Defiance is commonly associated with ADHD symptoms like weak impulse control and emotional regulation, but repetitive acts of defiance could be a sign of oppositional defiant disorder (ODD) or pathological demand avoidance (PDA). To determine the root cause of a child’s behavior, we must dig underneath inappropriate words and actions.

Why Is My Child So Defiant?

Many oppositional teens have a loud internal voice that tells them they’re a failure; they can’t do things right; no one likes them; they’re stupid. You name it.

As a parent, you’ve likely witnessed pushback resulting from this internal narrative. Your child’s defiance is an unskilled and ineffective attempt to manage some of these feelings. They’re trying to manage their external surroundings when things feel out of control on the inside.

Oppositional tweens and teens may demonstrate the following behaviors:

• lack of cooperation
• inappropriate language
• refusal to do tasks such as homework or chores
• instant anger or reactivity
• threatening behavior
• destruction of property

[Download: Free Guide to Ending Confrontations and Defiance]

Oppositional Defiant Disorder (ODD)

ODD is classified as a disorder in the DSM-V, but symptoms of ODD often present situationally. Kids with ODD who are openly resistant in one setting or with one authority figure may be completely cooperative in other areas of their life. Their behavior presents like a switch — angry one minute and fine the next.

This can be confusing to the parent of a child who acts out at home but not at school. Children with ADHD may exert authority in an area where they feel relatively secure. They may direct their defiance toward the parent who they think is most likely to take and/or forgive it. They may push back because they can.

Pathological Demand Avoidance (PDA)

Defiant behavior may signal PDA when it occurs almost without exception. This profile is characterized by an overwhelming and consistent need to avoid or resist demands. PDA is more intense and pervasive than is ODD; it is not limited to certain people or situations.

Kids with PDA are obsessive in their resistance to requests that they perceive as overly assertive. They may avoid compliance by resorting to manipulative behaviors and even turn down activities they enjoy. Parents may notice sudden changes in mood that are associated with the need to control or reject a demand.

PDA is not a standalone diagnosis in the U.S., but it falls under the umbrella of the autism spectrum diagnoses. It is seen most often in people with autism, ADHD, and high anxiety.

[ADDitude Directory: Find an ADHD Clinic]

Solutions to Address Oppositional Behavior

Parental communication style (and substance) can contribute to a child’s oppositional behavior — for better or for worse. Invitations, tag teaming, collaboration, being a body double, and noticing your child’s efforts all contribute to better cooperation. Reconsider how you ask your child to engage in a task and what happens when they fail to do so.

1. Nix Non-negotiable Words

A “no” might be a response to what your adolescent views as a demand rather than a request. The use of words such as “need,” “must,” or “will” may be triggering for kids who have PDA. These non-negotiables give them the impression that a decision has already been made.

Try the following phrases to reframe your requests:

• “Is it okay with you if…?”
• “How do you feel about…?”
• “Do you mind doing this…?”
• “If you’d be happy to, I would really appreciate…”
• “When you’ve finished with this, could you then do…?”

2. Encourage Shared Involvement

You can also encourage cooperation by using words like “us,” “we,” “let’s,” and “together.” Or give autonomy and decision-making opportunities to your child by engaging them in directed free choice. This means offering them two or three options in a situation so they feel empowered to make a decision rather than resentful or angry about being told what to do. Kids may also want to play a bigger role in the brainstorming process.

3. Plan for Patterns

ODD and PDA are repetitive patterns of behavior, so don’t treat them like isolated events. Plan for explosions. What options are available when your child acts out? What logical consequences can they expect as a result?

Maybe your teen is given one free hour of screen time a day. They can earn additional screen time after completing cooperative activities such as basic chores and homework. If they get angry, scale back on this incentive. Reduce the free screen time allotment. This teaches the lesson that “have-to” tasks are necessary to get “want-to” rewards.

4. Institute Takebacks

Lying is a social behavior that occurs between two people due to avoidance, denial, or a desire to avoid punishment. It creates comfort in the present and minimizes conflict based on something that’s happened in the past. Kids with ADHD may lie due to poor impulse control or inattention. They might not realize that they misinterpreted an event until after they’ve said it out loud.

This is when we want to give them an option to take it back. I call this the “take back of the day” or TBD approach. I did it with my kids when they were growing up and I’ve recommended it to hundreds of families as a tool to diffuse tension and bring awareness to disrespectful comments. I think it’s helpful when everyone in the family has a chance to take back something they said without risk of penalty–including adults who can model how it works.

5. Meet in the Middle

If your child is stuck, it may be that your demands are too difficult to meet. Fatigue or low energy could also be signs of sleep deprivation or depression. Technology addiction, while composed of many things, is often related to an ADHD brain hunting for dopamine. Creating a balance or flow with high dopamine and low dopamine activities helps kids with building their abilities for shifting and flexibility. If your approach is not working, ask some open-ended questions about what’s going on with your child that is interfering with their compliance (e.g. ‘What is making it tough to do this? What would make it more appealing? How can I offer you support to get through this?’), and adjust as needed.

To encourage your child to cooperate or tell the truth, you might also create ground rules that are negotiable in certain situations. Maybe your ground rule is no swearing, and your child broke that rule. Instead of imposing consequences right away, take a pause. Consider the STAR method: stop, think, act, and recover. This process includes taking a pause with a planned, self-soothing activity, coming back together to discuss what each person thinks they could have done differently occurred, what the next right action will be and doing it and then giving time and space for recovery and moving forward.

6. Acknowledge Effort

If you notice that your child’s behavior is improving, acknowledge it. “Efforting” is what I call a full-body experience for outside-the-box thinkers. It’s emotional, it’s social, it’s cognitive, and it’s physical. It’s more than simply trying. It may result in accomplishing something or it may show genuine efforts without completion. It’s the process that contributes to growth mindset. We want to acknowledge, validate, and encourage the progress that we see our kids making.

Oppositional Teen Behavior: Next Steps

• Download: 5 Ways to Improve Emotional Control at Home
• Read: You Can’t Change Your Defiant Teenager…
• Read: Two Families’ Stories of Oppositional Defiant Disorder

The content for this article was derived, in part, from the ADDitude ADHD Real-Time Support Group session titled, “Helping Oppositional Teens with ADHD” with Sharon Saline, Psy, D., which was broadcast via Facebook Live on February 10, 2023. Live support group meetings take place on Facebook most Fridays at 4 p.m. ET.

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Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

COMORBIDITIES: What co-existing conditions should my child’s doctor consider when evaluating for ADHD?

A: ADHD rarely exists in isolation. Clinicians must properly screen for and address ADHD and its comorbidities… | Keep reading on ADDitude »

DEPRESSION: What distinguishes ADHD from depression in children?

A: Clinical depression is more than just the blues. It’s a serious illness, and it affects more young people than parents realize… | Keep reading on ADDitude »

ANXIETY: What distinguishes ADHD from anxiety in children?

A: Some anxiety disorders can be hard to spot in children because symptoms include internal thoughts and feelings that don’t always… | Keep reading on WebMD »

OCD: What distinguishes ADHD from OCD in children?

A: Obsessive-compulsive disorder is marked by repetitive thoughts or fears (obsessions) that may turn into repetitive behaviors… | Keep reading on WebMD »

BIPOLAR: What distinguishes ADHD from bipolar disorder in children?

A: Medical science is learning more about bipolar disorder in children and teens. But the condition is still difficult to diagnose. That’s especially true for teenagers in whom irritability and moodiness… | Keep reading on WebMD »

DMDD: What are the symptoms of disruptive mood dysregulation disorder in children?

