Effects of child CBT and parent management training for children with disruptive behavioral disorders

Abstrakt

Populärvetenskaplig summering på svenska

Doktorandprojektet består av två delprojekt, en metastudie och en randomiserad kontrollerad studie. I båda projekten utvärderades effekten av behandling för barn med kliniska nivåer av utagerande beteendeproblem så som trotssyndrom och uppförandestörning. I metaanalysen utvärderades effekten av föräldraträning, (på engelska Parent Management Training; PMT) i randomiserade kontrollerade studier. I de studier som inkluderades, jämfördes PMT med väntelista. Resultatet visade att PMT är en effektiv behandling av utagerande beteendeproblem när besvären är så pass stora att de når kliniska nivåer i termer av effektstorlek var effekten av PMT medelstor. I metastudien undersöktes också b om barnet inkluderades i behandlingen så som vid den individuella PMT varianten Parent Child Interaction Therapy (PCIT) där barnet deltar i behandlingsrummet tillsammans med föräldern eller om barnet deltar parallellt så som vid PMT kombinerat med separat kognitiv beteendeterapi för barn (barn KBT) där barn tränas i ilske kontrollstrategier och problemlösningsstrategier. I metastudien jämfördes PCIT med väntelista och PMT kombinerat med barn KBT jämfördes med både väntelista och enbart PMT. Resultatet visade att PCIT var effektivt jämfört med väntelista och gav stora effekter i termer av effektstorlekar. Då det gäller PMT i kombination med barn KBT hittades enbart några få studier. Dådet var stora skillnader mellan resultaten från dessa studier kunde inga slutsatser dras.

I det andra projektet, den randomiserade kontrollerade studien ingick 120 barn i åldern 8-12 år med beteendesyndrom. I projektet utvärderades effekten av PMT kombinerat med barn KBT jämfört med enbart PMT direkt efter behandlingen och också två år efter behandlingens avslut. Resultatet visade att båda behandlingarna var effektiva och gav minskade beteendeproblem men inga skillnader kunde ses mellan behandlingsgrupperna. Resultatet höll sig över tid i båda behandlingsgrupperna.

Då det gäller sociala färdigheter var den kombinerade behandlingen med PMT och barn-KBT signifikant mer effektiv jämfört med gruppen enbart PMT direkt efter behandlingen. Vid två-årsuppföljningen kunde man se att behandlingseffekten höll i sig i PMT med barn- KBT gruppen då det gäller färdigheter i emotionsreglering och social kommunikation medan barnen i enbart PMT guppen kom ifatt under uppföljningsperioden till samma nivåer som PT med barn-KBT gruppen. I projektet utvärderades också föräldrafärdigheter och båda grupperna visade en minskning av stränga och auktoritära föräldrastrategier direkt efter behandling och efter två år.

Analys av effekten av behandlingen i olika subgrupper direkt efter behandling visade att de barn som hade stora svårigheter före behandlingsstart och barn som hade hög risk för antisocial utveckling förbättrades signifikant mer då det gäller minskade beteendeproblem av PMT med barn KBT jämfört med PMT.

Behandlingseffekterna i den randomiserade kontrollerade studien utvärderades också i termer av kostnads-effektivitet. In denna analys jämfördes andelen barn som hade återhämtat sig från trotssyndrom, det vill säga hur stor andel av barnen som hade förbättrats så pass mycket att de visade en kliniskt reliabel förbättring (Reliable clinical change) och hade symptom som låg under gränsvärdet för trotssyndrom två år efter behandling. En större andel barn i PMT med barn KBT gruppen visade en kliniskt signifikant återhämtning jämfört med barnen i PMT gruppen. En analys av kostnadseffektivitet visade att om beslutsfattare är villiga att betala € 62,354 (SEK 681,100) eller mer per barn som är kliniskt signifikant återhämtat då det gäller trotssyndrom, bedömdes PMT med barn KBT vara kostnadseffektivt jämfört med enbart PMT. Hur beslutfattare prioriterar då det gäller vilka behandlingsmetoder som skall erbjudas, bör påverkas av beteendeproblemens allvarlighetsgrad och erbjuda PMT med barn KBT i fall med svårare beteendeproblem och enbart PMT i lättare och medelsvåra fall.

