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Oppositional Defiant Disorder/Conduct Disorder and ADHD

Two distinct externalizing conditions, oppositional defiant disorder (ODD) and conduct disorder (CD) are found in as many as 40-60% of children and adolescents with ADHD. [Biederman: 2007] The impact of these comorbid diagnoses is considerable particularly for adolescents, to the point where some researchers argue that ADHD +ODD/CD should be a separate diagnostic entity from ADHD in adolescence. [Perera: 2012] Ten-year follow up of boys with ADHD and ODD or ODD /CD reveal a “compromised” outcome, including depression and worsening of symptoms. [Biederman: 2008] This has significant implications for both individual health and impacts on family, community, and society.

In the 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] Intermittent explosive disorder is a third type of disorder related to ODD and CD. All of these have both emotional and behavioral facets.

These disorders are defined as a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months, that occurs more frequently than is typically observed in children of comparable age and developmental level, and that 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
Oppositional behaviors that define ODD occur in much more systematic and severe patterns than in the normal oppositional behaviors of young children and early adolescents 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. Treatments include Parent Management Training Programs, psychotherapy, and skills training in problem solving and social interactions. Positive parenting techniques are critical to effective management.
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 towards people or animals, property destruction, habits including lying, cheating, or stealing, and a pattern of violating rules. [AACAP: 2013] Treatments can include behavior and psychotherapy, medications, school interventions, and home-based treatment models.

Intermittent explosive disorder is less frequently studied in the ADHD literature as a comorbidity. This disorder 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. As with ODD and CD, treatment of concurrent ADHD may help alleviate symptoms and severity of intermittent explosive disorder.

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. See DSM-5: Changes to the Diagnostic and Statistical Manual of Mental Disorders.

Treatment

A team approach by a psychologist, school system, and a pediatrician, with additional consultative support from a psychiatrist is recommended. Because there is lack of agreement among researchers regarding the best management practices of these comorbid conditions, an individualized approach will be necessary. Components of this treatment may include:
  • 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 is 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 (i.e., the child's ability to negotiate his 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: Includes parenting training, teacher training, and social skills training in the contexts of the family, peers, school and community.
  • Medication: Treatment of ADHD symptoms is often helpful in alleviating ODD symptoms. The child should receive adequate support/treatment for ADHD prior to diagnosing ODD, since these symptoms can sometimes remit. Stimulants, extended release guanfacine, clonidine, and atomoxetine can each be helpful in this population. [Biederman: 2007] [Findling: 2014] [Connor: 2010] Medications that specifically address the symptoms of ODD/CD are less commonly employed. Clonidine may be used in combinations with other agents in the treatment of the child's ADHD, with the clonidine specifically employed to address hyper-aroused behaviors (clonidine has limited impact on attention symptoms). Other pharmacological agents to address aggression may be used in extreme cases but is usually planned in consultation with a psychiatrist.
  • Integrative medicine: Consider supplements such as omega fatty acids. The evidence basis for use of certain supplements is growing, however studies are still quite limited and there is an abundance of misleading information on the Internet.
  • Other co-morbid disorders: In a child who is not responding well to treatment, consider mood disorders, sleep problems, traumatic events, inadequate nutrition, and/or learning disabilities that may be confounding results.

Medical Home Roles

  • Identifying the clinical concern for ODD/CD
  • Ensuring referral and treatment by a psychologist
  • Ensuring the parent's know-how to access appropriate school services
  • Ensuring family-centered team collaboration
  • Supporting parents in advocating for needed supports
  • Prescribing medication or consulting with a psychiatrist when indicated

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)
Brief summary of etiology, prognosis, and treatment issues.

Conduct Disorder (Medscape)
Brief summary of etiology, prognosis, and treatment issues.

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 Initiative.

For Parents and Patients

Support

Mental Health America
National non-profit organization, with numerous local affiliates, dedicated to helping all people live mentally healthier lives. Includes information on a variety of mental health topics in English and Spanish.

National Alliance of Mental Illness (NAMI)
A national organization that provides information and resources for families and professionals, including helpline, local chapter resources, and advocacy.

General

Oppositional Defiant Disorder Resource Center (AACAP)
Information for families about ODD from the American Academy of Child & Adolescent Psychiatry.

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

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

Helpful Articles

PubMed Search on ADHD and Conduct Disorder

Matsudaira T.
Attention deficit disorders--drugs or nutrition?.
Nutr Health. 2007;19(1-2):57-60. PubMed abstract

Woolfenden SR, Williams K, Peat JK.
Family and parenting interventions for conduct disorder and delinquency: a meta-analysis of randomised controlled trials.
Arch Dis Child. 2002;86(4):251-6. PubMed abstract / Full Text

Connor DF, Barkley RA, Davis HT.
A pilot study of methylphenidate, clonidine, or the combination in ADHD comorbid with aggressive oppositional defiant or conduct disorder.
Clin Pediatr (Phila). 2000;39(1):15-25. 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

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

Authors

Reviewing Author: Robyn Nolan, MD - 4/2015
Compiled and edited by: Lynne M Kerr, MD, PhD - 7/2009
Content Last Updated: 4/2015

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....

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

Perera S, Crewther D, Croft R, Keage H, Hermens D, Clark CR.
Comorbid externalising behaviour in AD/HD: evidence for a distinct pathological entity in adolescence.
PLoS One. 2012;7(9):e41407. PubMed abstract / Full Text