ADHD and ODD often occur together in kids. This can be a very challenging and disruptive combination. Find out what you can do now to have better outcomes for your family later. Learn about ODD treatment that’s also effective for ADHD.
This Is What You Need To Know About ADHD And ODD In Kids
So my son actually doesn’t have ODD. Yet. And it’s the “yet” that makes my hair stand on end. It’s the “yet” that makes me cringe on the inside whenever he literally stomps up the stairs to his room and slams the door. Twice. To make sure no one missed it.
It’s that “yet” that closely scrutinizes every instance of unmistakable backtalk. And it’s that “yet” that has me worried when he recently started talking about all of the vengeful consequences he’s going to dish out, if he doesn’t get what he wants. And when I shook my head to tell him how that really wouldn’t work out well for him, the angry wails that follow.
Given that this child is six and has ADHD, all of my “yet”s may well be wishful thinking. Possibly downright delusional since some experts believe that a child diagnosed with ADHD is 11 times more likely to develop ODD as well.
So, if you’re the parent of an ADHD kid, read on to start learning more about the dynamic of ADHD and ODD, what you should be looking for, and steps you can take to try and prevent or remedy any defiance behavior that may be disrupting your family.
RELATIONSHIP BETWEEN ADHD AND ODD
ADHD kids have a neurologically based condition that causes difficulty with regulation, self-control, and executive function. It’s characterized by a disruptive level of inattention, impulsivity, and/or hyperactivity that persistently interferes with daily living in multiple settings such home, school and work. Common ADHD symptoms in kids typically include an inability to ignore distractions, an inability to pause and consider the inevitable consequences of their actions, and an inability to delay gratification. ADHD kids often have trouble controlling their impulses and following directions.
As for ODD in children, it’s a behavioral disorder that involves a chronic pattern of defiant, uncooperative, hostile and argumentative conduct directed toward authority figures. It involves a level fo defiance that impacts the child’s normal daily functioning and causes problems with relationships, school, and other essential areas.
If you have an ADHD kid, then you’ve probably encountered some level of defiant behavior. And probably something that’s a little bit beyond the typical level of disobedient or rebellious behavior often seen with younger kids. Mild oppositional behavior is a normal part of development. But, often times, ADHD kids will have a level of defiance that trends higher than what you may see in their peers. And, depending on the frequency and intensity of this defiance, an extremely defiant child may actually have oppositional defiant disorder (ODD).
The occurrence rates for both ADHD and ODD are relatively small. According to various studies, approximately 11% of kids have ADHD (estimates range from 8% to 12%). And estimates for the occurrence of ODD range from 1% to 16%. So neither condition is all that “rare.” But, if you focus on kids who have both ADHD and ODD, the rate of co-occurrence is quite high. The estimates for comorbidity between ADHD and ODD range from 40% to 60% or more.
ADHD AND ODD IN KIDS: CAUSE FOR ALARM?
Do you find numbers like 40% to 50% rather disturbing. I certainly do. And, when you take a closer look at what having ADHD and ODD might actually look like, that doesn’t really allay any concerns.
What ADHD Success Can Look Like
While parenting an ADHD child definitely has its challenges, you can often find comforting and inspiring stories about kids and adults with ADHD. As well as stories about the positive attributes that can go along with ADHD. Some examples:
- 4 Surprising Benefits Of Having ADHD
- 17 Things to Love About ADHD!
- The Strengths of People With ADHD
- Those With ADHD Might Make Better Entrepreneurs. Here’s Why.
You can also readily find many stories discussing various celebrities who have ADHD and thrive. Examples:
What ODD Success Can Look Like
In contrast, ODD is characterized by defiance, spitefulness, negativity and hostility. You don’t really find many upbeat stories that talk about how those traits can be an advantage. Or, how they contributed to a recipe for success in later life. (But check out this one: The Strengths of the Oppositional Defiant Child).
The ODD “success” stories I found basically involve some years of harrowing experiences (from the parents’ perspective) followed by being able to successfully get intensely disruptive behaviors under control (more or less). Here’s two compelling examples:
- Back From the Brink: Two Families’ Stories of Oppositional Defiant Disorder
- Living with a Pathologically Disobedient Kid
After reading stories like these, you can breathe a sigh of relief that the families managed to make it to the proverbial light at the end of the tunnel. But the overall picture still seems troubling.
