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Oppositional defiant disorder (ODD), the forerunner of alcohol dependence: A controlled study
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AJP-574; No. of Pages 5 Asian Journal of Psychiatry xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Oppositional defiant disorder (ODD), the forerunner of alcohol dependence: A controlled study Abhishek Ghosh *, Savita Malhotra, Debasish Basu Department of Psychiatry, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 September 2013 Received in revised form 2 February 2014 Accepted 8 March 2014 Available online xxx
There are common genetic, neurobiological and psycho-social substrates for oppositional defiant disorder (ODD) and substance dependence. ODD can be regarded as the mildest and earliest form of disruptive behavioral disorder and also represents the threshold of vulnerability for substance dependence. But it is a less researched area. The aim of this research was to study any possible association between childhood ODD and adult alcohol dependence. Data are presented from a non probability sample of 100 adult alcohol dependent subjects and equal number of biologically unrelated control subjects. Assessment was conducted by the instrument Semi-Structured Assessment for the Genetics of Alcoholism for both the assessment of ODD and alcohol dependence. The results of this study demonstrated significant association between childhood ODD and adult alcohol dependence. The association remained significant even after the exclusion of the possible confounding effects of the presence of conduct disorder and attention deficit hyperactivity disorder. Our study should encourage further research in this area and is expected to open up an opportunity for preventive research. ß 2014 Published by Elsevier B.V.
Keywords: Oppositional defiant disorder Alcohol dependence
1. Introduction Oppositional defiant disorder (ODD) is defined as a recurrent pattern of negativistic, defiant, disobedient and hostile behaviors leading to impairment of day to day activities. The behaviors characteristic of ODD can lead to difficulties in all realms of social, academic, or occupational functioning. The central feature is conflict with authority. Problem behaviors are most frequently seen in interactions with those in charge (DSM IV, 2000). It is different from conduct disorder (CD) by the fact that diagnosis of CD requires persistent violation of others’ rights and social norms. There are two distinct schools of thoughts conceptualizing both the disorders in terms of either dimensions or categories. ODD has milder severity and an earlier onset as compared to CD. It has a different developmental trajectory in a substantial proportion of subjects. Hence, a dimensional approach might be clinically more appealing, but for the purposes of research, categorical approach might be more meaningful. The National Co-morbidity Survey Replication, a retrospective study of 3199 adults using DSM-IV criteria reported a lifetime prevalence of ODD as 10.2% (Angold and Costello, 1996). Research
* Corresponding author. Tel.: +91 9815890436. E-mail addresses: [email protected] (A. Ghosh), [email protected] (S. Malhotra), [email protected] (D. Basu).
in ODD so far has been directed to study temperament, certain psychological traits and environmental factors to explain difficult behaviors in children. Research in cognitive processing has focused on how defiant children develop a hostile perspective based on early negative experiences. In comparison to other children, those with ODD are more vigilant for hostile cues from others and twice as likely to generate aggressive responses to problems (Coy et al., 2001). Additional research shows how they have other deficits in social problem solving, using less pertinent social information and generating fewer alternative reactions. Studies focusing on information processing outside of relationships have found that children with ODD have difficulty with response preservation and motivational inhibition tasks (van Goozen et al., 2004). Various environmental factors are correlated with increased risk for ODD. Many family attributes are correlated with higher rates of oppositional behaviors. These include poor parenting practices, parental discord, domestic violence, low family cohesion, child abuse, and parental mental disorder, especially substance abuse and antisocial personality disorder (Greene et al., 2002). Similar kind of studies to find out common temperamental or environmental substrates of substance use disorders has also been conducted. Temperament deviations have been shown to be associated with psychopathology and substance abuse (Reich et al., 1993). Temperamental trait deviations found in youth at high risk for alcohol dependence include reduced attention span (Schaffer et al., 1984); high impulsivity (Noll et al., 1992); negative affect
http://dx.doi.org/10.1016/j.ajp.2014.03.006 1876-2018/ß 2014 Published by Elsevier B.V.
