Child Psychiatry Hum Dev (2008) 39:519–527

DOI 10.1007/s10578-008-0106-9

ORIGINAL PAPER

Oppositional Behavior and Anxiety in Boys and Girls:

A Cross-sectional Study in Two Community Samples

Gina Mireault Æ Siri Rooney Æ Kristen Kouwenhoven Æ Carolyn Hannan

Published online: 6 June 2008

Springer Science+Business Media, LLC 2008

Abstract Studies have repeatedly shown that oppositional behavior is linked to anxiety
in clinical samples of children. This study explored whether these variables were similarly
related in nonclinical samples of elementary and middle school students (N = 302).
Despite greater self-reported oppositional behavior among boys in these samples, anxiety
outweighed gender as a predictor of oppositional behavior. These findings suggest that the
relationship between anxiety and oppositional behavior is not exclusive to clinical samples
and that oppositional behavior that is clinical or developmental has common underlying
variables across childhood.

Keywords Oppositional behavior
Anxiety
Tantrums
Childhood

Oppositional behavior has been the subject of considerable research. Clinically, opposi-
tional behavior is generally characterized in the Diagnostic and Statistical Manual of
Mental Disorders––Fourth Edition [1] as ‘‘negativistic, defiant, disobedient, and hostile
behavior toward authority figures’’ (p. 91). However, oppositional behavior, like refusing
to comply with adult requests, occurs in nonclinical samples as well especially at particular
points in childhood [2], where it represents normative developmental change versus
functional impairment. Of interest is whether developmental and clinical variants of
oppositional behavior share common underlying variables across childhood. The present
study employed two community samples of school children to examine oppositional
behavior in relation to anxiety and gender, as these variables have been related in clinical
samples [3, 4]. We use the term ‘‘oppositional behavior’’ to broadly refer to disobedient,
noncompliant, defiant, or generally negative behavior that does not necessarily rise to the
level of a psychological disorder.
Kuczynski and Kochanska [5] observed that, at least mild oppositional behavior like
noncompliance is common in childhood, with rates in community samples ranging from

G. Mireault (&)
S. Rooney
K. Kouwenhoven
C. Hannan

Behavioral Sciences Department, Johnson State College, 337 College Hill, Johnson, VT 05656, USA
e-mail: gina.mireault@jsc.edu

123
520 Child Psychiatry Hum Dev (2008) 39:519–527

20% to 50% in different studies. Despite the fact that it is common, oppositional behavior
that is associated with typical development has received less research attention than the
clinical variety [6]. The former can be distinguished from the latter in two primary ways.
First, in nonclinical samples, oppositional behavior generally declines from the toddler to
school years [7–9] as children learn more skillful ways, for example, to resist requests from
authority figures. For instance, Kuczynski et al. [10] found that passive noncompliance and
direct defiance decreased in a cross-sectional sample of 1‘- to 3‘ -year -old children,
while negotiation increased. In contrast, oppositional behavior in clinical samples often
escalates into more serious conduct problems. Children identified as difficult to manage at
age three or four, can be at greater risk for behavioral challenges later in development
[11, 12]. Bird et al.’s cross-cultural study of nearly 2,500 5–13 year olds found that
aggressive behavior in the toddler years was among a handful of significant correlates of
disruptive behavior disorders in later childhood [11]. Some researchers have found that
hard-to-manage children have an approximately 50% chance of continued maladjustment
in middle childhood and adolescence [12, 13], including Conduct Disorder and Opposi-
tional Defiance Disorder [4].
Second, oppositional behavior that is developmentally typical is often regarded as a sign
of psychological growth instead of a precursor to later maladjustment [5]. Developmental
theory proposes that, at least in Western cultures, oppositional behavior plays an important
role in distinguishing self from other, and therefore in fostering autonomy [6]. Children
begin to discover their separate self in the second year and that is accompanied by or
reflected in their noncompliance, a behavior so common that toddlerhood has a distinct
reputation as the ‘‘terrible twos’’. Similarly, parents expect a certain degree of oppositional
behavior in adolescence when the task of identity development may manifest as noncom-
pliance, rebellion, or willful opposition [14]. In defense of the important developmental role
of oppositional behavior, Kuczynski and Kochanska [5] note that the counterpart of
oppositional behavior, namely compliance, is not a marker of competence especially at
developmental points when autonomy is the developmental task (e.g., toddlerhood). They
further add that compliance is sometimes associated with maladjustment. Thus, some
oppositional behavior is considered a classic sign of typical development that is simply part
of ‘‘a stage’’ and will eventually wane [2]. Oppositional behavior can provide children with
the opportunity to develop the skills to express their autonomy in ways that are socially
acceptable [5]. One question is whether the behavior that signals developmental growth in
some samples but functional impairment in others has common underlying variables.
Anxiety is one variable that has received attention from researchers studying opposi-
tional behavior in clinical samples, although Garland and Garland [3] speak to the
surprising paucity of comorbidity studies given ‘‘the prominence of oppositionality as a
clinical feature of children suffering from anxiety’’ (p. 956). They observed that among
highly anxious children, anxiety often manifests as severe oppositional avoidance. In their
study of 145 preadolescent outpatients, 31% diagnosed with ODD were comorbid for
an anxiety disorder. In addition, moderate correlations were found between parent and
teacher ratings of oppositional behavior and anxiety. Similarly, Lavigne et al. [15]
reported that oppositional behavior is related to the development of anxiety and mood
disorders. In their longitudinal study of 280 preschoolers, children with symptoms of ODD
were likely to continue exhibiting the disorder and to show increasing comorbidity with
anxiety, mood, and attentional disorders at 4- and 6-year follow-up. These findings are
echoed by another study [16] showing that 25% of 4–5 year old boys diagnosed with
Oppositional Defiant Disorder (ODD) carried a dual diagnosis for mood or anxiety dis-
orders at two-year follow-up.

