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 cost-effectiveness 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.

List of scientific papers

I. Helander, M., Asperholm, M., Wetterborg, D., Öst, L., Hellner, C., Herlitz, A., Enebrink, P. The efficacy of parent management training with or without involving the child in the treatment among children with clinical levels of disruptive behavior: A meta-analysis. [Submitted]

II. Helander, M., Lochman, M., Högström, J., Ljótsson, B., Hellner, C., Enebrink, P. (2018). The effect of adding Coping Power Program-Sweden to Parent Management Training-effects and moderators in a randomized controlled trial. Behavior Research and Therapy. Apr;103:43-52.
https://doi.org/10.1016/j.brat.2018.02.001

III. Helander, M., Enebrink, P., Hellner, C., Ahlen, J. Long-term effects of adding Coping Power Program-Sweden to Parent Management Training- Two-year follow-up of effects, moderators and reliable clinical change in a randomized controlled trial. [Submitted]

IV. Nystrand, C., Helander, M., Enebrink, P., Feldman, I., Sampaio, F. (2020) Adding the Coping Power Program-Sweden to Parent Management Training: the Cost-Effectiveness of Stacking Components for Children with Disruptive behaviour disorders. European Child and Adolescent Psychiatry.
https://doi.org/10.1007/s00787-020-01638-w