Managing ADHD and ODD When They Occur Together

Attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) are often comorbid (occur together in the same person). ADHD is a neurodevelopmental disorder marked by impulsive and hyperactive and/or inattentive behaviors. ODD is a behavior disorder marked by behaviors that are uncooperative, defiant, and at times hostile.

Addressing comorbid ODD and ADHD is a unique challenge for children and their parents. Treatment may involve a combination of medications, behavior therapy, and social skills training. Following a consistent routine and using calming techniques can also be helpful.

This article explains why ODD often occurs with ADHD, how the conditions are treated and managed, and coping strategies for parents and children.

Link Between ADHD and ODD

Research suggests that as many as one-third to one-half of children with either ADHD or ODD also meet the criteria for the other.

While it isn't entirely clear why ADHD and ODD co-occur so frequently, researchers have identified a few overlapping risk factors, including:

• Maternal smoking during pregnancy
• A family history of ODD or ADHD
• Higher levels of family conflict in childhood
• Abnormalities in a region of the brain called the frontal cortex

ADHD is a neurodevelopmental disorder, meaning that it affects the growth and development of the brain. As a result, ADHD can lead to challenges with language, emotions, behavior, self-control, learning, and memory.

ODD is a behavioral disorder, meaning it is characterized by persistent patterns of behavior that violate social norms or rules, impair a person's functioning, and disrupt the lives of others.

The two disorders cause different symptom profiles, some of which can overlap.

Common Symptoms

Children with ADHD often feel frustrated quickly, which can lead to angry temper tantrums—especially in response to boredom. Children with ODD are also prone to throwing tantrums, but those tantrums are more likely to become physically aggressive.

When paired with impulsivity, which is characteristic of both disorders, a child with ADHD and ODD may have angry outbursts in response to boredom that may lead to aggression. The child may refuse to comply with requests to apologize or blame others for their own mistakes.

Other examples of how ADHD and ODD manifest together include:

• Blasting the TV or radio in the early morning to wake parents up
• Trashing the house when bored then assaulting a parent upon being asked to clean up
• Verbally abusing a teacher upon being given simple directions in class
• Deliberately annoying or picking on classmates to the point of drawing tears
• Lashing out at a sibling for something as simple as blowing their nose
  

Unique Symptoms of ADHD

Some symptoms of ADHD in children include:

• Inattention: Such as being easily distracted, making "careless" mistakes, and having difficulty with the planning, organization, and follow-through of tasks
• Hyperactivity: Such as fidgeting, being constantly "on the go," and having difficulty staying seated
• Impulsivity: Such as interrupting, acting without thinking, and risk-taking

ADHD begins in childhood, but often persists into adulthood, though the symptoms can change over time.

Adults with ADHD may:

• Feel frequently restless
• Have poor planning and organizational skills
• Be forgetful, miss appointments and deadlines, and misplace items
• Have difficulty focusing on and finishing tasks
• Have trouble with time management
• Make sudden and short-sighted decisions

Unique Symptoms of ODD

ODD symptoms in children include:

• Excessive arguing
• Refusing to comply with appropriate requests
• Constantly questioning rules and refusing to follow them
• Intentionally annoying or upsetting others with their behavior
• Blaming others for their behavior or mistakes
• Being easily annoyed by others
• Frequently showing an angry attitude

As with ADHD, ODD is usually diagnosed in childhood (typically in preschool, while ADHD is diagnosed primarily in school-age children). ODD usually resolves by age 18 but can persist into adulthood both on its own or along with ADHD.

Adults with ODD may:

• Have difficulties maintaining friendships and romantic relationships
• Have strained relationships with parents
• Feel shut out and excluded by others
• Engage in hostile online behaviors, like embarrassing others on social media or making posts that purposefully upset others
• Frequently have conflicts with professors, managers at work, and other authority figures
• Frequently consider dropping out of college or quitting jobs

Causes

The exact causes of ADHD and ODD are not known, but both are believed to have a genetic link and are likely influenced by multiple factors.

Several studies suggest that ODD may be caused by parental influences such as insecure attachment, harsh parenting, inconsistent parenting, or abuse. It is important to note that while this correlation exists, children who have a loving, supportive, and consistent home environment can also develop ODD.

Diagnosis

ADHD and ODD both have distinct criteria outlined in the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5). While they may occur together, they are diagnosed separately according to their individual criteria.

Diagnosis typically begins with a visit to a healthcare provider who can perform a physical exam, ask about symptoms and family history, and make referrals as necessary.