A: DMDD causes children to experience unstable emotions they cannot regulate, including extreme outbursts of anger, leading to temper tantrums. These outbursts often occur in response to… | Keep reading on WebMD »

FIRST-PERSON: “How I Calmed My Daughter’s Anxiety Attack”

“It’s critical that you accept the attack as real. The dizziness, sweating, chest pain, racing heart — all of it is real. Don’t tell her that it’s just in her head or that she’s OK. So what can you do? Start by holding her close.” | Keep reading on ADDitude »

RELATED RESOURCES

SYMPTOM TEST: Generalized Anxiety Disorder in Children

Every child worries sometimes — about monsters or tests or new experiences. A child with anxiety feels anxious about nearly everything. | Take the self-test on ADDitude »

SYMPTOM TEST: Depression in Children

Does your child say they’re ‘too tired’ to do activities they used to love? Have trouble making even simple decisions? | Take the self-test on ADDitude »

8-Part Guide to ADHD Diagnosis in Children, from WebMD x ADDitude:

DECISION 1: How can I better understand ADHD, its causes, and its manifestations?
DECISION 2: How can I understand the aspects of ADHD that might be new to the doctor?
DECISION 3: How can I improve the odds of an accurate ADHD evaluation for my child?
DECISION 4: How can I find a professional to diagnose and treat my child’s ADHD?
DECISION 5: What should a thorough evaluation for pediatric ADHD include and exclude?
> DECISION 6: How can I be sure my child’s evaluation screens for psychiatric comorbidities?
DECISION 7: How can I be sure my child’s evaluation considers look-alike comorbidities?
DECISION 8: Should my child be screened for the sleep, eating, and other disorders?

DEPRESSION: What distinguishes ADHD from depression?

A: Depression is more than just an occasional case of the blues. It’s deep sadness and despair you feel every day for at least 2 weeks at a time… | Keep reading on WebMD »

ANXIETY: What distinguishes ADHD from anxiety?

A: When you have anxiety along with ADHD, it may make some of your ADHD symptoms worse, such as feeling restless or… | Keep reading on WebMD »

BIPOLAR: What distinguishes ADHD from bipolar disorder?

A: Approximately 20 percent of people with ADHD also suffer from bipolar disorder, characterized by depressive and manic episodes… | Keep reading on ADDitude »

MOOD DISORDERS: What distinguishes ADHD from a mood disorder?

A: Making the distinction between moodiness in ADHD, ODD, DMDD, and other disorders requires studying the mood’s intensity and… | Keep reading on ADDitude »

OCD: What distinguishes ADHD from obsessive-compulsive disorder?

A: Symptoms of OCD include recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions)… | Keep reading on ADDitude »

ODD: What distinguishes ADHD from oppositional defiant disorder?

A: Adults with ODD are more than just aggressive and irritating from time to time. They feel mad at the world every day, and lose their temper… | Keep reading on ADDitude »

FIRST-PERSON: “ADHD: ‘I Really Fouled That Up.’ Anxiety: ‘Hold My Beer.’”

“ADHD means I can’t be productive. Anxiety means I can’t relax. ADHD won’t let me resolve problems. Anxiety makes me think I have problems I don’t actually have. ADHD makes planning difficult. Anxiety convinces me I need to plan everything down to the tiniest of detail.” | Keep reading on ADDitude »

RELATED RESOURCES

SYMPTOM TEST: Generalized Anxiety Disorder in Adults

No two people experience anxiety in the same way, however common symptoms do exist. | Take the self-test on ADDitude »

SYMPTOM TEST: Depression in Adults

Do simple tasks take forever to accomplish? Do you feel irritable all the time, or stuck in life? | Take the self-test on ADDitude »

8-Part Guide to ADHD Diagnosis in Adults, from WebMD x ADDitude:

DECISION 1: How can I better understand ADHD, its causes, and its manifestations?
DECISION 2: How can I understand the aspects of ADHD that might be new to my doctor?
DECISION 3: How can I improve my odds of an accurate ADHD evaluation?
DECISION 4: How can I find a professional to diagnose and treat my ADHD?
DECISION 5: What should a thorough evaluation for adult ADHD include and exclude?
> DECISION 6: How can I be sure my ADHD evaluation screens for psychiatric comorbidities?
DECISION 7: How can I be sure my ADHD evaluation considers look-alike comorbidities?
DECISION 8: Should I also be screened for the sleep, eating, or other disorders?

The Clinicians’ Guide to Differential Diagnosis of ADHD is a clinical compendium from Medscape, MDEdge, and ADDitude designed to guide health care providers through the difficult, important decisions they face when evaluating pediatric and adult patients for ADHD and its comorbid conditions. This guided email course will cover the following topics:

• DECISION 1: How can I better understand ADHD, its causes, and its manifestations?
• DECISION 2: What do I need to understand about ADHD that is not represented in the DSM?
• DECISION 3: How can I avoid the barriers and biases that impair ADHD diagnosis for underserved populations?
• DECISION 4: How can I best consider psychiatric comorbidities when evaluating for ADHD?
• DECISION 5: How can I differentiate ADHD from the comorbidities most likely to present at school and/or work?
• DECISION 6: How can I best consider trauma and personality disorders through the lens of ADHD?
• DECISION 7: What diagnostic criteria and tests should I perform as part of a differential diagnosis for ADHD?

NOTE: This resource is for personal use only.

A further complication: youth with ADHD are at higher risk for developing mood disorders, such as disruptive mood dysregulation disorder (DMDD) or oppositional defiant disorder.

During a recent ADDitude webinar on irritability, we asked nearly 1,000 attendees, “What is the most challenging aspect of emotion regulation for your child or patient?” Here are the answers they gave:

• Dysregulation of emotions in the moment (e.g., feelings often subjugate thinking): 37.8%
• Intensity of felt emotions (e.g., sudden, violent outbursts): 34%
• Unrelenting nature of irritability (e.g., always angry, bristly, mean): 14%
• Poor recognition of other people’s feelings (e.g., apparent and/or real lack of empathy): 7.1%
• Frequency of mood changes (e.g., dizzying emotional lability): 6.7%

Comments and questions submitted during the webinar, titled “Emotion Regulation Difficulties in Youth: ADHD Irritability vs. DMDD vs. Bipolar Disorder” provided deeper insight into how ERD impacts youth with ADHD.

Emotion Regulation Manifestation #1: Explosive Outbursts

“My child screams and breaks down over issues with friends.”

“My son is verbally aggressive and used to destroy doors and walls. It is truly hard for me to cope with his crisis.”

“My 11-year-old son’s physical and verbal aggression seems to be reserved for home. He controls himself at school but not at home, where he is very argumentative and defiant. He is easily triggered when he does not get his way (e.g., he pushes, hits, and calls us names).”

“My 14-year-old daughter keeps it together at school but is defensive, aggressive, and explosive with her 11-year-old sister and us (her parents) when we intervene.”

[Self Test: Does My Child Have Disruptive Mood Dysregulation Disorder?]

Explosive Outbursts: Next Steps

• Download: 9 Truths About ADHD and Intense Emotions
• Read: Why Is My Child So Angry?!
• Read: What Is Intermittent Explosive Disorder? 

Emotion Regulation Manifestation #2: Rejection Sensitive Dysphoria

“It is hard for my child with ADHD to not respond in a passive-aggressive, irritating way toward people she feels have rejected her. This might look like getting into others’ personal space by doing things she knows bothers them. This has gotten her in trouble with peers whom she feels are her bullies.”

“My son is 16 and has had explosive emotional outbursts due to environmental factors since he was 18 months old. The emotional outbursts have lessened substantially, but they still happen when he is super frustrated, upset, or gets his feelings hurt by his friends.”

RSD: Next Steps

• Download: Understanding Rejection Sensitive Dysphoria
• Read: How ADHD Ignites Rejection Sensitive Dysphoria
• Self-Test: Could It Be Rejection Sensitive Dysphoria? Symptom Test for ADHD Brains

Emotion Regulation Manifestation #3: Extreme Irritability

“Irritability occurs when there is a change in the child’s expectations of a situation. For example, it is not going to happen or not happening soon enough according to the child’s understanding or expectation.”