Effects of child CBT and parent management training for children with disruptive behavioral disorders

Background: An early identification and treatment of children with disruptive behavior disorders such as oppositional defiant disorder and conduct disorder is important to prevent further development of psychiatric disorders and antisocial behavior. Parent management training (PMT) is considered an effective treatment and has been evaluated in numerous studies and meta-analyses. However, meta-analyses including randomized clinical trials on the sole effect of PMT on clinical levels of disruptive behavior disorder (i.e., disruptive behavior disorder diagnosis or disruptive behavior above clinical cut-off in validated measures) are lacking. Including the child in or alongside parent directed treatment may possibly increase treatment effects. Child cognitive behavior therapy (CBT) where the child receives training in anger management and problem-solving skills is considered an effective treatment although studies where child CBT is combined with PMT are scarce.

Aims: The objective for the present thesis was to evaluate the effects of PMT on clinical levels of disruptive behavior as well as more specifically investigate if there is a difference in effects if the child also participates in or alongside the treatment. Study I aimed at investigating the effect of PMT on clinical levels of disruptive behavior and the differential effects of child involvement in the treatment in a meta-analysis. The aim of Study II and III was to investigate the short- and long-term effectiveness of PMT compared to PMT combined with child CBT in terms of reduced disruptive behavior, increased social skills, improved parent management skills and reduced stress. The aim of Study IV was to investigate the effects of PMT compared to PMT combined with child CBT from a costeffectiveness perspective.

Methods: In Study I, twenty-five randomized controlled studies on PMT effects on clinical levels of disruptive behavior disorder were included in a meta-analysis. Studies comparing PMT with waiting list were synthesized, as were studies where the child was included in the treatment (i.e., Parent Child Interaction Therapy [PCIT] and PMT combined with child cognitive behavioral therapy [child CBT]). In addition, the effects of PMT combined with child CBT was compared directly to PMT alone. In Study II – IV, 120 children with disruptive behavior disorders were randomized to the PMT method Komet or to Komet combined with the child CBT program Coping Power Program (CPP). Assessments were made at baseline, post-treatment (analyzed in Study II) and at one- and two-year follow-up (analyzed in Study III and IV). Moderator analyses were made on child baseline characteristics.

Results: Study I, the meta-analysis, showed that both PMT and PCIT were more effective than waiting list in reducing disruptive behavior. PCIT had a larger effect in reducing disruptive behavior than PMT when both were compared to waiting list. Study II showed equally reduced disruptive behavior in PMT and compared with PMT with child CBT. Social skills were significantly more improved in the combined treatment. Moderator analyses showed that PMT with child CBT was more beneficial for children with high levels of ODD problems and high risk for antisocial development in reduced disruptive behavior. In Study III, treatment gains in reduced disruptive behavior were maintained and no difference was detected between both treatment arms at two-year follow-up. The early improvement in the PMT with child CBT condition in social skills was maintained at the two-year follow-up in the measures of emotion regulation- and social communication skills while the PMT condition reached similar improvement during the follow-up period. Study IV used the proportion of children that showed a reliable recovery from ODD which was larger in the combined treatment compared to Komet only. Results showed that if decision makers are willing to pay approximately 62,300 EURO per recovered case of ODD, Komet with CPP yielded positive net benefits, in comparison to Komet only. Sensitivity analysis from a health care perspective where school costs were excluded, a 50 % probability of cost effectiveness was reached at around 10,000 EURO.

Conclusions: The meta-analysis (Study I) gives support to treatment recommendations to offer PMT to children with clinical levels of disruptive behavior and highlights the additional benefits of PCIT. Offering PMT and child CBT simultaneously does not yield a significant treatment effect in reduced disruptive behavior compared to PMT only. The effects of adding child CBT to PMT were seen in a faster improvement in emotion regulation and social communication skills, in a larger proportion of recovered cases, and in beneficial effects among children with large behavior problems. Despite the relatively small cost for child CBT, the investment in combining PMT and child CBT should be guided by the severity of child disruptive behavior.