123
Child Psychiatry Hum Dev (2008) 39:519–527 521

The association between oppositional behavior and anxiety has received less attention in
community samples. Some research demonstrates that these variables also co-exist,
although to a lesser extent than in psychiatric samples [17, 18]. In a 14-year longitudinal
investigation with a community sample of 1,580 Dutch children, Roza et al. [19] found that
later anxiety was predicted by some early oppositional behaviors (i.e., delinquent and
aggressive behavior) as measured by the CBCL. If anxiety and oppositional behavior share
a similar association in clinical and nonclinical samples and across the span of childhood,
then the relationship may be developmental as much as clinical. For example, they may
be related through the ‘‘fight’’ (opposition) or ‘‘flight’’ (anxiety) reaction system that is
engaged in response to stress [20].
Several theoretical mechanisms have been proposed to explain what appears to be a
paradoxical relationship between anxiety, an internalizing response, and oppositional
behavior, an externalizing response, in children. Lieberman [21] noted that anxiety and
oppositional behavior first meet in the toddler years when ‘‘worries reappear in disguised
form as … frequent and intense tantrums, negativism … or a myriad of other symptoms
that can best be understood as the child’s cry for help’’ (p. 142). Subbotsky [22] proposed
that, at least for young children, characteristics of pre-operational thinking (e.g., egocen-
trism, magical thinking) may predispose children to stress and anxiety regarding even
mundane or ordinary events and therefore increase the vulnerability for oppositional
behavior. These theories suggest that oppositional behavior in young children is not simply
or necessarily willful misconduct, and may be a response to the increased stress and
confusion that can arise from the magical thinking characteristic of this developmental
stage.
In addition, young children may be too immature to access more complex cognitive
processes and coping skills to adequately manage their worries. Consistent with this idea,
Leung and Fagan [23] suggested that, young children’s feelings of insecurity and vul-
nerability might be manifested as oppositional responses. Kashani et al. [20] have similarly
proposed that oppositional behavior is one way that children cope with fear and anxiety,
and that anxious children may be more likely to perceive threat than non-anxious children.
They found that increased verbal and physical aggression was associated with higher levels
of anxiety among 210 children ranging from 8 to 17 years old, and suggested that anxiety
raises the ‘‘fight’’ response in some individuals. An additional explanation by Camerus [24]
is that oppositional behavior is a primitive defense against pain and loss that can be
manifested either by very young children or by older individuals with regressive or
immature coping styles. The observation that both oppositional behavior and anxiety
appear in adolescence [14, 25], may be explained in part by the many accelerated changes
that occur socially, academically, cognitively, and physically, all of which could activate
stress and coping responses in this age group.
The relationship between anxiety and oppositional behavior must also be understood in
the context of gender. Research has consistently found boys to exhibit more oppositional
behavior [1, 4, 26, 27] with earlier onset [28]. Preschool aged boys exhibit significantly
more oppositional behavior [13] including tantrums [29]. Similarly, Chaplin et al. [30]
found that 4 to 6-year-old boys displayed more disharmonious emotions (i.e., anger,
laughing at another’s expense) than girls, and these emotions were predictive of later
externalizing symptoms. This behavioral propensity is consistent with the theory that a
tendency to express anger, which is more common and acceptable among boys, may be
related to the development of externalizing problems [30].
In contrast, beginning in early childhood and extending across the lifespan, girls exhibit
a higher incidence of anxiety and anxiety disorders [31, 32]. Using retrospective data from

