Gender Differences in Children With ADHD, ODD, and

Co-Occurring ADHD/ODD Identified in a School Population

CARYN L. CARLSON , PH.D ., LEANNE TAMM, M.A., AND MIRANDA GAUB , B.A.

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)
including attention-deficit/hyperactivity d isorder
(AOHO), conduct disorder (CD), and oppositional
defiant disorder (ODD) in children has become increas-
ingly more responsive to issues that may enhance
understanding of potential influences on their course
and outcome. Two such issues are co-occurrence among
the OBOs and gender differences.
Co-Occurrence Among the DBDs
Data from both epidemiological and clinical popu-
lations suggests that co-occurrence among the OBOs is
Arupud May 22. /997.
From th~ Univmity ofTncas at Austin.
Portionsofthm data Irr presentedat th NIMH 5r.K Diffirrnm in ADHD
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
MH49827. awartkd to tb jim auth or. The study was made possibl through
collaboration with th Hogg Foundation School of thr Future Projut. The
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
their many houn ofdata mtry.
Reprint requests to Dr. Carlson. Departme nt of Psyrhology. M~us 33 0.
Univmity ofTncas at Austin, Austin. TX 787/2.
08 90 -8567/97/3612-1706/$O.300 /0 1997 by the American Academy of
Child and Adolescent Psychiat ry.
quite high. The overlap between "hyperactivity" and
"aggression" in clinical samples has been estimated to
be between 30% and 90% (Hinshaw. 1987). Somewhat
Jower estimates of co-occurrence are found in non-
referred populations. though such studies still reveal
sizable overlap. In a recent study of 7.231 schoolchil-
dren screened for the presence of disruptive behavior.
ODD was present in 32% and CD in 12% of those
with AOHO (August et al. , 1996). Overall, co-
occurring diagnoses characterize at least a sizable sub-
group of children with OBOs.
There is increasing recognition among researchers of
the critical importance of both documenting and elu-
cidating the effects of comorbidity among childhood
disorders. The influential research published in the
1980s suggesting that many of the poor outcomes that
had previously been attributed to ADHO were actually
linked to the co-occurrence of aggression and/or CD
(e.g., August et al., 1983; Schachar et al. 1981) alerted
researchers to the potential influence of comorbidity in
disentangling causes and correlates of disorders and
their outcomes . There is growing consensus that chil-
dren with overlapping AOHO and conduct problems

