Attention Deficit, Conduct, Oppositional, and Anxiety Disorders in Children: II. Clinical Characteristics

Attention Deficit, Conduct, Oppositional, and Anxiety Disorders in Children: II. Clinical Characteristics JAN C. REEVES M.B.Cu.B., M.RAN .Z.C.P., JOHN S. WERRY M.D., GAIL S. ELKIND PH.D., ALAN ZAMETKIN, M.D.

AND

Abstract. One hundred and five children aged 5-12 with diagnoses of Anxiety, Attention Deficit (ADDH), Conduct. or Oppositional Disorders were compared with each other and with normal subjects. Conduct and Oppositional Disorders resembled each other and seldom occurred in the absence of ADDH so were combined into an ADDH plus Conduct group. Anxiety Disorder children were less predominantly male. less socially or academically disabled. but had more anxious parents. The two ADDH groups resembled each other but the addition of Conduct Disorder brought greater social disability and more adverse family environments. J. Amer. Acad. Child Adol. Psychiat.• 1987,26,2:144-155. Key Words : Attention Deficit.Conduct. Oppositional. Anxiety Disorders. This paper is the second in a series examining the validity of four common DSM-III diagnostic categories, Attention Deficit Disorder (ADDH or H). the Conduct Disorders (CD). the An xiety Disorders (ANX), and Oppositional Disorder (OPP). In th e first paper (Werry et al., 1987). we reviewed the liter ature relating to these disorders and found that much of the empirical data describe differences between a single diagnost ic gro up (mostly ADDH or CD) and normal subjects. Onl y a handful of studies have compared diagnostic groups with each other and most of these have been of ADDH and CD. with or without ADDH + CD. It was concluded first that th ere is a large communality in the kind of differences found between each of the d iagnostic groups and normal subjects so that much of what is said to characterize individual d iagnoses is cha racteristic of patient status and not of an y particul ar diagnosis. Second, because of the much greater amount o f study and range of va ria bles examined in ADDH , much of the putative spec ificity of ADDH with respect to normal subjects is as yet untested against other diagnoses. T hird, although the few comparative studies among ADDH, CD. t\DDIi + CD. and ANX suggest much greater communality than difference, there are some indications of specificity. ADDII could well prove to be an earl y onset, early presenting, overwhelmingly male, neurodevelopmental disorder accompanied by high activity levels, impulsivity, and cognitive impairment leading to marked underachievement. CD seems to be an early presenting disorder marked by egocentricity. aggressiveness. a defect of empathic interpersonal relations, and ad verse child rearing en vironments. ANX, on the other hand, seems to result in least differences with respect to normal subjects, and the onl y important spec ificity revealed so far is that the parent(s) are also anxious. ADDH + CD seems to share characteristics of hoth disorders and, as a result. the degree of overall handicap may well be worse than

in each disorder alone. There are no data on OPP. Although we concluded as above, we also noted that the range of functions and correlates examined so far was generally too narrow (e.g., laboratory and other tests were uncommon) and there was a need for wide-ranging comparative studies before differences could be finally defined. Only one study (Koriath et al., 1985) has used anything approaching a comprehensive set of variables. The study to be reported here and elsewhere (Werry et al., in press) is one such and was centered on the four disorders of ADDH , CD, AN X, and OPP, which previous work (Anderson et al ., 1985; Werry et aI., 1983) had suggested were common enough for study. It was decided to eschew further subcategorization of these disorders as occurs in DSM-III, because there is considerable doubt about the reliability of these subeategories (Quay, 1986a . 1986b; Werry et al., 1983) and it would greatly increase the number of subjects required. Furthermore, most of the empirical data relate only to the major catego ries. Aims and Hypotheses The primary aim of the study was to examine the external validity of the four DSM-III major diagnostic categories of ADDH, CD, OPP, and ANX Disorders by studying a large number of their correlates, excluding those defining the diagnoses themselves, or, where they form part of the syndrome, by measuring them in objective ways independent of clinical methods. One ma in hypothesis was that these disorders would be different clinically and etiologically from each other and from normal children matched for age, sex, ability, and social class in the following areas: I. background, famil y, and soc ial ecology (age, sex ratio, social class, family characteristics, and family history of like disorders); 2. emotional nurturance (parental relationships, family ad versit y. in-care experiences); 3. duration of the disorder; 4. cognition (intelligence, ach ievement, learning, memory, attention ): 5. neurodevelopmental factors (perinatal history, motor coordination, soft signs, and minor physical anomalies); 6. activity level; 7. personality (temperament, impulsivity, locus of control); 8. stressors (recent life events); 9. arousal and habituation to stimuli; 10. auditory acuity (audiometry and tympanometry).

Received Nov. 6. N85 ; revised April 8. 1985; accepted April 4. I 98fJ.

From the Department of Psychiatry and Behavioural Science. School of Medicine. University ofAuckland. Auckland, New Zealand. The work described here was supported by the Medical Research Council otNcw Zealand. The authors would like to thank Dr. A. J. Costello for supplying the DISC-P and Dr. T. M. Achenbach fo r perm ission to lise the Social Competen ce Profile. Requests [or reprints to Professor Werry. Dept. of Psychiatry & Behuvioural Science. School of Medicine, University of Auckland. Private Bag. Auckland, New Zealand. 0890-8567/87/2602-0144$02.00/0 (c;) 1987 by the American Academy of Child and Adolescent Psychiatry. l AA