123
522 Child Psychiatry Hum Dev (2008) 39:519–527

over 1,100 adolescents, Lewinsohn et al. [33] reported that by age six, girls were already
more than twice as likely as boys to have experienced an anxiety disorder. Consistent with
this, Chaplin et al. [30] found that 4 to 6 year old girls express more submissive emotions,
including fear and worry, than boys. Finally, Armstrong and Khawaja [34] found gender
differences in anxiety among 97 undergraduate students with females showing heightened
sensitivity to the cognitive and somatic components of anxiety.
Gender differences in both anxiety and oppositional behavior implicate both biological
and socialization factors. Lewinsohn et al. [33] found that gender continued to be signif-
icantly related to anxiety even after controlling for ten psychosocial correlates of anxiety
on which there were significant gender differences, and concluded that female vulnerability
to anxiety may be genetic or biological. Additionally, studies of sex role expectations have
shown that boys learn that anger and aggression are more acceptable masculine emotions
than anxiety, sorrow, or fear [35, 36] which are more likely to be reinforced for girls [30].
Garside and Klimes-Dougan collected retrospective reports from 322 young adults who
recalled fathers having rewarded girls and punished boys for expressing fear [36]. Ginsburg
and Silverman [37] implicated sex-role orientation as one variable responsible for gender
differences in anxiety. They found that, in a clinical sample of 66 children ages 6–11,
masculine sex-role orientation was negatively related to fearfulness. These kinds of subtle
and overt socialization pressures likely contribute to gender differences in internalizing and
externalizing behaviors. Furthermore, Chaplin et al. [30] speculated that an early tendency
to express anger or sadness might be related to the subsequent development of external-
izing or internalizing, respectively.
Given that anxiety is more common among girls and oppositional behavior is more
common among boys, but that anxiety and oppositional behavior also co-occur, it is of
interest to determine if either gender or anxiety is more strongly related to oppositional
behavior. The purpose of the present study was to investigate the relationship between
anxiety, gender, and oppositional behavior in two community samples, and to add to the
existing literature by examining if oppositional behavior in community samples shares
common underlying variables with that in clinical samples. Oppositional behavior and
anxiety were self-reported by children in elementary school (grades 4 through 6; 8 to
12 year olds; N = 200) and middle-school (grades 7 and 8; 12 to 14 year olds; N = 102)
students. It was hypothesized that anxiety and oppositional behavior would be correlated in
both samples, despite their non-clinical status. In addition, it was hypothesized that boys
and girls would differ in their levels of anxiety and oppositional behavior, but that anxiety
would be a stronger predictor of oppositional behavior than gender.

Method

Participants

Elementary School Sample

Fourth (26.8%), fifth (42.8%), and sixth grade (30.4%) students ranging from eight to
twelve years (M = 10.2, SD = 0.86) were recruited from five rural Vermont elementary
schools (N = 200). Of the 192 that reported their gender, 41.5% (n = 83) were male and
54.5% (n = 109) were female. Data were self-reported, thus no information on annual
income or parental demographics were collected due to concerns regarding accuracy.
Information on race was not collected, but rural Vermont is 97% Caucasian [38].

123
Child Psychiatry Hum Dev (2008) 39:519–527 523

Middle School Sample

Seventh (53%) and eighth grade (47%) students from a rural middle school in northern
Vermont were recruited (N = 120). Eighteen participants were omitted due to incomplete
questionnaires (N = 102). The remaining sample was 55% female (n = 56) and 45% male
(n = 46), and ranged from 12 to 14 years old (M = 13.2, SD = 0.66). Again data were
self-reported, thus no information was collected regarding annual income or parental
demographics. Information on racial identity was not collected, but rural Vermont is 97%
Caucasian [38].

