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AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care

Topic Suggestion Description

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Date submitted: March 19, 2013

Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.
1. For children with disruptive behavior disorders (DBDs), including Oppositional Defiant Disorder (ODD), Conduct disorder (CD), and Disruptive Behavior Disorder Not Otherwise Specified (DBD NOS), what is the short-term and long-term comparative effectiveness of different psychological interventions/treatments?
o What is the comparative effectiveness (harms and benefits) of different psychological treatments versus "usual" community care for children with DBDs?
2. For children with DBDs, what is the comparative effectiveness of psychological treatment alone versus pharmacologic treatment alone or combined psychological and pharmacological treatment?
3. For children with DBDs, what is the comparative effectiveness of providing psychological interventions/treatments in different health care settings (e.g., Residential/inpatient care vs. Community based care).
4. For children with DBDs, is there evidence for matching particular psychological treatments to individual patients based on diagnosis/psychopathology, personality characteristics, socio-demographic characteristics, treatment preferences, or other measured factors?
o In other words, do psychological interventions vary in effectiveness across sub-populations with different socio-demographic and medical characteristics, including?
? Boys versus girls
? Age groups (< 6 years, 6-12 years, 13-18 years)
? Racial/ethnic minority groups
? Socioeconomic strata
? Co-morbidities (e.g., ADD/ADHD, anxiety, depression)
? ODD, CD, ADHD, and related personality traits and symptom clusters (e.g., Kolko & Pardini, 2010)
? Age of disorder onset/Duration of illness (ODD, CD, or DBD NOS)
? Treatment history (extent of prior exposure to treatment)
? Contact with justice\legal system
? Family characteristics (e.g., single parent household)
? Treatment preferences
Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)
If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:
? Psychological treatments/psychotherapies
• Individual cognitive–behavioral treatments
o Assertive training
o Anger control training
o Incredible Years Child Training (IY-CT)
o Interpersonal skills training
o Problem-Solving Skills Training (PSST)
o Self-Control training

• Parent-based treatments
o Behavioral parent training/Parent Management Training (PMT)
o Collaborative Problem Solving (CPS)
o Helping the Non-Compliant Child (HNC)
o Helping the Non-Compliant Child (HNC)
o Incredible Years Parent Training (IY-PT)
o Parent-Child Interaction Therapy (PCIT)
o Positive Parenting Program (Triple P)

• Family-based treatments
o Brief strategic family therapy
o Functional Family Therapy (FFT)
o Multi-systematic therapy (MST)
o Multidimensional Family Therapy
o Multidimensional treatment foster care (MTFC)

• School-based treatments
o Incredible Years Teacher Training (IY-TT)
o Teacher-Child Interaction Training (TCIT)

• Other Multi-component psychosocial treatments/programs
o Boot camps (including Outward Bound/wilderness therapy)
o Incredible Years combined treatments programs
o Perry Preschool Program (e.g., Heckman et al., 2010).

• Other interventions designated as evidence-based programs for DBDs in registries:
o Substance Abuse and Mental Health Services Administration's National Registry of Evidence-Based Programs and Practices (SAMHSA)
o Office of Juvenile Justice and Delinquency Prevention Model Programs Guide (OJJDP)
o Helping America's Youth (HAY)
o Center for the Study of Prevention of Violence: Blueprints for Violence Prevention (Blueprints)
o The California Evidence-Based Clearinghouse for Child Welfare (CWCH)

