Efficacy of a multimodal treatment for disruptive behavior disorders in children and adolescents: Focus on internalizing problems

Abstract

Disruptive Behavior Disorders (DBDs) are among the most common reasons for youth referrals to mental health clinics. Aim of this study is to compare short and medium term efficacy of a multimodal treatment program (MTP), compared to community care (treatment-as-usual, TAU). The sample included 135 youths with DBDs (113 males, age range 9–15 years, mean age 12±2.5 years) were assigned either to a MTP (n=64), or addressed to community care for a TAU (n=71). Outcome measures were the Child Behaviour Checklist (CBCL) and the Children׳s Global Assessment Scale (C-GAS). All subjects were assessed at the baseline (T0), after 1-year treatment (T1) and after a 2-year follow-up (T2). Compared with patients receiving TAU, youths in the MTP showed, both at T1 and T2, significantly lower scores on CBCL Externalizing Scale, Internalizing Scale, Anxious/Depressed, Social Problems, and Aggressive Behavior, and higher scores at the C-GAS. Improvement in Internalizing Scales was particularly evident, with a shift from the clinical to the non-clinical range. Rate of use of mental health services and scholastic failure were reduced in the MTP. It is suggested that the improvement of the Internalizing symptoms is a crucial component of the therapeutic process in this MTP.

Introduction

Disruptive Behavior Disorders (DBDs), including Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD), are among the most common reasons for youth referrals to mental health clinics (Steiner and Remsing, 2007), and they may be associated with academic failure, persistent maladaptive (impulsive and aggressive) behaviors, and future antisocial outcomes (Pardini and Fite, 2010). Psychosocial maladjustment can be negatively affected by co-occurring internalizing (mood and anxiety) disorders, with related social isolation, low-self esteem, suicidality, self-injury behaviors and substance abuse, although these problems are frequently overshadowed by impulsive aggression (Maughan et al., 2004, Masi et al., 2008). Internalizing comorbidity involves a strong portion of aggressive youths both in community and clinical settings (Boylan et al., 2007, Polier et al., 2012), it is associated with a higher risk of social and school dysfunction (Newcorn et al., 2004, Ezpeleta et al., 2006), with greater persistence of DBD lifetime (Maughan et al., 2004, Nock et al., 2007), and greatly increases the costs for communities (Kolko et al., 2014).

Much progress has been made in identifying evidence-based treatments that decrease aggression (Moffitt et al., 2008). Although psychosocial, psychotherapeutic and familial approaches are usually first-line treatment options, severe behavior disorders may be refractory to such approaches (Kazdin, 2000). Multimodal psychosocial interventions, usually including both youths and parents, have been found to be more effective than interventions delivered only to children (Lochman and Wells, 2002, Pappadopulos et al., 2003, Steiner and Remsing, 2007, Copeland et al., 2009, Kolko et al., 2014, Masi et al., 2013). A cognitive-behavioral therapy (CBT) on youth targets aggressive behaviors and cognitions through behavior management, role playing, social and token reinforcements, and problem solving (Lochman and Wells, 2002, Van Manen et al., 2004). Involvement of parents, aimed at promoting positive parenting practice, significantly increases the effectiveness of interventions (Garland et al., 2008, Larsson et al., 2009). Most of the studies have explored efficacy of these interventions in improving severe behavior symptoms, such as hostility and aggression (Kazdin, 2000). Fewer data is available on effects of treatments in improving internalizing symptoms, and their impact on global functioning. In a review article exploring the moderating role of comorbid dimensional symptoms (including those associated with ADHD, anxiety, and depression) on treatment outcomes for ODD/CD children, comorbidity had little or no effect on the treatment of child conduct problems (Ollendick et al., 2008). More specifically, children with and without a comorbid disorder did not differ at the end of treatment in terms of their antisocial behavior, problem behaviors observed in the home, or parent ratings across multiple symptom domains. Results of these studies suggest that comorbidity does not predict negative treatment outcomes for oppositional and conduct problem youth. More recently, Jarrett et al. (2014), in a study designed to evaluate the efficacy of the Coping Power Program (Lochman and Wells, 2004), and to examine how internalizing symptoms predicted change in externalizing problems, reported that greater depressive symptoms, but not anxiety symptoms (as reported by parent or teacher) were associated with a larger reduction in externalizing behaviors problems following a school-based preventative intervention.

Aim of this paper was to explore efficacy of a multimodal, CBT-inspired treatment for patients with DBDs, compared with a community care (“treatment as usual” – TAU), at the end of the treatment (1-year follow-up), and 1 year after the end of the treatment (2-year follow-up). Effects on externalizing and internalizing problems and on psychosocial functioning were separately evaluated.