145

ADD, CONDUCT, AND OPPOSITIONAL DISORDERS II

A second hypothesis was that although such distinctiveness would be statistically significant, it would not be absolute, with some children showing similarities across diagnostic conditions and ditTerences within major diagnostic categories, leading to possibilities both ofsubcategorization and of mixed diagnoses. It was also posited that many of the variables would be 'patient' rather than diagnosis related. We hypothesized further that there would be considerable overlap between the dependent variable measures used and that as a result their psychometric structure could be refined and cross validated. An alternative to our main hypothesis was that OPP and CD may well be the same condition, a proposal supported by previous work (Werry et al., 1983), except that OPP may be more common in girls, which suggests that it may be a less severe form of CD. Method SUBJECTS

All subjects were obtained by informed consent of parents and assent of children, all of whom enjoyed the testing. Particular care was taken to stress the lack of value of the research for direct patient care. The project had approval of the Auckland University Human Subjects Ethical Committee. All subjects had to meet the following criteria: (a) age 6-13 years (mean age = 8.84 years + 2.1 years), (b) not enrolled in an educationally subnormal class, (c) an lQ of> 69 on an intelligence test, (d) at least one parent who normally lived with the child and was willing to be interviewed, (e) significant impairment in social functioning both at home and in school, (f) no important physical illnesses: in particular, no evidence of gross neurologic disease or disorders of the child or concurrent treatments that might cause changes in brain function. Children taking medication were not excluded from the study but, where parents consented, medication was withheld for at least 48 hours before the child was seen and tested. Of the 25 children taking any kind of medication, only 4 (I control subject and 3 patients) took any medication on the day of testing.

Zealand children (Aman et al., 1983; Quay, 1983; Quay and Peterson, 1983) and had then been diagnosed after psychiatric examination by J. R. as having ADDH and/or any of the other three disorders in question. The mean score for this group on the Attention Problem Factor was 20.6, which defines marked problems of distractibility, inattentiveness, and impulsivity. CONTRAST SUBJECTS-NORMAl. CHILDREN

A "normal" or symptom free control group of children (mean age 8.93 years + 2.1 years), matched for age, sex, and socioeconomic status and of approximately similar ability, was selected by asking the teacher of each patient to select a suitable control subject from the same class whose above characteristics were as similar as possible. Parents were then contacted and invited to participate in the study. Where parental permission was not forthcoming or a suitable control child could not be found, a school close to the Medical School (a typical, socially mixed neighborhood) was asked to provide such a child. Not all patients were able to be matched. A sibling control group had to be abandoned because of an unexpected, marked shortfall in the age range required and discrepancies in sex ratios (F J M). PROCEDURE

All parents (mother and father) were asked to complete three questionnaires about themselves and three concerning their child, which were mailed out in advance. Each child was then accompanied by a parent to the Medical School for a testing period lasting about 2 hours. After a physical-neurological examination of about 20 minutes, the child was taken to the psychological laboratory and given a test battery for about l-'h hours (see Werry et al., in press). During this latter time the parent was interviewed by J. R. for about I hour and then asked to complete three additional questionnaires in the waiting room. In each case, the child's teacher was contacted by phone and asked to complete three questionnaires, which were then mailed out.

PATIENTS

These were obtained from two sources. The first, the clinic group, consisted of 88 children (64 male and 24 female) seen in 2 (of 3) child psychiatric clinics of the Auckland Hospital Board who had an agreed diagnosis made independently by two psychiatrists (J. R. and one other) of CD, OPP, ADDH, and/or ANX according to DSM-IlI criteria. Eight of these children (6 male and 2 female) were at a residential school for maladjusted children, but all of these had been referred to the school by the psychiatric clinics. The second, the community group, consisted of21 children (17 male and 4 female) whose parents had replied to a newspaper advertisement asking for hyperactive children to take part in a trial of fatty acids unrelated to the present study hut, after prcscrecning, were referred by that investigator (Dr. M. G. Aman) for inclusion in this study, plus two children referred as normal subjects but found to have ADD. All children in the community group had been scored by parental ratings of at least two standard deviations above the mean (i.c.. > 12), on the Attention Problem Factor of the Revised Behavior Problem Checklist (RBPC) as standardized for New

Psychiatric Diagnosis ofChildren

All patients and control subjects were assessed in the same manner. One parent (usually the mother) or both were seen by J. R. Fathers alone were present only in two instances. The parent(s) were given a shortened version (omitting items largely irrelevant to New Zealand) of the Diagnostic Interview Schedule for Children-Parent Version (DISC-P) of the U. S. National Institute of Mental Health (Costello et al., 1985). This is a standardized interview schedule designed by Costello and colleagues to enable clinicians and laypersons to make consistent and accurate psychiatric diagnoses in children in accordance with DSM-IlI criteria, and it takes 45 minutes to I hour to administer. It has two forms-child (DISC) and parent (DISC-P) administered. In view of the superiority of parent information over child (Rutter, 1976) and the time restrictions imposed by the laboratory measures, only the DISC-P was used here. Although this instrument is still under development, initial reliability and validity studies are reported as satisfactory (Costello et al., 1985). In order to increase the reliability of information obtained, all questions

146

REEVES ET AL.

in the DISC-P pertaining to school performance and behavior in the classroom were abstracted and sent to the child's teacher to answer, as it had been our experience that parents often did not know the answers and tended to guess. Using the DISC-P, children were excluded from the study if they did not meet the diagnostic criteria for at least one of the four disorders in question. They were then assigned to one of seven diagnostic groups, i.e., ADDH, CD, AN X, OPP, ADDH + CD (H + CD), ADD + OPP, and a multiple diagnostic group.

