Treating Disruptive Disorders

A Guide to Psychological, Pharmacological, and Combined Therapies

George M. Kapalka, George M. Kapalka

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317963271
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychopathologie

Treating Disruptive Disorders is a practical book for busy clinicians—psychiatrists, psychologists, mental health counselors, clinical social workers, and more—as well as students, interns, or residents in the mental health professions. It distills the most important information about combined as well as solitary treatments of a variety of psychological disorders characterized by disruptive behaviors, including those where disruptive aspects are part of core symptoms (like ADHD, ODD, or conduct disorder), and those where disruptive features are commonly associated with core symptoms (like mood, personality, and cognitive/developmental disorders). In addition to an analysis of the best in evidence-based practice and research, the volume also includes brief clinical vignettes to help present the material in an easily accessible, understandable, readable, and relevant format. The chapter authors are experts in the treatment of these disorders and review a wide variety of empirically supported treatments for children, adolescents, and adults.

Part I

Etiology, Epidemiology, and Course of Disruptive Disorders

1 To Medicate or Not to Medicate

Weighing the Benefits and Challenges of Available Treatments for Disruptive Disorders

George M. Kapalka and Angela A. Gorman

Since the days of Freud and Kraeplin and well into the mid-twentieth century, we seemed to have had only two widely recognized choices to treat patients with psychological disorders: long-term institutionalization (and, mostly, significant sedation) for the most severely ill and intensive psychoanalysis for those able to function outside the psychiatric hospitals. The decision of whether to sedate or hospitalize patients was primarily made on the basis of the degree of disruption these patients caused to those around them. Those most severely disruptive (e.g., violent) were usually sedated, and those patients were most likely to be institutionalized.

Over the past five decades, significant developments changed the face of mental health treatment. A plethora of research revealed that many individuals with psychological disorders exhibit structural and functional differences in their brains. For example, functional impairments in the anterior cingulate cortex (ACC) have been identified in youth with disruptive behaviors (Gavita et al., 2012), and researchers have explored the function and role of monoamine neurotransmitters such as serotonin and dopamine, which may play key roles in the development of disruptive behaviors (Malmberg et al., 2008). In general, imbalance in activity between “hot” and “cold” brain circuitry is currently believed to underlie many disruptive symptoms and features (see Chapter 2 in this volume for a review). Stress hormones like cortisol have also been implicated. For example, an association may exist between cortisol reactivity and callous unemotional (CU) traits in boys, which are often present in youth with disruptive behavior disorders (Van De Wiel et al., 2004). This is consistent with the body of literature that highlights the correlation between the reactivity of the hypothalamic pituitary adrenal (HPA) in times of stress and disruptive/aggressive behavior (Stadler et al., 2011).

Because brain changes are likely to be reflected in feelings and behaviors, psychopharmacological approaches were developed to try to address some of the biological factors that may be responsible, at least in part, for the symptoms. Many of these approaches have proven effective in reducing (and sometimes eliminating) many symptoms, including disruptive behaviors, and intervening pharmacologically has been shown to be beneficial, especially in cases where symptoms are severe and potentially dangerous.

But today many critics believe the pendulum has swung too far in the direction of pharmacological treatments. With the US Food and Drug Administration’s loosening of restrictions on direct-to-consumer medication advertisement (the United States is one of only two countries in the world allowing such advertisements), ads for various medications now fill the air, seemingly most of the day and on almost every radio and television station, and medication ads similarly have infiltrated much of the Internet. This is driving a culture where medications are seen as a quick fix that provide improvement with little effort or cost (if one has proper health insurance coverage), and the significant adverse effects that many of these medications may have tend to be underemphasized. In addition, medications are treatments and not cures, and so when the medications are discontinued, the symptoms are likely to return.

Many nonmedical mental health professionals tend to recognize these factors and usually seek to minimize pharmacological approaches, focusing instead on psychological treatments. Over the past five or six decades, research on various forms of psychotherapy has exploded and many specific treatments have been developed for many specific disorders. This is a reasonable approach, especially with children and the elderly population, as introducing medications in these populations may result in unpredictable reactions and medical risks. But is it realistic for psychotherapy to replace the need for psychotropic medications? Will symptom improvement be sufficient so that treatment with medications will not be needed?

The above questions are most appropriate in the context of disruptive symptoms and behaviors. Disruptive disorders are often-referred disorders for psychiatric (Jensen et al., 2007) and mental health services (Zisser & Eyberg, 2010), and most who encounter individuals with these disorders must decide whether the referral should be to a prescriber or a psychotherapist. On the one hand, disruptive behaviors by their very nature require quick stabilization, because the problems that patients and those around them experience as a result of aggressive and impulsive actions tend to be troubling and impairing. This suggests that treatment with medications may offer quicker improvement. But does that mean that psychotherapeutic treatments are not as desirable? And can the benefits be maximized when combined treatment approaches (including psychological and pharmacological treatments) are utilized? While the contributions to this volume grapple with these questions and strive to offer readers much-needed guidance, broad themes permeate these reviews, and contemplating these factors while consulting the reviews will help focus the readers on important aspects to consider when choosing the best treatment.

