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.

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

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.

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 Clinicians’ Guide to Differential Diagnosis of ADHD from Medscape and ADDitude

• How can I better understand ADHD, its causes, and its manifestations?
• What do I need to understand about ADHD that is not fully represented in the DSM?
• How can I avoid the barriers and biases that impair ADHD diagnosis for underserved populations?
• How can I best consider psychiatric comorbidities when evaluating a patient for ADHD?
  • What comorbidities are associated with ADHD?
  • How can diagnosticians differentiate symptoms of anxiety, depression, and ADHD?
  • What are the key distinctions between ADHD and depression?
  • How are the symptoms of ADHD and bipolar disorder often conflated?
  • What are the shared and distinct characteristics of obsessive compulsive disorder (OCD) and ADHD?
  • How can diagnosing clinicians differentiate between rejection sensitive dysphoria (RSD) – the emotional highs and lows associated with ADHD – and the similar ups and downs of bipolar disorder?
  • Free Webinar: Treating Anxiety and Depression Alongside ADHD
  • Free Webinar: ADHD Irritability vs. DMDD vs. Bipolar Disorder
  • Free Webinar: Why ADHD Is Mistaken for Bipolar Disorder in Women
• How can I differentiate ADHD from the comorbidities most likely to present at school and/or work?
• How can I best consider trauma and personality disorders through the lens of ADHD?
• What diagnostic criteria and tests are recommended for performing a differential diagnosis of ADHD?

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.

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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?

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.

#CommissionsEarned As an Amazon Associate, ADDitude earns a commission from qualifying purchases made by ADDitude readers on the affiliate links we share. However, all products linked in the ADDitude Store have been independently selected by our editors and/or recommended by our readers. Prices are accurate and items in stock as of time of publication.

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.

Oppositional Defiant Disorder (ODD) is one of ADHD’s most common co-existing conditions with a 20-45% comorbidity rate, yet little is known about its causes and treatments. This lack of meaningful awareness and understanding is even more puzzling when you consider how ODD ruins the lives of so many children and their families.

Children, adolescents, and adults with ODD are genetically and neurologically hardwired to oppose, thwart, and frustrate everyone who they perceive as telling them what to do. This brings them into conflict with virtually everyone — teachers, law enforcement, employers, and especially parents and spouses. Individuals with ODD lead lives of conflict that troubles and tortures them, their families, and their personal and professional lives.

ODD is a separate condition from ADHD with its own unique symptoms. It’s important to recognize these hallmarks — and to anticipate and prevent the problems that ODD creates. Successful treatment often requires behavioral management techniques and pharmacological strategies, though there is no medication approved by the FDA explicitly for the treatment of ODD. Creative techniques are often required for engaging people with ODD in therapy.

In this webinar, you will learn:

• How ADHD and ODD overlap in symptoms, genetics, and treatment
• How ODD may spontaneously go away or get much worse and develop into Conduct Disorder
• How to implement the two behavioral treatments for children and adolescents with ODD
• How to use medication in conjunction with behavioral management techniques
• How untreated ODD/CD can damage lives, relationships, families, marriages, and jobs

RSD Research

To participate in the rejection sensitive dysphoria research mentioned by Dr. Dodson, please email empathyrsd@gmail.com with the following information: name, email address, age, and whether you have clinician-diagnosed ADHD or not (control group).

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Read More on ODD in Children

ODD in Children: A Parent’s Behavior Management Guide

Will Anything Solve My Child’s Defiance and ODD?

4 Easy-to-Miss Characteristics of Oppositional Defiant Disorder (ODD)

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Meet the Expert Speaker

Dr. Bill Dodson is a board-certified adult psychiatrist who has specialized in adults with ADHD for the last 25 years. He was named a Life Fellow of the American Psychiatric Association in recognition of his clinical contributions to the field of ADHD (2012).  He was recipient of the national Maxwell Schleifer Award for Distinguished Service to Persons with Disabilities (2006). Dr. Dodson is semi-retired and maintains a consultative practice in Greenwood Village, Colorado. | See expert’s full bio »

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All children are sometimes angry or defiant when upset; they will argue and test limits as normal steps in the separation and individuation process. Children with attention deficit hyperactivity disorder (ADHD or ADD) exhibit these behaviors more often than those without ADHD. But when the behaviors become frequent and severe, they may indicate an emerging disruptive behavior disorder like Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD).

