ABSTRACT
ObJective: To examine gender differences among children with disruptive behavior disorders (OBOs) from an ethnically
diverse school sample . Method: From 2,984 children , children with attention-deficitlhyperactivity disorder, combined type
(AOHO-C) (46 boys, 11 girls), oppositional defiant disorder (ODD) (59 boys, 35 girls), and co-occurring AOHO-C/OOO
(76 boys, 27 girls), diagnosed by teacher-rated DSM-/V symptoms, were compared with each other and with 254 con-
trols on teacher ratings of symptoms, social functioning , and Achenbach Teacher's Report Form scales. Results:
Children with AOHO-C/OOO received the poorest ratings on all variables. In "pure" groups, children with ODD were rated
as learning more , work ing harder, and being less inattentive than children with AOHO-C; only the ODD group showed
more internalizing problems than controls . For AOHO-C and ODD groups , ratings of aggression and some individual
symptoms were higher in boys than girls. Girls with ODD were rated as more appropriate and less inattentive, but
unhappier and more socially impaired than boys with ODD. Overall, girls received higher peer dislike scores than boys.
Conclusions: Comorb idity and gender issues affect the correlates of OBOs, with learning problems higher in AOHO-C.
internalizing problems associated only with ODD, and greatest impairment for AOHO-C/OOO groups . Despite having sim-
ilar or less behav ioral dysfunction, girls with OBOs may have more social problems than boys with DBOs. J. Am. Acad.
Child Ado/esc. Psychiatry. 1997,36(12):1706--1714 . Key Words: attention-deficitlhyperactivity disorder, oppositional
defiant disorder, gender differences , comorbidity.
Research into the disruptive behavior disorders (OBOs) quite high. The overlap between "hyperactivity" and
including attention-deficit/hyperactivity d isorder "aggression" in clinical samples has been estimated to
(AOHO), conduct disorder (CD), and oppositional be between 30% and 90% (Hinshaw. 1987). Somewhat
defiant disorder (ODD) in children has become increas- Jower estimates of co-occurrence are found in non-
ingly more responsive to issues that may enhance referred populations. though such studies still reveal
understanding of potential influences on their course sizable overlap. In a recent study of 7.231 schoolchil-
and outcome. Two such issues are co-occurrence among dren screened for the presence of disruptive behavior.
the OBOs and gender differences. ODD was present in 32% and CD in 12% of those
with AOHO (August et al. , 1996). Overall, co-
Co-Occurrence Among the DBDs
occurring diagnoses characterize at least a sizable sub-
Data from both epidemiological and clinical popu- group of children with OBOs.
lations suggests that co-occurrence among the OBOs is There is increasing recognition among researchers of
the critical importance of both documenting and elu-
Arupud May 22. /997.
From th~ Univmity ofTncas at Austin. cidating the effects of comorbidity among childhood
Portionsofthm data Irr presentedat th NIMH 5r.K Diffirrnm in ADHD disorders. The influential research published in the
Workshop. and Gaub and Carlson (l997a) prooid a related r~port w ing an
ov~rlapping data set. This research was partially supported by N IM H grant
1980s suggesting that many of the poor outcomes that
MH49827. awartkd to tb jim auth or. The study was made possibl through had previously been attributed to ADHO were actually
collaboration with th Hogg Foundation School of thr Future Projut. The linked to the co-occurrence of aggression and/or CD
autbon thank Lynda Knox. Woyn~ Holtzman . Stott Keir; and Pam Diamondfo r
their contributions, as 111 as Ann~ Anderson, Jory Martin. and Scott Davisfo r
(e.g., August et al., 1983; Schachar et al. 1981) alerted
their many houn ofdata mtry. researchers to the potential influence of comorbidity in
Reprint requests to Dr. Carlson. Departme nt of Psyrhology. M~us 33 0. disentangling causes and correlates of disorders and
Univmity ofTncas at Austin, Austin. TX 787/2.
