Behavioral problems in children can range from mild mischievousness to serious misconduct that can interfere with normal development. Children and adolescents with extreme behavioral problems, more than typical childhood misbehavior, should be evaluated by their physician for oppositional defiant disorder (ODD) or conduct disorder (CD). These disorders typically involve hostile behavior, aggression toward people and/or animals, refusal to follow rules, and anger lasting for at least six months. Often times, these can occur concurrently with other diagnoses such as attention deficit hyperactivity disorder (ADHD), anxiety disorders, depression, and bipolar disorder. One of the most common comorbidities in those diagnosed with CD is ADHD. Once these disorders are formally diagnosed, parents and their children are faced with a number of treatment options from behavior therapy to medications. Although they may be confusing at first, knowing what to expect can help improve your decisions and experience while treating these conditions.
It has been shown that behavior therapy and psychotherapy for the individual diagnosed with ODD or CD as well as the family can help improve these disorders, but oftentimes behavioral therapy is challenging due to the child’s inability to be cooperative. Studies show that when behavioral therapy is not enough, medication can have an integral role in treatment as add-on therapy. Although there are no medications that have been approved by the FDA for use in ODD or CD, a number of medications have been studied and may be appropriate to treat certain symptoms associated with these disorders, such as depression, difficulty concentrating, aggression, and hyperactivity. There are also a number of medications that are approved for other conditions seen in children and adolescents such as ADHD, depression, anxiety, or bipolar disorder.
Medications prescribed for these conditions are from a number of classes including stimulants, selective serotonin reuptake inhibitors (SSRIs), selective norepinephrine reuptake inhibitors (SNRIs), and even anticonvulsants and atypical antipsychotics. These medication classes have a number of different uses, and some of their indications can seem alarming, especially when this is not the condition that your child is being treated for. Although it can seem overwhelming for the individual and their parents, your physician or pharmacist can help explain how these medications work for the condition that they are intended to treat.
Children who exhibit hyperactivity, difficulty concentrating, or who are diagnosed with ADHD can benefit significantly from stimulant medications. Although it seems counterintuitive, stimulants can help these children and adolescents stay focused and can help improve their performance in school and other extracurricular activities. Examples of stimulant medications include methylphenidate and amphetamines. Methylphenidate is one of the most studied medications for ADHD, and has been used extensively to appropriately treat the disorder. Although there is concern about the abuse potential of these medications, there are a number of sustained release formulations that allow for once daily dosing which can help prevent abuse and diversion. Some of these medications are also available in patch form or in capsules that can be opened and sprinkled on food for those who cannot swallow tablets. These medications are typically started at a low dose and slowly titrated to higher doses before adequate results are seen. Slowly increasing doses allows you to ensure that your child is being treated with the lowest effective dose without experiencing many side effects. With stimulants, it is important to take “drug holidays” to reevaluate the need for the medications as your child gets older. Some suggest utilizing summertime when children are not in school to discontinue the medication and reassess their condition, but the appropriateness of drug holidays should be discussed with the prescriber for each individual patient. Stimulants are considered first line for ADHD and to treat symptoms of hyperactivity and difficulty concentrating in CD and ODD, but there are other medications that can work as well. In a recent multicenter clinical trial conducted in Germany, and published in the Journal of Child and Adolescent Psychopharmacology, a medication, atomoxetine, which is currently used for ADHD in the U.S., was shown to be clinically significant in reducing symptoms of ADHD and CD/ODD in children aged 6-17 with a diagnosis of both ADHD and CD/ODD. This study shows promise that medications may become approved for use in CD and ODD.
Children diagnosed with CD or ODD who show symptoms of aggression can be treated with antipsychotic medications that help restore the balance of serotonin and dopamine in the brain, thus controlling aggressive behavior. The use of these therapies should be evaluated on an individual basis, and should be reserved for use when specific symptoms are present in children and adolescents. Also, when treating CD and ODD, medications should be used only as adjunct therapy when behavior therapy alone has failed.
With all drug therapies, there are side effects and risks that should be weighed against the benefit of medication, but in numerous studies it has been proven that when indicated and used correctly, medication used adjunctively with behavioral therapy can significantly reduce symptoms and improve functioning in children and adolescents. If your child has been diagnosed with a behavioral disorder or is exhibiting signs of one, they should be evaluated by a professional and after initiating behavioral therapy, the use of appropriate medications should be considered to successfully treat the condition.