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Epstein R, Fonnesbeck C, Williamson E, et al. Psychosocial and Pharmacologic Interventions for Disruptive Behavior in Children and Adolescents [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 Oct. (Comparative Effectiveness Reviews, No. 154.)
Psychosocial and Pharmacologic Interventions for Disruptive Behavior in Children and Adolescents [Internet].
Show detailsDisruptive Behavior Disorders (DBDs) are a group of related psychiatric disorders of childhood and adolescence marked by temper tantrums, interpersonal aggression, and defiance. These disorders and related symptoms may manifest in young children as significant behavioral problems at home and difficulties at school. Children with the highest levels of disruptive behavior in early childhood, often experience persistent impairment1 and are at increased risk for negative developmental outcomes including substance abuse problems, school problems, and delinquent, violent, and antisocial or criminal behaviors in adolescence.2-14
DBDs are among the most common child and adolescent psychiatric disorders, with recent estimates indicating that 3.5% of children between the ages of 3-17 years had behavioral or conduct problems from 2005-2011.15 Examples of DBDs include Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), attention deficit hyperactivity disorder (ADHD) (as categorized in the fourth edition Diagnostic and Statistical Manual of Mental Disorders;16 re-classified as a neurodevelopmental disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders)17 and disruptive behavior disorder not otherwise specified.18-22 Estimates suggest that disruptive behaviors that are problematic but do not meet formal diagnostic criteria may be more common than those meeting formal clinical diagnostic criteria.2 The etiology of DBDs is unknown, but temperamental, biological, and environmental factors are associated with increased risk.
DBDs are associated with increased risk for a wide range of negative developmental outcomes including substance abuse problems, school problems, and delinquent, violent, and antisocial or criminal behaviors.2-14 As many of these problems persist into adulthood, the economic costs of DBDs are high. The etiology of DBDs is unknown but temperamental, biological and environmental factors are associated with increased risk. Temperamental risk factors include callous-unemotional traits, behavioral disinhibition, and indicators of limited executive functioning such as having a short attention span.23 Biological risk factors include lower salivary cortisol levels, lower baseline heart rate levels, and higher increases in heart rate in response to frustration.24,25 Low birthweight children also are at increased risk for DBDs.26,27
Environmental risk factors include prenatal exposure to maternal smoking, substance use, illness, and stress.26 Children who have experienced abuse and neglect, early separation from their parents including adoption, and maternal anxiety and depression are also at increased risk.26 Risk attributable to factors such as maternal smoking, substance use, and anxiety and depression during pregnancy have been addressed by more general public health campaigns. Although DBD-specific preventive interventions have been developed, practical considerations including training requirements and cost pose challenges to broad implementation.28,29
Treatment
General outpatient psychotherapy and psychotropic medication management are the most commonly used interventions, either alone or in combination.18,30-33 Psychosocial interventions have been developed for some patient subgroups and for some symptoms/symptom clusters. Examples of these interventions include child-level interventions such as Cognitive-Behavioral Therapy (CBT); parent-level interventions such as the Positive Parenting Program (Triple P); and multicomponent interventions such as Multisystemic Therapy (MST).34-41
The use of psychotropic medications to manage disruptive behaviors has increased dramatically and has primarily, but not exclusively, been accounted for by increasing use of atypical antipsychotic medications.31-33,42 Using data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, Cooper and colleagues31 demonstrated that antipsychotic prescribing increased nearly five-fold from 8.6 per 1,000 U.S. children in 1995-96 to 39.4 per 1,000 U.S. children in 2001-02. Furthermore, the medication prescribing increases were greater for non-approved indications including DBDs than for approved indications such as schizophrenia, psychosis, Tourette's syndrome, autism, and mental retardation.