08 90 -8567/97/3612-1706/$O.300 /0 1997 by the American Academy of their outcomes . There is growing consensus that chil-
Child and Adolescent Psychiat ry. dren with overlapping AOHO and conduct problems
are more disturbed than those with either single diag- differ in level of impairment on these variables. Since
nosis; the co-occurring group displays an earlier age of girls referred to clinics were as impaired as their male
onset and more severe aggressive, antisocial, academic, counterparts, the authors concluded that girls with
and social impairment (Hinshaw et al., 1993). ADHD seen in treatment settings represented the most
Unfortunately, research considering co-occurrence severely affected of the girls with ADHD.
among the DBDs remains the exception rather than .the Few studies have assessed qualitative gender differ-
rule. The failure to consider co-occurring disorders in ences in the behavioral correlates associated with
much of the DBD research seems at least partly attrib- ODD/CD. In a recent review. Goodman and Kohlsdorf
utable to practical reasons; examining groups of chil- (1994) conclude that limited data suggest that aggression
dren with and without comorbid conditions requires in girls is not characterized by the poor information-
large populations which may be inaccessible to individ- processingand moral-reasoning problems found in boys.
ual researchers. While the recent trend of documenting These authors note, however, that these and other
rates of co-occurring conditions in research populations diagnostic and behavioral correlates of conduct prob-
is laudable, few studies examine such conditions as lems in girls are greatly underresearched.
independent grouping variables.
Clinic Versus Nonreferred Populations
TABLE 1
Demographic Characteristics
ADHD-C ODD ADHD-C/ODD Control
(n = 57) (n = 94) (n = 103) (n = 254)
Age: mean (SD) 7.55 (1.86) 8.11 (1.86) 7.87 (1.72) 7.77 (1.72)
Percent male 81 63 74 71
SES: mean (SD) 23.36 (9.60) 22.06 (6.12) 23.10 (5.6) 23.11 (7.57)
Grade
K II 14 II 36
1 19 16 21 56
2 8 20 33 61
3 7 14 11 34
4 7 15 18 40
5 5 15 8 28
Ethniciry
Hispanic 42 54 76 174
African-American 10 30 20 60
Caucasian 4 8 6 18
Other I 2 3
Note: ADHD-C = attention-deficit/hyperactivity disorder. combined type: ODD = oppositional defiant disorder; SES =
socioeconomic status.
"Available for 44% of sample.
00
:to
- 0 ......
'g Liken scale questions regarding social functioning (from a
questionnaire developed by Dishion, 1990). The teacher estimated
~ '"
+
Z
0 -
N
l/"\ \0
N ~ the proportion of the child's peers that like/accept, dislike/reject,
and ignore him or her based on a Likert scale ranging from I (very
-S fewlless than 25%) to 5 (almost all/more than 75%).
~o ;R 0
l/"\
0 ;
00
:to 0
"ION
s=
0 RESULTS
~ + Z
I"-I"-'<l'
'<l' l/"\
-0
~
,
c, Prevalence
< ;R l/"\N"I 0
Uo
0
::r:: Table 2 provides overall prevalence rates of ADHD-
00
::r::O ~ C, ODD, and co-occurring ADHD-C/ODD in boys
e
'"
''"0"
~ +
Z
0 \01"-"1
I"-NO
- 5::,
0
::r::
and girls. As expected, higher rates of disorder were
found among boys than girls. Of the total sample of
~ 0 #. '<l'N"I
2,984 children, 9% (13% of boys, 5% of girls) met
15 0
0 ~ criteria for ODD and 5% (8% of boys, 3% of girls)
0 ...'" 0 as
0 O'\l/"\'<l' .~ met criteria for ADHD-C. Among children with
Q ~ Z l/"\ "I 0'\ e
'"
t:; ADHD-C, 62% of boys and 71 % of girls also met
5:: ;R N-- '"
.5
5:: 0
criteria for ODD, with lower rates of co-occurring
=S ~o -S
rJ ~:t
.5 ; ADHD-C in those with ODD diagnoses (37% of boys,
e
0 ~ z
0 1"-01"-
N-"I 5::0~ 's 36% of girls).
::r:: OO#. ~l'-O\
0
::r::O~
~
-0
Group Comparisons on TRF and Social
btl
s ;R
0 ~f'..8 0
<:
~
c,
Functioning Scales
~O
2... ::l::r:: 0
::l ::r::
N t:l c..~ Z 0 -
00 0
v-; \0
00
~ Two (gender) x four (diagnostic group) analyses of
WO - - N .5
..J' s' 0 ~ I variance were conducted on the 4 TRF adjustment
mlJ s
~-o
; ~O
U ;R
::l:t
0 "I - N oo#.