Reliability and Bias An interdiagnoser reliability check was carried out between the principal psychiatrist-interviewer I.l, R.) and a U. S. Board certified-psychiatrist and second-year Fellow in child psychiatry (A. Z.) who was visiting New Zealand at that time. Thirteen subjects were seen by both psychiatrists together, with one conducting the DISC-P interview and the other observing, and both recorded symptoms on the protocol independently. A total of 19 diagnoses was made with 100% agreement. Diagnoses included each of the four disorders being investigated. In view of the fact that the DISC-P was designed for administration by lay interviewers and we used the same data base (rather than separate interviews), such extremely high reliability should not be too surprising. The neurological examination was also checked for reliability (see below). Because of level of funding only one psychiatrist could be employed; as it was not possible to keep the psychiatrist (J. R.) blind as to diagnosis, the measures she elicited may carry bias. This affects all physician-derived measures concerning normal subjects versus patients, and some parental measures after completion of the DISC-P (and assignment of a diagnosis), for the four diagnostic groups (assessment of marital state and family psychiatric history).

Child Measures-Child-Derived. Neurodevelopmental Abnormalities Neurological examination. The neurological examination used was a shortened version of an examination by Taylor (1972), selected because it had the best interexaminer reliability and the greatest discriminating power between normal children and children with learning or behavior problems. It comprised assessment of speech and nine tests primarily of sensorimotor coordination (hand and foot laterality, involuntary and mirror movements, finger and eye coordination, heel-toe walking, standing on one leg, and hopping). Definitions of items are based on Touwen and Prechtl (1970), and each item is rated for the right and left side of the body on a scale of a (normal), I (slightly abnormal), and 2 or 3 (markedly abnormal). The child was considered to have a positive neurodevelopmental score if 3 or more items were rated as markedly abnormal. Interrater reliability studies were carried out for the neurological examination on 13 patients, with an average percentage of agreement of 91.6% for two examiners (J. R. and A. Z.) rating all items on a scale of 0 (normal), I (slightly abnormal), and 2 or 3 (markedly abnormal). Percentage of agreement rose to 97.6% when only those items rated mark-

edly abnormal were considered. In this reliability check, A. Z. was blind to diagnosis. Minor physical anomalies (MPA). The examination for MPA was as described by Waldrop and Halverson (1971). Nineteen possible anomalies (e.g., large head, hypertelorism, low set ears) are scored present or absent and then given a weighted score of 0-2 according to their severity. A weighted score of 5 or more was chosen as indicating a high anomaly score. Speech. The 20-item Dunedin Articulation Screening Scale (DASS) was developed in New Zealand for use with New Zealand children (Silva, 1980) and has been shown to be a reliable, valid, and accurate method for identifying children with defective speech. The final score is the total number correct out of 20, with 15 or less considered to indicate probable speech pathology. Hearing, Audiometry and impedance tympanometry were performed on all children in the study.

Child Measures-Parent-Derived Backgroundfhistorical, Background medical and social information was obtained during the interview with the parent(s): age, sex, race, detail of "in-care" experiences, pre- and perinatal history with particular emphasis on whether there was a history of antepartum hemorrhage, toxemia requiring hospital admission or confinement to bed, infection, breech delivery, low birthweight, or other significant event likely to increase the risk of brain pathology. Revised Behavior Problem Checklist (RBPC). The RBPC (Quay, 1983; Quay and Peterson, 1983) lists 89 problem behaviors scored from a (not a problem) to 2 (a serious problem) and generates four major factors labeled as (I) Conduct Disorder, (II) Socialized Aggression, (III) Attention problems-Immaturity, (IV) Anxiety-withdrawal, and two minor factors labeled as (V) Psychotic Behavior and (VI) Motor Excess. Norms for factor scores are available (Aman et al. 1983; Quay, 1983). Life Events Record. The best known life stress measure for younger age groups, the Life Events Record (Coddington 1972a, I972b), elementary school version, was used. It is filled out by a parent and lists 36 possible events occurring during the previous 12 months. Scores are derived by summing values termed "life change units" that are assigned to the various events reported. Normative data are available for various age groups (Coddington, I972b). Social Competence Profile. This questionnaire is taken from The Child Behavior Profile (Achenbach, 1978) and consists of 7 items generating three social competence scales (Activities, Social, and School). The Activities scale reflects the amount and quality of involvement in jobs and chores, and sports and nonsport activities, and the Social scale reflects involvement in social relationships. The third scale reflects School performance and problems. The total raw scores obtained on each scale are transformed into normalized T scores derived from a normative sample of the child's age and sex (Achenbach and Edelbrock, 1983). Low scores are clinically significant. Family Adversity Index. An index of overall psychosocial disadvantage was calculated after Shaffer et al. (1975) by allocating one point for the presence of each of the following

147

ADD, CONDUCT, AND OPPOSITIONAL DISORDERS II

factors: (a) in-care experiences (i.e., foster or institutional care); (b) hospitalization for more than 4 weeks; (c) persistent parental discord; (d) separations from parents through discord; (e) hard or harsh discipline; (f) large family size (sibship of four or more); (g) low social class (unskilled or semiskilled occupation of father or principal breadwinner); and (h) psychiatric or criminal histories of parents. It is thus a mixture of fact and subjective judgment by the interviewer. The presence of four or more factors is rated as a positive family adversity index (Shaffer et al., 1975). Child Measures- Teacher Derived Conners' Teacher Questionnaire. The Conners' Teacher Questionnaire (TQ) (Conners. 1969; Goyette et al., 1978) is a 39-item checklist yielding four factors (I) Conduct Problem, (II) Inattentive-Passive, (III) Tension-Anxiety, and (IV) Hyperactivity. Extensive normative data are available for both normal and hyperactive populations, including norms for an Auckland population of children (Goyette et al., 1978; Taylor and Sandberg, 1984; Werry et al., 1975; Werry and Hawthorne, 1976). Teacher Assessment Form. This form was developed specifically for this study. It asks the teacher to rate the child on a 6-point scale, first on their actual achievement level for reading, writing, and arithmetic, plus an overall rating, and then to rate the child on the same subjects according to the teacher's estimate of their ability. The 6-point scale ranges from 0 = at mentally retarded level to 6 = superior ability. This scale, of course, approximates to the usual school "report" or "grades." Prosocial Behavior Questionnaire. This is a 20-item questionnaire (Weir and Duveen, 1981) designed to measure positive social interactions with peers and concern for others. It is scored by the teacher on a 3-point scale: 0, rarely; I, somewhat; 2, usually. Test-retest reliability and validation against independent peer judgments appears satisfactory (Weir et al., 1980). PARENT MEASURES

