Download Oppositional Defiant Disorder—Gender Differences in Co

J Abnorm Child Psychol (2011) 39:577–587
DOI 10.1007/s10802-011-9486-6
Oppositional Defiant Disorder—Gender Differences
in Co-occurring Symptoms of Mental Health Problems
in a General Population of Children
Linda Helen Munkvold & Astri Johansen Lundervold &
Terje Manger
Published online: 18 January 2011
# Springer Science+Business Media, LLC 2011
Abstract Informant- and gender-specific characteristics of
Oppositional Defiant Disorder (ODD) and how these might
relate to patterns of comorbidity need to be further clarified.
We collected data from 7,007 children (aged 7–9) who
participated in the Bergen Child Study (BCS), an ongoing
population-based study of children’s development and
mental health. A questionnaire containing the DSM-IV
behavioral descriptions of ODD was distributed to parents
and teachers. Co-occurring symptoms of mental health
problems were measured by the Strengths and Difficulties
Questionnaire (SDQ). The boys (n=122) and girls (n=41)
with symptomatic ODD had an increased risk of cooccurring emotional symptoms, hyperactivity or inattention
and peer problems, as compared to their peers without
symptomatic ODD. The impact of symptomatic ODD was
higher for boys than girls in teacher reported SDQ ratings,
except for emotional symptoms. There were no significant
interaction effects of gender in parent SDQ ratings. Our
results are contrary to the gender paradox hypothesis,
which states that co-occurring symptoms of mental health
problems are more frequent among girls with ODD as
compared to boys with ODD.
L. H. Munkvold (*) : A. J. Lundervold : T. Manger
Faculty of Psychology, University of Bergen,
5015 Bergen, Norway
e-mail: [email protected]
L. H. Munkvold
Division of psychiatry, Haukeland University Hospital,
5021 Bergen, Norway
L. H. Munkvold : A. J. Lundervold
Centre for Child and Adolescent Mental Health,
University of Bergen,
5020 Bergen, Norway
Keywords Oppositional defiant disorder . DSM-IV . SDQ .
Gender differences
Abbreviations
BCS Bergen Child Study
ODD Oppositional Defiant Disorder
SDQ Strengths and Difficulties Questionnaire
Oppositional Defiant Disorder (ODD) reflects a pattern of
negativistic, defiant, disobedient and hostile behavior towards
authority figures that lasts for at least 6 months, and is severe
enough to affect the child’s functioning (APA 2000). ODD is
one of the most prevalent and resource-demanding mental
health problems among children and adolescents (Loeber et
al. 2000). The prevalence rates range from 2.6% to 15.6% in
community samples, and from 28% to 65% in clinical
samples (Boylan et al. 2007). Although the developmental
progression from ODD to Conduct Disorder (CD) is
established in the DSM-IV criteria and in research, most
children with ODD do not go on to develop CD (Loeber et
al. 2000; Rowe et al. 2002), and a large proportion of
children with CD do not meet the diagnostic criteria for ODD
(Lahey et al. 2000a; Maughan et al. 2004; Rowe et al. 2002).
According to the DSM-IV, ODD cannot be diagnosed in
the presence of Conduct Disorder (CD). Due to this
hierarchical rule, ODD and CD are often combined in
empirical studies, or ODD is excluded altogether. Consequently, ODD has rarely been studied as an independent
disorder (Angold and Costello 2001; Angold et al. 1999).
Little is known, therefore, about the associations between
ODD and other mental disorders independent of comorbidity with CD. One of the few studies available, which
investigated comorbidity findings for the two diagnoses
separately (Maughan et al. 2004; Simonoff et al. 1997),
578
found ODD to be associated with more comorbidity as
compared to CD, and to involve a broader spectrum of
other disorders. Other studies have shown that ODD and
CD are associated with differential risk factors and with
distinct age-profiles (Dick et al. 2005; Frick et al. 1994;
Maughan et al. 2004). Whether ODD should be conceptualized as a milder version of CD, or whether it is a
complicating condition occurring only in the context of preexisting comorbid disorders, is still largely unknown (Nock
et al. 2007). Research on the distinct features of ODD may
have been constrained by the DSM-IV prohibition against
diagnosing ODD in the presence of CD (Green et al. 2002).
Studies of ODD as an independent clinical construct are
thus warranted, and the possible overlap with CD may be
disregarded for this purpose.
Disruptive, antisocial behavior such as ODD has
historically been considered a male problem (Loeber et al.
2000), and factors that account for the development of
ODD in girls are only partly understood (Hipwell et al.
2002; Messer et al. 2006). Population-based studies suggest
that ODD is more common among preadolescent boys than
girls (Boylan et al. 2007; Lahey et al. 1999; Munkvold et
al. 2009). At the same time, data on gender differences in
the prevalence of ODD generally are much more inconsistent than for CD (Loeber et al. 2000). Certain methodological explanations, such as biased sampling, have been
offered for this (Waschbusch and King 2006). The ratio of
boys to girls for ODD is commonly much higher in clinical
samples than in population-based samples (Rutter et al.