So, again, when I see statistics like “40% to 60%” I get really concerned. And every act of defiance I see in my own kid always comes with a wee extra bit of alarm. Every email in my inbox with the teacher’s name on it involves holding my breathe and a squinty eyed read hoping that calamity has not stricken.
And maybe that’s why physicians and professionals don’t lead with the ODD information. It doesn’t seem like most ADHD diagnoses come along with a warning of – oh, and by the way, there’s a fifty-fifty chance your child may also develop this other more disruptive condition over the next few years. Or, at least, I wasn’t told that.
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ADHD and ODD in Kids: Is a Dual Diagnosis Guaranteed?
Notwithstanding the high co-morbidity rates of ADHD and ODD, an ADHD diagnosis doesn’t mean that ODD will necessarily follow. ADHD does not actually cause ODD. And, if 40% to 60% of ADHD kids develop ODD, that also means that 40% to 60% don’t develop ODD, just based on the math.
So, even though there’s a relatively high association between ADHD and ODD, the presence of distinctively defiant behavior doesn’t mean ODD is present. Several other conditions can result in symptoms that seem like defiance, but may actually be something else.
These include, for example:
- Anxiety disorders
- Depression and mood disorders
- Learning differences
Anxiety in kids particularly has a strong chance of being mistaken for defiant behavior. Kids who appear oppositional are often shown to be severely anxious instead. Unrecognized anxiety often generates disruptive behavior.
What Causes Many ADHD Kids To Develop ODD As Well?
Hopefully, at this point in time, most reasonably informed people recognize that ADHD is an actual physical condition. Opinions as to the best way to treat it may vary widely and deeply (e.g., medications vs natural treatments), but there’s an abundance of scientific evidence showing that ADHD has neurological components and that to some extent it might be genetically based and hereditary.
The exact causes of ODD are not known. But most experts believe that it results from some combination of biological, developmental and environmental factors.
As for the high co-morbidity rates of ADHD and ODD, some experts say that ADHD and ODD may be linked to a common genetic factor. Also some genes implicated in the occurrence of ADHD are ones that may make some kids more sensitive to the effects of adverse environments. So, kids without those genetic factors may nonetheless thrive in certain negative environments, while the more susceptible kids do not.
Also, some kids may have emotional or developmental issues that makes them more susceptible to developing ODD. Notably, some of these traits are ones frequently seen in some ADHD kids.
These include traits such as:
- Highly reactive temperament (the 15-20% of babies who react strongly to unfamiliar people or situations)
- Being callous/showing lack of empathy
- Difficulty with social cues
Regardless of whether genetic or developmental factors contribute to the development of ODD, research suggests that there may often be large environmental factors associated with the occurrence of ODD.
The environmental factors that may contribute to the development of ODD include:
- Harsh discipline practices (discipline that’s disproportionate to the behavior at issue)
- Absence of meaningful supervision
- High family drama
- Parents with substance abuse issues
- Parents with mental health issues
- Child abuse or neglect
The timing of when ODD occurs could provide insight into the contributing factors in individual cases. Cases of ODD that arise early in childhood may have a larger genetic component. While ODD cases that don’t emerge until late childhood or adolescence may have a larger environmental trigger.
CAN ODD BE PREVENTED?
If you’re the parent of an ADHD child, you may, like me, be alarmed reading the high numbers associating ODD with ADHD. And your natural thought may be, “Well, how do I prevent this?”
According to the experts, there’s no research showing that ODD can actually be prevented. But there’s lots of credible research showing that it can be overcome with proper intervention and treatment. And, early treatment can also help prevent the progression of ODD into more a serious mental health concerns.
So, something to consider: If you’re the parent of an ADHD kid and ODD hasn’t cropped up yet, perhaps you should treat it like a latent, but potentially debilitating, virus. One that you should start treating before it fully ripens. Notably, the known ODD treatments that evidence-based research showing effectiveness also show effectiveness for treating ADHD.
