Oppositional Defiant Disorder (ODD) and ADHD
This article comes from two different subscribers’ questions. The first is: “Dear Dr. Handelman - I wanted to ask you why would a child at ten years old with ADHD push his mother into counters and walls when he is upset and not getting his way?”
The second question is “Dear Dr. Handelman - I wanted to ask you if my daughter has ADHD because she gets into trouble a lot at school by not concentrating, disrupting and blurting out and fighting a lot and she never shuts up. She gets hyper nearly every day and she can become very stressed and emotional and aggressive. She can get hyper on anything she eats.”
I appreciate both of these questions, because it is not easy to talk about such difficulties.
I will use both of these questions to teach you an important point. It relates to the fact that both of the descriptions above suggest that these kids have ADHD plus something else.
There is a concept in ADHD called comorbidity. You can review comorbidity by reviewing a previous article - comorbidity in ADHD. In summary, comorbidity means that there is a co-existing disorder that causes more ‘morbididty’ or in other words difficulties in one’s life.
While I cannot diagnose these children based on so little information, the comorbid condition which comes to mind is: Oppositional Defiant Disorder. This is often referred to as ODD.
Certainly in the first question where a ten year old boy is pushing his mother into the counters and walls when he’s upset and not getting his way - that’s more than ADHD - that’s a behavior problem. It is very uncommon for a child with ADD or ADHD to act in such a manner.
Oppositional Defiant Disorder is defined as having 4 out of 8 diagnostic criteria on a regular basis, over a period of at least 6 months.
The criteria of ODD include(from the DSM-IV-TR):
- Often loses temper
- Often argues with adults
- Often actively defies or refuses to comply with adults’ requests or rules
- Often deliberately annoys people
- Often blames others for his or her mistakes or misbehaviors
- Is often touchy or easily annoyed by others
- Is often angry and resentful
- Is often spiteful or vindictive
The DSM-IV-TR explains that these symptoms have to be present much more than would be expected for the individual’s developmental age.
Furthermore, the symptoms have to cause significant impairment - in social, academic, or occupational realms.
Conceptually, ODD is like a child going “up to the line”, which is put in place by parents or other adults and testing that line. Or tormenting the person holding the line. Or stepping over the line but coming back very quickly.
ODD doesn’t include clearly crossing the line. That moves into the realm of Conduct Disorder.
Now when a child has ODD with ADHD it can be a lot more complicated to deal with. It can really depend on the severity of the ODD. With mild ODD, it can be challenging for parents and teachers, but it can be like just an extra spirited child. Severe ODD can tear families apart and disrupt the school significantly.
So what do we do to treat Oppositional Defiant Disorder (ODD)?
Well as with all psychiatric disorders, there are medication approaches and there are behavioral approaches.
The medication approaches: there are no medications specific for ODD. Since ODD is mostly present with ADHD, then treating the ADHD well will often improve the ODD. This has been shown in multiple studies with stimulant medicines (Ritalin, Concerta, Adderall, Metadate, etc) and the non-stimulant - Strattera.
The non-medication approaches include behavioral and psychological techniques to help manage the ADHD and ODD. Parents need to learn to structure the environment very well for them to help them to keep on track. Parents need to get a ‘Ph.D. in parenting’ if you will. They need to learn specialized techniques and abilities to handle their child’s difficulties. A good resource for this is Dr. Tom Phelan’s work - including 1,2,3 Magic and Surviving Your Adolescents.These books can be found at The ADHD Bookstore.
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Written by Dr. Kenny Handelman - The ADHD Doctor
To find get a FREE special report on ADD/ADHD Medication, visit: Medication Mastery
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April 12th, 2007 at 4:03 am
Hi,
I would like to address your comment -’ It is not ADHD , it is behavior ‘ I would say it is not behavior , but ADHD plus …., not that he is a difficult kid , but a kid with severe difficulties. A behavior problem , implies that he is a difficult kid.
ODD is not a very helpful Dx , it just describes what the kid does , not why. It also presupposes that the behavior is deliberate , attention seeking , trying to get one’s way , the kid if he wanted to could behave , just lacks motivation. Because ODD is comorbid with so many other cognitive difficulties etc , ODD rarely travels alone see
http://www.dbpeds.org/articles/detail.cfm?id=119
I would look at the situation , there are more underlying factors to the kid’s behavior than to just call it attention seeking or trying to get his way, a behavior problem , this just does not go far enough to explain the problem. It could be so many things , it could be untreated ADHD and often treating the ADHD helps the ODD.
The med route could include meds like respiridal which treat ‘off label ‘aggression etc . Each child is different and no one size fits all , but we need to look beyond the dx , the med ( we don’t want meds to be a long term goal if we can help it ) and behavior modification. We as parents and care givers have to see our contribution to a kid’s meltdown , are we sensitive and responsive to a kid’s frustration tolerance or adaptability, maybe being in a shopping mall is too much of a trigger for a kid and should be avoided at the present , we need to be more compatible , as Alfie Kohn says discipline is the problem , not the solution because we never see our role in the situation , it is always the kid with the behavior problem. IMHO , the kid’s behavior is symptomatic of very poor coping skills , so if we see it as behavior , we see it as voluntary as teachers always say when they want to justify punishments for our kids instead of looking for positive learning interventions and accomodations , which is real inductive teaching and promotes self regulation.
here is a piece from a great site
http://schoolbehavior.com
Recognizing that we don’t want to be harsh or punitive about something that the child really can’t control, but that there are some behaviors that really are problematic, what would happen if we take punishment off the table? Would parents be more inclined to acknowledge that something needs to be addressed? Would parents and teachers find it easier to come up with an appropriate plan to help the student self-manage? My experience suggests that they would, but both parents and teachers need to share the goal of helping the child learn to self-regulate. If the teacher is stuck in the noncreative “He has to be taught a lesson for this by punishing him” mode, this won’t work. The teacher is right on one level: the child does need to be taught something. But what you teach the child and how you teach the child will make a tremendous difference in whether the child learns to self-manage.
When a child is struggling behaviorally, I take a “no fault” approach to understanding and trying to change things. I start from the premise that for whatever reason, the child or adolescent is predisposed to have particular behaviors, and that in light of those strong predisposing factors, we need to carefully consider what kind of environmental supports the child needs if they are to modulate this behavior. I do not assume, however, that just because the parents and teachers may not like something that it makes it a target for intervention. As you shall see, there are certain “tests” a behavior has to pass before I would attempt any intervention that involved consequences to the child.
And the very first thing I change or try to change is not the child or adolescent, but what the parents and teachers do before anything happens
Allan