::r::o~
"10'\0'\
N
- 0
::r::
questions, 11 TRF behavior scales, and 3 social function-
ing questions. Significant group effects were explored in
ci c..~ 0 \0_1"- ~ ~ follow-up analyses using Tukey tests, set at p < .05, to
0 Z '<l' -l/"\
as
0 compare group means. It should be noted that for these
;R ~\I"'\O'\ .5 ~ and symptom-rating analyses (below), the homogeneity
5:: caO 0
-0
wo l(o~ '"
=S rSo "I -e- I"- 00#. 1"-\01"- =
:.0 of variance assumption was violated for a number of
~
"I "I "I
rJ OI"-l"-
N N
::r::o~
e0 the comparisons. Because our data allowed the exami-
0 ~ u
nation of rare and, therefore, understudied groups (i.e.,
5:: ;R
,,;
::r::
"''"0E
0 "I - N
~ wO
.....
ca' diagnosed females), we chose not to use less powerful
0 rS::r:: .-=5::, ~ nonparametric statistics (which also do not allow an
~
0 00 l/"\ "I
'e"
u Z '<l' - \0 oo~ '<l' "I - .~ examination of interaction effects). As a result, findings
o::r::e.... '<l' "I '<l'
.e ti
'"
l
c,
"o
~ ;R
0
- -
l/"\ 00 _
O~ tJ-o
'" ...0
...
'"~~'"
...c:w
should be interpreted cautiously and need to be rep-
licated in future research. Planned comparisons of gen-
rS::r:: 0 OONO ";:, = der differences were examined using t tests comparing
~ Z N-'<l'
N - "I
=~ '0 <E!
boys and girls within each diagnostic group on depen-
"O
U ;R 0 00 "I l/"\
C;o~
o::r::e....
O~
-\0\0
N
- <.l::
",-0
"'9ca
=
o 0=
'g :E
'"
TABLE 3
Group and Gender Comparisons on T RF and Social Ratings
Co-Oc curring FRatio FRatio FRatio
ADHD-C ODD ADHD-C/ODD Control for for for
Variables Boys Girls Boys Girls Boys Girls Boys Girls" Gender Diagnosis" Interaction
TRF scales
Hard Working 2.38 2.60 3.7 1 3.88 2.07 2.00 4.63 4.88 0.70 82.00"' 0.23
(1.30) (0.97) (1.62) (1.4 I) (1.09) (1.04) (1.59) (1.15) NC>O>A&C
Appropriate Behavior 2.09 2.70 2.33 2.88t 1.51 1.68 4.50 4.89t 7.71" 141.48 "" 0.40
(1.22) (1.34) (1.18) (1.27) (0.78) (0.80) (1.48) (1.28) NC>O&A>C
Learning 2.64 2.60 3.72 4.15 2.32 2.12 4.62 4.74 0.17 62.70" " 0.66
(1.26) (1.17) (1.52) (1.65) (1.34) (1.13) (1.53) (1.36) NC>O>A&C
Happy 3.52 3.50 3.36 2.65t 2.74 2.44 4.68 4.64 2.92 64.87*" 1.50
(1.39) (1.51) (1.21) (0.95) (1.26) (1.00) (1.40) (1.16) NC>A&O&C:
A>C
Withdrawn 2.27 2.30 3.41 2.82 4.68 5.42 1.80 1.75 0.01 26.06"" 0.76
(2.45) (2.50) (2.80) (2.46) (3.65) (2.95) (2.48) (2.54) C>A&O&NC:
O>NC
Somatic Complaints 0.84 2.00 0.54 0.62 1.89 2. 12 0.45 0.53 2.43 11.66"" 0.72