1706 J. AM . ACAD. CHILD ADOLES C. PSY CHIATRY, 36:12. DECEMB ER 199 7

 GENDER DIFFERENCES IN ADHD , ODD , AND ADHD/ODD
are more disturbed than those with either single diag-
nosis; the co-occurring group displays an earlier age of
onset and more severe aggressive, antisocial, academic,
and social impairment (Hinshaw et al., 1993).
Unfortunately, research considering co-occurrence
among the DBDs remains the exception rather than .the
rule. The failure to consider co-occurring disorders in
much of the DBD research seems at least partly attrib-
utable to practical reasons; examining groups of chil-
dren with and without comorbid conditions requires
large populations which may be inaccessible to individ-
ual researchers. While the recent trend of documenting
rates of co-occurring conditions in research populations
is laudable, few studies examine such conditions as
independent grouping variables.
Gender Differences in the DBDs
Research examining gender differences in the DBDs
also remains scant. DBDs are less prevalent in girls
(American Psychiatric Association [APAJ, 1994), and
studies typically include too few girls to warrant sep-
arate data analyses, or they exclude girls altogether. The
majority of prevalence studies conducted with children
report higher rates of ODD in boys, with male-to-
female ratios ranging from 1.5:1 to 10:1 (Rey, 1993).
CD prevalence rates range between 6% and 10% for
boys and between 2% and 9% for girls (APA, 1994).
Obtaining adequate samples of girls with DBDs to
examine gender differences is likely to be particularly
problematic when subjects are recruited from treatment
clinics, since girls seem to be most underrepresented in
referred samples. For example, prevalence estimates
of ADHD in clinic samples typically find up to a nine-
fold greater incidence in boys (APA, 1994), whereas
population-based studies typically report smaller gender
disparities of 2: 1 to 4:1 (APA, 1994; Gaub and Carlson,
1997aj Szatmari et al., 1989).
In a meta-analysis of gender differences in ADHD,
Gaub and Carlson (l997b) found. among other results,
that some gender differences were clearly moderated by
the effect of referral source. Among children with
ADHD identified from nonreferred populations, girls
with ADHD displayed lower levels of inattention, less
internalizing behavior, and less peer aggression than
boys with ADHD. However, girls and boys with
ADHD identified from clinic-referred samples did not
J. AM . ACAD. CHILD ADOL ESC . PSYCHIATRY. 36:12. DECEMB ER 19 9 7
differ in level of impairment on these variables. Since
girls referred to clinics were as impaired as their male
counterparts, the authors concluded that girls with
ADHD seen in treatment settings represented the most
severely affected of the girls with ADHD.
Few studies have assessed qualitative gender differ-
ences in the behavioral correlates associated with
ODD/CD. In a recent review. Goodman and Kohlsdorf
(1994) conclude that limited data suggest that aggression
in girls is not characterized by the poor information-
processingand moral-reasoning problems found in boys.
These authors note, however, that these and other
diagnostic and behavioral correlates of conduct prob-
lems in girls are greatly underresearched.
Clinic Versus Nonreferred Populations
Studying childhood behavior disorders using clinic
populations may be problematic to the extent that
referral bias makes such populations unrepresentative of
the general population of disordered children. Impor-
tantly, the use of clinical populations to examine co-
occurrence among the DBDs may skew findings , as
referred populations are atypical in their overrep-
resentation of subjects with more than one diagnosis
(Berkson, 1946). Furthermore, given the relatively
greater underrepresentation of girls in clinic versus
population-based samples of children with DBDs, and
the suggestion that a more severe pattern of dysfunction
is found in girls with ADHD from referred versus non-
referred populations (Gaub and Carlson, 1997b), the
use of population-based samples to study DBD gender
differences may be particularly appropriate.
The Current Study
In the current study, a school-based population was
used to examine teacher perceptions of gender differ-
ences in prevalence and behavioral correlates of "pure"
ODD, "pure" ADHD-C (combined type), and co-
occurring ADHD-C/ODD. Boys and girls diagnosed
by teacher ratings were compared with each other and
with nondiagnosed controls on Achenbach Teacher's
Report Form scales, symptom ratings, and ratings of
social functioning. The goals of this study were to
enhance the existing literature by examining co-
occurrence and gender differences in DBDs using a
large, school-based sample to prevent contamination by
referral bias.
1707
CARLSON ET AL.

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.

METHOD 103 children with co-occurring ADHD-C/ODD (76 boys, 27 girls).

