Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 3: Children and Mental Health
Overview of Mental Disorders in Children
Disruptive Disorders
Treatment
Several psychosocial interventions can effectively reduce antisocial behavior in
disruptive disorders. A recent review of psychosocial treatments for children
and adolescents identified 82 studies conducted between 1966 and 1995 involving
5,272 youth (Brestan & Eyberg, 1998). The criterion for inclusion was that the
child was in treatment for conduct problem behavior, based on displaying a
symptom of conduct disorder or oppositional defiant disorder, rather than on a
DSM diagnosis of either, although children did meet DSM criteria for one of
these conditions in about one-third of the studies.
By applying criteria established by the American Psychological Association Task
Force (see earlier) to the 82 studies, two treatments met criteria for well-
established treatment and 10 for probably efficacious treatment. Two
well-established treatments, both directed at training parents, succeeded in
reducing problem behaviors. The two treatments were a parent training program
based on the manual Living With Children (Bernal et al., 1980) and a videotape
modeling parent training (Spaccarelli et al., 1992). The first teaches parents
to reward desirable behaviors and ignore or punish deviant behaviors, based on
principles of operant conditioning. The second provides a series of videotapes
covering parent-training lessons, after which a therapist leads a group
discussion of the videotape lessons. The identification of 12 treatments as
well-established or probably efficacious is very encouraging because of the
potential to intervene effectively with youth at high risk of poor outcomes. A
new and promising approach for the treatment of conduct disorder is
multisystemic therapy, an intensive home- and family-focused treatment that is
described under Home-Based Services.
Despite strong enthusiasm for improving care for conduct-disordered youth, there
are important groups of children, specifically girls and ethnic minority
populations, who were not sufficiently represented in these studies to ensure
that the identified treatments work for them. Other issues raised by Brestan and
Eyberg (1998) are cost-effectiveness, the sufficiency of a given intervention,
effectiveness over time, and the prevention of relapse.
No drugs have been demonstrated to be consistently effective in treating conduct
disorder, although four drugs have been tested. Lithium and methylphenidate have
been found (one double-blind placebo trial each) to reduce aggressiveness
effectively in children with conduct disorder (Campbell et al., 1995; Klein et
al., 1997b), but in two subsequent studies with the same design, the positive
findings for lithium could not be reproduced (Rifkin et al., 1989; Klein, 1991).
In one of the latter studies, methylphenidate was superior to lithium and
placebo. A third drug, carbamazepine, was found in a pilot study to be
effective, but multiple side effects were also reported (Kafantaris et al.,
1992). The fourth drug, clonidine, was explored in an open trial, in which 15 of
17 patients showed a significant decrease in aggressive behavior, but there were
also significant side effects that would require monitoring of cardiovascular
and blood pressure parameters (Kemph et al., 1993).
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