Psychiatric Illness. Each accompanying parent was interviewed (J. R.) regarding common psychiatric symptoms of adult life, and when indicated, diagnoses were made according to DSM-III criteria. In addition, information was sought regarding a childhood history of ADDH after Wender et al. (1981). Diagnoses on parents who had not been interviewed were made from information given by the other parent using the Family History Research Diagnostic Criteria (FH-RDC) (Andreasen et al., 1977). which was developed to enable investigators to use a consistent set of criteria for diagnosing psychiatric illness in relatives of index subjects when it is not possible to examine the relatives directly. Recent Life Events. A 67-item inventory scaled in terms of the capacity to produce either a "change in life style" or "emotional distress," adapted for Australia by Tennant and Andrews (1976) was used because it was felt to be culturally closer to New Zealand than the original U. S. version. As with the children's scale, events are scored for the previous 12 months. Eysenck Personality Inventory (Evsenck and Eysenck,

1964). This yields normative Extraversion-Introversion and Neuroticism scores. This was analyzed for natural parents only because there is said to be a significant hereditary component in this test and we wished to separate out this effect. Marital Inventories. These were completed by one parent (almost always the mother). I. Short Marital Adjustment Test (SMA T) is a IS-item measure ofgeneral marital satisfaction, which is of established reliability and discriminant validity between harmonious and disturbed marriages (Locke and Wallace, 1959). It has been recommended as one of the best available indices of marital satisfaction (O'Leary and Turkewitz, 1978). It consists of a visual analogue scale for depicting degree of marital happiness and 14 items assessing the extent to which couples agree on such matters as handling family finances, demonstrations of affection, matters of recreation, and so forth. The maximal score obtainable is 158. Scores of about 100 or more are generally considered to be indicative of good marital adjustment (Kimmel and Van der Veen, 1974: Rosenbaum and O'Leary, 1981), whereas those scores below 90 are considered to indicate marital disharmony (Weiss et al., 1973). 2. O'Leary-Porter Scale (revised version 1983) (Porter and O'Leary, 1980) has 10 items to be completed by parent(s) and was devised as a measure of openly expressed marital conflict observed by the child. It has high internal consistency and test-retest reliability, and it is moderately correlated with the SMAT (r = 0.63). The maximal score is 40 and high scores are positive (minimal marital conflict observed by the child). Laboratory measures. This extensive test battery is described in a subsequent paper (Werry et al., in press), but briefly, it surveyed attention, memory, and other cognition, locus of control, reward dependence, seat activity, and some psychophysiological functions. Data Analysis

Nominal variables were tested for significance by an overall chi-square test followed by inspection to locate source of any significance. In all comparisons among the 3 diagnostic groups, continuous variables were analyzed by factorial Analysis of Variance (Factor I Diagnosis and Factor II Patient/Normal). Where the interaction Fwas significant, a one-way ANOVA was run across diagnostic groups only, partialling out the effect of age, sex, and IQ (which were unevenly distributed across the diagnostic groups). If this F ratio was still significant, a post hoc test (Schcffe) to locate the source of significance was done. When a significant difference across diagnostic groups was found, the group that differed was compared by age and IQadjusted A NOV A with its control group to see if this difference was maintained and thus was a specific diagnostic difference and not just one attributable to any peculiar, extraneous, features of the selection process affecting this particular diagnostic group and its normal control subjects. Results Diagnoses

As can be seen from Table I a total of 180 diagnoses were given to 108 children. The majority were referred to the study with only one diagnosis, but 52% were found at interview to

4.5: I 3.3 : I 10 : I 4

2.7: I

lO 26 22 45 176

Diagnostic

-

- -

12 67

97

30 II 14

- -

12

II

I 0 0'

3

---~ _._

2

- ----

22

52 15 8

.

- --

Probability"

" N = 108: range = 1-5.

2 3+

Number of Diagnoses

M 40 36 4

Children 52 (48 %) 49 (45 %) 7 (7 %)

TABLE 2. Number ofDiagnoses per Child"

12 1J 3

F

" Significantly difTerent (fl < 0.05). ~ Level I = highly probahle diagnosis - congruent diagnoses from more than one independent source. Level 2 = prohahle diagnosis- diagnosisfrom a single source plus validating symptoms from one or more other sources. Level 3 = possihle diagnosis - diagnosis from a single source. (after Anderson et al., in press). , Oppositional Disorder was not diagnosed unless confirmed by necessary and sufficient symptomatology in teacher ratings as required hy DSM-IIl criteria.

:5

- -- _ .

Attention Deficit Disorder Conduct Disorder Oppositional Disorder Overanxious Disorder Separation Anxiety Disorder Avoidant Disorder Phohic Disorder Total

.... _-

M:F" N

Diagnoses

(N = J()8 Children)

TABLE I. Diagnoses. Sex Ratios. and Probability ofDiagnosis

As shown in Table 5. there are sex ratio differences in that ANX children are slightly more likely to be female, whereas ADDH and H + CD are mostly male. especially the latter. Age at the time of the study (i.e.. of presentation in most patients) is not significantly different. although ANX are slightly older. but their age at onset is significantly so. PPVT IQ was not different across diagnoses. although as already noted. normal subjects generally had somewhat higher IQs than control subjects.

