Objective:  While parents and clinicians have described oppositional features as interfering with the management of children with anxiety, research on this relation is lacking. We designed this study to investigate the presence of oppositional symptoms in children presenting with mood and anxiety symptoms.
Method:  In a mood and anxiety disorders clinic, we used the DSM-IV Child Symptom Inventory to document the presence and correlates of oppositional defiant symptoms in 145 preadolescents assessed during a 2-year period.
Results:  Oppositional defiant symptoms were found to correlate (P < 0.01) with generalized anxiety symptoms in both parent and teacher ratings. Correlations remained significant after controlling for the presence of symptoms of attention-deficit hyperactivity disorder (ADHD). Parents found both boys and girls to be equally oppositional, while teachers found boys to be significantly more oppositional.
Conclusion:  Oppositional features are found in clinically referred children with anxiety and are potentially significant for treatment and prognosis of anxiety disorders in children.

(Can J Psychiatry 2001;46:953–958)

Key Words:  oppositional defiant disorder; childhood anxiety disorders

Avoidance is a characteristic manifestation of anxiety disorders and is a core feature of the diagnostic criteria for separation anxiety disorder (SAD), agoraphobia, social phobia, and specific phobias (1). In children, this avoidance will frequently manifest as extreme opposition to complying with developmentally appropriate expectations that provoke anxiety. The symptom of refusal to attend school is a long-researched presentation of anxiety disorders in children (2–8), antedating the more recent diagnostic classifications. While school refusal is a nonspecific presentation of panic disorder with or without agoraphobia, generalized anxiety disorder (GAD), or SAD, the child’s opposition to attending school may become the condition’s most disabling feature. The behaviours associated with this refusal may become extreme (9). Similarly, extreme responses to forced separation at nighttime are a major presenting concern of the children’s parents. In both SAD and agoraphobia, the child’s refusal to function without the parent’s presence inevitably interferes with the developmental tasks of independence and socialization.

Manuscript received December 2000, revised, and accepted July 2001.
¹Clinical Associate Professor, Department of Psychiatry, University of British Columbia; Director, Mood and Anxiety Disorders Clinic, British Columbia’s Children’s Hospital Vancouver, British Columbia.
²Summer Research Student, Department of Psychiatry, University of British Columbia,Vancouver, British Columbia.
Address for Correspondence:  Dr EJ Garland, C429 4480 Oak Street, Vancouver, BC V6H 3V4
e-mail:  jgarland@cw.bc.ca

Managing anxiety disorders requires the child to cooperate with cognitive and exposure treatment, and with pharmacotherapy, when indicated. In managing these disorders, however, the child’s oppositional stance often becomes a barrier to progress with the necessary psychotherapeutic strategies. In one controlled study, 9/16 subjects assigned to cognitive-behavioural therapy dropped out because they were reluctant to persist with uncomfortable exposure components (7). Difficulty managing this oppositional quality is the major complaint of parents participating with their children in the cognitive-behavioural treatment groups in our clinic. Further, oppositionality is associated with noncompliance with pharmacotherapy in children with anxiety and depression (10). It is our impression that children with anxiety who are more oppositional have a poorer prognosis; this may account for the 30% of children with a poor long-term outcome after school refusal (11). We lack data on this relation, however.

It is remarkable that little research has specifically examined the occurrence of oppositional attitudes and behaviours in children with anxiety, despite the potential impact this may have on compliance with recommended treatment. General comorbidity has been noted between anxiety, mood, and disruptive behaviour disorders (12,13).