Comorbidity of Juvenile Obsessive-Compulsive Disorder

with Disruptive Behavior Disorders

DANI EL A. GELLER, M.B.B.S., JOSEPH BIEDERMAN , M.D., SUSAN GRIFFIN, B.A., JAN ICE JONES, B.A.,
AND TODD R. LEFKOWITZ, B.A.

ABSTRACT
Objective: To examine the full spectrum of psychiatric comorbidity in juvenile obsessive-compuls ive disorder (OCD)
in a naturalistic manner when no exclusionary criteria are used for sample selection. Method: Consecutive referrals to
a specialized pediatric OCD clinic were evaluated by means of structured diagnostic interviews and rating scales. No
exclusionary criteria were used for sample selection. Findings were compared with those of previously published reports
of juvenile OCD. Results: Compared with previous studies, our sample of juveniles with OCD had high rates of
comorbidity not only with tic, mood, and anxiety disorders but also with disruptive behavior disorders. Conclusions:
Our findings indicate that in the naturalistic setting, juvenile OCD is heavily comorbid with both internalizing and
externalizing disorders. The presence of such a complex comorbid state has important clinical and research implications
and stresses the relevance of limiting exclusionary criteria in studles of juvenile OCD. J. Am. Acad. Child Ado/esc.
Psychiatry, 1996, 35 (12 ):1637-1646. Key Words: obsessive-compulsive disorder, comorbidity, pediatric samples,
disruptive behavior.

In contra st to a body of literature on patterns of
psychiatric comorbidity in clinical samples of adults
with obsessive-compulsive disorder (O CD) (Karno
et al., 1988; Rasmussen and Eisen, 1992a,b; Weissman
et al., 1994), a more limited body of literature exists
on this subject in pediatric samples. Several previously
publ ished studies (Hanna, 1995; Last and Strauss,
1989; Riddle et al., 1990; Swedo et al., 1989; Toro
et al., 1992) have reported on psychiatric comorbidity
in clinically referred juvenile samples. These studies
reported that, as in adults, children and adolescents
with OCD frequently have high levels of comorbidiry
with major depression, other anxiety disorders, and
Tourette's syndrome (T S).
Accepted April 2, 1996.
From the Pediatric Psychopharmacology Unit , Mcl.ean Hospital, Belmont,
U4 (D rs. Geller and Biederman, Ms. j ones, and M r. Lefkowitz); the Pediatric
Psychopharmacology Unit, Massachusetts Genera/ Hospital. Boston (D rs. Geller
and Biederman. M s. Griffin , M s. j ones, and Mr. Lefkowitz); and the Depart-
ment of Psychiatry, H a rva rd M edical School, Boston (D rs. Geller and
Biederman).
Reprint requests to Dr. Geller, joint Program in Pediatric Psychopharmacol-
ogy, Mc l.ean Hosp ital, 115 Mill Street, Belmont, U4 02 178; telephone: (617)
855-2846; fax : (617) 855-3 722.
0890-8567/96/3512- 1637$03.00/0 ©1996 by the American Academy
of Child and Adolescent Psychiatry.
Although these studies provided useful clinical infor-
mation regarding patterns of comorbid ity in juvenile
O CD, their generalizability is limited because of the
numerous exclusiona ry criteria used. For example ,
Swedo et al. (1989) excluded subjects with a concurrent
diagnosis ofTS, schizophr enia, " primary major depres-
sion," organic mental disorder , or mental retardation.
This was based in part on their desire to have a
homogeneous group for a pharmacological treatment
trial. Riddle et al. (1990) excluded almost half of the
subjects from data analysis because of subthreshold
symptoms, a diagnosis of trichotillomania but not
OCD, T S, prior major depression, or psychosis. Also
excluded were subjects with anorexia nervosa, a " pri-
mary phobic disorder," or pervasive developmental
disorder. Hanna (1995) excluded patients with primary
major depression, bipolar disorder, psychosis, and an-
orexia nervosa; some of his sample were also enrolled
in a clomipramine treatm ent study.
The complication of using numerous exclusionary
criteria in previous studies aimed at understanding
patterns of comorbidity in juvenile OCD is that the
information provided may not represent the true scope
of comorb idity in clinical samples, since clinicians are
asked to evaluate and treat OCD children without

