Table 3.
Summary of recommendations: pharmacotherapy for oppositional behaviour, conduct problems, and aggression in children and adolescents with ADHD, ODD, or CD
| Medication | Population | Outcome | Magnitude of benefit and side effect burden | Recommendation (strength, direction) | Dosing information |
|---|---|---|---|---|---|
| Psychostimulants | Children and adolescents with ADHD, with or without ODD or CD | Oppositional behaviour, conduct problems, and aggression | Benefit: moderate to large Adverse effects: minor Quality of evidence: high | Strong, in favour (↑↑) | Dosing varies by psychostimulant formulation; consult individual product monographs for dosing recommendations |
| Atomoxetine | Children and adolescents with ADHD, with or without ODD or CD | Oppositional behaviour | Benefit: small Adverse effects: minor Quality of evidence: high | Conditional, in favour (↑?) | Doses used in included studies: 0.5 to 2.0 mg/kg/day (up to a maximum of 90.0 mg/day) |
| Canadian product monograph57 recommended dosing for the treatment of ADHD: titrate in 3 steps up to a target dose of 1.2 mg/kg/day, not to exceed 80.0 mg/day; maximum dose is 1.4 mg/kg/day, not to exceed 100.0 mg/day | |||||
| Guanfacine | Children and adolescents with ADHD, with or without ODD | Oppositional behaviour | Benefit: small to moderate Adverse effects: moderate Quality of evidence: moderate | Conditional, in favour (↑?) | Doses (extended-release formulation) used in included studies: 1.0 to 4.0 mg/day (monotherapy or adjunct to a psychostimulant) |
| Canadian product monograph (extended-release formulation)34 recommended dosing for the treatment of ADHD: in children 6 to 12 years and ≥25 kg, start 1 mg/day and increase in increments of no more than 1 mg/week up to a maximum of 4 mg/day (monotherapy or adjunctive therapy) | |||||
| Clonidine | Children and adolescents with ADHD, with or without ODD or CD | Oppositional behaviour and conduct problems | Benefit: small Adverse effects: moderate Quality of evidence: very low | Conditional, in favour (↑?) | Doses (immediate- or extended-release formulation) used in included studies: 0.1 to 0.6 mg/day (monotherapy or adjunct to a psychostimulant) |
| Canadian product monograph (immediate-release formulation)58 recommended dosing: safety and efficacy in children not established | |||||
| Risperidone | Children and adolescents with average IQ and ODD or CD, with or without ADHD | Disruptive and aggressive behaviour | Benefit: moderate Adverse effects: major Quality of evidence: high | Conditional, in favour (↑?) | Doses used in included studies: |
| Monotherapy: 0.5 to 1.5 mg/day | |||||
| Adjunct to a psychostimulant: 1.0 to 2.5 mg/day | |||||
| Canadian product monograph59 recommended dosing: safety and efficacy in children <18 years not established and use is not recommended | |||||
| Risperidone | Children and adolescents with low IQ and ODD or CD, with or without ADHD | Conduct problems and aggression | Benefit: moderate to large Adverse effects: major Quality of evidence: moderate | Conditional, in favour (↑?) | Doses used in included studies: 0.5 to 4.0 mg/day |
| Canadian product monograph59 recommended dosing: safety and efficacy in children <18 years not established and use is not recommended | |||||
| Quetiapine | Adolescents with CD, with or without ADHD | Conduct problems | Benefit: large Adverse effects: major Quality of evidence: very low | Conditional, against (↓?) | Doses (immediate-release formulation) used in included study: 200 to 600 mg/day |
| Canadian product monograph60 recommended dosing: not recommended for use in patients under <18 years | |||||
| Haloperidol | Children with CD | Aggression | Benefit: some benefit, but magnitude uncertain Adverse effects: major Quality of evidence: very low | Strong, against (↓↓) | Not applicable, given the strong recommendation against its use |
| Valproate | Children and adolescents with ODD or CD, with or without ADHD | Aggression | Benefit: large Adverse effects: major Quality of evidence: low | Conditional, in favour (↑?) | Doses used in included studies: |
| Monotherapy: 750 to 1500 mg/day (immediate release) | |||||
| Adjunct to a psychostimulant: 20 mg/kg/day (extended release) | |||||
| Canadian product monograph61 recommended dosing for the treatment of epilepsy: start 15 mg/kg/day and titrate weekly by 5 to 10 mg/kg/day; maximum dose is 60 mg/kg/day | |||||
| Lithium | Children and adolescents with CD | Aggression | Benefit: large Adverse effects: major Quality of evidence: low | Conditional, against (↓?) | Doses (immediate-release formulation) used in included studies: 900 to 1200 mg/day OR dosed to maintain a serum level of 0.6 to 1.0 mmol/L |
| Canadian product monograph62 recommended dosing for the treatment of bipolar disorder: dosing must be individualized for each patient according to blood levels and clinical response; use is not recommended in children <12 years | |||||
| Carbamazepine | Children with CD | Aggression | Benefit: none Adverse effects: major Quality of evidence: very low | Strong, against (↓↓) | Not applicable, given the strong recommendation against its use |