Disruptive behavior disorders are among the easiest to identify of all coexisting conditions because they involve behaviors that are readily seen such as temper tantrums, physical aggression such as attacking other children, excessive argumentativeness, stealing, and other forms of defiance or resistance to authority. These disorders, which include ODD and CD, often first attract notice when they interfere with school performance or family and peer relationships, and frequently intensify over time.
Behaviors typical of disruptive behavior disorders can closely resemble ADHD—particularly where impulsivity and hyperactivity are involved—but ADHD, ODD, and CD are considered separate conditions that can occur independently. About one third of all children with ADHD have coexisting ODD, and up to one quarter have coexisting CD. Children with both conditions tend to have more difficult lives than those with ADHD alone because their defiant behavior leads to so many conflicts with adults and others with whom they interact. Early identification and treatment may, however, increase the chances that your child can learn to control these behaviors.
Oppositional Defiant Disorder
Many children with ADHD display oppositional behaviors at times. Oppositional defiant disorder is defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as including persistent symptoms of “negativistic, defiant, disobedient, and hostile behaviors toward authority figures.” A child with ODD may argue frequently with adults; lose his temper easily; refuse to follow rules; blame others for his own mistakes; deliberately annoy others; and otherwise behave in angry, resentful, and vindictive ways. He is likely to encounter frequent social conflicts and disciplinary situations at school. In many cases, particularly without early diagnosis and treatment, these symptoms worsen over time—sometimes becoming severe enough to eventually lead to a diagnosis of conduct disorder.
Conduct disorder is a more extreme condition than ODD. Defined in the DSM-IV as “a repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate social rules are violated,” CD may involve serious aggression toward people or the hurting of animals, deliberate destruction of property (vandalism), stealing, running away from home, skipping school, or otherwise trying to break some of the major rules of society without getting caught. Many children with CD were or could have been diagnosed with ODD at an earlier age—particularly those who were physically aggressive when they were younger. As the CD symptoms become evident, these children usually retain their ODD symptoms (argumentativeness, resistance, etc) as well. This cluster of behaviors, combined with the impulsiveness and hyperactivity of ADHD, sometimes causes these children to be viewed as delinquents, and they are likely to be suspended from school and have more police contact than children with ADHD alone or ADHD with ODD.
Children with ADHD whose CD symptoms started at an early age also tend to fare more poorly in adulthood than those with ADHD alone or ADHD with ODD—particularly in the areas of delinquency, illegal behavior, and substance abuse.
ODD and CD: What to Look For
A child with ADHD and a coexisting disruptive behavior disorder is likely to be similar to children with ADHD alone in terms of intelligence, medical history, and neurological development. He is probably no more impulsive than children with ADHD alone, although if he has conduct disorder, his teachers or other adults may misinterpret his aggressive behavior as ADHD-type impulsiveness. (Attention-deficit/hyperactivity disorder behavior without CD, however, does not typically involve this level of aggression.) A child with ADHD and CD does have a greater chance of experiencing learning disabilities such as reading disorders and verbal impairment. But what distinguishes children with ODD and CD most from children with ADHD alone is their defiant, resistant, even (in the case of CD) aggressive, cruel, or delinquent, behavior. Other indicators to look for include
- Relatives with ADHD/ODD, ADHD/CD, depressive disorder or anxiety disorder. A child with family members with ADHD/ODD or ADHD/CD should be watched for ADHD/CD as well. Chances of developing CD are also greater if family members have experienced depressive, anxiety, or learning disorders.
- Stress or conflict in the family. Divorce, separation, substance abuse, parental criminal activity, or serious conflicts within the family are quite common among children with ADHD and coexisting ODD or CD.
- Poor or no positive response to the behavior therapy techniques at home and at school. If your child defies your instructions, violates time-out procedures, and otherwise refuses to cooperate with your use of appropriate behavior therapy techniques, and his aggressive behavior continues unabated, he should be evaluated for coexisting ODD or CD.
Children with ADHD and disruptive behavior disorders often benefit from special behavioral techniques that can be implemented at home and at school. These approaches typically include methods for training your child to become more aware of his own anger cues, use these cues as signals to initiate various coping strategies (“Take five deep breaths and think about the three best choices for how to respond before lashing out at a teacher.”), and provide himself with positive reinforcement (telling himself, “Good job, you caught the signal and used your strategies!”) for successful self-control. You and your child’s teachers, meanwhile, can learn to better manage ODD or CD-type behavior through negotiating, compromising, problem-solving with your child, anticipating and avoiding potentially explosive situations, and prioritizing goals so that less important problems are ignored until more pressing issues have been successfully addressed. These highly specific techniques can be taught by professional behavior therapists or other mental health professionals recommended by your child’s pediatrician or school psychologist, or other professionals involved with your family.
If your child has a diagnosis of coexisting ODD or CD, and well-planned classroom behavioral techniques in his mainstream classroom have been ineffective, this may lead to a decision to place him in a special classroom at school that is set up for more intensive behavior management. However, schools are mandated to educate your child in a mainstream classroom if possible, and to regularly review your child’s education plan and reassess the appropriateness of his placement.
There is growing evidence that the same stimulant medications that improve the core ADHD symptoms may also help coexisting ODD and CD. Stimulants have been shown to help decrease verbal and physical aggression, negative peer interactions, stealing, and vandalism. Although stimulant medications do not teach children new skills, such as helping them identify and respond appropriately to others’ social signals, they may decrease the aggression that stands in the way of forming relationships with others their age. For this reason, stimulants are usually the first choice in a medication treatment approach for children with ADHD and a coexisting disruptive behavior disorder.
The earlier stimulants are introduced to treat coexisting ODD or CD, the better. A child with a disruptive behavior disorder whose aggressive behavior continues untreated may start to identify with others who experience discipline problems. By adolescence, he may resist treatment that could help him change his behavior and make him less popular among these friends. He will have grown accustomed to his defiant “self” and feel uncomfortable and “unreal” when stimulants help check his reckless, authority-flaunting style. By treating these behaviors in elementary school or even earlier, you may have a better chance of preventing your child from creating a negative self-identity.
If your child has been treated with 2 or more types of stimulants and his aggressive symptoms are the same or worse, his pediatrician may choose to reevaluate the situation and replace the stimulant with other medications. If stimulant medication alone led to some but not enough improvement, his pediatrician may continue to prescribe stimulants in combination with one of these other agents.