In early 2018, the Journal of Child Psychology and Psychiatry published data from a systematic review and meta-analysis of psychosocial interventions for disruptive behaviour problems in children in low and middle-income countries. The study, conducted by Professor Matthew Burkey and colleagues, found that child-focused and behavioural parenting interventions may be effective for affected children in these socioeconomic groups.
Disruptive behavioural problems are a common psychopathology in children and adolescents, with an estimated global prevalence of 5.7% for any disruptive behaviour disorder1. The majority of intervention studies performed to date have focused on children residing in high-income, Western countries: whether the findings from these studies are transferable to other populations — namely low-income and middle-income countries (LMIC) — is unknown.
To bridge this knowledge gap, Professor Burkey and colleagues conducted a systematic review of randomized controlled trials to determine the efficacy of psychosocial interventions in preventing or reducing disruptive behaviour problems (namely oppositional defiant disorder and conduct disorder) in children (<18 years) living in LMIC. They also evaluated the range and type of interventions for behaviour problems that have been assessed in children living in LMIC, and aimed to identify any issues with regards to intervention implementation and/or dissemination.
The systematic review of 26 randomized controlled trials included 4,441 subjects and 28 active (non-pharmacological) psychosocial interventions that primarily targeted children, parents, families or teachers. Of these interventions, 15 were prevention interventions targeting general or at-risk populations and 13 were treatment interventions for those with behavioural problems. As predicted, the number of studies conducted in LMIC was low, with only 12% conducted in low-middle income and 31% conducted in low-income countries compared to 58% conducted in high-income countries. Geographic representation was restricted by only few studies conducted in Asia (n=5) and the diversity of low-income countries overall.
The researchers found a significant reduction in disruptive behaviour problems across the prevention and treatment studies conducted in LMIC. Strong evidence was found for child-focused (including social skills training and cognitive behavioural therapy) and behavioural parent training interventions, suggesting that these strategies may be effective for children of all age and socioeconomic status groups. In addition, the use of group delivery models for most interventions and the requirement for non-specialist providers in ~50% of the included studies supports their applicability to LMIC where resources are sparse.
Despite positive results, some limitations must be acknowledged. First, the researchers noted a high level of statistical heterogeneity in the intervention effects among the studies included in their meta-analysis. In addition, selection and performance biases were common in the studies included in the review. Despite these two limitations, the effects remained significant across multiple subgroup analyses, suggesting that many psychosocial interventions may be effective in reducing disruptive behavioural problems in children in LMIC. In terms of prevention, no studies specifically evaluated a reduction in the incidence of behavioural disorders, which is considered a primary outcome in prevention research.
In conclusion, Burkey and colleagues report strong support for the feasibility and effectiveness of prevention and treatment interventions to reduce disruptive behaviour problems in children in LMIC. The researchers propose that future research into the interventions for behaviour problems in LMIC need to follow a more rigorous study design, with in-depth reporting in the trials to accurately inform future implementation. With >90% children living in LMIC, the researchers emphasize that implementing proven treatment interventions for disruptive behaviours in this population should be a global priority.
Burkey, M.D., Hosein, M., Morton, I., Purgato, M., Adi, A., Kurzrok., Kohrt, A.B. & Tol, W.A. (2018), Psychosocial interventions for disruptive behaviour problems in children in low- and middle-income countries: a systematic review and meta-analysis. J Child Psychol Psychiatr, doi:10.1111/jcpp.12894
1Polanczyk, G.V. et al. (2015) Annual Research Review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatr, 56:345-365. doi:10.1111/jcpp.12381
Conduct disorder (CD): CD is characterized by behaviour that violates either the rights of others or major societal norms. To be diagnosed with conduct disorder, symptoms must cause significant impairment in social, academic or occupational functioning. The disorder is typically diagnosed prior to adulthood.
Oppositional defiant disorder (ODD): ODD is characterised by a pattern of negativistic, hostile and defiant behaviour. The disturbance in behaviour causes clinically significant impairment in social, academic or occupational functioning and the behaviours do not occur exclusively during the course of a psychotic episode or mood disorder.
Behavioural parent training: an approach to treating child behaviour problems at home in which parents use taught procedures to alter interactions with their child, promote prosocial behaviour and decrease deviant behaviour.
Cognitive behavioural therapy: a form of talking therapy that encourages patients to manage their psycho-social problems by changing the way they think and behave; CBT focuses on current problems and finds practical ways to improve state-of-mind on a day-by-day basis.
Randomised controlled trial: an experimental setup whereby participants are randomly allocated to an intervention/treatment group or a control/placebo group; randomization of participants occurs after assessments for eligibility, and is used to minimize selection bias.