2003), and the ODD/CD literature contains a mixture of
both sample-types. Biased diagnostic criteria provides
another common explanation, as the DSM-criteria for
ODD and CD primarily are based on studies of preadolescent boys (Lahey et al. 1994). Their suitability for
diagnosing ODD/CD in girls has thus been questioned by
several authors (Crick and Zahn-Waxler 2003; Hartung and
Widiger 1998; Zoccolillo 1993).
One important, unresolved issue in the area of ODD and
gender differences is whether boys and girls with ODD differ
in their patterns of comorbidity (Maughan et al. 2004).
Certain studies have shown that although the prevalence of
antisocial behavior is lower in females than in males, the risk
of comorbid conditions such as emotional problems is higher
among females. This phenomenon is commonly referred to
as the “gender paradox of comorbidity” in the ODD/CD
research literature (Eme 1992; Loeber and Keenan 1994;
Zahn-Waxler et al. 1995). Eme (1992) suggests that this is
related to the “selective female affliction” phenomenon,
whereby the prevalence of childhood psychiatric disorders is
lower among girls than boys, but when girls do have
disorders, they are more severely afflicted. Within male peer
groups conflicts and physical aggression such as hitting,
kicking and attacking the property of others is quite normal
J Abnorm Child Psychol (2011) 39:577–587
even at an early age (Maccoby 2004). Overt aggression is
relatively uncommon among young girls, and symptoms of
ODD/CD in girls could thus be reflective of more severe
dysregulation and impairment.
In support of the “gender paradox hypothesis”, more
recent population-based studies have demonstrated lower
prevalence of ODD/CD, but stronger developmental links
between ODD, ADHD, and CD, among girls aged 5–16 as
compared to boys (Costello et al. 2003; Maughan et al.
2004). One study of children and adolescents aged 9–16
found the association between ADHD and CD to be
explained by the presence of ODD in boys, whereas ADHD
alone was considered a significant predictor of CD in girls,
even when controlling for comorbid ODD (Lahey et al.
2000a). A longitudinal study of Dutch children aged 4–18
found that the proportion of boys following a deviant CD
trajectory was twice as high as for girls. Interestingly,
engagement in this deviant trajectory was predicted by
ODD and ADHD in girls, but only by ODD in boys (van
Lier et al. 2007). A recent study of inpatient adolescents in
Finland found no gender differences in the prevalence of
ODD/CD symptoms, but girls with ODD/CD had higher
rates of comorbid mental health problems as compared to
boys (Lehto-Salo et al. 2009). Results from the Great Smoky
Mountains Study found ODD to be highly predictive of CD
only in boys, whereas ODD in girls predicted subsequent
depression and anxiety (Rowe et al. 2002). The key role of
ODD in the development of internalizing problems in girls
has been confirmed in other studies (Burke et al. 2010).
Some studies have not reported higher rates of co-occurring
mental health problems in girls with ODD/CD as compared
to boys (see Loeber et al. 2000, for a review). Although the
data on this issue are somewhat inconsistent, there is ample
evidence that gender is a crucial parameter in the development of ODD and its comorbid conditions.
One possible basis for the inconsistent findings
concerning comorbidity and gender differences in ODD
has to do with underlying informant discrepancies
(Maughan et al. 2004). Assessment of mental health
problems in children commonly relies on information
provided by multiple informants such as parents and
teachers. However, the consistency in multiple-source
information is at best moderate (Achenbach et al. 1987;
Cai et al. 2004). As a consequence, the estimated
prevalence of ODD/CD varies between 1.6% and 10.2%
in community samples (Munkvold et al. 2009; Offord et al.
1996), and between 9.7% and 23% in clinical samples
(MacLeod et al. 1999). Much of this variation depends on
whether parents, teachers, children, or clinicians are used as
separate or combined informants. Previous research has
demonstrated that ODD/CD identified by parents versus
teachers is associated with different correlates and patterns
of comorbidity (Drabick et al. 2007; Munkvold et al. 2009;
J Abnorm Child Psychol (2011) 39:577–587
Offord et al. 1996). Moreover, informant discrepancy is a
challenge in itself in the assessment of potential comorbid
conditions such as ADHD (Gomez 2007), mood disorders,
and anxiety (Youngstrom et al. 2000). Unfortunately, very
few epidemiological studies of ODD have included teacher
reports. The British Child Mental Health Survey is one
exception (Maughan et al. 2004), but for analyses of
comorbidity teacher and parent reports were combined.
The possible situational or informant-specific differences in
ODD and its associated mental health problems still need to
be further clarified.