There is wide range of medications used with a significant degree of decisional uncertainty around safety, efficacy, and which combinations to use.43 Classes of medications that have been studied for treatment of disruptive behaviors include antipsychotics, mood stabilizers, anticonvulsants, and psychostimulants.44 Combination therapy with antipsychotics and stimulants is commonly used for patients with attention deficit hyperactivity disorder (ADHD) comorbid with DBD or aggression;45 however, superiority over monotherapy and tolerability of combined pharmacologic treatment is unclear.
Systematic Reviews and Guidelines
We identified a number of systematic reviews and meta-analyses published recently evaluating pharmacotherapy for youth with disruptive behaviors.45-53 Other recent reviews evaluated the effectiveness of parenting programs, cognitive behavior therapies, social skills, and other nonpharmacologic treatments such as acupuncture and dietary supplementation.54-63
The recently published Treatment of Maladaptive Aggression in Youth guidelines64,65 from the Center for Education and Research on Mental Health Therapeutics (CERT) recommend psychosocial interventions and address the use of combination therapy. The guidelines suggest initial medication management and psychosocial treatments to address any underlying condition, followed by use of an antipsychotic or mood stabilizer to treat persistent aggression.64,65 Data from high quality studies are needed to confirm these recommendations.
Antipsychotic drugs have FDA approval for a limited set of specific indications in children, including bipolar and irritability associated with autism, although not for Disruptive Behavior Disorder. Nonetheless, pediatric use of both first and second-generation antipsychotics has rapidly increased in recent years, including in conditions for which they are not FDA indicated. Recent reviews have concluded that there is an absence of evidence from controlled studies on the long-term efficacy and safety of these drugs in children.66 Although there is a recent review of antipsychotics for pediatric patients, this review is not specific to disruptive behavior disorders and concludes that there are important gaps in the literature on the comparative effectiveness and relative safety of these drugs.67 The authors of a systematic review of antipsychotic and psychostimulant drug combination therapy for ADHD and DBD noted that most studies were performed over short time periods, and several studies lacked blinding.45
A review from the Substance Abuse and Mental Health Services Administration (SAMHSA) describes “promising” practices for treatment and prevention of disruptive behaviors in children.68 Despite the existence of these and other reviews of pharmacologic and psychosocial interventions, there remains an absence of clear and accessible guidance for best practice.
Wide variations in clinical management of DBDs, including the use of polypharmacy and tailored psychosocial approaches, frequently administered with little to no adherence to a standard protocol, are described in the literature. In the absence of clearly synthesized information about which interventions are most safe and effective for specific patient subgroups, it is difficult for healthcare providers to make informed treatment recommendations. For example, individual studies of Problem-Solving Skills Training and Parent-Child Interaction Therapy have reported positive results for children with DBDs, but it is unclear how healthcare providers should select between a child-level intervention, a parent-level intervention, a multicomponent intervention, and pharmacotherapy. The role of early risk factors, family ecology, and treatment history on treatment response remains unclear. Treatment decision dilemmas are further complicated for patients with medical and/or psychiatric comorbidities. The safety of atypical antipsychotics also is an important concern.45,50-52
Scope of the Review
DBDs are a heterogeneous group of conditions; disruptive behaviors are also heterogeneous and are often present in the absence of a specific DBD diagnosis. Studies that are intended to assess treatment for conditions such as ADHD, for example, are likely to report changes in disruptive behaviors as outcomes. For this reason, and because a review of ADHD currently exists,69 we focused the current review on studies in which the aim of treatment was specifically a disruptive behavior, with or without a DBD diagnosis. We excluded studies focusing on treating ADHD and other conditions that may include disruptive behaviors, (e.g., autism, developmental disability) but are not intended to assess treatments focused on reducing disruptive behaviors themselves.
