ADHD and Oppositional Defiant Disorder

Oppositional defiant disorder (ODD) is the most common comorbid condition in children with ADHD. As much as 60% of patients with ADHD have also been diagnosed with ODD.

That high frequency of comorbidity brings up two questions: What is oppositional defiant disorder and how do you tell the difference between ADHD and ODD?

What Is Oppositional Defiant Disorder?

Oppositional defiant disorder is defined as “a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior towards authority figures that is more pronounced than what is usually seen in children of similar age and lasts for at least 6 months.” This can manifest as:

• Temper tantrums
• Actively defying rules
• Dawdling
• Argumentativeness
• Stubbornness
• Being easily annoyed

The diagnosis first appeared in the Diagnostics and Statistical Manual (DSM) III but serious concerns about the usefulness of the diagnostic construct have sparked debates in the decades since its inclusion. Among the biggest issues: How do you distinguish between a clinical disorder and the oppositional and defiant behavior that is typical for children at the same stage of development?

Additionally, ODD is a controversial and extremely stigmatizing disorder. There is a significant history of racism and other types of marginalized communities being diagnosed with ODD (or other conduct disorders) rather than their neurodivergence or when marginalized communities were fighting for their rights.

Children and adolescents, who are exploring, learning, and growing into the adults they will one day become are known to push boundaries, challenge rules, and otherwise have periods of opposition and defiance targeted at the key authority figures in their lives: parents and teachers.

The line between typical and disordered disobedience is far from clear-cut. That line becomes even more blurred when you factor in other disorders that can look a lot like ODD.

ADHD and ODD Can Look Similar from the Outside

For parents, teachers, and others in the patient’s life, it can be easy to confuse ADHD symptoms that a patient simply can’t help with deliberate defiance and disobedience that look like ODD. After all, two common features of ADHD are emotional dysregulation and impulsivity, both of which can lead to explosive outbursts, irritability, risk-taking, and difficulties with resisting impulses.

If a child with undiagnosed ADHD takes a cookie from the cupboard after being told to wait until after dinner, how does the parent determine whether they did so because they lack impulse control or because they have ODD?

How can a teacher tell the difference between a teenager who is actively refusing to follow the rules and one who struggles with poor attentional control and, therefore, spaces out while a teacher is explaining those rules?

This overlap can make it difficult to tell the difference between the two disorders or accurately identify when a child has both ADHD and ODD. This is further complicated by the fact that diagnosis of both disorders in childhood relies heavily on parent and teacher evaluations rather than on a medical evaluation of the patient’s internal symptoms like inattention, executive dysfunction, and emotional dysregulation.

A meta-analysis of ODD research found that informant discrepancies were common, with parents usually rating symptoms as more pronounced than teachers do. Another study similarly found that the discrepancy between parent and teacher ratings was highest when said parents showed heightened levels of distress.

This suggests that the diagnosis of ODD can hinge heavily on how much it’s affecting the people around the patient—rather than on how it’s affecting the actual patient.

The Risk of Misdiagnosis

Making a misdiagnosis can be harmful and frustrating for everyone involved because the treatment approaches for ODD and ADHD are very different. To treat ADHD, healthcare providers often use a mix of medication and cognitive behavioral training for the patient while providing guidance to parents and teachers on how to help their child manage their symptoms.

To treat ODD, healthcare providers often rely on parent training, in which parents are taught how to enforce healthy boundaries—an approach that wouldn’t work well for a child with ADHD, for whom lack of boundaries is not the primary problem.

As a result of the harm that can come from misdiagnosis, a key concern when diagnosing ODD is making sure healthcare providers are careful to rule out all other possible disorders or sources of behavioral problems before settling on ODD.

Taking the time to rule out other possibilities can also help identify any comorbid conditions alongside the possible ODD, like ADHD, trauma, or a mood disorder. Having those comorbid diagnoses can help healthcare providers develop a more effective treatment plan for each patient.

Identify the Internalized Symptoms to Better Distinguish Between ADHD and ODD

If you or your child was diagnosed with one or the other, but you’re now reconsidering that diagnosis, reflecting more thoroughly on any internalized symptoms can help you decide whether it makes sense to bring your concerns to your doctor.

First, here are some internalized symptoms that both ADHD and ODD share:

• Irritability, such as feeling intense negative emotions about things that you know are not that big of a deal (or not a problem at all).
• Feeling impatient.
• Interrupting conversations or talking a lot, driven by the feeling that you need to say what you want to say right this second.
• Impulsive actions, done with little to no thought or planning. In ADHD, this might look more like reward-seeking impulses like skipping work to go to a party or gorging on junk food. In ODD, it might look more like aggressive impulses, like lashing out at someone with cruel words or physical violence.

Some internalized symptoms of ADHD not shared by ODD include:

• Inattention, which is experienced as a struggle to focus your attention on the task at hand and ignore distractions, no matter how hard you’re trying to focus.
• Fidgeting and difficulty sitting still for long periods of time.
• Mind-wandering and spacing out, even when you’re trying to stay engaged and focused
• Forgetfulness, including forgetting appointments and misplacing things.
• Losing track of time often, and especially during periods of “hyperfocus” where you’re so absorbed in a task, it feels like the rest of the world has disappeared.

Meanwhile, some internalized symptoms of ODD not shared by ADHD include:

• Strong and frequent feelings of resentfulness and anger, which is a chronic or frequent emotional state rather than sudden, short-lived bursts.
• Feeling generally unappreciated, disliked, or misunderstood—especially all-or-nothing feelings like “everyone hates me” or “no one ever notices how hard I work.”
• A strong and almost innate disdain for authority figures, which can feel like an urge to defy or ignore advice or commands from said authority figures just on principle.

If the majority of your most frequent or long-lasting symptoms fall into one category or the other, that’s a good sign you might want to talk to a doctor about getting a diagnosis. If you feel like you identified with a mix of symptoms from the ADHD-only, ODD-only, and overlap lists, you might want to discuss the possibility of a comorbid diagnosis.

Treatment Options for ADHD and ODD

Research suggests that the most effective treatments for ODD are collaborative parent-child therapy and parent training. Parent-child therapy provides a space for strengthening that relationship while also collaborating on problem-solving and emotional regulation techniques to help ease symptoms. Parent training helps parents understand why their child is acting out and how they can adapt their parenting style to better meet their child’s needs and set healthier boundaries.

Similarly, for adults with ODD, therapy that focuses on developing emotional regulation skills and behavioral training can help.

For ADHD, stimulant medications have proved the most effective at improving systems in patients of all ages. Likewise, cognitive behavioral therapy has also shown promise as a way to give patients the skills to generate internal motivation, compensate for time blindness, and otherwise manage ADHD symptoms.

For those with comorbid ADHD and ODD, a personalized combination of treatments for both conditions will have the best odds of helping you manage your symptoms. For example, doctors might recommend parent training that includes guidance on both setting healthy boundaries and making accommodations for a child’s ADHD at home.