Prioritizing Psychosocial Interventions for Disruptive Behaviors

The article by Selph et al in this issue of Pediatrics emphasizes the importance of psychosocial interventions for disruptive behaviors in children and adolescents.1 The authors conducted a meta-analysis of 64 randomized controlled trials of psychosocial interventions for preschool to school-aged children comparing the effectiveness of psychosocial interventions to treatment as usual or waitlist. The authors investigated which category of psychosocial interventions (parent-only, child-only, multicomponent) were helpful with what age group (preschool, school-aged, adolescent) in reducing disruptive behaviors.1 The study found that for preschool and school-aged children, multicomponent (parent/caregiver or teacher plus child) and parent-only psychosocial interventions were better than treatment as usual or waitlist at reducing parent-reported disruptive behaviors immediately post-intervention.1The authors included studies with children and adolescents formally diagnosed with a disruptive behavior disorder (DBD) as well as studies of children and adolescents with clinically significant disruptive behaviors based on assessments with validated instruments but without a formal diagnosis of a DBD.1 Psychosocial interventions resulted in greater improvement in disruptive behavior scores in both preschool and school-aged children with and without a formal DBD diagnosis, reassuring clinicians and parents that there can be effective intervention even without a formal diagnosis.1These findings emphasize the importance of identifying disruptive behaviors. Opportunities for identification emerge when parents or caregivers report concerns about noncompliance, aggression, or temper loss that are atypical for the child’s developmental age, are persistent, occur across environments, cause impairment in functioning, and cause distress for the child and family.2 Examples of screening tools for disruptive behaviors include but are not limited to the Eyberg Child Behavior Inventory and the Retrospective-Modified Overt Aggression Scale.3,4 Disruptive behaviors may also be identified during global behavioral, social, and emotional screenings recommended by the American Academy of Pediatrics annually at preventive health visits and whenever concerns are raised.5 Use of standardized screening instruments can help avoid missing cases that would benefit from intervention.6,7 To aid pediatric primary care clinicians in effectively screening for not only disruptive behaviors but a wide range of behavioral and emotional problems throughout childhood and adolescence, the American Academy of Pediatrics recently published a comprehensive clinical report that includes information about validated and accessible tools available in the public domain or at cost.5Once disruptive behaviors are identified, families should be provided with information about available resources to ameliorate symptoms. There is evidence that early psychosocial intervention can be effective in preventing adult psychopathology in children with early starting conduct problems.8 Selph et al have shown that parent management training (PMT) is effective in reducing disruptive behaviors in preschool and school-aged children.1 PMT is a psychosocial intervention that is effective at changing parenting behavior and preventing or mitigating early childhood behavior problems9; a few studies have documented evidence promoting the use and effectiveness of internet-assisted PMT programs in improving parenting and child behavior.10,11 Examples of evidence-based PMT programs include the Triple P-Positive Parenting Program,12 The Incredible Years,13 and Tuning Into Kids.14 There are states that offer free online PMT programs (such as Triple P in Ohio),15 and we encourage pediatric primary care clinicians to investigate the availability of free and/or reduced cost PMT programs in their region.The study by Selph et al also found that multicomponent interventions resulted in reduced disruptive behavior scores in preschool and school-aged children.1 Examples of multicomponent interventions include parent-child interaction therapy (PCIT), Brief Strategic Family Therapy, the Coping Power Program, and Functional Family Therapy, which have a strong evidence base with in-person (region-dependent) and/or online (program dependent) options available.16 There is evidence supporting the use of internet-delivered PCIT (I-PCIT), which can support service delivery to underserved and rural areas and families with transportation challenges.17 Clinicians should also inquire about school-based psychosocial interventions. According to data from the School Pulse Panel, in the 2021 to 2022 academic year, nearly all (96%) public schools offered at least 1 type of mental health service, most (84%) offered individualized interventions such as 1-on-1 counseling, and more than half (70%) offered mental health case management or coordination.18 There are also published studies on strategies to equip teachers to promote positive child behaviors and decrease the frequency of behavior problems in school, such as teacher-child interaction training.19,20 This is an intervention tailored from PCIT that addresses teacher communication and interaction skills to enhance teacher-child relationships and positive behavior in children with various needs.20 Since the pandemic, 67% of schools increased the type and/or amount of mental health services provided, 46% of schools created or expanded programs for social-emotional well-being of all students, and 41% of schools hired new staff to focus on student mental health and well-being.18 Nevertheless, schools continue to face barriers, including staffing shortages, compensation for services, and the challenge of collaborating with families and primary care clinicians.Although there are a growing number of primary care practices that have integrated behavioral health clinicians, this is not universal. When a behavioral health specialist is not readily available, primary care clinicians must rely on external referral sources, including online or internet-assisted psychosocial interventions, or school-based psychosocial interventions. Once resources and/or referrals are provided, it is important to have systems to ensure that care proceeded as planned and that there was clinical improvement. Inquiring about referral completion, services obtained, or barriers encountered is recommended.21Of course, child behavior is influenced by social drivers of health.22 Any attempt to promote positive child behavior must address social needs faced by the whole family. The task may be daunting, but pediatricians must stay diligent in emphasizing effective behavioral health care for children and adolescents and collaborating with schools and communities to advocate for policy elevating this priority.