ADHD And ODD: What It Means When They Occur Together

Reviewed by Heather Cashell, LCSW

Published 01/07/2021

Attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) are regarded as disruptive behavior disorders. Although 50 percent of children with ADHD also fit the criteria for diagnosing ODD, the two disorders are distinct, with different causes and treatment methods, but they can occur together.

The Nature Of ADHD And ODD

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ADHD is usually considered a neurobiologically-mediated issue, while ODD seems to have a significant association with environmental risk factors and psychosocial stressors. Therefore, during assessment for possible ODD in a patient with disruptive behavior, it is necessary to check carefully for psychosocial factors responsible for the oppositional behavior.

The treatment of ADHD may require  medication or behavioral therapy. The two major types of evidence-based treatments for those with ODD are individual therapy targeted at problem-solving and social skills and parent management training. The latter is crucial particularly, and providing required external behavioral regulation at home is immensely beneficial for treating ADHD and ODD.

A good percentage of children with attention deficit hyperactivity disorder first get a diagnosis and eventual treatment from their primary care physician. These doctors can manage children with ADHD who exhibit signs of inattention successfully in most cases. However, ADHD is sometimes accompanied by symptoms like aggression, defiance, and hostility. In fact, Disruptive behavior is the most prevalent mental health disorder seen by primary care doctors, and proper diagnosis and treatment of these behavioral disorders is often a problem. This article focuses on the co-occurrence of ADHD and ODD in patients and the proper diagnosis and treatment approach.

When ADHD And ODD Co-Occur

ODD is associated with children's behavior and their interactions with other people, including friends, family, and teachers. ADHD is a neurodevelopmental condition. As mentioned earlier, the conditions are different, but they can co-occur. Certain apparently defiant symptoms may be associated with impulsivity in ADHD. It is thought that up to 40 percent of children diagnosed with ADHD also have ODD. Although, like ADHD, not every patient with an ODD diagnosis has ADHD.

For instance, a child with ADHD only may be bustling with energy or be extremely thrilled during playtime with classmates. This may likely cause roughhousing and indeliberate harm to others. Children with ADHD may also have a bad temper and throw tantrums. However, this is not the usual indication of the disorder. Instead, the tantrum can be triggered by frustration or boredom. If the same patient has ODD, they will have a problem controlling their impulses and have a terrible temper that can escalate to physical aggression.

These children may throw tantrums because they are unable to regulate their emotions, including anger. They may be vindictive, annoy others deliberately and blame other people for their errors. They may hurt others out of over-excitement due to ADHD, but children who have ODD will also exhibit lack of remorse and vindictiveness.

It is necessary to understand that signs of ODD and ADHD can also be present with learning disabilities and other behavioral disorders. Healthcare providers should be cautious and gain a full understanding of the symptoms before making a diagnosis. Behavioral disorders also include actions like stealing, lying, damaging properties, aggressive behavior to people and animals and gross violation of rules like missing classes or running off from home. Also, approximately one out of three children with ADHD show indications of anxiety and depression.

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The question of  why ADHD and ODD are often diagnosed together is an interesting one.  Experts think it may be because the two conditions share genetic factors. There are also risk factors of ODD associated with the immediate environment or home and psychological factors.

When someone has the oppositional irritability and defiance linked to ODD, it often translates to a flammable combination with the inattention, hyperactivity and impulsivity. Simply put, they build on each other. Also, each condition implicates the treatment process of the other. When ADHD occurs with ODD, what often occurs is more of the treatment-resistant attribute of ADHD. It is likely to lower the effectiveness of conventional ADHD treatments in kids when it co-occurs with ODD. You could think of it as a cough. If someone has a cough but also developed fever due to an infection, for instance, it will make treating the cough more difficult – so the patient is no longer treating one condition.

Understanding Disruptive Disorders

The types of disorders that are categorized presently by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, under disruptive behavior disorders include ADHD (including all the three subtypes; inattentive, hyperactive-impulsive and mixed), oppositional defiant disorder (ODD), conduct disorder (CD) and disruptive behavior disorder not mentioned. These diagnoses have the same primary elements of poor self-regulation and related interpersonal difficulties. While the diagnosis may have similar "externalizing" symptoms, there are disparities in how they are perceived. Externalizing symptoms are negative behaviors that a patient exhibits as a way to manage internal distress, like flight or running off.)

Although there has been an increase in the data available for neurobiological dysfunction in people with ADHD, the association established between monoamine neurotransmitter systems and dysfunction in the prefrontal cortex, there is limited data showing a defined role for neurobiological dysfunction in ODD. Some studies mention details related to serotonergic dysfunction and impulsivity and aggression, while others mark the presence of an abnormality in the autonomic nervous system as proof of catecholamine dysfunction. Nevertheless, there is less understanding of ODD from a biological perspective and seems to show a stronger association to psychosocial stressors and environmental risk factors.