The magnitude of discrepancies between parent and
teacher reports tends to vary depending on the gender of the
child being rated: Correlations between parent and teacher
ratings are generally higher for boys than girls (Collishaw
et al. 2009; Javo et al. 2009). Studies of the relative
predictive value of parent and teacher reports with respect
to mental health problems, have shown that parents are
slightly more reliable informants regarding emotional
disorders in children, whereas teachers are more reliable
informants regarding conduct and hyperactivity disorders
(Goodman et al. 2003). A multi-informant approach to the
assessment of ODD is therefore warranted, and in order to
examine informant-specific associations with comorbid
conditions, parent and teacher ratings need to be studied
separately. To our knowledge, no population-based study of
ODD has previously done this.
Aims of the Study
The current study examined parent and teacher reports of
co-occurring symptoms of mental health problems among
children with symptoms of ODD above the DSM-IV
diagnostic threshold (here referred to as “symptomatic
ODD”) in a population-derived sample of boys and girls
aged 7–9. We expected boys to display more ODD
symptoms than girls. We also expected the association
between ODD symptoms and symptoms of other mental
health problems to vary as a function of informant (parent
or teacher), and as a function of the gender of the child
being rated. In line with the”gender paradox” hypothesis,
we expected girls with symptomatic ODD to be identified
with more co-occurring symptoms of mental health problems as compared to boys with symptomatic ODD.
Material and Methods
Sample
The sample was derived from the first wave of the Bergen
Child Study (BCS), an ongoing population-based study of
579
children’s development and mental health. The BCS is
described in detail in separate publications (Heiervang et al.
2007; Stormark et al. 2008), and only a brief presentation is
provided here. The sampling frame included all 9,430
children in the 1993 through 1995 birth cohorts in the
municipality of Bergen, Norway. Bergen is the second
largest city in Norway with a population of 233,291 in
2002, at the time of data collection. Teacher and parent
versions of a set of screening instruments were distributed
by the school teachers in October of 2002 when the
children attended 2nd–4th grade (7-9 years of age). At that
time most teachers had known their students for at least one
year. Based on parental informed consent, 7,007 children
(74.3%; 3,529 boys and 3,478 girls) participated in the
study. In 2002 6.4% of the population in Norway was made
up of immigrants; 66% of whom were from non-western
countries. In the present sample 5% of the children spoke a
foreign language at home. Questions about other demographic characteristics of the sample were not included in
the screening-phase of the BCS, and it is not considered
appropriate to ask about ethnicity in Norway.
Measures
In the first stage of the BCS, parents and teachers rated
children’s behavior and mental health on a four-page
screening questionnaire. Both parents and teachers were
asked to rate the child’s behavior during the last six months.
The screening questionnaire covered a wide range of
emotional and behavioral symptoms and associated functional impairment (see Heiervang et al. 2007 for details).
The questionnaire included a Norwegian translation of the
SNAP-IV (Swanson, Nolan, and Pelham-IV) questionnaire
(Swanson et al. 2001), and the Strengths and Difficulties
Questionnaire (SDQ) (Goodman 1997, 1999). The SNAPIV is a checklist based on the DSM-IV symptom description for ODD (APA 2000) and other diagnoses. On the
original form, the rater was asked to indicate on a fourpoint scale whether the eight behavioral descriptions of
ODD fit the child “not at all”, “just a little”, “pretty much”
or “very much” (Swanson et al. 2001). For the purpose of
the Bergen Child Study, the items were translated into
Norwegian, and the scoring was altered to a three-point
scale in order to ensure identical response categories for the
entire questionnaire (0 = “not true”, 1=”somewhat true”,
and 2=”certainly true”). The scores on these eight DSM-IV
based items (here referred to as the ODD-scale) were used
to identify children with symptoms of ODD.
The SDQ is a dimensional measure of child mental
health with good sensitivity and specificity regarding the
identification of children with clinical disorders (Goodman
and Goodman 2009; Goodman 2001; Goodman et al.
2004). We used the SDQ-scores to examine co-occurring
580
symptoms of mental health problems. The SDQ is divided
into five subscales (hyperactivity or inattention, emotional
symptoms, conduct problems, peer relationship problems,
and prosocial behavior), each consisting of five questions
with three possible response categories (0 = “not true”,
1=”somewhat true”, and 2=”certainly true”). A total
difficulties score is computed by combining the first four
subscale scores. The subscale scores ranged from 0–10, and
the total difficulties score ranged from 0–40. In addition, an
impact assessment is based on the overall problem severity,
distress to the child, interference in everyday life and
burden to others. In the screening phase of the BCS a child
was defined as screen positive if: (1) the total difficulties
score exceeded the 90th percentile for parents and/or
teachers SDQ scores, and/or (2) there were severe impairments according to the impact section of the SDQ, and/or
(3) scores on one of the other scales included in the
screening questionnaire were equal or above the 98th
percentile.
