ADHD and Behavior Problems

We think of kids with ADHD as having trouble paying attention. But for many of them — and their parents — behavior is a big problem, too. Sometimes a bigger problem. They may be quick to lash out, throw a tantrum or be defiant when they are asked to do things they don’t want to do.

Tantrums and defiance are not symptoms of ADHD itself, but they are often a result of ADHD symptoms. Inattention and impulsivity can make it very difficult for kids to tolerate tasks that are repetitive, or take a lot of work, or kids find boring. Children with ADHD can be overwhelmed with frustration, and throwing a shoe or pushing someone or yelling “shut up!” can be the result of impulsivity. They are less able than other kids their age to manage powerful feelings without an outburst.

But behavior problems can also go beyond impulsive outbursts. Some kids with ADHD develop negative behavior patterns, and those, argues David Anderson, PhD, a clinical psychologist at the Child Mind Institute, are a response to years of finding themselves in conflict with adults

In cases where kids with ADHD are chronically defiant, they are also diagnosed with a behavior disorder called oppositional defiant disorder (ODD). As many as 40 percent of kids with ADHD are also diagnosed with ODD. But many more of them are in conflict with parents or teachers over their behavior — as many as 80 percent, observes Dr. Anderson, a clinical psychologist.

To understand why kids with ADHD are often angry, aggressive or defiant, Dr. Anderson says, you have to think about their history growing up with ADHD.

Kids with ADHD are wired to be attracted by things that are outside the bounds of what we want them to be doing, he explains, which leads to conflict with parents from a very young age. “There’s no malicious intent on the part of these young kids,” he adds. “Because of the hyperactive and impulsive symptoms of ADHD, they don’t want to stay in their seat. They want to explore the entire restaurant. They want to run away from you at the park to check something out that looks cool. That can result in pretty stressed out parents pretty quickly.”

This leads to a lot of negative interaction. “If you’re being told from an early age that your behavior is wrong, or isn’t what a kid is supposed to be doing, either you internalize it and you start thinking, ‘There really is something wrong with me,’ or you react aggressively towards the people who are telling you that you’re wrong.”

For kids with ADHD, tasks that are repetitive or boring or require a lot of effort can be acutely challenging, and elicit a lot of resistance, especially if it means stopping something that’s pleasurable — like playing a video game. So things like homework, going to bed, getting dressed and coming to dinner can become battlegrounds. Unfortunately for parents, the avoidance strategies that these kids typically use are tantrums, arguing, defiance and power struggles.

“If they throw a fit, it’s very likely that someone will change the task demands, make it easier on them, or settle for the bare minimum compliance,” adds Dr. Anderson. That works for the kid, so the behavior tends to be repeated.

When kids have developed a pattern of negative interaction, discipline that works with other kids may be ineffective. “People do certain things naturally in parenting,” says Dr. Anderson. “For most kids, it works just fine. For kids with a behavioral issue, these things fail miserably.”

One thing that doesn’t work is losing your temper. For a child who rarely misbehaves, a parent who raises their voice may have an impact. “But kids who misbehave often habituate to this quickly. If you yell a lot, they eventually decide that’s the way of the world. People are just going to yell at them so why pay that much attention?”

Similarly, Dr. Anderson explains, punishment loses its effectiveness. “If kids get punished a lot, punishments stop mattering because, after all, they’re living in a perpetual state of punishment.  How much is it really going to matter if they get punished a little bit more?”

Kids with ADHD often need more structure than other kids, and clearer instruction as to what kinds of behavior an adult is looking for. “As parents we need to help kids figure out what acceptable behaviors are, teach those acceptable behaviors and catch kids being good as often as we possibly can,” says Dr. Anderson. Praise and opportunities for a positive relationship with parents are powerful tools for managing disruptive behavior, which tends to escalate when a relationship is mostly negative interactions.

Clinicians call this kind of proactive structure “scaffolding.” Kids who are having trouble regulating their own behavior within acceptable limits need a family environment that provides external regulation of behavior. The structure that parents provide is a model for what we want kids to learn, and keeps them in good standing as they develop better self-regulation.

Self-regulation is the ability to manage your emotions and behavior in accordance with the demands of the situation. It includes being able to resist highly emotional reactions to upsetting stimuli, to calm yourself down when you get upset, to adjust to a change in expectations and to handle frustration without an outburst.

Poor self-regulation is so common in kids with ADHD that some experts, including veteran ADHD researcher Russell Barkley, think it should be one of the core symptoms of the disorder.

But Dr. Anderson notes that it makes sense as an outgrowth of the impulsivity that’s part of ADHD; these kids have difficulty with inhibition, with planning and with delay of gratification.

“You take all of that together, you’ve got a kid who’s more likely to look for the short-term payoff than long-term payoffs,” he says. “You’ve got a kid who doesn’t want to wait, who finds it excruciating to wait, who’s quickly distractable, and for one reason or another is impaired on repetitive tasks, tasks that take a lot of work or tasks that kids find boring.

Unfortunately, the behavior problems kids with ADHD exhibit often affect their relationships not just with adults but with other kids.

“There are a host of reasons why we see friendships being impaired by ADHD symptoms,” notes Dr. Anderson. “For a kid who’s highly distractable, it could be they can’t keep up with a pace of conversation and their friends just notice they’re zoned out. For the kid who’s really impulsive, it might be they interrupt other kids and don’t let anybody else get a word in edgewise. For kids who have real difficulty delaying gratification, it may be that they always have to choose the activity, and anybody who doesn’t want to go along with it gets some impulsive speech directed at them.”

 In one study of kids at summer camp, after only a few hours of interaction, the boys with ADHD were far more likely to be disliked and rejected by their peers than the boys without a diagnosis.

The main reasons given for the quick negative perceptions was their explosive, retaliatory and impulsive behavior patterns, researchers found. Stephen Hinshaw, PhD, one of the authors of the study and now the professor of psychology at the University of California, Berkeley.

And Dr. Hinshaw notes that girls with ADHD are subject to even more peer rejection than boys, “probably because their behavior patterns are more gender atypical.”

When children with ADHD develop serious behavior problems, whether they had a diagnosis of ODD or not, the most effective treatment is parent training. There are many parent training programs, but what they have in common is that they teach parents how to reset the relationship with the child.

Parents learn how to use praise effectively, to encourage the behaviors they want to encourage, and how to deploy consistent consequences when kids don’t comply. The result is that kids learn to modulate their behavior to meet expectations and enjoy much more positive interactions with their parents. Social skills training and individual cognitive behavioral therapy can also help kids interact in a healthier way with both adults and their peers.

For kids with ADHD, stimulant medication that reduces symptoms of inattention, impulsivity and hyperactivity may also help improve behavior. Anti-psychotic medications like Abilify (aripiprazole) and Risperdal (risperdone), which have been shown to reduce aggression and irritability, are frequently used in cases where a child is at risk of being removed from the school or home.

But even when medication is used, experts recommend that it be paired with parent training for the best results.