Please cite this article in press as: Ghosh, A., et al., Oppositional defiant disorder (ODD), the forerunner of alcohol dependence: A controlled study. Asian J. Psychiatry (2014), http://dx.doi.org/10.1016/j.ajp.2014.03.006
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AJP-574; No. of Pages 5 2
A. Ghosh et al. / Asian Journal of Psychiatry xxx (2014) xxx–xxx
states, such as irritability, hostility (Brook et al., 1998); and emotional reactivity (Blackson, 1994). Parental divorce and marital conflict are associated with increased rates of offspring alcohol initiation heavier use of these substances (Needle et al., 1990) and greater risk of problem use (Fergusson et al., 1996; Hoffman and Johnson, 1998; Needle et al., 1990). Both these psychological and environmental factors are identical with that of the findings in ODD. Observing the commonality between ODD and alcohol dependence in relation to their underlying overlapping temperament and social factors, it would be worthwhile to study their association which is under evaluated till now. This is in contrast to the extensive literature on CD, which generally has indicated CD to be a common antecedent of substance use disorders (Manuzza et al., 1991; Boyle et al., 1992; Wilens et al., 1996; Moss and Lynch, 2001). The reason for limited research on ODD might well be explained by the fuzzy distinction between ODD and CD and questionable stability of ODD (Lahey et al., 1997; Loeber et al., 2002; Maughan et al., 2004). From the literature it is evident that ODD antedates CD. Our hypothesis is that ODD may also antedate substance use disorders including alcohol dependence. With its earlier onset and milder form, ODD carries a prospect of future preventive research (Angold and Costello, 2001). It can also lower the threshold of vulnerability for substance use disorders which may have its clinical and research implications. Hence with this background the aim of this research was to find out whether there is an association between ODD and alcohol dependence. In other words, whether it is possible to identify the high risk children at the earliest and with the lowest threshold of vulnerability for alcohol dependence in future? 2. Methods 2.1. Study samples Index group: Sample consisted of subjects recruited from the patient population attending the Outpatient and the Inpatient services of the Drug De-addiction and Treatment Centre (DDTC) of a tertiary care medical institute in Northern India. One hundred subjects with the diagnosis of alcohol dependence according to ICD10 (WHO, 1992) or DSM IV either in past or present and meeting the inclusion and exclusion criteria were selected as study subjects. The index group subjects were the ‘cases’ for this study. Inclusion criteria for index group (1) (2) (3) (4)
Fulfilling ICD10 criteria of alcohol dependence past/present. Either sex. Age < 50 years. Those who gave informed consent. Exclusion criteria for index group
(1) Childhood psychotic illness. (2) Subjects with other substance use/dependence (except tobacco). (3) History suggestive of mental retardation. (4) Any organic disease – Visual, hearing problem, pervasive development disorders and seizure disorder. Control group: This consisted of one hundred persons accompanying index group subjects hailing from similar socioeconomic background but who had never used alcohol in their lifetime. The control subjects were neither biologically related nor the spouse of the index group subjects. They were other male persons accompanying the subjects, like their neighbors, their
colleagues or someone from subject’s in-laws. They were also screened for childhood disruptive disorders and ADHD (childhood/adult) using the same instruments. The cohesive sociofamilial environment of India has perhaps enabled us to obtain such a unique control group. The control group subjects were the ‘controls’ for this study. 2.2. Instruments used Patient input sheet: Includes socio demographic profile and clinical diagnosis. Semi Structured Assessment for the Genetics of Alcoholism (SSAGAIV): The SSAGA-IV was designed to assess the physical, psychological, and social manifestations of alcohol abuse or dependence and other psychiatric disorders. It is a polydiagnostic instrument that assesses alcohol, nicotine, and marijuana and drug abuse/dependence. This scale was used to assess alcohol dependence in this study. This same instrument was also applied to diagnose CD and ODD in the study subjects during their childhood (Hesselbrock et al., 1999; Bucholz et al., 1994). Kiddie-Sads-Present and Lifetime Version (K-SADS-PL) Version 2.1 of October 1996: The K-SADS-PL is a semi-structured diagnostic interview designed to assess current and past episodes of psychopathology according to DSM-III-R and DSM-IV criteria. KSADS-PL was used to diagnose Childhood ADHD retrospectively. The K-SADS-PL is a semi-structured interview. The probes that are included in the instrument do not have to be recited verbatim. Rather, they are provided to illustrate ways to elicit the information necessary to score each item (Kaufman et al., 1997). 