This resource provides primary care clinicians with a brief overview of disruptive behavior disorders (DBDs) that are common comorbidities of attention-deficit/hyperactivity disorder (ADHD), namely, oppositional defiant disorder (ODD), conduct disorder (CD), and intermittent explosive disorder (IED). This resource summarizes evidence-based assessment and treatment of these common externalizing disorders in the context of comorbid ADHD.

Impulsive aggression is a common feature in disruptive behavior disorders including, ODD, CD, and IED, and many children and adolescents have symptoms of 1 or more of these disorders. Disruptive behavior disorders, including ODD and CD, are found in as many as 40-60% of children and adolescents with ADHD. [Biederman: 2007] The impact of these disruptive behavior diagnoses is considerable due to the increased risk for later adverse outcomes, including dropping out of school, substance abuse, poor social skills, and other mental health problems. [Radwan: 2020] Children with conduct disorders are also at increased risk for violent or criminal behaviors. A 10-year follow-up of boys with ADHD and ODD or ODD/CD reveals a “compromised” outcome, including depression and worsening symptoms. [Biederman: 2008] This has significant implications for individual health and impacts on family, community, and society.

Treatment guideline

Canadian evidence-based guidelines advise use of psychostimulants > atomoxetine or alpha-2 agonists (guanfacine > clonidine) > risperidone for treatment of disruptive or aggressive behavior associated with ADHD. [Gorman: 2015] The Society for Developmental & Behavioral Pediatrics Clinical Guidelines for Assessment and Treatment of Complex ADHD recommends treating children with ADHD and coexisting DBDs with evidence-based behavioral interventions for ADHD, including behavioral parent training, with the addition of stimulant medications as first-line treatment when medication is indicated. [Austerman: 2015]

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), ADHD is now classified as a neurodevelopmental disorder, whereas ODD and CD are classified as disruptive, impulse-control, and conduct disorders. [American: 2013] While children with ADHD can have difficulty with impulsive emotional changes, ODD and CD are characterized by difficulty regulating emotions (specifically anger) that are not explained by overall difficulties with attention or impulsivity. Additionally, there is clinical overlap with ADHD, ODD, CD, and disruptive mood dysregulation disorder (DMDD), a DSM-5 diagnosis of children and adolescents with chronic, severe irritability and severe temper outbursts, categorized as a type of mood disorder; see Attention-Deficit/Hyperactivity Disorder (ADHD) & Mood Disorders for more information.
ODD and CD are defined as a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months, occurs more frequently than is typically observed in children of comparable age and developmental level, are not better explained by a mood disorder, and causes clinically significant impairment in social, academic, or occupational functioning. Behaviors included in the definition:

• Losing one's temper
• Arguing with adults
• Actively defying requests
• Refusing to follow rules
• Deliberately annoying other people
• Blaming others for one's own mistakes or misbehavior and
• Being touchy, easily annoyed or angered, resentful, spiteful, or vindictive

Behaviors may occur in only one setting and are more likely to be present with familiar adults, making the clinical history from caregivers and others who know the child well a key element to diagnosis. DSM-5 diagnostic criteria should be used to formally diagnose these disorders. For suspected comorbid conditions with ADHD, primary care physicians should strongly consider consulting with a psychiatrist and/or child psychologist.

Oppositional Defiant Disorder

Oppositional behaviors that define ODD occur in much more systematic and severe patterns than in the normal oppositional behaviors expected for age or developmental level and cannot better be explained by poor attention and impulsivity in the context of ADHD. In the DSM-5, ODD now has 3 sub-types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness.

Conduct Disorder

Children and adolescents with CD demonstrate a pattern of difficulty following rules and behaving in a socially appropriate way, beyond the severity of ODD. Youth with CD can have aggressive behaviors toward people or animals, property destruction, habits including lying, cheating, or stealing, and a pattern of violating rules. [AACAP: 2013] The aggressive behavior tends to be predatory or premeditated in CD. [Radwan: 2020] Treatments can include behavior and psychotherapy, medications, school interventions, and home-based treatment models.

Intermittent Explosive Disorder

IED is a third type of disorder related to ODD and CD. It is less frequently studied in ADHD literature as a comorbidity. IED is diagnosed based on a persistent pattern of intense, severe, impulsive outbursts of anger and hostility. These outbursts can be either verbal or physical, including destruction of property and attacking others. Between episodes, the person may have depressed, angry, or irritable moods, but anger is not present most of the time (in contrast to disruptive mood dysregulation disorder). Children with isolated IED do not experience problems with sustaining attention. As with ODD and CD, treatment of concurrent ADHD may help alleviate symptoms and severity of IED.

The primary care clinician should strongly consider consultation with a psychologist or psychiatrist to clarify suspected comorbid diagnoses and provide input on treatment plans.

Treatments are broad and may include Parent Management Training Programs, psychotherapy, and skills training in problem-solving and social interactions, as well as medications. Positive parenting techniques are critical to effective management. A team approach by a psychologist, school system, and a pediatrician, with additional consultative support from a psychiatrist, is recommended. Because there is a lack of agreement among researchers about the best management practices of these comorbid conditions, an individualized approach is necessary. The components of treatment that may be included are described below.