j . AM . ACA D . CHILD ADOLE SC . PSYCH IATRY, 35:12, DECEMBE R 19 96 1637

GELLER ET AL.
exclusionary rules. For example, although the previous
studies (Last and Strauss, 1989; Riddle et al., 1990;
Swedo et al., 1989; Toro et al., 1992) found relatively
low rates of comorbid disruptive behavior disorders
among juveniles with OCD, much higher rates appear
to be common in clinical practice. The low rate of
comorbid disruptive behavior disorders in prior studies
of children with OCD is particularly surprising consid-
ering that TS (Singer and Walkup, 1991), juvenile
major depression (Biederman et al., 1987, 1992), and
juvenile anxiety disorders (Biederman et al., 1991a,b,
1994) are frequently comorbid with disruptive behavior
disorders, suggesting that disruptive disorders may be
more prevalent in samples of juveniles with OCD than
previously reported. Thus, there is a need to reevaluate
patterns of psychiatric comorbidity in juveniles with
OCD in a more naturalistic manner to secure the
ecological validity of findings.
A comprehensive assessment of the full scope of
psychiatric comorbidity has major therapeutic, research,
and public health implications. From a clinical perspec-
tive, comorbid conditions may require a treatment
approach that is different from that used in noncomor-
bid cases. For example, consideration of the high risk
for added disability and morbidity associated with
concomitant disruptive behavior disorders in children
and adolescents with OCD may permit clinicians to
improve the treatment outcome of complex OCD
cases. The current enthusiasm for the application of
behavioral techniques in the treatment of children and
adolescents with OCD should also take into account
the presence of any concurrent disruptive behavioral
disorders. Pharmacological approaches and responses
for these different diagnostic conditions may be rela-
tively specific, with little therapeutic overlap. From a
research perspective, the presence of comorbid condi-
tions may help decrease the heterogeneity of psychiatric
disorders by identifying more homogeneous subgroups
based on cornorbidiry: this in turn permits evaluation
of whether correlates of specific disorders are due to
the disorder of interest, its cornorbidity, or both. From
a public health perspective, subjects with high levels
of comorbidity may be at greater risk for the develop-
ment of more severe dysfunction over time than non-
comorbid subjects.
The purpose of this report is to reexamine patterns
of psychiatric comorbidity in clinically referred children
1638 j. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:12, DECEMBER 1996
and adolescents with OCD without exclusionary crite-
ria. To this end we systematically evaluated the presence
of comorbid psychiatric disorders in an entire clinical
program dedicated to the assessment and treatment of
children and adolescents with OCD and compared
them with findings from the several previously reported
studies (Hanna, 1995; Last and Strauss, 1989; Riddle
et al., 1990; Swedo et al., 1989; Toro et al., 1992)
on juvenile OCD. We hypothesized that the comor-
bidity with disruptive behavior disorders in children
and adolescents with OCD would be higher than
expected by chance (population rates) and higher than
noted in earlier reports.
METHOD
This was a systematic record review of all subjects aged 18 years
and younger referred since 1993 to a specialized outpatient program
for children and adolescents with OCD under the direction of the
senior author (D.A.G.) for whom complete records were available.
This program offers comprehensive diagnostic evaluation and treat-
ment for pediatric subjects with OCD and their families provided
by a specialized multidisciplinary team consisting of a social worker,
a child and adolescent psychiatrist and psychopharmacologist
(D.A.G.), and cognitive and behavioral therapists, and it includes
regular support group lectures and meetings. To be included in
this record review study, subjects had to fully satisfy DSM-III-R
diagnostic criteria (American Psychiatric Association, 1987) for
OCD based on clinical assessment and confirmed on a structured
diagnostic interview (Schedule for Affective Disorders and Schizo-
phrenia for School-Age Children-Epidemiologic version) (K-SADS-
E) (Orvaschel, 1985) administered by trained raters under the
supervision of the service director (J.B.). The K-SADS-E is a
widely used, semistructured, DSM-lII-R-based psychiatric diagnos-
tic interview with established psychometric properties. It was de-
signed for use in clinical and epidemiological research to obtain a
past and current history of psychiatric disorders in children and
adolescents aged 6 to 17 years. It can be effectively administered
by clinicians or trained interviewers in 60 to 90 minutes. It provides
a standardized method of obtaining and recording symptoms
necessary for the assessment of most Axis I DSM-III-R categories.
This study received approval by the Institutional Review Board.
In addition to diagnostic assessments, we used the DSM-lII-R
Global Assessment of Functioning (GAF) scale (American Psychiat-
ric Association, 1987) (l = worst to 90 = best) to assess overall
psychosocial functioning. Severiry and type of obsessive and com-
pulsive symptoms were rated by the senior author (D.A.G.), using
the Children's Yale-Brown Obsessive Compulsive Scale (CY-
BOCS) (an unpublished instrument). The CY-BOCS, the children's
version of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
(Goodman et al., 1989a, b: Hardin et al., 1991; Riddle et al.,
1993), is a clinician-rated 10-item scale, with each item rated on
a 4-point scale (0 = "no symptoms" to 4 = "extreme symptoms")
(total range = 0 through 40), with subtotals for obsessions (irems
1 through 5) and compulsions (items 6 through 10). The CY-
BOCS includes a Symptom Checklist of more than 60 examples of
obsessions and compulsions organized into several larger categories
according to their rhematic content (for example, hoarding or