2.3. Procedure Ethical clearance was obtained from the institutional ethics committee. Subjects with a clinical diagnosis of alcohol dependence as per ICD10 after discussion with consultant psychiatrist and meeting the inclusion and exclusion criteria were approached for participation in the study. They were explained about the nature of the study and subjects willing to participate and providing informed consent were recruited. A cross-sectional examination was completed by applying SSAGA IV scale to reconfirm the diagnosis of alcohol dependence. The same instrument was also applied to diagnose childhood disruptive disorders (CD/ ODD) in the past. KSADS-PL was applied to diagnose ADHD in childhood. Taking into consideration the retrospective nature of the study and the potential for recall bias, whenever possible the information provided by the patient was corroborated with other informants like their elder sibs or parents. 2.4. Data analysis Socio demographic profiles of both the index and control groups were compared with the help of Chi square test or Fisher’s exact test wherever applicable. An association between alcohol dependence (AD) and oppositional defiant disorder (ODD) was studied using chi square test and the strength of association was measured by odds ratio (OR). For association, significance level was kept as p value < 0.05. Their association was reexamined by same statistical methods after excluding the role of possible confounders like conduct disorder (CD) and attention deficit hyperactive disorder (ADHD). 3. Results In the study groups i.e. in both the cases and the controls there were more number of married people; most of the people were clerk/shop owner or farmer and matriculate. Most of them came
Please cite this article in press as: Ghosh, A., et al., Oppositional defiant disorder (ODD), the forerunner of alcohol dependence: A controlled study. Asian J. Psychiatry (2014), http://dx.doi.org/10.1016/j.ajp.2014.03.006
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AJP-574; No. of Pages 5 A. Ghosh et al. / Asian Journal of Psychiatry xxx (2014) xxx–xxx Table 1 Comparison of socio-demographic profile between cases and controls. Chi square/ exact value (p value)
Cases (alcohol dependence); N = 100
Controls; N = 100
Number (%)
Number (%)
15 85(85)
11(11) 89(89)
0.7 (0.4)
17 48 27
21 51 21
1.3 (0.7)
8
7
Education Illiterate/literate Primary Middle Matriculate Inter/diploma Graduate Masters/professional
3 2 11 37 19 22 6
3 5 14 28 12 28 10
6.2 (0.4)
Religion Hindu Sikh/Islam
53(53) 47(47)
54 46
0.02 (0.9)
Type of family Nuclear Extended/joint
39(39) 61(61)
39(39) 61(61)
0
Residence Urban Rural
40 60
44(44) 56(56)
0.3 (0.6)
Variable
Marital status Single/divorced/separated Married Employment Professional/semiprofessional Clerical/shop owner/farmer Skilled/semiskilled/unskilled worker Unemployed/student
from extended family of rural areas; Hindus closely out numbered the Sikh. There were no significant difference in the socio demographic profile between the study group and the control as tested by Pearson’s Chi square test or Fisher’s exact test wherever applicable (Table 1). The mean age of the cases and the controls were 39.2 years (SD = 6.9) and 38.20 years (SD = 7.8) respectively. The difference was not significant as tested by independent sample ‘t’ test (t = 0.958; p > 0.05). So both these groups were matched as per as their age and socio-demography were concerned. Among the 100 alcohol dependent subjects studied, 35 were found to have a history positive for ODD in childhood. Study of the controls revealed 16 of them had ODD. Pearson Chi-Square test suggested that significantly larger number of alcohol dependent patients had a positive history of ODD in childhood compared to the control group (chi squared value = 9.5; p < 0.01). The odds ratio of having ODD in childhood in an alcohol dependent subject as compared to a control subject was 2.82 (95% CI = 1.4–5.5). Seventeen had conduct disorder (CD) amongst the subjects with alcohol dependence as opposed to 6 in the matched control group. The association was found to be statistically significant (chi squared value = 5.9; p < 0.02).
