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.