It’s difficult to distinguish between ODD and CD — both predominantly male disorders that revolve around problems with self-control. Both also involve disobedience, resisting rules, and defying authority. These children tend to be angry and spiteful, and they blame others rather than accept responsibility for their actions.

Many experts consider the two disorders on a continuum, with CD being a more severe version of ODD. Indeed, most children with CD have previously had an ODD diagnosis. The escalation from ODD to CD involves increasing physical aggression and violations of others’ rights. Although both disorders often resolve before adulthood, the outcomes for CD tend to be poorer than for those with ODD.

Conduct Disorder and ADHD in Teens

ADHD is difficult to manage on its own; it is even harder to handle in conjunction with co-existing disorders. Roughly half of all children with ADHD will also develop ODD or CD. The prevalence of co-occurring CD increases with age and the disorder may affect as many as 50 percent of teens with ADHD. Likewise, about 60 percent of teens with CD also have co-occurring ADHD. CD is most likely to develop in those with severe ADHD symptoms. Those with both disorders tend to experience an earlier age of symptom onset, more severe symptoms, and more emotional and psychiatric problems than those with just ADHD or CD.

[Could Your Child Have Oppositional Defiant Disorder? Take This Self-Test]

Types of Conduct Disorder

The CD diagnosis specifies subtypes based on age of onset, with child symptoms presenting before age 10, and adolescent symptoms defined as appearing after age 10. Those with child onset symptoms, sometimes recognizable as early as preschool, have the more serious prognosis, characterized by physical aggression and disturbed family and peer relationships. The adolescent onset group tends to be less physically aggressive and more likely to have some positive peer relationships.

Another subtype is characterized by limited prosocial emotions (LPE). Those with LPE appear to lack remorse, guilt, empathy, and concerns about their performance. Characterized by unemotional traits, this subtype includes those with insensitivity to punishment, fearlessness, and planned aggression. This subtype is the most likely to persist into adulthood.

Early Signs of Conduct Disorder

There is evidence that a difficult early temperament may predict the development of CD. Some of these behaviors include emotional hyper-reactivity, irritability, and inflexibility. Other early indicators include below-average intelligence, with especially poor verbal skills. New research suggests that predictors of ADHD and CD can be identified in children of kindergarten age. Poor academic performance and problematic behaviors should be addressed early. Both respond to treatment at a young age. If they co-occur and are not addressed, they are very likely to lead to CD.

Boys with ADHD and CD are twice as likely to have reading difficulties than those with ADHD alone. Both genders engage in delinquent behaviors, but boys’ behaviors tend to be more aggressive than girls.’ Girls are more likely to exhibit lying, truancy, running away, and prostitution. They also tend to engage in more relational aggression, manipulating and verbally abusing others.

[Could Your Teen Have Intermittent Explosive Disorder? Take This Self-Test]

Causes of Conduct Disorder: Genes and Environment

Genetics and environment contribute to the development of both disorders. CD is more likely to develop if a family member has CD or ADHD. Research suggests that harsh and inconsistent discipline coupled with parental neglect or rejection increase the risk of CD. Several studies predict a higher risk in children exposed to chronic trauma, such as parents abusing alcohol or drugs, or struggling with depression. If left untreated, those with ADHD and CD face significant risks of substance abuse, dropping out of school, and trouble with the law. Studies of correctional settings show that more than 40 percent of inmates meet the criteria for ADHD and CD.

Impact of Conduct Disorder on Family Life

Children with ADHD and CD are especially difficult to manage, and parents can’t go it alone. Studies show that many parents — frightened, frustrated, and humiliated by their children’s behavior — tolerate this struggle for an average of two years before seeking help.

Conduct Disorder Interventions and Treatment

The first step is a comprehensive assessment that identifies all risk factors. Interventions should be tailored to the individual based on age, symptoms, temperament, and quality of family relationships. The best solution is a multimodal treatment plan — with active interventions addressing multiple levels of functioning simultaneously. In all cases, psychoeducation should precede any treatment approach, so that all family members understand the disorder, current and potential co-occurring issues, and the long-term outcomes.

Unlike treatment for ADHD, the best interventions for CD are not medication-based. The greatest successes come from a combination of behavioral parent training (BPT) and cognitive behavioral skills training (CBST). These are long-term programs that involve working with a therapist consistently. The psychosocial programs should start as early as possible. Both require serious family commitment but have proved to be quite successful.