“My kid seems to be frequently irritable and grouchy and has angry outbursts.”

“I’ve noticed a big increase in irritability for my 13-year-old son with ADHD.”

“My 12-year-old wants to buy things or have things bought for her. Telling her ‘no’ results in irritability and a major tantrum.”

Extreme Irritability: Next Steps

• Download: 10 Ways to Neutralize Your Child’s Anger
• Read: New Insights Into Emotional Dysregulation and Treatment Considerations
• Read: “My Child’s In a Bad Mood Every Morning!”

Emotion Regulation Manifestation #4: Lack of Flexibility

“My granddaughter is often agitated and gets things stuck in her head, and there is no working around it. Screen time is about all that keeps her focused and calm. Everything is a challenge — routines, grooming, sitting down to dinner. Everything”

“My son is very rigid and has no ability to cope when he doesn’t get his way.”

“I struggle with my daughter’s need to be in control of everything and everyone. So much so, even making doctor’s appointments are hard to do.”

Lack of Flexibility: Next Steps

• Download: Why Is My Child so Defiant?
• Read: What’s Really Behind Your Child’s Bad Behavior?
• Read: Exaggerated Emotions: How and Why ADHD Triggers Intense Feelings

[Self-Test: Does My Child Have ADHD? Symptom Test for ADHD]

Emotion Regulation Manifestation #5: Self-Harm

“I have an 11-year-old daughter who has had explosive outbursts and big highs and lows since age 4. She began expressing suicidal ideation and was self-harming and experiencing intrusive thoughts.”

“During fits, my child makes comments about ‘not wanting to live,’ and ‘can’t take it anymore.'”

Self-Harm: Next Steps

• Download: Easy Mindfulness Exercises for Kids with ADHD
• Read: ADHD & Self-Harm: How to Help the Girls Who Suffer Most
• Read: How Is Your Emotional Resilience? Learning to Cope with Intense ADHD Feelings

Emotion Regulation Manifestation #6: Overly Emotional

“We’re struggling with my son because he’s not combative, just EXTREMELY emotional. He has crying episodes or extended periods of being upset where he cannot regroup for up to an hour.”

“My son does OK in most environments, but at home, he displays a lot more irritability and dysregulation, anger, frustration, and sadness.”

“My son is explosive at times. I remain calm with few words spoken, but he escalates quickly by yelling and running out of the house. This creates a very stressful environment for everyone in the house. I don’t know how to get him out of his terrible moods, where he fixates on ‘small’ things that bother him.”

Overly Emotional: Next Steps

• Download: Evaluate Your Teen’s Emotional Control
• Read: Q: How Do I Teach My Teen to Manage Emotions?
• Read: Calm Starts at Home: How to Teach Emotional Regulation Skills

Emotion Regulation Manifestation #7: Physical Aggression

“My 8-year-old son with ADHD cannot focus or keep still long enough to finish his schoolwork. Then he gets frustrated, which ends with him hitting his peers or teachers.”

“My daughter has a very hard time with aggressive behavior and has had to have the ‘room cleared’ twice this month, along with three in-school suspensions.”

“So often parenting advice recommends setting firm boundaries with kids, such as saying, ‘you can be mad, but I won’t let you throw things/ damage furniture/ etc.” However, with my kid with ADHD, when his lid is flipped, and he’s having a rage outburst, any attempt to say those things seem to ‘feed the fire.’ He just escalates more, often becoming physically aggressive with us.”

Physical Aggression: Next Step

• Download: Free Guide to Ending Confrontations and Defiance
• Read: Anger Is Important — But Only When It’s Managed
• Read: When “Keep Your Hands to Yourself” Doesn’t Work: Fixes for Hitting

More on Emotion Regulation and ADHD

• Free Download: 15 Ways to Disarm (and Understand) Explosive ADHD Emotions
• Read: How Dysregulated Emotions Hijack the Teen ADHD Brain
• Read: ADHD and Emotional Regulation: A Parent’s Guide

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

October 7, 2022

Mood swings. Sleep disturbances. Deteriorating relationships. Worsening grades. Total lack of interest in recreational activities. These are among the troubling behaviors observed by more than half of caregivers since the start of the pandemic, according to a new ADDitude survey on the mental health of youth with ADHD.

Our 1,187 survey responses mirror reports by the U.S. Surgeon General with one important caveat: The mental health crisis plaguing today’s youth appears even more severe for adolescents with ADHD.

The mother of a 14-year-old in Michigan put it this way: “My daughter has developed social anxiety and sometimes has difficulty going to school or to stores where other teens might be present. She is overly obsessed with her looks, so much so that she covers our mirrors. She went from an honor roll student to Ds and Es.”

[ADDitude Special Project: Mental Health Out Loud]

Many high school students, as we now know, weren’t doing well before the pandemic: One in three reported a persistent feeling of sadness or hopelessness between 2009 and 2019, according to U.S. Surgeon General Vivek Murthy. And one in five children aged 3 to 17 reportedly had a mental, emotional, developmental, or behavior disorder during that time period.

But in the last two to three years, mental health challenges grew even more troublesome for high school students with ADHD, according to the caregivers who responded to the ADDitude survey: An astounding 67% of teens have now been diagnosed with anxiety and 46% with depression. Among children ages 3 to 17 with ADHD, the survey also revealed above-average levels of oppositional defiant disorder (11%), sleep disorders (6.75%), and eating disorders (5.32%), not to mention the learning differences that impact more than one in five students with ADHD.

The Social Media Effect

Less than 6% of parents surveyed said their adolescents with ADHD have “very good” mental health today. On a 4-point scale, this group’s average mental health rating was 2.27.

The most alarming signs of a mental health crisis revealed by the survey data involved adolescent girls with ADHD who use social media. The rate of anxiety among this group is a startling 75%, and the rate of depression is 54%, according to the survey. More than 14% have a sleep disorder, and nearly 12% report an eating disorder—more than three times the national average for neurotypical women. Though the survey cannot demonstrate causality with social media use, it does reveal that this demographic has the most severe mental health challenges.

The most “pervasive and troubling” emotions impacting all adolescents with ADHD today include anxiousness (66%), irritability (60%), apathy (59%), withdrawal (47%), and anger or aggression (45%).

[Free Resource: Too Much Screen Time? How to Regulate Your Teen’s Devices]

Among adolescent girls with ADHD, the most common sources of anxiety were school (76%); COVID-19 (54%); finances (31%); gun violence in schools and social media use (28% each). Among teens with ADHD who are not cisgender, 38% report feeling anxiety over political violence.

“Sometimes my son goes through acute depression,” said a caregiver of a transgender adolescent with ADHD, anxiety, and depression. “When this happens, the entire world goes dark for him, and we just do what we can to get him through.”

If your child is experiencing troubling symptoms of anxiety, depression, or self-harm, call or text 9-8-8 to access mental health services in the United States.

How to Protect Your Teen’s Mental Health

Talk to your child’s pediatrician if you are concerned about your child’s mental health. Learn about the signs of anxiety and depression (and other signs of distress) and ask your child’s doctor if screenings for these conditions are warranted. If your child has been diagnosed with anxiety, depression, and/or other conditions, ensure that they are adhering to treatment plans.

1. Model emotional regulation at home.

Practice self-care and prioritize your well being. Even if it doesn’t seem like it, your behaviors serve as a guide for your teen.  Keeping calm will help your teen do the same – or at least prevent emotions from escalating. Make sure you aren’t enabling your child’s anxiety.

2. Try to minimize exposure to negative news.

Avoiding discussing potentially stressful subjects – finances, marital problems, etc. – around your child, as these topics could undermine your child’s sense of safety and stability. Limit your family’s exposure to distressing news events. Learn more about navigating conversations around gun violence and school shootings here.

