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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Comments

  1. 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

  2. Thank you Allen for your comment; it was very helpful. I am a grad student and just wrote a paper on ADHD and comorbidity. I agree with your comment that it is very easy for teachers or counselors to label and then medicate a child which would limit their perspective in seeing and implementing “positive learning interventions and accomodations , which is real inductive teaching and promotes self regulation.”
    The environment in which the child is coping has a lot to do with his difficulties.
    Thank you again,
    Andrea Roche

  3. Hi. My name is Issac “Elite” Oghenekevebe. I have have ODD and ADHD since I was 8 years old. It’s not as easy to get rid of as people may think but it is possible. I easily feel irritated esp. when my cell goes off and think that everyone is watching or talking about me. I have many musical talents and I use music to express myself. I feel when Im writting, Im free to express myself like Im talking to someone. The music I produce is all genres because I consistantly have to switch things up. Running my record label is a what I do and sometimes its hard to sit and focus on the music because of my ADHD. I love to dance too, any type. It helps my mind and body. I know its funny that I should be typing this instend of speaking to someone but I just thought maybe someone else might feel the way I do. The only real way to live life with ODD/ADHD is with Jesus Christ as your savior because he loves you when everyone else has rejected you and he can show you a better and happier life with purpose and meaning. He talks to me, like a conscience, in a still small voice and tells me that people arent out to get me and helps me with attention and focus. I still stuggle with it but its alot better than before. I thought you should hear this from someone with ODD and ADHD and not a doctor because this is the truth. You can do it, but not alone, remember that.

  4. I am hoping someone can help me figure out if my ADHD son also has this other ODD. He is taking medication for ADHD and was undiagnosed for YEARS because he was likeable to his teachers as a younger kid. It seemed he just couldnt settle. After many difficult years I finally took him to a pediatrition who specialized in ADHD. He is now 14 and in the 8th grade has been taking medication for only about a year and a half. Pairing the sever ADHD with adolesence has been a challenge. I am now wondering about ODD because if and when he forgets his medicine I ALWAYS get a call about his disruptive behavior and blurting out disrespectful comments etc. I also notice that at home in the afternoons he is irritating and never able to complete a task without another dose. It wasnt like this at first. What can I do…maybe its my parenting and I need some tips or something….he is a great kid but its like we cant get past this hurdle. He is the youngest of 5 and it seems that it is beyone just normal teenager junk.
    PLease comment.
    Thanks

    • My 13 year old son was diagnosed with ADHD due to poor grades, refusal to work/study, classroom outbursts, etc. 1 1/2 years ago. Shortly thereafter, ODD was added to the diagnosis because of his refusal to follow house rules, study for good grades, cursing around the house and violent outbursts. His violent outbursts can come out of nowhere but are mainly the result of his frustration when a consequence is handed out. This is why setting consequences is so difficult for his father and me. He is supposed to lose his cell phone for 1 day for every curse word he utters and that has generally worked pretty well. Recently he has refused to attend weekly mass with us and we consider that a most severe form of defiance. We have taken his laptop for one week (until he attends the following week). This is very frustrating for all of us, but his little brother (10) is the most hurt and damaged by witnessing all of this. We try so hard to keep things calm and peaceful for our youngest, but we just can’t ignore the bad behaior.
      Does anyone relate to this at all and have any advice? My husband is also ADHD and goes from one extreme to the other – first wanting to ignore the ODD behavior just to avoid conflict and then wanting to throttle him. I think the right thing is to continue to impose consequences in a consistent manner, but then is it right to expose the siblings to the madness?

      • mamamia, I have a 12 year old son with ADHD and ODD. He is extremely difficult to deal with and his social worker is at her wits end as are we. I believe consequences are very inportant. They have to be held accountable for their behavior rather than passing the blame (my son’s favorite). If you ignore the behaviors ODD kids see it as a free pass. They are purposely trying to push buttons. If they are attention seeking always go out of your way to praise the poistive how ever infrequent those instances may be. ODD is hard on the entire family and I believe harder on the non ODD members of the family than the child with the ODD.

  5. I have an 8 year old male whose been diagnosed with adhd and odd. He started kindergarten on a patch called daytrama. This was good for a year! since than he has been on concerta,ritalin.aderal, all diff. mg’s and time frames!! nothing seems to work! They wont put him on an I.E.P because the principal and the man at the board of education says academicly he is further ahead than others in his room. Can anyone tell me of a med that works in combination for adhd/odd that i haven’t mentioned!

    • My son had the same problem. What you need is a 504 Plan. Basically, they will make accommodations within the class for dealing with the issues he struggles with. I suggest researching 504 plans. It covers persons with disabilities…which this is classified as. Good luck

  6. Shelly,

    My daughter (now 15) has many comorbidities with her ADHD that we are trying to work through. She has been on all of the meds you mentioned (since 3rd grade) and they worked for a short time but stopped working after awhile. She has been on Focalin which is wonderful, but then we switched her to Vyvanse which is even better because it has a longer acting component to it that gets her through evening time with homework, chores, etc. Both of those are awesome meds that have really made a difference for her!