Pharmacological Treatment of Disruptive Disorders

Research findings reveal that many medications are effective in reducing disruptive symptoms and features. Most notably, psychostimulants have been shown to reduce impulsivity (MTA Cooperative Group, 1999), while mood stabilizers—including anticonvulsants (Stanford et al., 2001), atypical antipsychotics (Buitelaar et al., 2001), and lithium (Jones et al., 2011) as well as serotonergic antidepressants (especially selective serotonin reuptake inhibitors, or SSRIs; Coccaro et al., 2009)—have been shown to reduce propensity toward impulsive aggression and violence. Of course, medications come with risks, and various patients tolerate medications to varying degrees. Thus clinicians must frequently consider whether the benefits outweigh the risk, and, if so, which patients are best candidates for medications.

Severity of the symptoms often influences the decision of whether treatment with medications is needed. For example, milder forms of impulsivity or agitation may respond well to psychotherapy. Severe variants of these symptoms may be difficult to treat with psychological therapies, however, and intense and dangerous symptoms are likely to require psychopharmacological treatment. Therefore most clinicians find that individuals with seriously compromised self-control and significant potential for violence usually require an approach that includes pharmacological treatment. Jensen et al. (2007) confirmed, for example, that the use of psychotropic agents are usually limited to cases in which symptoms are more severe and may not be as responsive to psychological interventions alone.

When psychosocial treatment is effective, progression of improvement is gradual, requiring several sessions to become evident. Even those variants termed “brief therapy” generally require 8–15 sessions before significant improvement is expected. When disruptive symptoms debilitate patients and pose significant risks to those around them, waiting so long for improvement may not be prudent. Conversely, many pharmacological treatments produce at least some improvement within days of the onset of treatment, although a few weeks (in some cases, four to six) may be needed for more comprehensive response. Still, this is usually faster than psychological treatments, and the amount of improvement seen with medications may be greater than the improvement seen with psychotherapy over the same period of time.

In order for psychological treatments to be effective, patients need to attend sessions regularly. If rapid progress is needed, sessions need to be scheduled at least weekly. Yet driving to the therapist’s office once per week, and spending an hour in the office, may be difficult for some patients (or families) with significant time obligations. When the patient is a child or adolescent, psychotherapy must be done outside of school hours, because missing school one day per week to attend psychotherapy is neither practical for the family nor beneficial to the student.

The cost of weekly psychotherapy is also likely to constitute a significant expense for many families, and few are able to cover such costs out of pocket. In the United States, most patients with health-care coverage are covered by private plans, usually purchased through an employer. The quality of this coverage varies widely. Unfortunately, mental health care is often considered to be the “step-child” of the health-care industry, and levels of coverage for mental health treatment are often much lower than they are for medical care. Although laws on the federal and state levels have been passed to close that gap, many exclusions exist, and the disparity between medical and mental health coverage continues.

Limiting the patient’s access to care is one common method of containing health-care costs. Many individuals with managed health-care coverage have benefits that are primarily evident “on paper” and virtually disappear when the insured seeks treatment. Gatekeepers review the need for care, and these reviews delay sessions and interrupt the continuity of care. Gatekeepers may initially authorize four to six sessions, and additional reviews are needed for each subsequent block. It is up to the discretion of the gatekeeper to authorize further treatment, and when the gatekeeper believes that a patient has made sufficient progress, or that sufficient progress is not evident, further authorization may not be issued. Although every insurer has appeals procedures, these appeals are internal to the insurer, and patients usually have no external review to invoke if the insurer refuses to authorize continued care. To make matters worse, appeals often take months; in the meantime patients are getting no care and, in the case of disruptive symptoms, continue to pose risks to themselves and those around them.

Another challenge is that millions of children and adolescents in the United States have no health-care coverage. While federal and state authorities are striving to close this gap, there continues to be a significant portion of our society without insurance coverage that cannot afford mental health care. Various agencies exist that may service these individuals, including networks of community mental health centers (CMHCs) that provide care to those who need it, sometimes without (or with minimal) cost. In many states, however, CMHCs are overextended, and long wait times are necessary (in some cases, up to eight weeks) before the agency is able to provide care. Meanwhile, patients are suffering and are receiving no treatment. In addition, in rural states, the nearest CMHC may be a long distance away. For all of those reasons, patients and their families may need to utilize psychopharmacological treatment either instead of or in addition to psychosocial interventions.