3. Encourage healthy social media use.

Have ongoing conversations about online experiences, and watch for warning signs of problematic Internet use. Listen to our conversation with Linda Charmaraman, Ph.D., on social media and youth mental health for more strategies. If unhealthy social comparison over social media is a problem for your teen, read this article.

4. Encourage healthy habits.

Consistency and routine ground us, as do sufficient sleep, nutritious meals, and physical activity. Social connection is also vital for teens. Take steps to ensure that your child’s life has all these elements.

5. Prioritize a good relationship with your child above all else.

A stable, supportive environment does wonders for fostering resiliency and confidence. Bond with your child over things they enjoy (don’t come in with an agenda), and really listen to your child’s concerns without judgment. (Check your immediate reactions and unsolicited advice at the door.)

ADHD & the Mental Health Crisis: Next Steps

• Join Us! Mental Health Out Loud Event on Eating Disorders in Teens
• Read: Special 2022 Mental Health Report from ADDitude
• Read: Compare & Despair: Social Media & Mental Health Concerns in Teens with ADHD
• Listen: “Mental Health Out Loud – The Mental Health Fall Out from Social Media Use”
• Free Resource: Social Anxiety Facts & Falsehoods
• Read: A Clinicians’ Guide to Serving and Protecting LGBTQIA+ Youth  

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Adolescents with ADHD and high conduct problems are more likely to develop substance-related problems (SRPs) — including “seven-fold increased odds for illicit drug use” and increased odds for frequent alcohol intoxication, says a new report. Teens with ADHD and high conduct problems who also experienced negative life events such as the death of a loved one or trauma from violence face the highest risk for SRPs, according to a study published recently in the Journal of Attention Disorders. ¹

The study assessed the severity of self-reported conduct problems and its association with SRPs in 9,411 Norwegian adolescents aged 16 to 19. Researchers linked data from a large population-based study conducted in 2012 with registry-based data gathered between 2008 and 2018.

Adolescents with ADHD were grouped into three categories: ADHD only, ADHD plus low conduct problems, and ADHD plus high conduct problems. SRPs were measured on five variables: illicit drug use, high-level alcohol consumption, frequent alcohol intoxication, a positive CRAFFT score (potential drug or alcohol related problems), and level of total symptoms as measured by the first four variables.

Of the 170 adolescents with ADHD, 29% screened positive for conduct disorder compared to 10% of the full survey sample. Adolescents with ADHD plus high conduct problems were more often boys (65.3%) and they experienced higher rates of SRPs. Nearly 29% of adolescents had three or more indicators of SRPs compared to the survey sample (4.7%) and ADHD only subgroup (3.9%).

Previous research suggests that children with ADHD face an increased risk for comorbid disorders, including disruptive behavior diagnoses like conduct disorders and oppositional-defiant disorders.^{2, 3} An estimated 44% to 90% of children and adolescents with ADHD have at least one comorbid disorder.^4–8

“Our findings thus lend support to the notion that the risk of SRPs among ADHD-diagnosed adolescents can largely be attributed to co-existing conduct problems and that ADHD in itself does not increase the risk of adolescent illicit drug use beyond the effect of conduct-related disorders,” the researchers wrote.¹

Of the adolescents that indicated conduct disorders in the ADHD plus high conduct problems subgroup, only about 10% had received a formal diagnosis.

“The results underline the need for CAMHS and other relevant health services to enhance identification of adolescents with ADHD and severe conduct problems, and by this ensure access to interventions that may contribute to break negative cycles related to substance abuse,” the researchers wrote.

Sources

¹Heradstveit, O., Askeland, K. G., Bøe, T., Lundervold, A. J., Elgen, I. B., Skogen, J. C., Pedersen, M. U., & Hysing, M. (2022). Substance-Related Problems in Adolescents with ADHD-Diagnoses: The Importance of Self-Reported Conduct Problems. Journal of Attention Disorders. https://doi.org/10.1177/10870547221105063

²Elia, J., Ambrosini, P., Berrettini, W. (2008). ADHD characteristics: I. Concurrent co-morbidity patterns in children & adolescents. Child and Adolescent Psychiatry and Mental Health, 2(1), 15–19.

³Pfiffner, L. J., McBurnett, K., Rathouz, P. J., Judice, S. (2005). Family correlates of oppositional and conduct disorders in children with attention deficit/hyperactivity disorder. Journal of Abnormal Child Psychology, 33(5), 551–563.

⁴Barkley, R. A. (1998). Attention-deficit hyperactivity disorder. Scientific American, 279(3), 66–71.

⁵Biederman, J., Newcorn, J., Sprich, S. (1991). Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. American Journal of Psychiatry, 148(5), 564–577.

⁶Mitchison, G. M., Njardvik, U. (2019). Prevalence and gender differences of ODD, anxiety, and depression in a sample of children with ADHD. Journal of Attention Disorders, 23(11), 1339–1345.

⁷Szatmari, P., Offord, D. R., Boyle, M. H. (1989). Ontario Child Health Study: Prevalence of attention deficit disorder with hyperactivity. Journal of child psychology and psychiatry, 30(2), 219–230.

⁸Willcutt, E. G., Pennington, B. F., Chhabildas, N. A., Friedman, M. C., Alexander, J. (1999). Psychiatric comorbidity associated with DSM-IV ADHD in a nonreferred sample of twins. Journal of the American Academy of Child and Adolescent Psychiatry, 38(11), 1355–1362.

ODD is characterized by persistent hostility, aggression, and defiance. What’s more, it often co-occurs with ADHD. So, how can parents manage their kids’ ODD symptoms and not exacerbate negative behaviors?

Here, ADDitude readers share their tips for managing oppositional defiance. Read about their experiences below and share yours in the Comments section below.

“My son’s ODD tends to flare when he becomes frustrated by seeing something as ‘wrong.’ The infraction could be serious, or something as small as a different pronunciation of a word. He becomes so disturbed and obsessed with that ‘wrong’ that he tries to right it whatever the cost. But, often, his solution becomes a much bigger ‘wrong’ than the original issue. It could mean interrupting an event, shaming someone, or just discouraging them. It can really hurt others he cares about. My main strategy for dealing with this opposition and negativity is a light-hearted, humorous distraction. When I’m feeling patient and light-hearted, it’s easier to do. And when my rapport with my son is pretty good, it’s easier for him to receive it.” — Nathan

“My 10-year-old son with ADHD exhibits ODD symptoms only at home. He questions everything he is told to do, argues for the sake of argument, and responds aggressively if told to do something he doesn’t like. We try to give him room to share his feelings with us, good or bad, but we often intervene when the aggression is aimed at his younger sister, who is neurotypical. We send him to his room, not as a traditional timeout, but as a physical pause button to stop the aggression. We usually talk through the scenario after he calms down, and we have sought outside counseling to help our family deal with the conflict.” — Anonymous

[Get This Free Download: Why Is My Child So Defiant?]

