Temperament and Character Inventory The Korean version of the JTCI has been completed by the parents of the children. The JTCI is a version of the Temperament and Character Inventory for children and adolescents and consists of 108 items. It was developed by Luby et al. [27]. The JTCI evaluates Cloninger's 7-factor structure of four temperament and three character dimensions [28]. Temperament represents innate dispositions to respond stimuli and is assumed to be moderately heritable and stable across time [28]. Temperament dimensions consist of Novelty Seeking, Harm Avoidance, Reward Dependence, and Persistence. In contrast to temperament, aspects of character are thought to be influenced by social learning rather than genetic factors and to mature throughout the life span [28]. The three character dimensions are Selfdirectedness, Cooperativeness, and Self-transcendence. The Cronbach α values for the Korean version of the JTCI are from 0.48 to 0.80 for the temperament dimensions and 0.63 to 0.69 for the character measures [29]. 2.2. Data analysis The χ2 test or Fisher exact test (categorical variables) and t test (dimensional data) were performed to assess differences in demographic data. Analysis of covariance (ANCOVA) was used to examine whether the CBCL or JTCI profiles differ between the ODD subjects and controls or between the ODD cases with and without ADHD. Using a Bonferroni correction, significance level for these analyses was set at .007 for comparisons of the 7 JTCI scales and at .006 for the 8 CBCL scales between the groups. When we used standard deviation of 3.5 and minimum detectable difference of 3.0, the power for the comparison between the ODD subjects and controls was 99.9% and the one for the analysis between the ODD cases with and without ADHD was 85.4%. The χ2 test or Fisher exact test were also used to compare patterns of comorbidity between the ODD cases with and without ADHD. Unadjusted and adjusted odds ratios (OR) were obtained by logistic regression analysis. Statistical analysis was performed using SPSS (version 12.0), and statistical significance was defined for all other comparisons at P b .05; all comparisons were 2-tailed. 3. Results 3.1. Prevalence and psychiatric comorbidities of ODD The 1-year prevalence rate of ODD in Korean children was 4.41% (95% confidence interval [CI], 3.68-5.28). Table 1 shows the demographic characteristics of the total

Table 1 Demographic characteristics of ODD subjects and controls

Age, years Mean (SD) Gender, n (%) Boys Girls SES n (%) a High Middle Low a b

ODD (n = 118)

Controls (n = 94)

F or χ2

Pb

10.4 (3.1)

10.4 (3.0)

0.021 0.272

0.885 0.602

67 (56.8%) 51 (43.2%)

50 (53.2%) 44 (46.8%)

41 (44.1%) 47 (50.5%) 5 (5.4%)

44 (46.8%) 48 (51.1%) 2 (2.1%)

0.497

The numbers of the groups differ due to missing data. t test, χ2 test, and Fisher's exact test between the 2 groups.

sample of 118 subjects with ODD and 94 controls. The mean ages of the ODD subjects and the controls were not significantly different at 10.4 years (SD, 3.1 years) and 10.4 years (SD, 3.0 years), respectively. The 2 groups did not show significant differences in gender or SES distribution (P = .602, P = .497, respectively). In addition, 26 (22.0%) of the ODD subjects also had ADHD. The adjusted OR for ADHD was 5.37 (95% CI, 3.26–8.86). Among the 118 children and adolescents with ODD, 43 subjects (36.4%) had at least one comorbid disorder other than ADHD. We found that 30 subjects (25.4%) had an anxiety disorder, 5 (4.2%) had a mood disorder, 3 (2.5%) had an elimination disorder, and 5 (4.2%) had a tic disorder. Anxiety and mood disorders were significantly associated with ODD in the Korean children and adolescents. The adjusted OR and 95% confidence intervals (CI) for each disorder associated with ODD were as follows: 3.47 (95% CI, 2.21–5.45) for anxiety disorder and 41.61 (95% CI, CI: 9.52–181.80) for mood disorder. Elimination (OR=2.31, 95% CI, 0.66–8.09) and tic disorders (OR=1.61, 95% CI, CI: 0.63–4.16) were not significantly increased compared to the non-ODD subjects. The associations between ODD and anxiety and mood disorders were significant, even controlling for the effect of comorbid ADHD (P b .001 and P b .001 respectively). Among the 118 children with ODD, the parents of 94 subjects completed the JTCI and CBCL. No significant differences were found between those who did and those who did not complete the CBCL and JTCI regarding age, gender, and SES (P = .986, P = .119, P = .916, respectively). 3.2. Temperament and psychopathological profiles of ODD The temperament and psychopathological profiles of the ODD and control groups adjusted for the effect of comorbid ADHD are shown in Table 2. Children and adolescents with ODD manifested higher Novelty Seeking [F2,185 = 29.92, P b .001, η2p = 0.139], lower Self-directedness [F2,185 = 32.33, P b .001, η2p = 0.149], and lower Cooperativeness [F2,185 = 11.24, P = .001, η2p = 0.057] compared to the controls, irrespective of co-occurring ADHD.

