Nevertheless, a Medline and Psycinfo literature search failed to turn up any studies directly examining the relation of oppositionality and anxiety, other than 1 case report (14) and observations on the relation of insecure attachment in preschoolers to externalizing problems or controlling attachment patterns (15). Yet, the common occurrence of defiance in the context of anxiety, particularly phobic, panic, and separation anxiety, is illustrated in typical case examples in review articles (16) and textbooks (9). Neither the prevalence of oppositional defiance in children with anxiety disorders nor implications for treatment and prognosis have been examined. To begin to address this gap in the literature, this study examines the occurrence and correlates of oppositional features in preadolescent children referred to a specialized mood and anxiety disorders clinic. In addition to an expected relation between attention-deficit hyperactivity disorder (ADHD) symptoms and oppositional defiance, we predicted that children with more anxiety symptoms would also have increased oppositional defiant features.

Methods

Setting

This study was carried out in a specialized mood and anxiety disorders clinic that receives referrals for diagnostic assessment and treatment recommendations for children with symptoms of anxiety and mood disorders. This clinic is one of several subspecialty clinics (for example, urgent assessment, general psychiatry, ADHD, neuropsychiatry, infant psychiatry, and eating disorders clinics) within a large outpatient department that is the referral centre for British Columbia. Clinic programs include a group cognitive-behavioural treatment program for children with anxiety, “Taming Worry Dragons.”

Staff Survey

To examine common clinical experience, we surveyed professionals in the psychiatric outpatient department regarding their observations on the relative presence of oppositional defiant behaviours (as

listed in DSM-IV criteria) in children with anxiety, compared with typical children and children with other psychiatric diagnoses.

Chart Review

We reviewed the charts for all children aged 6 to 12 years referred to the mood and anxiety disorders clinic in the 2-year period from January 1, 1998, to January 1, 2000. Each child had a psychiatric diagnostic assessment including DSM-IV diagnoses, and parents and teachers completed the DSM-IV Child Symptom Inventory (CSI) (17). The CSI parent and teacher inventories yield dimensional scores for symptom severity and criteria-based cut-offs for psychiatric diagnoses; these have been shown to have good reliability, compared with a structured diagnostic interview, the Schedule for Affective Disorder and Schizophrenia for School-Age Children (K-SADS). In this retrospective chart review, the parent and teacher DSM-IV CSI reports for each referred child were scored dimensionally for symptoms of GAD, oppositional defiant disorder (ODD), and ADHD. In addition, we noted diagnostic cut-off scores for DSM-IV diagnoses. The clinical psychiatric diagnoses, based on comprehensive interviews of the child and family, as well as on rating scales and collateral information from teachers, were also recorded.

Statistical Analysis

We obtained statistical consultation. Data were entered into the computerized Statistical Package for the Social Sciences 8.0 (18) to record sex, age, and all clinical diagnoses and comorbidity, as well as CSI categorical and dimensional scores for anxiety, oppositional defiant, and ADHD symptoms. Statistical analyses included frequencies of diagnoses, mean scores for symptom categories, and 2-tailed Pearson correlations between oppositional dimensional scores and anxiety scores for parent and teacher ratings, with and without controlling for ADHD symptom scores.