Is it ADHD or is it ODD?

Many ADHD and behavioral professionals are stressing the importance of knowing that children with ADHD are at an increased risk of developing Oppositional Defiant Disorder (ODD). This is so vitally important because when this occurs, the long-term outcomes for children are likely to be much worse than for a child suffering from ADHD alone. Today, Dr. James Wiley will highlight the ODD symptoms we should be aware of and what challenges are involved to distinguish the two disorders.

Explaining ODD

ODD is considered to be an ADHD comorbidity, as in the two conditions tend to exist at the same time. It sometimes occurs alone, but more frequently it occurs with other mental health issues. It is characterized by oppositional defiant behavior. This would include things like not wanting to do what the adult wants them to do. It’s a pattern for angry, irritable mood and argumentative, defiant behavior. Or being vindictive, such as planning to get the last word or planning to do things to pay someone back for the way they treat you. For example, destroying property or taking something that doesn’t belong to you. It’s also characterized by a frequent loss of temper, being irritable or easily annoyed or angry and associated with blame-shifting or annoying others or defying others. These symptoms need to be occurring over a six-month period. Given that the symptoms overlap with a broad number of mental health conditions, it’s important to distinguish them.

The relationship between ADHD and ODD

It’s been indicated in recent research that as many as 10% of those with ADHD also have ODD. In the MTA study, which is an old study looking at medication management and behavioral treatment for ADHD, it was much higher than that. It’s certainly one of the most commonly diagnosed comorbidity with ADHD. Those numbers may be overrepresented because of the overdiagnosis of ODD but it varies from study to study.

Additionally, the research suggests that boys are more commonly diagnosed with ODD than girls. It’s more common in boys because girls with ODD tend to internalize their symptoms. In other words, they tend to be more anxious; they are more likely for instance to develop symptoms of Obsessive-Compulsive Disorder (OCD) or depression. In contrast, boys typically act out more and this is what can then persist to become ODD.

Distinguishing ADHD between ODD

It’s very common for kids to be impulsive, to do things without thinking about it. For example, the inattentive symptoms of ADHD can lead to children forgetting what they were told to do or not completing a task on time. For a teacher or a parent, this can appear to be a deliberate act of defiance, when in fact they have simply forgotten or didn’t fully understand what was asked of them. I think this is one of the things that contribute to the mis- and overdiagnosis of ODD – because of the confusion around the interpretation of a child’s behavior. What complicates matters further is that, in my experience, patients with ADHD, tend to shift the blame.

They will say things like: “well, I don’t think the teacher told me” or “she didn’t write it down” or “the boy next to me was distracting me”. These behaviors are characteristic of ODD as well. In addition, kids with ADHD sometimes will lie to protect themselves, they will make things up or say “no, I didn’t do that” or “no, you didn’t tell me to do that”. They’re doing this to cover their tracks. Again, I believe this comes from this frequent interrogation of kids with ADHD that they face in their daily life – why did they get this wrong? Why did they do this rather than that … and so it goes on. To summarize, untreated ADHD and related disorders often contribute to oppositional/defiant behaviors and understanding these underlying diagnoses as well as the child’s social stress level can help us provide more comprehensive care to support these young people and their families.

Read more on ODD and ADHD in the second part of this series: ODD – a problem of misdiagnosis?

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