Due to overlapping items on the SDQ conduct problems
scale and the ODD-scale, the SDQ conduct problems scale
was excluded from the current analyses. The prosocial
behavior subscale was also excluded. As recommended by
Goodman (2001), a cut-off at the 90th percentile was used
to define children as high scorers on the remaining three
SDQ-subscales (i.e. emotional symptoms, hyperactivity or
inattention and peer problems).
Of the returned questionnaires, 6,150 children (88%;
3,064 boys and 3,086 girls) had no missing items on the
ODD-scale in parents’ and teachers’ reports. The percentages of missing cases varied from 4.4% to 5.7% on the
SDQ subscales. There were no statistically significant
differences between children with and without complete
ODD-scales regarding age, gender or screen status (i.e.
being screen negative or screen positive). Due to the large
number of subjects in our study, children without complete
ODD-scales were excluded, and listwise deletion of
missing cases was used in all statistical analyses.
For the purpose of the current study, the ODD-scale
derived from the SNAP was rated by parents and teachers
on a 3-point scale (0 = “not true”, 1=”somewhat true”, and
2=”certainly true”). The categories 0 and 1 were collapsed
to form a dichotomy: Absence of behavior (0, 1=0) and
presence of behavior (2=1). A child was assigned to the
ODD group if a total of four or more ODD-symptoms (i.e.
above the DSM-IV threshold) were reported by the parent
and/or the teacher (i.e. a total of 4+ symptoms from either
informant in any combination). This strategy, known as the
or-rule, is commonly applied in research and has shown
satisfactory validity as compared to other strategies for
integrating multi-informant information (Munkvold et al.
2009; Piacentini et al. 1992). Based on the or-rule, 163
children, or 2.7% of the 6,150 children with complete ODD
J Abnorm Child Psychol (2011) 39:577–587
scales, were identified with symptomatic ODD. This
included significantly more boys (4.0%) than girls (1.3%)
(χ=42.0, p <0.001). Considered separately, both parents
and teachers identified 1.4% children with symptomatic
ODD, but they only co-identified 0.2% (2 girls and 10
boys). In order to examine the full range of ODD
symptoms, our definition of ODD suspended the DSM-IV
rule that ODD cannot be diagnosed in the presence of CD.
This strategy has been referred to previously as “inclusive
ODD” (Maughan et al. 2004).
Statistical Analyses
We used the full range of responses (0, 1, and 2) and
performed independent-samples t-tests to analyze gender
differences in mean sum-scores on the SDQ scales. The
magnitudes of gender-differences in the mean sum-scores
in parents’ and teachers’ ratings are reported as effect sizes
(Cohen’s d), and are interpreted according to the guidelines
of Cohen (1988): A d-value of 0.20 is small, 0.50 is
medium, and 0.80 is large. The three selected SDQ
subscales were dichotomized at the 90th percentile for the
whole sample, and children with scores above the 90th
percentile were defined as high scorers. Cross-tabulations
were used to estimate the risk of children with ODD to be
defined as high scorers on the SDQ scales, as compared to
non-ODD children. Analyses were done separately for boys
and girls, and for parent and teacher SDQ ratings. Results
are presented as odds ratios (OR) with 95% confidence
intervals. Finally, we performed a series of two-way
between-groups analyses of variance to explore the impact
of gender and group status (i.e. ODD or non ODD) on cooccurring symptoms of mental health problems (as measured by the SDQ). Results are presented as main- and
interaction effects, and effect sizes are reported as partial
eta squared. The SPSS version 18.0 was used for all
statistical analyses.
Ethics
The study was approved by the Regional Committee for
Medical and Health Research Ethics, Western Norway, and
by the Ombudsman for Privacy in Research, Norwegian
Social Science Data Services.
Results
There was a statistically significant gender difference on all
three SDQ subscales, except for teacher-reported emotional
symptoms. For parent ratings the effect sizes (d-values)
were small or small to medium, whereas for teacher ratings
they were small and medium to large (see Table 1).
J Abnorm Child Psychol (2011) 39:577–587
581
Table 1 90th percentile cut-offs
and gender differences in mean
SDQa ratings
Full sample (n=7,007)
90th pct cut-off
Parent SDQa ratings
Emotional symptoms
Hyperactivity
Peer problems
Teacher SDQa ratings
Emotional symptoms
Hyperactivity
Peer problems
a
Strengths and Difficulties
Questionnaire
d Cohen’s d; * p<0.01; ** p<
0.001
The total number of SDQ subscales was six (three from
teacher reports and three from parent reports). Of the 163
children with symptomatic ODD, 96.4% were identified as
high scorers on at least one SDQ subscale, either by parents
or teachers (Table 2). Almost half (47.9%) of the ODD
children were identified as high scorers on four or more
SDQ subscales, and 12.1% were identified as high scorers
on all six SDQ subscales (14.5% of ODD boys and 4.9% of
ODD girls). There was a tendency to an increased male
preponderance with increasing symptom-load regarding cooccurring symptoms of mental health problems (see
Table 2).