H.W. Kim et al. / Comprehensive Psychiatry 51 (2010) 412–418 Table 2 Temperament and psychopathological profiles (mean scores on JTCI and CBCL scales) of ODD subjects and controls ODD (n = 94) Mean JTCI Novelty Seeking Harm Avoidance Reward Dependence Persistence Self-directedness Cooperativeness Self-transcendence CBCL Withdrawn Somatic Complaints Anxious/Depressed Social Problems Thought Problems Attention Problems Delinquent Behaviors Aggressive Behaviors

SD

Controls (n = 94) Mean

F

Table 3 Psychiatric comorbidities in ODD subjects with and without ADHD

P

SD

8.6 9.6 5.4 1.9 9.8 12.2 2.1

3.5 4.8 2.2 1.8 3.6 3.7 1.5

5.4 8.6 5.9 2.7 13.3 14.2 2.2

2.9 4.3 1.8 1.6 3.1 2.5 1.5

29.92 0.46 1.68 2.86 32.33 11.24 1.54

b.001 .498 .197 .093 b.001a .001a .216

67.3 55.4 55.6 55.9 53.8 55.9 54.9 56.7

15.8 10.3 7.5 8.4 7.0 7.6 5.8 7.8

65.6 52.2 51.5 52.0 52.0 51.2 51.1 50.8

16.4 4.2 3.7 4.3 5.9 2.7 2.8 2.4

0.28 5.91 10.59 8.27 0.75 14.50 16.94 27.15

.600 .016 .001b .004b .389 b.001b b.001b b.001b

a

ANCOVA adjusted for the effect of comorbid ADHD (P b .05/7 = .007). ANCOVA adjusted for the effect of comorbid ADHD (P b .05/ 8 = .006). a

b

When adjusted for the effects of comorbid ADHD, 5 subscale scores of CBCL were significantly higher in the ODD subjects compared to the controls: (a) Anxious/ Depressed [F2,185 = 10.59, P = .001, η2p = 0.054], Social Problems [F2,185 = 8.27, P = .004, η2p = 0.043], Attention Problems [F2,185 = 14.50, P b .001, η2p = 0.073], Delinquent Behaviors [F2,185 = 16.94, P b .001, η2p = 0.084], and Aggressive Behaviors [F2,185 = 27.15, P b .001, η2p = 0.128].

Anxiety Disorder Unadjusted OR Adjusted ORa Mood Disorder Unadjusted OR Adjusted ORa Elimination Disorder Unadjusted OR Adjusted ORa Tic disorder Unadjusted OR Adjusted ORa

ODD with ADHD (n = 26)

ODD without ADHD (n = 92)

Pb

6 (23.1%)

24 (26.1%)

.756

3.91 (1.55-9.86) 3.05 (1.18-7.89) 2 (7.7%) 70.89 (11.33-443.59) 136.87 (16.03-1168.72) 2 (7.7%)

4.60 (2.82-7.51) 3.54 (2.15-5.83) 3 (3.3%) 28.67 (5.71-144.06) 26.92 (5.24-138.30) 1 (1.1%)

11.75 (2.58-53.44) 4.44 (0.94-21.09) 1 (3.8%) 2.09 (0.28-15.73) 1.05 (0.14-8.03)

1.55 (0.20-11.73) 1.15 (0.15-8.85) 4 (4.3%) 2.37 (0.84-6.73) 1.87 (0.65-5.36)

.322

.122

1.000

The reference group for determining the OR was “no ODD.” a Adjusted for age, gender and comorbidity with ADHD. b χ2 test or Fisher's exact test between ODD subjects with and without ADHD.