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Despite the differences in etiology, ADHD usually goes beyond the primary indicators of attention deficits, impulsivity and hyperactivity. Healthcare professionals regularly attend to children whose parents are bothered by their child's tantrums, defiance and low tolerance to frustration. These conducts are usually best attributed to the child's biological vulnerabilities, which may be worsened by problematic family and parental reactions. Knowing the relationship between the connection between oppositional and inattentive behaviors has a significant impact on treatment decisions.

The Co-Occurrence Of ODD And ADHD Is Likely Bidirectional

The overlap of symptoms makes it hard to distinguish the two disorders distinctly and brings up some questions for the healthcare provider. Where does one condition start and the other end? Is there a chance that ODD is a result of severe ADHD? Is there a similar identifier for the evolution of disruptive behavior diagnosis? Can ODD symptoms improve by only treating ADHD in a patient?

For primary care physicians, the essence of detecting co occurring disorders such as ADHD and ODD deals with the likelihood of prompt intervention, which has a higher possibility of having an impact, than the treatment of a more persistent pathology, which may occur without quick or timely intervention.

For ODD And ADHD Diagnosis

The precise cause of ADHD and ODD is unknown. According to scientists, both genetics and environmental factors play a part. For instance, someone may have both conditions if there is a history of both conditions in the family. Symptoms may be different but may include behavioral patterns that can lead to self-harm. Such patients may also handle regular social interactions with aggression. Regarding environmental factors, exposure to lead can increase the risk of ADHD. A child may also likely develop ODD if there is a history of abuse, harsh discipline, or neglect at home.

To diagnose ODD, patients must show indications of antagonism and hostility, struggle with normal daily function, and have symptoms or traits that go beyond that would be normal for a developmentally matched peer. The symptoms need to have been present for over six months.

The symptoms should also not be caused by another mental illness (for instance, a separation anxiety disorder in a child that tries to avoid school or psychotic disorder in a paranoid child that shuns food. Opposition and defiance should also not be a symptom of a biologically mediated condition (e.g., autism, schizophrenia).

Looking at how children adopt self-regulation during normal development can help one get a good overview of how disruptive behavior works. Toddlers, while trying to develop a level of independence, exhibit poor self-developmental phase. This is an acceptable development phase that aids in forming new skills for self-soothing and handling lousy mood disorders. Physicians do not consider the diagnosis of ODD for a child in the developmental stage. However, if, after growing older, the child is unable to learn new skills and keeps up having tantrums and external indications of emotional instability, hostility, and defiance, in that case, it is okay for the family to reach out for support from their primary care provider.

The Treatment For These Conditions

When ADHD and ODD is present at the same time, the best approach to treatment is a multimodal one. This means utilizing multiple approaches, such as behavioral therapy or medication. Have a balanced approach. Treatments involve using medication to decrease hyperactivity and inattention and behavioral therapy to correct disruptive behavior.

Stimulants used for ADHD treatment help by creating a balance for brain chemicals. The drugs act quickly, but it may take some time to get the patient's correct dosage. Some stimulants have been blamed for heat-related mortality in children who have heart conditions. The doctor may recommend an electrocardiogram before prescribing meds. The tests determine the level of electrical activity in the child's heart and check for heart conditions.

Some antidepressants, anti-hypertensive medication, and cognitive-enhancing medication can also be effective in treating ADHD. Family therapy, social skills training, and behavioral therapy may also be beneficial for some patients. Medications are not often recommended for ODD treatment unless some symptoms are present to treat. There are currently no FDA-approved medications to treat ODD. Treatment generally entails family and individual therapy. Family therapy can improve communication and interactions between parents and children.

The patient may also undergo cognitive problem-solving training. The lessons assist them in correcting the negative thought patterns responsible for behavior issues. Some patients can also undergo social skills training to learn the correct way to interact with colleagues and peers.

Get Necessary Help

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Getting a diagnosis of both ADHD and ODD can create issues at home, work or school. It can cause strained relationships with their siblings, parents and colleagues. In children, poor school performance can occur if the child is unable to focus or remain still and arguing with the teachers. Without treatment, the two conditions can cause depression or low self-esteem. This may increase the risk factors for substance use, self harm or suicidal ideation.

Patients who have signs of ADHD, ODD, or both need to talk to their doctor. The doctor may provide referrals to a mental health professional. The psychologist or psychiatrist can diagnose and develop a treatment plan, depending on the severity of the child's condition.

The Bottom Line

Early intervention and  treatment is vital when symptoms of ADHD and ODD are present. Treatment might require combining psychotherapy and medication to alleviate the symptoms and remove negative patterns. Even if therapy is effective, patients need ongoing treatment to manage the problem. If you would like to get help, start by completing an assessment test.