Participants and Procedure
Data for this study were collected under the auspices of a large-
scale research program. the School of the Future Project (SO F).
SOF was a 5-year program implemented by the Hogg Foundation
from 1990 to 1995 to provide school-based mental health inter-
vention in several low-income areas in Texas. An annual evaluation
of students (including teacher ratings) which assessed the effective-
ness of service delivery in these schools provided data for the current
study.
Data were collected during April 1994 for all children with
parental con sent (roughly 96% of eligible children) . The final
sample consisted of 2.984 children (\,562 boys. \,422 girls) from
nine elementary (K-5) schools with sufficient data available for the
1993-1994 year. The sample was screened for children who met
DSM-IV teacher rating criteria for ADHD-C , ADHD-predomi-
nandy inattentive (IA), ADHD-predominandy hyperacti ve-
impulsive (HI) , ODD, and co-occurring diagnoses. Children were
assigned d iagnoses according to DSM-IV criteria. with items
endorsed as "very much" or "quite a bit" tallied as symptoms. Thus,
children with six or more inattentive and six or more hyperactive-
impulsive symptoms received ADHD-C diagnoses, those with six or
more inattentive and fewer than six hyperactive-impulsive symptoms
received ADHD-IA diagno ses. those with six or more hyperactive-
impulsive and fewer than six inattentive symptom s received ADHD-
HI diagnoses. and those with four or more ODD symptoms
received ODD diagnoses. More lenient diagnostic criteria than
those used in a previous study (Gaub and Carlson , 1997a) were nec-
essary for the current report. to ensure an adequate number of girls
for gender analyses. Thus, although the ADHD-C group included
in the current study overlaps with that in the previous report , the
samples are not directly comparable because the previous report used
a stricter symptom cutoff.
These criteria identified 94 children with "pure" ODD (59 boys.
35 girls). 57 children with "pure" ADHD-C (46 boys. II girls), and
Because the number of females in the ADHD-IA and ADHD-HI
groups was too small to allow adequate statistical examination, these
groups are identified in the prevalence table but only ADHD-C sub-
type is included in additional analyses. It should be noted that the
"pure" ODD group excludes children with ADHD-IA and ADHD-
HI diagnoses (in addition to excluding those with ADHD-C
diagnoses). For each child with a diagnosis, a control matched for
grade, gender, and ethniciry was chosen, yielding a control group of
254 children (181 boys, 73 girls). When possible, controls for each
d iagnosed child were chosen from the same classroom (17% were
from different classrooms in the same school, and 2% were from
different schools). This sample was predominantly Hispanic , and
from middle to lower socioeconomic status (SES) as assessed by
Duncan's Sociometric Index (Stevens and Featherman, 1981). The
mean age for the sample (n = 508) was 7.83 (SD = 1.76), and the
mean SES (available only for 44% of the sample) was 22.94 (SD =
7.26); groups did not differ significantly on either variable. Table I
provides demogr aphic characteristics.
Measures
DSM-IV Rating Scal for ADHD and ODD. This teacher-com-
pleted diagnostic symptom checklist (which updates the DSM-lII
SNAP and the DSM-IlI-R DBD rating scale) (Pelham et al., 1992)
co nsists of all DSM-IV ADHD and ODD sym p to ms. The
symptoms, which closely parallel DSM-IVwording, are rated on a 4-
point scale and can be assigned a 0 to 3 value (0 = "not at all," I =
"just a little," 2 = "quite a bit," or 3 = "very much.").
Child Behavior Chrcklist-Teacher': Report Form (CBCL- TRF). The
CBCL-TRF is a widely used, standardized tool for the assessment of
childhood functioning and impairment, with adequate reliability
and validity (Achenbach, 1991). Teachers rated children on problem
items as 0 ("not true"), I ("somewhat true") , or 2 ("very true/often
true") . Because t scores are based on gender norms , raw scores were
used in analyses to allow direct gender comparisons .

1708 J. AM. ACAD. C H I L D ADOLES C. PSYCHI ATRY. 36 :12. D ECEMBER 1997

 GENDER DIFFERENCES IN ADHD, ODD, AND ADHD/ODD

;R '<l' .:.. Social Functioning Assessment. Teachers rared children on three

~o 0 0

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
'"

