This project is ongoing and does not have results.
The Patient-Centered Outcomes Research Institute (PCORI) is partnering with the Agency for Healthcare Research and Quality (AHRQ) to develop a systematic evidence review on Psychosocial and Pharmacologic Interventions for Disruptive Behavior in Children and Adolescents. The American Academy of Pediatrics (AAP) plans to use this systematic evidence review to develop related clinical guidelines.
Disruptive behavior disorders (DBD) are a group of related psychiatric disorders of childhood and adolescence. Disruptive behaviors, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), are behaviors that violate the rights of others or bring the individual into significant conflict with societal norms or authority figures. Disruptive behavior disorders often cooccur with other behavioral and psychiatric disorders, especially childhood mood disorders and attention-deficit/hyperactivity disorder (ADHD).
DBD are among the most common behavioral disorders in children and adolescents. Defining criteria are largely subjective and context-dependent, and approaches to diagnosis in practice vary considerably; thus, true prevalence is difficult to discern. Children diagnosed with DBD can experience significant impairment and are at risk for negative outcomes throughout their lives, including difficulty with familial and/or peer relationships; problems at school; substance abuse; delinquent, antisocial or criminal behavior; and a higher prevalence of internalizing disorders such as depression.
Treatment options for DBD include psychosocial, pharmacologic, or combined interventions. Psychosocial interventions target the individual, parents, or family, and include approaches like cognitive behavioral therapy, parent training, or multicomponent interventions. Medications, including stimulants, nonstimulants, antipsychotics, and antiepileptics, can be used as adjunctive treatment for symptom management in children and adolescents but is not recommended as the sole intervention. Findings of treatment effectiveness must be interpreted carefully while considering differences between treatment groups and between studies in how DBD was diagnosed, baseline patient characteristics including race/ethnicity and gender, and clinical history including history of trauma and adverse childhood experiences (ACEs).
No clinical practice guideline, informed by a systematic review of the evidence and comprehensively addressing psychosocial and pharmacologic treatment of DBD, has been published since 2013. In 2015, AHRQ published a comprehensive systematic review on psychosocial and pharmacologic interventions for treating disruptive behavioral disorder in children and adolescents. More recent reviews were narrow in scope, did not assess both psychosocial and pharmacologic treatments for DBD in children and adolescents, and/or are dated.
An update to the 2015 systematic review is needed in the face of new evidence for these consequential conditions. An updated review will support the development of a clinical practice guideline on psychosocial and pharmacologic interventions for DBD in children and adolescents to inform decision-making for healthcare professionals, clinicians, patients, and caregivers.
Proposed Key Questions (KQs)
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?
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?
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 KQ 2 for improving short-term and long-term psychosocial outcomes?
4. In children under 18 years of age treated for disruptive behaviors, are any combined psychosocial and pharmacologic interventions listed in KQ 2 more effective for improving short-term and long-term psychosocial outcomes than individual interventions?
5. What are the harms associated with treating children under 18 years of age for disruptive behaviors with either psychosocial or pharmacologic interventions or combined interventions?
6a. Do interventions intended to address disruptive behaviors and identified in KQs 1-4 vary in effectiveness based on patient characteristics, including sex; age; racial/ethnic minority; developmental status or delays; family history of disruptive behavior disorders; family history of mental health disorders; prenatal use of alcohol and drugs, specifically methamphetamine; history of trauma or ACEs; parental ACEs; access to social supports (e.g., neighborhood assets, family social support, worship community); personal and family beliefs about mental health (e.g., stigma around mental health); socioeconomic status; or other social determinants of health?
6b. Do interventions intended to address disruptive behaviors and identified in KQs 1-4 vary in effectiveness based on characteristics or manifestations 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?
6c. Do interventions intended to address disruptive behaviors and identified in KQs 1-4 vary in effectiveness based on treatment history of the patient?
6d. Do interventions intended to address disruptive behaviors and identified in KQs 1-4 vary in effectiveness based on characteristics of the treatment, including setting, duration, delivery, timing, and dose?