The sequencing of treatments for disruptive behavior in adolescents
Interventions should be integrated or sequenced in the treatment of disruptive youth.12 This proposed sequence involves some early family and parent work to interrupt individual symptom-maintaining family interactions, without which individual work founders:
• Stabilize behavior through pharmacology and parent management training.
• Work with the interactive process through family therapy.
• Identify individual family dynamics that require intervention.
• Encourage individual adolescent therapy (eg, cognitive-behavioral, interpersonal, psychodynamic, or supportive) as the adolescent gets older.
• Consider larger systemic interventions: residential treatment, multisystemic treatment.
Acute behavior is stabilized through the treatment of medical illness, which addresses substance abuse when present and uses psychopharmacology to treat severe symptoms. Prescribing medication for nonspecific, developmentally mediated disruptiveness is off-label. However, prescribing medications for specific disorders (eg, ADHD, bipolar disorder, autism), which can include disruptive behavior as part of the core condition, is not off-label (Table 2).
Parent management training with an adolescent focus should accompany these biological interventions. Such training provides immediate strategies for behavior control through the use of behavioral contingencies. Second, the assessment of the family often dictates a need for an intervention, informed by various schools and techniques of family therapy.13 Unfortunately, parent management interventions are often not implemented because of specific parental and marital dynamics.
When families impede an adolescent’s development of self-regulation, they facilitate specific cognitive sets that predispose the adolescent to enduring personality pathology. Both J.P. and J.C. were entitled youths who were increasingly disruptive and maladaptive in their relationships. Although too young for a formal diagnosis of personality disorder, both patients demonstrated precursors of a narcissistic disorder. It was anticipated that individual therapy would be increasingly relevant for these boys as they got older.
A multimodal sequenced series of interventions focused on helping the adolescent develop behavioral control may, in severe cases, include other environmental interventions.14 Coordinated multisystemic approaches include hospitalization, in-home interventions, school consultations, and out-of-home placements. The family emphasis of this article does not imply that family interventions are the only approach to children with disruptive disorders, although families must be involved in all aspects of treatment.
Cognitive-behavioral therapy and skills training may be helpful, especially when there is comorbidity (eg, depression).15 While psychodynamic psychotherapy provides a framework to understand the developmental constructs, it has not been shown to be effective as a sole treatment intervention.16 Finally, perhaps the most empirically validated modality is behaviorally oriented parent management training programs.17
The ultimate goal in working with disruptive adolescents is to enhance self-regulation in all domains. Although this is difficult, it is the cornerstone of child and adolescent development.18 Such development takes place within the family, and any treatment must foster the efforts of the family who is raising children to confer the fundamental life skill of self-control.
Drugs Mentioned in This Article
Carbamazepine (Carbatrol, Tegretol, others)
Lithium (Eskalith, Lithane, Lithobid)
Methylphenidate (Ritalin LA)
Valproic acid (Depakote)
1. Finch AJ Jr, Nelson WM III, Hart KJ. Conduct disorder:description, prevalence, and etiology. In: Nelson WM III, Finch AJ Jr, Hart KJ, eds. Conduct Disorders: A Practitioner’s Guide to Comparative Treatments. New York: Springer Publishing; 2006:1-13.
2. Kramer DA. Commentary: gene-environment interplay in the context of genetics, epigenetics, and gene expression. J Am Acad Child Adolesc Psychiatry. 2005;44:19-27.
3. Rutter M. Environmentally mediated risks for psychopathology: research strategies and findings. J Am Acad Child Adolesc Psychiatry. 2005;44:3-18.
4. McHugh PR. Striving for coherence: psychiatry’s efforts over classification. JAMA. 2005;293:2526-2528.
5. Rueve ME,Welton RS. Violence and mental illness. Psychiatry. 2008;5:35-48.
6. Moreno C, Laje G, Blanco C, et al. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry. 2007;64:1032-1039.
7. Jensen PS, Youngstrom EA, Steiner H, et al. Consensus report on impulsive aggression as a symptom across diagnostic categories in child psychiatry: implications for medication studies. J Am Acad Child Adolesc Psychiatry. 2007;46:309-322.
8. Gunlicks ML,Weissman MM. Change in child psychopathology with improvement in parental depression: a systematic review. J Am Acad Child Adolesc Psychiatry. 2008;47:379-389.
9.Weissman MM, Pilowsky DJ,Wickramaratne PJ, et al. Remissions in maternal depression and child psychopathology. JAMA. 2006;295:1389-1398.
10. Diamond G, Josephson A. Family-based treatment research: a 10-year update. J Am Acad Child Adolesc Psychiatry. 2005;44:872-887.
11. Shonkoff JP, Phillips DA. From Neurons to Neighborhoods: The Science of Early Child Development. Washington, DC: National Academy Press; 2000.
12. Josephson AM, Serrano A. The integration of individual therapy and family therapy in the treatment of child and adolescent psychiatric disorders. Child Adolesc Psychiatr Clin N Am. 2001;10:431-450.
13. Josephson AM. Child and Adolescent Psychiatric Clinics of North America. Philadelphia: WB Saunders Company; 2001;10:3.
14. American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children and adolescents with oppositional defiant disorder. J Am Acad Child Adolesc Psychiatry. 2007;46:126-141.
15. Rohde P, Clarke GN, Mace DE, et al. An efficacy/ effectiveness study of cognitive-behavioral treatment for adolescents with comorbid major depression and conduct disorder. J Am Acad Child Adolesc Psychiatry. 2004;43:660-668.
16. American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children and adolescents with conduct disorder. J Am Acad Child Adolesc Psychiatry. 1997;36:122S-139S.
17. Mabe PA,Turner MK, Josephson AM. Parent management training. Child Adolesc Psychiatric Clin N Am. 2001;10:451-464.
18. Vitiello B, Calderoni D. Pharmacologic treatment of children and adolescents with impulsive aggression and related behaviors In: Vitiello B, Masi G, Marazziti D, eds. Handbook of Child and Adolescent Psychopharmacology. Boca Raton, FL: Informa Healthcare; 2006:297-314.
Gunlicks ML, Weissman MM. Change in child psychopathology with improvement in parental depression: a systematic review. J Am Acad Child Adolesc Psychiatry.2008;47:379-389.
Moreno C,Laje G,Blanco C,et al.National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry. 2007;64:1032-1039.