How to handle both ADHD and ODD
- Sara L
- Mar 31, 2024
- 7 min read
A question that I have seen coming regularly is when children have both a diagnosis of ADHD and ODD, and how to effectively manage the aggression that comes with it.
If we have 100 people who have ADHD, anywhere between 35-65 of them will have ODD as well. Making matters worse is that the presence of the ODD makes the ADHD symptoms worse than if they just had ADHD alone¹. This can be very stressful for families who have to manage children with both diagnoses at once.
As ODD and ADHD occur together making it tricky to tease them apart. One way to tell whether it is ODD, as opposed to just a period of bad behavior, is to figure out whether their failure to listen and to do what they are being told is not actually thanks to their ADHD (making it hard for them to pay attention and/or sit still), or due to kids being kids and pushing boundaries (which is developmentally appropriate), but actually due to being defiant/argumentative from the ODD itself.
A little background on ODD
ODD is a pattern of angry/irritable mood/ defiant behavior, or vindictiveness lasting at least 6 months. Less than that and it is not classified as ODD.
If they are younger than 5 the behavior must occur on most days for at least 6 months.
If they are 5 and older, the behavior must occur at least once per week for at least 6 months.
They must have 4 of the following often:
Their behavior causes distress in those around them and negatively impacts their social and educational life. Also it cannot be because of other conditions such as depression, bipolar or DMDD.
There are other things to look out for that a Child Psychiatric healthcare provider would be able to identify to tell you whether or not it is ODD or something else, so best to get a full evaluation from a healthcare provider to find out.
What should we try to do first to address aggression?
The first line treatment (the first thing that should be attempted) is therapy, namely PMT, Parent Management Training. It focuses on teaching you how to break down the behaviors you want to see into steps for your child to understand, and use positive reinforcement. It also teaches you how to set boundaries and provides tricks for discouraging negative behaviors. The Child Mind Institute has a nice short article introducing the types of PMT programs. Click the link here.
CBT (Cognitive behavioral Therapy) for children and parents is also a great option for decreasing aggressive behaviors and negative thoughts, and teaching children coping skills².
And now for medication options…
There is currently no medication that solely targets aggression unfortunately.
Medications are not recommended as the first thing you should try to control ODD but they could be helpful when used at the same time as therapy² or if therapy is not available/ not working well.
A comment I see is 'the healthcare provider told us that stimulants would help with the aggression, but so far it has not.'
Research has shown that in co-occurring ADHD and ODD, stimulants like methylphenidate or amphetamine can reduce aggression because it is believed that the stimulant helps with the frustration caused by ADHD symptoms that can make ODD worse. Methylphenidates are thought to be slightly better at helping than amphetamines³. Stimulants are noted to be the best medication for helping both ADHD and ODD⁴.
But this doesn't mean that they will work well for everyone. They can actually cause aggression, irritability and agitated behavior in some people. If 100 people take a stimulant, around 2-11 people will experience this side effect making it not a great medication for a handful of people who have both ADHD and ODD.
If stimulants don't work then discuss other medication options with your child's healthcare provider such as adding non stimulants, such as Clonidine for aggression, or Atomoxetine which has been shown to help in ODD that coexists with ADHD.
Here is a brief summary of these medications below:
Atomoxetine (Strattera) is FDA approved to treat children 6-17 years old. It works by increasing the amount of norepinephrine in the brain. Norepinephrine helps with attention and focus. That is why it is prescribed in ADHD. It is unclear as to how it helps with ODD⁶, though it is thought to have something to do with better control of ADHD symptoms leading to less frustration and impulsivity improving ODD overall. It is thought to work better for ADHD/ODD than either Clonidine or Guanfacine. Takes about 2-4 weeks to kick in.
It can be used at the same time as stimulants so can be added on top of the stimulant that your child is already taking, or can be taken on its own. It can be used just once or twice a day, though dosing twice a day is thought to lessen the tummy upset that it can cause. It can also be given at bedtime if it causes low energy and sleepiness. It appears to be more effective in improving issues with attention, not as effective in controlling hyperactivity.
Side effects include headache, tummy pain, decreased appetite, fatigue nausea and vomiting. Compared to just treating ADHD on its own, when ODD is thrown into the mix higher dosing is recommended to control both sets of symptoms from ADHD and ODD⁵.
Clonidine has also proven to work well in controlling ODD that exists with ADHD². It is FDA approved to treat children 6-17 years old. It works differently from Strattera and that it is an alpha 2 adrenergic agonist. It acts on a different chemical system in the brain from Strattera and it helps with impulsivity, restlessness, agitation and hyperactivity. It does not help with attention. It can also be used to help with anxiety and difficulty sleeping. I can be used at the same time as a stimulant, if the stimulant is causing anxiety or sleeping problems, or on its own for children who do not do well on a stimulant.