This review specifically focused on psychosocial and pharmacologic interventions for disruptive behavior. We also sought studies of combined or co-interventions (i.e., combinations or pharmacologic agents or psychosocial intervention, or medication used in conjunction with psychosocial interventions). We included studies of parent-targeted psychosocial interventions if the study reported changes to child disruptive behavior. For pharmacologic interventions, we targeted the literature on their use in disruptive behavior disorders, focusing on a smaller but more focused literature base. The choice of outcomes on which to focus the analysis and particularly the strength of evidence was challenging for this review. Many different measures are used to assess components of disruptive behavior, not all of which have been validated. We extracted data on behavioral and functional outcomes and emphasized the use of validated measures, particularly the ECBI and CBCL for conducting strength of evidence assessments and in the meta-analysis.
We outline the population, interventions, comparators, outcomes, timing, and setting for the review in the PICOTS (Table 1).
Table 1
PICOTS.
Key Questions
The treatments for disruptive behaviors and disruptive behavior disorders include both psychological and pharmacologic approaches. Nonpharmacologic interventions usually are recommended as the initial strategy, but clinicians and families are likely to use both approaches at some point, possibly simultaneously, creating further decisional dilemmas related to co-therapy, polypharmacy, and the role of treatment history. We therefore framed the Key Questions to ascertain the comparative effectiveness of various psychological and pharmacologic treatments aimed at disruptive behaviors, compared both within and between treatment types, and ascertain whether there are combinations of psychological and pharmacologic therapeutic approaches that are optimal.
Key Question 1: In children under 18 years of age treated for disruptive behaviors, are any psychosocial interventions more effective for improving short-term and long-term psychosocial outcomes than no treatment or other psychosocial interventions?
Key Question 2: In children under 18 years of age treated for disruptive behaviors, are alpha-agonists, anticonvulsants, beta-blockers, central nervous system stimulants, first-generation antipsychotics, second-generation (atypical) antipsychotics, and selective serotonin reuptake inhibitors more effective for improving short-term and long-term psychosocial outcomes than placebo or other pharmacologic interventions?
Key Question 3: In children under 18 years of age treated for disruptive behaviors, what is the relative effectiveness of any psychosocial interventions compared with the pharmacologic interventions listed in Key Question 2 for improving short-term and long-term psychosocial outcomes?
Key Question 4: In children under 18 years of age treated for disruptive behaviors, are any combined psychosocial and pharmacologic interventions listed in Key Question 2 more effective for improving short-term and long-term psychosocial outcomes than individual interventions?
Key Question 5: What are the harms associated with treating children under 18 years of age for disruptive behaviors with either psychosocial or pharmacologic interventions?
Key Question 6a: Do interventions intended to address disruptive behaviors and identified in Key Questions 1-4 vary in effectiveness based on patient characteristics, including sex, age, racial/ethnic minority, family history of disruptive behavior disorders, family history of mental health disorders, history of trauma, and socioeconomic status?
Key Question 6b: Do interventions intended to address disruptive behaviors and identified in Key Questions 1-4 vary in effectiveness based on characteristics of the disorder, including specific disruptive behavior or disruptive behavior disorder (e.g., oppositional defiant disorder, conduct disorder, aggression), concomitant psychopathology (e.g., attention deficit hyperactivity disorder or substance abuse), related personality traits and symptom clusters, presence of comorbidities (other than concomitant psychopathology), age of onset, and duration?
Key Question 6c: Do interventions intended to address disruptive behaviors and identified in Key Questions 1-4 vary in effectiveness based on treatment history of the patient?
Key Question 6d: Do interventions intended to address disruptive behaviors and identified in Key Questions 1-4 vary in effectiveness based on characteristics of the treatment, including duration, delivery, timing, and dose?
Organization of This Report
We have organized the report by Key Question. For Key Question 1 (psychosocial interventions) we present the studies by age (categorized as preschool, school-age, and adolescent) and then further divide the sections by single or multiple intervention components. For Key Question 2 (pharmacologic interventions) we present the study information by study drug categories. For Key Question 5 we present the harms information from included studies, existing reviews, and gray literature. We limited the meta-analysis to Key Question 1 and more specifically to those outcomes reported using a common and validated outcome measure for disruptive behavior.
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