contamination). Family history of psychopathology in first-degree
relatives was obtained at the time of the clinical interview by the
senior author (D.A.G.) by reviewing information provided by the
family at the time of assessment.
Findings from our sample were compared with those from
previous studies reported in the literature (Hanna, 1995; Last and
Strauss, 1989; Riddle et al., 1990; Swedo et al., 1989; Toro et aI.,
1992). Swedo et al. (1989) reported on the clinical phenomenology
of 70 consecutively referred children and adolescents seen at the
National Institute of Mental Health who were included in a
clomipramine treatment trial. Assessments included the Diagnostic
Interview for Children and Adolescents (DICA) (Welner et aI.,
1987). Riddle et al. (1990), using a standard clinical psychiatric
assessment, the Child Behavior Checklist (CBCL) (Achenbach,
1978; Achenbach and Edelbrock, 1983), and the Yale OCD
Questionnaire (an unpublished instrument), reported on the phe-
nomenology of 21 clinically referred children and adolescents.
Structured clinical interviews were not included as part of this
assessment. Hanna (1995) reported on a clinically referred sample
of 31 pediatric OCD patients and described their comorbidity by
using the DICA as well as their demography and symptomatology.
Last and Strauss (1989) identified 20 children and adolescents
with OCD from among 190 consecutive referrals to an anxiety
disorder clinic and assessed rhem and their families for lifetime
psychopathology, using structured interviews (Schedule for Affective
Disorders and Schizophrenia for School-Age Children-Present Epi-
sode version [Puig-Antich and Chambers, 1978]). Toro et al.
(1992) selected and reviewed the clinical records of all cases with
a diagnosis of OCD from among thousands of patients who had
attended either a hospital or a private clinic in Barcelona over a
10-year period. Demographic information, sample ascertainment,
exclusion criteria, type and severity of presenting obsessive-compul-
sive symptoms, comorbid diagnoses, and family history of OCD
were compared between these reports and our sample.
Because distributions between samples were likely to be different
from each other and from nonclinical samples due to ascertainment
biases, continuous data regarding demographic variables between
groups were not analyzed. Because of such biases, formal statistical
comparisons of rates of presenting symptoms and comorbid diagno-
ses were deemed invalid and were also not performed. Categorical
data (gender and intact family) were analyzed using X2 tests as
indicated. All tests were two-tailed and statistical significance was
defined at the 1% level (p < .01).
RESULTS
McLean OCD Sample
The subject pool in this study consisted of 30
consecutively referred subjects who satisfied DSM-III-R
diagnostic criteria for OCD based on clinical assessment
and confirmed by structured diagnostic interview. The
mean (±SD) age of this group was 12.6 (±2.9) years
and the mean (±SD) age of onset of OCD was 8.5
(±4.0) years. Seventy percent of the subjects were
male. The mean socioeconomic status (Hollingshead,
1965) was 1.8 (±0.8), and 23 subjects (79%) came
from intact families. No exclusion criteria were used.
j, AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:12, DECEMBER 1996
DISRUPTIVE BEHAVIOR IN JUVENILE OeD
Analysis of OCD characteristics revealed that more
than one third of our sample had poor or no insight
into the nature of their OCD symptoms, which were
not reported to be ego-dystonic despite the marked
impairment they caused. The number of subjects with
only compulsions (n = 3, 10%) or only obsessions (n =
1, 3%) was quite low, while the large majority of
subjects in our study had both multiple compulsions
and multiple obsessions. The most frequently reported
obsessions were those of violent and/or catastrophic
events, often involving a loved one (60%), followed by
those of contamination (53%). Common compulsions
included repeating (73%), washing and cleaning (57%),
checking (43%), and ordering/arranging (40%) rituals.
The mean total CY-BOCS score in the 23 subjects
with available information was 23, placing the severity
of OCD symptoms in the moderately severe range.
Similarly impaired were scores on the DSM-III-R GAF
scale; the average (±SD) score was 43 (±8), placing
subjects in the severe impairment range. Measures of
school functioning showed similarly high levels of
impairment in that 48% of our subjects had received
remedial help, 40% were placed in a special class, and
7% had repeated a grade. All of our patients had
received some type of treatment prior to assessment
in our clinic; 87% had been medicated for their OCD
and 37% had required inpatient psychiatric care.
Comorbid psychopathology was almost universal in
our sample, with only one subject failing to meet