Behavioral Parent Training (BPT) can improve parent effectiveness in addressing a child’s challenging behaviors. With a therapist, parents learn to set and enforce appropriate limits, reward desired behaviors, provide consequences for non-compliance, and practice stress reduction techniques. This approach includes contingency management training, to help families create explicit expectations and agreed-upon rewards and consequences. BPT has been shown to improve poor conduct, increase positive parenting skills, and improve parents’ mental health. These sessions are best handled with regular attendance of both parents in the therapist’s office, but there are also programs available on the Internet. While not as effective as in-person training, online programs can be useful if both parents can’t be present for in-office training.

CBST addresses the child’s deficits in social information processing. Focusing on curbing impulsivity and angry responses, the structured sessions teach good interactions with peers, complying with authorities, and handling stress. This training works best one-on-one with a therapist who can role-play, give prompts, and provide immediate feedback. Social competence training is particularly useful for reducing aggressive responses in children ages six to 12.

In family sessions, a psychologist or social worker trained to work with disruptive behavior disorders can provide a check-in for what is being learned in the separate treatments, help to reduce the tension level in the home, allow everyone to be heard in a safe environment, and ultimately bring the family closer together.

Stimulants can help. They don’t target CD behaviors, but they are effective for treating co-occurring ADHD symptoms like impulsivity and irritability, which can worsen CD symptoms. Other medications, like atomoxetine and risperidone, have been shown to have some success in improving agitation and mood.

Prevention programs are an important component. There are early interventions designed to stop the escalation of problems that can be associated with conduct disorder.

Parent support groups offer a window into the lives of others who share similar struggles. This safe context can allow parents to learn from others’ experiences, feel less fearful, and be more hopeful about the future of their family.

The Warning Signs of Conduct Disorder

The DSM-5 diagnostic criteria for CD describe a persistent pattern of behaviors that violate the rights of others and/or societal norms. (In contrast, those with impulsive combined type ADHD alone generally do not intentionally violate the rights of others or social norms.) There are 15 behaviors reflecting four categories of behavior: aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violations of rules. A CD diagnosis requires at least three of the 15 behaviors being present in the previous 12 months, and at least one present in the previous six months.

In addition to these core criteria, other characteristics of the disorder are often present. Those with CD tend to have early onset of sexual behavior and substance use. They also tend to perceive others as having hostile intent.

Recent research suggests that CD impairs the ability to correctly read facial expressions, which contributes to misreading others’ intentions. Unable to identify someone’s distress or fear, children with CD may process only emotional intensity. When these children perceive mal-intent in others, they may interpret it as an attack. Those with ADHD and CD often misinterpret facial expressions, while those with ADHD alone generally do not.

Conduct Disorder and ADHD: Next Steps

• Download: Free 2-Week Guide to Ending Defiant Behavior
• Learn the Difference Between ADHD and ODD
• Read “How to Parent a Defiant Child”

Ellen B. Littman, Ph.D., has been involved in the field of attention disorders for over 30 years. She is a pioneer in the identification of gender differences in ADHD. Internationally published, she is the co-author of Understanding Girls with ADHD (#CommissionsEarned)

Sources

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Disruptive Behavior Disorders. CHADD. https://chadd.org/about-adhd/disruptive-behavior-disorders/

Villodas, Miguel T et al. “Prevention of serious conduct problems in youth with attention deficit/hyperactivity disorder.” Expert review of neurotherapeutics vol. 12,10 (2012): 1253-63. doi:10.1586/ern.12.119

Morgan, P. L., Li, H., Cook, M., Farkas, G., Hillemeier, M. M., & Lin, Y.-c. (2016). Which kindergarten children are at greatest risk for attention-deficit/hyperactivity and conduct disorder symptomatology as adolescents? School Psychology Quarterly, 31(1), 58–75. https://doi.org/10.1037/spq0000123

Bowen, E. Conduct Disorder Symptoms in pre-School Children Exposed to Intimate Partner Violence: Gender Differences in Risk and Resilience. Journ Child Adol Trauma 10, 97–107 (2017). https://doi.org/10.1007/s40653-017-0148-x

Groenmann, Annabeth, et al. Childhood Psychiatric Disorders as Risk Factor for Subsequent Substance Abuse: A Meta-Analysis. Journal of the American Academy of Child & Adolescent Psychiatry (2017). https://www.sciencedirect.com/science/article/abs/pii/S089085671730206X