Measures

Oppositional Defiance Disorder Symptom Checklist

Utilizing the diagnostic criteria for Oppositional Defiance Disorder as defined in the DSM-IV
[1], a self-report, point-in-time checklist for oppositional defiance was devised to measure
the number and intensity of ODD criteria in this sample. The measure, entitled ‘‘What I Do
and Feel’’, was comprised of eight valid items (derived directly from the DSM-IV). The
items were (in order): ‘‘I lose my temper,’’ ‘‘I argue with grownups,’’ ‘‘I refuse to follow
rules,’’ ‘‘I annoy people on purpose,’’ ‘‘My mistakes are usually someone else’s fault,’’ ‘‘I
am easily annoyed,’’ ‘‘I mostly feel mad,’’ and ‘‘I try to get back at other people when they
hurt me or my feelings.’’ The checklist also included six bogus items. Each item was rated
according to ‘‘whether the item is true for you’’, using the following four point scale: one
(never), two (not usually), three (sometimes), or four (most of the time). Cronbach’s alpha
for this sample was .73.

Revised Children’s Manifest Anxiety Scale [R-CMAS]

The R-CMAS was developed by Reynolds [39] on a community sample of children as a

point-in-time measure of anxiety. This self-report scale, entitled ‘‘What I Think and Feel’’,
is comprised of 37 questions, 9 of which can be scored separately as a Lie scale. The other
28 items comprise a single manifest anxiety score. Each item is rated on a two-point scale:
yes (1 point) or no (0 points). Items include: ‘‘I have trouble making up my mind,’’ ‘‘I am
afraid of a lot of things,’’ and ‘‘I am nervous.’’ Reynolds [39] reported considerable
concurrent validity between the R-CMAS and the State-Trait Anxiety Inventory, r = .85,
p \ .001. Cronbach’s alpha for this sample was .79.

Procedure

The research protocol first received approval for research involving human participants
from the Institutional Review Board. To recruit the elementary and middle school samples,
a letter describing a study on ‘‘children’s feelings and behaviors’’ and asking for parental
consent was sent home with children in cooperation with school principals. Graduate
students in counseling who were concurrently enrolled in a research methods course
administered the questionnaires at the schools during participants’ class time. Participants
were advised that their participation was anonymous and voluntary, and explicitly told not
to put their names on any of the materials, the order of which was purposely varied among
them. They were told that neither parents nor teachers would see their response sheets, and
were instructed on how to complete the questionnaires for which they were allowed 15

123
524 Child Psychiatry Hum Dev (2008) 39:519–527

minutes. Questionnaires were then immediately collected. No students declined partici-

pation, and no compensation was offered.

Data Analysis

Data analyses were conducted separately for each sample, beginning with descriptive sta-
tistics for continuous variables. T-tests for independent means were employed to compare
boys and girls on anxiety and oppositional behavior. Pearson correlations were calculated to
assess the degree of association between anxiety and oppositional behavior. After insuring
that regression assumptions were met, stepwise regression was employed to assess the
strength of anxiety and gender (dummy coded, 0 = male, 1 = female) as predictors of
oppositional behavior. SPSS for Windows 13.0 was used for all statistical analyses.

Results

In the elementary school sample, anxiety scores on the R-CMAS ranged from 0 to 26
(M = 10.3, SD = 6.5), and oppositional scores ranged from 8 to 31 (M = 17.4, SD = 4.8).
Contrary to the hypothesis, there were no gender differences in anxiety, t(190) = -.254, n.s.
However, as predicted, elementary school boys reported more oppositional behavior
(M = 18.61, SD = 4.6) than girls (M = 16.40, SD = 4.5), t(190) = 3.35, p = .001. As
expected, self-reported anxiety was positively correlated with oppositional behavior,
r(200) = 0.48, p \ .01.
In the middle school sample, scores on the R-CMAS ranged from 0 to 27 (M = 9.2,
SD = 5.9), and oppositional scores ranged from 8 to 33 (M = 18.8, SD = 4.5). There was
a non-significant trend for girls to report more anxiety (M = 10.08, SD = 5.68) than boys
(M = 8.04, SD = 5.93), t(101) = -1.78, p = .078, and as expected, boys reported more
oppositional behavior (M = 20.34, SD = 4.50) than girls (M = 17.59, SD = 4.21),
t(100) = 3.18, p = .002. As hypothesized, self-reported anxiety and oppositional behavior
were positively associated, r(102) = 0.37, p \ .001.
Stepwise regression using SPSS was used to assess whether the independent variables
anxiety and gender (dummy coded, 0 = male, 1 = female) were significant predictors of
oppositional behavior. There were only two independent variables in this study, and both
were included in the regression analysis. Regression assumptions were met (e.g., homo-
geneity of variance). As predicted, for the elementary school sample, anxiety accounted for
21.4% of the variance in oppositional behavior, (r = .463), entering the equation before
gender which accounted for an additional 6% (r = .524). The final model included both
variables, F(2, 189) = 35.75, p \ .0009, and accounted for 27.4% of the variance. Similar
findings were also confirmed for the middle school sample with anxiety explaining 13.3%
of variance in oppositional behavior and entering the equation first, (r = .365), followed
by gender which accounted for an additional 13.8%, (r = .520). The final model included
both variables, F(2,99) = 18.36, p \ .0009, and accounted for 27.1% of the variance in
oppositional behavior (See Table 1).

