Response to treatments in youth with disruptive behavior disorders
Introduction
Disruptive Behavior Disorders (DBDs) including Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD), are stable and impairing disorders, which can be associated with poor prognosis and future antisocial outcomes [1]. Children and adolescents with this condition also engage in behavior that places them at a disadvantage for academic success, early substance abuse problems and a host of other negative outcomes [2]. Much progress has been made in identifying evidence-based treatments that decrease children’s aggression [3]. Multimodal psychosocial interventions, usually including both parents and youths, have been found to be more effective than interventions delivered only to children [4], [5], [6], [7]. Multimodal interventions on youths target aggressive behaviours and cognitions through techniques such as behaviour management, role playing, social and token reinforcements, and problem solving [8], [9]. However, the outcomes of these interventions have shown enormous variability in improving externalizing problems, and severe behavior disorders are frequently refractory to such approaches [6], [10]. Especially when aggression is the main symptom, and/or when comorbidity is heavier, medications can improve some maladaptive behaviors and increase the person’s ability to benefit from non-pharmacologic interventions [11]. Mood stabilizers and atypical antipsychotics are frequently used, but antidepressants and psycho-stimulants are also administered, although efficacy data are scarce [11]. A recent review explored efficacy and safety of atypical antipsychotics in children and adolescents with DBDs, according to randomized controlled trials, concluding that limited evidence supports only short-term efficacy of risperidone [12]. Divalproex sodium has been used in adolescents with CD and impulsive or proactive aggression in a randomized, double-blind, placebo-controlled trial, with a good response rate (64%) in patients with impulsive aggression, including those with severe CD, but not in those with proactive aggression (22%) [13]. However, further high-quality research is required with large samples of clinically representative youths and long-term follow-up to replicate current findings.
A major goal in clinical research is to discover possible predictors of response to treatments, according to specific demographic and clinical variables, which may help to organize the best treatment strategies for each patient. Previous studies from our group suggest that efficacy of psychosocial and/or pharmacological treatments is negatively affected by greater baseline severity [14], [15], characteristics of aggression, predatory rather than impulsive [15], [16], [17], type of treatment (pharmacologic treatment with or without a psychosocial intervention) [14], and specific psychopathological features, such as the psychopathy [17].
A major dimensional component of the concept of psychopathy, along with narcissism and impulsivity, is an affective factor including callous (lack of empathy and guilt) and unemotional (shallow emotions) trait [18]. The role of the psychopathic dimension, specifically the callous–unemotional (CU) trait, has been underlined during the DSM-V revision of the diagnostic criteria for mental disorders in childhood and adolescence, in order to further specify a clinically meaningful subtype of CD with significant CU trait [19], [20]. The prevalence rates of CU traits in a sample of referred youths with CD were estimated in a recent epidemiological study, indicating that 50% of the subjects presented the CU trait based on combined-informant (youth and parent) report, and 31% based on parent report alone [21]. The analyses showed that a high level of CU trait can be a mechanism leading to an increased risk for severe antisocial behavior [22] and that it may identify a subgroup of youths not only with similar clinical features and outcomes, but also with similar etiology [23], [24].
There is some controversy as to whether the CU trait is a risk factor for treatment outcomes in children, and whether this trait can change. Although Kolko et al. found that CU traits did not predict outcomes [25], other longitudinal data showed that CU traits add to the prediction of serious and persistent criminal behavior in boys [1]. According to Dadds and colleagues [26], when dimensions of CU trait and of CD were disentangled, CU trait had unique and predictive validity in childhood. More specifically, CU trait positively correlated with program failure and re-arrest in adolescents referred to a juvenile diversion program [27]. Similarly, psychopathic characteristics negatively affected treatment process and outcome (attrition, participation, improvement and recidivisms) in individuals referred for treatment to a substance abuse program [28]. Furthermore, the psychopathic features were associated with a worse outcome (days required to progress in treatment) in adolescents followed in a juvenile-justice setting [29]. Finally, some evidence suggests that CU traits are a negative predictor for the efficacy of methylphenidate in children with ADHD and comorbid conduct problems [30]. Our previous study indicated that the CU trait is among the negative predictors of efficacy in a multimodal treatment program in children and adolescents with CD [17].
Ascertaining the presence of high levels of CU trait may help clinicians in focusing their intervention in a more specific way [31]. Deficits in emotional arousal to fear and distress, as well as low sensitivity to punishment and low impact of the negative consequences of actions, not only increase the risk of antisocial behavior, but also sensitivity to treatment [21].
The aim of the present study was to further explore, in a new, larger sample of referred youths with DBDs, rate of response and predictors of negative outcome after a multimodal treatment, with specific attention to the role of CU trait.
Section snippets
Participants and data collection
The clinical sample of DBDs included 118 consecutively referred children and adolescents, 90 with ODD (76%) and 28 with CD (24%), age range 6.6 to 14.4 years, mean age 11.1 ± 2.5 years, 102 males (86%) and 16 females (14%). All patients received a systematic evaluation, using historical information, prolonged observations of interactions with peers, parents and/or examiners, and a structured clinical interview according to DSM-IV criteria, the Schedule for Affective Disorders and Schizophrenia for
Comparison between responders or non-responders to treatments
When rate of response was assessed, irrespective of the type of treatment, 60 subjects (50.8%) were responders, and 58 (49.2%) non-responders. When responders and non-responders were compared, age, gender ratio, type of treatment (multimodal alone or with pharmacotherapy) and type of pharmacotherapy were not related to clinical response. Having a diagnosis of CD rather than ODD, a lower C-GAS, and a comorbid mood disorder (depression or bipolar disorder) were all associated with non-response to
Discussion
The treatment of patients with DBDs is a crucial issue, given the risk of antisocial outcome in subjects with poorer response to interventions. Predictors of good or poor response in psychosocial treatments of children and adolescents with DBDs are still poorly understood. We explored this issue in a large sample of consecutive children and adolescents treated with a multimodal psychosocial intervention, part of whom receiving a pharmacotherapy. The strengths of this study are the large sample
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2021, Journal of the American Academy of Child and Adolescent PsychiatryEmotional dysregulation and callous unemotional traits as possible predictors of short-term response to methylphenidate monotherapy in drug-naïve youth with ADHD
2020, Comprehensive PsychiatryCitation Excerpt :It is noteworthy that CU traits, assessed with the APSD, failed to predict ADHD symptoms severity at follow-up, after MPH treatment. Previous findings indicate that youths with disruptive behavior disorders and elevated CU traits display a poorer response to non-pharmacological interventions [21–23]. However, pretreatment CU traits did not predict worse outcome in aggressive children with ADHD receiving a stimulant pharmacotherapy [36].
Emotional processing deficits in Italian children with Disruptive Behavior Disorder: The role of callous unemotional traits
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