Elsevier

Psychiatry Research

Volume 238, 30 April 2016, Pages 8-13
Psychiatry Research

Combined pharmacotherapy-multimodal psychotherapy in children with Disruptive Behavior Disorders

https://doi.org/10.1016/j.psychres.2016.02.010Get rights and content

Highlights

  • Psychotherapy improved aggression, mood swings and callous unemotional traits.

  • Additional pharmacotherapy further improved aggression and mood.

  • Additional pharmacotherapy did not affect callous unemotional traits.

  • In comorbid ADHD, methylphenidate was more effective than other drugs.

Abstract

Although multi-component psychotherapeutic interventions are first-line treatments for Disruptive Behavior Disorders (DBD), pharmacotherapy is often associated for more severe patients. Our aim was to explore effectiveness of an associated pharmacotherapy in referred children with DBD receiving a one-year psychotherapeutic intervention. Aggression, callous unemotional (CU) traits and emotional dysregulation were outcome measures. The sample included 144 children, aged 8−12 years, 41 (29%) with an ADHD comorbidity. Fifty-five (38%) patients received an additional pharmacotherapy with one medication, methylphenidate, a second generation antipsychotic, or a mood stabilizer. Data were collected before and after the one-year treatment. According to the Child Behavior Checklist (CBCL), aggressive behaviors, rule-breaking behaviors and emotional dysregulation improved in the whole group, as well as parent- and child-reported CU traits. The hierarchical regression model showed that additional pharmacotherapy significantly predicted lower scores at the CBCL aggressive behaviors and emotional dysregulation, but not CU traits at the end of the treatment. The interaction between methylphenidate and ADHD comorbidity predicted lower aggressive behaviors after the treatment. In summary, this naturalistic investigation suggest that an additional pharmacotherapy significantly improved aggression and emotional dysregulation, but not CU traits. When ADHD was comorbid, methylphenidate was more effective than antipsychotics or mood stabilizers in reducing aggression.

Introduction

Disruptive Behavior Disorders (DBD), including Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD), are among the most represented clinical conditions in child and adolescent mental health settings. There is a long and extensive history of research on DBD, namely regarding the best treatment strategies and the predictors of treatment response (American Psychiatric Association, 2000, Moffitt et al., 2008). Major goals in clinical research of DBD are to develop effective treatment models for improving aggressive and rule breaking behaviors, as well as for defining possible risk factors of poor outcomes or relapses. Consistent findings from clinical studies and meta-analyses indicate that a multi-component intervention, usually including child-oriented sessions, family sessions, interventions at school, and based on cognitive behavioral principles and practices, are usually the first-line treatment option for DBD (Mc Cart et al., 2006, Eyberg et al., 2008). Evidence from studies on pharmacological treatments in patients with DBD is still poorly informative, although some limited data support efficacy of second generation antipsychotics (SGA), mood stabilizers (MS), and stimulants (Ipser and Stein, 2007, Turgay, 2009, Loy et al., 2012, Gorman et al., 2015). However, considering that in the clinical practice a co-treatment with psychotherapeutic interventions and pharmacotherapy is a frequent strategy, namely in the more severe patients with DBD, there is a dearth of studies exploring the clinical implications of this association. Recent studies suggest that a combination of both psychotherapeutic and pharmacological approaches can improve the outcome of aggressive children and adolescents with DBD (Aman et al., 2014, Gadow et al., 2014).

A critical issue in evaluating the effectiveness of DBD treatments is patient heterogeneity within the same diagnostic category (Klahr and Burt, 2014). Disentangling this diagnostic domain in meaningful clinical subgroups may have significant clinical and treatment implications. At least two subtypes of DBD can be described, one associated with Callous Unemotional (CU) traits and predatory aggressiveness, and another associated with impulsive and reactive aggression, often co-occurring with mood and anxiety disorders (Vitiello and Stoff, 1997, Blair, 2013). Compared to patients with impulsive/reactive aggression, children and/or adolescents with CU traits and predatory aggression have been found to be more resistant both to medications (Masi et al., 2006, Masi et al., 2009), and to multi-component interventions (Hawes et al., 2014, Masi et al., 2001, Masi et al., 2013). However, previous studies have suggested that CU traits can decrease during multi-component treatments, including parenting intervention, individual psychotherapy and pharmacotherapy (Kolko and Pardini, 2010, Muratori et al., 2015).