Discussion

The purpose of this study was to explore the relationship between anxiety, gender and
oppositional behavior in two community samples of children. The relationship between

123
Child Psychiatry Hum Dev (2008) 39:519–527 525

Table 1 Summary of stepwise regression analyses for variables predicting oppositional behavior by sample
Varible B SE b R2

Elementary school (N = 192)

Step 1 Anxiety .335 .046 .463 .214
Step 2 Anxiety .338 .045 .468
Gender* 2.29 .579 .245 .274
Middle school (N = 102)
Step 1 Anxiety .281 .072 .365 .133
Step 2 Anxiety .331 .067 .429
Gender* 3.41 .790 .376 .271
* Gender was dummy-coded for this analysis (0 = male, 1 = female)
Note: Elementary sample DR2 = .06 for Step 2, p \ .05. Middle school sample DR2 = .133 for Step 2,
p \ .05

anxiety and oppositional behavior has previously been observed in clinical samples of
children [3, 20]. Kashani et al. [20] suggest that oppositional behavior may be a response to
anxiety among individuals with poor coping skills. Anxiety may also increase in response to
oppositional feelings and behaviors, or may predispose children to oppositional behavior [3].
Alternatively, Stormshak and Bierman [40] note that both anxiety and oppositional
behavior may stem from other factors such as parenting practices, temperament, and
gender-related variables like differential socialization, which this study did not explore but
which deserve attention in future investigations.
Most children exhibit oppositional behavior at an early age, including developmentally
typical tantrums and aggression, but this tends to diminish as they mature [2, 7–9]. In typical
development, oppositional behavior signals the child’s insistent movement toward autonomy
and marks developmental growth. In adolescence, angst and oppositional behavior can be a
manifestation of independence and identity formation that is common and developmentally
expected, particularly in the face of sweeping social, physical, cognitive, and academic
changes. These changes are associated with increased unease, but the role of anxiety in
adolescent oppositionality, including rebellion, has received relatively little attention. Even
elementary school aged children who display relatively low rates of psychological problems
compared to other developmental cohorts, still provide evidence of the enduring and con-
sistent link between anxiety and ODD. The current study supports other research suggesting
that anxiety is related to oppositional behavior and feelings in childhood and adolescence,
although not necessarily causally [3, 17, 18]. These findings further suggest that the rela-
tionship between these variables is consistent, even when neither rises to a clinical level.
Gender differences in anxiety were not observed in these non-clinical samples, although
a trend in that direction was observed among the oldest children in the sample (12–14 year
olds). Despite gender differences in oppositional behavior in the elementary and middle
school samples, anxiety continued to be the best predictor of oppositional behavior in both
samples. However, it is important to note that models derived from stepwise regression
may not generalize well to other data sets, and therefore must be interpreted cautiously. In
addition to replicating these results, future studies should examine potential moderating
variables, including gender, to better understand this relationship.
The correlational nature of these findings obscure the type of relationship between anxiety
and oppositional behavior, and the findings are further limited by the homogeneity of these

123
526 Child Psychiatry Hum Dev (2008) 39:519–527

rural Vermont samples and reliance on concurrent self-report. Children tend to under-esti-
mate their externalizing behavior, therefore the use of self-report in this study may have
resulted in a conservative estimate or restricted range of oppositional behavior, further
masking the relationship between variables. Future research would benefit from multiple
informants. However, this research is consistent with previous work that suggests caregivers,
teachers, and clinicians should consider that anxiety might co-occur with oppositional
behavior for both boys and girls. In addition, if oppositional behavior commonly co-occurs
with anxiety, and if the strength of that relationship is at least moderate, then it may respond
well to reassurance and modeling of mature coping skills. Further research should explore if
preventing or treating anxiety, can simultaneously diminish oppositional behavior.