Boys and girls with symptomatic ODD had a statistically
significant higher risk of being identified as high scorers on
all six SDQ subscales as compared to non-ODD children
(Table 3). For instance, 46.3% of girls and 49.2% of boys
with symptomatic ODD were rated by their parents as high
scorers on the emotional symptom scale, as compared to
10.3% for non-ODD girls and 9.5% for non-ODD boys.
According to teacher reports, 73.0% of boys and 34.1% of
girls with symptomatic ODD were rated as high scorers on
the hyperactivity scale, as compared to 14.8% of non-ODD
boys and 2.9% of non-ODD girls. All differences between
children with symptomatic ODD and their non-ODD peers
were statistically significant at the p<0.001 level.
There were significant main effects of group status (i.e.
ODD vs. non-ODD) on all SDQ subscale scores, both in
parent and teacher reports. Group status explained 4-7% of
Girls (n=3,478)
M (SD)
Boys (n=3,529)
M (SD)
t
d
4
1.2 (1.7)
1.4 (1.7)
*-2.9
-0.07
6
3
2.3 (1.9)
0.9 (1.4)
3.0 (2.3)
1.0 (1.6)
**14.8
**4.6
0.36
0.12
2
5
2
0.6 (1.3)
1.4 (1.7)
0.6 (1.3)
0.7 (1.3)
2.9 (2.7)
0.9 (1.6)
0.7
**25.7
**7.8
0.02
0.62
0.19
the variance in SDQ scores. There were also significant
main effects of gender on parent- and teacher reports of
hyperactivity, and in teacher reports of peer problems, with
effect sizes ranging from 0.01 to 0.02 (i.e. 1-2% explained
variance). The only significant group x gender interaction
effects were found on teacher reports of hyperactivity and
peer problems, with an effect size of 0.01 (see Table 4). All
interaction effects were ordinal, and main effects could thus
also be interpreted.
Discussion
In our population-derived sample of 7,007 children aged 79 years we found that symptomatic Oppositional Defiant
Disorder (ODD) was significantly less frequent among girls
than boys (1.3% vs. 4.0%, respectively). Compared to nonODD children, boys and girls with symptomatic ODD had
an increased risk of exhibiting emotional symptoms,
hyperactivity and peer problems, as reported on the
Strengths and Difficulties Questionnaire (SDQ) (Goodman
1999). In fact, 96.4% of children with symptomatic ODD
were identified as high scorers on one or more SDQ
subscales, either according to parents or teachers, and
almost half (47.9%) ranked as high scorers on four or more
SDQ subscales. There were significant main effects of
group status (i.e. ODD vs. non-ODD) on all SDQ ratings,
both according to parents and teachers. There were also
Table 2 The frequency of children with symptomatic ODD identified either by parents or teachers as high-scorers on one or more SDQa
subscalesb
High-score SDQa subscalesb [% (n)]
ODD children (n=163)
ODD Girls (n=41)
ODD Boys (n=122)
1+
2+
3+
4+
5+
6
96.4 (159)
92.7 (38)
97.6 (121)
84.2 (139)
82.9 (34)
84.7 (105)
71.5 (118)
61.0 (25)
75.0 (93)
47.9 (79)
39.0 (16)
50.8 (63)
32.1 (53)
17.1 (7)
37.1 (46)
12.1 (20)
4.9 (2)
14.5 (18)
a
Strength and Difficulties Questionnaire
b
emotional problems, hyperactivity problems and peer problems
582
J Abnorm Child Psychol (2011) 39:577–587
Table 3 The risk (odds-ratio) of girls and boys with symptomatic ODD to be classified as high scorers on the SDQasubscales
High scoring Girls
High scoring Boys
Non-ODD% (n)
ODD% (n)
Parent SDQ-ratings
Emotional symptoms
Hyperactivity
Peer problems
Teacher SDQ-ratings
10.3 (313)
6.3 (192)
10.1 (307)
46.3 (19)
39.0 (16)
65.9 (27)
Emotional symptoms
Hyperactivity
Peer problems
15.4 (468)
2.9 (87)
17.1 (521)
53.7 (22)
34.1 (14)
58.5 (24)
a
OR (95% CI)
Non-ODD% (n)
ODD% (n)
OR (95% CI)
*7.5 (4.0–14.1)
*9.5 (5.0–18.1)
*17.2 (8.9–33.1)
9.5 (280)
12.3 (361)
13.5 (397)
49.2 (60)
56.6 (69)
55.7 (68)
*9.2 (6.3–13.4)
*9.3 (6.4–13.5)
*8.1 (5.5–11.7)
*6.4 (3.4–11.9)
*17.6 (8.9–34.8)
*6.8 (3.6–12.8)
14.5 (427)
14.8 (435)
21.1 (621)
59.8 (73)
73.0 (89)
71.3 (87)
*8.8 (6.0–12.8)
*15.5 (10.3–23.5)
*9.3 (6.2–13.9)
Strength and Difficulties Questionnaire
* p<0.001
significant main effects of gender on parent- and teacher
reports of hyperactivity, and teacher reports of peer
problems. There was a significant interaction effect of
group status x gender on teacher reports of hyperactivity
and peer problems, but there were no interaction effects on
any parent SDQ ratings. The “gender paradox hypothesis”,
which regards ODD/CD and the co-occurrence of mental
health problems, was not evident among the children in our
sample (aged 7-9).