“My son exhibits characteristics of ODD, however, it is more prevalent when he deals with adults who are inflexible in their own thinking.” — Anonymous

“Both of my teens have ADHD, which manifests in different ways. The defiance increases with parental demands to pick up dirty dishes or do homework, etc. This is not only frustrating for me as a parent, but it causes my overwhelmed ADHD brain to fixate on them completing the task. My daughter ignores the request, and my son burrows into his blanket or becomes overwhelmed and yells at me to leave him alone.” — Anonymous

“I’ve learned not to push them. It only results in a battle of wills, which I know I won’t win. Instead, I try to lead them to make good decisions. I give them options or offer information to get them thinking on the right track.” — Dee

“A very aggressive ‘No!’ is my daughter’s first response to most requests. I calmly repeat whatever it is I expect her to do or stop doing and then walk away to give her the space to calm down and digest what she needs to do.” — Anonymous

[Read This: Why Is My Child So Angry and Defiant? An Overview of ODD]

“I see ODD in my 7-year-old son when he’s unmedicated. If I ask him to do something, the answer is immediately ‘No!’ or ‘Never!’ It seems like an automatic reaction. I just wait and give him a chance to think about what he’s said. He then toddles off to do what he’s told (with all the usual distractions along the way). He’s not like that when he’s medicated. It took me a long time to work out that he can’t help it, and I need to deal with it calmly.” — Nikki

“I never tell them directly what to do, except in an emergency. I make them think that it’s their idea, give choices, or I even tell them to do the opposite. I don’t react if they do something odd. I just raise an eyebrow and carry on. I am never angry with tantrums or oppositional verbal naysaying. It’s best to laugh it off as it’s often funny. Most of these things take the sting out.” — Paul

“Mine are still young (6-year-old twins). One twin has ADHD and ODD, and I’m sure they feed off each other. I make corrections using redirection. We are trying behavioral charts with short-term and long-term rewards.” — LC

“My son has both ADHD and ODD. The ODD is only directed at home to us. Other authority figures like teachers or doctors are questioned but not defied. We are constantly re-establishing order in the house. It’s exhausting to plan for him to defy a new boundary. We are consistent and very careful with our words. We maintain control by repeating and disengaging. It’s isn’t pretty, but we are doing our best.” — Anonymous

“My teenage son has ADHD with ODD with symptoms of CD (conduct disorder). Anybody with authority is treated with disdain. It makes it difficult for him to get an education, keep a job, hold on to his driver’s license, the list goes on. In between bouts of lawlessness, he is a fantastic kid. We all have professional support; it helps us more than him. He will be 18 soon, and we worry about his future.” — Chris

“There is nothing we can ask our 10-year-old to do that is not met with some level of resistance. Initially he gets angry. Then he complains. Often, he cries. Depending on how tired or overwhelmed he is, he may go into full meltdown mode. We are finally learning to pick our battles, but it’s never easy when so much of his behavior requires correction. He figured out that reading calms him and hugs help (once he’s over his meltdown). I know he doesn’t want to make our lives difficult on purpose and he wishes he could be different. It inspires me to show empathy and continue to educate myself about ADHD and ODD to do better for him.” — Anonymous

ODD Parenting Advice: Next Steps

• Self-Test: Oppositional Defiant Disorder (ODD) in Children
• Read This: How to Discipline a Child with Oppositional Defiant Disorder (ODD)
• Learn: Oppositional Defiant Disorder Strategies — 8 Discipline Rules

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Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Select measures of impulsivity and risk-taking in children with attention deficit hyperactivity disorder (ADHD) are linked to symptoms of comorbid oppositional defiant disorder (ODD), according to a longitudinal study recently published in Frontiers in Psychiatry¹ that examines the relationship between these disorders, reward-related dysfunctions, and other factors.

Specifically, the study found that high approach motivation (the tendency to approach a rewarding stimulus while dismissing any associated threats or risks) in children might indicate a higher likelihood of developing comorbid symptoms of ADHD or ODD. The researchers also argue that another overlapping psychopathological dimension called callous-unemotional (CU) traits — associated with reduced guilt and remorse, callousness, and low empathy — may appear alongside dimensions of ADHD and ODD/CD in children who exhibit this high approach motivation.

Research Background

Existing research has established a significant link between ADHD, ODD, and conduct disorder (CD). Reward-related dysfunctions are, likewise, prevalent in individuals with ADHD and ODD/CD. Early emerging measures of impulsivity, including high approach motivation and low inhibitory control (IC) may indicate later development of these disorders.

While low reward-related inhibitory control (RRIC) is common in children with ADHD as well as in those with ODD/CD, it is thought that children with ADHD symptoms and comorbid CU traits show fewer RRIC deficits.

Studies also show that children with ADHD exhibit low autonomic reactivity in response to reward-related tasks, which may be caused by comorbid ODD/CD symptoms. These studies, however, have not assessed the role of CU traits in this relationship.

The authors of the new study examined all these factors in a sample of 198 preschool children, hypothesizing that:

• Low RRIC would be associated with developing ADHD, and would overlap with comorbid ODD symptoms
• High reward-related approach behavior would be associated with developing ADHD and could be explained by ODD symptoms and CU traits
• Low autonomic reactivity to reward-related stimuli would be linked to ADHD and overlap with ODD symptoms and CU traits

Approach Motivation Study

Participants, aged 4 to 5 years at the start of the study, were all screened for ADHD. (Children with high ADHD symptoms were oversampled.) To measure RRIC, researchers used a Snack-Delay task (participants wait for a cue before they can take a snack). The Stranger-with-Toys task (how long it takes the child to talk to a stranger) was used to measure approach motivation. Parents also completed ADHD and ODD rating scales.

Researchers assessed the participants again at age 8. RRIC was measured using a Gift-Bag task (children wait for a cue to look at their gift). To measure approach motivation, children were scored based on how long it took for them to speak to a stranger who placed toys in front of them while asking a series of questions. Autonomic reactivity was measured based on the participants’ reactions to the stranger’s questions. (Electrodes were attached to participants’ hands.) Parents also completed ADHD, ODD, and CU scales/questionnaires.

Findings show that low RRIC, whether at preschool age or school age, is uniquely related to ADHD, and is not associated with ODD or CU traits. Preschool RRIC, in particular, predicted later ADHD development. Low autonomic reactivity was also uniquely associated with ADHD alone.

High approach motivation at preschool, however, is associated with ADHD at school age — particularly in children with comorbid ODD symptoms and CU traits.

Sources

¹ Schloß, S., Derz, F., Schurek, P., Cosan, A. S., Becker, K., & Pauli-Pott, U. (2021). Reward-Related Dysfunctions in Children Developing Attention Deficit Hyperactivity Disorder-Roles of Oppositional and Callous-Unemotional Symptoms. Frontiers in psychiatry, 12, 738368. https://doi.org/10.3389/fpsyt.2021.738368

Symptoms of inattention and irritability uniquely predict an increased likelihood of internalizing disorders, like anxiety and depression, from childhood to adolescence, according to a new study published in the Journal of Attention Disorders¹ that examined the dimensions of attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) linked to these comorbidities.

The study’s authors noted that, while childhood ADHD and ODD are separate risk factors for internalizing problems, unique dimensions of each disorder — like inattention and hyperactivity in ADHD, and irritability and opposition in ODD – differently predict the incidence of these comorbid conditions. The study aimed to simultaneously and independently discern these dimensions over time to improve understanding of the risk factors behind internalizing problems.

For the study, researchers followed 230 children with and without ADHD over 7 years, and assessed symptoms like inattention, hyperactivity, irritability, and oppositionality based on parent-teacher responses to rating scales. Parents and teachers also rated emotional and behavioral problems at ease phase. Follow-up assessments were conducted every 2 to 3 years, for a total of 3 “waves.”

Findings show that escalating symptoms of inattention, but not hyperactivity, uniquely and positively predicted internalizing problems overall. And escalating irritability, but not oppositionality, positively predicted parent-rated internalizing and anxiety problems.

These results, according to the authors, demonstrate the importance of a dimensional approach to evaluating risk for internalizing disorders. Most research for ADHD’s ties to internalizing problems, for example, is often based on ADHD vs. non-ADHD designations, which limits the role of subclinical ADHD and specific symptoms. Most studies also treat childhood ADHD as a fixed predictor for internalizing problems, which assumes invariance in symptoms, even though symptoms are known to change and fluctuate over time.

The findings also have important clinical implications. The authors suggest that inattention and irritability may reflect an early phenotypic presentation for internalizing problems in adolescence and that screenings for anxiety and depression should begin in childhood.

