Industry leaders in improving attention. |
|
For more information call (800) 788 - 6786 or request
a |
What is Oppositional Defiant Disorder
I've received several questions after last month's issue concerning the article on how parents of children with ADHD interpret their child's behavior. Recall that the article described a study in which parents were found to hold children with ADHD less responsible for core ADHD behaviors (i.e. inattentiveness and overactivity) than parents of children without ADHD. In addition, parents of children with ADHD also believed their child had less control over behaviors that were more deliberately oppositional and perhaps reflective of Oppositional Defiant Disorder ODD).
The authors of this study speculated that believing that ADHD children were not able to exercise control over these latter behaviors might make parents less likely take appropriate steps to correct these behaviors. Conceivably, this could contribute to these behaviors becoming more prominent.
Several subscribers sent messages describing how their child seemed to be much more oppositional when not on Ritalin, and that the medication helped both primary ADHD symptoms AND behaviors that appeared more oppositional in nature. They wondered whether this meant that their child also had ODD in addition to ADHD. I thus thought I tried to address this important question more completely in this issue of the newsletter.
Listed below are DSM-IV symptoms for ODD:
- often loses temper;
- often argues with adults;
- often actively defies or refuses to comply with adult requests or rules;
- often deliberately annoys people;
- often blames others for mistakes or misbehavior;
- is often touchy or easily annoyed by others;
- is often angry and resentful;
- is often spiteful and vindictive;
For ODD to be an appropriate diagnosis, at least 4 of the symptoms listed above must be present for at least 6 months; the behavior must occur more frequently than is typical for a child of comparable age, and the behavior must create significant impairment in a child's social or academic functioning. In addition, the oppositional behavior can not occur only during times when a child is depressed.
An important difference that you will note from the symptoms of ADHD is that none of the ADHD symptoms involve behavior that is considered to be deliberate and willful. Thus, although children with ADHD often engage in behavior that annoy others and fail to follow through on requests, such behavior is not deliberately and willfully initiated.
So, what does it mean if a child with ADHD is much less oppositional when on their medication? First, as far as diagnosis goes, it should be emphasized that the diagnosis of ODD is made based on whether the symptomatic criteria described above are met, and not whether medication is effective in eliminating or substantially reducing the difficulties. This is of course true for ADHD as well - the diagnosis is made if the criteria are met and not whether a child has a good response to medication.
When ODD symptoms are significantly reduced by stimulant medication, it is probably because for that child, it is his or her impulsivity and overactivity that precipitates much of their oppositional behavior. For example, a child may lash out verbally in response to a parent's demand because their impulsivity makes it difficult for them to stop and think about what they are about to say. Or, running around in the store may precipitate a conflict with a parent that turns into a major argument. When medication helps the child to control such behaviors - to be less impulsive and hyperactive - the kinds of interactions with parents that can deteriorate into major oppositional power struggles are just less likely to get started. This is probably the most plausible explanation for why ODD symptoms may be reduced by stimulant medication. For these children, it is probably unlikely that they would meet full diagnostic criteria for ODD to begin with.
Other children, however, may be severely oppositional and defiant for reasons that have very little to do with impulsivity. Their oppositional behavior is more deliberate and premeditated. They may or may not also have ADHD, but even if they do, their oppositional behavior is still quite prominent when they are on medication, EVEN if the medication helps with the primary ADHD symptoms.
Such children can certainly not be treated effectively by medication alone. Behavioral interventions, and in some cases, individual or family therapy may be necessary to more fully address the difficulties of such children. Several excellent books have been written for parents on behavioral interventions for oppositional behavior. You may want to look at "1-2-3 Magic - Training Your Child to Do What You Want" by Dr. Thomas Phelan or "Behavior Management at Home - a Token Economy Program for Children" by Dr. Harvey Parker.
These kinds of difficulties are critically important to bring under control as soon as possible, because such behavior becomes more entrenched and difficult to change the longer it persists. In addition, children with ODD are at significant risk for the development of the more severe kinds of behavioral disturbance that is characteristic of Conduct Disorder, and the long term outcomes for children with Conduct Disorder are especially worrisome.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.