Another important clinical specifier for a DBD subtyping is the co-occurrence of emotional dysregulation, including mood instability, severe irritability, aggression, temper outburst, and hyper-arousal (Masi et al., 2015b, Mbekou et al., 2014). The Child Behavior Check List Dysregulation Profile (CBCL-DP), with simultaneous high values (above two Standard Deviations) in three CBCL syndrome scales (Anxious/Depressed, Attention Problems, and Aggressive Behavior), has been proposed as a possible diagnostic tool for identifying children with Emotional Dysregulation (Faraone et al., 2005, Youngstrom et al., 2005, Volk and Todd, 2007, Holtmann et al., 2011, Mc Cart et al., 2006). Previous studies investigated CBCL-DP in DBD (Volk and Todd, 2007, Masi et al., 2015b, Mbekou et al., 2014), and found that the CBCL-DP score may be associated with an increased risk of persisting ADHD or superimposed mood disorders. However, to date, implications of this conceptualization on treatment outcome are poorly explored.

Our aim was to address the topic of effectiveness of a combined pharmacotherapy-psychotherapy in children with DBD referred in a clinical setting and treated with a multi-component intervention. This naturalistic investigation compared children receiving the combined treatment and children those receiving the same psychotherapeutic intervention, but not medications. Although it is not possible to draw firm information on the efficacy of the treatments from a naturalistic observation, significant information may stem on effectiveness and course under a specific treatment. In order to explore the specific impact of the two treatment strategies, not only aggressive behavior, but also callous-unemotional traits and emotional dysregulation we selected as outcome measure. In order to explore more specific pharmacological strategies, efficacy of methylphenidate was compared with second generation antipsychotics or mood stabilizers.

Section snippets

Participants and procedures

In this naturalistic study, a consecutive sample of children initially referred for behavioral problems received a systematic evaluation at the Child and Adolescent Psychiatry and Psychopharmacology Department of our Hospital. At the baseline, trained child psychiatrists administered separately to parents and children a clinical interview, the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL) (Kaufman et al., 1997). Patients also

Results

T-test analysis showed that according to the CBCL, in the whole group the aggressive behaviors decreased from 71.72 to 67.56 (t=6.15, p<.001), rule-breaking behaviors from 66.16 to 63.36 (t=4.47, p<.001), CBCL-DP score from 204.70 to 195.95 (t=6.48, p<.001). Furthermore, parent-reported CU traits evaluated by APSD decreased from 5.72 to 4.74 (t=3.54, p<.001), and self-reported CU traits evaluated by ICU from 27.86 to 24.46 (t=8.83, p<.001).

When the 55 patients receiving the medication were

Discussion

Considering that multi-component treatment programs are the first option in DBDs, are there further specific treatment protocols targeted for specific distinct DBD subtypes? The aim of this study was to verify if a combined pharmacotherapy improved the response to treatment in a large sample of children with DBD during a multi-component cognitive-behavioral intervention.

Patients receiving and not receiving additional pharmacotherapy were not randomized, but the medication was naturalistically

Conflict of interest

Dr. Masi was in the advisory boards for Eli Lilly, Shire and Angelini, has received research grants from Eli Lilly and Shire, and has been speaker for Eli Lilly, Shire, Lundbeck, and Otsuka. All the other authors do not have conflicts of interest to declare.

References (44)

  • E. Youngstrom et al.

    Bipolar diagnoses in community mental health: achenbach child behavior checklist profiles and patterns of comorbidity

    Biol. Psychiatry

    (2005)
  • G.A. Aarons et al.

    Advancing and conceptual model of evidence-based practice implementation in public service sectors

    Adm. Policy Ment. Health

    (2011)
  • M.G. Aman et al.

    What does risperidone add to parent training and stimulant for severe aggression in child attention-deficit/hyperactivity disorder?

    J. Am. Acad. Child. Adolesc. Psychiatry

    (2014)
  • American Psychiatric Association

    Diagnostic and Statistical Manual of Mental Disorders: DSM-IV TR

    (2000)
  • T.M. Achenbach et al.

    Manual for the ASEBA School-Age Forms and Profiles

    (2001)
  • R.J.R. Blair

    The neurobiology of psychopathic traits in youths

    Nat. Rev. Neurosci.

    (2013)
  • E. Ciucci et al.

    The emotional correlates to callous unemotional traits in children

    J. Child. Fam. Stud.

    (2015)
  • M.H. Deutz et al.

    The dysregulation profile in middle childhood and adolescence across reporters: factor structure, measurement invariance, and links with self-harm and suicidal ideation

    Eur. Child. Adolesc. Psychiatry

    (2015)
  • S.M. Eyberg et al.

    Evidence-based psychosocial treatment for children and adolescence with disruptive behaviour

    J. Clin. Child. Adolesc. Psychol.

    (2008)
  • S.V. Faraone et al.

    The CBCL predicts DSM-IV bipolar disorder in children: a receiver operating characteristic curve analysis

    Bipolar Disord.

    (2005)
  • P.J. Frick et al.

    Antisocial Process Screening Device

    (2001)
  • P.J. Frick

    Inventory of Callous–Unemotional Traits. Unpublished Rating Scale

    (2004)
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