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Moreover, 14 of 35 in alcohol dependent and 5 of 16 in control subjects had history of ODD exclusively, i.e. without co-morbid CD and/or ADHD. When Chi-square test was administered to test an association of this group with alcohol dependence, it once again came out to be statistically significant (chi squared value = 4.7; p < 0.05). Strength of association as measured by OR was 3.1 (95% CI = 1.1–8.9) (Table 2). 4. Discussion The results of this study demonstrated that significantly more persons with alcohol dependence in adulthood had a history of ODD in their childhood. This association remained significant even when co-morbid CD and ADHD were excluded from the analysis. These findings indicate an independent and significant association of ODD and adult alcohol dependence. Disruptive Behavior Disorders (DBDs), which include both CD and ODD, appear to be among the most common co-morbid conditions in adolescents affected with an alcohol use disorder (AUD) (Cohen et al., 1993; Bukstein et al., 1989; Brown et al., 1996; Clark et al., 1997; Stowell and Estroff, 1992; Grillo et al., 1996). Prospective evidence suggests that, when controlling for other DBDs, Conduct Disorder is the most predictive of subsequent substance use disorders (Manuzza et al., 1991; Boyle et al., 1992; Wilens et al., 1996). In their research Moss and Lynch (2001) suggested that effects of ADHD and ODD on alcohol use disorder (AUD) were mediated only through CD. This result was in contrast to our finding. The term AUD used in that study was a broad one which included alcohol abuse and dependence. They also had used DSM III criteria to diagnose ODD or CD and there were subjects of both genders. These major methodological differences might explain the discrepancy in the results of the previous and the current research. Taking clue from this, we conjecture that ODD is associated with the most severe form of alcohol use (i.e., alcohol dependence) and that this association is especially true for male gender. Almost all literature described CD and its association with alcohol dependence and did not focus specifically on ODD. Speculations can be made to find out the reason for ODD being less researched. Critics of the DSM often point to ODD as an example of how psychiatry errs by defining normal behavior as pathological; critics argue that oppositional behavior is a reasonable part of the ‘terrible twos’ or teen-aged rebellion, not a mental illness. Some researchers noted that ODD symptoms are virtually synonymous with the content of personality traits called high negative emotionality and low agreeableness (e.g., Lahey and Waldman, 2003). Some thought ODD involving conflict between a child and one parent could be redefined as a relational disorder. Nevertheless, proponents of ODD as a disorder noted that it is a precursor not only to CD, but also to ADHD, depression, anxiety, bipolar disorder, and substance abuse (e.g., Speltz et al., 1999); implying that treating ODD provides a valuable opportunity to prevent many other disorders. Proponents also noted that a diagnosis of ODD serves many families as a ‘soft option,’ promoting
Table 2 Association between oppositional defiant disorder (ODD) and alcohol dependence (AD) (CD – conduct disorder; ADHD – attention deficit hyperactive disorder).
ODD including CD & ADHD ODD with out CD or ADHD CD Childhood ADHD
Alcohol dependence
N = 100 (subjects having disorder)
Chi-square value
p value
OR
AD Control AD Control AD Control AD Control
35 16 14 5 17 6 10 1
9.5
0.002
2.8
1.4–5.5
4.7
0.03
3.1
1.1–8.9
5.9
0.02
3.2
1.2–8.5
7.8
0.01
11
95% CI
1.4–87.6
Please cite this article in press as: Ghosh, A., et al., Oppositional defiant disorder (ODD), the forerunner of alcohol dependence: A controlled study. Asian J. Psychiatry (2014), http://dx.doi.org/10.1016/j.ajp.2014.03.006
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timely use of treatment services for a child, while avoiding a potentially more damaging diagnostic label. Influenced by the preventive aspect and potential of ODD research, especially its later association with other disorders, we decided to study this disorder separately and found a significant and independent association of ODD with adult alcohol dependence. Though current research did not take into account the factors mediating this association, investigators have emphasized mediation analysis as an important next step in research on the development of substance use disorders (Cicchetti and Luthar, 1999). Cross-sectional and longitudinal studies focusing primarily on conduct disorder suggest several personality, temperamental traits and social influences which mediate this association. Some of these factors are poor self-control and coping skills, deviant peer group affiliation, and increased life stress (Wills et al., 1998, 1999; Wills and Stoolmiller, 2002; Tarter, 2002; Giancola and Mezzich, 2003). Personality characteristics such as extraversion, reward dependence and risk taking have long been associated both concurrently and prospectively with substance use problems and conduct symptoms (Block and Block, 1988; de Wit and Richards, 2004). Though not studied so far these factors might explain the tentative association of ODD and alcohol dependence as well. In this study, sample was drawn from subjects attending a de addiction clinic for treatment rather than from the community. Thus the extent to which the findings of this study may be generalized is limited to the clinic attending, treatment seeking subjects, though this actually increased the homogeneity of the population studied. The basis of determination of the presence of ODD, CD, ADHD were essentially and necessarily retrospective in nature. Hence, factors such as recall bias, selective forgetting and retrospective falsification cannot be ruled out. To minimize the effect of these factors information put forth by the subjects was corroborated from available informants whenever feasible. Moreover this was a cross-sectional study where the comment on association can only be tentative. But our research hopefully will open up a possibility of future prospective studies. This association points toward a developmental trajectory of alcohol dependence. It starts long before the first sip of alcohol being consumed. Oppositional defiant disorder thus appears to be a harbinger of adult alcohol dependence. With this assumption, alcohol dependence might be amenable to preventive strategies targeted at young children and adolescents suffering from ODD, which is much milder in severity and also appears early in life. Hence, early meaningful interventions can have the potential to prevent future CD and alcohol dependence thereafter.