Common side effects include dry mouth, low energy, dizziness, constipation, headache and fatigue/sedation.
Because it is also used to treat hypertension, let your child's healthcare provider know if your child starts to become dizzy, light headed or faints. The medication is making her blood pressure drop too low if this happens and they will have to adjust the medication. It is thought to help with impulsivity and outbursts associated with ODD.
Because Clonidine causes sedation it is often prescribed for sleep issues in ADHD. However, there are some children for whom Clonidine actually will actually worsen sleep and/or make them more aggressive and irritable (anywhere from 1-9 children out of every 100 who are on the medication). This is down to genetics and how their bodies interact with the medication and how the medication interactions with their bodies.
Unfortunately the only way to know is to trial it and see how a child responds. Genetic testing like GeneSight can help predict whether there will be any side effects to the medication, but cannot predict how well it will work for any given child.
Guanfacine (Intuniv) is from the same family as Clonidine and so is also thought to help with aggression in ODD³.
Why is my child’s healthcare provider suggesting an antipsychotic for ODD?
As a very last resort you could consider Risperidone which is an effective antipsychotic for severe aggression. Despite working very well it does have down sides such as side effects such as weight gain and causes sleepiness, and should really only be reserved for when other medications have been tried but did not work (Flessner & Picentini, 2019).
Risperidone is otherwise the most frequently used antipsychotic in Children and adolescents (Stahl, 2021). Data shows that it is safe and effective for behavioral disturbances in children (Stahl, 2021), so it is a great back up to have when nothing else seems to be working.
In place of Risperidone, other antipsychotics can also be used instead to control aggression, such as Abilify. The antipsychotic chosen will be down to the preference and discretion of the healthcare provider prescribing the medication.
If your child ends up taking an antipsychotic they will need to be monitored regularly by their healthcare provider. Testing that will need to be done includes regular weigh-ins, blood pressure checks, and blood tests to check glucose and cholesterol levels. In addition your child's health care provider will want to see them regularly in person to make sure that they do not develop something called Tardive Dyskinesia, which are abnormal movements that can sometimes happen with antipsychotics.
Conclusion
ADHD and ODD occur together a lot of the time.
The good news is that there are treatment options available that can help both the symptoms of ADHD and ODD at the same time.
Therapy should be attempted first and then medications added if needed. Stimulants are a good option for controlling both the symptoms of ADHD and ODD, but may not work for everyone.
Other options are non-stimulants and again these help with both the symptoms of ADHD and ODD.
For severe aggression, or if the other medications and therapies mentioned do not help, antipsychotics can be used but these will require regular monitoring and followup with your child’s healthcare provider because of the side effects of increased cholesterol, weight gain and abnormal movements they may cause.
Have a discussion with your child’s healthcare provider regarding these treatment options. They should be able to look at the whole picture, help you identify the symptoms that need targeting, and guide you.
In the PDF here that I have attached, I have provided an 'Irritability Tracker' to track angry episodes over time and to try to gain an understanding of what happens before an episode/what contributes to an episode. The goal is to give you a sense of understanding of why outbursts are happening so that honest and compassionate discussions can follow with your child.
This site is for general informational purposes only and does not constitute the giving of medical advice. The contents do not constitute the practice of medicine, nursing, or other professional health care services. No provider–patient relationship is formed. Please consult with your child's healthcare provider when considering supplementation for children.
³https://www.uspharmacist.com/article/an-introduction-to-oppositional-defiant-disorder-and-conduct-disorder#:~:text=Stimulants%20help%20improve%20symptoms%20of,to%20benefit%20from%20psychosocial%20therapies.&text=Nonstimulants%20may%20be%20used%20second,in%20ODD%20with%20comorbid%20ADHD.
⁴https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4344946/#:~:text=The%20evidence%20profile%20for%20psychostimulants,or%20without%20ODD%20or%20CD.
⁶https://publications.aap.org/pediatrics/article-abstract/121/2/e314/68727/Atomoxetine-for-the-Treatment-of-Attention-Deficit?redirectedFrom=fulltext
Flessner, C. A. & Picentini, J. C. (2019) Clinical Handbook of Psychological Disorders in Children and Adolescents; A step by step treatment manual. The Guilford Press.
Stahl, S. M (2021) Essential Pscychopharmacology: Prescriber's Guide. Seventh Ed. Cambridge University Press.
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