Anne dreads waking up in the morning. Her son, Sam, who is nine, is unpredictable. Sometimes he just goes along with the morning routine. Other times, he'll lash out at the smallest thing — a request to get dressed, an unplanned stop on the way to school, or a simple "No" to a request for pizza for dinner.
"On any given day, I never know what to expect from him," says Anne, a public relations manager for an independent high school in New Hampshire. "He'll start yelling and kicking when anything doesn’t go his way."
Sam was diagnosed with ADHD at five, and while that explained some of his difficulties in school, it never explained his aggressive and defiant temperament. It wasn't until the beginning of this school year that Anne sought additional help for her son's behavior, which was becoming stressful to her family. The pediatrician determined that Sam was suffering from oppositional defiant disorder (ODD).
Recognize ODD in Your Child
Children with ODD have a pattern of angry, violent, and disruptive behaviors toward parents, caretakers, and other authority figures. Before puberty, ODD is more common in boys, but, after puberty, it is equally common in both genders. Sam is not alone in his dual diagnosis of ADHD and ODD; up to 40 percent of children with ADHD are estimated to have ODD.
Every child will act out and test his boundaries from time to time, and ODD seems like typical adolescent behavior: arguing, anger, and aggression. The first step to fixing a child's problematic behavior is recognizing ODD. How do you know whether your child is just being a child or if he needs professional help?
There is no clear line between "normal defiance" and ODD, says Ross Greene, Ph.D., associate clinical professor of psychiatry at Harvard Medical School and author of The Explosive Child. The lack of clear criteria explains why professionals often disagree as to whether a child should be diagnosed with ODD.
Greene emphasizes that it is up to parents to decide when to get help for a defiant child. "If you're struggling with your child's behavior, and it is causing unpleasant interactions at home or at school, then you've easily met the criteria for having a problem," says Greene. "And I'd suggest you seek professional help."
Anne had never heard of ODD when she called a cognitive behavioral therapist to discuss coping strategies for her son's erratic behavior. After spending some time in the family's home, observing Sam and his interactions with his mother, the therapist saw signs of ODD. "I didn't know what she was talking about," says Anne. At Sam's next doctor's visit, Anne asked whether ODD could explain Sam's behavior, and the physician said yes.
"When I thought about it, the diagnosis made sense," says Anne. "Nothing I used with my older daughter — like counting down to some set consequence before punishing her — to control her behavior ever worked for Sam."
Another mother, Jane Gazdag, an accountant from New York, began noticing troubling behavior in her son, Seamus Brady, now eight, when he was four. "He would scream for two or three hours over the smallest thing," says Jane. "He fought everything."
When Jane realized that she had stopped trying to do fun things with her son, like spending the day in Manhattan, because they were too stressful for her, she suspected that he had ODD and spoke to her pediatrician about it. Seamus was diagnosed as having it.
Signs of ODD can be seen in a child's behavior toward his primary caregiver. The defiant behavior may spread to a secondary caregiver and to teachers or other authority figures, but if it appears in a child with ADHD, ODD will appear within two years of an ADHD diagnosis.
If a child does start to become defiant, there is an easy way to tell whether that behavior is a consequence of ADHD or is a sign of ODD. "ADHD isn't a problem with starting a task, it's a problem with finishing a task," says Russell Barkley, Ph.D., a clinical professor of psychiatry and pediatrics at the Medical University of South Carolina. "If a child can’t start a task, that's ODD."
The Impulsive/ Defiant Link
Understanding why ODD is found so frequently in children with ADHD is to understand the two dimensions of the disorder — the emotional and social components, says Barkley. Frustration, impatience, and anger are part of the emotional component. Arguing and outright defiance are part of the social aspect.
Most children with ADHD are impulsive, and this drives the emotional component of ODD. "For people with ADHD, emotions are expressed quickly, whereas others are able to contain their feelings," says Barkley. This is why the small subset of children who have the inattentive type of ADHD is less likely to develop ODD. Children who have ADHD, along with intense impulsivity, are likely to be diagnosed with ODD.
Anger and frustration are hard to manage in a child with ODD and ADHD, but it is defiance that exacerbates the family stress caused by ODD. The surprising thing is that parents fuel the defiance. If a parent is quick to give in when a child has a tantrum, the child learns that she can manipulate situations by getting angry and putting up a fight. This aspect of ODD is a learned behavior, but it can be unlearned through behavioral therapy.
ADHD First, Then ODD
Before tackling a child's ODD, it is important that his ADHD be controlled. "When we reduce a child’s hyperactivity, impulsiveness, and inattention, perhaps through medication, we see simultaneous improvement in oppositional behavior," says Greene.
The traditional stimulant medications are the initial drugs of choice because they have been shown to decrease the impairments of ADHD, as well as ODD, by up to 50 percent in more than 25 published studies, says William Dodson, M.D., who specializes in the treatment of ADHD, in Greenwood, Colorado. Non-stimulant medications may also help. In one study, researchers found that the drug atomoxetine, the generic form of the active ingredient found in Strattera, significantly reduces ODD and ADHD symptoms. The researchers note in the study, published in the Journal of the American Academy of Child and Adolescent Psychiatry, in March 2005, that higher doses of the medication were needed to control symptoms in children who were diagnosed with both conditions.
Strattera helped Seamus control his emotions, reducing the number and intensity of his tantrums. "It made a big difference," says Jane. For some, medication is not enough, and after a child's ADHD symptoms are under control, it's time to address ODD behaviors.
Although there is little evidence to show that any treatment is effective in treating ODD, most professionals agree that behavioral therapy has the most potential to help. There are many forms of behavioral therapy, but the general approach is to reward good behavior and provide consistent consequences for inappropriate actions and behaviors.
Behavioral therapy programs don't start with the child; they start with the adult. Because a child with ODD usually has a caretaker who gives in to tantrums and violent behavior, or offers inconsistent punishment for bad behavior, the child thinks that acting out will get him what he wants. Therefore, a child's primary caretaker has to be educated to effectively respond to a child with ODD. Another part of parental training is to consider whether ADHD has gone undiagnosed in the parent; adults with the condition are likely to be inconsistent in managing a child’s behavior.
Implementing consistent punishment is only one part of a behavioral therapy program; a parent must learn to use positive reinforcement when a child behaves himself.
Stick with It
A behavioral therapist works with parent and child together to reduce troubling behaviors. At the top of Anne's list was her son's "Shut up," which he shouted at anyone. Anne kept a tally sheet to list the number of times her son would shout it in a day. At the end of the day, Anne and her son looked at the total together. If the number was under the set goal for the day, she gave him a small reward, a toy or time spent playing video games. Day by day, Sam tried to reduce the number of times he said "shut up," and Anne tried to be consistent in her punishments.
All of a child's caregivers should participate in the program. Grandparents, teachers, nannies, and other adults who spend time alone with your child must understand that the need for consistency in behavioral therapy extends to them as well.
"ODD has a deleterious effect on relationships and communication between kids and adults," says Greene. "You want to start improving things as soon as you can."
Anne believes that her diligence will pay off. "We hope that all the work we've done will one day click for Sam," she says.
To exchange tips with other parents on managing anger in ADHD kids, visit the Parents of ADHD Children support group on ADDConnect.