Sources

¹ So, F. K., Chavira, D., & Lee, S. S. (2021). ADHD and ODD Dimensions: Time Varying Prediction of Internalizing Problems from Childhood to Adolescence. Journal of Attention Disorders. https://doi.org/10.1177/10870547211050947

Visual and auditory information are processed differently by children with ADHD, depending on their diagnosed ADHD subtype and the presence of comorbid conditions, according to a new Journal of Attention Disorders study exploring cognitive distinctions between the ADHD sub-types and between children with and without ADHD comorbidities.¹  Notably, the research found that children with combined-type ADHD respond best to visual information, though children without ADHD outperform those with inattentive- or combined-type ADHD on Continuous Performance Tests measuring attention, inhibition, and working memory.

One hundred fifty participants, aged 7 to 10, were grouped according to ADHD presentation (combined or inattentive) or comorbid diagnosis (anxiety, ODD, both, or neither). Their performance on the Integrated Visual and Auditory Continuous Performance Test (IVA-CPT) was compared to a control group of 60 children without ADHD. Diffusion decision modelling was used to break down performance into cognitive components.

Children with combined- or inattentive-type ADHD had slower and less accurate visual and auditory processing than did controls. Those with combined-type ADHD were more sensitive to changes in presentation modality than those with inattentive-type and controls; they reacted more favorably to visual information than they did to auditory information, overall. “These results could be important for educational strategies regarding the most useful modality for presentation of educational materials: in a context with frequent targets (go stimuli), presenting them visually rather than auditorily helped particularly children with ADHD-C to achieve faster and more accurate processing,” the study reported.

Children with comorbid ADHD, ODD, and anxiety disorders demonstrated an increased tendency toward making premature decisions than did the children with ADHD and anxiety only, ODD only, or no comorbidity. Researchers suggest that additional biases may occur in cognitive processing with double comorbidity due to the confounding effect of “comorbidity load.”

These findings highlight the need for cognitive tests with multiple conditions because clinical associations appear when changes in cognitive components are examined across conditions. Identifying underlying cognitive components of types of ADHD and co-morbid diagnoses could help tailor treatments to the needs of different individuals with ADHD, and improve educational interventions.

Sources

¹ Ging-Jehli NR, Arnold LE, Roley-Roberts ME, deBeus R. Characterizing Underlying Cognitive Components of ADHD Presentations and Co-morbid Diagnoses: A Diffusion Decision Model Analysis. Journal of Attention Disorders. June 2021. doi:10.1177/10870547211020087

Children with ADHD who experience significant social, emotional, and executive-function impairments also demonstrate significantly higher rates of oppositional defiant disorder (ODD) and conduct disorder (CD), according to a nationwide study of Turkish children published in the Journal of Attention Disorders.¹ Impairment ratings by caregivers and educators considered the child’s relationship with his/her siblings, relationships with friends, ability to do homework, general adjustment at home, and self-esteem. In addition, the study’s nationwide representative samples demonstrated a prevalence of ADHD in Turkish children of 19.5% without impairment and 12.4% with impairment.

Researchers studied functional impairments in 5,842 students aged 8 to 10 years, who participated in a diagnostic interview, were screened with a DSM-IV-based scale for Disruptive Behavior Disorders, and had their impairments assessed by both parents and teachers.

When researchers considered the impairment criteria, the overall prevalence of ADHD was found to be 12.4%: 6.8% inattentive presentation, 0.7% hyperactive presentation, and 4.9% combined presentation. This overall prevalence of ADHD was much higher than the pooled prevalence rates of 5.29% and 7.1% reported in two extensive meta-regression-analysis studies.^2,3  This is likely because the new study applied epidemiological methodology. All presentations of ADHD were significantly higher among boys, regardless of impairment criteria. In comparing psychiatric comorbidities between ADHD groups with and without impairment, researchers found a higher prevalence of ODD and CD in the former. ODD was found in 15.1% of children with ADHD and significant impairment from symptoms, but in only 8.7% of children with ADHD and no significant impairment. CD was found in 2.2% of children with ADHD and high impairment, yet in only .2% of children with ADHD and minimal impairment.

In addition to contributing to a more accurate understanding of nationwide ADHD prevalence, these findings suggest that children with ADHD who experience more severe impairment are at a greater risk for disruptive behavior disorders. This study was limited to children attending urban schools in Turkey, which represented 71.4% of the population.

Sources

¹ Ercan ES, Unsel-Bolat G, Tufan AE, et al. Effect of Impairment on the Prevalence and Comorbidities of Attention Deficit Hyperactivity Disorder in a National Survey: Nation-Wide Prevalence and Comorbidities of ADHD. Journal of Attention Disorders. May 2021. doi:10.1177/10870547211017985

² Polanczyk, G., de Lima, M. S., Horta, B. L., Biederman, J., Rohde, L. A. (2007). The worldwide prevalence of ADHD: A systematic review and metaregression analysis. The American Journal of Psychiatry, 164(6), 942–948. https://doi.org/10.1176/ajp.2007.164.6.942

³ Willcutt, E. G. (2012). The prevalence of DSM-IV attention-deficit/hyperactivity disorder: A meta-analytic review. Neurotherapeutics: The Journal of the American Society for Experimental Neurotherapeutics, 9(3), 490–499. https://doi.org/10.1007/s13311-012-0135-8

However, emotional dysregulation is not exclusive to attention deficit hyperactivity disorder (ADHD or ADD). Chronic moodiness is also a central component of mood disorders like bipolar disorder, which may complicate the evaluation, diagnosis, and treatment process, particularly for adult patients. Differentiating moodiness as it appears in ADHD, bipolar disorder, and similar disorders is critically important — and not always straightforward.

Emotional Dysregulation Across Disorders

Emotional dysregulation, while present in many conditions, shows up in different ways and in different grades of severity. Making the distinction between characteristics of moodiness in ADHD, ODD, DMDD, and other disorders often requires studying the mood’s intensity and the degree to which it disrupts the individual’s functioning.

ADHD

Chronic Irritability

Many individuals with ADHD report feeling easily irritated and frustrated. Minor frustrations at home, work, and/or school, can cause substantial irritability. (Social pressures outside of the home may keep individuals from lashing out in these settings.) A scenario warranting a 2 on a 10-point scale, for example, can often feel like a 7 or 9 to a person with ADHD. They can be quick to anger, as a result, and may lash out with angry outbursts or through passive-aggressive behaviors. Frustrations, however, are often over quickly. Some may feel upset or regretful later, once the emotional overreaction has subsided.

Oppositional Defiant Disorder (ODD)

ODD is one of the most common comorbidities seen with ADHD. Roughly one-third to one-half of children with ADHD also have ODD, characterized by disruptive, defiant, and irritable behavior. Children with ODD can be quick and impulsive, or sullen and sustained, with their oppositional behaviors toward authority figures. ODD usually becomes apparent around age 12 and lasts until the start of adulthood. Most patients outgrow ODD, but for some, it may turn into conduct disorder, which typically involves delinquent activity, physical aggression, violence, theft, and/or destruction of property.

[ODD vs. ADHD: The Facts About Oppositional Defiant Disorder and Attention Deficit]

Disruptive Mood Dysregulation Disorder (DMDD)

DMDD is a relatively new diagnostic category reserved for children over age 6. It is characterized by steady, persistent problems with mood dysregulation. A child with DMDD experiences severe and recurrent temper outbursts, either verbal or behavioral, that are grossly out of proportion and inconsistent with what is typically expected for a child their age. These outbursts typically occur three or more times a week. Between outbursts, children with DMDD are often persistently irritable or angry. To merit a diagnosis, these symptoms need to be chronically present for at least a year.

DMDD is a way of categorizing major mood problems in children without the bipolar label.

Bipolar Disorder

Bipolar I Disorder

A main feature of bipolar I disorder is a distinct period of abnormally and persistently elevated, expansive, or irritable mood. Bipolar I may also be characterized by a period of “hypomania,” or out-of-the-ordinary, increased activity or energy lasting persistently for at least a week. Depressive moods may also occur concurrently or at other times. These moods are severe enough to cause marked impairment in social or occupational functioning, and often warrant psychiatric hospitalization. There may also be increased risk of suicide or suicide attempts.