ADHD AND ODD TREATMENT AND INTERVENTION
For ADHD, a range of treatment and intervention options exist, including medication based treatments. But, for ODD, most of the ODD treatments that have evidence of effectiveness focus on behavioral interventions. For younger kids and school-aged children, effective behavioral interventions primarily focus on training parents.
You can find several different models of evidence-based parent behavioral training programs. Note that some of these treatments do not directly include the child at issue. Rather, they focus on providing training to parents individually or to groups of parents. Treatment generally runs from 8 to 20 sessions.
RECOGNIZED/ESTABLISHED MODELS OF ODD TREATMENT
At a general level, many of the effective programs have several common features. These include:
- A focus on increasing positive parent-child interactions and communication.
- Teaching time-out and the necessity of parental consistency.
- Training parents to set clear expectations and to establish an effective system of rewards and consequences.
- Providing opportunities to practice specific skills either through role-playing, or through in-session practice of parenting skills with child.
These are some of the most well-established evidence-based training programs.
Parent Management Training (PMT)
In PMT, a therapist usually works with the parents alone, without the child present. The therapist will provide a series of teaching sessions on the principles and techniques of behavior modification. As training progresses, the therapist will demonstrate interventions and provide coaching on how techniques can be applied at home.
Parents learn to identify and define specific behaviors that require change, and how to chart or record behavior. PMT also trains parents to become more careful and deliberate in how they respond to their child’s behavior. Specifically, PMT emphasizes offering positive reinforcement for desirable behaviors, and avoiding the inconsistent treatment of unwanted behaviors.
Notably, positive reinforcement does not necessarily mean tangible treats. Through PMT, parents learn that effective positive reinforcement can include praise, extra parental attention, hugs, stickers, or increased privileges.
As for unwanted behaviors, parents learn that inconsistent responses can unintentionally reinforce and increase poor behavior. For instance, if a parent caves in the face of a tantrum and provides the treat or outcome sought by the child even on only the rare occasion, this encourages the child to have more frequent or more dramatic tantrums.
Essentially, this encourages the child to play the odds and increase the opportunities for the desired reward. In other words, it creates a tantrum slot machine. It may not always pay off, but persistence will usually get you something.
PMT usually runs for at least 10 sessions, and it is recommended for kids ages 3 to 13.
The Incredible Years provides group training to parents of kids from infants through age 12. The programs are divided into different age groups and range from 12 to 20 weeks. Incredible Years also offers specialized training for parents of kids diagnosed with ADHD and ODD.
Each group parent session focuses on a different topic. The program first works to set a foundation of improving parent-child relationships. It then moves through topics such as establishing consistent routines, setting limits, and various behavior management strategies such as redirection, logical and natural consequences, and problem-solving.
The Incredible Years website provides information for parents on finding a group nearby.
Parent-Child Interaction Therapy (PCIT)
Parent-Child Interaction Therapy (PCIT) is a parent-training program that aims to decrease defiant and disruptive behaviors in young children (kids aged 2 through 7). PCIT works with parents and children together, teaching them skills to interact in a positive, productive way. Parents receive live coaching through an ear piece as a therapist watches from behind a one-way mirror. Parent and child perform a series of tasks, and parents practice specific responses to both desired and undesired behavior. Treatment usually requires 14 to 17 weekly sessions.
Positive Parenting-Program (Triple-P)
The Triple-P Program provides a multi-level system of parent training and family support, and it targets a broad range of children. It essentially has 5 different levels of intervention, as well as an on-line program available to parents directly.
The first three levels of the program basically apply to children with minimal to moderate behavior issues and involve limited therapist interaction, if any.
Level 4 includes intensive behavioral parent training. It targets parents of children with serious behavior problems and lasts for 8 to 10 sessions. Level 5 targets families with more complicated issues and includes enhanced behavioral family intervention.
The program is administered over the course of eight weeks, with a series of group sessions that last two hours each, and a series of phone calls to individual participants that last between 15 and 30 minutes.