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Please cite this article in press as: Ghosh, A., et al., Oppositional defiant disorder (ODD), the forerunner of alcohol dependence: A controlled study. Asian J. Psychiatry (2014), http://dx.doi.org/10.1016/j.ajp.2014.03.006
AJP-574; No. of Pages 5 Asian Journal of Psychiatry xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Oppositional defiant disorder (ODD), the forerunner of alcohol dependence: A controlled study Abhishek Ghosh *, Savita Malhotra, Debasish Basu Department of Psychiatry, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 September 2013 Received in revised form 2 February 2014 Accepted 8 March 2014 Available online xxx
There are common genetic, neurobiological and psycho-social substrates for oppositional defiant disorder (ODD) and substance dependence. ODD can be regarded as the mildest and earliest form of disruptive behavioral disorder and also represents the threshold of vulnerability for substance dependence. But it is a less researched area. The aim of this research was to study any possible association between childhood ODD and adult alcohol dependence. Data are presented from a non probability sample of 100 adult alcohol dependent subjects and equal number of biologically unrelated control subjects. Assessment was conducted by the instrument Semi-Structured Assessment for the Genetics of Alcoholism for both the assessment of ODD and alcohol dependence. The results of this study demonstrated significant association between childhood ODD and adult alcohol dependence. The association remained significant even after the exclusion of the possible confounding effects of the presence of conduct disorder and attention deficit hyperactivity disorder. Our study should encourage further research in this area and is expected to open up an opportunity for preventive research. ß 2014 Published by Elsevier B.V.
Keywords: Oppositional defiant disorder Alcohol dependence
1. Introduction Oppositional defiant disorder (ODD) is defined as a recurrent pattern of negativistic, defiant, disobedient and hostile behaviors leading to impairment of day to day activities. The behaviors characteristic of ODD can lead to difficulties in all realms of social, academic, or occupational functioning. The central feature is conflict with authority. Problem behaviors are most frequently seen in interactions with those in charge (DSM IV, 2000). It is different from conduct disorder (CD) by the fact that diagnosis of CD requires persistent violation of others’ rights and social norms. There are two distinct schools of thoughts conceptualizing both the disorders in terms of either dimensions or categories. ODD has milder severity and an earlier onset as compared to CD. It has a different developmental trajectory in a substantial proportion of subjects. Hence, a dimensional approach might be clinically more appealing, but for the purposes of research, categorical approach might be more meaningful. The National Co-morbidity Survey Replication, a retrospective study of 3199 adults using DSM-IV criteria reported a lifetime prevalence of ODD as 10.2% (Angold and Costello, 1996). Research
* Corresponding author. Tel.: +91 9815890436. E-mail addresses: [email protected] (A. Ghosh), [email protected] (S. Malhotra), [email protected] (D. Basu).
in ODD so far has been directed to study temperament, certain psychological traits and environmental factors to explain difficult behaviors in children. Research in cognitive processing has focused on how defiant children develop a hostile perspective based on early negative experiences. In comparison to other children, those with ODD are more vigilant for hostile cues from others and twice as likely to generate aggressive responses to problems (Coy et al., 2001). Additional research shows how they have other deficits in social problem solving, using less pertinent social information and generating fewer alternative reactions. Studies focusing on information processing outside of relationships have found that children with ODD have difficulty with response preservation and motivational inhibition tasks (van Goozen et al., 2004). Various environmental factors are correlated with increased risk for ODD. Many family attributes are correlated with higher rates of oppositional behaviors. These include poor parenting practices, parental discord, domestic violence, low family cohesion, child abuse, and parental mental disorder, especially substance abuse and antisocial personality disorder (Greene et al., 2002). Similar kind of studies to find out common temperamental or environmental substrates of substance use disorders has also been conducted. Temperament deviations have been shown to be associated with psychopathology and substance abuse (Reich et al., 1993). Temperamental trait deviations found in youth at high risk for alcohol dependence include reduced attention span (Schaffer et al., 1984); high impulsivity (Noll et al., 1992); negative affect
http://dx.doi.org/10.1016/j.ajp.2014.03.006 1876-2018/ß 2014 Published by Elsevier B.V.