(1.51) (4.00) (1.12) (1.28) (3.24) (3.09) (1.50) (1.76) C>A&O&NC
Anxious/Depressed 3.59 4.00 4.98 6.38 8.68 10.19 2.60 3.00 2.65 39.27"" 0.41
(3.77) (4. 14) (4.57 ) (4.38) (6.63) (6.20) (3.55) (4.66) C>A&O&NC:
O>NC
Social Problems 4.84 4.40 4.67 6.38 t 9.13 10.62 1.52 1.50 2.73 120.22"" 2.05
(2.90) (3.83) (3,44) (3.90) (4.79) (5.40) (2.22) (2.89) C>O&A>NC
Thought Problems 0.86 0.33 0.98 0.55 1.99 1.91 0.15 0.18 1.73 24.53 "" 0.57
(1.27) (0.71) (1.8 I) (1.23) (2.95) (2.29) (0.53) (0.63) C>O&A>NC
Attention Problems 24.68 21.40 11.51 8.50 t 27.65 27.33 5.80 3.50t 8.97"' 298.14"" 0.81
(6.75) (10.27) (6.86) (6.92) (5.66) (5.06) (5.63) (4.68) C>A>O>NC
Delinquent Behavior 4.79 3.20 5.02 4.29 7.66 9.00 1.24 1.03 0.90 159.02*" 3.43"
(2.91) (3. 16) (2.99) (3.18) (3.44 ) (3.27) (1.75) (1.56) C>O&A>NC
Aggressive Behavior 19.33 IHOt 24.91 20.87t 34.06 35.35 4.43 3.17 8.79"' 353.94"" 3.04'
(7.98) (9.24) (8.53) (9.56) (8.65) (9.21) (6.05) (4.67) C>O>A>NC
Internalizing 6.36 8.00 8.37 9.09 14.36 16.62 4.81 5.11 1.8 1 37.59"" 0.35
(5.46) (7.80) (6.66) (6.14) (11.23) (10.00) (5.83) (7.31) C>O&A&NC:
O>NC
Externalizing 24.00 15.60t 30.00 24.00t 41.4 3 44.19 5.80 4.50 8.12" 382.64"" 4.46""
(9.02) (11.82) (10.31) (11.41) (10.46) (10.78) (7.37) (5.85) C>O>A>NC
Total Problem score 61.45 49.80 56.15 48.09 94.84 101.65 18.15 15.08 3.01 370.98"" 2.85"
(14.83) (28.46) (22.32) (21.10) (24.62) (20.5 I) (14.80) (16.3 I) C>A&O>NC
Social ratings
Peer Like 3.33 3.27 2.98 2.94 2.45 2.12 4.38 4.32 1.05 100.69"" 0.43
(1.17) (1.27) (1.04) (0.97) (1.15) (0.95) (0.87) (0.88) NC>A&O>C
Peer Dislike 1.91 2. 18 2.22 2.34 3.0 1 3.46 1.25 1.22 3.93" 111.01"' 1.54
(0.94) (0.98) (0.88) (0.97) (1.27) (1.14) (0.59) (0.54) C>O&A>NC
Peer Ignore 1.91 1.90 1.90 1.77 2.2 1 2.3 1 1.37 1.36 0.02 21.12"" 0.21
(0.98) (0.88) (0.79) (0.84) (1.23) (1.16) (0.79) (0.59) C>O>NC:
A>NC
Note: Values represent mean (SO). ADHD-C = attention-deficit/hyperactivity disorder, combined type: ODD = oppositional defiant dis-
order, TRF = Teacher's Report Form.
"Because of missing data, range of n's is as follows: ADHD-C boys = 36 to 45, ADHD-C girls = 10 to II , ODD boys = 55 to 58, ODD girls
= 30 to 34, co-occurring ADHD-C/ODD boys = 68 to 75, co-occurring ADHD-C/ODD girls = 23 to 26, control boys = 173 to 180, control
girls = 68 to 73.
bNC = nondiagnosed controls; 0 = ODD: A = ADHD-C; C = co-occurring ADHD-C/ODD.
"p < .05; ""p < .00 1; t gender means differ at p < .05.