dent variables (when appropriate, Levene's correction

for violations of the homogeneity assumption was
rS::r:: '"
t:; '"
0
used). Table 3 reports the results of these analyses.
~ ~
N 00 0
~~~ 'I" :
0
=U UII Simple effects of gender were found for five variables,
C;o~ '0
ca-~ '"~ 0 N N'<l' ::r::;R ~r:::~ 00 with girls rated as showing more appropriate behavior,
w
rS~z
\0 N 00
l/"\ '<l' 0'\ ~e.... ::r:: o lower attention problems, higher peer dislike scores, and
v.l~ -:-:N' ~ as
"
... ~.~ lower aggression and externalizing scores (these latter
'>''''''i:
" '" ca"'"' '>'''''i:
" '" ca"""' ~6.. two scores were qualified by significant interactions, dis-
~0rS
0'- 0
a::Ic..?f-'" .5 cussed below).

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 36:12. DECEMBER 1997 1709

CARLSON ET AL.

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.
On the TRF adjustment variables, the control group
was rated as functioning significantly better than the
three diagnostic groups. The ODD group had higher
rates of working hard and learning than AOHD-C or
ADHD-C/ODD groups . The ADHD-C/ODD group
was perceived as showing less appropriate behavior than
the ODD and ADHD-C groups and as being more
unhappy than the ADHD-C group.
On the TRF Behavior Problem scales, the ADHD-
c/ODD group was rated as significantly more impaired
than the other three groups . Children with ODD
received higher ratings on Withdrawn, Anxious/
Depressed, and Internalizing scales than controls; chil-
dren with ADHO-C did not differ from those with
ODD or controls on these scales. Children with
ADHD showed higher rates of Attention Problems
than children with ODD; both were rated higher than
controls . Children with ODD and those with AOHD-
C did not differ on ratings of Social Problems, Thought
Problems, or Total Problem score; both groups showed
higher ratings than controls. Children with ODD
received higher Aggressive Behavior and Externalizing
scores than children with ADHD-C, and both groups
received higher ratings than controls. On Delinquent
Behavior, children with ADHD-C and those with
ODD received higher ratings than controls (these latter
three variables and Total Problem score were qualified
by gender by group interactions, discussed below).
For peer like and dislike ratings, the ADHD-
C/ODD group was rated as most impaired and the con-
trol group as least impaired , with ADHD-C and ODD
groups not differing from each other. The ADHD-
C/ODD group was perceived as more ignored than
ODD and control groups; ADHD-C and ODD groups
were both rated as more ignored than controls.
Significant gender x group interactions were found
for Delinquent Behavior, Aggressive Behavior. External-
izing, and Total Problem scores. To explore these inter-
actions, t tests were used to compare boys and girls
within each diagnostic group. For Aggressive and
Externalizing behavior, girls received lower ratings than
boys in the ADHD-C and the ODD groups; no gender
differences emerged in ADHD-C/ODO or control
groups. Although no pairwise gender comparisons
yielded significant t test findings for Delinquent
Behavior or Total Problem scores, the pattern of means
showed lower scores for girls versus boys in the ADHD-
J. AM. ACAD . CHILD ADOL ESC. PSYCHIATRY. 36:12, DE C EMB ER 199 7
C, ODD, and control groups and higher scores for girls
versus boys in the ADHD-C/ODD group.
Planned comparisons to explore gender differences
within group were conducted via t test analyses on each
variable. In addition to the findings discussed above,
significant results were found for only four variables.
For both ODD and control groups, girls were rated as
showing more appropriate behavior and fewer attention
problems than boys. In addition, girls with ODD were
rated as less happy and showing higher social problems
than boys with ODD.
Group Comparisons on Symptom Patterns
To examine whether singly diagnosed and co-occur-
ring groups differed with regard to type of symptoms
displayed, 2 (diagnostic group) X 2 (gender) analyses of
variance were used to compare the 0 to 3 symptom
ratings of the children with AOHD-C to those with co-
occurring ADHD-C/ODD on the 18 DSM-IV ADHD
symptoms. Analyses also compared children with ODD
and co-occurring ADHD-C/ODD on the eight DSM-
WOOD symptoms.
Comparisons between the ADHO-C and co-occurring