? Pharmacological (Psychotropic) agents
o 1st & 2nd generation antipsychotics
What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)
? Boys and girls with ODD (age 18 and younger)
? Boys and girls with CD (age 18 and younger)
? Boys and girls with DBD NOS (age 18 and younger)
? Youth exhibiting aggressive behavior
? Youth with history of violent behavior
? Youth with non-compliant, delinquent, antisocial, and other disruptive behavior
? Youth with impulsive behavioral symptoms or disorders
Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)
? Boys and girls
? Age groups (< 6 years, 6-12 years, 13-18 years)
? Racial/ethnic minority groups
? Youth in low SES/disadvantaged homes
? Youth within the foster care system
? Co-morbid pervasive developmental disorders, including autistic spectrum disorder
? Youth who committed or are incarcerated for criminal offenses
? Common psychological co-morbidities (e.g., ADD/ADHD, depression, anxiety, PTSD, substance use)
? Prevalent medical comorbidities, including epilepsy, obesity, and sleep disorders
? Learning disabilities (language and reading impairment)
? Differences in other potentially significant moderators of treatment effectiveness:
o Age of disorder onset/duration of illness (ODD, CD, or BDB NOS)
o Treatment history (Prior exposure to treatment)
o History of abuse, neglect, or domestic violence
o Contact with juvenile justice\legal system
o Family characteristics (e.g., single parent household, parental supervision)
Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)
? Amelioration of behavioral & emotional symptoms (number, frequency, & severity):
o Reduced hostile behavior
o Reduced aggressive behavior, including bullying
o Reduced violent behavior
o Reduced delinquent behavior
o Reduced impulsive behavior
o Reduced fighting, destruction of property, theft, and rule violations
o Increased compliance with parents, teachers, and institutional rules
? Remission of disorder (i.e., diagnosis of ODD, CD, or DBD NOS)
? Reduction in comorbid mental health symptoms and disorders (e.g. mood disorders, ADHD, anxiety disorders, substance abuse, etc.)
? Improved co-morbid health conditions (e.g., sleep disturbances, obesity)
? Improved school performance/attendance
? Improved child functioning at home
? Improved family functioning/cohesion
? Improved interpersonal/social functioning and competence (e.g., greater peer acceptance, quality of life for child and family)
? Reduced interactions with the legal/juvenile justice system (e.g., arrests, detention)
? Reduced health care system utilization (e.g., social services)
Describe any health-related risks, side effects, or harms that you are concerned about.
? Potential harms associated with different psychological treatment approaches, including relative decrease in treatment adherence and drop-out
? Short- and long-term side effects of pharmacological treatments, including relative decrease in treatment adherence and withdrawal due to adverse events
? Impaired growth and maturation
? Self-injury and suicide-related behaviors
? Increased disruptive, violent, criminal, or other socially deviant behavior, for instance due to contagion effect (i.e., peer support and modeling of deviant behaviors in groups).

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?
Which priority area(s) and population(s) does this topic apply to? (check all that apply)
EHC Priority Conditions (updated in 2008)
  • Depression and other mental health disorders
  • Developmental delays, attention-deficit hyperactivity disorder, and autism
  • Functional limitations and disability
  • Obesity
  • Pregnancy, including preterm birth
  • Substance abuse
AHRQ Priority Populations
  • Low income groups
  • Minority groups
  • Children
  • Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care
Federal Health Care Program
  • Medicaid
  • Medicare
  • Other


Describe why this topic is important.
? DBDs are highly prevalent: Between 9% and 16% of all children and adolescents are diagnosed with ODD, CD or DBD NOS at some point during the developmental period, ranking disruptive behavior disorders (DBDs) as the first or second most common mental health condition among youth (Bonin et al., 2011; Kessler et al., 2005; Russo & Beidel, 1994; U.S. Department of Health and Human Services, 1999). Additionally, roughly three times as many youth suffer from sub-clinical conduct problems (Sainsbury Centre for Mental Health, 2009).

? DBDs in youth are severe, chronic, and perpetuate into adulthood: Over time, youth with conduct problems frequently exhibit persistent patterns of substance abuse, school truancy and drop-out, interpersonal violence, delinquency, and antisocial/criminal behavior (Loeber, 1991; Sansbury Centre for Mental Health, 2009). Children and adolescents with DBDs have the poorest prognosis for adult adjustment of all childhood disorders (Meier, Slutske, Heath, & Martin, 2011; Murrihy, Kidman, & Ollendick, 2010); up to 50% of these youth eventually develop adult antisocial personality disorder (Bonin et al., 2011; Kohlberg, Ricks, & Snarey, 1984).