Children with symptomatic ODD had a significantly
higher risk of being defined as high scorers on all SDQscales as compared to non-ODD peers. For instance, 73.0%
of the boys were defined as high scorers in teacher ratings
of hyperactivity as compared to 14.8% of the non-ODD
boys. For the girls, 46.3% were defined as high scorers in
parent ratings of emotional symptoms, as compared to
10.3% of non-ODD girls. Our results are in line with
previous studies that report strong associations between
ODD/CD and other mental health problems such as
depression, anxiety disorders, and hyperactivity (Angold
et al. 1999; Boylan et al. 2007; Maughan et al. 2004). One
of the research questions most relevant to the forthcoming
DSM-V is related to the empirical foundation of the
diagnosis of ODD. A reconsideration of its status as a
mental disorder has been suggested, and authors have
argued that ODD is a transient condition, unless it occurs
together with other mental disorders (see Moffitt et al.
2008, for a further discussion). ODD is not merely a
predisposing factor for CD, but also a common starting
point for the later development of other mental disorders
such as anxiety and depression (Loeber et al. 2009). We
found that symptoms of ODD occurred jointly with at least
one symptom of other mental health problems in 96.4% of
the cases. In 12.1% of the cases, children with ODD had
co-occurring emotional symptoms, hyperactivity and peer
problems according to parents and teachers. ODD could
Table 4 Mean group- and gender differences on the Strengths and Difficulties Questionnaire (SDQ) subscales
Girls
Non-ODD
(n=3,045)
Parent SDQ-ratings
Emotional symptoms
Hyperactivity
Peer problems
Teacher SDQ-ratings
Emotional symptoms
Hyperactivity
Peer problems
Boys
ODD
(n=41)
Non-ODD
(n=2,942)
ODD
(n =122)
Groupa
Groupa x Gender
Gender
F
η
F
η
η
F
1.3 (1.6)
2.2 (1.9)
0.8 (1.4)
3.8 (2.7)
5.1 (2.8)
3.4 (2.1)
1.1 (1.6)
2.9 (2.2)
0.9 (1.5)
3.4 (2.5)
6.1 (3.0)
3.5 (2.8)
**255.5
**268.9
**376.3
0.04
0.04
0.06
3.1
**19.2
0.6
0.01
0.01
0.00
0.3
0.8
0.1
0.00
0.00
0.00
0.6 (1.2)
1.4 (1.7)
0.6 (1.3)
2.4 (2.4)
4.4 (3.0)
2.8 (2.5)
0.6 (1.2)
2.7 (2.5)
0.8 (1.4)
2.7 (2.4)
7.1 (2.9)
3.8 (3.0)
**277.0
**353.2
**432.9
0.04
0.05
0.07
0.9
**100.6
**21.5
0.00
0.02
0.01
1.5
**11.8
*10.1
0.00
0.01
0.01
Values represent means (SD)
a
ANOVA
ODD vs. non-ODD; ** p<0.001; * p<0.01; η=partial eta squared
J Abnorm Child Psychol (2011) 39:577–587
thus be considered an important marker for a broader
pattern of behavioral and emotional dysregulation. This is
in line with other longitudinal studies demonstrating the
key role of ODD in the development of psychopathology in
children and adolescents (Burke et al. 2010; Copeland et al.
2009).
Hyperactivity is a known risk factor for antisocial
behavior (Moffitt et al. 2001). But why do symptoms of
hyperactivity and ODD co-occur more frequently among
boys than girls, as our results have indicated? Older studies
have shown that boys who are inattentive and impulsive are
more likely to become aggressive as compared to girls with
similar attention deficits (Berry et al. 1985; Carlson et al.
1997). Developmental models suggest that biological
vulnerabilities may play a role in early emerging gender
differences in behavioral and emotional dysregulation (Eme
2007; Rutter 2003; Susman and Pajer 2004). Adult
responses to disruptive behavior are also essential in the
escalation of childhood disruptive behavior (Burke et al.
2008; Granic and Patterson 2006). There are indications
that adults respond differently towards boys and girls who
display socially unacceptable behavior (Lytton and Romney
1991). For instance, boys are more likely to receive
physically harsh discipline from their parents, whereas girls
are inclined to get firm, verbal requests aimed at regulating
and inhibiting disruptive behavior (Webster-Stratton 1996).