ADHD-C/ODD groups revealed no simple effects for
gender. Group differences were found for five symp-
toms, indicating greater severity in the co-occurring
ADHD-C/ODD group than the ADHD-C group on
symptom ratings of "fails to give close attention to
details or makes careless mistakes" (F[I,155] = 7.17,p =
.008), "talks excessively" (F[l, 155] = 4.28, P = .04),
"difficulty waiting turn" (F[I,155] = 11.29, P = .00l),
and "interrupts or intrudes on others" (F[I,155] =
15.96,p = .000). The other symptom, "does not seem to
listen," on which a significant group effect was obtained
(F[I,155] = 6.00,p = .015) was qualified by a trend for
a group by gender interaction (F[I,155] = 3.72. P =
.0 55); in the ADHD-C group, boys received
significantly higher ratings than girls (p = .017), whereas
there was a trend in the ADHD-C/ODD group for
girls to receive higher ratings than boys (p = .060).
For comparisons between the ODD and co-
occurring ADHD-C/ODD groups, simple effects of
gender were found for two symptoms, indicating lower
ratings for girls than for boys on "loses temper"
(F[l,l92] = 6.29, P = .013) and "argues with adults"
(F[ 1,191] = 4.08, P = .000). Significant group effects
were found for five symptoms, with the ADHD-
C/ODD group receiving more severe ratings than the
1711
CARLSON ET AL.
ODD group on "argues with adults" (F[I,191] = 15.18
P = .000), "deliberately annoys people" (F[ 1, 192] =
36 .17, P = .000), and "touchy or easily annoyed"
(F[I,191] = 4.16, P = .043). For the other two
symptoms that yielded simple group effects, "defies or
refuses to comply" (F[I,I92] = 20.81, P = .000) and
"blames others for mistakes" (F[ 1,192] = 21.24, P =
.000), significant group by gender interactions indi-
cated that the boys with ODD were rated more severely
than the girls with ODD (p < .02 and p < .03,
respectively) but that there were no gender differences
in symptom severity in the ADHD-C/ODD group .
DISCUSSION
Consistent with previous research showing high over-
lap among DBDs, in the current sample about two
thirds of children with ADHD-C met criteria for co-
occurring ODD and about one third of children with
ODD met criteria for co-occurring ADHD-C. These
results extend previous work by finding similar rates of
co-occurring ODD in ADHD-C girls (71%) and boys
(62%), and similar rates of co-occurring ADHD-C in
ODD girls (36%) and boys (37%) . Also, as expected
from previous research showing more severe correlates
and outcomes of children with comorbid ADHD-C
and externalizing problems (Hinshaw et aI., 1993), the
current results found that the co-occurring ADHD-
C/ODD group was rated as significantly more impaired
than the other three groups on nearly every dependent
variable. Thus, the co-occurring ADHD-C/ODD group
was rated as showing significantly less appropriate beha-
vior and significantly higher Internalizing, External-
izing, and Social Problems than either the "pure"
ADHD-C or ODD groups. The co-occurring group
also showed higher symptom ratings than their singly
diagnosed counterparts for 5 of the 18 ADHD symp-
toms and 5 of the 8 ODD symptoms. It is interesting
that the co-occurring group was rated more severely
than the "pure" ADHD-C group on two of the three
impulsivity symptoms. Halperin er al. (1990) found
that children with mixed hyperactive/aggressive
behavior were most impulsive on a continuous perform-
ance task; current results suggest that behavior ratings
also reflect highest impulsivity among those ADHD-C
children with co-occurring externalizing problems. No
gender differences were found within the co-occurring
ADHD-C/ODD group on TRF scales, though girls
1712 ] . AM . ACAD. C H I L D AD OLES C. PSYCHIATRY, 3 6 :12 . D ECEMBER 1997
received lower ratings than boys on the ODD symptoms
"loses temper" and "argues with adults," and there was a
trend (p < .06) for girls to be rated higher than boys on
the ADHD symptom, "does not seem to listen."
Children in the "pure" ADHD-C and ODD groups
showed interesting patterns of associated deficits.
Relative to controls , both groups received significantly
poorer ratings on adjustment variables, Social Problems,
Somatic Complaints, and Attention Problems. Children
with ADHD-C received poorer ratings on variables
reflecting academic performance (inattention, learning,