Young, S et al. “Co-morbid psychiatric disorders among incarcerated ADHD populations: a meta-analysis.” Psychological medicine vol. 45,12 (2015): 2499-510. doi:10.1017/S0033291715000598

Lillig, Mathias. Conduct Disorde: Recognition and Management. American Family Physician (2018) https://www.aafp.org/afp/2018/1115/p584.html

Shabnam Javdani, et al. Affect recognition among adolescents in therapeutic schools: relationships with posttraumatic stress disorder and conduct disorder symptoms. Child and Adolescent Mental Health, 2017; 22 (1): 42 DOI: 10.1111/camh.12198

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According to a new national study, children with ADHD struggle more than their neurotypical peers to complete household chores without reminders and/or assistance. Of the 797 primary caregivers surveyed, fewer than one third reported that their children with ADHD often or very often complete chores satisfactorily or independently. Additionally, this study found that more than 90% of parents believe that ADHD impedes their child’s ability to complete chores well.¹

A wealth of research suggests that household routines and chores play an important role in a child’s development and psychosocial adjustment. Some studies have even linked engagement in household routines to lower levels of depression and anxiety,² improved impulsivity control, and greater self-regulatory capacity in children.³ One study called household chores essential to a child developing a “sense of predictability, stability, and feeling of security.”⁴ Additionally, longitudinal studies tell researchers that the benefits of household routines and chores will continue to benefit a child’s life as participation in household chores is strongly predictive of future positive relationships with family and friends, decreased rates of substance use, and professional success during adulthood.⁵

This new study, published in the Journal of Attention Disorders, investigated the relationship between ADHD and household chore performance in a large, diverse national sample of youth. The study included 797 primary caregivers of children with ADHD between the ages 6 and 18. All participants’ children lived with them during the school year, and all participants lived in the United States. The study excluded children with comorbid autism spectrum disorder, intellectual disability, or another serious condition that would significantly compromise their ability to complete chores, such as cerebral palsy or arthrogryposis. Participants of this study comprised only of primary caregivers of children with ADHD: Thus, there is no non-ADHD control group available for comparison.¹

The CDC-supported public information center, the National Resource Center for ADHD, and CHADD, a national nonprofit organization, recruited participants for this study through inquiries posted on Facebook and emailed via newsletters.

Caregivers took a 72-question survey developed in Qualtrics. The voluntary, anonymous online questionnaire collected demographic and clinical data as well as subjective parent assessments. Questions asked about the degree to which children with ADHD could competently or independently complete chores, the impact of ADHD on their ability to complete chores, and whether caregivers believe their children require more reminders to complete chores than do neurotypical children.

Researchers divided chores into two subtypes: Self-care chores (SC) and family-care chores (FC). Researchers asked parents about SC chores using two examples: making one’s bed and cleaning one’s bedroom. Additionally, the survey included six FC chores: setting or clearing the table, taking out the garbage, washing or drying dishes, housecleaning, laundry, and assisting with family meals or snack preparations. On top of asking about specific examples of chores, researchers offered study participants the chance to rate their child’s performance overall on each chore subtype.

Then, researchers utilized widely approved scientific analysis tools such as spearman correlation, chi-square test, and weighted kappa analysis.

In addition to inadequate chore completion, researchers found that parents of children with ADHD overwhelmingly believe their child’s symptoms detract from chore performance. Further, the majority of parents report that they believe their children need more reminders than do their neurotypical peers to complete SC and FC chores — 86.5% and 84.3%, respectively.¹ These reminders can put a great strain on parents, as another study links greater parental involvement with chores with higher rates of parenting stress.⁶

Interestingly, this study found that when parents expected a child to complete a chore more frequently, children with ADHD were more likely to meet or exceed chore performance expectations.¹ More research is needed to understand this correlation.

The large sample size allowed researchers to analyze the impact of ADHD subtype impact and comorbid Oppositional Defiant Disorder (ODD) on chore completion as well. It also examined parental expectations of chore frequency and beliefs regarding the impact on chore performance by ADHD subtype and presence of comorbid ODD.

To separately assess ODD as a variable, researchers conducted separate analyses to compare children with and without comorbid ODD. Since ODD is more commonly diagnosed in boys than in girls, researchers limited their analyses to boys between the ages of 8 and 13 years who had ADHD, combined type (CT). In all, there were 265 boys who met selection criteria: 67 boys with comorbid ODD and 198 boys without comorbid ODD.