? DBDs create an immense societal and economic burden, and effective early treatment may reduce crime and save health care dollars: Public expenditures on youths with CD are substantially larger than for youths with closely related conditions (Foster & Jones, 2005). For instance, the public costs per child in the UK related to CD has been estimated to far exceeded $1,000,000 over a lifetime (Knapp, McDaid, & Parsonage, 2011; Scott, Knapp, Henderson, & Maughan, 2001; Romeo, Knapp, Scott, 2006). Conversely, a number of effectiveness trials suggest that implementation of evidence-based parenting programs is likely to yield large cost savings to the public sector and society (Heckman, Moon, Pinto, Savelyev, & Yavitz, 2010; Bonin et al., 2011). According to the NHS, when the wider cost of crime are included,
What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)
? Our organization would like to develop evidence-based clinical practice guidelines for the treatment of youth with DBDs. Guidance on the effective psychosocial treatment of DBDs is a high priority for psychologists, patients, and parents/families, as well as for schools, allied health professionals, residential facilities and the victims of antisocial behavior; yet, there is currently a lack of guidance the relative benefits and effective use of psychosocial treatments for DBDs.

? The treatment of DBDs is particularly relevant to the public interest given the excessive burden on school, juvenile justice, and mental health systems. However, currently there is a dearth of research-based guidance to inform/facilitate best practices among psychologists and other health care providers. The lack of current treatment guidelines means that many youth do not receive needed psychosocial programs for DBDs. These youth generally exhibit increasingly severe problems with antisocial and criminal behavior that persist into adulthood.

? There is a lack of balanced clinical practice guidelines (CPGs) that may promote improved patient care and public education. Furthermore, as indicated below, the few existing CPGs have serious limitations.

1. American Academy of Child and Adolescent Psychiatry: Steiner et al. (2007). Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 46(1), 126-41.
o Recommends clinicians "consider parent intervention based on one of the empirically tested interventions." However, the guidelines do not differentiate between different parent training programs.
o Furthermore, this guideline has a narrow scope on ODD; it's a bit dated and does not include some of the best quality trials that have been conducted over the past several years.

2. NICE guideline on "Parent-training/education programs in the management of con
Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)
If yes, please explain:
? Implementation of interventions for DBDs has been hampered by a lack of clear consensus on which treatments are the "best" (and which treatments are ineffective or contraindicated). Moreover, it is not clear whether particular interventions are more effective for girls or boys, as well as how co-morbidities moderate treatment outcome.

? Although many individual, family, and school/teacher-based psychosocial interventions have been developed, there is uncertainty regarding the relative effectiveness of these different treatments, and which treatment approaches should be more widely disseminated and implemented in routine care.

? The use of antipsychotic medications in children and adolescents for indications other than psychosis or Tourette syndrome is controversial (Cooper et al., 2004). There is uncertainty over the use and possible harms from pharmacological interventions for youth with DBDs, as well as the questionable benefits of combined psychological and pharmacological treatment, which is the most commonly reported approach used in community settings (Tcheremissine & Lieving, 2006).

? Uncertainty about the benefits of current "standard" community care for youth with DBDs. Concerns about the potential harms to children, families, and society of ineffectively treating DBDs, especially with medication.

? Some studies have found variations in treatment response among sub-groups of youth with DBDs and various co-morbidities (e.g., ADHD) and personality traits, while others have not (Cunningham & Ollendick, 2010; Kolko & Pardini, 2010); thus, it remains unclear whether these youth can be matched with treatment programs/interventions that are most effective given the clinical presentation.

