ADHD and aggression

Question 1

CADDRA recommendations for treating children with ADHD and comorbid ODD

Answer 1

Optimize pharmacotherapy of ADHD

Parent and other behavioural treatments.

Question 2

CADDRA recommendations for ADHD and comorbid conduct disorder

Answer 2

Medications are usually effective in reducing ADHD and impulsive aggression

Usually these children benefit from multimodal treatment

May require antipsychotics or mood stabilizers (but relative benefits unclear).

Question 3

Effect size for psychostimulants for aggression, oppositional behaviour, and conduct problems in youth with ADHD (with or without ODD and CD)

Answer 3

Parent: 0.55

Teacher: 0.84

High quality evidence, moderate to large effect

Question 4

Effect size for guanfacine for oppositional behaviour in youth with ADHD, with and without ODD

Answer 4

0.43 (small to moderate)

Moderate quality evidence

Question 5

Effect size for atomoxetine for oppositional behaviour in youth with ADHD, with and without ODD and CD

Answer 5

0.33 (small effect)

High quality evidence

Question 6

Which class of medication for ADHD has been studied with respect to aggression in youth?

Answer 6

Only studies of psychostimulants have evaluated all 3 outcomes of oppositional behaviour, conduct problems, and aggression.

Question 7

How do comorbid ODD and CD affect the medication treatment for ADHD?

Answer 7

Comorbid ODD or CD are correlated negatively with effect size for disruptive and aggressive behaviour with psychostimulants.

For atomoxetine, there are no differences based on presence or absence of comorbid ODD and CD. (Pringsheim et al Can J. Psych 2015)

Question 8

What is the first-line treatment for a child with ADHD with symptoms of ODD, CD, or aggression?

Answer 8

Psychostimulants - whether or not there is a diagnosis of ODD or CD. They have the largest effect size for ADHD symptoms and aggression / oppositional / conduct symptoms.

Question 9

Evidence for risperidone for ADHD and aggression / oppositional behaviour.

Answer 9

Risperidone has moderate-quality evidence of moderate-to-large effect in youth with subaverage IQ and ODD, CD, or DBD NOS. (ES=0.72)

Risperidone has high-quality evidence of moderate effect on aggression and disruptive behaviour in youth with average IQ and ODD or CD, +/- ADHD. (ES=0.60)

(Pringsheim et al 2015)

Question 10

The most-studied psychosocial interventions for children 8 years of age and younger for aggression.

Answer 10

Group parent training programs (effect size 0.5-0.83, comparable to risperidone).

Question 11

Psychosocial interventions for children older than 8 years, for aggression

Answer 11

Brief strategic family therapy (ES=0.68)

Multisystemic therapy (ES=0.25)

CBT (ES=0.58)

(Treatment of maladaptive aggression in youth guidelines)

Question 12

Goal of brief strategic family therapy for aggression

Answer 12

Modify family interactions (T-MAY)

Question 13

Goal of multisystemic therapy for aggression in youth

Answer 13

Increase family communiction

Parenting skills

Increase peer relationships

(Treatment of maladaptive aggression in youth)

Question 14

Evidence for quetiapine in conduct problems in youth with CD.

Answer 14

Very low quality evidence, large effect. (Pringsheim et al 2015, CJP)

Question 15

What is the evidence for haloperidol for aggression in youth with CD?

Answer 15

Very-low-quality evidence, magnitude of effect uncertain. (Pringsheim et al 2015, CJP)

Question 16

Evidence base for lithium for aggressive behaviour in youth with CD?

Answer 16

Low-quality evidence that lithium is associated with higher odds of response or remission than placebo. (Pringsheim et al 2015, CJP)

Question 17

Evidence base for divalproex for aggressive behaviour in youth?

Answer 17

Low-quality evidence that divalproex is associated with a higher odds of response or remission compared with placebo, for aggressive behaviour in youth with ODD or CD, +/- ADHD.

Question 18

Evidence for carbamazepine for management of aggression in youth.

Answer 18

Very-low-quality evidence that CBZ is no different from placebo for management of aggression in youth with CD. (Pringsheim et al, 2015, CJP)