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Psychosocial and Pharmacologic Interventions for Disruptive Behavior in Children and Adolescents
Comparative Effectiveness Reviews, No. 154
Richard Epstein, PhD, MPH, Christopher Fonnesbeck, PhD, Edwin Williamson, MD, Tarah Kuhn, PhD, Mary Lou Lindegren, MD, MPH, Katherine Rizzone, MD, Shanthi Krishnaswami, MBBS, MPH, Nila Sathe, MA, MLIS, Cathy H Ficzere, PharmD, BCPS, Genevieve Lynn Ness, PharmD, Geoffrey W Wright, MS, Mamata Raj, MD, Shannon Potter, MLIS, and Melissa McPheeters, MD, MPH.
Structured Abstract
Objectives:
We systematically reviewed evidence on psychosocial and/or pharmacologic treatment for children with disruptive behavior disorders.
Data sources:
We searched MEDLINE® via PubMed® and PsycInfo®, as well as the reference lists of included studies. We used the Comparative Effectiveness Plus interface for the Iowa Drug Information Service (IDIS) database to identify regulatory information.
Review methods:
We included studies published in English from January 1994 to June 2014, did dual data extraction, and rated risk of bias and strength of evidence of the literature in accordance with the Agency for Healthcare Research and Quality Methods Guide. We analyzed data qualitatively and quantitatively. Our quantitative analysis was based on a Bayesian estimation approach, and we therefore did not conduct statistical significance tests.
Results:
We identified 84 unique studies that addressed one or more Key Questions. Of these, 66 studies assessed psychosocial interventions and 13 assessed pharmacologic interventions. The active treatment arms of studies of psychosocial interventions were categorized as interventions including only a child component (n = 2) or only a parent component (n = 25), or as multicomponent interventions (n = 39). Multicomponent interventions included were defined as including two or more of a child component, parent component, or other component (e.g., teacher, family together). All interventions included in this study that were categorized as multicomponent interventions included a parent component. Studies provided consistent evidence that multicomponent interventions and interventions including only a parent component resulted in significantly greater improvement on parent reports of child disruptive behavior than controls. Our quantitative analysis of the 28 of these studies that met additional criteria for inclusion in our Bayesian multivariate network meta-analysis indicated that all three intervention types were more effective than control conditions. The probability of being the best treatment (i.e., having the largest effect) was the same for multicomponent interventions (43%) and for interventions with only a parent component (43%), followed by interventions with only a child component (14%). Pharmacologic studies evaluated the effectiveness of antipsychotics, antiepileptics, and stimulants and nonstimulants used to treat attention deficit hyperactivity disorder. Studies of antipsychotic medications and valproic acid, an antiepileptic medication, had mixed results over the short term. Two randomized controlled trials (RCTs) of atomoxetine suggested it was more effective at reducing oppositional defiant disorder (ODD) symptoms than placebo. One RCT of guanfacine extended release also reported significant reductions over placebo in ODD symptoms. Two RCTs reported that stimulants were more effective than placebo at reducing ODD and conduct disorder symptoms. We included related publications and an additional four studies to address harms and predictors of treatment effects.
Conclusions:
Qualitative and quantitative analyses generally suggest that psychosocial interventions for children with disruptive behavior disorders that include a parent component, either alone or in combination with other components, are likely to be more effective at reducing disruptive child behaviors than interventions that include only a child component or control conditions. Small studies of antipsychotics and stimulants report positive effects in the very short term. The most commonly reported outcomes are parent-reported outcomes. Long-term and functional outcomes were not consistently reported. There was variability in the duration of long-term followup and functional outcomes reported.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Background
- Methods
- Findings
- Description of Included Studies
- 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 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 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 6 Do interventions intended to address disruptive behaviors and identified in - vary in effectiveness based on patient characteristics (KQ6a), characteristics of the disorder (KQ6b), treatment history of the patient (KQ6c), or characteristics of the treatment (KQ6d)?
- Discussion
- References
- Abbreviations
- Appendix A Search Strategies
- Appendix B Literature Screening Forms
- Appendix C Risk of Bias Assessment Forms and Summaries
- Appendix D Meta-Analytic Methods
- Appendix E Outcome Measures Used in the Meta-Analysis of Intervention Effects
- Appendix F Summary of Existing Systematic Reviews
- Appendix G Applicability Tables
- Appendix H Reasons for Exclusion
- Appendix I Pharmacologic Approval Status, Harms, and Indications
- Appendix J Evidence Profile
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2012-00009-I. Prepared by: Vanderbilt Evidence-based Practice Center, Nashville, TN
Suggested citation:
Epstein R, Fonnesbeck C, Williamson E, Kuhn T, Lindegren ML, Rizzone K, Krishnaswami S, Sathe N, Ficzere CH, Ness GL, Wright GW, Raj M, Potter S, McPheeters M. Psychosocial and Pharmacologic Interventions for Disruptive Behavior in Children and Adolescents. Comparative Effectiveness Review No. 154. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2012-00009-I.) AHRQ Publication No. 15(16)-EHC019-EF. Rockville, MD: Agency for Healthcare Research and Quality; October 2015. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Vanderbilt Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2012-00009-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies may not be stated or implied.
This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov.Search on the title of the report.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
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