Please cite this article in press as: Ghosh, A., et al., Oppositional defiant disorder (ODD), the forerunner of alcohol dependence: A controlled study. Asian J. Psychiatry (2014), http://dx.doi.org/10.1016/j.ajp.2014.03.006
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states, such as irritability, hostility (Brook et al., 1998); and emotional reactivity (Blackson, 1994). Parental divorce and marital conflict are associated with increased rates of offspring alcohol initiation heavier use of these substances (Needle et al., 1990) and greater risk of problem use (Fergusson et al., 1996; Hoffman and Johnson, 1998; Needle et al., 1990). Both these psychological and environmental factors are identical with that of the findings in ODD. Observing the commonality between ODD and alcohol dependence in relation to their underlying overlapping temperament and social factors, it would be worthwhile to study their association which is under evaluated till now. This is in contrast to the extensive literature on CD, which generally has indicated CD to be a common antecedent of substance use disorders (Manuzza et al., 1991; Boyle et al., 1992; Wilens et al., 1996; Moss and Lynch, 2001). The reason for limited research on ODD might well be explained by the fuzzy distinction between ODD and CD and questionable stability of ODD (Lahey et al., 1997; Loeber et al., 2002; Maughan et al., 2004). From the literature it is evident that ODD antedates CD. Our hypothesis is that ODD may also antedate substance use disorders including alcohol dependence. With its earlier onset and milder form, ODD carries a prospect of future preventive research (Angold and Costello, 2001). It can also lower the threshold of vulnerability for substance use disorders which may have its clinical and research implications. Hence with this background the aim of this research was to find out whether there is an association between ODD and alcohol dependence. In other words, whether it is possible to identify the high risk children at the earliest and with the lowest threshold of vulnerability for alcohol dependence in future? 2. Methods 2.1. Study samples Index group: Sample consisted of subjects recruited from the patient population attending the Outpatient and the Inpatient services of the Drug De-addiction and Treatment Centre (DDTC) of a tertiary care medical institute in Northern India. One hundred subjects with the diagnosis of alcohol dependence according to ICD10 (WHO, 1992) or DSM IV either in past or present and meeting the inclusion and exclusion criteria were selected as study subjects. The index group subjects were the ‘cases’ for this study. Inclusion criteria for index group (1) (2) (3) (4)
Fulfilling ICD10 criteria of alcohol dependence past/present. Either sex. Age < 50 years. Those who gave informed consent. Exclusion criteria for index group
(1) Childhood psychotic illness. (2) Subjects with other substance use/dependence (except tobacco). (3) History suggestive of mental retardation. (4) Any organic disease – Visual, hearing problem, pervasive development disorders and seizure disorder. Control group: This consisted of one hundred persons accompanying index group subjects hailing from similar socioeconomic background but who had never used alcohol in their lifetime. The control subjects were neither biologically related nor the spouse of the index group subjects. They were other male persons accompanying the subjects, like their neighbors, their
colleagues or someone from subject’s in-laws. They were also screened for childhood disruptive disorders and ADHD (childhood/adult) using the same instruments. The cohesive sociofamilial environment of India has perhaps enabled us to obtain such a unique control group. The control group subjects were the ‘controls’ for this study. 2.2. Instruments used Patient input sheet: Includes socio demographic profile and clinical diagnosis. Semi Structured Assessment for the Genetics of Alcoholism (SSAGAIV): The SSAGA-IV was designed to assess the physical, psychological, and social manifestations of alcohol abuse or dependence and other psychiatric disorders. It is a polydiagnostic instrument that assesses alcohol, nicotine, and marijuana and drug abuse/dependence. This scale was used to assess alcohol dependence in this study. This same instrument was also applied to diagnose CD and ODD in the study subjects during their childhood (Hesselbrock et al., 1999; Bucholz et al., 1994). Kiddie-Sads-Present and Lifetime Version (K-SADS-PL) Version 2.1 of October 1996: The K-SADS-PL is a semi-structured diagnostic interview designed to assess current and past episodes of psychopathology according to DSM-III-R and DSM-IV criteria. KSADS-PL was used to diagnose Childhood ADHD retrospectively. The K-SADS-PL is a semi-structured interview. The probes that are included in the instrument do not have to be recited verbatim. Rather, they are provided to illustrate ways to elicit the information necessary to score each item (Kaufman et al., 1997). 2.3. Procedure Ethical clearance was obtained from the institutional ethics committee. Subjects with a clinical diagnosis of alcohol dependence as per ICD10 after discussion with consultant psychiatrist and meeting the inclusion and exclusion criteria were approached for participation in the study. They were explained about the nature of the study and subjects willing to participate and providing informed consent were recruited. A cross-sectional examination was completed by applying SSAGA IV scale to reconfirm the diagnosis of alcohol dependence. The same instrument was also applied to diagnose childhood disruptive disorders (CD/ ODD) in the past. KSADS-PL was applied to diagnose ADHD in childhood. Taking into consideration the retrospective nature of the study and the potential for recall bias, whenever possible the information provided by the patient was corroborated with other informants like their elder sibs or parents. 2.4. Data analysis Socio demographic profiles of both the index and control groups were compared with the help of Chi square test or Fisher’s exact test wherever applicable. An association between alcohol dependence (AD) and oppositional defiant disorder (ODD) was studied using chi square test and the strength of association was measured by odds ratio (OR). For association, significance level was kept as p value < 0.05. Their association was reexamined by same statistical methods after excluding the role of possible confounders like conduct disorder (CD) and attention deficit hyperactive disorder (ADHD). 3. Results In the study groups i.e. in both the cases and the controls there were more number of married people; most of the people were clerk/shop owner or farmer and matriculate. Most of them came