1710 J. AM . ACAD . CHILD ADOL ESC. PSY CHIATRY, 36:12, DECEMBER 199 7
G END ER DIFFERENCES IN ADHD. ODD . AND ADHD/ODD
Simple effects of group were found for every variable. C, ODD, and control groups and higher scores for girls
On the TRF adjustment variables, the control group versus boys in the ADHD-C/ODD group.
was rated as functioning significantly better than the Planned comparisons to explore gender differences
three diagnostic groups. The ODD group had higher within group were conducted via t test analyses on each
rates of working hard and learning than AOHD-C or variable. In addition to the findings discussed above,
ADHD-C/ODD groups . The ADHD-C/ODD group significant results were found for only four variables.
was perceived as showing less appropriate behavior than For both ODD and control groups, girls were rated as
the ODD and ADHD-C groups and as being more showing more appropriate behavior and fewer attention
unhappy than the ADHD-C group. problems than boys. In addition, girls with ODD were
On the TRF Behavior Problem scales, the ADHD- rated as less happy and showing higher social problems
c/ODD group was rated as significantly more impaired than boys with ODD.
than the other three groups . Children with ODD
Group Comparisons on Symptom Patterns
received higher ratings on Withdrawn, Anxious/
Depressed, and Internalizing scales than controls; chil- To examine whether singly diagnosed and co-occur-
dren with ADHO-C did not differ from those with ring groups differed with regard to type of symptoms
ODD or controls on these scales. Children with displayed, 2 (diagnostic group) X 2 (gender) analyses of
ADHD showed higher rates of Attention Problems variance were used to compare the 0 to 3 symptom
than children with ODD; both were rated higher than ratings of the children with AOHD-C to those with co-
controls . Children with ODD and those with AOHD- occurring ADHD-C/ODD on the 18 DSM-IV ADHD
C did not differ on ratings of Social Problems, Thought symptoms. Analyses also compared children with ODD
Problems, or Total Problem score; both groups showed and co-occurring ADHD-C/ODD on the eight DSM-
higher ratings than controls. Children with ODD WOOD symptoms.
received higher Aggressive Behavior and Externalizing Comparisons between the ADHO-C and co-occurring
scores than children with ADHD-C, and both groups ADHD-C/ODD groups revealed no simple effects for
received higher ratings than controls. On Delinquent gender. Group differences were found for five symp-
Behavior, children with ADHD-C and those with toms, indicating greater severity in the co-occurring
ODD received higher ratings than controls (these latter ADHD-C/ODD group than the ADHD-C group on
three variables and Total Problem score were qualified symptom ratings of "fails to give close attention to
by gender by group interactions, discussed below). details or makes careless mistakes" (F[I,155] = 7.17,p =
For peer like and dislike ratings, the ADHD- .008), "talks excessively" (F[l, 155] = 4.28, P = .04),
C/ODD group was rated as most impaired and the con- "difficulty waiting turn" (F[I,155] = 11.29, P = .00l),
trol group as least impaired , with ADHD-C and ODD and "interrupts or intrudes on others" (F[I,155] =
groups not differing from each other. The ADHD- 15.96,p = .000). The other symptom, "does not seem to
C/ODD group was perceived as more ignored than listen," on which a significant group effect was obtained
ODD and control groups; ADHD-C and ODD groups (F[I,155] = 6.00,p = .015) was qualified by a trend for
were both rated as more ignored than controls. a group by gender interaction (F[I,155] = 3.72. P =
Significant gender x group interactions were found .0 55); in the ADHD-C group, boys received
for Delinquent Behavior, Aggressive Behavior. External- significantly higher ratings than girls (p = .017), whereas
izing, and Total Problem scores. To explore these inter- there was a trend in the ADHD-C/ODD group for
actions, t tests were used to compare boys and girls girls to receive higher ratings than boys (p = .060).
within each diagnostic group. For Aggressive and For comparisons between the ODD and co-
Externalizing behavior, girls received lower ratings than occurring ADHD-C/ODD groups, simple effects of
boys in the ADHD-C and the ODD groups; no gender gender were found for two symptoms, indicating lower
differences emerged in ADHD-C/ODO or control ratings for girls than for boys on "loses temper"
groups. Although no pairwise gender comparisons (F[l,l92] = 6.29, P = .013) and "argues with adults"
yielded significant t test findings for Delinquent (F[ 1,191] = 4.08, P = .000). Significant group effects
Behavior or Total Problem scores, the pattern of means were found for five symptoms, with the ADHD-
showed lower scores for girls versus boys in the ADHD- C/ODD group receiving more severe ratings than the
J. AM. ACAD . CHILD ADOL ESC. PSYCHIATRY. 36:12, DE C EMB ER 199 7 1711
CARLSON ET AL.