ODD is usually diagnosed in early childhood. ADHD is typically diagnosed by age 12, but it's not uncommon for adults to be diagnosed with ADHD that was missed in childhood, particularly in women.

Treatment often involves addressing each condition separately when they occur together, but there can be overlap.

Treating ADHD and ODD

Children with comorbid ADHD and ODD are at an increased risk of developing anxiety, depression, conduct disorder, and personality disorders later in life. They are also more likely to engage in aggressive or criminal behaviors than people with ADHD or ODD alone. Starting treatment from an early age reduces these risks.

Medication

Medication is not effective for treating the core symptoms of ODD. For someone with ODD and ADHD, medication is typically prescribed to reduce the inattentive, hyperactive, and impulsive symptoms of ADHD.

The first-line treatment for ADHD is stimulant medication, such as:

• Vyvanse (lisdexamfetamine)
• Concerta (methylphenidate)
• Ritalin (methylphenidate)
• Adderall (amphetamine and dextroamphetamine)

When ODD occurs with ADHD, stimulant medication can help manage ADHD symptoms, allowing for more effective treatment for ODD using other measures.

Behavior Modification

Behavior modification is an effective treatment for people with ADHD and ODD, especially when used in conjunction with medication to treat ADHD symptoms.

The goal of behavior modification is to learn or strengthen positive behaviors and eliminate ones that are unwanted. It also involves forming developmentally appropriate consequences for misbehavior.

Behavior modification may be carried out by therapists, teachers, parents, or other caregivers. For children younger than six, behavior modification guided by parents, known as behavioral parent training (BPT), is recommended before prescribing ADHD-specific medication.

Behavioral parent training is widely considered the first-line treatment for children with ODD. However, the main criticism of BPT is that it does not directly identify, address, or engage with the underlying emotions that lead to misbehavior.

Therapy

Individual, family, and peer group therapy can be helpful for ADHD and/or ODD. This can include the following:

• Cognitive behavioral therapy (CBT) teaches coping skills to change the way a person thinks about difficult situations along with how they react to them.
• Psychoeducation involves educating an individual (and sometimes their parents) about their disorder, along with specific skills to manage it.
• Social skills training improves social skills, emotional regulation, general behavior, school performance, and more.
• Physical activity improves cognitive functioning in children, as well as symptoms of inattention, impulsivity, and problems with executive functioning (i.e., planning and focusing).
  

Calming Techniques

A 2023 study published in Frontiers of Psychology showed that combined yoga and music interventions on a daily basis can be an effective treatment for children with comorbid ADHD and ODD.

Other practices that have a calming effect on children and adults include:

• Mindful breathing exercises: Involves slow, deliberate breathing to relax the body and brain
• Imagery: Involves imagining oneself in a peaceful environment, such as a beach or meadow, in order to gain emotional control over a present situation
• Mindfulness meditation: Involves shifting attention inward and sustaining focus on one's thoughts, emotions, and body sensations

Parenting Children With ADHD and ODD

Parenting a child with ADHD and/or ODD can be daunting, but there are effective strategies:

• Routine: Develop and stick to a routine. This helps kids know what to expect and what is expected of them.
• Stay calm: Frequent yelling can cause children to become used to it and tune it out, making it less effective.
• Be clear: Say exactly what you want your child to do, set boundaries, and communicate what will happen if they break them.
• Be consistent: Enforce the consequences you have laid out in a fair and consistent manner.
• Be generous with praise: Effective praise is important, both as positive reinforcement and to mitigate the frequent negative feedback children often receive.
• Help them manage emotions: Label emotions and talk through them with your child. Show them how to express emotions in acceptable ways.
• Pick your battles: Prioritize what is important and then follow through on it.
• Avoid power struggles and arguments: Calmly and firmly state the consequence without getting into a back-and-forth. Step away and take a break if you feel yourself escalating.
• Spend quality time together: Find activities you and your child can enjoy together. Building a relationship outside of rules and consequences is important.
• Seek support: In addition to professional support for your child, it may be helpful to find a support group of other parents who understand what you are going through. Having time and interests outside of your child is beneficial too.
  

Summary

ADHD and ODD are separate conditions but often occur together. ADHD is a psychodevelopmental disorder that causes hyperactivity and impulsivity and/or inattention, while ODD is a behavior disorder that causes defiant, irritable, and hostile behavior.

Medication is often helpful for ADHD but rarely used for ODD alone. Several forms of therapy are useful for both disorders. Early intervention is associated with more successful treatment. Routine, consistency, clear expectations, and consequences are key to parenting children with ADHD and/or ODD.