criteria for at least one additional psychiatric diagnosis
other than OCD (Fig. 1). Seventy-three percent of
our subjects had major depression, with 27% also
meeting DSM-III-R criteria for mania. Of the entire
sample, 16 (53%) subjects had a diagnosis of at least
100
%
N=l
Mood Disrnptlve Multiple TIcs & Psychosis No Other
Disorders Behavior Anxiety Tourette's Diagnosis
Disorders Disorder
Fig.1 Frequency of comorbid diagnoses in pediatric obsessive-compulsive
disorder patients (N = 30).
1639
GELLER ET AL.
one disruptive behavior disorder, making disruptive
behavior disorders the second most common comorbid
condition; 33% had attention-deficit hyperactivity dis-
order (ADHD), 43% oppositional defiant disorder,
and 7% conduct disorder. In addition, 43% had multi-
ple (two or more) anxiety disorders, 34% had chronic
tics or TS, 30% had psychosis, 27% had a develop-
mental speech or language disorder, and 37% had
enuresis.
An analysis of patterns of comorbidity in juvenile
OCD subjects with and without comorbid TS found
higher rates of separation anxiety, simple phobia, and
encopresis (p S .01) in those with TS. However, when
analyses were extended to the presence of non-TS tic
disorders, there were no significant findings. A further
analysis of OCD subjects found significantly higher
rates of bipolar disorder, developmental speech and
language (but not learning) disorder, and enuresis (p
S .01) in subjects with comorbid ADHD. Our data
do not allow us to distinguish between ADD with
and without hyperactivity because we used DSM-III-R
criteria, which do not separate the two conditions for
diagnostic purposes.
The mean age of onset of comorbid conditions (Fig.
2) showed a developmental progression with disruptive
behavior (ADHD = 1.8 years; ODD = 7.1 years)
beginning much earlier than the onset of OCD (8.5
years) and major depression (9.1 years).
Family psychiatric history obtained by clinical inter-
view at the time of referral and evaluation of juvenile
OCD probands showed high rates of Axis I psychopa-
thology in first-degree relatives, with mood disorders
12
N=9
Age
ADHD 1'5 Mult Anx ODD om Conduct Tics MOD Bipolar Psycbosls
Fig. 2 Mean age of onset of comorbid psychiatric disorders among
pediatric OCD patients (N = 30). ADHD = attention-deficit hyperactivity
disorder; TS = Tourettc's syndrome; Mulr Anx = multiple anxiety disorder;
ODD = oppositional defiant disorder; OCD = obsessive-compulsive disor-
der; MOD = major depressive disorder.
1640
(57%), anxiety disorders (39%), ADHD (32%), OCD
(23%), substance use disorders (17%), and chronic tic
disorders (11%) as the most prevalent conditions. Three
probands (11 %) had a first-degree relative with a history
of psychiatric hospitalization. Comparisons with respect
to family psychiatric history with other studies could
not be made because of insufficient information
provided.
Comparison with Previous Studies
There was a variable rate of positive family history
of OCD in first-degree relatives of young pro bands
with OCD, ranging from 8% to 24%; this was assessed
by structured interviews (Last and Strauss, 1989; Swedo
et al., 1989), clinical interview (Riddle et al., 1990;
this study), and clinical record review (Toro et al.,
1992) (Table 1).
Most studies reported that multiple obsessions and
multiple compulsions are the most common OCD
presentation in juveniles (Table 2). In our series, we
found a higher frequency of sexual obsessions and a
lower rate of somatic obsessions compared with previ-
ous reports. Hanna (1995) reported higher rates of
contamination obsessions and Toro et al. (1992) re-
ported lower rates of aggressive and religious obsessions
compared with other studies. Swedo et al. (1989)
reported lower rates of ordering/arranging and a higher
rate of washing compulsions than was found in our
sample. Last and Strauss (1989) reported very low rates
of repeating and hoarding compulsions compared with
other studies (Table 2). In contrast, we found no
differences in rates of several other common obsessions
(hoarding) and compulsions (checking and counting)
compared with other studies. The relatively common
finding in our sample of poor insight could not be
directly compared with previous studies because its
absence precluded entry into one of the studies (Swedo
et al., 1989) and the others (Hanna, 1995; Last and
Strauss, 1989; Riddle et al., 1990; Toro et al., 1992)
did not report on this issue.
The only other study to report on the mean CY-
BOCS scores (Hanna, 1995) showed no significant
difference with findings reported in our sample. Other
measures of impairment such as the GAF scale (Ameri-
can Psychiatric Association, 1987) did not lend them-
selves for comparison with the previous studies because
of insufficient information.
]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:12, DECEMBER 1996
 DISRUPTIVE BEHAVIOR IN JUVENILE ocn