ODD group on "argues with adults" (F[I,191] = 15.18 received lower ratings than boys on the ODD symptoms
P = .000), "deliberately annoys people" (F[ 1, 192] = "loses temper" and "argues with adults," and there was a
36 .17, P = .000), and "touchy or easily annoyed" trend (p < .06) for girls to be rated higher than boys on
(F[I,191] = 4.16, P = .043). For the other two the ADHD symptom, "does not seem to listen."
symptoms that yielded simple group effects, "defies or Children in the "pure" ADHD-C and ODD groups
refuses to comply" (F[I,I92] = 20.81, P = .000) and showed interesting patterns of associated deficits.
"blames others for mistakes" (F[ 1,192] = 21.24, P = Relative to controls , both groups received significantly
.000), significant group by gender interactions indi- poorer ratings on adjustment variables, Social Problems,
cated that the boys with ODD were rated more severely Somatic Complaints, and Attention Problems. Children
than the girls with ODD (p < .02 and p < .03, with ADHD-C received poorer ratings on variables
respectively) but that there were no gender differences reflecting academic performance (inattention, learning,
in symptom severity in the ADHD-C/ODD group . working hard) than children with ODD (although chil-
dren with ODD were still more impaired than controls
on these variables). Relative to controls, children with
DISCUSSION
ODD received higher ratings on Anxious/Depressed
Consistent with previous research showing high over- and Withdrawn scales, whereas children with ADHD-
lap among DBDs, in the current sample about two C did not differ. Thus, "pure" ADHD-C children did
thirds of children with ADHD-C met criteria for co- not show abnormal levels of internalizing problems.
occurring ODD and about one third of children with August et al. (1996) also found in their school-based
ODD met criteria for co-occurring ADHD-C. These sample that mood and anxiety disorders occurred
results extend previous work by finding similar rates of infrequently with ADHD alone, but they were more
co-occurring ODD in ADHD-C girls (71%) and boys likely to be seen in combination with multiple DBDs.
(62%), and similar rates of co-occurring ADHD-C in High rates of comorbidity between ADHD-C and
ODD girls (36%) and boys (37%) . Also, as expected internalizing problems have been found in some studies
from previous research showing more severe correlates (Biederman et al., 1991). The role of co-occurring
and outcomes of children with comorbid ADHD-C ODD in influencing the presence of internalizing
and externalizing problems (Hinshaw et aI., 1993), the symptoms in children with ADHD-C warrants further
current results found that the co-occurring ADHD- investigation, particularly with clinical samples.
C/ODD group was rated as significantly more impaired Some gender differences emerged among the "pure"
than the other three groups on nearly every dependent ADHD-C and ODD groups, indicating relatively
variable. Thus, the co-occurring ADHD-C/ODD group poorer functioning among boys than girls. For both
was rated as showing significantly less appropriate beha- ADHD-C and ODD groups, aggression ratings were
vior and significantly higher Internalizing, External- significantly higher in boys than girls; this pattern is
izing, and Social Problems than either the "pure" consistent with those from the meta-analysis (Gaub and
ADHD-C or ODD groups. The co-occurring group Carlson , 1997b), suggesting lower rates of aggression in
also showed higher symptom ratings than their singly girls among nonreferred samples of children with
diagnosed counterparts for 5 of the 18 ADHD symp- ADHD-C. In addition, the girls with ODD were rated
toms and 5 of the 8 ODD symptoms. It is interesting as showing more appropriate behavior and fewer atten-
that the co-occurring group was rated more severely tion problems , but being more unhappy, than the boys
than the "pure" ADHD-C group on two of the three with ODD. Symptom ratings indicated that, among
impulsivity symptoms. Halperin er al. (1990) found children with ADHD-C, boys showed more severe
that children with mixed hyperactive/aggressive ratings on "does not seem to listen" and that, among
behavior were most impulsive on a continuous perform- children with ODD, boys showed more severe ratings
ance task; current results suggest that behavior ratings on "loses temper," "argues with adults, " "defies or
also reflect highest impulsivity among those ADHD-C refuses to comply," and "blames others." Thus, girls
children with co-occurring externalizing problems. No from the ADHD-C and ODD groups were somewhat
gender differences were found within the co-occurring less impaired than boys in their symptom severity and
ADHD-C/ODD group on TRF scales, though girls aggressive, inappropriate behavior.