? Uncertainty regarding the best point (or points) of intervention along the trajectory of disruptive behavioral problems from onset to development of chronic symptomatology.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?
? The proposed systematic review on DBDs will provide an up-to-date synthesis of quality research on the effectiveness (and potential harms/benefits) of psychological treatments for youth with disruptive behavior disorders. The data will be used by our organization to develop evidence-based treatment guidelines to inform psychologists, consumers, and other stakeholders about the comparative effectiveness of current treatments for DBDs. Increasing awareness about the characteristics and availability of effective psychosocial treatments will encourage their use in clinical practice.

? Given the significant number of children who become chronically antisocial and delinquent during the school years, and the high costs to society, children, and families, it is important to identify effective treatments for disruptive behavior problems and disorders (McCabe, Lucchini, Hough, Yeh, & Hazen, 2005).

? The proposed systematic review will identify gaps in research data and areas to target for improvement in treatment implementation, which will guide future research by psychologists and other disciplines on DBDs (and may result in greater funding for such research).

References Cited

Berkout, O. V., Young, J. N., & Gross, A. M. (2011). Mean girls and bad boys: Recent research on gender differences in conduct disorder. Aggression and Violent Behavior, 16(6), 503-511.

Bonin, E. M., Stevens, M., Beecham, J., Byford, S., & Parsonage, M. (2011). Costs and longer-term savings of parenting programmes for the prevention of persistent conduct disorder: a modelling study. BMC public health, 11, 803. doi: 10.1186/1471-2458-11-803.

Cooper, W. O., Hickson, G. B., Fuchs, C., Arbogast, P. G., & Ray, W. A. (2004). New Users of Antipsychotic Medications Among Children Enrolled in TennCare. Arch Pediatr Adolesc Med, 158(8), 753-759. doi: 10.1001/archpedi.158.8.753

Cunningham, N. R., & Ollendick, T. H. (2010). Comorbidity of anxiety and conduct problems in children: Imp
Describe the timeframe in which an answer to your question is needed.
Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.
? Children from low income families and disadvantaged/underserved communities are disproportionally affected by DBDs (McMillen et al., 2005; Shoemaker, 2010; Wu et al., 1999). Moreover, DBDs are significantly more common among several racial and ethnic minority groups, including African Americans, Native Hawaiians (NHs), and Pacific Islanders (PIs) (Nguyen, Huang, Arganza, & Liao, 2007). Within Asians, NHs, and PIs, CD has been strongly associated with adult antisocial behavior, substance use and affective disorders (Nguyen et al., 2007). Further research is needed to elucidate prevalence and predictors of DBDs among different minority groups (Sakai et al., 2008).

? Despite public enthusiasm for reducing disruptive, violent, and antisocial behavior in youth, girls and ethnic minority populations were not sufficiently represented in prior literature reviews (due to lack of controlled research) to ensure that the identified treatments work for them (U.S. Department of Health and Human Services, 1999).

? Gender may be a critical moderator of treatment efficacy/effectiveness. In fact, Turpin, Stewart, Beach, and Boesky (2002) suggested that gender specific interventions may be particularly helpful for treating female behavioral difficulties, and this idea bears future empirical investigation. Examination of these issues may lead to the development of more effective treatments for girls with CD, and ultimately inform efforts to develop targeted intervention and/or prevention programs for both genders. (Berkout, Young, & Gross, 2011).

? In addition, the many systems involved in the treatment of youth with ODD and CD face a significant challenge in finding and implementing successful treatments. For example, in 2008, more than 81,015 offenders were in custody in juvenile residential placement facilities (Sickmund, 2010). It is unclear whether this is the best placement for these youth.

Nominator Information

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  • Other Health Care Professional
  • Professional Society
  • Researcher
Are you making a suggestion as an individual or on behalf of an organization?
Organization - American Psychological Association (APA)
Please tell us how you heard about the Effective Health Care Program
From AHRQ presentations and the AHRQ website.