Optimizing Treatments for Youths with Persistent and Severe Disruptive Behaviors

Summary

Disruptive behaviors or DBs (e.g., aggressive, defiant, and rule-breaking behaviors) are a common reason for youths to be referred for mental health treatment. About 4-8% of youths have clinical DBs that result in diagnoses of Conduct Disorder or Oppositional Defiant Disorder.¹ DBs are associated with a tremendous burden to youths, their family, and society. DBs predict school truancy and dropout,² substance use,³ criminal behaviors,⁴ and increased risk of adult psychopathology including antisocial personality disorder⁵ and depression.⁶ Furthermore, youths with DBs incur 10 times the costs of youths without DBs,⁷ with costs spanning health, child welfare, educational, and legal sectors. For example, youths with DBs are more likely to use emergency department services and social welfare benefits, are more likely to require special education services, and are more likely to engage in criminal activities that result in costs to the community for legal proceedings and to victims.^7,8 Among youths with DBs, there are differences in factors that contribute to their behaviours. Some youths have callous-unemotional traits (CU) – they often lack remorse or empathy and seem indifferent to the consequences of their behaviours. Youths with CU tend to have more severe and stable DBs. About 20-30% of youths with DBs have CU, and standard treatments do not work as well for them (i.e., they begin treatment with greater severity and continue to have severe DBs after treatment).⁹ Notably, most DB treatments are not effective at reducing CU themselves.⁹ There remains a need for effective tailored treatments for youths with DBs+CU in order to improve their quality of life.

Our research team aims to integrate user-centered designs and implementation science to develop and evaluate a tailored intervention for adolescents with DBs+CU. This intervention is to be delivered in outpatient mental health settings to maximize reach as youths with DBs+CU are likely to have been referred for treatment prior to involvement in more restrictive care and legal settings. First, we are conducting a series of surveys and semi-structured interviews with research, clinical, and caregiver experts to identify treatment priorities. Results from the surveys and interviews will be triangulated to yield a list of discrete areas to target in treatment. Second, we will co-design the intervention with primary and secondary users. Primary users will include caregivers, adolescents, and service providers. Secondary users will include system administrators and leaders who make decisions regarding implementation of treatments at their local agencies. Structured testing and revision cycles will be conducted with users to inform the content, format, and delivery of the intervention. Potential implementation barriers will be identified and discussed with users throughout these cycles. Designs that are responsive to these barriers will be incorporated into the intervention. Third, we will conduct a pilot trial to evaluate the preliminary feasibility and effectiveness of the intervention. Last, we will conduct a full trial to simultaneously evaluate intervention effectiveness and factors that may impact implementation.

Significance

Youths with DBs+CU carry a substantial lifetime burden, impacting not just themselves but society as a whole. Implementing effective interventions are critical to reduce this burden. Incorporating user-centered designs can improve equity by engaging users from underrepresented populations.¹⁰ Most treatment studies for DBs and CU include samples that are predominantly male (>50%) and lack racial/ethnic diversity.^9,11 Our research program prioritizes engaging with users who have been underrepresented in treatment studies, specifically females and racial/ethnic minoritized youths, in order to design treatments that are responsive to their needs.

Research also documents racial disparities in the identification of DBs in youths. Relative to their White peers, youths from racial and ethnic minority groups are more likely to be diagnosed with a disruptive behavior disorder than Attention-Deficit/Hyperactivity Disorder.¹² A diagnosis of a DB disorder instead of another behavioral or neurodevelopmental disorder can have clinical, social, and legal implications (e.g., inappropriate treatment receipt, greater perceptions of behavioral problems and resulting disciplinary actions by adults, harsher judgments of guilt and responsibility in legal settings). Although less research has examined these implications for youths with DBs+CU, it is likely that these effects remain or are even magnified. Thus, developing an effective intervention for youths with DBs+CU has potential to mitigate these negative consequences.

Benefits

Demonstrated benefits are those that have been observed and are verifiable.

Potential benefits are those logically expected with moderate to high confidence.

Develop recommendations for priority treatment areas for DBs+CU informed by multiple partner perspectives. potential.

Clinical

Guidelines

Integrate user-centered design and implementation science to inform DB intervention development that better meets local user and local context needs. potential.

Clinical

Investigative procedures

Develop an effective, tailored intervention for youths with DBs+CU by targeting high-priority needs. potential.

Clinical

Therapeutic procedures

Alter the trajectory and/or reduce severity of DBs and CU in youths. potential.

Community

Disease prevention & reduction

Disseminate therapeutic handouts and workbook to treatment providers who work with youths with DBs+CU. potential.

Community

Health education resources

Offer a tailored treatment for youths with DBs+CU that is more effective than usual care. potential.

Community

Health care quality

Improve social relationships, quality of life, and overall mental health in youths with DBs+CU. potential.

Community

Life expectancy & quality of life

Reduce risky behaviors and delinquency in youths with DBs+CU. potential.

Community

Life expectancy & quality of life

Reduce social and economic burden related to DBs (legal, school, medical). Although no research examined cost-savings of treatments for youths with DB+CU specifically, studies estimate that $1 invested in prevention and early intervention of DBs generally yielded a 17% investment return.¹³ potential.

Economic

Societal & financial cost of illness

This research has clinical, community, and economic implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.¹⁴

Clinical

In the clinical domain, it is anticipated that the developed intervention will be more effective in reducing DBs for youths with DBs+CU compared to usual care. Recommendations for priority treatment areas for DBs+CU informed by multiple partner perspectives are anticipated this year based on the survey and interview results. Findings will be disseminated in academic and clinical journals that publish treatment guidelines. Other researchers can use our findings to guide their own treatment development for DBs+CU. Findings will also be translated into infographics for dissemination to participants and on our research team’s website.

Community

In the community domain, the developed intervention is anticipated to improve quality of care for a difficult-to-treat population. The tailored intervention has the potential to be more effective for youths with DBs+CU than existing interventions, which is expected to result in greater reduction in DBs and CU symptoms, greater reduction in risky behaviors and delinquency, and corresponding greater improvement in quality of life, overall mental health, and functioning in youths.

Economic

In the economic domain, the developed intervention has the potential to reduce societal and financial costs associated with DBs. To increase translational impact, partners will be consulted throughout the research project to identify effective strategies for sharing research findings and clinical education resources (e.g., therapeutic handouts and workbooks) and to promote public buy-in for and scale-up of the intervention.

Lessons Learned

Clearly articulating our vision and the types of benefits we hope to achieve has helped us plan our research process and build infrastructure in advance. For example, to demonstrate economic impacts, we are now carefully considering different cost measurements in our studies, which is a new and exciting direction for us.