ADHD & ODD: What’s The Connection?
I’d really like to rewrite these two sections of the DSM-5
I’d like to rewrite the DSM-V, please
(Just a couple of sections…)
As Dr. Barkley so aptly explains, when you include the emotional dysregulation and low frustration tolerance symptoms in the diagnostic criteria for ADHD, then everyone with ADHD is only two additional symptoms away from qualifying for an ODD diagnosis.
To be clear, I’m not always a fan of Dr. Barkley’s approach to ADHD. As a psychiatrist, he of course uses a medical model, which can be very pathologizing and pessimistic.
While I may disagree with Dr. Barkley’s stances, he is one of the world’s leading experts on ADHD and I cannot disregard his extensive, in-depth knowledge because of our philosophical differences.
When it comes to the overlap of ADHD and ODD symptoms, Dr. Barkley is spot on, so I will refer to his work in this article.
Firstly, I will explain how difficulties with emotional regulation is a key component of ADHD.
ADHD and Emotions
People with ADHD struggle with executive functioning (EF). Many EF processes are important to regulating, or controlling, one’s emotions and reactions.
People with ADHD will often have difficulty transitioning from one task to another, which is referred to as task switching.
What is less well known is that people with ADHD also struggle shifting their thoughts from one topic to another, a process called set shifting.
When children are very young and upset, what do we usually do? Comfort them and, if we can’t make it all better, we distract them.
As adults when we’re upset and our emotions are running high, what is the advice we usually give ourselves and each other? Things like don’t make any big decisions when you’re mad, or wait 24 hours before you respond.
What do we do when a solution is not readily available and we just have to endure the uncomfortable feelings for a while?
Okay, let me rephrase. When we’re thinking with a clear head, what would be the most adaptive way to handle a difficult situation without making it worse?
Perhaps listen to music, read a book, go for a run, or do some mindless tasks. In other words, we might distract ourselves in the short-term until we’re ready to revisit the problem, or until our emotions have settled a bit.
People who struggle with set shifting have trouble temporarily redirecting their attention to something else in order to allow emotional reactions to settle before responding.
We’re prone to rumination. We may go over the scenario in our heads repeatedly, dissecting social interactions, and marinating in our anger or other distressing feelings. It can be extremely difficult for us to get our minds on another track once they’ve zeroed in on something, which is a form of hyperfocus.
Hyperfocus happens when we “lock on” to something and have difficulty shifting our attention from one subject to another.
I usually find it to be a positive trait. When I write, I hyperfocus, which allows me to tune everything else out to put all my energy into what I’m working on.
Unfortunately, when it comes to distressing emotions or experiences, this makes our brains sticky and makes it hard for us to move on or set something aside in the interim.
Can we talk about the irony of hyperfocus for a minute? We ADHDers, who are known for being distractible, are also more likely to get stuck on something and unable to tear our attention away from it.
Like, really, nature? Really?
The other EF deficit that impacts our emotions and subsequent response is working memory. Working memory, in essence, is holding information in mind while working with it, but it there is a lot more to it than that.
There are different types of working memory, but the one most impacted by ADHD, and the one that is meant to help us use past experiences to inform current and future behaviour is called nonverbal working memory (Barkley, 2015).
Nonverbal working memory (NVWM) allows us to produce visual representations of past interactions, use those to remember and learn from past experiences, and then apply those lessons to inform our decision-making.
So when you look at one of the DSM-V criteria for ODD:
“Often actively defies or refuses to comply with requests from authority figures or with rules.”
We would have to make assumptions about someone’s intent. How do we really know that someone is refusing to comply? What if they truly forgot the rules, or forgot what an authority figure had told them to do previously?
Refusal and defiance are so much more complex than that, they would require another article to dissect, but we’d have to have a very superficial view of someone’s behaviour to label it as defiant.
The prefrontal cortex (PFC) is the region most responsible for our executive functioning, and plays a very significant role in emotional regulation.
Reduced activity in the PFC, combined with increased activation of the amygdala, during emotional events has been demonstrated in both ADHD and autism.
The PFC is like the cool-headed friend who is supposed to hold back the hot-headed amygdala when they start to get worked up. The PFC is meant to calm the amygdala, as well as communicate to the motor cortices to slow down and think before acting.
When our PFC is under-active and our amygdala is over-active, that makes it a lot harder for the PFC to do its job, and harder for us to keep our cool.
That combined with impulsivity, which I’ve written about extensively, leaves us more vulnerable to being perceived “as often losing our temper”.
What Does It Mean?