To merit diagnosis, at least three of the following symptoms must be present:

• Inflated self-esteem or grandiosity
• Decreased need for sleep
• Pressured speech, racing thoughts
• Extreme distractibility (beyond what is associated with ADHD)
• Increase in agitation (restlessness) or goal-directed activity
• Excessive involvement in risky activity, including over-spending, sexual indiscretions, and/or heavy drinking (the latter often done in an attempt to calm down)

Bipolar I disorder is typically diagnosed around age 18, when a first episode occurs. Many but not all patients go on to experience more episodes.

[Read: Solving the ADHD-Bipolar Puzzle]

Bipolar II Disorder

Bipolar II disorder is usually less severe than bipolar type I, but it can be more complicated to diagnose and significantly impairing. With bipolar type II, there’s at least one hypomanic episode lasting at least four full consecutive days, as well as three or more of the symptoms outlined for bipolar I disorder. These episodes are usually not accompanied by psychotic symptoms; they are not severe enough to cause marked impairment in functioning or to require hospitalization.

Patients with bipolar type II will also meet the criteria for a current or past episode of major depression (MDD). With bipolar I, patients may or may not have accompanying MDD. A major depressive episode is marked by at least 5 of the following symptoms:

• Persistently depressed mood
• Markedly diminished interest or pleasure
• Significant increase or decrease in appetite
• Increased restlessness or slowing down
• Fatigue, loss of energy
• Feelings of guilt or worthlessness
• Diminished ability to think or concentrate
• Recurrent thoughts of death or suicide

Bipolar Disorder vs. ADHD

Bipolar disorder and ADHD do share some characteristics of moodiness, irritability, and other aspects of emotionality. The chart below differentiates these characteristics as they usually appear.

• + = presence
• – = absence
• ++ = more present
• +/– = may be present
• +++ = most present

Bipolar Disorder in Children

Bipolar disorder in children is not always marked by clearly defined episodes of severe moods. Another factor complicating diagnosis is that about 80 percent of children and adolescents with bipolar disorder will also have ADHD, ODD, and/or major depressive episodes. This makes it difficult to tell whether a patient with ADHD and serious mood problems has severe ADHD, bipolar disorder, or both.

But aiding diagnosis is the fact that ADHD and bipolar disorder are highly familial. (ADHD has a heritability index of .76; bipolar disorder is between .6 to .85.) Assessing  for history of mood problems can help determine the diagnosis.

Mood Disorders and ADHD: Treatments and Considerations

Emotional dysregulation and severe moodiness in ADHD and bipolar disorder are often treated with medication. This intervention alone, however, is usually not sufficient. Through psychotherapy, patients and families can receive essential support around understanding and addressing problems with mood and emotional dysregulation, including:

• Identifying triggers to episodes involving family systems
• Using strategies to avoid worsening episodes
• Understanding family history of mood problems
• The limitations of medication

Clinicians should also consider that patients with bipolar type II may not warrant or choose to follow the treatments prescribed for bipolar I. In a hypomanic episode, for example, some patients may want to “tap in to” this energy for work or creative projects. In this case, it’s important to have a conversation with patients about recognizing the signs of an episode.

ADHD and Bipolar Medication Options

The first course of action for treating bipolar disorder with ADHD is to stabilize mood, which can be addressed with medications like Lamictal, Abilify, Risperidone, Zyprexa, or Lithium.

Stimulant Medications

Though not explicitly approved to do so, stimulant medications for ADHD often improve moodiness in patients without a mood disorder. A patient’s effective dose is not based on their age, weight, or severity of symptoms, but rather how sensitive the patient’s body chemistry is to a particular medication. This requires monitoring and fine-tuning dosing to fit individual sensitivity as well as the patient’s lifestyle to ensure the medication is active when they most need it.

For patients with ADHD and bipolar disorder, however, stimulants may exacerbate symptoms of emotional dysregulation. If levels of irritability or agitation are made worse on this medication, the clinician should instead prescribe a mood stabilizer to treat and reduce these issues. When the patient’s mood has stabilized but ADHD symptoms persist, stimulants can be added to treatment, but cautiously. The most prescribed stimulants are Vyvanse and Adderall XR.

“Stimulant rebound” is also important factor for clinicians and patients to consider. Patients who report feeling or acting excessively wired and irritable, or who lose their “sparkle” while the stimulant is active, may be taking a dose that is too high or taking medication that does not work for them. But if these effects are occurring as the medication is wearing off, that’s a different issue of “stimulant rebound”, meaning that the medication is dropping off too fast. Usually, this issue can be fixed by administering a small dose of the short-acting version of the medicine, which smoothes its “exit ramp” and avoids these difficulties.

Nonstimulant Medications

Guanfacine-XR (Intuniv) is a nonstimulant approved for ADHD treatment that may help improve restlessness, impulsivity, and hyperactivity in patients with both ADHD and mood problems. This medication dosage needs to be increased slowly to a maximum of 4 mg per day.

SSRIs

Many prescribers are hesitant to add SSRIs to a bipolar treatment plan, as they can increase the risk of a hypomanic or manic episode and cause suicidal thoughts. But if a patient’s mood is stabilized and symptoms of depression persist, an SSRI like fluoxetine may help improve their mood to baseline. SSRIs should be monitored carefully, especially in the first several weeks of administration.

The Role of the Family

Parent Emotional Dysregulation

How families respond to moodiness and emotional outbursts can make a big difference. Should patients, especially children and adolescents, pursue therapy, it is also important to address parental temper and moods as well. Assessing interactions at home can reveal triggers and sensitive scenarios that contribute to mood instability.

Parental Polarization

A patient’s parents may not share the same approach to addressing irritability and moodiness. One parent may insist on patience and support, while the other adopts a “crackdown” approach. Often, each parent ends up taking a more extreme view over time. Both may fail to see how either approach could be right depending on the situation, to the detriment of the child. Therapy can be an appropriate setting for working through these issues.

Mood Disorders: Next Steps

• Read: The ADHD-Anger Connection: New Insights into Emotional Dysregulation and Treatment Considerations
• Guide: Where ADHD and Bipolar Disorder Overlap
• Download: Bipolar Disorder and ADHD: How to Tell the Difference

The content for this article was derived from the ADDitude Expert Webinar “Is It Bipolar Disorder or ADHD Moodiness? A Guide to Getting the Right Diagnosis and Treatment” [Video Replay & Podcast #347] with Thomas E. Brown. Ph.D., and Ryan J. Kennedy, DNP, which was broadcast live on March 10, 2021.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Families impacted by ODD can often feel alone and unsupported in their struggles. They might even wonder if treating the disorder and other existing conditions is possible under the circumstances of extreme defiance. Interventions are indeed available for ODD in children, but it is critical for families to understand the facets of the disorder, including how disruptive behaviors actually play out in daily life, and their potential impact on family dynamics and even quality of treatment and care.

What is ODD?

ODD is listed under the DSM-5’s disruptive behavior disorders category. To merit a diagnosis, a patient must exhibit at least four of the symptoms outlined below that demonstrate a pattern of angry or irritable mood, argumentative or defiant behavior, or vindictiveness for at least six months with at least one individual who is not a sibling:

Anger or Irritable Mood

1. Often loses temper
2. Is often touchy or easily annoyed
3. Is often angry and resentful

Argumentative or Defiant Behavior

4. Often argues with authority figures or, for children and adolescents, with adults
5. Often actively defies or refuses to comply with requests from authority figures or with rules
6. Often deliberately annoys others
7. Often blames others for his or her mistakes or misbehavior

Vindictiveness

8. Has been spiteful or vindictive at least twice within the past 6 months

[Self Test: Oppositional Defiant Disorder (ODD) in Children]

These behaviors are associated with distress in others but the individual usually does not see their behaviors as wrong, unjustified, and harmful to others. The behaviors can also severely impact social, educational, and familial areas of functioning.