Incons istent but suggestive evidence emerged that girls (t[42] = 2.17; p = .036). Despite the peer rejection
girls with DBDs have poorer social functioning than and difficulty modulating social behavior in accordance
boys. On the peer dislike variable, a main effect for with situational cues and role prescriptions seen in chil-
gender revealed higher dislike scores for girls than boys. dren with ADHD, they continue to seek out social
Although t tests comparing genders within each group relations with others (Whalen, 1989). Girls with ODD
revealed no significant differences, this suggests a gen- may be more socially aware of the subtle nuances of
eral trend across DBD groups for higher dislike ratings peer relationships and as a result be unhappier about
among girls. In addition, among children with ODD, their poor social status.
girls received higher ratings than boys on the TRF
Social Problems scale. Cohen (1989) investigated gen- Limitations
der differences in a clinically referred population, 69% One possible limitation of this study is the extent to
of whom had CD as their primary presenting problem . which the results can be generalized to the overall pop-
Cohen (1989) reported that on the "School" subscale of ulation, since the current sample was predominantly
the CBCL Social Competence scale, girls were rated by Hispanic and of low SES. Ethnic and cultural studies
their parents as significantly less competent than males. have revealed differences in social expectations for males
Although gender differences were not found for the and females across cultures. The Hispanic culture, in
total Social Competence scale, this parent rating of particular, has strict expectations for the behavior of
clinic-referred girls' difficulties in social relations at females, stressing the importance of their obedience and
school seems consistent with the observations made by compliance, while tending toward permissiveness with
teachers in our nonreferred sample. the behaviors exhibited by males (Paniagua, 1994).
The need to explore why girls with DBDs may be at Thus, externalizing behavior in girls may be particularly
higher social risk despite similar (or less severe) beha- incongruent with cultural expectations of behavior,
vioral patterns is apparent. It is possible that behaviors leading to greater social consequences in this sample.
associated with externalizing behavior problems are This possibility merits further exploration. Since a pre-
more congruent with social expectations generally held vious article based on this sample exploring DSM-1V
of boys. Because preadolescent boys and girls tend to subtype differences in ADHD (Gaub and Carlson,
segregate by gender (Maccoby, 1990), the behavior of 1997a) yielded results consistent with two other
girls with DBDs may be perceived as more disturbing, methodologically similar studies, however, ethniciry
thus leading to less social acceptance. Kavanagh and does not seem to pose a general limitation to the
Hops (1994) speculated that aggressive behavior in a generalizability of results.
preadolescent girl, exceeding normative criteria, would A second limitation is the exclusive use of teacher
stand out far more in contrast to same-sex peers than ratings on a symptom checklist both to assign diagnoses
would that in a boy. It is possible teachers may have and rate dependent variables . This is problematic
been susceptible to the same normative gender expecta- because neither the age of symptom onset nor informa-
tions and rated the girls as less socially competent. This tion regarding cross-situationaliry (i.e., parent reports)
conclusion would predict that the degree of social was obtained. However, prevalence estimates are con-
rejection of girls would vary across culture and ethniciry sistent with those reported in previous epidemiological
based on the socialized gender expectations of groups; reports, indicating that the criteria used to classifychil-
these areas require further exploration. dren were not overly inclusive. Furthermore, the levels
One hypothesis about the higher level of unhap- of deviant behavior demonstrated in diagnosed groups
piness among girls with ODD than boys with ODD is suggested that these children were experiencing diffi-
that their poorer peer relationships are especially dis- culties at a clinically significant rate across a range of
turbing to them. Girls tend to show greater sensitivity domains.