Returning emotional dysregulation symptoms to the DSM-V criteria for ADHD would leave anyone with ADHD only two symptoms from also being diagnosed with ODD.
That, combined with the additional stress and strife that most people with ADHD already endure, really renders the ODD diagnosis redundant and obsolete.
How does one ethically diagnose a disorder that only exists when there are other people engaging with the individual? One can’t be “defiant” all alone, it requires another person to defy.
“You can’t have two people pushing against each other if one of them doesn’t participate! You can’t have a power struggle with only one person engaged.” — Susan Stiffelman
Based on this, and my other writings on these topics, I would argue that ODD is an unnecessary and harmful label that places unfair blame on the child, and usually one with an underdeveloped PFC to begin with.
This “diagnosis” stigmatizes developmentally and situationally appropriate behaviour, and worse than that, it labels and stigmatizes children.
Once adults hear a child is “ODD”, they’re likely to view all their behaviour through that lens, and assign malicious intent to potentially benign or innocent behaviours.
If we’re calling a child’s behaviour defiant, then don’t we have to call our response defiant as well? How can a child be defiant without an adult also pushing back just as much?
“In every power struggle between an adult and a child, there’s an adult who wants their own way, too.” — Dr. Ross Greene
People with ADHD and other divergent brains already deal with stigma and ignorance on a regular basis, we really don’t need to add to it.
© Jillian Enright, ADHD 2eMB
Barkley, R. A. (2015). Attention-deficit hyperactivity disorder: A handbook for diagnosis & treatment. The Guilford Press.
Battistutta, L., Schiltz, C. & Steffgen, G. (2021). The Mediating Role of ADHD Symptoms and Emotion Regulation in the Association Between Executive Functions and Internalizing Symptoms: a Study Among Youths with and Without ADHD and/or Dyslexia. Advances in Neurodevelopmental Disorders. https://doi.org/10.1007/s41252-021-00212-y
Boshomane, T., Pillay, B. J., & Meyer. A. (2021). Mental flexibility (set-shifting) deficits in children with ADHD: A replication and extension study. Journal of Psychology in Africa, 31(4), 344–349. 10.1080/14330237.2021.1952637
Buttelmann, F., & Karbach, J. (2017). Development and Plasticity of Cognitive Flexibility in Early and Middle Childhood. Frontiers in Psychology, 8, 1040. https://doi.org/10.3389/fpsyg.2017.01040
Groves, N.B., Kofler, M.J., Wells, E.L. et al. (2020). An Examination of Relations Among Working Memory, ADHD Symptoms, and Emotion Regulation. Journal of Abnormal Child Psychology 48, 525–537. https://doi.org/10.1007/s10802-019-00612-8
Greene, Ross, W. (2021). Lost & Found: Unlocking collaboration and compassion to help our most vulnerable, misunderstood students, and all the rest. (2nd ed.). Jossey-Bass.
Hirsch, O., Chavanon, M. Riechmann, E., Christiansen, H. (2018).
Emotional dysregulation is a primary symptom in adult Attention-Deficit/Hyperactivity Disorder (ADHD). Journal of Affective Disorders, 232, 41–47. https://doi.org/10.1016/j.jad.2018.02.007
Ibrahim, K., McCarthy, G., & Sukhodolsky, D. G. (2020). Neural mechanisms of emotional dysregulation. Encyclopedia of Autism Spectrum Disorders. Springer. doi:10.1007/978–1–4614–6435–8_102453–1
Ozel-Kizil, E. T., Kokurcan, A., Aksoy, U. M., Kanat, B., Sakarya, D., Bastug, G., Colak, B., Altunoz, U., Kirici, S., Demirbas, H., & Oncu, B. (2016). Hyperfocusing as a dimension of adult ADHD. European Neuropsychopharmacology, 24(1), S707-S708. doi:10.1016/j.ridd.2016.09.016
Shaw, P., Stringaris, A., Nigg, J., & Leibenluft, E. (2014). Emotion dysregulation in attention deficit hyperactivity disorder. The American journal of psychiatry, 171(3), 276–293. https://doi.org/10.1176/appi.ajp.2013.13070966
Stiffelman, Susan. (2013). Parenting Without Power Struggles: Raising Joyful, Resilient Kids While Staying Cool, Calm and Connected. Simon & Schuster.
Substance Abuse and Mental Health Services Administration. (2016). DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet]. Substance Abuse and Mental Health Services Administration (US). Table 18, DSM-IV to DSM-5 Oppositional Defiant Disorder Comparison. https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t14