Caroline Helwick

October 25, 2012

NEW ORLEANS — For most preschoolers with disruptive behavior disorder (DBD), parent management training (PMT) is the optimal approach, but this may present challenges for physicians and parents, one expert says.

"Generally, in the preschool period we think about medications for aggression only if the behavior is not responding to other interventions, such as PMT," said Mary Margaret Gleason, MD, assistant professor of psychiatry and pediatrics, Tulane University School of Medicine in New Orleans.

"We literally put our focus on the child's experience, and if we have done all of that, and the child is exhibiting behavior that is putting him or her — or others — at risk, then medications can be considered," she said.

Dr. Gleason was speaking here at the American Academy of Pediatrics (AAP) 2012 National Conference and Exhibition.

She bases this approach on a lack of randomized controlled trials in this age group to validate the efficacy of a pharmacological approach to DBD. This includes oppositional defiant disorder (ODD) and conduct disorder (CD).

Only retrospective chart reviews of small numbers of patients have been published, and they have failed to establish the efficacy of risperidone and other atypical antipsychotics, alpha agonists, and mood stabilizers/antiepileptics.

These small studies do suggest that patients may improve on medications, but they lack structured comparisons.

"In contrast, we have literally hundreds of randomized trials of PMT for DBS in preschoolers, so the weight of the evidence is really in favor of PMT," she said.

Dr. Gleason provided 4 guidelines for treating DBD in preschoolers:

  • Give adequate therapy;

  • Consider whether parental treatment is also necessary, including medication;

  • Treat comorbid attention-deficit/hyperactivity disorder (ADHD) first if medication is being considered;

  • Use medications only if severe aggression puts the child or others at risk and if nonpharmacological intervention has failed.

Providers should also ensure that the child is in a safe place during the day, such as a structured child care setting, and that the child's behavior is not just "a reenactment of trauma or violence in the home."

The PMT Model

Dr. Gleason acknowledged that parents want immediate effects. "With highly stressed families, as we typically see with these preschool kids, the question is how to keep them engaged in a process that will take time and work to see the benefits," she offered.

"I find myself having many conversations about why I am not prescribing drugs," she continued. "Parents say, 'We need something to work now; our child is being thrown out of day care."

When parents have "safety nets," as they do in her system at Tulane, she said "they stick with us." But she acknowledged that the urgency of the situation may warrant a different course of action and should be part of the decision-making.

Pediatricians at the session asked how PMT can be made more user-friendly for their practices. One asked, "Is there a model that will teach us to do PMT in 15-minute appointments, or at every 2-week visit? We especially need this where there is a lack of access to specialty care."

Dr. Gleason answered that primary care models for PMT are indeed available, including the "Triple P" model developed in Australia — the Positive Parenting Program — which can be initiated without formal training.

The main goal, she said, is to teach parents the principles of dealing with the disruptive child: to reinforce the positive, ignore annoying behavior, and provide safe and consistent consequences.

"It's important to bring parents in to see you regularly. These are hard changes to make without support," she added.

When Drugs May Help

For children who do warrant medication, first-line treatment depends on whether the child also fits the profile for ADHD.

For children without ADHD, first-line treatment is with risperidone. She cautioned that there are no randomized controlled trials in "typically developing" preschoolers, although the drug is approved by the US Food and Drug Administration for aggression/irritability in children as young as 5 years with pervasive development disorder.

Risperidone must be given with caution to preschoolers. In animal studies, early exposure to atypical antipsychotics resulted in abnormal dopamine receptor function, and studies have shown that levels of prolactin in young risperidone users are at least 5 times normal levels.

Substantial weight gain is also likely with atypical antipsychotics (5 to 9 kg over 10 weeks), as are metabolic effects; therefore, frequent monitoring, including blood draws, is necessary.

"These are not reasons not to go this route, but they are part of the decision-making process," she said.

In addition to laboratory monitoring, symptoms should be monitored with a structured instrument. If there is no improvement, a trial with an alpha agonist, such as clonidine, is an option.

In fact, for children with concomitant ADHD, clonidine might be a first choice, though this is supported by even less evidence than risperidone, she pointed out.

"I am perfectly happy to try an alpha agonist first," she said. "Truthfully, I have not run into many children without an ADHD profile, and so most kids will go down this path anyway."

With clonidine, monthly monitoring of blood pressure and heart rate is warranted; it is also warranted when dosage is adjusted. Rebound hypertension is associated with abrupt discontinuation, but this is usually not an issue with once-daily dosing. Dr. Gleason said that she also warns parents that "death is one of the side effects" of clonidine; therefore, it must be taken as prescribed.

All medications should be approached as temporary measures, she emphasized. "You plan for discontinuation, and you discuss this with the family," she said. Discontinuation is often possible after 1 year of treatment, she added.

When All You Have Is a Hammer...

Commenting on the study findings, Mark E. Helm, MD, MBA, of Arkansas Pediatric Clinic in Little Rock, said that he found the presentation highly relevant.

"This information is critical for primary care doctors," he told Medscape Medical News. He added that pediatricians are largely unaware of side effects and complications of drugs they do not prescribe routinely, which is especially important when they receive referrals from mental health systems.

"In this case, children no longer have access to who prescribed the drug originally, and the expectation is that we will take over the prescribing," he said. "This puts us in an extraordinarily uncomfortable situation."

Regarding management of DBD, he said the condition and its treatment are both "multifactorial," and within mental health systems, care may not be optimal.

"When all you have is a hammer, everything looks like a nail, and the nail that sticks up the highest gets hammered," he said. "What I mean is a lot of kids will have a 15-minute assessment and then be placed on medicine, and we don't think that is the most appropriate management."

He agreed with Dr. Gleason that PMT is critical, but he said it is often bypassed in favor of the easy alternative — medication.

"If you do PMT, you will have a more durable intervention," he emphasized, "but our problem is that it's hard to get this paid for and it's hard to have access to people trained in doing this. It limits our toolbox."

Dr. Gleason and Dr. Helms have disclosed no relevant financial relationships.

American Academy of Pediatrics (AAP) 2012 National Conference and Exhibition. Presented October 20, 2012.

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