While ODD has an estimated prevalence of 10 percent, it occurs in about half of children with ADHD, making it one of the most common disorders occurring with ADHD¹.

ODD in Children: The Reality

The DSM-5’s description of ODD (as with many other disorders) fails to truly capture its breadth. It effectively ignores a central feature of ODD: that the person is genetically and neurologically hardwired to thwart, frustrate, antagonize, and defeat anyone whom they perceive in a position of authority. This is the feature that destroys the individual’s ability to create or sustain relationships, that alienates them, that makes treatment difficult, and that can ultimately crush families.

The person with ODD is also willing to suffer severe consequences for their disruptive behaviors. The goal is not so much to score a “win” over the authority figure, but to bring them down, defeat, thwart, and humiliate the authority figure. The mere perception of authority can, therefore, change the behavior of an individual with ODD from agreeable and mild-mannered to hostile.

[ODD vs. ADHD: The Facts About Oppositional Defiant Disorder and Attention Deficit]

Even then, ODD doesn’t always manifest in overt displays of negative behaviors. Disruptive behaviors, especially thwarting an authority figure’s efforts, can be covert. People with ODD are not always “up in your face.” They may be disguised, for example, as pseudo-compliance. For example, they may agree to do something but have no intention of ever doing it. They may agree to take their medication only to cheek the pill and spit it out later.

What’s more, people with ODD typically do not regard themselves as oppositional or defiant. They often justify their behaviors as a response to unreasonable demands or provocation from the person in authority. As such, there is often no remorse or discomfort involved with these disruptive behaviors.

Dealing with ODD: Behavior Management and Medication

Can ODD in Children be Managed?

Parents often assume that ODD can be wholly reined in. But the uncomfortable truth is that ODD doesn’t work like this. The reality is that the individual with ODD often has the upper hand. Even in treatment, they might sabotage parent and clinician efforts by feigning compliance (“I agreed to give it a try, but it doesn’t work for me”), by diverting attention away from the topic, by picking fights, and other methods. Showing enthusiasm for any intervention often triggers the patient’s urge to defeat it. (Children and adolescents with ODD are not the only ones who may thwart treatment; given ODD’s heritability, it’s possible that one parent or family member also has the disorder and secretly sabotages everything the other parent tries to do.. The oppositional behaviors, therefore, may even come from them!)

And while ODD symptoms do improve over time for the majority children, the disorder is a strong predictor for conduct disorder¹, characterized by behaviors that can include aggression toward people and animals, destruction of property, deceitfulness and theft, and rule breaking. ODD’s genetic aspect² also means that the condition is unlikely to resolve on its own, and psychotherapy alone is typically only so effective.

Early intervention and treatment in the form of behavior therapy and medication, therefore, are critical for addressing ODD and managing its impact on the individual and others.

Medications for ODD

While there are currently no FDA-approved medications to treat ODD, clinicians commonly prescribe a series of medications off-label that can dramatically impact symptoms. Which medications are prescribed often depend on co-existing conditions.

Stimulants for ODD

For co-occurring ODD and ADHD, clinicians often prescribe stimulants to treat ADHD first. Typically, the ADHD stimulant medications greatly reduce ODD symptom severity and frequency. One study also found that patients with ADHD who consistently took medication significantly lowered their risk of developing ODD or CD in later life compared to patients with lower drug adherence³. In practice, clinicians often use liquid formulations to avoid having the patient potentially dispose of tablets.

Atypical Neuroleptics (Antipsych0tics) for ODD

Risperidone (Risperdal), Aripiprazole (Abilify), and Olanzapine (Zyprexa) are among the most commonly prescribed antipsych0tics to treat symptoms of ODD off-label, including acute and chronic maladaptive aggression. All of these products have oral dissolving tablet formulations that are useful to prevent “cheeking.”

When the atypical antipsych0tic medications work, they provide dramatic benefits at low dosages, and fairly quickly. This allows trials on medication to be done in a matter of days. Clinicians can start patients on 1 mg of Risperidone at bedtime and increase by half a milligram the next two nights if well tolerated. If there is not a robust positive response, clinicians can stop Risperidone and switch to 2.5 mg of Aripiprazole the following evening and then 5 mg the following evening. If this medication is not effective, the clinician can stop the Aripiprazole and switch to 2 mg of Olanzapine the following evening, and 5 mg the next.

Behavior Management Therapy for ODD

Behavior therapy and psychosocial treatment are essential components of ODD treatment. Medication can work to minimize symptoms, but patients and families still need to learn techniques and strategies to manage behaviors. Some effective programs for children and adolescents with ODD include:

• Defiant Children: A Clinician’s Manual for Assessment and Parent Training (3rd Edition) (#CommissionsEarned). Created by Russell Barkley, Ph.D., this program trains parents to deal with noncompliant behaviors mainly through parent effectiveness training (rewarding appropriate behaviors and ignoring misbehavior; time-outs when failing to comply). While parents must implement strategies at home, practicing management strategies under professional trained supervision is essential to the program. (Families sometimes choose to work in a group to find a child specialist who can guide them in this program.) The program is an effective treatment, when practiced over time, for managing oppositionality. The 3rd edition has been expanded to include behavior management techniques when outside the home at school, in restaurants, and out shopping.
• The Real Economy System for Teens – R.E.S.T. (#CommissionsEarned) by David B. Stein, Ph.D. and Edward Smith. This program essentially teaches oppositional teens what the world is going to require from them once they leave home. The program requires parents to calculate the cost of daily living for their teen (from Internet use to clothes to video games), and only provide them with their day’s money if they complete a list of tasks without being reminded. While the program can be done at home with no clinical intervention, many families find it helpful to follow the program in a support group.

Dealing with ODD in Children: The Bottom Line

The very nature of ODD can make patients fight against and even sabotage any plan to address symptoms. Even if they seem in compliance, patients may lie about actually taking medication; report intolerable, impossible side effects; or otherwise try to thwart interventions. After all, people with ODD seldom see themselves as even having a disorder at all.

With ODD, families and clinicians must understand that good patients are made – not born. It can take years to see adherence and progress, and improvement requires enormous amounts of patience. The process can be aided by reflecting back to the patient the unavoidable consequences of their behaviors over time until they can begin to see patterns and their own role in negative situations.

It is also important for families to remember that ODD is an illness. Focusing on blame and fault will certainly discourage adolescents and adults with ODD from participating in treatment, and it may even fuel symptoms. Rather than framing behaviors as right or wrong, it can help to question the individual on whether their behaviors are actually working for them (the answer, of course, is no). These questions can eventually get the person to at least try an intervention in earnest – for themselves.

The content for this article was derived from the ADDitude Expert Webinar “How Oppositional Defiant Disorder Ruptures Families — and How You Can Learn to Manage It” [Video Replay & Podcast #349] with William Dodson, M.D., LF-APA, which was broadcast live on April 6, 2021.

ODD in Children: Next Steps

• Read: The ADHD and ODD Link in Children
• Read: How to Discipline a Child with Oppositional Defiant Disorder (ODD)
• Read: Could Positive Parenting Decrease the Risk for Oppositional Defiant Disorder?

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Sources

¹ Eskander N. (2020). The Psychosocial Outcome of Conduct and Oppositional Defiant Disorder in Children With Attention Deficit Hyperactivity Disorder. Cureus, 12(8), e9521. https://doi.org/10.7759/cureus.9521

² Aggarwal A, Marwaha R. Oppositional Defiant Disorder. [Updated 2020 Nov 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557443/

³ Wang LJ, Lee SY, Chou MC, et al. Impact of drug adherence on oppositional defiant disorder and conduct disorder among patients with attention-deficit/hyperactivity disorder. J Clin Psychiatry. 2018;79(5):17m11784.