Another body of research indicates that children’s behaviors
exert at least as much influence on parenting behavior as
the vice-versa (Huh et al. 2006; Pardini et al. 2008). Since
boys have more hyperactivity problems than girls, and
these are likely to influence parental behavior (Deault
2010), differential socialization pressures may exacerbate
gender differences in displays of disruptive behaviors, and
lead to a stronger association between symptoms of
hyperactivity and ODD in boys.
Disruptive behaviors such as ODD are associated with
different patterns of co-occurring symptoms of mental
health problems, depending on whether parents or teachers
report them (Drabick et al. 2007; Munkvold et al. 2009;
Offord et al. 1996). According to our results these
informant-specific patterns of co-occurring problems vary
as a function of gender: The impact of symptomatic ODD
on teacher ratings of hyperactivity and peer problems
depends on the gender of the child being rated. According
to their teachers, ODD boys had higher mean levels of cooccurring symptoms of mental health problems than ODD
girls (except for emotional symptoms). One line of
argument could provide an explanation for this: It is well
known that the biological maturation is slower in boys as
compared to girls (Rutter et al. 2003). Boys are more likely,
at an early age, to be exposed to risk factors for ODD/CD
such as neurodevelopmental problems and family adversity
(Lahey et al. 2006; Moffitt and Caspi 2001). The skids are
583
then greased for boys entering school exhibiting more
symptoms of behavioral and emotional dysregulation,
which may contribute to gender differences in responsitivity to socialization pressures (Zahn-Waxler and Polanichka
2004). Once enrolled in school, boys exhibit relatively
greater reading problems (Messer et al. 2006), and
impulsive, aggressive boys are more often rejected by their
school peers (Laird et al. 2001). These early experiences of
academic and social failure can trigger negative selfevaluative emotions, such as shame. In response, the victim
often becomes angry and aggressive (Izard 2002). Teachers
tend to respond differentially to aggressive and disruptive
behavior in boys and girls. For instance, they more often
ignore disruptive behavior in girls, but if they respond to
disruptive behavior they are less likely to follow through on
their efforts to dampen it in boys (Arnold et al. 1998).
Gender differences, with respect to neurodevelopmental
vulnerability and exposure to contextual adversity could
therefore explain why ODD shows a stronger association to
symptoms of hyperactivity and peer problems in boys as
compared to girls in a school setting.
There were no main effects of gender or interaction
effects of gender x group (i.e. ODD vs. non-ODD) on
parent- or teacher ratings of emotional symptoms. Other
studies have reported a higher risk for emotional problems
such as depression among females with ODD/CD, but
commonly this pattern does not emerge until adolescence
(Moffitt et al. 2001). There is thus a probability that our
finding is a consequence of the relatively young age of the
children in our sample. Another possibility is that we did
not have enough statistical power to distinguish between
different dimensions of ODD and investigate whether these
relate differently to co-occurring emotional problems for
boys and girls. Factor analyses have suggested that
symptoms of ODD load on the dimensions “negative
affect” and “oppositional behavior” (Burke et al. 2010). In
a recent longitudinal study of girls aged 5-8 Burke and
colleagues (2010) found that “negative affect” predicted the
subsequent development of depression, whereas symptoms
of oppositional behavior predicted later CD. Temperamental dimensions measured at the age of 38 months have
indicated that “negative emotionality” predict comorbidity
between ODD and depression, whereas the temperamental
dimension “activity” better predict comorbidity between
ODD and ADHD (Stringaris et al. 2010). Other authors
have argued that ODD is reflective of the personality traits
“low agreeableness” and “high negative emotionality”
(Lahey and Waldman 2003). Frequent displays of such
traits would probably result in a difficult relationship
between the child and the parent/teacher. If a child with
hyperactivity problems has co-occurring symptoms of ODD
this could worsen the prognosis, as psychosocial treatment
of hyperactivity is most effective in the context of a positive
584
relationship between the parent/teacher and the child (Taylor
and Sonuga-Barke 2008). There is evidence that ODD could
have an equally worsening effect on emotional problems:
Frequent displays of negative emotionality and low agreeableness could increase the level of conflict in the child’s
close relationships, leading to stressful life events (e.g. being
expelled from school, exposed to harsh discipline or rejected
by friends), which increases the likelihood of subsequent
emotional problems (Fergusson et al. 2003). In support of
this line of argument, studies have demonstrated that ODD/
CD commonly precedes the development of depression in
adolescents (Burke et al. 2005; Burke et al. 2010; Moffitt et
al. 2001; Rowe et al. 2006), and depression is more common
among adolescents with ODD/CD than in the general
population (Costello et al. 2003; Loeber et al. 2000;
Maughan et al. 2004).