  7. My daughterwas diagnosed July 2010. We tried 7 different meds from.July until Feb 2011, I watched my beautiful baby lose her mind. Adderall was the worst, her therapist kept upping her dose. She droppex so much weight and wasnt sleeping. I finally found a doctor and admitted her. she was properly diagnosed ADHD/ ODD. She was in patient for 5 days, outpatient for 7. its still a struggle amd we go day to day. I think schools need to have more training. The way my daughter was dealt with was suspending up to 3 times a week. She was totally discriminated against. At her school we have 6 bi-lingual teachers but no help for ED kids. They wouldnt even put her in Special Ed because her IQ is so high. I did my homework and pushed and finally 2 days before school was out I got help. Would really like some advice on what different te,hniques help. Thks Ry’s mom.

  8. My son just turned 8 today, he started showing sighns of a behavorial problem at 5 years old. The 1st time I took him to get evaluated i was told he was just an extremely smart child who has learned to manipulate me when he doesn’t get his way. I left that office everything put on me that i needed to be more consistant more strict, now i have another son 2 1/2 years older that my discipline has worked for but i do know that every child is different too, so for the next 2 years I struggled to find a discipline that not only worked but that I could use consistantly. Nothing worked but only got worse more intense to the point that I was questioning myself and my ability to parent with the words of that therapist constantly in my mind. I even seeked help for myself because the everyday battle with my son was not only wearing on me, I was stressed & depressed thinking “what am I doing wrong”. I became unpleasant to be around because after battling with my son I would snap at anyone else around me. Finally @ 7 years old in 1st grade his behaviorstarted showing at school & causing problems, he was being looked at as a troublemaker because his grades were average, teachers saying he does what he wants to do they couldn’t get him to do work, stay seated, sometimes total refusal to even get up & leave the class room. Fortunately around this time that did the routine MAPS tseting to see were the kids were at & my son tested the highest in all his grade in that school. This seemed to bring attention to the teacher that something was wrong with him to be that smart but be having the behavioral issues. I took him back to the same place I took him 2 years before but seen someone different. He was 1st diagnosed with ADHD by having us and all the teachers fill out evaluations on him. The next step was for her to do her own hour long evaluation with just him. When we met to talk about all the results she said he had ODD and was the most extreme ODD she had personally ever seen, but with his intelligence he acted not like a normal 7 year old with ODD but like a 15 year old with ODD. When explained what ODD stood for Oppostional Defiant Disorder I knew by the name itself described my son to a T. I felt a huge weight off my shoulders immediately! I also realized it meant something was wrong with my son but knowing what it was and knowing that if we know means we can start to help him was so relieving. We started him on ADHD medicine which was said that if you can help the ADHD you can help the ODD. Meaning that if you can get him to sit down and focus on what he is suppose to do than you won’t have the confrontations of trying to correct him which is when the ODD was most obvious. They 1st ADHD meds Methythinadate ? for spelling than Adderall we could tell within days was not going to work becuase he goit more aggressive, the ODD was more extreme. Thats when they realized that he was reacting negativily to the stimulate in those meds. So They put him on Intuniv which is a nonstimulant and we saw a difference in my son immediately. Now we did hit a wall with each dosage after a few months but once we got to the highest of 4 mg he became too sleepy most of the time. So at this time we are going back down to 3 mg but we are going to add something for his moods to it b/c thats what seems to still be present even with the meds. His ODD is very mood driven but his reactions and agressions have greatly been decreased with meds and monthly family therapy. The therapy allows him to learn positive ways to manage his disorder by learning choices and rewards. It also helps me learn how to handle him and help him manage. My son can now tell you how he use to feel out of control of himself and that he didn’t like the way he use to feel but now he does. Are life is by no means perfect but we now are living are lives thanks to medicine & therapy. Its has to be both because without the medicine they can’t control how they feel long enough to learn how to manage it. His dad & I have been divorced most all of his life but his dad can tell me that he suffered the same symptoms as a child with no one who cared enough to get him help, which lead to conduct issues and substance abuse as a teen. now has an adult he has never been able to control his emotions at times was abusive still abusing drugs from time to time, in & out of jail and can’t hold a job more than 3 months due to getting angry with bosses qiuting or getting fired. I really truly believe that my son’s dad suffers from this and its been left undiagnosed & untreated, which makes me even more dtermined to help my son treat and manage this disorder so he can have control of his life instead of the disorder controlling him. My son now in 2nd grade is making the honor roll & showing just how smart he really is. He also can tell me what meds work by how they make him feel & can tell me he doesnt want to go without them because he never wants to feel like that again.

    • I could have written Donna’s comment! Except we are continuing to search for the right combo of meds. It’s so reassuring to find you’re not the only person dealing with these struggles. Thank you so much for sharing!!!