Background Factors

There were no significant differences between the patients and the respective control subjects on four matching variables of sex. age. SES. and ethnic group (Table 4). However. although teachers had been asked to match patients and control subjects "ability". the PPVT IQ did differ in the ADDH and H + CD groups.

Intcrdiagnostic Comparisons

The percentages (occasionally means) in each category on selected clinical and social variables for all patients and their matched control subjects are shown in Table 3. It can be seen that subjects differ from normal non patients in having been "in care" significantly more often. in having a greater frequency of abnormal birth histories, in receiving psychotropic medication. in being more often left-handed, in being less likely to be living with their mother. and in having parents with more discordant marriages and higher neuroticism scores on the Eysenck Personality Inventory. Subjects also exhibit less prosocial behavior towards peers. They do not differ on parental ethnicity, supervision. large family size. mother working. neurodevelopmental or minor physical anomalies, and recent life events in child or parents.

Patients versus COli/rot Subjects (N = 108)

(1985). comparison on all clinical variables had shown no significant differences between ADD + CD and ADD + OPP-mean age of the CD group was slightly but not significantly older than OPP (9.1 years. S.D. = 2.4 versus 8.4 years, S.D. = 1.8). and other variables. including Conners TQ and RBPC factor scores. life events, abnormalities of pregnancy, "in care" experiences. and academic achievement were not significantly different. There were too few (N = 6) children with diagnoses of CD or OPP only. so they were dropped from all analyses except those looking at 'caseness' versus normality. as were the seven children with three or more diagnoses. because the interactive effects were impossible to judge. One child had no control subject and so was dropped from the analysis. Children with a diagnosis of one (or more) Anxiety Disorders of any kind were combined into one group ANX (N = 21) because subtypes were too few in number for analyses and there is considerable doubt about the reliability of the subcategories (Quay. 1986a). This left three groups. together with their matched control groups. for interdiagnostic comparisons-a pure ADDH group (N = 39) of whom about half came from the community group. a combined group of ADDH + CDjOPP (hereinafter H + CD) (N = 35), and an ANX group (N = 21), or a total N of95 .

REEVES ET AL.

meet DSM-lII diagnostic criteria for at least one more diagnosis as well. Only four children were found to have a Conduct Disorder (unaccompanied by any other diagnosis) and only two children an Oppositional Disorder alone. The criteria of certainty of the assigned diagnosis devised by Anderson et al. (in press) were used as set out in Table 1. ADDH, CD, and OPP all reached high levels of diagnostic probability, whereas the Anxiety Disorders fell to level 3 (possible) in II cases, reflecting the fact that these disorders often go unrecognized by teachers who are critical to a level I diagnosis. The sex ratio was significantly different (I' < 0.05) across disorders-equal for Anxiety Disorders but predominantly male in ADDH. H + CD. and strikingly so in OPP. The range of diagnoses per child (Table 2) was 1-5. with approximately equal numbers receiving one or two diagnoses (around 45%) and seven receiving three or more diagnoses. There were no obvious sex ratio differences between children with one or two diagnoses and too few with three or more for analysis. To have groups of adequate size for analysis it was decided to combine all those with ADDH and an additional diagnosis of either CD (N = 18) or OPP (N = 17) into an ADD + CDj OPP group because it was considered that CD and OPP are qualitatively similar disorders, and a previous study (Werry et al ., 1983) had shown that this combining greatly improves the reliability of CD. Also. as in the study by Anderson et al.

148

149

ADD, CONDUCT, AND OPPOSITIONAL DISORDERS II TABLE 3. Selected Clinical and Social Variablesfor Patients and Control Subjects ---~-~~---~

Patients Variable

105)"

(N =

o.

Control Subjects (N = lOS)"

%

%

-------------

I. Child PPVT IQ Prosocial behavior total score Family /ecological Coddington Life Events Has been "in care" Child left unsupervised Mother white Father white Parents of mixed race 6+ persons in home Parents living apart Child living with mother Mother working part-time Mother working full-time Neurological/physical Pre, peri, or postnatal insults> I On psychotropic medication Neurodevelopmental abnormalities ;;.3 Minor physical anomalies ;;.5 Right-handed II. Parents Eyscnck Personality Inventory Mother: N Score E Score Father: N Score E Score Tennant and Andrews Life Events Scale Mother: Distress score Life Change score Father: Distress score Life Change score Marriage O'Learv-Porter scorch Locke-Wallace Marriage scorch

95.4 13t

103.9 27t

68t 18 46 91 93 13 8 38 47 26

57t 2 57 85 91 12 14 27 93 56 32

57 15 41 28 80

43 5 32 23 91

13 14

II

77

13

13 9 13

43 58 40 59

38 56 32 49

II

29 96 -

---

31 111

------

"All scores arc percentages corrected to nearest integer unless indicated by t (means). " High score = positive feature (all other scores psychopathological).

ANX and normal groups it was mostly antiasthma or antiallergy in type. It should be noted in passing that the low number of children on psychotropic medication (methylphenidate only was involved) probably reflects a rather more conservative position held by the two child psychiatrists in Auckland (1. S. Werry and R. J. Methven), as compared with attitudes in the U. S., rather than any real differences in patient groups.

Neurological Physical As shown in Table 6, the two H groups had more perinatal insults, although only the H-CD group differed from its normal control group in this respect. Otherwise, there were no differences in neurodevelopmental function except that the H group had the highest frequency of any group, but this fell short of significance. No diagnostic group differed from any other nor from normal subjects in hearing, whereas a previous study (Silva et al., 1982) had found an association between impaired hearing and psychopathology, especially ADDH/CD symptoms, in children.