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
ODD received higher ratings on Anxious/Depressed
and Withdrawn scales, whereas children with ADHD-
C did not differ. Thus, "pure" ADHD-C children did
not show abnormal levels of internalizing problems.
August et al. (1996) also found in their school-based
sample that mood and anxiety disorders occurred
infrequently with ADHD alone, but they were more
likely to be seen in combination with multiple DBDs.
High rates of comorbidity between ADHD-C and
internalizing problems have been found in some studies
(Biederman et al., 1991). The role of co-occurring
ODD in influencing the presence of internalizing
symptoms in children with ADHD-C warrants further
investigation, particularly with clinical samples.
Some gender differences emerged among the "pure"
ADHD-C and ODD groups, indicating relatively
poorer functioning among boys than girls. For both
ADHD-C and ODD groups, aggression ratings were
significantly higher in boys than girls; this pattern is
consistent with those from the meta-analysis (Gaub and
Carlson , 1997b), suggesting lower rates of aggression in
girls among nonreferred samples of children with
ADHD-C. In addition, the girls with ODD were rated
as showing more appropriate behavior and fewer atten-
tion problems , but being more unhappy, than the boys
with ODD. Symptom ratings indicated that, among
children with ADHD-C, boys showed more severe
ratings on "does not seem to listen" and that, among
children with ODD, boys showed more severe ratings
on "loses temper," "argues with adults, " "defies or
refuses to comply," and "blames others." Thus, girls
from the ADHD-C and ODD groups were somewhat
less impaired than boys in their symptom severity and
aggressive, inappropriate behavior.
 GENDER DIFFERENCES IN ADHD , ODD, AND ADHD/ODD
Incons istent but suggestive evidence emerged that
girls with DBDs have poorer social functioning than
boys. On the peer dislike variable, a main effect for
gender revealed higher dislike scores for girls than boys.
Although t tests comparing genders within each group
revealed no significant differences, this suggests a gen-
eral trend across DBD groups for higher dislike ratings
among girls. In addition, among children with ODD,
girls received higher ratings than boys on the TRF
Social Problems scale. Cohen (1989) investigated gen-
der differences in a clinically referred population, 69%
of whom had CD as their primary presenting problem .
Cohen (1989) reported that on the "School" subscale of
the CBCL Social Competence scale, girls were rated by
their parents as significantly less competent than males.
Although gender differences were not found for the
total Social Competence scale, this parent rating of
clinic-referred girls' difficulties in social relations at
school seems consistent with the observations made by
teachers in our nonreferred sample.
The need to explore why girls with DBDs may be at
higher social risk despite similar (or less severe) beha-
vioral patterns is apparent. It is possible that behaviors
associated with externalizing behavior problems are
more congruent with social expectations generally held
of boys. Because preadolescent boys and girls tend to
segregate by gender (Maccoby, 1990), the behavior of
girls with DBDs may be perceived as more disturbing,
thus leading to less social acceptance. Kavanagh and
Hops (1994) speculated that aggressive behavior in a
preadolescent girl, exceeding normative criteria, would
stand out far more in contrast to same-sex peers than
would that in a boy. It is possible teachers may have
been susceptible to the same normative gender expecta-
tions and rated the girls as less socially competent. This
conclusion would predict that the degree of social
rejection of girls would vary across culture and ethniciry
based on the socialized gender expectations of groups;
these areas require further exploration.
One hypothesis about the higher level of unhap-
piness among girls with ODD than boys with ODD is
that their poorer peer relationships are especially dis-
turbing to them. Girls tend to show greater sensitivity
to potentially negatively influential peer relations and
peer group disruption than boys (e.g., Gavin and
Furman , 1989). It is interesting that ADHD girls (who
