The relationship between ADHD and ODD

1 minute summary: 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). But there are a number of other issues that could lead to a child being oppositional or out of control in school or at home. Dr. James Wiley explains the relationship between ADHD and ODD.

What is ODD?

ODD is considered to be an ADHD comorbidity, as both conditions tend to exist at the same time. It’s been indicated in recent research that as many as 10% of those with ADHD also have ODD. It sometimes occurs alone, but more frequently it occurs with other mental health issues. It is characterized by oppositional defiant behavior – a pattern of negative, hostile, or defiant behavior. This would include things like:

• Defiant, for example not wanting to do what an adult wants them to do
• Being angry, irritable, and argumentative
• Being vindictive, such as planning to do things to pay someone back for the way they treated you
• A frequent loss of temper
• Blame-shifting or annoying 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.

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 over-diagnosis 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.

Why ODD can be misdiagnosed

When we’re making mental health diagnoses, the thing that strikes me is that the last criteria for ODD listed in the DSM-5 diagnostic manual is almost always “not better explained by something else”. In other words, there’s not another condition that better explains the patient’s symptoms. We know that there is this crossover between oppositional defiant behavior and other mental health diagnoses. Therefore, for me, I always feel like a failure when I do diagnose ODD, because I want to find some other reason for their behavior.

Whether that is the result of untreated ADHD and all the negative messages kids receive because of this, whether it’s because of a need to do things in a certain way for OCD sufferers or whether someone’s autism means they can’t comply with your request to work in a group. Depression can also influence behavior – kids with depression may not be motivated and feel that they couldn’t care less what the consequences of their actions are. With depression in kids, it’s not just this feeling of sadness but another predominant symptom is a total apathy and a lack of interest.

Anxiety too can influence ODD like symptoms. Anxious people by definition can be irritable and fatigued or easily agitated. When anxious children feel cornered or their anxiety levels increase, they very often show their teeth and their claws or they shut down or don’t participate. They avoid situations. A perfect example of this would be the child that won’t do the public speaking assignment at school. They will take a zero or fail public speaking, but they’re not going to get up on the stage.

Ways to further our understanding of defiant behavior

As a pediatrician specializing in the care of youth with ADHD and co-morbid conditions, I find the presentation of ODD symptoms to be complex and consideration should be given to other causes for these behaviors before labeling them ODD. Looking for the clues for other conditions, for me in my practice, is the key to helping kids with ODD to get better. I ask myself: why are they oppositional and defiant? What is their underlying reason? I must also consider other external factors – perhaps the patient’s parents are going through a nasty divorce or they’re being bullied at school. Perhaps they’re insecure for any number of reasons, financial or otherwise. There are other things that leads to these types of behaviors. I always say that kids that ‘can do’ seem to manage okay. Kids that ‘can’t do’ end up being labeled or viewed as one of three things: they either shut down or they are the class clown or they meltdown.

Those are the three behaviors that you’re likely to see in children or who are stressed or overwhelmed. I think girls tend to shut down and boys tend to act out but that’s not always the case. We’ve certainly learned in recent years that you can’t paint with a gender brush because it’s too broad. But often, this is the case.

The risks of ODD being left untreated

A child’s level of aggression can escalate. Certainly, when you have a child who is frustrated and angry and you add the hormones of adolescence – this can lead to more aggression and more acting out. The more that young person is punished, whether that’s exclusion, or restricted or physically punished, the more anger rises. At some point, the young person asks themselves, “What do I have to lose”? This is where their behavior can escalate.

I often tell parents in these situations that it’s as though you’ve given them a prison sentence – they have nothing else to lose; they might as well act out in any way that they wish and they probably don’t feel like they can succeed. The pendulum swings to one extreme and they become more protective, perhaps more aggressive, or they shut down more. Instead of just not doing their homework, they don’t show up at school and become truant because they feel like they can’t be successful anyway, so why bother going. Those are just examples of the natural consequences of us not getting a handle on ODD.

Treating ODD

As of now, there’s no medication for ODD. Although I’m not a therapist myself, my understanding is that the aim of treatment is to unlock the underlying reason for that oppositional defiant behavior. Many people who were diagnosed with both ADHD and ODD, have been found to reduce oppositional defiant behavior, once the ADHD is treated with stimulant medications. Let me be clear, however, this is not a treatment for ODD. Nevertheless, I think the studies are clear in that when ADHD is treated or when OCD is treated or when a mood disorder is treated, then the ODD symptoms diminish because of the treatment of those comorbid mental health issues. So, in my opinion, treating the co-morbidity and then working with a behavioral therapist can be helpful.

Parent training

This is where parent training really shines. Because parents are up against this opposition behavior and so are teachers, for that matter – and they don’t know where this behavior is coming from. The assumption is, almost always in my experience, to blame the child. To say things like – “they’re being noncompliant, they’re not trying, they’re having a meltdown, they’re becoming disruptive or they’re becoming aggressive”. This is what people would typically describe as naughty behavior.

Whereas, from our clinical perspective, we like to say it’s neurological, it’s not naughty behavior. It looks like naughty behavior but they’re not trying to be bad – there’s something that’s driving that behavior. A great example of that is the kid with ODD who won’t complete a writing exercise because they don’t like the way it looks on the paper and so they tear it out and they won’t start the task because they’re not certain what it is the teacher wants them to do. Pediatricians, parents and teachers aren’t trained to recognize these very important triggers for this behavior and kids are left with the blame as well as being incorrectly labeled.

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