Commentary: Finding out the best way to tailor psychological interventions for children and families--a commentary on Ng and Weisz (2016)

Personalised interventions for subgroups of children with conduct problems

BACKGROUND

Conduct problems are a range of disruptive behaviours in childhood that are associated with long-term adverse outcomes in adolescence and adulthood, including antisocial behaviour, substance misuse, and poor academic achievement. Children with conduct problems can vary according to age of onset, comorbidities, and environmental factors, and it has been suggested that certain groups of children may have different treatment outcomes. Therefore, it is important to assess the extent to which personalised interventions for different groups of children with conduct problems may affect outcomes. To our knowledge, this is the first review to systematically identify and appraise the effectiveness of personalised interventions, adapted, or developed, for prespecified subgroups of children with conduct problems.

OBJECTIVES

To assess whether personalised interventions, adapted or developed for subgroups of children with conduct problems are effective in improving outcomes.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search was 1 February 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), in any setting, in children (aged two to 12 years) with conduct problems and within a prespecified subgroup, comparing a personalised intervention with a non-personalised intervention, waitlist control, or treatment as usual. Personalised interventions included adaptations to standard practice, such as parent-training programmes; other recommended interventions for children with conduct problems; or interventions developed specifically to target subgroups of children with conduct problems. We excluded non-personalised and non-psychological interventions (e.g. pharmacological or dietary intervention). Prespecified subgroups of children with conduct problems, however defined, were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. child conduct problems or disruptive behaviour and 2.

ADVERSE EVENTS

Our secondary outcomes were 3. personalised treatment outcomes relevant to each subgroup, 4. parenting skills and knowledge, 5. family functioning, engagement and decreased dropout, and 6. educational outcomes. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We identified 13 RCTs (858 participants). Seven studies were conducted in the USA, five in Australia, and one in Germany. Eleven studies reported their source of funding, with five studies receiving grants from the National Institute of Mental Health. In total, 15 different funders supported the studies included in the review. We separated subgroups of children with conduct problems into three broad categories: children with co-occurring conditions (e.g. emotional difficulties), parent characteristics (e.g. conflict between parents), or familial/environmental circumstances (e.g. rural families). All studies delivered a personalised intervention that was adapted or developed for a prespecified subgroup of children with conduct problems. We rated all trials at unclear or high risk of bias in most domains. Below, we report the results of improvement in child conduct problems and disruptive behaviour, personalised treatment outcomes, and parenting skills and knowledge for our main comparison: personalised versus non-personalised interventions. Improvement in child conduct problems and disruptive behaviour Compared with a non-personalised intervention, a personalised intervention may result in a slight improvement in child conduct problems or disruptive behaviour measured using the Eyberg Child Behavior Inventory (ECBI) Problem subscale in the short term (mean difference (MD) -3.04, 95% confidence interval (CI) -6.06 to -0.02; 6 studies, 278 participants; P = 0.05), but may have little to no effect on improving child conduct problems or disruptive behaviour measured by the ECBI Intensity subscale (MD -6.25, 95% CI -16.66 to 4.15; 6 studies, 278 participants; P = 0.24), or the Externalising subscale of the Child Behaviour Checklist (CBCL) (MD -2.19, 95% CI -6.97 to 2.59; 3 studies, 189 participants, P = 0.37) in the short term. We graded the certainty of evidence as very low for all three outcomes, meaning any estimate of effect is very uncertain.  Personalised treatment outcomes, relevant to each subgroup Although six studies reported personalised treatment outcomes, relevant to each subgroup, we were unable to pool the data due to differences between the measures used in the studies and the heterogeneity this would produce in analysis. The results for this outcome were inconclusive. Parenting skills and knowledge Although seven studies reported parenting skills and knowledge, we were unable to pool the data due to differences between the measures used in the studies and the heterogeneity this would produce in analysis. The results for this outcome were inconclusive.  Adverse events None of the trials reported monitoring adverse events. Summary of results In summary, there is limited evidence that personalised intervention improves child conduct problems, personalised treatment outcomes, relevant to each subgroup, or parenting skills and knowledge compared with a non-personalised intervention.

AUTHORS' CONCLUSIONS

There is limited evidence for the effectiveness of personalised interventions for subgroups of children with conduct problems. The certainty of evidence for all outcomes was very low, meaning that we have very little confidence in the estimated effects and the true effects may be different to our findings, which will limit the relevance of our findings to clinical decisions. To overcome the limitations of the evidence, large-scale RCTs are needed to determine whether personalised interventions, adapted or developed, for subgroups of children with conduct problems are effective in improving outcomes. Consensus on the most appropriate measures to use in these studies is needed in order to facilitate cross-study comparisons. Persistent conduct problems predict a range of adverse long-term outcomes, so future research should investigate the medium- and long-term effects of personalised treatments. Studies are needed in low- and middle-income countries as well as studies recruiting children aged between nine and 12 years, as they were under-represented in the studies.

Editorial: Therapies for mental health difficulties: finding the sweet spot between standardization and personalization

There are strong arguments for standardizing therapies for mental health difficulties in young people and for the development of digital therapies. At the same time, the importance of personalized treatments is also increasingly apparent. In this editorial, we discuss challenges and the continued need to find the sweet spot between standardization and personalization when it comes to therapies for mental health difficulties. We illustrate our discussion with reference to insomnia in adolescents/young adults as well as the chronic health condition type 1 diabetes.

Effects of Behavioral Treatment Modified to Fit Children with Conduct Problems and Callous-Unemotional (CU) Traits

Research suggests that children with conduct problems (CP) and callous-unemotional (CU) traits show a diminished response to behavior therapy, perhaps due to a reward-oriented, punishment insensitive learning style. Children with CP and CU may benefit from personalizing behavioral treatment for them by emphasizing rewards and de-emphasizing punishments. This hypothesis was tested in a sample of 46 children (78.3% boys), ages 7.0 to 12.6 years (M = 9.3, SD = 1.4). All participants met criteria for ODD and ADHD and 63% also met criteria for CD. Participants were oversampled for high CU, but CU scores ranged from average to high. Children received four weeks of modified behavior therapy that emphasized rewards and de-emphasized punishments and four weeks of treatment as usual, which was standard behavior therapy that balanced rewards and punishments. Treatments were implemented in a summer treatment program and compared using a within-subjects design, with order of treatment counterbalanced. Disruptive behavior was equal or slightly higher in modified behavior therapy than in standard behavior therapy on point system measures, but lower on parent weekly ratings. End of treatment ratings showed both treatments produced significant improvements compared to pre-treatment ratings but did not differ from each other. Personalizing behavior therapy for children with CP and CU produced inconsistent findings relative to standard behavior therapy. Behavior therapy is likely to be a necessary part of treatment for children with CP and CU, but treatment personalization efforts may provide some benefit by addressing other deficits shown by these children.