Summary

This study explored whether oppositional behavior, anxiety and gender were related in two
community samples of school children as these variables have repeatedly been linked in
clinical samples. The school children in this study provided anonymous self-reports of their
oppositional behavior (using DSM-IV criteria) and anxiety (using the R-CMAS). In both
samples, there were no significant gender differences in anxiety but boys reported more
oppositional behavior. Despite the gender differences in oppositionality, anxiety was a
stronger predictor of oppositional behavior. These results suggest that the relationship
between oppositional behavior and anxiety is similar in clinical and nonclinical samples of
boys and girls. Whether oppositional behavior is developmentally typical or rises to a
clinical level, anxiety appears to play a role.

References

1. American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders, 4th edn.
American Psychiatric Association, Washington, DC
2. American Academy of Pediatrics (1996) The classification of child and adolescent mental diagnoses in
primary care. American Academy of Pediatrics, Washington DC, pp 18–20
3. Garland J, Garland O (2001) Correlation between anxiety and oppositionality in a children’s mood and
anxiety disorder clinic. J Psychiatry 46:953–960
4. Kann T, Hanna F (2000) Disruptive behavior disorders in children and adolescents: How do girls differ
from boys? J Couns Dev 78:267–274
5. Kuczynski L, Kochanska G (1990) Development of children’s noncompliant strategies from toddler-
hood to age 5. Dev Psychol 26:398–408
6. Quay HC, Hogan AE (eds) (1999) Handbook of disruptive behavior disorders. Kluwer Academic/
Plenum Publishing, New York
7. Achenbach TM (1991) Manual for the child behavior checklist/4–18 and 1991 profile. University of
Vermont Department of Psychiatry, Burlington, VT
8. Stanger C, Achenbach TM, Verhulst FC (1997) Accelerated longitudinal comparisons of aggressive
versus delinquent syndromes. Dev Psychopathol 9:43–58
9. Tremblay RE, Boulerice B, Harden PW, McDuff P, Perusse D, Pihl RO, Zoccolillo M (1996)
Do children in Canada become more aggressive as they approach adolescence? Growing up in Canada.
Statistics Canada, Ottawa, pp 127–137
10. Kuczynski L, Kochanska G, Radke-Yarrow M, Girnius-Brown O (1987) A developmental interpretation
of young children’s noncompliance. Dev Psychol 23:799–806
11. Bird H, Davies M, Duarte C, Shen S, Loeber B, Canino G (2006) A study of disruptive behavior
disorders in Puerto Rican Youth: II. Baseline prevalence, comorbidity, and correlates in two sites. J Am
Acad Child Adolesc Psychiatry 45:1042–1053
12. Campbell S (1994) Hard-to-manage preschool boys: externalizing behavior, social competence, and
family context at two-year follow up. J Abnorm Child Psychol 22:147–166

