Ross W. Greene

Is childhood oppositional defiant disorder a precursor to adolescent conduct disorder? Findings from a four-year follow-up study of children with ADHD.

OBJECTIVE To evaluate the overlap between attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), addressing whether ODD is subsyndromal form of conduct disorder (CD) and, if so, whether it is a precursor or prodrome syndrome of CD. METHOD Assessments from multiple domains were used to examine 140 children with ADHD and 120 normal controls at baseline and 4 years later. RESULTS Of children who had ADHD at baseline, 65% had comorbid ODD and 22% had CD. Among those with ODD, 32% had comorbid CD. All but one child with CD also had ODD that preceded the onset of CD by several years. ODD+CD children had more severe symptoms of ODD, more comorbid psychiatric disorders, lower Global Assessment of Functioning Scale scores, more bipolar disorder, and more abnormal Child Behavior Checklist clinical scale scores compared with ADHD children with non-CD ODD and those without ODD or CD. In addition, ODD without CD at baseline assessment in childhood did not increase the risk for CD at the 4-year follow-up, by midadolescence. CONCLUSIONS Two subtypes of ODD associated with ADHD were identified: one that is prodromal to CD and another that is subsyndromal to CD but not likely to progress into CD in later years. These ODD subtypes have different correlates, course, and outcome.

Are Students with ADHD More Stressful to Teach? Patterns of Teacher Stress in an Elementary School Sample

The inattentive and/or hyperactive—impulsive behaviors that typify attention-deficit/hyperactivity disorder (ADHD) have been associated with increased stress in parents of children who are so diagnosed and are known to adversely affect the quality of parent—child interactions. Far less is known, however, about the effects of ADHD on interactions between students with the disorder and their teachers and on levels of teacher stress. Using the Index of Teaching Stress, an instrument assessing a teachers subjective level of stress and frustration in response to teaching and interacting with a particular student, we found that general education elementary school teachers rated students with ADHD as significantly more stressful to teach than their classmates withoutADHD. However, we found that the stress reported by teachers was highly individualized.Students with ADHD who evidenced oppositional/aggressive behavior or severe social impairment were rated as significantly more stressful to teach than students with ADHD who did not evidence these associated difficulties.

Toward a new psychometric definition of social disability in children with attention-deficit hyperactivity disorder.

OBJECTIVE To investigate a new mechanism for identifying social disability in children with attention-deficit hyperactivity disorder (ADHD), employing psychometric methodology used in defining learning disabilities. METHOD Two groups of index children were examined: 140 children with ADHD (referred from both psychiatric and pediatric sources) and 120 non-ADHD comparison children. Subjects were defined as socially disabled if they had a value greater than 1.65 on a standardized discrepancy score between observed and expected scores on a measure of social functioning (with expected scores derived as a function of the childs estimated Full Scale IQ). Children identified as socially disabled were compared with non-socially disabled probands on psychopathology, familiality, cognitive functioning, school history, and treatment history. RESULTS Using this psychometric approach, 22% of the ADHD probands qualified as socially disabled, whereas none of the comparison probands qualified (p < or = .001). Socially disabled ADHD probands were significantly more impaired than were non-socially disabled ADHD probands in global and specific measures of social functioning and patterns of psychiatric comorbidity. CONCLUSIONS The psychometrically defined construct of social disability may identify children with ADHD who are at very high risk for severe social dysfunction and whose course and prognosis may vary from those of other children with ADHD. This subgroup of children with ADHD may be at heightened risk for poor outcome, and their identification may facilitate the development of clinical interventions aimed at ameliorating their specific difficulties.

Social Impairment in Girls With ADHD: Patterns, Gender Comparisons, and Correlates

OBJECTIVE To investigate social impairment in girls with attention-deficit/hyperactivity disorder (ADHD), compare the social functioning of boys and girls with ADHD, and explore the association between social dysfunction and conditions comorbid with ADHD. METHOD Four groups of index children were studied: 267 children (127 girls) with ADHD and 234 non-ADHD comparison children (114 girls). Groups were compared on social functioning, psychopathology, and demographic characteristics. RESULTS Girls with ADHD manifested significant deficits in interpersonal functioning compared with girls without ADHD and evidenced a similar degree of social impairment compared with boys with ADHD. ADHD and associated comorbid disorders were significant correlates of specific domains of social dysfunction in boys and girls with ADHD. CONCLUSIONS Interpersonal deficits are a major correlate of ADHD, irrespective of gender, and appear to stem from the behaviors associated with ADHD as well as behaviors characteristic of conditions comorbid with ADHD.

Toward a Transactional Conceptualization of Oppositional Defiant Disorder: Implications for Assessment and Treatment

The conceptualization and treatment of oppositional defiant disorder (ODD) has been characterized by surprising homogeneity. In this paper evidence is presented to underscore the heterogeneity within ODD, including research demonstrating (a) the distinction between reactive and proactive forms of aggression; (b) the importance of affective modulation and self-regulation, and associated cognitive skills, in the development of the skill of compliance; and (c) high levels of comorbidity between ODD and other disorders. The disparate pathways that give rise to oppositional behavior suggest that different children with ODD may require different forms of intervention. The necessity of a transactional conceptualization, of achieving a comprehensive understanding of the factors underlying the difficulties of individual children with ODD, and of matching intervention ingredients to the specific needs of different children and families is discussed.