TABLE 1
Clinical Characteristics of Samples of Pediatric OCD
Swedo et al. Riddle et al. Hanna Last & Strauss Toro et al. This Study
(N = 70) (N = 21) (N = 31) (N = 20) (N = 72) (N= 30)

Sample Recruited for Clinic referrals Clinic referrals; Anxiety clinic Clinic tecord Clinic referrals
ascertainment clinical drug clinical drug teferrals review
trial trial
Exclusion Major depression; Phobia; Major depression; None reported Organic mental None
criteria Touretre's, Tourerte's: bipolar; disorder; IQ
psychosis psychosis; PDD psychosis; <70
anorexia nervosa
Assessment DICA Clinical DICA K-SADS-P Clinical K-SADS-E
Demographics Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
Age 13.7 2.7 12.2 3.1 13.5 2.8 12.7 3.2 12 3.3 12.6 2.9
Age of onset 10.1 3.5 9.0 2.9 10.0 3.0 10.7 NR II 2.9 8.5 4.0
SES NR 1.9 1.1 2.2 I.2 3.2 1.1 NC 1.8 0.8
No. % No. % No. % No. % No. % No. %
Males* 47 67 9 43 19 61 12 60 47 65 21 70
Intact
families* NR 16 76 27 87 NR 65 90 23 79
Family history
of OCDa 17 24 4 19 NR 3 8 II 15 7 23
Assessment
source SADS-L/DICA Clinical interview NA SCID/K-SADS-P Record review Clinical interview

Note: OCD = obsessive-compulsive disorder; PDD = pervasive developmental disorder; DICA = Diagnostic Interview for Children and
Adolescents; K-SADS-P and K-SADS-E = Schedule for Mfective Disorders and Schizophrenia for School-Age Children, Present Episode
and Epidemiologic versions; SES = socioeconomic status; NR = not reported; NC = not comparable (reported as "low = 50%, medium =
33%, high = 17%, by father's education"); NA = not applicable; SADS-L = Schedule for Affective Disorders and Schizophrenia-Lifetime
version; SCID = Structured Clinical Interview for DSM-IIJ-R.
a First-degree relatives.
* p < .01 by overall X2•

Rates of comorbid psychiatric diagnoses could not DISCUSSION

often be directly compared because of the numerous
exclusion criteria used in the previous studies (Table
1). Even when data are available, sample ascertainment
biases preclude valid statistical comparisons between
groups. Subjects with severe or primary major depres-
sion, mania, panic, psychosis, and TS were not included
in many of the previous reports, yet these disorders were
commonly found in our subjects (Table 3). Among
disorders that were assessedin most studies, higher rates
of separation anxiery disorder, ADHD, oppositional
defiant disorder, and enuresis were identified in our
subjects compared with the those of previous reports
(Table 3). In contrast, few differences were found
in rates of dysthymia, social phobia, simple phobia,
overanxious disorder, conduct disorder, tic disorders,
and developmental speech and language disorders.
In a systematic reevaluation of patterns of psychiatric
comorbidity in consecutively referred juveniles with
OCD, we found high levels of comorbidity not only
with TS, mood, and anxiety disorders previously iden-
tified in these subjects, but also with disruptive behavior
disorders as well. These findings confirm our study
hypothesis and document that disruptive behavior dis-
orders may be more prevalent in clinical practice than
previously reported in samples of pediatric OCD
patients.
The age at referral, age at onset of OCD, gender
distribution, family history of OCD, and nature of
presenting OCD symptoms as well as comorbidity
with mood and anxiety disorders are highly consistent
with previous studies ofjuvenile OCD. The consistency
of findings in our sample compared with those of

j, AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:12, DECEMBER 1996 1641

GELLER ET AL.

TABLE 2
Phenomenology and Severity of Obsessive-Compulsive Disorder in Pediarric Parients
Swedo er al. Riddle et al. Hanna Last & Strauss Toro et al. This Study
(N= 70) (N = 21) (N = 31) (N = 20) (N = 72) (N = 30)

Presentation % % % % % %
Poor or no insight oa NR NR NR NR 37
Compulsions only NR 10 0 NR NR 10
Single obsession At onset NR 3 NR NR 30
Multiple obsessions Frequent 90 97 NR NR 60
Obsessions only NR NR 0 20 NR 3
Single compulsion At onset NR 0 40 NR 10
Multiple compulsions Frequent 90 100 40 NR 87
Obsessions
Contamination 40 52 87 NR NR 53
Aggressive/catastrophe 28 38 81 NR 13 60
Sexual 4 14 26 NR 6 27
Religious 13 29 23 NR 4 23
Hoarding 11 10 36 NR NR 17
Somatic NR 38 10 NR NR 3
Miscellaneous 10 NR 55 NR 11 23
Compulsions
Repeating 51 76 64 5 74 73
Washing/cleaning 85 67 84 40 56 57
Checking 46 57 64 20 51 43
Ordering/arranging 17 62 61 30 42 40
Counting 18 24 42 20 NR 30
Hoarding 11 10 42 5 3 20
Miscellaneous 26 NR 39 NR NR 53
Severity Mean Mean Mean Mean Mean Mean b
CY-BOCS
Obsessions NR NR NR NR NR 11.8
Compulsions NR NR NR NR NR 11.5
Total NR NR 24.4 NRc NR 23
GAP NR NR NR NR NR 43.1