Please cite this article in press as: Ghosh, A., et al., Oppositional defiant disorder (ODD), the forerunner of alcohol dependence: A controlled study. Asian J. Psychiatry (2014), http://dx.doi.org/10.1016/j.ajp.2014.03.006
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AJP-574; No. of Pages 5 A. Ghosh et al. / Asian Journal of Psychiatry xxx (2014) xxx–xxx Table 1 Comparison of socio-demographic profile between cases and controls. Chi square/ exact value (p value)
Cases (alcohol dependence); N = 100
Controls; N = 100
Number (%)
Number (%)
15 85(85)
11(11) 89(89)
0.7 (0.4)
17 48 27
21 51 21
1.3 (0.7)
8
7
Education Illiterate/literate Primary Middle Matriculate Inter/diploma Graduate Masters/professional
3 2 11 37 19 22 6
3 5 14 28 12 28 10
6.2 (0.4)
Religion Hindu Sikh/Islam
53(53) 47(47)
54 46
0.02 (0.9)
Type of family Nuclear Extended/joint
39(39) 61(61)
39(39) 61(61)
0
Residence Urban Rural
40 60
44(44) 56(56)
0.3 (0.6)
Variable
Marital status Single/divorced/separated Married Employment Professional/semiprofessional Clerical/shop owner/farmer Skilled/semiskilled/unskilled worker Unemployed/student
from extended family of rural areas; Hindus closely out numbered the Sikh. There were no significant difference in the socio demographic profile between the study group and the control as tested by Pearson’s Chi square test or Fisher’s exact test wherever applicable (Table 1). The mean age of the cases and the controls were 39.2 years (SD = 6.9) and 38.20 years (SD = 7.8) respectively. The difference was not significant as tested by independent sample ‘t’ test (t = 0.958; p > 0.05). So both these groups were matched as per as their age and socio-demography were concerned. Among the 100 alcohol dependent subjects studied, 35 were found to have a history positive for ODD in childhood. Study of the controls revealed 16 of them had ODD. Pearson Chi-Square test suggested that significantly larger number of alcohol dependent patients had a positive history of ODD in childhood compared to the control group (chi squared value = 9.5; p < 0.01). The odds ratio of having ODD in childhood in an alcohol dependent subject as compared to a control subject was 2.82 (95% CI = 1.4–5.5). Seventeen had conduct disorder (CD) amongst the subjects with alcohol dependence as opposed to 6 in the matched control group. The association was found to be statistically significant (chi squared value = 5.9; p < 0.02).
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Moreover, 14 of 35 in alcohol dependent and 5 of 16 in control subjects had history of ODD exclusively, i.e. without co-morbid CD and/or ADHD. When Chi-square test was administered to test an association of this group with alcohol dependence, it once again came out to be statistically significant (chi squared value = 4.7; p < 0.05). Strength of association as measured by OR was 3.1 (95% CI = 1.1–8.9) (Table 2). 4. Discussion The results of this study demonstrated that significantly more persons with alcohol dependence in adulthood had a history of ODD in their childhood. This association remained significant even when co-morbid CD and ADHD were excluded from the analysis. These findings indicate an independent and significant association of ODD and adult alcohol dependence. Disruptive Behavior Disorders (DBDs), which include both CD and ODD, appear to be among the most common co-morbid conditions in adolescents affected with an alcohol use disorder (AUD) (Cohen et al., 1993; Bukstein et al., 1989; Brown et al., 1996; Clark et al., 1997; Stowell and Estroff, 1992; Grillo et al., 1996). Prospective evidence suggests that, when controlling for other DBDs, Conduct Disorder is the most predictive of subsequent substance use disorders (Manuzza et al., 1991; Boyle et al., 1992; Wilens et al., 1996). In their research Moss and Lynch (2001) suggested that effects of ADHD and ODD on alcohol use disorder (AUD) were mediated only through CD. This result was in contrast to our finding. The term AUD used in that study was a broad one which included alcohol abuse and dependence. They also had used DSM III criteria to diagnose ODD or CD and there were subjects of both genders. These major methodological differences might explain the discrepancy in the results of the previous and the current research. Taking clue from this, we conjecture that ODD is associated with the most severe form of alcohol use (i.e., alcohol dependence) and that this association is especially true for male gender. Almost all literature described CD and its association with alcohol dependence and did not focus specifically on ODD. Speculations can be made to find out the reason for ODD being less researched. Critics of the DSM often point to ODD as an example of how psychiatry errs by defining normal behavior as pathological; critics argue that oppositional behavior is a reasonable part of the ‘terrible twos’ or teen-aged rebellion, not a mental illness. Some researchers noted that ODD symptoms are virtually synonymous with the content of personality traits called high negative emotionality and low agreeableness (e.g., Lahey and Waldman, 2003). Some thought ODD involving conflict between a child and one parent could be redefined as a relational disorder. Nevertheless, proponents of ODD as a disorder noted that it is a precursor not only to CD, but also to ADHD, depression, anxiety, bipolar disorder, and substance abuse (e.g., Speltz et al., 1999); implying that treating ODD provides a valuable opportunity to prevent many other disorders. Proponents also noted that a diagnosis of ODD serves many families as a ‘soft option,’ promoting
Table 2 Association between oppositional defiant disorder (ODD) and alcohol dependence (AD) (CD – conduct disorder; ADHD – attention deficit hyperactive disorder).