Achievement As shown in Table 6, teacher's estimates indicated that in all areas, ANX children were better than the two H groups, but in reading and math they still showed a trend (II > 0.05 < 0.10) to be inferior to normal subjects. Not shown in Table 6 is that when the teachers were asked to rate the child's classroom performance against their estimated ability, all three diagnostic groups were judged significantly underachieving with respect to their control subjects. This was most marked in the Hand H-CD groups but was still significant in the ANX group.

Ecological Factors As shown in Table 7, the H + CD group had a much higher frequency of adverse family backgrounds and was much more likely to have been "in care" (mostly residential schools for the maladjusted). The other two groups resembled normal subjects. Otherwise, there were no significant differences between diagnostic groups and normal subjects on living conditions or stress factors, except that ANX children were rated TABLE 4. Patients and Control Subjects: Matching Variables ----------~---

--~.-

---------

Sex

Clinical/Symptomatological As shown in Table 5, the Conners TQ and parent RBPC factor scores of symptomatology differed across diagnostic groups in the expected directions, roughly cross-validating the

psychiatrist's DSM-III diagnoses and, with minor variations, both scales generally supported each other. The level of disability on axis V and other measures of social function was lower in ANX than in the two H groups. On the Prosocial Behavior Checklist and the Social Competence Profile, the level of disability was also shown to be somewhat greater in the H + CD than in the pure ADDH group. There was no difference in the number of children on medication, although the frequency was low in all groups. However, in the two H groups medication was all stimulant in type, whereas in the

Age M F

Socioeconomic Status

PPVT IQ

Anxiety (N = 21) Patients Control subjects

12

3.75

100

10.32 9 12

3.56

104

ADDH (N = 39) Patients Control subjects

8.88 32 7 8.84 32 7

4.10 3.1.) 1

94" 102"

ADDH + Conduct Disorder (N= 35) Patients Control subjects

9.21 31 9.29 31

4.17 3.86

94" 106"

10.25

I.)

4 4

" Significant difference between patient and control group

0.(5).

(I'

<

%

1.3 2.2

HC = H>A HC>H = A A
AH = A A H = HC HC>H>A

0.000 1 0.00 2 0.000 1 NS NS 0.000 7 0.000 1 0.0008 0.04 0.0001 1.9 2.2 1.6

1.2

9 0.9 5.7 9.4

50 51 50

45 41 43

A>HC

NS NS 0.0 1

0.00 1

-

1.3

1.0 1.4 1.8

4.6 0.7 2.3 3.3 0.4 0.8

28

A
A
-

0.000 3" NS NS NS" 0.0 5" NS" 0.007 " 19

104

Control Subjects (N= 2 1)

A> H> HC

An xiety (N = 2 1)

10

AH = HC

Source of Significance

3:4 10.3 ± 2. 1 100 95 50 14 48

Diagno stic Group Differences

" By chi-square for these va riables. Others by A NaYA. corrected for age. sex, and PPYT IQ. h A = Anxie ty; H = ADDJ-f.

Sex (M: F) Mean age in years PPYTIQ Pervasi veness Onset <5 On medicati on now AXIS Y. DSM-III: Adapti ve fun ctioning < fair or poor Prosocial beh avior (tota l score) Ch ild Beha vior Chec klist-Social Co mpeten ce Profile T scores: Activities Social Schoo l Revised Behavior Probl em C hecklist Conduct Disorder Socialized Aggression Attention De ficit Anxiety/withdrawal Psychotic beh avior Motor excess Conners Teacher Qu estionnaire Conduct probl em Inattentive-passive Ten sion- an xiet y Hypera ct ivity

Yariable

%

0.05 0.02 0.02 NS

NS NS 0.02 0.0001 NS NS

0.04 0.006 0.02

0.001

0.002

NS

p

1.5 2.8 1.8 2.6

21 2 18 6.7 3.2 5.7

43 40 38

13

4.5:1 8.9 ± 1.4 94 100 70 15 90

(N= 39)

ADDH

%

TABLE 5. Background and Symptomatological Factors

1.0 1.5 1.6 1.4

5.4 0.7 2.9 3.5 0.4 1.I

46 48 50

25

5 8

102

(N= 39)

Control Subjects

%

0.0001 0.0001 NS 0.0001

0.0001 0.02 0.0001 0.002 0.0001 0.0001

NS 0.0001 0.0001

0.0001

NY 0.0001

0.02

p

3.1

1.7

2.2 2.7

28 4.9 17 7.4 3.4 5.7

43 34 36

9.3

7.75: I 9.2 ± 2.2 94 97 83 9 89

(N= 35)

Conduct Disorder

1.3

1.0 1.5 1.5

4.9 0.1 2.7 2.1 0. 2 1.0

49 50

44

26

9 14

106

(N = 35)

% Control Subj ects

+

% ADDH

0.0001 0.0001 NS 0.0001

0.0001 0.0001 0.0001 0.0001 0.0001 0.0001

NS 0.0001 0.0001

0.0001

NY 0.0001

0.00 3

p

r

;l>

-i

!;l m

<

m

:= m

o

Q'1

....

151

ADD, CONDUCT, AND OPPOSITIONAL DISORDERS II

NCI'l ~Z

o

CI'l

Z

CI'l

Z

- - -8888

0000

by the psychiatrist as having less psychosocial stress on axis IV of the DSM-III than the two H groups. Parental Factors As shown in Table 7. there were few differences among diagnostic groups or from normal subjects (except for father's education, which was lower on the ANX and H-CD groups). The overall pattern of mother's Life Events Stresses did differ across groups but no one group was significantly different from any other, although raw scores and differences from normal subjects suggested that the two H groups were worse. There was no difference across groups or from normal subjects (except possibly for the ANX group) in Marital Adjustment (SMAT) or parental strife observed by the child (O'Leary Porter Scale). Parental Psychiatric Illness

If)

-

I,Q

-N

CI'l CI'l o zz v

00

~

z

Discussion

""

Patients versus Normal Subjects

v :r: II :r: v ~ ;qe.t'J oZ ci

vvvv :r::r::r::r: II

II

II

II

:r::r::r::r: v vv v ~~~~

r.r;

Z

As shown in Table 7, there was no significant difference among diagnostic groups on the total frequency of psychiatric disorder in parents. However. ANX children had mothers with significantly increased rates of Anxiety Disorder compared with the other groups and their own control subjects, whereas H + CD children had significantly more alcoholic and antisocial personalities in fathers. There was only one case of parental ADDH and that was in the mother ofa child with a similar disorder.