Note: CY-BOCS = Children's Yale-Brown Obsessive Compulsive Scale; GAP = Global Assessment of Functioning; NR = not reported.
aRituals or thoughts "deemed unreasonable" by patient.
b N = 23 for CY-BOCS.
c Fifty percent or more rated as "severe or very severe."

previous studies indicates that our subjects were not
atypical but rather representative of clinically referred
juveniles with OCD.
Despite these common characteristics with previous
studies, we found a rate of comorbidity with disruptive
behavior disorders that was much higher than in most
previously reported studies. Moreover, when present,
disruptive behavior disorders developed years before
the onset of OCD, suggesting that the finding of
disruptive behavior in our sample is not an artifact of
diagnosis of OCD but instead may represent a genuine
clinical observation. The excess of disruptive behavior
disorders in this sample of referred juveniles with OCD
is consistent with our own recent report of a 32%
overlap between OCD and ADHD in a separate sample
of juveniles treated with fluoxetine for OCD (Geller
et al., 1995). This overrepresentation ofADHD among
juveniles with OCD is also consistent with findings
reported by Hanna (1995) of a 16% rate of ADHD
in his sample of children with OCD.
In contrast, the majority of previous studies of
juvenile OCD failed to identify an excess of disruptive
behavior disorders. While the numerous exclusionary
criteria used by previous investigators (Hanna, 1995;
Last and Strauss, 1989; Riddle et al., 1990; Swedo
et al., 1989; Toro et al., 1992) may be understood in
light of their desire to collect relatively homogeneous
patients unencumbered by other diagnoses at a time
when the clinical entity of juvenile OCD was less
clearly recognized, these exclusions could nevertheless

1642 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:12, DECEMBER 1996

 DISRU PTIVE BE HAVIOR I N JUVEN ILE OCD

TABLE 3
Comorbid Psychiat ric D iagnoses in Pediatric O bsessive-Compu lsive D isorder Pat ients
Swedo et al. Riddle et al. H anna Last & Strauss Toro et al. T his Study
(N = 7 0)a (N = 2W (N = 3 1)a (N= 2W (N = 72)a (N=3W
No. % No . % No . % No . % No . % No. %

Mood disorders
Major depression" 23 33 2 10 4 13 NR 16 22 22 73
Dysthymia NR 4 19 3 10 NR 11 15 2 7
Man ia" NR NR Excluded NR NR 8 27
Any mood disorder" NR 6 29 10 32 4 20 27 38 22 73
Anxiety disorders
Panic NR NR NR NR NR 8 28
Agoraphobia NR Exclud ed NR NR NR 7 23
Social phobia NR Excluded NR 4 20 NR 3 10
Simp le phobia" 12 17 Excluded 2 6 7 35 7 10 5 17
Overanxious 11 16 5 24 4 13 5 25 20 28 11 38
Separation anxiety 5 7 5 24 2 6 4 20 3 4 10 33
Multiple anxiety disorder NR NR NR NR NR 13 43
Any anxiety disorder" NR 8 38 8 26 14 70 30 42 21 70
Disruptive behavio r disorders
ADHD 7 10 2 10 5 16 NR 4 6 10 33
Conduct disorder 5 7 NR 1 3 NR 0 0 2 7
ODD 8 11 NR 5 16 NR 2 3 13 43
Any disruptive behavio r NR NR 9 29 NR NR 16 53
Tic disorde rs
Tourerre's b Excluded Excluded 4 13 NR 11 15 3 11
Chronic tics NR NR NR NR NR 7 23
Any tics 14 20 5 24 8 26 NR 12 17 12 40
O ther
Psychosis" Excluded Excluded Exclude d NR 1 9 30
PDDb NR Excluded 1 3 NR NR 2 7
Development al S/L 17 24 3 14 7 23 NR NR 8 27
Enuresislenco presis 5 7 NR 2 6 NR 11 15 11 37
Mental retardation NR Excluded NR NR Excluded 2 7
No orher disorder" 18 26 8 38 5 16 4 20 16 27 1 3
Note: ADHD = atte ntion-deficit hyperactivity diso rder; O D D = oppositional defiant disorder; PDD = pervasive developmental disorder;
S/L = speechlla nguage disorder; NR = not reported .
a Ca tegories are nor mutually exclusive.
b Exclusion criteria used; see T able 1.

