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“Behavioral disorders in pediatric patients—primarily ADHD—pose a clinical challenge for healthcare providers to accurately assess, diagnose, and treat.”1

-Dr. Joseph Austerman, DO

“Behavioral disorders in pediatric patients—primarily ADHD—pose a clinical challenge for healthcare providers to accurately assess, diagnose, and treat.”1

-Dr. Joseph Austerman, DO

Disruptive behaviors can mimic ADHD symptoms

Children with attention-deficit/hyperactivity disorder (ADHD) may have a temperament-neuropsychological profile characterized by argumentativeness, irritability, and impulsivity—making differential diagnosis a challenge.1

The table below can be used as a guideline for the differential distinctions between ADHD and behavioral disorders.

Behavioral Disorders
Behavior Disorders and ADHD

Behavior disorders and ADHD

Shared Features
Differential Distinguishers
Key Facts
Oppositional defiant disorder (ODD)
Shared Features
  • Resistance to tasks2
  • Difficulty with self-control2
  • Executive functioning deficits2
Differential Distinguishers
  • ADHD: oppositional behaviors are more likely due to forgetfulness and difficulty sustaining attention and focus2
  • ODD: defiance may be vindictive, or part of an attempt at dominance1
Key Facts
  • A persistent pattern of oppositional behavior that is within the 4 ODD categories and lasts ≥6 months is suggestive of ODD2
  • ODD occurs in ~50% of children with combined (inattentive/ hyperactive) ADHD and in ~25% of those with inattentive ADHD2
Conduct disorder (CD)
Shared Features
  • Poor self-control2
  • Possible behavioral aggression2
  • Disregard for rules and boundaries2
Differential Distinguishers
  • ADHD: impulsive behavior typically does not violate societal norms or rights of others2
  • CD: purposeful aggression, eg, fire setting, physical cruelty towards others or animals, lack of remorse or empathy, bullying on social media2
Key Facts
  • Children with CD may have a pattern of school truancy and running away from home before the age of 132
  • ~25% of children/teens with combined ADHD have a comorbid diagnosis of CD2
Intermittent explosive disorder (IED)
Shared Features
  • Failure to control impulsive behavior1
  • Symptoms can manifest as early as 3 or 4 years of age1
Differential Distinguishers
  • ADHD: impulsive behavior is not typically aggressive2
  • IED: patients can show serious aggression towards others, out of proportion to provocation1
Key Facts
  • IED is relatively rare in children and adolescents2
Tic disorder
Shared Features
  • Fidgeting2
  • Disruptive movements or vocalizations2
  • Symptoms often seen first in childhood, with a higher prevalence in males2
Differential Distinguishers
  • ADHD: disruptive behavior can be managed with appropriate therapies and treatment2
  • Tic disorder: while they may appear purposeful, tics are generally involuntary; however, they may be suppressed for periods of time2
Key Facts
  • Impairment caused by comorbid tic disorder may be minimal compared to the impact on academic and social functioning associated with ADHD2

This table is intended as a quick reference guide only. For full diagnostic criteria, please refer to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM–V).

Managing comorbid behavioral disorders and ADHD

In pediatric patients with ADHD, comorbid behavioral problems should be addressed in the treatment plan.1 A multimodal management approach that involves pharmacologic therapy as well as participation of the child’s parents and school are recommended.1*

  • First-line therapy for comorbid ODD or conduct disorder involves use of a stimulant in addition to behavioral therapy interventions that target disruptive behavior1
  • If the behavioral comorbidity is severe, alpha agonists and even second-generation antipsychotics may be added to the treatment plan1

You can learn more about the multimodal management of ADHD comorbidities here.

There is no FDA-approved medication for ODD. However, antipsychotic medications are frequently prescribed if a child is at risk of being removed from school or the home.3

More to ADHD

Visit our patient site for resources designed for parents of children and adolescents with ADHD.

Visit MoreToADHD.com

References:1. Austerman J. ADHD and behavioral disorders: assessment, management, and an update from DSM-5. Cleveland Clinic J Med. 2015;82(suppl 1):S2-S7. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Publishing; 2013. 3. Kahn S, Down J, Aouira N, et al. Current pharmacotherapy options for conduct disorders in adolescents and children. Expert Opin Pharmacother. 2019;20(5):571-583.