did not differ from ADHD boys in ratings of hap-
piness) were rated as significantly happier than ODD
J. AM . AC AD . CHILD AD OLESC. PSYCHIATRY, 36:12 , D EC EMBER 199 7
girls (t[42] = 2.17; p = .036). Despite the peer rejection
and difficulty modulating social behavior in accordance
with situational cues and role prescriptions seen in chil-
dren with ADHD, they continue to seek out social
relations with others (Whalen, 1989). Girls with ODD
may be more socially aware of the subtle nuances of
peer relationships and as a result be unhappier about
their poor social status.
Limitations
One possible limitation of this study is the extent to
which the results can be generalized to the overall pop-
ulation, since the current sample was predominantly
Hispanic and of low SES. Ethnic and cultural studies
have revealed differences in social expectations for males
and females across cultures. The Hispanic culture, in
particular, has strict expectations for the behavior of
females, stressing the importance of their obedience and
compliance, while tending toward permissiveness with
the behaviors exhibited by males (Paniagua, 1994).
Thus, externalizing behavior in girls may be particularly
incongruent with cultural expectations of behavior,
leading to greater social consequences in this sample.
This possibility merits further exploration. Since a pre-
vious article based on this sample exploring DSM-1V
subtype differences in ADHD (Gaub and Carlson,
1997a) yielded results consistent with two other
methodologically similar studies, however, ethniciry
does not seem to pose a general limitation to the
generalizability of results.
A second limitation is the exclusive use of teacher
ratings on a symptom checklist both to assign diagnoses
and rate dependent variables . This is problematic
because neither the age of symptom onset nor informa-
tion regarding cross-situationaliry (i.e., parent reports)
was obtained. However, prevalence estimates are con-
sistent with those reported in previous epidemiological
reports, indicating that the criteria used to classifychil-
dren were not overly inclusive. Furthermore, the levels
of deviant behavior demonstrated in diagnosed groups
suggested that these children were experiencing diffi-
culties at a clinically significant rate across a range of
domains.
Finally, a caveat must be made regarding ODD
classification. Although CD symptoms were not
assessed, some children included in the ODD group
may have had CD diagnoses and thus would not have
received ODD diagnoses by DSM-IV criteria (in which
1713
CARLSON ET AL.
a diagnosis of ODD is precluded if CD is present).
Since virtually all children with CD qualify for ODD
diagnoses (e.g., Frick et al., 1992), the "ODD" group in
the current study may be more accurately described as a
mixed CD/ODD group. This practice seems justifiable;
it is not inconsistent with the current body of literature,
diagnostic criteria are such that receiving a diagnosis of
CD in elementary school is relatively rare, and recent
findings suggesting that ODD may be a milder variant
or a developmental precursor to CD have led some to
conclude that ODD and CD may not warrant diagnos-
tic separation (e.g., Achenbach, 1993; Schachar and
Wachsmuth, 1990).
Clinical Implications
These results illustrate that both gender and co-
occurrence among disorders have an impact on the
expression of DBDs in children. Specifically, both boys
and girls with co-occurring ADHD-C/ODD may be
expected to show severe and pervasive dysfunction. The
presence of ODD should alert clinicians to assess for
int ernalizing symptomatology, given the specific link
berween ODD and ratings of withdrawn and anxious/
depressed behavior. Academic functioning should also
be evaluated: although both ODD and ADHD-C chil-
dren were rated higher on learning problems than con-
trols, these problems were most severe in children with
ADHD-C. Finally, although girls in the "pure" ADHD-
C and ODD groups may show milder symptom
severity and less aggression, they appear to be at a parti-
cularly high risk for social dysfunction. It may be useful
to assess parents', teachers', and peers' views of girls with
DBD, with cultural and familial expectations being a
potentially relevant aspect of this assessment.
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