Taken together, our results do not support the “gender
paradox hypothesis” (Loeber and Keenan 1994) stating that
the gender with the lowest prevalence of ODD/CD (girls)
has the highest rate of co-occurring symptoms of mental
health problems. For instance, we found that symptomatic
ODD was associated with significantly more hyperactivity
problems in boys as compared to girls (according to
teachers), contrary to other studies indicating a stronger
association between ODD and ADHD in girls (Maughan et
al. 2004). There are several possible explanations for our
lack of support for the “gender paradox hypothesis”. Older
studies commonly combined ODD/CD into one category,
or excluded ODD all together. It is thus possible that the
“gender paradox” is associated with CD, and not ODD.
Another possibility is that the paradox will not be evident
until adolescence, i.e. when the onset of comorbid
conditions such as anxiety and depression commonly show
a marked female preponderance (Zahn-Waxler et al. 2008).
Compared to other epidemiological studies, the prevalence
rate of ODD among boys is strikingly low in our sample
(4.0%). This has been referred to as “the advantage of
Nordic mental health”, and possible explanations have been
discussed by other authors (Heiervang et al. 2008).
Although still more prevalent among boys than girls,
ODD is probably less normative among Norwegian boys
as compared to boys in other western countries. Following
the previously mentioned theoretical explanation for the
“gender paradox hypothesis”, ODD could thus be reflective
of a broader emotional/behavioral dysfunction for boys, as
well as for girls.
Some of the shortcomings of previous ODD studies have
encompassed the exclusion of girls (Drabick et al. 2007),
the use of clinical samples only (Lehto-Salo et al. 2009),
and the absence of teacher ratings (Lahey et al. 2000b). The
present study included a large number of both girls and
boys in a population-derived sample, and both teacher and
parent ratings - assessed approximately at the same time –
J Abnorm Child Psychol (2011) 39:577–587
were included. A possible point of criticism for this study is
the use of SNAP/DSM-IV-derived items to identify
children with symptomatic ODD, in that the original rating
scale was altered from four points to three points for the
purpose of the BCS. It remains unclear how this might have
affected the magnitudes of our estimates. Analyses of the
SNAP/DSM-IV-derived inattention scale (Sorensen et al.
2008), and the altered SNAP/DSM-IV-derived ODD scale
(Munkvold et al. 2009), have yielded satisfactory results
regarding internal consistency and impact on daily life
functions. However, these findings were derived from the
same sample as in the current study.
Another limitation of the study is the cross-sectional
nature of the data. This makes it difficult to make casual
inferences about ODD and associated mental health problems, as our results only reflect a snapshot in time.
However, the rarely used synonym for a cross-sectional
study - prevalence study - captures the primary purpose of
this paper: to shed light on the unresolved issues in the
literature regarding gender differences in the prevalence of
ODD (Loeber et al. 2000), and gender differences in the cooccurrence of mental health problems associated with ODD
(Maughan et al. 2004). Due to relatively few descriptive
studies of ODD as an independent diagnostic category, and
the few population-based studies providing teacher reports,
we argue that our study contribute to the generation of
hypothesis about the informant- and gender-specific characteristics of ODD as a clinical construct. Another
advantage of a cross-sectional design is that there is no
loss to follow-up. This, in combination with a high
response-rate (74.3%), strengthens the external validity of
our study.
The clinical implications of this study are that when
parents or teachers report symptoms of ODD above the
diagnostic threshold, there is a very high probability that
the child simultaneously displays symptoms of other mental
health problems. Clinicians should therefore carefully
assess these children in order to provide adequate treatment,
addressing the specific problems experienced by the
individual child. In a longitudinal perspective, a substantial
number of children displaying early symptoms of antisocial
behavior or ODD/CD go on to adolescence and young
adulthood experiencing significant mental health problems,
physical health problems, academic problems, economic
problems, and engaging in serious violence (Burke, et al.
2010; Colman et al. 2009; Copeland et al. 2009; Odgers et
al. 2008). The cost-estimates of the long-term public health
burden following childhood ODD/CD and antisocial behavior are very high (Romeo et al. 2006; Scott et al. 2001).
Providing easily accessible treatment at an early developmental stage aimed at reducing ODD symptoms should
therefore be of high priority to public health planners, as
even a small reduction of the long-term consequences of
J Abnorm Child Psychol (2011) 39:577–587
these problems would be beneficial to the individual, the
family and the society as a whole.
Acknowledgements Our special thanks go to all the participants in
the Bergen Child Study (BCS), and the members of the BCS-project
group for the collaboration and effort that made this study possible.
The authors would like to thank Jim Stevenson and Robert A.
Wicklund for reading and commenting on drafts of this manuscript.
Financial support The current study was supported by the
University of Bergen, the Norwegian Directorate for Health and
Social Affairs, the Western Norway Regional Health Authority and the
Research Council of Norway, and by “The National Program for
Integrated Clinical Specialist and PhD-training for Psychologists”.
The program is a joint cooperation between Universities in Norway,
the Regional Health Authorities, and the Norwegian Psychological
Association. The program is funded jointly by The Ministry of
Education and Research, and the Ministry of Health and Care
Services.
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