Effectiveness of collaborative problem solving in affectively dysregulated children with oppositional-defiant disorder: initial findings.

Oppositional-defiant disorder (ODD) refers to a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures. Research has shown that children with ODD and comorbid mood disorders may be at particular risk for long-term adverse outcomes, including conduct disorder. In this study, the authors examined the effectiveness of a cognitive-behavioral model of intervention--called collaborative problem solving (CPS)--in comparison with parent training (PT) in 47 affectively dysregulated children with ODD. Results indicate that CPS produced significant improvements across multiple domains of functioning at posttreatment and at 4-month follow-up. These improvements were in all instances equivalent, and in many instances superior, to the improvements produced by PT. Implications of these findings for further research on and treatment selection in children with ODD are discussed.

Long-Term Stability of the Child Behavior Checklist in a Clinical Sample of Youth With Attention Deficit Hyperactivity Disorder

Evaluated the long-term stability of the Child Behavior Checklist (CBCL) in a longitudinal clinical sample of youth with attention deficit hyperactivity disorder (ADHD), testing the hypothesis that the CBCL scales will show stability over time. Participants were 105 Caucasian, non-Hispanic boys with ADHD between the ages of 6 and 17 assessed at baseline and at a 4-year follow-up. Stability of CBCL scales were computed for dimensional (intraclass correlation coefficients [ICCs], Pearson correlations) and dichotomized scale scores (kappa coefficients and odds ratios [ORs]). Evidence was found for stability of the categorical and dimensional types of scores, as demonstrated by statistically significant stability of the Pearson correlation coefficients, kappas, and ORs. The robust findings obtained from ICCs and kappa coefficients document substantial stability for CBCL scales over time within individuals with ADHD. These results support the informativeness of the CBCL as a useful measure of longitudinal course in clinical samples of youth with ADHD.

A transactional model of oppositional behavior: Underpinnings of the Collaborative Problem Solving approach

Oppositional defiant disorder (ODD) refers to a recurrent pattern of developmentally inappropriate levels of negativistic, defiant, disobedient, and hostile behavior toward authority figures. ODD is one of the most common (and debilitating) comorbid disorders within Tourettes disorder (TD). Diverse psychosocial treatment approaches have been applied to childrens ODD-related behaviors. In this paper, the authors articulate a transactional developmental conceptualization of oppositional behavior and describe a cognitive-behavioral model of intervention-called collaborative problem solving (CPS)-emanating from this conceptualization. The specific goals of the CPS approach are to help adults (1). understand the specific adult and child characteristics contributing to the development of a childs oppositional behavior; (2). become cognizant of three basic strategies for handling unmet expectations, including (a). imposition of adult will, (b). CPS, and (c). removing the expectation; (3). recognize the impact of each of these three approaches on parent-child interactions; and (4). become proficient, along with their children, at CPS as a means of resolving disagreements and defusing potentially conflictual situations so as to reduce oppositional episodes and improve parent-child compatibility. Summary data from an initial study documenting the effectiveness of the CPS approach (in comparison to the standard of care) are also presented.

Students with Attention-Deficit Hyperactivity Disorder and Their Teachers

The past three decades have witnessed heightened levels of awareness and study of what has come to be known as attention-deficit hyperactivity disorder (ADHD). Children diagnosed with ADHD exhibit a constellation of “developmentally deviant” behaviors represented diagnostically by the broad categories of “inattentiveness” or “hyperactivity/impulsivity,” or both, as specified in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994). The style of behaving associated with ADHD places these children at heightened risk for behavioral, academic, and social difficulties, as well as for a variety of comorbid diagnoses (e.g., Abikoff & Klein, 1992; Biederman, Faraone, Keenan, & Tsuang, 1991; Cantwell & Baker, 1992; Jensen, Shervette, Xenakis, & Richters, 1993; Mannuzza, Klein, Bessler, Malloy, & LaPadula, 1993).

Differential Responses of Children with Varying Degrees of Reactive and Proactive Aggression to Two Forms of Psychosocial Treatment

ABSTRACT This study examined differential treatment effects for children with varying degrees of reactive and proactive aggression who received one of two types of psychosocial treatments that were specifically designed to address the unique characteristics associated with these two subtypes of aggression. Forty-seven affectively dysregulated children with oppositional defiant disorder (ODD) participated in the study and were randomly but proportionately assigned to Collaborative Problem Solving (n = 28) or Parent Training (n = 19) treatment conditions. Results indicate a main effect for type of treatment, modest support for the moderating role of proactive aggression, and no support for reactive aggression as a moderator of treatment outcome. Implications for assessment and treatment of aggression are discussed.