Overlap of ADHD and oppositional defiant disorder DSM-IV derived criteria.

Abstract

One possible reason for being controversies regarding ADHD may be related to the validity and reliability of diagnostic criteria of attention deficit hyperactivity disorder and oppositional defiant disorder. Diagnostic criteria of oppositional defiant disorder include eight symptoms. This study examines the factor structure of oppositional defiant disorder symptoms, its discriminant validity from attention deficit hyperactivity disorder, its convergent validity and internal reliability.
Parents of 111 referral children and adolescents with attention deficit hyperactivity disorder completed DSM-IV referenced based attention deficit hyperactivity disorder and oppositional defiant disorder checklists.
Factor analysis indicated that the attention deficit hyperactivity disorder symptom of: "often has trouble organizing activities" and "often runs about or climbs when and where it is not appropriate" were a part of the oppositional defiant disorder component. These symptoms less often than other symptoms differentiate attention deficit hyperactivity disorder from oppositional defiant disorder. The convergent validity for oppositional defiant disorder symptoms ranged from 0.64 to 0.79.
The parent-rating checklist of oppositional defiant disorder symptoms properly differentiates oppositional defiant disorder from attention deficit hyperactivity disorder. However, two items of the attention deficit hyperactivity disorder were listed as symptoms of oppositional defiant disorder. If the factor loading of the items is to be confirmed in further studies, it might be necessary to revise these symptoms criterion in future editions of DSM-IV diagnostic criteria.

Full text

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Archives of Iranian Medicine, Volume 14, Number 3, May 2011179
Original Article
Abstract
Objective: One possible reason for being controversies regarding ADHD may be related to the validity and reliability of diagnostic criteria
of attention de?cit hyperactivity disorder and oppositional de?ant disorder. Diagnostic criteria of oppositional de?ant disorder include eight
symptoms. This study examines the factor structure of oppositional de?ant disorder symptoms, its discriminant validity from attention de?cit
hyperactivity disorder, its convergent validity and internal reliability.
Methods: Parents of 111 referral children and adolescents with attention de?cit hyperactivity disorder completed DSM-IV referenced
based attention de?cit hyperactivity disorder and oppositional de?ant disorder checklists.
Results: Factor analysis indicated that the attention de?cit hyperactivity disorder symptom of: “often has trouble organizing activities” and
“often runs about or climbs when and where it is not appropriate” were a part of the oppositional de?ant disorder component. These symp-
toms less often than other symptoms differentiate attention de?cit hyperactivity disorder from oppositional de?ant disorder. The convergent
validity for oppositional de?ant disorder symptoms ranged from 0.64 to 0.79.
Conclusion: The parent-rating checklist of oppositional de?ant disorder symptoms properly differentiates oppositional de?ant disorder
from attention de?cit hyperactivity disorder. However, two items of the attention de?cit hyperactivity disorder were listed as symptoms of
oppositional de?ant disorder. If the factor loading of the items is to be con?rmed in further studies, it might be necessary to revise these
symptoms criterion in future editions of DSM-IV diagnostic criteria.
Introduction
A
agnostic entity.1,2 According to the Diagnostic and Statisti-
cal Manual of Mental Disorders, fourth edition (DSM-IV), the
presence of at least six symptoms of inattentiveness or hyperactiv-
