What is the effect of atypical antipsychotics compared with placebo on reducing aggression or conduct problems in children and youths with a diagnosis of disruptive behavior disorder?
TYPE OF REVIEW
This is a Cochrane review containing meta-analyses of eight randomized controlled trials: two meta-analyses were performed for aggression, two for conduct problems, and one for the adverse effect of weight gain.
RELEVANCE FOR NURSING
Disruptive behavior disorders include conduct disorder, characterized by repetitive patterns of behavior that violate the basic rights of others or major age-appropriate societal rules or norms; oppositional defiant disorder, a potential precursor of conduct disorder; and disruptive behavior disorder not otherwise specified. The prevalence of conduct disorder in children and adolescents in the general population is estimated to be between 1.5% and 4%. Numerous studies show a significant increase in the use of atypical antipsychotics in children and youths with disruptive behavior disorders, but clinical research evaluating their efficacy and safety is lacking.
CHARACTERISTICS OF THE EVIDENCE
A total of 678 participants (336 in the intervention groups and 342 in the control groups) between ages five and 18 with a diagnosis of a disruptive behavior disorder were included across the eight randomized controlled trials. The intervention of interest was any atypical antipsychotic medication compared with placebo. Seven trials used risperidone as the intervention treatment (mean doses at end point ranged from 0.98 to 1.5 mg/day) and one trial used quetiapine (mean dose at end point was 294 ± 78 mg/day, with a range of 200 to 600 mg/day). Both drugs were administered orally.
The primary outcomes were aggression (assessed by rating scales), conduct problems (assessed by rating scales), and weight gain and metabolic parameters (lipid and glucose profiles).
The first meta-analysis for aggression (of three trials) showed that risperidone significantly reduced aggressive behaviors compared with placebo, while the second (of two trials, one with quetiapine) demonstrated a nonsignificant reduction in aggressive behaviors. Regarding conduct problems, the first of two meta-analyses (of two trials) had a statistically significant reduction in conduct problems with risperidone, while the second (also of two trials, one with quetiapine) had a nonsignificant result.
One meta-analysis (of two trials) showed that participants receiving risperidone gained 2.37 kg more on average over six to 10 weeks than those taking placebo. The only study that used quetiapine did not assess weight gain. Only one study reported data about metabolic parameters, but the results could not be interpreted since fasting and nonfasting glucose values were mixed.
BEST PRACTICE RECOMMENDATIONS
The use of risperidone led to a reduction in aggression and conduct problems in children and youths with disruptive behavior disorders after six weeks of treatment, and the medication appeared safe. Although the size of the effect is likely to be clinically meaningful, because of the limited number of high-quality studies, caution is advised in the interpretation of findings. During a period of six to 10 weeks, participants receiving risperidone gained over 2.3 kg on average, but it's unclear if this adverse effect will attenuate over time. There is no evidence to support the use of quetiapine for disruptive behavior disorders in children and youths.
More randomized controlled trials are needed to examine the longer-term effects and safety of atypical antipsychotics in treating disruptive behavior disorders in children and youths.
Loy JH, et al. Atypical antipsychotics for disruptive behaviour disorders in children and youths Cochrane Database Syst Rev. 2012(9):CD008559