Psychological Treatment of Disruptive Disorders

Although there are good reasons why pharmacology may be appropriate for some patients, psychological treatments clearly have their place, and much research has shown that psychosocial interventions are effective. Cognitive and behavioral interventions are most clearly supported for the treatment of disruptive disorders and tend to aim directly at the problematic thoughts and behaviors. For example, interventions that have demonstrated efficacy include problem-solving skills training (Kazdin et al., 1987b), problem-solving skills training and practice (Kazdin et al., 1989), rational emotive mental health program (Block, 1978), Triple P enhanced and Triple P standard (Sanders et al., 2000), anger control training (Lochman et al., 1993), group assertive training (Huey & Rank, 1984), incredible years child training (Webster-Stratton & Hammond, 1997), and problem-solving social skills training (Kazdin et al., 1992). In addition, combining the use of playgroups and social modeling has been effective for teaching social skills to youth with disruptive behavior disorders (Nash & Schaefer, 2011). Effective interventions that target parents include parent management training (Bernal et al., 1980; Kazdin et al., 1992), problem-solving skills training and parent management training (Kazdin et al., 1987a), helping the noncompliant child (Peed et al., 1977), incredible years parent training (Webster-Stratton & Hammond, 1997), multidimensional treatment foster care (for both children and caregivers; Chamberlain & Reid, 1998), multisystemic therapy (for both children and parents; Henggeler et al., 1992), parent–child interaction therapy (Schuhmann et al., 1998), Barkley’s (1997) manual-based parent management training model, and Parenting Your Out-of-Control Child (Kapalka, 2007). Similar interventions have also been developed that target teachers, including Eight Steps to Classroom Management Success (Kapalka, 2009).

Psychological therapies may be especially well suited in situations where impairment from the symptoms does not severely impair patients or affect the safety of those around them. With some patients, introducing medications may be risky, which is especially concerning when medications are used with patient populations that are medically or developmentally vulnerable, like children, adolescents, and the elderly. Most studies that investigated the use of psychotropic medications lasted at most a few months, and therefore long-term effects of most medications are not known. In addition, improvement from medications usually lasts only as long as the medications are administered, and return of the original symptoms is likely upon discontinuation of medications. Conversely, psychosocial treatments teach patients new skills that are applicable in a wide variety of life situations that they may encounter, and at least in theory those new skills are acquired more permanently. Even after therapy terminates, the presumption is that the therapeutic benefits derived during treatment will continue.

Even in the short term, many medications have risks and adverse effects. Many of the medications utilized to diminish disruptive behaviors are sedating (psychostimulants being the notable exception), at least at first, and so they may adversely affect the patient’s day-to-day functioning and ability to work or attend school. In addition, most medications carry other risks, including effects on memory and concentration, changes in appetite and sleep patterns, cardiovascular reactions, metabolic changes, and a variety of other physical and psychological reactions. While the severity of these adverse effects varies from one person to another, if symptoms are not severe enough to require immediate improvement, it may be worth it to avoid those risks and initially try psychological treatments.

While psychoanalysis usually required long-term treatment, many current psychosocial approaches are more clearly time limited and problem focused. In most cognitive and behavioral treatments at least some progress is expected after three or four sessions, and more significant improvement usually occurs over eight to fifteen sessions. When disruptive symptoms are not unusually debilitating and do not pose significant risks to those around them, this time frame may provide sufficiently rapid improvement.

Because in psychological treatments patients generally attend sessions regularly, the mental health professional usually has the opportunity to get to know the patient well. This familiarity allows the professional to monitor the patient’s symptoms and clarify or change the diagnosis as further symptoms become apparent. This is especially important in the context of disruptive disorders, as comorbidity with other disorders is the rule rather than the exception. An astute mental health professional is able to tailor treatment to address all the symptoms and disorders that are becoming apparent as the treatment is unfolding.

For patients with good health-care coverage, the cost of psychotherapy may only involve copayment (especially when using in-network providers), thus limiting out-of-pocket expenses. Those without health care may be candidates for various forms of free or subsidized care available through federal, state, and local government agencies as well as various nonprofit organizations. Although availability of those programs varies widely from state to state (and often from one portion of the state to another), in some parts of the country pati...

Table of contents

• Cover Page
• Half Title page
• Clinical Topics in Psychology and Psychiatry
• Title Page
• Copyright Page
• Contents
• List of Contributors
• Series Editor’s Foreword
• Preface
• PART I Etiology, Epidemiology, and Course of Disruptive Disorders
• PART II Disorders With Disruptive Behaviors as Core Symptoms
• PART III Disorders With Disruptive Behaviors as Commonly Associated Features