ity/impulsivity in addition to certain other conditions are required
to diagnose ADHD. The presence of some symptoms is not equal
to an ADHD diagnosis and is not reliable. Detection of pathologi-
cal symptoms or ADHD criteria and making a diagnosis are high-
ly dependent on the clinician’s experiences and judgment.3
Oppositional de?ant disorder (ODD) is a common psychiatric
disorder in children with ADHD. Its rate in clinical samples has
been reported from 30 to 60%.4,5 The most common co-morbid
disorder with ODD is ADHD.4 This high rate of co-morbidity has
raised the question whether ODD and ADHD are distinct clinical
entities. Some studies have reported these two disorders as dis-
tinct, however, they have many common variables.6,7
There are several reasons to have highly valid and reliable di-
agnostic criteria to differentiate ADHD from ODD. First, ODD
might mimic ADHD symptoms.4 Secondly, there is no real objec-
tive assessment for making a diagnosis of ADHD and subjective
reports are used. 3,4 Thirdly, in fact, what we usually use as ob-
s much as attention de?cit hyperactivity disorder (ADHD)
is a common psychiatric disorder, it is a controversial di-
jective measurements are rating scales. These measures provide
quantitative information based on ADHD criteria. Other objective
methods such as actigraphy are not diagnostic instruments. Ad-
ditionally, ADHD is not a disease with constructive validity, but
rather it is a cluster of symptoms. 4 ADHD lacks an underlying
unique genetic, neurologic and/or psychological etiology. There-
fore, clinicians have to use ratings scales and diagnostic criteria.
3 Also, a reliable symptom of ADHD or ODD criterion may be
repeated in further evaluations; however, each symptom should
have enough validity. Lack of suf?cient validity of the diagnostic
symptoms may cause a mistaken diagnosis or the inability to dif-
ferentiate distinct disorders such as ODD and ADHD from each
other.4 This consequence of mistaken diagnosis is not just limited
to treatment; it directly affects research results. Finally, there is a
serious concern that economical-related con?ict of interest may
raise the number of children diagnosed with ADHD.4 The above-
mentioned reasons emphasize the necessity for ADHD children to
be diagnosed as much as possible with more valid and reliable in-
struments. In other words, validity and reliability of the criteria is
a crucial subject. Rating scales with enough reliability and valid-
ity can decrease the discrepancy of results from different studies.
In a prior study, we compared factor structures from a Farsi
parents’ rating checklist with diagnostic de?nitions of ADHD as
described by DSM-IV diagnostic criteria in a clinical sample of
ADHD children. The 18-item checklist re?ected the DSM-IV def-
inition of ADHD. The two factors extracted were inattentiveness
and hyperactivity/impulsivity. In the two-factor model of factor
analysis, all items related to inattentiveness were loaded on one
factor and all hyperactivity-impulsivity related items were loaded
on the other factor of which both had suf?cient convergent and
discriminant validities. Internal reliability of the two factors was
excellent.8 However, more surveys in different cultures needs to
Overlap of ADHD and Oppositional De?ant Disorder
DSM-IV Derived Criteria
Ahmad Ghanizadeh MD•1
Keywords: ADHD, DSM-V, oppositional de?ant disorder, reliability, validity
Author’s af?liation: 1Research Center for Psychiatry and Behavioral Sciences,
Department of Psychiatry, Shiraz University of Medical Sciences, Hafez Hospi-
tal, Shiraz, Iran.
•Corresponding author and reprints: Ahmad Ghanizadeh MD, Research Cen-
ter for Psychiatry and Behavioral Sciences, Department of Psychiatry, Hafez
Hospital, Shiraz, Iran.
Telfax: +98-711-627-9319
E-mail: ghanizad@sina.tums.ac.ir
Accepted for publication: 22 September 2010
A. Ghanizadeh

