ADHD & ODD: Confronting the Challenges of Disruptive Behavior

ABSTRACT: Disruptive behavior is the most common mental health problem seen by pediatricians. Although attention-deficit/ hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) are both considered disruptive behavior disorders—and although about half of children with ADHD also meet the diagnostic criteria for ODD—the 2 disorders are distinct, having different etiologies and responding to different types of treatment. ADHD is generally viewed as a neurobiologically mediated problem, while ODD appears to have a stronger link to environmental risk factors and psycho-social stressors. Thus, when assessing for possible ODD in a child with disruptive behavior it is important to carefully investigate any psychosocial factors that may underlie the oppositional behavior. Treatment of ADHD clearly involves medication therapy. The 2 principal types of evidence-based treatments for children with ODD are individual therapy with a focus on problem-solving and social skills and parent management training. The latter is especially important; moreover, the provision of needed external regulation of behavior in the home has substantial benefits in the treatment of both ADHD and ODD.

A significant portion of children with attention-deficit/hyperactivity disorder (ADHD) first receive the diagnosis and subsequent treatment from their primary care pediatrician. Children with ADHD who present primarily with symptoms of inattention are often managed successfully by primary care clinicians. However, ADHD is often accompanied by symptoms such as hostility, defiance, and aggression. In fact, disruptive behaviors are the most common mental health problem seen by pediatricians,¹ and properly diagnosing and treating these problem behaviors is often a challenge.

In this article I address the diagnostic challenges posed by oppositional behavior in children with ADHD. I discuss approaches to evaluation and treatment that have proved particularly successful in these patients, and I provide tips on when referral may be warranted.

THE NATURE OF THE DISRUPTIVE DISORDERS
Disruptive behavior in children is not just a contemporary concern, as evidenced in this comment by Socrates: "Our youth now love luxury. They have bad manners and contempt for authority and disrespect for their elders. Children nowadays are tyrants."² The group of disorders that are currently classified by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, as disruptive behavior disorders include ADHD (all 3 of its subtypes—inattentive, hyperactive-impulsive, and combined), oppositional defiant disorder (ODD), conduct disorder (CD; both of childhood and adolescent onset), and disruptive behavior disorder not otherwise specified.³ These diagnoses share primary features of poor self-regulation and associated interpersonal difficulties. Although the diagnoses share "externalizing" symptoms, there are differences in how they are conceptualized. (Externalizing symptoms are negative behaviors that a patient displays as a means of managing internal distress; examples are fighting or running away.)

ADHD is generally viewed as a neurobiologically mediated problem that requires pharmacological treatment as a primary evidence-based intervention.⁴ ADHD is diagnosed in 3% to 7% of school-aged children3 and when untreated can be associated with significant morbidity (delinquency, drug use, poor academic success, increase in injuries). A number of diagnoses commonly occur comorbidly with ADHD: ODD, anxiety disorders, depressive disorders, learning disorders, and substance use disorders.

While the data for the neurobiological dysfunction in persons with ADHD have mounted, with links to the monoamine neurotransmitter systems and dysfunction in the prefrontal cortex now well established, there is a dearth of data demonstrating a clear role for neurobiological dysfunction in ODD and CD. Some studies cite information on the relationship between serotonergic dysfunction and impulsivity and aggression, while others point to the existence of an abnormality of arousal in the autonomic nervous system as evidence of catecholamine dysfunction. Nonetheless, ODD and CD remain less well understood from a biological standpoint and appear to have a stronger link to environmental risk factors and psychosocial stressors.

Despite these etiological differences, ADHD often involves more than its core features of attention deficits, impulsivity, and hyperactivity. Clinicians routinely see children whose parents are challenged by their child's tantrum behaviors, poor frustration tolerance, and defiance.³ These behaviors are often best understood as resulting from biological vulnerabilities of the child that may be exacerbated by problematic family/parental responses. Understanding the relationship between oppositional and inattentive behaviors has critical importance for management decisions.

Although CD has been more systematically studied, the focus in this article will not be on children with this more serious disorder, who, by definition, intrude on the basic rights of others, break laws, and commit crimes. Instead, I have chosen to focus on ODD in order to help primary care clinicians better understand and intervene with children before severe conduct problems develop.