Table 4 presents the temperamental and psychopathological profiles of the ODD subjects with and without ADHD. Persistence [F3,90 = 8.67, P = .004, η2p = 0.088] and Selfdirectedness [F3,90 = 8.10, P = .005, η2p = 0.083] were significantly lower in the ODD subjects with ADHD than in those without ADHD. When adjusted for multiple comparisons, Harm Avoidance and Cooperativeness were not significantly different between the 2 groups. Table 4 Temperament and psychopathological profiles (mean scores on JTCI and CBCL scales) of ODD subjects with and without ADHD ODD without ADHD (n = 73)

3.3. ODD with and without ADHD Among the 118 subjects who were diagnosed as having ODD, 26 (22.0%) also had comorbid ADHD. The ODD subjects with ADHD tended to be younger than those without ADHD, although the difference was not statistically significant (P = .065). The mean age (SD) of the ODD subjects with and without ADHD were 9.4 (2.6) and 10.6 (3.1). The 2 groups showed significant differences in gender distribution (P b .001). Boys were significantly more prevalent in the ODD group with ADHD, compared to the group without ADHD; 44 boys (47.8%) and 48 girls (52.2%), and 23 boys (88.5%) and 3 girls (11.5%), respectively. Therefore, we adjusted the effect of age and gender in further analyses. The 2 groups were not significantly different in SES (P = .630). Table 3 illustrates the psychiatric comorbidities for the ODD children and adolescents with and without ADHD and also shows the unadjusted and adjusted OR. Both ODD subjects with and without ADHD were significantly associated with anxiety and mood disorders. The comorbid rates of all disorders were not significantly different between the 2 groups.

415

Mean JTCI Novelty Seeking Harm Avoidance Reward Dependence Persistence Self-directedness Cooperativeness Self-transcendence CBCL Withdrawn Somatic Complaints Anxious/Depressed Social Problems Thought Problems Attention Problems Delinquent Behaviors Aggressive Behaviors

SD

ODD with ADHD (n = 21) Mean

F

P

SD

8.1 9.1 5.5 2.2 10.3 12.6 2.0

3.4 4.4 2.1 1.8 3.4 3.6 1.5

10.0 11.3 5.3 0.9 8.0 11.0 2.5

3.6 5.5 2.4 1.0 3.8 3.7 1.4

3.23 5.93 0.09 8.67 8.10 3.93 1.08

.075 .017 .771 .004a .005a .050 .301

67.0 55.2 54.3 54.9 52.9 54.4 53.9 55.3

16.4 11.2 5.2 7.8 6.3 6.1 5.1 6.6

68.3 56.2 60.3 59.3 57.0 61.0 58.3 61.5

13.6 6.3 11.5 9.6 8.6 10.1 7.1 9.6

0.49 1.80 11.34 5.54 5.80 12.28 11.12 11.67

.485 .183 .001b .021 .018 .001b .001b .001b

a ANCOVA adjusted for the effect of age and gender (P b .05/7 = 0.007). b ANCOVA adjusted for the effect of age and gender (P b .05/8 = 0.006).

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Among the subscales of CBCL, 4 subscale scores were significantly increased in the ODD subjects with ADHD compared to those without: Anxious/Depressed [F3,90 = 11.34, P = .001, η2p = 0.112], Attention Problems [F3,90 = 12.28, P = .001, η2p = 0.120], Delinquent Behaviors [F3,90 = 11.12, P = .001, η2p = 0.110], and Aggressive Behaviors [F3,90 = 11.67, P = .001, η2p = 0.115].

4. Discussion To the best of our knowledge, this is the first study to investigate 2 relevant clinical correlates of ODD—comorbidity and temperament—independent of co-occurring ADHD, in a large Asian epidemiological sample using the DISC-IV as a diagnostic instrument. In addition, this is the first study to estimate the prevalence of ODD in the Korean community based on a structured interview. The prevalence of ODD in Korean children and adolescents in this study was 4.41%. This is quite similar to the prevalence reported in other cultures of 3% to 6% in community samples [2], but lower compared to a previous study conducted in Korea [30]. This discrepancy may be related to the fact that the previous study from Korea was based on rating scales. The prevalence rates of externalizing disorders are known to be lower when estimated by structured interviews compared to rating scales or checklists [31]. The main findings of this study were that, independent of ADHD, ODD was associated with specific temperament patterns and comorbid psychopathology. Subjects with ODD showed temperament and character profiles that included high Novelty Seeking, low Self-directedness, low Cooperativeness, and a distinct pattern on the CBCL, and they were at increased risk for anxiety and mood disorders compared to the control group. These results were obtained after controlling for the effect of comorbid ADHD. The results of this study are in line with previous findings that implied unique clinical characteristics [15] or genetic influences in ODD [32] and support the validity of the ODD diagnosis as a meaningful clinical entity. The temperament profile for high Novelty Seeking in ODD compared to controls in this study agreed with previous findings [4,7] and confirmed that ODD is related to high Novelty Seeking regardless of comorbid ADHD. Although subjects with ADHD are known to show increased levels of Novelty Seeking [18,33], disruptive behavior disorders are reported to be associated with higher levels of Novelty Seeking compared to ADHD [4]. Cloninger's dimension, “Novelty Seeking,” means behavioral activation in response to novelty, reward, or avoidance of punishment [34] and was suggested as the best predictor of stable, highly delinquent behavior [35]. The results of this study also indicated that children and adolescents with ODD had character patterns that reflected low Self-directedness and Cooperativeness, independent of comorbid ADHD. Character refers to individual differences