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Archives of Iranian Medicine, Volume 14, Number 3, May 2011
180
be conducted to study the validity and reliability of ODD symp-
toms. It is recently reported that ADHD diagnostic classi?cation
should be broaden and ODD should be considered as an alter-
native presentation of ADHD.9 However, others do not con?rm
this view.9,10 Considering these controversies and debates, current
study surveys the factor structure of ODD symptoms, its discrimi-
nant validity from ADHD symptoms, its convergent validity and
internal reliability. It also examines whether there is any overlap
for ADHD and oppositional de?ant disorder DSM-IV-derived
items.
Materials and Methods
The sample consisted of 111 consecutively referred children
and adolescents with ADHD from a child psychiatric clinic. Pa-
tients and their parents were informed about the study. Participa-
tion was voluntary and all participants orally consented to take
part in the survey. The children and at least one of their parents
were interviewed face to face. Psychiatric diagnosis were made
using the valid, reliable Farsi version of the Schedule for Affec-
tive Disorders and Schizophrenia for School-Age Children ac-
cording to Diagnostic and Statistical Manual of Mental Disorders,
fourth edition (DSM-IV) diagnostic criteria.5,11 The ADHD and
ODD checklists of Child Symptom Inventory-4, a screening test,
were used.12,13,14 Parents reported ADHD and ODD symptoms
by completing the checklists. The ADHD checklist contained 18
symptoms, which included nine each from ADHD-inattentive
and ADHD-hyperactive impulsive types. The ADHD and ODD
checklists of Child Symptom Inventory-4 were translated into
Persian and re-translated into English. Its content validity was
con?rmed by several child-adolescent psychiatrists and psycho-
logists.13 Convergent and discrimina tion validities of the ADHD
checklist were adequate. The internal reliability for ADHD-inat-
tentive type, ADHD-hyperactive impulsive type, and combined
type of ADHD were 0.81, 0.85, and 0.83, respectively.8
The ODD checklist consisted of eight symptoms, which are
DSM-IV diagnostic criteria. The symptoms are scored on a Lik-
ert type scale with choices of: “never,” “sometimes,” “often,” and
“almost always.” In the categorical model of scoring, the number
of symptoms is counted. Score 0 refers to the category of “never/
sometimes,” and 1 refers to the category of “often/ almost al-
ways.” The maximum score is nine with a minimum score of zero
for each dimension of the ADHD criteria. Minimum and maxi-
Items
Factors
Oppositional
de?ant factor
Inattentiveness
factor
Hyperactivity-
impulsivity
factor
-0.317 “Often has trouble keeping attention on tasks or play activities”
“Often avoids, dislikes, or doesn›t want to do things that take a lot of mental effort for a long period of
time”
“Often has trouble organizing activities”
“Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other
activities”
“Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or
tools)”
“Is often easily distracted”
“Is often forgetful in daily activities”
“Often does not follow instructions and fails to ?nish schoolwork, chores, or duties in the workplace (not
due to oppositional behavior or failure to understand instructions)”
“Is often angry and resentful”
“Is often spiteful or vindictive”
“Often loses temper”
“Is often touchy or easily annoyed by others”
“Often blames others for his or her mistakes or misbehavior”
“Often argues with adults”
“Often deliberately annoys people”
“Often actively de?es or refuses to comply with adults› requests or rules”
“Often does not seem to listen when spoken to directly”
“Often runs about or climbs when and where it is not appropriate”
“Often gets up from seat when remaining in seat is expected”
“Is often «on the go» or often acts as if «driven by a motor»”
“Often ?dgets with hands or feet or squirms in seat”
“Often has trouble playing or enjoying leisure activities quietly”
“Often talks excessively”
“Often blurts out answers before questions have been ?nished”
“Often interrupts or intrudes on others”
“Often has trouble waiting one›s turn”
Extraction Method: Maximum likelihood.
0.3760.759
0.212 0.822 -0.263
0.4680.446 -0.404
0.3820.550 -0.395
0.284 0.793 -0.365
0.219
0.185
0.802
0.546
-0.295
-0.287
0.224 0.544-0.283
0.402
0.363
0.345
0.404
0.378
0.374
0.447
0.607
0.547
0.530
0.772
0.648
0.534
0.605
0.598
0.636
0.843
0.828
0.525
0.404
0.415
0.356
0.335
0.297
0.346
0.457
0.521
0.355
0.140
0.176
0.494
0.327
0.358
0.229
0.311
0.457
-0.337
-0.765
-0.783
-0.867
-0.776
-0.802
-0.559
-0.600
-0.592
-0.444
-0.394
-0.544
-0.537
-0.574
-0.358
-0.199
-0.372
-0.446
Table 1. Con?rmatory factor analysis with three factor solution.
ADHD and Oppositional De?ant Disorder

