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Attention-Deficit/Hyperactivity Disorder (ADHD) & Disruptive Behaviors

Attention-Deficit/Hyperactivity Disorder (ADHD) & Disruptive Behaviors

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.

Background

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.

Pearls & Alerts

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]

Clinical Assessment

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.

Treatment

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.

Medical Home Roles

  • Identify the clinical concern for externalizing disorders, including ODD, CD, and IED.
  • Ensure referral and treatment by a psychologist or psychiatrist.
  • Ensure the parent's know-how to access appropriate school services.
  • Ensure family-centered team collaboration.
  • Support the parents in advocating for needed supports.
  • Prescribe medication or consulting with a psychiatrist when indicated.
  • Recognize and address comorbid sleep disorders, mood disorders, inadequate nutrition, learning disabilities, and/or traumatic events that can limit response to treatment. See Attention-Deficit/Hyperactivity Disorder (ADHD) & Mood Disorders, Sleep Issues, Specific Learning Disability for more information.

Resources

Information & Support

For Professionals

Conduct Disorder Resource Center (AACAP)
Information to share with families and links to useful primary care resources; American Academy of Child & Adolescent Psychiatry.

Oppositional Defiant Disorder (Medscape)
Summary of etiology, prognosis, and treatment issues.

Intermittent Explosive Disorder
Discusses the process of diagnosis and the tests involved.

Implementing Mental Health Priorities in Practice: Disruptive Behavior and Aggression (AAP)
Video tool to help with motivational interviewing techniques to elicit concerns and address behaviors in the primary care setting; American Academy of Pediatrics Mental Health Initiatives.

For Parents and Patients

Disruptive Behavior Disorders (HealthyChildren.org)
Information about warning signs, diagnosis, and treatment of oppositional defiant disorder and conduct disorder; from the American Academy of Pediatrics.

Conduct Disorder (AACAP)
Information for families about repetitive and persistent behavioral and emotional problems in youngsters; American Academy of Child & Adolescent Psychiatry.

Conduct Disorder (Mental Health America)
Fact sheet from a national non-profit organization offering information and support.

Conduct Disorder Basics (Child Mind Institute)
Includes information about symptoms, inheritance, diagnosis, finding a specialist, related diseases, and support organizations; Genetic and Rare Diseases Information Center of the National Center for Advancing Translational Sciences.

Quick Facts on Intermittent Explosive Disorder (Child Mind Institute)
A brief overview of the signs and symptoms of intermittent explosive disorder and how it's treated in children and adolescents.

Practice Guidelines

Austerman J.
ADHD and behavioral disorders: Assessment, management, and an update from DSM-5.
Cleve Clin J Med. 2015;82(11 Suppl 1):S2-7. PubMed abstract
This article provides information, assessment, and treatment recommendations for behavioral disorders in pediatric patients.

Helpful Articles

PubMed Search on ADHD and Conduct Disorder

Gorman DA, Gardner DM, Murphy AL, Feldman M, Bélanger SA, Steele MM, Boylan K, Cochrane-Brink K, Goldade R, Soper PR, Ustina J, Pringsheim T.
Canadian guidelines on pharmacotherapy for disruptive and aggressive behaviour in children and adolescents with attention-deficit hyperactivity disorder, oppositional defiant disorder, or conduct disorder.
Can J Psychiatry. 2015;60(2):62-76. PubMed abstract / Full Text
This article provides evidence-based Canadian guidelines on pharmacotherapy for severe disruptive and aggressive behaviour in children and adolescents with attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), or conduct disorder (CD). The guidelines assume that psychosocial interventions have been pursued but did not achieve sufficient improvement.

Pringsheim T, Hirsch L, Gardner D, Gorman DA.
The pharmacological management of oppositional behaviour, conduct problems, and aggression in children and adolescents with attention-deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder: a systematic review and meta-analysis. Part 1: psychostimulants, alpha-2 agonists, and atomoxetine.
Can J Psychiatry. 2015;60(2):42-51. PubMed abstract / Full Text
Systematic review and meta-analysis indicate that psychostimulants, alpha-2 agonists, and atomoxetine can be beneficial for disruptive and aggressive behaviors in addition to core ADHD symptoms; however, psychostimulants generally provide the most benefit.

Pringsheim T, Hirsch L, Gardner D, Gorman DA.
The pharmacological management of oppositional behaviour, conduct problems, and aggression in children and adolescents with attention-deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder: a systematic review and meta-analysis. Part 2: antipsychotics and traditional mood stabilizers.
Can J Psychiatry. 2015;60(2):52-61. PubMed abstract / Full Text
A systematic review and meta-analysis of randomized controlled trials (RCTs) of antipsychotics, lithium, and anticonvulsants for aggression and conduct problems in youth with ADHD, ODD, and CD. With the exception of risperidone, the evidence to support the use of antipsychotics and mood stabilizers is of low quality.

