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The Uncontrollable Child: Family and Educational Interventions

The Uncontrollable Child: Family and Educational Interventions

It is estimated that about 20% of children and adolescents meet criteria for a mental health disorder, and a high percentage of these youths are impaired by disruptive behavior problems. Children with disruptive behavior problems include those who meet criteria for attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), or conduct disorder (CD), as well as those who have impairments related to disruptive behavior who may not meet formal criteria for one of these diagnoses. While medication is generally an effective treatment for children with disruptive behavior problems, in particular ADHD,1 some form of nonpharmacological treatment is often necessary to help these children function normally in academic and social settings.

A wide range of nonpharmacological interventions have been shown to be effective in managing family and school impairments associated with disruptive behavior problems. Psychosocial interventions can be family-based or school-based. (For a description of school-based interventions, see the review by Power and colleagues.2) In this article, we summarize empirically supported family-based psychosocial treatments for children aged 5 to 12 years with disruptive behavior problems, including ADHD, ODD, and CD. We emphasize family-based interventions that can have an effect on children's functioning in both family and school settings and that can be delivered within the pediatric primary care setting or in connection with a mental health practice. Because these interventions require slight adjustments depending on developmental stage and economic background of the child,3 we also review adaptations for working with preschool children, adolescents, and families from underserved populations.

Unfortunately, well below 50% of children who need mental health care actually receive services. Children and adolescents who are least likely to receive services are those belonging to racial and ethnic minority groups, who are disproportionately represented among the poor and uninsured in this nation.4 Barriers to mental health care can be divided into access problems (cost of services, availability of care) and family beliefs (lack of trust in health care system or providers, unfavorable views about evidence-based treatments) that may preclude engagement in services.5

Pediatric primary care practices and schools are major venues for the delivery of mental health services to children and adolescents. Providing mental health services in these settings can improve access and help overcome some of the barriers to care. Nonetheless, when addressing the needs of youths with disruptive behavior problems, pediatric providers face substantial challenges, including limited time, reimbursement issues, and lack of mental health care training.6 Models of collaborative practice with mental health providers have been developed to address these limitations and are discussed in this article in an effort to help pediatricians implement evidence-based interventions.

EVIDENCE-BASED PSYCHOSOCIAL TREATMENT

Family-based behavioral interventions. More than 4 decades of research indicate that family-based psychosocial interventions are effective treatments for children with ADHD, ODD, or CD.7-9 These interventions are guided primarily by attachment theory, social learning principles, and cognitive-behavioral theories of change that involve both altering antecedents and consequences of behavior and building cognitive skills. Often referred to as “parent training” programs, effective family-based interventions are typically parent-mediated in that the bulk of therapeutic work is conducted face-to-face with parents in an effort to modify the home environment and patterns of parent-child interaction.

Parent training protocols involve a number of common elements in that they:

• Educate parents about their child's condition and how symptoms lead to concerns at home, at school, and with peers.

• Teach parents ways to establish or maintain a warm and positive relationship that facilitates attempts to regulate their children's behavior.

• Help parents implement behavior management skills at home. Specific skills include the use of effective commands and positive reinforcement/praise in response to appropriate behavior, the development of a contingency management system (ie, token economy, point system), and the use of strategic punishment.

The goal of parent training protocols that address childhood ADHD, ODD, antisocial behavior, and other externalizing problems is to improve relationships among family members and teach effective behavior management strategies. Depending on the nature of the problem, parent training programs can be delivered via group treatment with parents and children, individual treatment with parents only, or individualized family treatment. Parent training programs typically last between 10 and 20 weekly or biweekly sessions, with follow-up “booster sessions” to track progress and problem-solve future challenges.

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