in self-concepts about goals and values. On the JTCI, the Self-directedness scale measures the ability to regulate and adapt behavior to given situations, whereas Cooperativeness measures social tolerance and willingness to be helpful [34]. Self-directedness and Cooperativeness are reported to be moderately correlated with one another, operating synergistically over the course of early development [36]. Tillman et al. [37] found that lower scores on these dimensions may be related to the symptoms often seen in ODD, concurrent with our results. The subjects with ODD also displayed higher scores on the Anxious/Depressed, Social Problems, Attention Problems, Aggressive Behaviors, and Delinquent Behaviors scales of the CBCL and were at elevated risk for internalizing disorders in this study. Comorbidity among different domains of externalizing problems is supposed to be high, and ODD is known to increase the risk for CD in adolescence and antisocial behaviors during adulthood [8]. On the other hand, ODD has been associated with internalizing disorders across childhood and adolescence and is suggested to share several environmental and genetic factors with these disorders [2]. The results of this study confirmed the previous findings from Western cultures and indicated that, regardless of comorbid ADHD, ODD is related to substantial psychiatric comorbidity or psychopathology. Another main finding was that the children and adolescents with both ODD and ADHD showed decreased levels of Persistence and Self-directedness and higher scores on 4 subscales of the CBCL (Anxious/Depressed, Attention Problems, Delinquent Behaviors, and Aggressive Behaviors) compared to those with only ODD, although the patterns of psychiatric comorbidity were not significantly different. These temperamental profiles of ODD subjects with ADHD were similar to our previous report on ADHD [18], which showed high Novelty Seeking/low Persistence/low Selfdirectedness/low Cooperativeness, and Rettew et al's study [4] which reported the specific association between low Persistence and ADHD. Our results indicated that the ODD subjects who have low Persistence as well as high Novelty Seeking/low Self-directedness/low Cooperativeness are more likely to be comorbid with ADHD. The differences on 4 CBCL subscales suggested that the ODD cases with ADHD tend to suffer from more severe psychological problems, both internalizing and externalizing, compared to those without, and are consistent with previous research implying more severe behavioral and emotional difficulties or differentially higher levels of functional impairment in cooccurring ODD and ADHD [10,14,15], although most previous research focused on the effect of ODD in the context of ADHD. The results of this study provided evidence for the detrimental effect of ADHD in terms of ODD and suggested that improving recognition and understanding of ADHD among children and adolescents with ODD is worthwhile. Some limitations should be considered in interpreting our findings. First, a group of children with ADHD alone was

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not included in this analysis. Comparison with this group would be required to further clarify the uniqueness of the temperamental and psychopathological patterns associated with ODD. Second. the DISC-IV interview, the JTCI and CBCL ratings were performed only by parents. Parents are known to underreport psychiatric symptoms, especially affective and neurotic symptoms [38]. Thus, further research using the youth version of the DISC-IV and the CBCL selfor teacher reports are recommended. Third, attrition may have affected the estimates of ODD and psychiatric comorbidities, and the missing data from the JTCI and CBCL could lead to attrition bias. Despite these limitations, this study has the following strengths: (a) a community sample was assessed, avoiding biases associated with clinic referral; (b) standardized instruments were used for the diagnosis of ODD and comorbid disorders; and (c) subjects of this study represented a non-Western culture from Asia. In conclusion, ODD was associated with specific temperamental and behavioral/emotional characteristics in this Korean epidemiological sample, independent of ADHD. Moreover, the results of this study support that co-occurring ADHD and ODD have differentially higher levels of behavioral and emotional difficulties.

[10]

[11]

[12]

[13]

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[15]

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[17] [18]

Acknowledgment

[19]

This study was supported by a Seoul Child and Adolescent Mental Health Center Grant (07-2005-013-02).

[20]

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