Family Intervention

Parent training on behavioral management (e.g., reinforcing positive behaviors, discipline, behavioral contracting and contingencies, effective communication and negotiation, problem-solving, facilitating generalization of learned behaviors) and how to enhance their child's social skills are critical. Parental mental health disorders, family dysfunction, and psychosocial stressors should be addressed as these appear to mitigate the child/families' response to treatment in ODD.

Child Intervention

Here the focus is on the child's development and includes fostering competence (e.g., the child's ability to negotiate their own developmental passages), improving adaptive function, enhancing problem-solving skills, teaching mechanisms for self-control and anger management, and reinforcing prosocial behaviors (play, friendship, and conversation skills). Comorbid conditions should be identified and treated (mood disorders, anxiety, learning disability, etc.).

Multi-Systemic Treatment

Multi-systemic treatment includes parenting, teacher, and social skills trainings in the contexts of the family, peers, school, and community.

Medication

Treatment of ADHD symptoms can be helpful in alleviating oppositional behavior, aggression, and conduct problems. The child should receive adequate support/treatment for ADHD prior to diagnosing ODD since these symptoms can sometimes remit. No U.S. FDA-approved medications exist to treat symptoms of ODD/CD; however, some evidence supports the use of medications to treat symptoms of ADHD with improvements in co-morbid ODD. [Lillig: 2018] Stimulants have the strongest evidence for efficacy, with more limited evidence for guanfacine and atomoxetine and limited information on clonidine. [Biederman: 2007] [Findling: 2014] [Connor: 2010] The Society for Developmental and Behavioral Pediatrics Guidelines recommends the use of stimulant medication as first-line treatment. Canadian evidence-based guidelines advise use of psychostimulants > atomoxetine or alpha-2 agonists (guanfacine > clonidine) > risperidone for treatment of disruptive or aggressive behavior associated with ADHD. [Austerman: 2015] [Gorman: 2015] Other pharmacological agents to address aggression may be used in extreme cases in consultation with a psychiatrist.

A summary of various studies addressing the use of medications to treat ADHD and ODD or CD follows:

• Stimulants: Systematic optimization of stimulant monotherapy often reduces aggression without the need to use additional medications. [Blader: 2010] One randomized controlled trial (RCT) investigated the adverse effects of methylphenidate on stimulant-naïve children with ADHD with comorbid emotional symptoms, including ODD. This study found that children with lower baseline comorbid symptoms (anxiety, depression, oppositionality, irritability, fatigue, headache, stomachache) tended to have increased emotional and somatic symptoms on high-dose methylphenidate; those with higher initial comorbid symptoms, including ODD, had decreased comorbid symptoms on high dose methylphenidate. [Froehlich: 2020] Another study observed improved emotional symptoms in children with ADHD and ODD/CD treated with methylphenidate for a year. [Kutlu: 2017]
• Alpha-2 Agonists: Both extended-release guanfacine and clonidine are FDA-approved treatments for ADHD. Extended-release guanfacine demonstrated improvement of oppositional behavior in children with ADHD. [Pringsheim: 2015] Clonidine may be used alone or in combinations with other agents in the treatment of the child's ADHD and comorbid ODD or CD. Clonidine specifically addresses hyper-aroused behaviors (clonidine has a more limited impact on attention symptoms) but has only low-quality evidence of improvements in oppositional behavior and conduct problems in youth with ADHD. [Connor: 2000] [Pringsheim: 2015]
• Atypical Antipsychotics: Some evidence supports the use of risperidone in children with ODD who do not have ADHD. Trials looking at the use of risperidone as an adjunctive treatment to stimulant medication in children with ADHD and ODD showed improvement in ODD symptoms but inconsistent results around improvement of ADHD symptoms. [Jahangard: 2017] [Pringsheim: 2015] [Gadow: 2014] Comparison of risperidone and aripiprazole in children with ADHD and ODD showed similar improvements in both groups. [Safavi: 2016] Risks of using atypical antipsychotics include increased weight gain, metabolic and hormonal changes and the risk of extrapyramidal side effects, so these medications should be used cautiously and considered only after previous treatments have failed. [Shafiq: 2018]

Integrative Medicine

Consider supplements, such as omega fatty acids, to support the treatment of ADHD. The evidence basis for certain supplements is growing; however, studies are still quite limited and there is an abundance of misleading information on the Internet. Limited evidence supports mindfulness practices to address aggression and anger management, with a recent study specifically looking at mindfulness in boys with ADHD and ODD. [Muratori: 2020] Very limited evidence suggests a possible role for Qigong or Tai Chi (moving meditation practices) to help address both hyperactivity and other behavioral disorders. [Rodrigues: 2019] See Integrative Medicine for CYSHCN.

Other Comorbid Disorders

In a child who is not responding well to treatment, consider mood disorders, sleep problems, traumatic events, inadequate nutrition, language, and/or learning disabilities that may be confounding results.