Disruptive Behavior Disorders

What is the need for a behavioral management program for children and teens with
ADHD and disruptive behaviors?

ADHD remains the behavioral problem most often diagnosed by pediatricians. Research
has established that disruptive behavior disorders are commonly seen with ADHD. From
30% to 50% of children with ADHD in a community sample, and 50% of children in a
clinically referred sample, are likely to have another externalizing, disruptive behavior
disorder. (Wilens et al., 2002; Busch et al., 2002) In clinical practice, children with
ADHD often have behavioral problems including ODD/CD. The presence of these
externalizing behavior disorders significantly complicates the acute presentation of
ADHD and is associated with more severe ADHD symptoms and overall impairment and
a worse overall long-term prognosis. Considering this negative prognosis, early
identification and treatment of behavior and conduct problems in children and teens with
ADHD cannot be overemphasized.

The American Academy of Pediatrics in their Guidelines for the Assessment and
Treatment of ADHD, recommend that pediatricians assess for coexisting conditions in
addition to ADHD symptomatology. They are then urged to begin treatment of diagnosed
children with “stimulant medications and/or behavioral treatment” after “negotiating
target outcomes.” (AAP, 2001) Stimulant medications have long been known to be safe
and effective in the treatment of ADHD and should be considered the first line of
treatment for children and teens with ADHD and coexisting ODD/CD. However, if
ADHD symptoms respond but ODD/CD symptoms persist after medication intervention,
psychosocial treatment should then be added to the treatment regime. If symptoms
associated with ODD/CD are extreme at the time of diagnosis, multimodal treatment is
often needed from the beginning.

The role of psychosocial interventions alone or in combination with medication
for the treatment of ADHD have been studied extensively. The NIMH MTA study
(MTA Cooperative Group, 1999; MTA Cooperative Group, 2004) and the Multimodal
Psychosocial Treatment study (MPT, also known as the New York/Montreal study)
(Klein et al., 2004) have examined the effects of pharmacological and behavioral
treatments on ADHD symptoms when used alone or in multimodal treatment programs.
These large-scale, long-term, randomized clinical trials have greatly contributed to the
field as to the efficacy of long-term medication treatment and the role of psychosocial
interventions in ADHD.

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