Children with various subtypes differed in neither their ability to meet or exceed parental chore expectations nor in the number of reminders they needed to complete a chore. Likewise, there were no discrepancies between boys with comorbid ODD and boys without an ODD comorbidity in regard to chore performance.¹

This finding surprised researchers, as ODD is primarily associated with oppositional behavior. Previous studies have shown that boys with higher scores on an ODD factor assessment, based on the DSM-4 criteria for ODD, had greater difficulties completing homework. Researchers expected difficulty with homework performance to go hand in hand with increased difficulty in chore performance for boys with comorbid ODD. More research must be conducted to determine the true nature of this comorbidity’s relation to chore performance.

This study examines the largest and most diverse sample to date compared to other studies investigating the same topic, but the sample group was still not representative of the general population. Surveyed caregivers were disproportionately older parents (27% of parents were over 50 years old), held more higher education degrees (39% had a graduate degree), and identified as white (88% of surveyed parents identified as white).¹ Researchers hope that future studies will utilize more diverse sample groups, as well as including a baseline group of caregivers of children without ADHD for comparison.

Since many studies confirm that participation in household routines has significant implications on a child’s short-term and long-term wellbeing, the results of this study should not be taken lightly. In fact, children with ADHD may have the most to gain from participation in household chores; according to the authors of the study, “To the extent that children and adolescents with ADHD have greater issues with impulsivity and self-regulation, they likely stand to gain the most from increased engagement with household tasks.”¹ More research will help clinicians illuminate the link between ADHD and chore performance.

Sources:

¹Spaulding, S. L., Fruitman, K., Rapoport, E., Soled, D., & Adesman, A. (2020). Impact of ADHD on Household Chores. Journal of Attention Disorders. https://doi.org/10.1177/1087054720903359
²Pennick, M. R. (2013). Understanding the relation between routines and problem behaviors in children with clinical diagnoses [Doctoral dissertation]. https://search.proquest.com/openview/0a045bfacfd5dc4b116dd68813a2e0ff/1?pq-origsite=gscholar&cbl=18750&diss=y
³Bater, L. R., Jordan, S. S. (2017). Child routines and self-regulation serially mediate parenting practices and externalizing problems in preschool children. Child Youth Care Forum, 46(2), 243–259. https://doi.org/10.1007/s10566-016-9377-7
⁴Sytsma, S. E., Kelley, M. L., Wymer, J. H. (2001). Development and initial validation of the child routines inventory. Journal of Psychopathology and Behavioral Assessment, 23(4), 241–251.
⁵Rossmann, M. (2002). Involving children in household tasks: Is it worth the effort? https://ghk.h-cdn.co/assets/cm/15/12/55071e0298a05_-_Involving-children-in-household-tasks-U-of-M.pdf
⁶Dunn, L., Coster, W. J., Cohn, E. S., Orsmond, G. I. (2009). Factors associated with participation of children with and without ADHD in household tasks. Physical & Occupational Therapy in Pediatrics, 29(3), 274–294. https://doi.org/10.1080/01942630903008327

Emotional dysregulation is a core, and often overlooked, symptom of attention deficit disorder (ADHD or ADD). It is commonly comorbid with mood disorders including oppositional defiant disorder, anxiety, and depression. Yet no physical link between ADHD and emotional instability disorders was documented — until last month.

A recent study¹, conducted by the Swedish Karolinska Institutet and published in Molecular Psychiatry, finds biological similarities between ADHD and conduct disorder traits. The study’s researchers examined magnetic resonance imaging (MRI) scans of 1,093 adolescents. They found similar changes in the brains of youth with ADHD and those with conduct disorder traits. Both conditions manifested as reduced brain volume, and smaller surface area of the frontal lobe and nearby regions.

These findings suggest that the two conditions are related, and should be considered in tandem when diagnosing symptoms. Researchers hope their findings will lead to better understanding and treatment of patients with emotional symptoms and instability.

This study was part of the IMAGEN project, a European research mission dedicated to understanding biological, psychological, and environmental influences on adolescent brain development and mental health.

¹Frida Bayard, Charlotte Nymberg Thunell, et al. “Distinct brain structure and behavior related to ADHD and conduct disorder traits.” Molecular Psychiatry, 14 August 2018. doi: 10.1038/s41380-018-0202-6