Radwan K, Coccaro EF.
Comorbidity of disruptive behavior disorders and intermittent explosive disorder.
Child Adolesc Psychiatry Ment Health. 2020;14:24. PubMed abstract / Full Text
Aggressive behavior in children and adolescents may be accounted for by several disruptive behavioral disorders (DBD), including attention-deficit/hyperactive (ADHD), conduct (CD), oppositional defiant (ODD), and disorders and intermittent explosive disorder (IED). This study estimates the comorbidity of IED with each of the DBDs.

Lillig M.
Conduct Disorder: Recognition and Management.
Am Fam Physician. 2018;98(10):584-592. PubMed abstract
This article reviews conduct disorder essentials for the primary care clinician.

Authors & Reviewers

Initial publication: September 2008; last update/revision: April 2021
Current Authors and Reviewers:
Authors: Jennifer Goldman, MD, MRP, FAAP
Reviewer: Robyn Nolan, MD
Authoring history
2015: first version: Jennifer Goldman, MD, MRP, FAAPSA; Robyn Nolan, MDR
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

AACAP.
Conduct Disorder.
Facts for Families. 2013; (No. 33):1. Washington, DC: American Academy of Child and Adolescent Psychiatry; http://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/Facts...

American Psychiatric Association.
Highlights of Changes from DSM-IV-TR to DSM-5 .
2013; 19. American Psychiatric Publishing; http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5....

Austerman J.
ADHD and behavioral disorders: Assessment, management, and an update from DSM-5.
Cleve Clin J Med. 2015;82(11 Suppl 1):S2-7. PubMed abstract
This article provides information, assessment, and treatment recommendations for behavioral disorders in pediatric patients.

Biederman J, Petty CR, Dolan C, Hughes S, Mick E, Monuteaux MC, Faraone SV.
The long-term longitudinal course of oppositional defiant disorder and conduct disorder in ADHD boys: findings from a controlled 10-year prospective longitudinal follow-up study.
Psychol Med. 2008;38(7):1027-36. PubMed abstract

Biederman J, Spencer TJ, Newcorn JH, Gao H, Milton DR, Feldman PD, Witte MM.
Effect of comorbid symptoms of oppositional defiant disorder on responses to atomoxetine in children with ADHD: a meta-analysis of controlled clinical trial data.
Psychopharmacology (Berl). 2007;190(1):31-41. PubMed abstract

Connor DF, Findling RL, Kollins SH, Sallee F, López FA, Lyne A, Tremblay G.
Effects of guanfacine extended release on oppositional symptoms in children aged 6-12 years with attention-deficit hyperactivity disorder and oppositional symptoms: a randomized, double-blind, placebo-controlled trial.
CNS Drugs. 2010;24(9):755-68. PubMed abstract

Findling RL, McBurnett K, White C, Youcha S.
Guanfacine extended release adjunctive to a psychostimulant in the treatment of comorbid oppositional symptoms in children and adolescents with attention-deficit/hyperactivity disorder.
J Child Adolesc Psychopharmacol. 2014;24(5):245-52. PubMed abstract / Full Text

Gorman DA, Gardner DM, Murphy AL, Feldman M, Bélanger SA, Steele MM, Boylan K, Cochrane-Brink K, Goldade R, Soper PR, Ustina J, Pringsheim T.
Canadian guidelines on pharmacotherapy for disruptive and aggressive behaviour in children and adolescents with attention-deficit hyperactivity disorder, oppositional defiant disorder, or conduct disorder.
Can J Psychiatry. 2015;60(2):62-76. PubMed abstract / Full Text
This article provides evidence-based Canadian guidelines on pharmacotherapy for severe disruptive and aggressive behaviour in children and adolescents with attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), or conduct disorder (CD). The guidelines assume that psychosocial interventions have been pursued but did not achieve sufficient improvement.

Lillig M.
Conduct Disorder: Recognition and Management.
Am Fam Physician. 2018;98(10):584-592. PubMed abstract
This article reviews conduct disorder essentials for the primary care clinician.

Muratori P, Conversano C, Levantini V, Masi G, Milone A, Villani S, Bögels S, Gemignani A.
Exploring the Efficacy of a Mindfulness Program for Boys With Attention-Deficit Hyperactivity Disorder and Oppositional Defiant Disorder.
J Atten Disord. 2020:1087054720915256. PubMed abstract
This study was the first attempt to explore the efficacy of a mindfulness protocol for children with attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), and their parents.

Radwan K, Coccaro EF.
Comorbidity of disruptive behavior disorders and intermittent explosive disorder.
Child Adolesc Psychiatry Ment Health. 2020;14:24. PubMed abstract / Full Text
Aggressive behavior in children and adolescents may be accounted for by several disruptive behavioral disorders (DBD), including attention-deficit/hyperactive (ADHD), conduct (CD), oppositional defiant (ODD), and disorders and intermittent explosive disorder (IED). This study estimates the comorbidity of IED with each of the DBDs.

Rodrigues JMSM, Mestre MICP, Matos LC, Machado JP.
Effects of taijiquan and qigong practice over behavioural disorders in school-age children: A pilot study.
J Bodyw Mov Ther. 2019;23(1):11-15. PubMed abstract
This small pilot study suggests a possible role for Qigong or Tai Chi (moving meditation practices) to help address both hyperactivity and other behavioral disorders.