ODD including CD & ADHD ODD with out CD or ADHD CD Childhood ADHD
Alcohol dependence
N = 100 (subjects having disorder)
Chi-square value
p value
OR
AD Control AD Control AD Control AD Control
35 16 14 5 17 6 10 1
9.5
0.002
2.8
1.4–5.5
4.7
0.03
3.1
1.1–8.9
5.9
0.02
3.2
1.2–8.5
7.8
0.01
11
95% CI
1.4–87.6
Please cite this article in press as: Ghosh, A., et al., Oppositional defiant disorder (ODD), the forerunner of alcohol dependence: A controlled study. Asian J. Psychiatry (2014), http://dx.doi.org/10.1016/j.ajp.2014.03.006
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AJP-574; No. of Pages 5 A. Ghosh et al. / Asian Journal of Psychiatry xxx (2014) xxx–xxx
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timely use of treatment services for a child, while avoiding a potentially more damaging diagnostic label. Influenced by the preventive aspect and potential of ODD research, especially its later association with other disorders, we decided to study this disorder separately and found a significant and independent association of ODD with adult alcohol dependence. Though current research did not take into account the factors mediating this association, investigators have emphasized mediation analysis as an important next step in research on the development of substance use disorders (Cicchetti and Luthar, 1999). Cross-sectional and longitudinal studies focusing primarily on conduct disorder suggest several personality, temperamental traits and social influences which mediate this association. Some of these factors are poor self-control and coping skills, deviant peer group affiliation, and increased life stress (Wills et al., 1998, 1999; Wills and Stoolmiller, 2002; Tarter, 2002; Giancola and Mezzich, 2003). Personality characteristics such as extraversion, reward dependence and risk taking have long been associated both concurrently and prospectively with substance use problems and conduct symptoms (Block and Block, 1988; de Wit and Richards, 2004). Though not studied so far these factors might explain the tentative association of ODD and alcohol dependence as well. In this study, sample was drawn from subjects attending a de addiction clinic for treatment rather than from the community. Thus the extent to which the findings of this study may be generalized is limited to the clinic attending, treatment seeking subjects, though this actually increased the homogeneity of the population studied. The basis of determination of the presence of ODD, CD, ADHD were essentially and necessarily retrospective in nature. Hence, factors such as recall bias, selective forgetting and retrospective falsification cannot be ruled out. To minimize the effect of these factors information put forth by the subjects was corroborated from available informants whenever feasible. Moreover this was a cross-sectional study where the comment on association can only be tentative. But our research hopefully will open up a possibility of future prospective studies. This association points toward a developmental trajectory of alcohol dependence. It starts long before the first sip of alcohol being consumed. Oppositional defiant disorder thus appears to be a harbinger of adult alcohol dependence. With this assumption, alcohol dependence might be amenable to preventive strategies targeted at young children and adolescents suffering from ODD, which is much milder in severity and also appears early in life. Hence, early meaningful interventions can have the potential to prevent future CD and alcohol dependence thereafter.
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Please cite this article in press as: Ghosh, A., et al., Oppositional defiant disorder (ODD), the forerunner of alcohol dependence: A controlled study. Asian J. Psychiatry (2014), http://dx.doi.org/10.1016/j.ajp.2014.03.006