title: Canadian guidelines on pharmacotherapy for disruptive and aggressive behaviour in children and adolescents with attention-deficit hyperactivity disorder, oppositional defiant disorder, or conduct disorder.
abstract: OBJECTIVE
  To develop evidence-based guidelines on pharmacotherapy for severe disruptive and aggressive behaviour in children and adolescents with attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), or conduct disorder (CD). The guidelines assume that psychosocial interventions have been pursued but did not achieve sufficient improvement.
  
  
  METHODS
  A multidisciplinary consensus group used the Grading of Recommendations Assessment, Development and Evaluation approach for rating evidence quality and for grading recommendations. We conducted a systematic review of medications studied in placebo-controlled trials for treating disruptive and aggressive behaviour in children and adolescents with ADHD, ODD, or CD. We followed consensus procedures to make 1 of 4 recommendations for each medication: strong, in favour (↑↑); conditional, in favour (↑?); conditional, against (↓?); and strong, against (↓↓).
  
  
  RESULTS
  For children and adolescents with disruptive or aggressive behaviour associated with ADHD, psychostimulants received a strong recommendation in favour of use, while atomoxetine and alpha-2 agonists received a conditional recommendation in favour of use. If these patients do poorly with ADHD medications, the medication with the most evidence is risperidone. Risperidone also has the most evidence for treating disruptive or aggressive behaviour in the absence of ADHD. However, given risperidone's major adverse effects, it received only a conditional recommendation in favour of use. We recommended against using quetiapine, haloperidol, lithium, or carbamazepine because of the poor quality of evidence and their major adverse effects.
  
  
  CONCLUSIONS
  When severe disruptive or aggressive behaviour occurs with ADHD, medications for ADHD should be used first. Other medications have major adverse effects and, with the exception of risperidone, very limited evidence to support their use.
authors.affiliation: Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario; Psychiatrist, The Hospital for Sick Children, Toronto, Ontario.
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Gorman
authors.affiliation: Professor, Department of Psychiatry and College of Pharmacy, Dalhousie University, Halifax, Nova Scotia.
authors.forename: David M
authors.initials: DM
authors.lastname: Gardner
authors.affiliation: Associate Professor, Department of Psychiatry and College of Pharmacy, Dalhousie University, Halifax, Nova Scotia.
authors.forename: Andrea L
authors.initials: AL
authors.lastname: Murphy
authors.affiliation: Associate Professor, Department of Paediatrics, University of Toronto, Toronto, Ontario; Paediatrician, The Hospital for Sick Children and St Joseph's Health Centre, Toronto, Ontario.
authors.forename: Mark
authors.initials: M
authors.lastname: Feldman
authors.affiliation: Clinical Assistant Professor, Department of Paediatrics, Université de Montréal, Montreal, Quebec; Paediatrician (Diplôme d'études spécialisées Paediatric Neurology), Centre hospitalier universitaire Sainte-Justine, Montreal, Quebec.
authors.forename: Stacey A
authors.initials: SA
authors.lastname: Bélanger
authors.affiliation: Professor, Departments of Psychiatry, Family Medicine, and Paediatrics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario.
authors.forename: Margaret M
authors.initials: MM
authors.lastname: Steele
authors.affiliation: Assistant Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario.
authors.forename: Khrista
authors.initials: K
authors.lastname: Boylan
authors.affiliation: Lecturer, Department of Psychiatry, University of Toronto, Toronto, Ontario; Psychiatrist, Youthdale Treatment Centres, Toronto, Ontario.
authors.forename: Kate
authors.initials: K
authors.lastname: Cochrane-Brink
authors.affiliation: Clinical Assistant Professor, Department of Paediatrics, University of Calgary, Calgary, Alberta.
authors.forename: Roxanne
authors.initials: R
authors.lastname: Goldade
authors.affiliation: Child and Adolescent Psychiatrist, Glenrose Attention-Deficit Hyperactivity Disorder Clinic, Edmonton, Alberta.
authors.forename: Paul R
authors.initials: PR
authors.lastname: Soper
authors.affiliation: Clinical Lecturer, Department of Psychiatry, University of Alberta, Edmonton, Alberta.
authors.forename: Judy
authors.initials: J
authors.lastname: Ustina
authors.affiliation: Assistant Professor, Department of Clinical Neurosciences, Psychiatry, Community Health Sciences, and Paediatrics, University of Calgary, Calgary, Alberta; Neurologist, Director, Calgary Tourette and Paediatric Movement Disorders Clinic, Calgary, Alberta.
authors.forename: Tamara
authors.initials: T
authors.lastname: Pringsheim
mesh_terms: D000293:Adolescent; D000374:Aggression / Q000187:drug effects*; D001289:Attention Deficit Disorder with Hyperactivity / Q000188:drug therapy*; D019958:Attention Deficit and Disruptive Behavior Disorders / Q000188:drug therapy*; D002170:Canada; D002648:Child; D019955:Conduct Disorder / Q000188:drug therapy*; D006801:Humans; D017410:Practice Guidelines as Topic / Q000592:standards*