123
Child Psychiatry Hum Dev (2008) 39:519–527 527

13. Sanson A, Prior M (1999) Temperamental and behavioural precursors to oppositional defiant disorder
and conduct disorder. In: Quay HC, Hogan AE (eds) Handbook of disruptive behavior disorders.
Kluwer Academic/Plenum Publishing, New York, NY, pp 397–417
14. Marohn RC (1980) Adolescent rebellion and the task of separation. Adolesc Psychiat 8:173–183
15. Lavigne J, Cicchetti C, Gibbons R, Binns H, Larsen L, Devito C (2001) Oppositional defiant disorder
with onset in preschool years: longitudinal stability and pathways to other disorders. J Am Acad Child
Adolesc Psychiatry 40:1393–1401
16. Speltz ML, McClellan J, DeKlyen M, Jones K (1999) Preschool boys with oppositional defiant disorder:
clinical presentation and diagnostic change. J Am Acad Child Adolesc Psychiatry 38:838–845
17. Bird H, Gould M, Staghezza B (1993) Patterns of diagnostic comorbidity in a community sample of
children aged 9 through 16 years. J Am Acad Child Adolesc Psychiatry 32:361–368
18. McConaughy S, Achenbach T (1994) Comorbidity of empirically based syndromes in matched general
population and clinical samples. J Child Psychol Psychiatry 35:1141–1157
19. Roza SJ, Hofstra MB, van der Ende J, Verhulst FC (2003) Stable prediction of mood and anxiety
disorders based on behavioral and emotional problems in childhood: a 14-year follow-up during
childhood and young adulthood. Am J Psychiatry 160:2116–2121
20. Kashani J, Deusner W, Reid J (1991) Aggression and anxiety: a new look at an old notion. J Am Acad
Child Adolesc Psychiatry 30:218–222
21. Lieberman A (1993) The emotional life of the toddler. Free Press, New York, NY, pp 3–184
22. Subbotsky E (2004) Magical thinking––reality or illusion? Psychologist 17:336–339
23. Leung A, Fagan J (1991) Temper tantrums. Am Fam Physician 44:559–564
24. Camerus M (1990) Adolescent anger. Bull Menninger Clin 54:512–525
25. Berman SL, Weems CF, Stickle TR (2006) Existential anxiety in adolescents: prevalence, structure,
association with psychological symptoms and identity development. J Youth Adolescence 35:303–310
26. Cunningham C, Boyle M (2002) Preschoolers at risk for attention deficit hyperactivity disorder and
oppositional defiant disorder: family, parenting, and behavior correlates. J Abnorm Child Psychol
30:555–569
27. Romano E, Tremblay R, Vitaro F, Zoccolillo M, Pagani L (2005) Sex and informant effects on
diagnostic comorbidity in an adolescent community sample. Can J Psychiatry 50:479–489
28. McCabe K, Rodgers C, Yeh M, Hough R (2004) Gender differences in childhood onset conduct
disorder. Dev Psychopathol 16:179–192
29. Bhatia MS, Dhar NK, Singhal PK, Nigam VR, Malik SC, Mullick D (1990) Temper tantrums: prev-
alence and etiology. Clin Pediatr 29:311–315
30. Chaplin T, Cole P, Zahn-Waxler C (2005) Parental socialization of emotion expression: gender dif-
ferences and relations to child adjustment. Emotion 5:80–88
31. Albano AM, Krain A (2005) Issues in clinical child psychology. In: Bell DJ, Foster SL, Mash EJ (eds)
Handbook of behavioral and emotional problems in girls. Kluwer Academic/Plenum Publishers, New
York, NY, pp 79–116
32. Silverman WK, Carter R (2006) Anxiety disturbance in girls and women. In: Worell J, Goodheart CD
(eds) Handbook of girls’ and women’s psychological health: gender and well-being across the lifespan.
Oxford University Press, New York, NY, pp 60–68
33. Lewinsohn PM, Gotlib IH, Lewinsohn M, Seeley JR, Allen NB (1998) Gender differences in anxiety
disorders and anxiety symptoms in adolescents. J Abnorm Psychol 107:109–117
34. Armstrong K, Khawaja N (2002) Gender differences in anxiety: an investigation of the symptoms, cog-
nitions, and sensitivity towards anxiety in a nonclinical population. Behav Cogn Psychoth 30:227–231
35. Brody L (2000) The socialization of gender differences in emotional expression: display rules, infant
temperament, and differentiation. In: Fischer AH (ed) Gender and emotion: social and psychological
perspectives. Cambridge University Press, New York, NY, pp 24–47
36. Garside R, Klimes-Dougan B (2002) Socialization of discrete negative emotions: gender differences
and links with psychological distress. Sex Roles 47:115–128
37. Ginsburg GS, Silverman WK (2000) Gender role orientation and fearfulness in children with anxiety
disorders. J Anxiety Disord 14:57–67
38. United States Census Bureau (2007) State and county quickfacts. Data derived from population esti-
mates. Retrieved January 20, 2008, from http://quickfacts.census.gov/qfd/states/50/50015.html
39. Reynolds CR (1980) Concurrent validity of what I think and feel: the revised children’s manifest
anxiety scale. J Consult Clin Psychol 48:774–775
40. Stormshak E, Bierman K (2000) Parenting practices and child disruptive behavior problems in early
elementary school. J Clin Child Psychol 29:17–30

123