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Sex Differences in Oppositional Defiant Disorder 667 Psicothema 2011. Vol. 23, nº 4, pp. 666-671 ISSN 0214 - 9915 CODEN PSOTEG www.psicothema.com Copyright © 2011 Psicothema Sex differences in oppositional defi ant disorder Esther Trepat and Lourdes Ezpeleta Universidad Autónoma de Barcelona The goal was to analyze the sex differences in symptoms, comorbidity and functional impairment in outpatient children with Oppositional Defi ant Disorder (ODD). A sample of 343 children, aged 8 to 17 years and diagnosed with ODD, were assessed with a semi-structured diagnostic interview and dimensional measures of psychopathology and functional impairment. Boys with ODD more frequently displayed the symptoms «deliberately annoys» and «blames others», presented comorbid ADHD, and had greater functional impairment in school and community contexts; girls presented higher comorbidity with internalizing symptomatology (anxiety, depression and somatic complaints). Given that some clinical differences are apparent in ODD between boys and girls, it is necessary to consider the sex of the patient in order to identify and treat this disorder effi ciently and effectively in boys and in girls. Diferencias de sexo en el trastorno negativista desafi ante. El objetivo es analizar las diferencias de sexo en la prevalencia, sintomatología, comorbilidad y deterioro funcional en pacientes externos con Trastorno Negativista Desafi ante (TND). Una muestra de 343 niños y adolescentes de entre 8 y 17 años diagnosticados de TND fueron evaluados con una entrevista diagnóstica semiestructurada y otras medidas dimensionales de psicopatología y deterioro funcional. Los niños con TND mostraron con mayor frecuencia los síntomas «molestar deliberadamente» y «acusar a otros», mayor comorbilidad con trastorno por défi cit de atención con hiperactividad y mayor deterioro funcional en el colegio y en la comunidad; las niñas presentaron mayor comorbilidad con sintomatología interiorizada (ansiedad, depresión y quejas somáticas). Niños y niñas presentan un cuadro clínico de TND con algunas diferencias. Es necesario adoptar una perspectiva de sexo para identifi car y tratar el TND de manera efi caz y efi ciente en niños y en niñas. The study of sex differences in childhood psychopathology is manifested in covert, less observable ways, with the purpose has gained relevance in recent years. Identifying these differences of excluding peers, whilst boys’ aggressive behaviours are more should permit the development of diagnostic instruments obvious, and have been associated with defi cits in moral processing appropriate for boys and girls that avoid biases due to sex (under- or (Kann & Hanna, 2000). Although few studies have dealt with this over-diagnosis) and prevention and treatment programmes adapted issue, Waschbusch and King (2006) suggested that there may be a to the common and differential variables for each sex. Among sample of girls with behaviour problems, with greater impairment externalizing disorders, oppositional defi ant disorder (ODD) is one in their level of functioning than the girls in their normative group, of those requiring most research in this regard, given its prevalence and whom the current diagnostic criteria fail to identify. Ohan and and the scarcity of studies carried out to date. Johnston (2005) have proposed that the defi nition of ODD include The prevalence of ODD in the general population is situated relational aggression behaviours (refusing to talk to someone, between 4% and 8% (DSM-IV-TR, 2000). Various studies have being malicious, avoiding blame) in the identifi cation of girls with shown that the prevalence of ODD is greater in boys than in girls oppositional characteristics. (Kroes et al., 2001; Lahey et al., 2000; Maughan, Rowe, Messer, The fact that the tendency to present oppositional behaviours Goodman, & Meltzer, 2004). However, questions have arisen over and disruptive emotions (anger, poking fun, etc.) is more commonly whether this difference is real, or an effect of the way the disorder observed in boys than in girls is consistent with the theory that the is defi ned. In the last ten years there has been a debate over whether expression of anger is more common and acceptable in boys, which it is appropriate to use common diagnostic criteria for boys and may explain, in part, the greater presence of externalizing problems girls in externalizing disorders such as ODD. Girls’ aggressiveness in boys (Bird, 2006; Chaplin, Cole, & Zahn-Waxler, 2005). However, in clinical samples, ODD is also associated with anxiety disorders. Garland and Garland (2001) suggest a bidirectional relationship between oppositional behaviour and anxiety, pointing Fecha recepción: 23-1-11 • Fecha aceptación: 25-5-11 out that ODD may be a precursor of anxiety problems in the