We systematically reviewed evidence on psychosocial and/or pharmacologic treatment for children with disruptive behavior disorders.
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.
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.
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.
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.
Epstein RA, Fonnesbeck C, Potter S., et al. Psychosocial Interventions for Child Disruptive Behaviors: A Meta-analysis. Pediatrics peds.2015-2577; published ahead of print October 19, 2015, doi:10.1542/peds.2015-2577.