have led to an und erestimation of ADH D in their
O CD subjects. In addition, the Riddle et al. (1990)
and Toro et a!' (1992) studies did not use structured
diagnostic interviews, which may also have led to
underdiagnosis of these disorders. Last and Strauss
(1989) used structured diagnostic interviews but did
not report at all on the presence of AD H D or other
disruptive behavior disorders in their sample of 20
pediatric O CD subjects, making it difficult to know
whether disruptive behavior disorders were not found
or not assessed.
Whether the comorbidity of O CD with disruptive
behavior disorders is a correlate of juvenile forms of
OCD only or of OCD at any age remains unknown
because this issue has not been systematically investi-
gated in samples of adults with OCD . Adult O CD
patients are typically not screened for the presence of
ADHD because, for the most part, structu red diagnos-
tic interviews lack modules for this disorder and its
occurrence in adults is still a matter of debate in some
circles. Because comorbidity with AD H D has been
linked to early-onset mood (Biederman et a!', 1995a)
and panic disorder (Biederman et al., 1995b), it could
represent a marker for a developmental subtype of early-
onset OCD. An analysis of patterns of comorbidity in
our juvenile OCD subjects found preliminary evidence
for such subtypes with higher rates of anxiety and
developmental disorders (in subjects with TS) and

]. AM . ACAD. C H I LD ADO LESC . PSYCHIATRY, 35: 12 , DEC EM BER 1996 1643

GELLER ET AL.
bipolar and developmental disorders (in subjects with
ADHD), although the numbers are small and further
studies are needed.
Considering the likely heterogeneity of OCD, atten-
tion to a developmental subtype may lead to the
identification of more homogeneous subgroups of the
disorder. For example, a number of reports have indi-
cated that the familiality and, by extension, the genetic
contribution to the etiology of OCD is increased
in younger-age-of-onset subjects (Geller et al., 1995;
Lenane et al., 1990; Pauls et al., 1995; Swedo et al.,
1989). Furthermore, childhood-onset OCD is signifi-
cantly male-predominant compared with adult-onset
OCD and may be associated with other prototypical
neurodevelopmental disabilities. Thus, continuities and
discontinuities between very-early-onset (childhood)
and late-onset (adult) OCD have yet to be established
(Pauls, 1995).
In addition to an excessof disruptive behavior disor-
ders in our sample of juveniles with OCD, we also
found high rates of mania and psychosis in our sample.
Inasmuch as these two diagnoses have also been a
primary target of exclusionary criteria in previous stud-
ies of juvenile OCD, it is not at all surprising that
the rates of these disorders were low or nonexistent in
previous studies. In fact, the need to exclude OCD
subjects with mania and psychosis suggests that these
comorbid diagnoses do exist.
Although the diagnosis of juvenile mania remains
controversial, work by our group and others has begun
to challenge the notion that mania is uncommon or
nonexistent in juveniles (Kafantaris, 1995; Weller et al.,
1995; Wozniak et al., 1995). Our finding of a high
rate of mania in juveniles with OCD fits well with
recent reports documenting a higher than expected
overlap between OCD and mania (Kruger et al., 1995),
TS and mania (Kerbeshian et al., 1995), and panic
disorder and mania (Biederman et al., 1995b); these
novel patterns of comorbidity have never before been
reported. Also, considering that juvenile major depres-
sion is frequently bipolar (Geller et al., 1993; Strober
and Carlson, 1982; Strober et al., 1988), and that
unipolar depression is a recognized comorbidity of
OCD in children and adolescents, it is not surprising
to find an excess of bipolarity in these subjects. In
that respect we view the additional comorbidity with
psychosis as a correlate of mania since psychotic symp-
toms are common in mania (Wozniak et al., 1995).
1644 ]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:12, DECEMBER 1996
The finding of comorbidity with psychosis in our
sample of OCD juveniles is consistent with recent
reports highlighting this overlap. While once thought
to be rare, the co-occurrence of psychotic symptoms
in adult patients with OCD was recently reviewed by
Dowling et al. (1995), who concluded that comorbidity
between OCD and psychotic disorders may not be
rare and that earlier hierarchical approaches to diagnoses
may have minimized the study of psychotic symptoms
in OCD patients. Considering that the comorbidity
with mania and psychosis was the major factor account-
ing for the high rate of psychiatric hospitalization
documented in our sample (37%), the appropriate
identification of these disorders is of much clinical
relevance.
In our study, subjects given diagnoses of mania and
psychosis met full DSM-III-R diagnostic criteria for
these disorders. In particular, subjects were not consid-
ered psychotic based on lack of insight into their
obsessive-compulsive symptoms, a fact important to
record in view of the DSM-IVfield trial recommenda-
tions (Foa and Kozak, 1995) to deemphasize insight
as a diagnostic requirement of OCD and the new
DSM-IV specifier of "with poor insight" (American
Psychiatric Association, 1994).
If confirmed, the wider scope of psychiatric cornor-
bidity of juvenile OCD not only with TS, unipolar
depression, and other anxiety disorders but also with
disruptive behavior disorders, mania, and psychosis has
important clinical and scientific implications. Clini-
cally, because treatment decisions follow diagnosis, the
identification of these comorbid diagnoses may lead
to more successful treatment approaches and perhaps
a more successful outcome for affected children and
adolescents with complex OCD. In contrast to the
potential benefits of antiobsessional medications for
comorbid depression and anxiety, these compounds
have no known benefits in the treatment of disruptive
behavior disorders. In addition, the potential impact
of comorbid disruptive behavior disorders on the effi-
cacy of recently emphasized behavioral treatments
(March, 1995; March et al., 1994) for young subjects
with OCD should be considered. Because these behav-
ioral techniques require a fair degree of cooperation
on the part of subjects and their families, their ability
to participate may be compromised by inattentiveness
and oppositionalism.