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Archives of Iranian Medicine, Volume 14, Number 3, May 2011181
mum scores for ODD symptoms are 0 and 8, respectively.
Statistical analysis
Data was statistically analyzed using SPSS for Windows statisti-
cal software. Con?rmatory factor analysis was applied to examine
the factors loading for items of ADHD and ODD. Because of the
interdependency of ADHD and ODD, an oblique rotation method
was used. The Kaiser-Meyer-Olkin Measure of Sampling Ade-
quacy and Bartlett’s Test of Sphericity were conducted to indi-
cate if the data were suitable for factor analysis. Cronbach’s alpha
was used to assess internal consistency, reliability, or the extent
to which items measured the same concept for each of the factors
in the questionnaire. Pearson’s r correlation coef?cient was used
to examine convergent validity of ODD symptoms and assess the
discriminant validity of ODD from ADHD symptoms.
Results
The mean age of the children was 9.2 years (standard deviation:
1.9). About 80% were boys. The Kaiser-meyer-olkin Measure
was 0.84 and Bartlett’s Test of sphericity criteria for factor analy-
sis was 0.001, which supported that the data met the criteria for
factor analysis. The three-factor solution accounted for 51.3% of
the total variance. Table 1 shows the loading of items on the three
factors.
Component one was named the oppositional behavior symp-
toms factor. There were eight items that loaded strongly on this
factor from 0.44 to 0.86.
Component two consisted of nine items that were named inat-
tentiveness items, which had a range of loading from 0.52 to 0.82.
All ODD items were loaded in the ODD component more than the
other two components.
Table 1 indicates that the item of “Often has trouble organizing
activities” similarly loaded in both the ODD (0.46) and inatten-
tiveness (0.44) components.
The item of “Often runs about or climbs when and where it is
not appropriate” was loaded on the ODD component more than
hyperactivity-impulsivity component.
The Cronbach’s ? calculation for the eight ODD items was 0.88
with a convergent validity range of 0.64 – 0.79. Regarding dis-
criminant validities, the ranges of ODD items correlations with
inattentiveness and hyperactivity/impulsivity were 0.16 – 0.41
and 0.42 – 0.58, respectively (Table 2).
Convergent validity shows the correlation of each criterion with
the mean score of the scale that the criterion belongs to. For exam-
ple, the range of correlation of the inattentiveness criteria with the
mean score of the inattentiveness scale was 0.60 to 0.79. Its dis-
criminant validity with hyperactive/impulsivity and ODD mean
scores were 0.39 (P<0.001) and 0 .41 (P<0.001).
Discussion
In a previous study, the components of ADHD which included
inattentiveness and hyperactivity-impulsivity were extracted as
proposed by the DSM-IV classi?cation.8 All of the inattentiveness
items were loaded on the component of inattentiveness. However,
the factor loading for the item of “Often has trouble organizing
activities” for ODD and inattentiveness components were very
similar. In fact, it was higher in the ODD component than the inat-
tentiveness component of which, according to DSM-IV, it actu-
ally belongs.
One possible explanation is that the concept or construct mea-
sured by this item in the Farsi version is not equal to the original
English version. However, its face validity has been previously
con?rmed.13,14 If more studies con?rm this ?nding, it might be
necessary to revise “Often has trouble organizing activities” in the
DSM diagnostic criteria. In addition, current results indicate that
ODD symptoms have suf?cient convergent validity and discrimi-
nant validity. In other words, ODD symptoms can be well-differ-
entiated from ADHD items. However, the current results differ
with previous study results where few items of hyperactivity were
loaded on the impulsivity factor.8 Whereas, in the current study,
all hyperactivity and impulsivity items were loaded on the factor
as proposed by DSM-IV, with the exception of: “Often runs about
or climbs when and where it is not appropriate”.11 The internal
reliability of ODD items in the current study was very similar to
an Italian study, which was 0.84.1 This indicates a high degree of
internal consistency.
Current results indicate that the use of an ODD- and ADHD-ref-
erenced items checklist is a valid and reliable instrument15, which
is in accordance with many previous studies in other cultures.16,17
In addition, parents are sensitive in identifying and differentiating
between ODD and ADHD.1 Therefore, considering covariant ef-
fect of ODD and ADHD is very important.
There are some limitations that need to be considered. Both K-
SADS and CSI-4 survey symptoms according to DSM-IV diag-
nostic criteria from a clinical sample that this may impact current
results. the sample was from a specialized clinic. So, generaliza-
tion of the results to general population is not guaranteed. Further
studies from general population with a large sample size are rec-
ommended.
Considering that the parent-rating checklist properly differenti-
ates between ADHD and ODD, its use is recommended for de-
creasing discrepancies among different studies’ results by accu-
Scale
Number of items
per scale
Convergent
validity (range of
correlation)
Discriminant validity
with oppositional
de?ant disorder (range
of correlation)
Scaling success (for
discriminant validity)
Scaling
success rate
Inattentiveness9 0.60 – 0.790.16 – 0.419/9100
Hyperactive/impulsiveness9 0.64 – 0.790.42 – 0.589/9100
Oppositional de?ant disorder8 0.64 – 0.79———
Table 2. The range of convergent validity and discriminant validity for the items of the oppositional de?ant disorder checklist.
A. Ghanizadeh

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Archives of Iranian Medicine, Volume 14, Number 3, May 2011
182
rate screening of children with ODD. Moreover, if the loading of
the items, “Often has trouble organizing activities” and “Often
runs about or climbs when and where it is not appropriate” should
be con?rmed in further studies, revision of this symptom criterion
might be necessary in future editions of DSM-IV diagnostic cri-
teria. In addition, it may also indicate that the Farsi translations of
these two items are not equal to the original English versions and
therefore their Farsi translations need to be revised.
Acknowledgement
There are no con?icts of interest or commercial support of the
author.
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ADHD and Oppositional De?ant Disorder