C/)

Z

Although this study was primarily of differences among diagnostic groups and their normal control groups, some comments on the characteristics of 'caseness' is indicated. The differences between patients and normal subjects showed that patients were not functioning as well socially. academically, or cognitively and tended to have more adverse perinatal histories and parental discord. The differences in PPVT IQ requires comment because it will be remembered that teachers were asked to match patient and control subject "on ability." Two possibilities emerge: The first is that teachers are exhibiting a negative halo effect towards patients. seeing them as not working as hard as they should, when the reality is they are not quite as intelligent (verbally) as nonpatients. The other is that this is a genuine correlate or effect of psychiatric disorder. However. there were no differences in race, family background. family size, working mothers, and recent life events affecting parents. This apparent negative finding might be a consequence of matching. However. if it is a true finding. it does raise some questions about currently accepted views of the general etiology of psychopathology in children. especially the role of working mothers and recent life stresses in parents. neither of which were matching variables. In our previous review (Werry et al., 1987), we drew attention to the fact that studies of individual diagnostic groups and normal subjects had indicated that most of the above differences were probably characteristic of being a patient rather than of any diagnosis, but only comparisons across diagnoses and normal subjects can answer this.

39% 33% 28% 6%

88% 6% 6% 33% 32 43 10% 10% 5%

38 45 10% 10% 48%

0.002 0.02 H-CD>A = H H-CD>A = H A>H-CD= H

NS

NS

35 38

36 40

NS NS

0% 5% 48% 42 43%

I

Normal N= 21

5% 0% 62% 44 38%

Anxiety N= 21

H-CD>A = H H-CD>A = H NS NS H-CD = H>A

Difference Source

NS NS 0.05

NS NS

0.02

0.05

NS NS

NS NS NS NS NS

P

13% 13% 13%

6% 6% 13%

0.04 0.04

57 74 35 47

NS

56% 9% 34% 23%

61% 26% 13% 19%

NS NS NS

NS

NS NS

34 36

35 36

P

NS NS NS NS NS

I

Normal N= 39

5% 0% 54% 62 55%

8% 8% 46% 59 74%

ADDH N= 39

31% 31% 3%

50 72

76% 10% 14% 26%

34 38

32% 40% 34% 79 66%

ADDH + Conduct Disorder N= 35

" All scores rounded to nearest interger. Significance determined by chi-square, Fisher exact test, or ANOV A adjusted for age sex and PPVT IQ.

Social ecology Family adversity Has been "in careChild unsupervised Coddington Life Events Axis IV (Stress) Parent factors Mother's age Father's age Father's education < Grade II Grade II > Grade II Marital Adjustment Scale «90) Life Events Scale Mother: Distress Life change Parental Psychiatric Disorder Father: Antisocial PD Alcoholism Mother: Anxiety Disorder

Variable

TABLE 7. Selected Social Ecological and Parent Factors"

3% 6% 0%

22 45

48% 31% 21% 17%

35 38

6% 0% 57% 59 43%

I

Normal N= 35

0.05 0.05 NS

0.003 NS

NS

0.05

NS NS

0.02 0.01 NS NS NS

P

:J>

r

m

...,

m (10

"mm-<

l-:>

..... 01

ADD, CONover, AND OPPOSITIONAL DISORDERS II

Diagnostic Pal/ems

The first question is why there were so few pure CD and OPP. hoth of which diagnoses nearl y always occurred in associat ion with ADDH. This could be due to the DSM-III diagnostic criteria or. more likely, its promotion of multiple diagnoses. eschewed in the ICD 9, although the latter does have Hyperkinetic Conduct Disorders as a diagnostic category. However . it does raise doubts about the possibilit y of comparability of systems that promote multiple diagnoses and those that emphasize single diagnoses. Again, the DISCP. a structured. multi-item. comprehensive. forced reply schedule. could be responsible either by failing to differentiate the critical ADDH symptoms wel1 enough from those of CD. or more likely. by dredging up less prominent symptoms. Whatever the source of the problem (DSM-III, DISC-P, or referral bias), it operates in one direction only-A DOH occurs without CD. but does CD occur without ADDH? Others. using neither DSM-III criteria nor multi-item schedules like DISC-P. have been able to find pure CD (e.g.. August and Stewart. 1982: Koriath et al., 1985: Thorley. 1984). but even in two of the three . concurrence of ADDH and CD was more common than pure CD . One stud y using sim ilar methods to the present (Anderson et al., in press) did find that. although mixed forms did occur. pure CD-OPP was somewhat more frequent. However. their sample was a nonreferred, epidemiological one and most of the CD were. in fact. OPP. The two symptom checklists used here on parents (RBPC) and teachers (Conner TQ) (see Table 5) provide some information on this question. although the y are both partial1y contaminated by the fact that the RBPC came from the same source as the DISC-P data and some of the items in the RBPC and TQ occur in the DISC-P in the same or similar form. These scales suggest that ADDH and ADDH + CD groups do have rather similar profiles in the areas of ADDH symptomatology but that the CD group does generally have higher scores in antisocial. noncompliant. aggressive symptomatology. This suggests that the ADDH + CD group is probably best considered for the moment as a mixed disorder. although this wil1 be discussed further when correlates independent of defining symptomatology are discussed. The distinctiveness of ADDH and CD is. of course. a hotly debated one. The findings here and in the other studies cited above indicate that ADDH without CD certainly occurs commonl y enough. and , as this stud y shows. does not necessarily or even possibly often result in clinic referral in New Zealand. However. as noted above . the reverse question. does CD occur without ADDH. has hardl y been tested adequately. especial1y with the kind of comprehensive diagnostic techniques and DSM-III multi-diagnosis system used here. One possibilit y beyond those mentioned alread y is that of selective referral. Just as the concurrence of CD with ADDH probably enhances the prospect of referral for ADDH . it is arguable that the reverse is also true. Whatever the cause , our previous review (Werry et al., 1987) showed that in the studies that have compared CD with normal children there is a marked occurrence in the symptoms that define ADDH (short attention span , distractibility. restlessness) in CD children. so the problem of separating CD from ADDH + CD may have to devolve onto exclusionary criteria of one for the other. Before doing