  9. Early diagnosis can really help a great deal in knowing whether our kids do have ODD, ADHD, ADD or a combination of each one. It’s easy to just label kids with behavior problems as defiant and extremely naughty but we often fail to realize that ther may be more to their negative behavior. Treating any of these disorders can take time since one should make sure if the behavior modification programs and the medications can relieve them of their symptoms. This is why the best thing a parent to do is ask help from experienced professionals as well as parents who have the same experiences as them. From there, we can get tips and ideas on how to effectively deal with your defiant teens – whether they suffer from ODD/ADHD or not. Consider this a good read:
    http://www.teenwildernessprograms.org/teen-wilderness-programs/tips-for-parents-of-addadhd-teenagers.html

  10. my son has just been diagnosed with odd i have been fighting for him since he was 18 months old and now he is 9 i just kept getting told that he is just a boisterous boy he has been put forward to go on a anger management course and that there is no medication for him what i would like to say if you know that there is something not right with your child be persistant and you will get a answer in the end thank you

  11. I have a 10 year old daughter who has been diagnosed with ODD. SHe does not have ADD or ADHD..her therapist thinks she has a mood disorder or explosive disorder. We have seen a psychiatrist and he does not agree. My question is..are there any meds that help ODD alone?
    Everything is a fight..getting to bed..waking up..getting dressed..brushing our teeth…we spent a week in Disney with family and she was miserable..saying at least 3 times a day she hated us and wanted to go home..

    • My name is Jodi and my son is 10 and 1/2 and was diagnosed with odd three years ago. I agreed to medication the summer of 2010. They have him on Celexa. It is a antidressant which seems to work well with odd. They added Tenex in Sept or 2011. This helps him stay focused. He does not have add or ADHD, but does have the hyperactivity sometimes. He’s had extensive testing these past two months for his IEP at school. He is in the superior to very superior range ( and that’s with him being “available” 20% of the day,,the other 80% he’s acting out or just shuts down). You need to find a good teacher who really cares about your child. Still unsure of his future at his school, but they are trying. I wish I knew of an elementary school that specialized in behavioral kids.

  12. To everyone here….my son after a rough year in second grade and us as well years of telling PCP there is something else going on and finally his second grade teacher HELPING US! Our PCP said oh he is just being a boy. Finally as of this ageing after doing my own research and having him see the school psychologist and a recommend psychologist he was officially diagnosed ADD ADHD AND ODD. ODD usually NOT ALWAYS goes with ADHD. So now FINALLY HE IS GETTING THE HELP HE NEEDS. A lot of changes on our part as well to help him! Here is how I finally got the help. My Mom gut, if you will, told me something is not right. So I pressed the doctor after 5 years and saidI enough is enough. I kept looking for someone to help….I know doctors go to school for years. No disrespect here, HOWEVER, I am the Mom and I do KNOW MY CHILD! If a parent tells you something is wrong, Listen!!!!! Give your full attention they are asking for your help and we know when something is not right! Now he is getting the help he needs to be a better kid and help him with school and in social settings and at home and with other issues. 3 things…keep going and listen to your gut and keep pushing!.

    Alex’s Mom

  13. I wanted to follow up, as most of us know things change by the day with these kids..I have taken my son off all meds as of April. The school hired a Cert. Behaviorist who is also a Spec. Ed. teacher to put together a very strict behavioral plan. I did not tell the school I took him off the meds. I did not think they were changing anything and sure enough, they weren’t……My son has done fantastic! The team has all been trained by the behaviorist and are on my son like white on rice…
    This is not to say that he still does not have his moments of outbursts and interruptions, but he is in reg. ed class all day and its working well.
    My main objective in this post….Certified Behaviorist….Put together a plan as a team,,,train ALL that will have contact with your child

    Good luck
    Jodi

  14. My son has spent more of this year at home instead of school due to being constantly suspended. He has ADHD with ODD and depression. We have tried focalin different milligrams, vyvanse with celexa and kapvay, concerta with kapvay, concerta with ambilify, and now currently making changes. The psychiatrist and counselor have told the school to stop sending him home and to find a way to appeal his work to his senses. They are making it worse by suspending him everyday and they expect a miracle over night. I don’t have problems with him at home. Just at school and had a problem one time at his church classes so now I sit with him but he won’t participate when groups get about past ten. Please help!!!! He has special Ed accommodations but nothing is working especially since school just suspends him every time we turn around.

  15. Hi, My sixteen year old son lewis has ADHD and ODD.
    All I can say is it sucks!,

    I am a Front line British Soldier served 2 tours of Northern Ireland, 2 tours of Iraq. My son has been out of control since he was 2 years old.

    He has Attacked me numerous times smashed every married quarter up that we have lived in through not getting what he wanted,

    Stupid trivial things like not being aloud to make a sandwich when dinner is about to be served. that made him smash the front door window and rip off the garden gate and smash it up.

    When I refuse to let 5 of his teenage friends stay over night. result “Dad if you don’t shut up i will beat you up like i did in Germany”. then he put his guitar through his double glazed bedroom window.

    this is only a small part of the stuff me and my wife and my other two kids have to put up with.

    He refused to ware school uniform in every school he has been too. and has been excluded from every one. Now he has ago at me for not finding him a job.

    Give me a war zone any day lol.

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