Transcript A Meta-Analysis of Non-stimulant Medication Effects on Overt

A Meta-Analysis of Non-stimulant
Medication Effects on Overt
Aggression-Related Behaviors in
Youth with SED
by Daniel F. Connor, R. Thomas Boone,
Ronald J. Steingard, Ivan D. Lopez,
& Richard H. Melloni, Jr.
Presented by: Tzu Min Lee
Radford University
Purpose
• To determine the effect size for non-stimulant
medications on symptoms of overt aggressionrelated behaviors in referred children and
adolescents with serious emotional and
behavioral disturbances.
- Prevalence of pharmacological interventions
- Overall efficacy of medications to treat aggression
unclear
- A literature review back to 1955 revealed no other
meta-analysis except one in 2002 to assess the
effects of stimulant medications on overt and covert
aggression in youth with ADHD
Issues to Consider
• How is medications determined?
- used to treat aggression-related behaviors in youth
with developmental delay, ADHD, CD, depression,
schizophrenia, anxiety disorders, bipolar disorder
and tic disorders
• How is aggression-related behaviors defined?
- why overt aggression
- defined broadly to be consistent with the
multiplicity of aggression problems faced by
clinicians in practice
Literature Review
• 1970-2001 medical & behavioral science
• Methods
- Electronic Sources
* Medline
* PsycInfo
* Pub Med
- Journal bibliographies
• Studies
- 41 were found
- 33 met the inclusion/exclusion criteria
Studies to Include
• Report quantitative data on independent drug effects
(neuroleptics, atypical antipsychotics, mood
stabilizers, antidepressants and adrenergic agents)
• Published in peer-reviewed scientific journal
• Use a placebo control either in cross-over or
parallel-group methodological design
• Have a mean sample age of 19 years or younger
• Use a valid rating scale or method of observation to
assess aggression-related behaviors
• Open studies, case reports and review articles are
excluded.
Dependent Measures
• Overt aggression-related behaviors
- physical assault, verbal threats, oppositional and
defiant behavior, noncompliance, rule defiance,
malicious teasing of others, conduct problems,
disruptive behavior, poor self-control, explosive
outbursts of property destruction, temper tantrums,
hyperactivity/impulsivity, explosive rage attacks,
hostility, and/or irritability
Dependent Measures
• Clinician Rating
- Brief Psychotic Rating Scale (BPRS)
- Children’s Psychiatric Rating Scale (ChPRS)
- Rating Scale of Abnormal Behavior Checklist (RSABC)
• Parent Rating
- Conners Parent/Teacher Rating Scale (CPRS & CPRS)
• Teacher Rating
- Teachers Self-Control rating Scale (TSCRS)
• Overall Rating
- Average of effects for all reporters in each given study
Results
* p < .0001 for all ratings
EFFECTS OF DRUGS ON
OVERT AGGRESSIVE BEHAVIOR
95% CI
Criteria
N
d
L
U
Filedrawer
X
Clinician Rating
560
.75
.27
2.20
146
Parent Rating
496
.77
-.10
4.08
315
Teacher Rating
835
.63
.27
2.33
430
Overall Rating
1221
.68
.57
2.36
1047
Potential Moderators
• Mean sample age
• Percentage of boys in the sample
• Drug group
- neuroleptics, atypical antipsychotics and
mood stabilizers
- antidepressants and adrenergic agents
• Study design
- within-subjects
- between-subjects
• Interaction between drug type & study design
Results – Moderators Drug Group,
Study Design and their Interaction
DRUG GROUP
STUDY DESIGN
Within-subjects
Antipsychotic
Antidepressant
Between-subjects
.78
1.03
3.05
.44
Study Limitations
• Limitations of the extant published literature
- small sample sizes, absence of drug use means and
standard deviations
• Grouping medications to increase statistical
power diminished the precision of analysis
• Risk of inflating Type 1 error by combining
diverse ratings within an individual study into
a single rating
• Haloing effects of medication improvements
on core features of psychiatric disorders
Clinical Implications
• Results support the continued use of medication
therapy as part of a multimodal treatment plan.
• Parent ratings of their children did not entirely
endorse medication interventions as always effective
• Benefits of medical interventions must be balanced
with their potential risks.
• Need for a thorough, multidisciplinary psychoeducational evaluation since overt aggression is
heterogeneous in etiology.
• Treatment plans must consider diverse psychosocial
family, individual, community, educational, and
psychopharmacological treatment interventions.
Future Research
• A need for continued, comprehensive research
• Define aggressive behavior explicitly
• Examine drug effects on certain types of
aggression
- physical assault, reactive aggression, proactive
aggression, covert aggression, CD/ODD
• Investigate social validity measures
- effects of drugs on quality-of-life measures for
child and family