ADHD, ODD and CD

Today it is World Mental Health Day and I want to celebrate this day by drawing attention to some of the lesser known mental health conditions that sometimes exist alongside ADHD.

When one or more additional conditions exist alongside a primary condition, we call it ‘comorbidity.’ In some cases, the comorbid condition can mask the symptoms of ADHD and make its diagnosis much more difficult- I once taught a child with a diagnosis of Global Developmental Delay and it took me a while to realise that she probably had extremely inattentive ADHD that we just had not spotted before- her mum agreed.

*Side note- whilst having English as an additional language (EAL) is not a medical condition or considered comorbid by any means. Sometimes EAL children also struggle to have their symptoms recognised as the language barrier is blamed for some of their challenges. *

More than two thirds of individuals with ADHD have at least one other coexisting condition (CHADD, 2017). Some of the most common comorbid mental health conditions that exist alongside ADHD are Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), Anxiety, Depression and Bipolar Disorder.

When I was researching this piece, ODD and CD were missing from some articles completely, but others had startling information. CHADD, The National Resource on ADHD (USA) reports that around 40% of individuals with ADHD have ODD, rates of CD vary to around 27% of children, 45% to 50% of adolescents and then back down to 20% to 25% in adults with ADHD.(CHADD, 2017).

Another study carried out called, ADORE (Attention-Deficit Hyperactivity Disorder Observational Research in Europe) was a study carried out in ten European countries with 1478 children between 6 and 18 (84% were male). While the percentages in the study differ from the figures reported by CHADD, the most common comorbid condition found was ODD at 67% and CD at 46% (ADHD Institute, 2017).

Despite the evidence that ODD and CD are clearly very prevalent alongside ADHD, so little is known about them that they don’t even merit mentions in every publication.

This is pretty significant to me, as I also have ODD as a comorbid condition with my ADHD, but I never realised I was part of such a large sub group.

In fact, when I was first diagnosed, I went online searching for ADHD groups and I found an abundance of them- in a post later on this month I’ll be talking about how important support groups are- but I could not find anything online about ODD in the UK at all. So, I joined some American groups in the hopes of meeting people like me but found that most groups were for parents of children with ODD. I have remained a member because reading the stories about their children and reflecting on how similar some them are to me, has been a very useful experience and I’ve learnt more about myself through that reflection than I would have from a limited number of articles.

So, on World Mental Health Awareness Day, I will attempt to describe ODD, or certainly my experience of it, in a bid to raise awareness of this little-known condition.

Oppositional Defiant Disorder

Lots of children are stubborn and on occasion, defiant and even the most well-behaved children have arguments and conflict with their siblings, parents, teachers and other adults. That does not automatically mean that a child has ODD.

Using the DSM-5 criteria for diagnosis of ODD symptoms should:

Occur with at least one individual who is not a sibling
Cause significant problems at work, school or home
Occur on its own, rather than as part of the course of another mental health problem, such as a substance use disorder, depression or bipolar disorder
Last at least six months

In addition, there should be at at least four symptoms from any of these categories:

Angry and irritable mood:

Often loses temper X
Is often touchy or easily annoyed by others X
Is often angry and resentful X

Argumentative and defiant behaviour:

Often argues with adults or people in authority X
Often actively defies or refuses to comply with adults’ requests or rules X
Often deliberately annoys people X
Often blames others for his or her mistakes or misbehaviour

Vindictiveness:

Is often spiteful or vindictive
Has shown spiteful or vindictive behaviour at least twice in the past six months

(Mayo Clinic, 2017)

The items on the list that I have marked X are all behaviours I can identify in myself as a child and adolescent after a long period of reflection- some persist to this day. When I first found a really good article about ODD, I sent it to my mum to read. Shortly after, she text me back to say, “yes, I would agree with all that.” And if she is reading this (she knows about the blog) then I’m sure she would agree with all of the items that I have marked X, though I imagine there is one unticked item on that list she would include;

“Often blames others for his or her mistakes or misbehaviour”

Now, while I AM oppositional and defiant, I think our disagreement on that item would come from the different way we interpret things. In fact, the reason that I can recognise my ODD symptoms today is that I am being treated successfully for ADHD and I have been able to experience clarity for the first time in my life, so can now reflect on some of my childhood behaviours and realise that my parents and others saw me in a completely different way to how I saw myself.