153

this though. the validity of ADDH + CD as a distinct entity from ADDH and CD needs proper testing. The separateness of CD and OPP is another issue. Previous research is sparse and is conflicting as to reliabilit y of an y difference (Anderson et al., in press: Werry et al., 1983). There are no data as yet on validit y (see Werry et al., 1987). We tested the distinctiveness of these two disorders along a number of variables and failed to find any significant differences. We have thus elected. as did Anderson et al. (in press) to say they are the same so as to improve the cel1 frequencies for analys is. but it seems likely that even if OPP and CD are qualitatively similar. the y are not quantitatively so and this may have attenuated our findings and those of Anderson et al. somewhat. We wil1 return to this whole issue below in the light of validating characteristics. Differences among Diagnostic Groups

No differences were found in a number of areas-first. in ncurodcveloprnent. including soft signs. minor physical

anomalies, speech. and handedness. Furthermore, in these , al1 diagnostic groups resembled their normal control groups except in soft signs. where the ADDH group was significantly different. In family background and parental factors. there were few real differences among social ecological factors. parental personality. marital confl ict. and stress in fathers across the diagnostic groups or indeed from their normal control groups. although the latter . as far as social ecology is concerned. would be expected to be sim ilar because of matching procedures. Some of these findings , however, are in conflict with better measures. Nevertheless . some differences suggesting a valid distinctiveness. independent of defining symptomatology, to ANX. ADDH, and ADD + CD were found here. ANX children are more often female. with onset and presentation at a somewhat later age. They are less handicapped socially, cognitively, and in achievement than children with ADDH and ADDH + CD but nevertheless are a little inferior to normal children. Unlike the other groups they do not differ from normal subjects in the frequency of adverse perinatal historie s, recent stress experienced by the child, or distress in their mothers. The y. like ADDH children. also do not differ from normal children in perinatal histories (nor from each oth er) or in the frequenc y of cumulative family adversity. The one area in which the y are more disadvantaged than the other groups and normal subjects is that their mothers are more likely to have or have had an an xiety disorder themselves. As far as ADDH and ADDH + CD are concerned, they general1y resemble each other more than they differ in sex ratio (where boys predominate). in age of onset and presentation. in frequenc y of perinatal insults , in psychosocial stress. in handicap in cognition and ach ievement. in al1 of which (except for perinatal insults in ADDH) the y are worse off than ANX and normal subjects. ADDH children, however . are somewhat less handicapped than ADDH + CD in social function, but both groups are stil1 inferior to ANX and to normal subjects. The ADDH + CD group is most clearly distinguished by the occurrence, in a third of cases, of severe. adverse family

154

REEVES ET AI..

backgrounds (including alcoholic/antisocial fathers) in which the other two diagnostic groups do not differ from normal groups. Also, they function the worst socially.

Conclusions This study has some obvious shortcomings: the principal diagnostician was not blind when doing physical and parental assessments, estimates of parental psychiatric disorder were crude, there was no direct assessment of children's symptomatology, and there was a melange of measures from different instruments. Despite this, the findings generally confirm those of the few previous comparative studies (see Werry et al., 1987) and suggest that ANX is a less disabling disorder that may he related in some way to maternal anxiety, whereas ADDH is a serious, at least partly cognitive, disorder, of uncertain, possibly neurodeveloprncntal, origin, ADDH + CD resembles ADDH, except that the social handicap is somewhat more severe and the etiology now includes marked factors adverse to child rearing coupled with alcoholic, antisocial fathers. This study suggests, then, that ADDH + CD may he some kind of interaction between whatever is the cause of ADDH and psychosocial environmental factors. Whether this is simply due to the addition of CD to ADDH or whether ADDH + CD is actually the same as CD cannot he answered here. but there is good evidence that ANX is distinct and that ADDH + CD both resernbles but is also distinctive from ADDH . In another report (Werry et al. , in press) we will report the laboratory (psychological. motor activity, and psychophysiological findings). Briefly, however, it may be said that there were few differences among diagnostic groups that were not due primarily to age, sex. or IQ rather than diagnosis. The differences from normal subjects were generally in the expected direction for ADDH and ADDH + CD but were attributable largely to differences on a single underlying factor ofcognitive ability. The question therefore arises as to whether this is due to inadequate matching of patients and normal subjects or whether, as has been frequently posited, it reflects the fundamental deficit of ADDH . In the end, the acid test of the validity of these disorders must lie elsewhere-in differential outcome or response to treatment or both , Although the findings here and in other studies (Werry et al ., 1987) arc weak and hardly inexorable features of a given diagnosis. there are now sufficient data here and in other studies to encourage further investigation.

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