Matching treatments to children with disruptive behaviour

By CAMH Discovers Quarterly — February 1, 2017

Acting out and testing the rules occasionally are normal aspects of childhood development. For some children, these or other difficult or disruptive behaviours occur frequently and consistently, adding stress to everyday life and, in some cases, affecting learning and relationships with other children. It’s estimated that five to 15 per cent of school-aged children have disruptive behaviour problems, which may be either observed by a parent or teacher, or formally diagnosed as oppositional defiant disorder or as a symptom of attention-deficit hyperactivity disorder (ADHD).

Since he joined CAMH in 2009, CAMH’s Dr. Brendan Andrade and the Better Behaviours Service team have been conducting research to improve treatments and prevent behaviour problems from developing altogether. His research includes treatment studies in the clinic and brain-imaging studies (see below, “Looking inside the brain”). “Our overarching goal is to understand the broad spectrum of what contributes to and reduces disruptive behaviour, from causes to effective interventions,” says Dr. Andrade, Clinician Scientist in CAMH’s Child, Youth and Emerging Adult Program, part of the Margaret and Wallace McCain Centre for Child, Youth & Family Mental Health. 

The question driving the team’s research now is: Which treatments work for which children? “The challenge today is we have no evidence to tell us which treatment to select for a specific child and family,” says Dr. Andrade. Through a four-year study, the team is developing group profiles of children with shared traits who benefit – or not – from two proven group-based treatments. It’s a step toward matching a child with the optimal treatment and identifying patient needs that may be better addressed through other treatments or combinations of treatments. “We should be fitting our treatments to kids, not kids to our treatments,” says Dr. Andrade.

Effective treatments — and gaps

The Better Behaviours Service offers two different types of treatment for children and their families: group-based treatment or individualized treatment. Both are predominantly cognitive-behavioural interventions, with research evidence demonstrating their effectiveness. Most parents report a noticeable drop in their child’s disruptive behaviour after either form of treatment.

Despite this success, a significant portion of kids and families who come for treatment don’t sufficiently benefit, says Dr. Andrade. This group includes children with an insufficient reduction in disruptive behaviour, based on clinical measures or parent or teacher reports, as well as children and families who drop out because the treatment may not be meeting their needs. 

Toward personalized treatment

An insight from his earlier study sparked the idea for his new research. After completing the study, the team examined children's response to treatment in relation to two kinds of symptoms: mood and anxiety difficulties, and level of empathy toward other kids. They found that while children generally benefited from treatment, kids with elevated mood and anxiety difficulties benefited less from treatment than those with lower levels of mood and anxiety concerns. 

In his new study, Dr. Andrade and team are evaluating several characteristics related to disruptive behaviour. The team aims to identify profiles or subgroups of children with similar traits, and, most importantly, to determine how these subgroups differ in their response to the same group-based treatment. The characteristics cover three broad categories: observed behaviours (for example, irritability and confrontational or oppositional behaviour), psychological characteristics that influence behaviour (such as mood and anxiety problems, and empathy) and areas related to thinking and the brain (such as attention and problem-solving). 

As the first part of the study, all children and their families referred to the Better Behaviours Service are participating in an augmented assessment to determine if group-based or individualized treatment will be a better fit based on their needs. Developed by the CAMH team, the new assessment process is an initiative to better understand parents’ and children’s concerns so that the team can begin to offer personalized treatment. Dr. Andrade expects group-based treatment will be a fit for most families. Children and their families receiving group-based treatment are eligible to continue in the second part of the study. The four-year study, funded by the Canadian Institutes of Health Research (CIHR), is in its first year and is based out of CAMH and two community agencies. 

The findings will take the team’s work in new directions, says Dr. Andrade. By learning which children benefit from group-based treatment, based on their profile, the team will be able to develop screening tools to identify children with these characteristics. For children and families who aren’t benefiting sufficiently from current treatments, the next step would be to test other kinds of existing treatments or create new interventions that may better address children’s and parents' needs. “Over the long term, we’ll be able to develop care pathways that will match a child and family with the treatment that will be most effective for them,” says Dr. Andrade.

Looking inside the brain

An arm of Dr. Brendan Andrade’s research is identifying the biological factors in children that may influence disruptive behaviour or their response to treatment. In another study he’s conducting with CAMH’s Dr. Stephanie Ameis and co-investigators, Dr. Andrade is looking at brain changes in children participating in his study to develop personalized treatment approaches (see above). By taking brain scans using magnetic resonance imaging, the goal is to determine if changes in disruptive behaviour with treatment correspond with changes in the brain. The researchers will also assess how brain structure and function in children with disruptive behaviour compare to those of a control group of kids without these behaviours. The aim is to find brain markers that may play a role in disruptive behaviour. This research is funded in part by the American Psychological Foundation.