Pharmacologic management of aggression or severe irritability in children/adolescents with syndromal or subsyndromal oppositional defiant disorder and/or conduct disorder*

ODD/CD: oppositional defiant disorder and/or conduct disorder; ADHD: attention deficit hyperactivity disorder; SGA: second-generation antipsychotic.

* Our preference is to treat all individuals with syndromal or subsyndromal symptoms of ODD/CD with an evidence-based psychosocial intervention as the first treatment option. However, for individuals with aggression and/or irritability that affect the treatment or cause psychosocial distress (eg, school, interpersonal, work), we use pharmacologic management in addition to psychosocial intervention.

¶ We treat individuals with comorbid disorders (eg, ADHD, mood disorders) with an evidence-based pharmacologic treatment for that particular disorder. Refer to UpToDate content for treatment of other disorders in children and adolescents, including mood disorders, anxiety disorders, and substance use disorders.

Δ We consider a therapeutic trial to be four to six weeks at the maximum-tolerated dose within the therapeutic range. For all individuals whose symptoms do not improve despite a therapeutic trial, we review the diagnosis, adherence to treatment, and for the presence of environmental stressors that may be exacerbating the symptoms. We address these as indicated.

◊ Refer to UpToDate content for choice, titration, and monitoring of SGA medications in children and adolescents.

§ There are limited data guiding treatment duration for children or adolescents who respond to treatment for syndromal or subsyndromal ODD/CD. Refer to UpToDate content for discussion of treatment duration and tapering of medications.

¥ Choice of subsequent agents are based on extant evidence, patient preference, history of prior treatment, family history of treatment with medications, and clinician comfort with and familiarity with agents. Refer to UpToDate content for further discussion of these subsequent choices.