Cl inically, the presence of an additional disruptive
behavior disorder is also likely to confer more severe
impairment and may even represent the most troubling
set of symptoms to children and their families. For
example, H anna (1995 ) found that th e O CD subjects
with a concurr ent disruptive behavior disorder had
higher Internalizing, Externalizing, and T otal Problem
scores on the CBCL (Achenbach, 1991) . In contrast,
C BCL scores did not correlate with any demograph ic
variables. Scientifically, stratification of O CD subjects
on the basis of patterns of comorbidity may lead to
the identifi cation of more homogeneous subtypes with
differing correlates, outcome, and treatment responses.
This in turn may yield more fruitful research when
identified subgroups are studied.
The findin gs reported here should be examined in
light of their methodological limitations. M ost studies,
including this one, reported only small numbers of
pediatric O CD cases. H owever, the cum ulative tot al
of OCD subjects reviewed here is 244 in six samples.
Because the samples in th is and the other studies
reviewed in this report are of clinically referred children
and adolescents, and because it might be assumed that
patients seeking care in a specialized clinical sett ing
are likely to have mo re than one diagnosis (Berkson's
bias), we do not know whether these findings will
generalize to nonreferred samples. T o date, pediatric
epidemio logical studies on O CD have repo rted only
on adolescent samples (Flament et al., 1989; Valleni-
Basile et al., 1994). Thus, although OCD cases iden -
tified through epidemiological studies may differ from
clinically referred cases, th e failure to find a higher
than expected prevalence of ADHD or mania in epide-
miological studies may also reflect errors of omission
rath er than the absence of these comorbid conditions.
Alth ough more work is needed to furt her evaluate this
important issue, even if not generalizable to epidem io-
logical samples, our findin gs may generalize to other
clinically referred samples.
Because patients in our study were evaluated in a
tertiary care specialized pro gram for juveniles with
OCD, it could be argued that our cases are more
severe or complex than in other samples of pediatric
OCD patients. However, as we described above, our
patients' characteristics closely resemble those of oth er
referred pediatric OCD samples, suggesting that our
findings could generalize to other referred OCD sam-
ples treated in cente rs with specialized interest or exper-
tise in the management of OCD childr en and
J. AM . ACAD . C H ILD ADOLES C. PSYCH IA TRY , 35 : 12 , DECEMB ER 1996
DISRUP T IVE BEHAV IOR IN JUVEN I LE OC D
adolescents. Ho wever, likely un even distributions re-
sulting from ascertainment biases in reviewed reports
precluded valid formal statistical comparisons ofcornor-
bidi ty between groups.
Another limitation is that the structu red diagno stic
interview information was not collected blindly to the
diagnoses of OCD. Ho wever, O CD patients received
a systematic assessment battery administered to all
referred children and adolescents in our center with and
without O CD. T he use of such structured diagnostic
interviews minimizes the biases in assigning diagnoses
and may lead to more accurate estimates of
psychopathology.
Finally, the findings obtained by the different meth-
odologies used in our and in previous studies may not
be easily amenable to direct comp arisons. For example,
a direct comparison of the present ing symptoms of
O CD is limit ed by a lack of clarity and information
regarding the definiti on of symptom clusters, e.g..
aggression/catastrophe obsessions.
Despite these limitations, using structured diagno stic
interview meth odology and no exclusionary criteria,
we found that patterns of psychiatric comorbidity in
juvenile O CD may include not only tics, depression,
and anxiety disorders, bur also disruptive behavior
disorders, mania, and psychosis as well. Although these
findin gs await confirmation, they highlight a need for
careful assessment of psychiatric comorbidity in clinical
and research samples of pediatric O CD subjects.
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