future. Correspondencia: Esther Trepat de Ancos These authors also observed that in children with higher levels of Facultad de Psicología Universidad Autónoma de Barcelona anxiety, this anxiety was often manifested through oppositional 08193 Barcelona (Spain) behaviour. In their study with 145 pre-adolescents, 31% presented e-mail: [email protected] a diagnosis of ODD with comorbidity of some anxiety disorder. SEX DIFFERENCES IN OPPOSITIONAL DEFIANT DISORDER 667 In a similar line, Lavigne et al., (2001) reported that oppositional families (n= 25) refused to participate in the study. In the group behaviour was related to the development of mood and anxiety that refused to participate there were more girls (p= 0.012) and the disorders. In their longitudinal study with 280 pre-schoolers, over children were older (p= 0.037) than in the group who agreed to 4-6 years of follow-up, children with symptoms of ODD maintained participate, but there were no differences by socioeconomic status those symptoms and showed an increase in comorbidity with mood (p= 0.771). and anxiety disorders and attention-defi cit hyperactivity disorder (ADHD). Although there is evidence of comorbidity between ODD Instruments and internalizing disorders, it is not clear whether this association is stronger in boys or in girls. Diagnosis of the children was established with the Diagnostic Sex differences in the comorbidity of oppositional behaviour, Interview for Children and Adolescents-IV (DICA-IV) (Reich, both with other externalizing disorders and with internalizing Shayka & Taibleson, 1991) in its three versions: for children (8-12 disorders, imply different biological and socialization factors. years), for adolescents (13-17 years) and for parents. The DICA- Studies on role expectations according to sex have shown that boys IV is a semi-structured diagnostic interview based on the criteria of learn that anger and aggression are more acceptable emotions in the DSM-IV (APA, 1994), which covers the diagnostic categories males than anxiety, sadness or fear (Garside & Klimes-Dougan, most commonly found in children and adolescents. It obtains 2005; Mireault, Rooney, Kouwenhoven, & Hannan, 2008), information on the lifetime presence or absence of symptoms in and that they are reinforced more in boys than in girls (Chaplin the child or adolescent. Diagnoses are generated by combining the et al., 2005). Such subtle socialization styles may contribute information from parents and children; the symptom is considered to differences between sexes in internalizing symptoms and in to be present when both the child and the parents report it. The externalizing behaviours. Given that anxiety is more common psychometric properties of the Spanish adaptation are good (de la among girls and oppositional behaviour is more common in boys, Osa, Ezpeleta, Doménech, Navarro, & Losilla, 1997; Ezpeleta, de but at the same time anxiety and oppositional behaviour are also la Osa, Doménech, Navarro, & Losilla, 1997). correlated with one another, it is important to ascertain whether The Child and Adolescent Functional Assessment Scale greater comorbidity is associated with sex. (CAFAS) (Hodges, 1997) assesses level of functional impairment. The association between oppositional behaviour and daily Scores are assigned by the clinician after obtaining the information functioning diffi culties has been less studied. The degree to which from the parents or the child in the assessment process, taking a particular disorder interferes with or impairs an individual’s into account age, sex, social class and the individual’s cultural everyday life is one of the most relevant variables for reaching context. The instrument comprises eight subscales representing the a diagnosis, as defi ned in the DSM-IV-TR (APA, 2000), and for following functioning domains: home, school/work, community, establishing the need for intervention. Ezpeleta, Keeler, Erkanli, behaviour toward others, moods/emotions, self-harmful behaviour, Costello and Angold (2001) found a greater association between thinking, and substance use. Each domain receives points as severe diffi culties in relations with peers and in family functioning follows: 30 (severe impairment), 20 (moderate impairment), in ODD than in conduct disorder (CD). Likewise, despite the fact 10 (mild impairment) and 0 (minimal/none). The scale can be that psychological distress is not a criterion of clinical signifi cance used from the age of 7 to 17. The psychometric properties of the in ODD, individual symptoms of ODD have been reported to be instrument have been widely studied by the author (Hodges, 1999) signifi cantly associated with distress (Ezpeleta, Reich, & Granero, and in the adaptation for Spanish samples (Ezpeleta, Granero, de 2009). la Osa, Doménech, & Bonillo, 2006). In such
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