...serious violations societal norms, is present in a quarter to half of all cases (Barkley, DuPaul, & McMurray, 1990; Biederman, Newcorn, & Sprich, 1991; Szatmari, Boyle, & Offord, 1989). The social impairment, course and prognosis, and response to treatment in ADHD cannot be understood without considering comorbidities. Children having both ADHD and CD have more learning problems, neuropsychological deficits, and poorer prognosis with high rates of antisocial outcomes (Jensen et al., 1997). The combination of ADHD and CD is associated with an earlier age of onset for CD and more persistent and serious conduct problems (Lahey, McBurnett, & Loeber, 2000). ODD is generally considered a milder disorder than CD, but it is far from benign: it is associated with functional impairment and disturbed interpersonal relations, and in some cases it progresses to CD. However, many cases of prepubertal ADHD + ODD do not progress to the prepubertal form of CD (Lahey et al., 2000), which is the classic early-onset pattern associated with persistent and serious antisocial behavior (Farrington, 1995; Moffitt, 1993). Despite extensive research into risk factors for CD, little attention has been given to specifying those associated with comorbid ODD and those that are specific to comorbid CD. Knowledge of these factors is important for both preventing and treating these serious comorbid conditions.

Multiple risk factors related to heredity and family environment have been linked to each of the disruptive behavior disorders (Johnston & Mash, 2001). ADHD itself is familial (Barkley et al., 1990; Biederman, Faraone, Keenan, Knee, & Tsuang, 1990; Faraone, Biederman, & Milberger, 1994; Frick, Lahey, Christ, & Loeber, 1991). The association between paternal APD and child CD in boys has been replicated in several studies (Biederman, Munir, & Knee, 1987; Frick, Lahey, Loeber, & Stouthamer-Loeber, 1992; Lahey et al., 1988). Frick et al. (1992) report an association between APD and ODD, although not as strong as for APD and CD. In an ADHD sample, Pfiffner et al. (1999) also report that paternal APD predicted comorbid CD, and to a lesser extent comorbid ODD, in boys. Together, these studies suggest strong familial risk via APD for the development of CD in ADHD children, and a significant, but weaker association between APD and ODD. Parental depression also has been linked to disruptive behavior in children, perhaps via common familial vulnerabilities (e.g., Biederman et al., 1991), via an association with parental antisocial behaviors, or due to the difficulty of raising children with a disruptive behavior disorder. There is less evidence for a specific association between parental anxiety and disruptive behavior disorders, particularly when comorbid anxiety in the child is controlled (e.g., Biederman et al., 1991; Pfiffner et al., 1999).

Parenting practices form a second set of family risk factors. Studies examining interaction patterns among families with children having ADHD have found parents to be more directive, commanding, and negative than parents of children without ADHD (Johnston & Mash, 2001). Dysfunctional parenting may partly be a reaction to the difficulties of raising a child with ADHD, but it may also serve an etiological role in the emergence of comorbid disruptive behavior disorders among youth with ADHD (see Johnston & Mash, 2001). However, dysfunction is not always found in families with an ADHD child (Cunningham, Benness, & Siegel, 1988; Schachar & Wachsmuth, 1991), and difficulties that are found are often mild. These inconsistencies may indicate that parenting problems, far from being ubiquitous in ADHD, may be specific to subgroups of children with ADHD who also have ODD or CD. Consistent with social learning theory, children with oppositional and conduct problems often have families characterized by coercive interaction styles, inconsistent discipline, lack of parental involvement, and lack of positive and warm interactions between parent and child (Fletcher, Fischer, Barkley, & Smallish, 1996; Loeber & Tengs, 1986; Patterson, Reid, & Dishion, 1992). Recent studies with ADHD children suggest that certain kinds of dysfunctional parenting, including maternal lack of responsiveness (Johnston & Mash, 2001; Johnston, Murray, Hinshaw, Pelham, & Hoza, 2002), lack of warmth and positive involvement, overly negative discipline (Kashdan et al., 2004), lax and inconsistent parenting, and a lack of cohesion among family members (Lindahl, 1998), are related to comorbid oppositional or conduct problems rather than ADHD per se. Negative parenting practices also predict persistence of comorbid ODD rather than ADHD (August, Realmuto, Joyce, & Hektner, 1999).

The relative contribution of parent psychopathology and dysfunctional parenting to the emergence of coexisting ODD vs. CD in ADHD children has not been studied, but several studies have tried to separate these family factors in predicting CD. Among children with a primary disruptive behavior disorder, Frick et al. (1992) found little relationship between maternal parenting and child conduct problems after controlling for paternal APD, but a strong relationship between paternal APD and child CD after controlling for maternal parenting--leading the authors to conclude that APD was the more important risk factor for CD. Capaldi, Pears, Patterson, and Owen (2003) also found that father antisocial behavior was associated with externalizing problems in young children after controlling for father's parenting practices. Other studies suggest that parenting practices play a partial role (e.g., Frick & Loney, 2002; Smith & Farrington, 2004) or actually are the key factors in the development of primary conduct problems (Patterson et al., 1992). Laub and Sampson (1988) reported that the effects on delinquency of parent criminality and alcohol abuse were mediated by family process variables, most notably, maternal supervision, parental discipline, and parental attachment. Recently, Conger, Neppi, Kim, and Scaramella (2003) reported that continuity in angry, aggressive parenting styles across generations is what accounted for connections in aggressive behavior from one generation to the next. The importance of parenting was also highlighted in a study of ADHD children in which Anderson, Hinshaw, and Simmel (1994) reported that maternal negativity predicted observed noncompliance and laboratory stealing, even after controlling for maternal psychopathology and child negativity.

However, there is also evidence that parent psychopathology might moderate the association between parenting and child conduct problems. McCord (1991) found that criminality in the father appeared to moderate the relationship between parenting and criminality in the sons, although the direction was different across aspects of parenting. For those with a criminal father, affection or confidence in maternal parenting reduced the risk for offspring criminality. However, low parental supervision was associated with criminality only for offspring without a criminal father. This literature highlights the complexities associated with the linkage among different family factors in predicting conduct problems. One implication is that in some cases, disruptive behavior problems may occur via disruption of normal parenting or via familial transmission of antisocial behaviors, and in other cases a combination of both factors is important for increasing risk. How these factors might differentially predict ODD vs. CD is not known.

In this study, our objective was to disentangle family factors associated with comorbid ODD from those associated with comorbid CD in boys and girls having DSM-IV-defined ADHD (all subtypes). One set of analyses examined the association between parent disorder symptoms and comorbid CD and ODD, with the prediction that APD symptoms would be most strongly associated with comorbid CD. A second set of...

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