Debate on that point aside, I did not have the vindictive traits, my ADHD brain moved so fast that it protected me from people who hurt me, so I quickly moved on from incidents that other people dwell on… thank goodness, I had enough of the other traits to deal with!

ODD, like many conditions, is a spectrum and:

Mild: Symptoms occur only in one setting, such as only at home, school, work or with peers.
Moderate: Some symptoms occur in at least two settings
Severe: Some symptoms occur in three or more settings.

(Mayo Clinic, 2017)

My ODD was mild, in that I only exhibited behaviours at home and generally kept it away from school- barring one incident in my 3^rd year where five boys were allowed to goad me for an entire lesson without intervention. Eventually I answered them back… well at least I thought I did. I found myself sitting in a room, being left to “calm down” for what felt like hours. To this day I have no idea how long I was left there without being checked, anger building and the injustice.

I was obsessed by fairness and justice, and could be quite black and white about fairness consequently, any time I believed my brother to be favoured over me, I would lose my temper.

The oldest anecdote in my family is one my gran loves to tell, when I was four days old and being taken home from the hospital, she brought a hat for me that had a huge fluffy bobble on the top and when she tried to tie it round my chin… apparently, I touched my chin to my chest to stop her! Now I’m not sure if a four-day old baby has the strength in its neck to do that, but my gran insists I did, and I find it quite funny too.

True or not I have certainly always been wilful and fiercely independent. As a teenager, I never asked for help because I never wanted help- not because I thought I knew it all- far from it. I just wanted to do everything my way and if I make a mistake, I’d deal with it and learn from it. I was never afraid of making mistakes as long as they were my own with no outside interference. Inside my head was utter chaos so maintaining control over one aspect of me gave me comfort and focus.

By far, my biggest trigger, guaranteed to make me lose my temper was (and still can be) any perceived slight. If I feel belittled or mocked- I am hypersensitive to people’s emotions, their tone of voice, facial expressions and the choice of words they use. When you live in a world as an alien species and your brain does not process light, sound, words… anything, the same way as the rest of the inhabitants, you function with an incredibly wound up tight stress level. It’s bad enough being that stressed, but if you feel under attack…

Of course, other people may not think they have done anything to warrant the reaction they get and that is true if it is out of the blue and unexpected, but if the same incident happens every day and your child loses their temper every day over the same thing, you can persist in pushing their button until they magically grow out of reacting badly (they won’t). Or you can be the bigger person and choose not to push their buttons and work on building a relationship, rather that building resentment.

Conduct Disorder

I did not know much about Conduct Disorder prior to writing this post, but as it affects a lot of people with ADHD and is lesser known, I definitely wanted to include information about it today.

Conduct disorder is a serious behavioural and emotional disorder where the child may display disruptive and violent behaviour and have difficulties with following rules.

While some children and teens may have behaviour-related problems at one point, “a phase.” Conduct Disorder occurs when the behaviour lasts for a longer period and violates the rights of others, goes against accepted norms of behaviour and disrupts the child’s or family’s everyday life.

Symptoms of Conduct Disorder

Symptoms may vary depending on the age of the child and the severity on the spectrum; mild, moderate, or severe.

Typical symptoms are as below:

Aggressive behaviour: threatening or causing physical harm e.g. fighting, bullying, being cruel to others or animals, using weapons, and forcing another into sexual activity.

Destructive behaviour: Intentional destruction of property e.g. arson and vandalism.

Deceitful behaviour: Repeated lying, shoplifting, or breaking into homes or cars in order to steal.

Violation of rules: This involves going against accepted rules of society or engaging in behaviour that is not appropriate for the person’s age. These behaviours may include running away, skipping school, playing pranks, or being sexually active at a very young age.

So what causes these behavioural disorders in such a high number of children with ADHD.

Some studies suggest that defects in or injuries to the brain can lead to serious behavioral problems and ODD has been linked to abnormal functioning of neurotransmitters. If these chemicals are not working properly, messages may not make it through the brain correctly, leading to symptoms of ODD, and other mental illnesses.

Many people with ODD have close family members with mental illnesses, including mood disorders, anxiety disorders, and personality disorders. This suggests that a vulnerability to develop ODD may be inherited.

A dysfunctional family life, family history of mental illnesses and/or substance abuse, and inconsistent or overly harsh physical discipline by parents may contribute to the development of behavior disorders.

I hope you learned more about ODD today and please remember to share far and wide to spread awareness.

References