For the families with more severe behavior problems, there’s a 12-session parent-and-child-focused treatment. A therapist meets one-on-one with parents to discuss skills and strategies. Some sessions include kids where the therapist provides live coaching.
A series of experimental studies has examined various levels of Triple-P in a number of different populations.
Parent Management Training-Oregon Model (PMT-O)
This Program now has a new name: GenerationPMTO. You can find this Program offered in both a group format and an individual format.
In the Program’s group version, parents meet weekly to learn core parenting practices such as limit setting, skill encouragement, problem solving and positive involvement. They also learn about active communication, emotional regulation and promoting academic success. Group facilitators work with parents using role playing, problem solving and other experiential activities. The Program offers a 10, 12 and 14 session format.
The individual format typically runs for 10 to 25 weekly sessions.
Helping the Noncompliant Child (HNC)
Helping The Noncompliant Child is an intensive behavioral parenting program delivered in a clinical setting. Trained staff watch parents and children through a one-way mirror, or in the home environment. Sessions generally run 75–90 minutes, and treatment typically spans 8 to 12 sessions. The HNC sessions focus on parents mastering a sequence of five parenting skills designed to manage disruptive behaviors. Parents master one skill before advancing to the next one. The skills addressed are (1) attending, (2) rewarding, (3) ignoring, (4) clear instructions, and (5) time-out.
Psychologist Rex Forehand developed the HNC Program. He outlines the basics of the program in his related book, Parenting the Strong-Willed Child.
WHAT ABOUT ODD TREATMENT FOR TWEENS & TEENS?
At some point, kids get too old for time out, and where defiant behavior has become ingrained, it may be resistant to influence from other strategies typically taught in parent training programs. So, for older kids, interventions based on problems solving (rather than rewards and consequences) may be more effective.
Prominent psychologist and ADHD expert Dr. Ross Green originated the Collaborative Problem Solving (CPS) approach. (After an intellectual property and professional dispute, Dr. Greene now refers to his model as the Collaborative and Proactive Solutions (CPS) model.) Regardless of the current name, Dr. Greene describes his approach in his book The Explosive Child. He also provides an overview of the basic principles of the evidence-based CPS Model on his website.
The goal is to foster a collaborative partnership between adults and kids and to engage kids in solving the problems that affect their lives. This approach essentially involves three basic steps. First, working with your child to identify and understand his concern that underlies the problem, conflict or behavior at issue. Second, identifying your parental concern about the same issue. And, third, parent and child brainstorming together to arrive at a solution.
Although this approach is not limited to teens, older kids may be in a better position to engage in the problem-solving dialog necessary to make this work.
Another problem-solving oriented approach can be found in the work of Dr. Russell Barkely, another well known psychologist and ADHD expert. You can seek out a therapist who follows the principles in Dr. Barkely’s manual for clinicians called Defiant Teens.
The first half of this program focuses on teaching parents effective tools for handling noncompliant and defiant behavior. In the remainder of the program, both parent and teen learn effective problem-solving communication skills so that they can improve their communication and work toward mutually desirable negotiated outcomes. The program also includes training for the adolescent to help him become a participant in changing the family dynamic.
Dr. Barkely also has a book for parents called, Your Defiant Teen. That book sets out a 10-step program for parents to resolve conflict and rebuild their relationship with their teen.
SO WHAT’S THE BOTTOM LINE?
If you are parenting a child who has both ADHD and ODD, he is likely extremely familiar with criticism and negative attention from the adults around him. As a consequence, experts say that the impulse to punish bad behavior as a primary disciplinary approach ultimately won’t work with ADHD + ODD kids in the long run. They become inured to criticism and punishment. Moreover, kids with ODD are committed strivers who are hard-wired to battle authority figures.
Any attention paid to negative behaviors, even negative attention, is its own reward. So withdrawing attention to minor transgressions will ultimately achieve better results. Frequently reinforcing positive behavior, even small ones, will get a better reaction.
The nature of defiance tends to push people away. And, ultimately, it can damage relationships. But a defiant child needs just as much love and affection as an otherwise compliant child, and they may need you to say it and show it a little bit more. So, incorporating the positive principles underlying effective training programs can help you make sure that happens.