to potentially negatively influential peer relations and Finally, a caveat must be made regarding ODD
peer group disruption than boys (e.g., Gavin and classification. Although CD symptoms were not
Furman , 1989). It is interesting that ADHD girls (who assessed, some children included in the ODD group
did not differ from ADHD boys in ratings of hap- may have had CD diagnoses and thus would not have
piness) were rated as significantly happier than ODD received ODD diagnoses by DSM-IV criteria (in which
a diagnosis of ODD is precluded if CD is present). August GJ. Stewart MA. Holmes CS (1983). A four-year follow-up of hyper-
act ive bo ys with and without conduct d isorder. Br J Psy chiatry
Since virtually all children with CD qualify for ODD 143 :192-198
diagnoses (e.g., Frick et al., 1992), the "ODD" group in Berkson J (1946) . Limitations of the application of fourfold table analysis to
hospital data. Biometrics 2:47- 53
the current study may be more accurately described as a Biederm an J. Newcom J. Sprich SE (1991) . Comorbidiry of ADHD with
mixed CD/ODD group. This practice seems justifiable; conduct . depressive. anx iet y. and other di sorders. Am J Psychiatry
148:564-577
it is not inconsistent with the current body of literature, Cohen N (1989). Sex differen ces in child psych iatric outpatients: cogn itive,
diagnostic criteria are such that receiving a diagnosis of personal ity. and behavi oral characteristics. Child Psychiatry Hum Dru
CD in elementary school is relatively rare, and recent 20:113-121
D ish ion T (1990). Peer co nt ext of troublesome ch ild and adolescent
findings suggesting that ODD may be a milder variant behav ior. In : Understanding Troubled and Troubling Youth: Multip/~
or a developmental precursor to CD have led some to Prrspectiues, Leone PE. ed , Newbury Park. CA: Sage, pp 128-153
Frick PJ. Lahey BB. Loeber R, Srourharner-Loeber M. Christ MAG . Hanson
conclude that ODD and CD may not warrant diagnos- K (1992), Familial risk factors to oppositional defiant disorder and con-
tic separation (e.g., Achenbach, 1993; Schachar and duct disorder: parental psychopathology and maternal parenting. J
ConsultClin Psycho/60:49-55
Wachsmuth, 1990). Gaub M, Carlson CL (l997a) , Behavioral characteristics of DSMIVADHD
subtypes in a school-based population. J Abnorm Child Psycho! 25:
Clinical Implications 103-111
Gaub M. Carlson CL (l997b). Gender d ifferences in ADHD: a meta-anal-
These results illustrate that both gender and co- ysis and critical review. J Am AcadChildAdolesc Psychiatry 36 :1036-1045
occurrence among disorders have an impact on the G avin LA. Furman W (1989) . Age d ifferences in adolescent perceptions of
their peer groups. DeuPrychopathoI25:827-834
expression of DBDs in children. Specifically, both boys Goodman SH . Kohlsdorf G (1994) . The developmental psychopathology of
and girls with co-occurring ADHD-C/ODD may be conduct problems: gender issues. In: Progress in Experimental Pmonalisy
and Psychopathology Rmarch. Fowles DC. Surker P, Goodman SH . cds.
expected to show severe and pervasive dysfunction. The New York: Springer. pp 121-161
presence of ODD should alert clinicians to assess for Ha lperin JM , O 'Brien JD. Newcom JH er al. (1990). Validation of hyper-
active. aggressive. and mixed hyperactive/aggressive childhood disorders:
int ernalizing symptomatology, given the specific link a research note . J Child PsycholPrychiatry 31 :455-459
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activity and conduct problems/aggression in child psychopathology.
depressed behavior. Academic functioning should also Psycho/Bul/lOl :443- 463
be evaluated: although both ODD and ADHD-C chil- Hinshaw SP, Lahey BB. Hart EL (1993) . Issues of taxonomy and cornor -
dren were rated higher on learning problems than con- bidity in the development of conduct d isorder. DeuPrychopathoI5 :31-49
Kavanagh K. Hops H ( 1994). Good girls? Bad boys? Gender and devel-
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ADHD-C. Finally, although girls in the "pure" ADHD- Child Psychology, Vol 16. Ollendick T H. ed . New York: Plenum. pp
45-79
C and ODD groups may show milder symptom Maccoby EE (1990). Gender and relationships: a developmental account.
severity and less aggression, they appear to be at a parti- Am PsychoI45 :513-520
Paniagua FA (1994), Assessing and Treating Culturally Diverse Clients: A
cularly high risk for social dysfunction. It may be useful Practical Guid: Thousand Oaks . CA: Sage
to assess parents', teachers', and peers' views of girls with Pelham WE. Gnagy EM. Greenslade KE. Milich R (1992). Teacher ratings of
DSM/IIR symproms for the disruptive behavior disorders. J Am Acad
DBD, with cultural and familial expectations being a Child Adolesc Psychiatry 31 :2 10- 2 18
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