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Evaluation of a Booster Intervention Three Years after Acute Treatment for Early-Onset Disruptive Behavior Disorders
Kolko DJ, Lindhiem O, Hart J and Bukstein OG
Journal of Abnormal Child Psychology, 42:339-342, 2014

There have been numerous evidence-based treatments (EBTs) conducted in both clinical and community settings designed to teach skills to caregivers and their children, and treat children's externalizing problems or disruptive behavior disorders (DBD).  However, relatively little research has taken place that aids in our understanding of the timing, scope, and effects of booster treatment methods in clinically referred children with DBD.  In a study published in a special issue of the Journal of Abnormal Child Psychology, Drs. David Kolko, Oliver Lindhiem and their colleagues examined the impact of a brief booster treatment administered three years after the delivery of an acute treatment administered in a community or clinic setting in a group of clinically referred boys and girls ages 6 to 11 (n=118) originally diagnosed with Oppositional Defiant Disorder or Conduct Disorder. Follow-up effects of acute treatment assessed through three-year follow-up revealed significant clinical benefits in both conditions.  

At the end of the three-year follow-up period, the sample was re-randomized into Booster Treatment or Enhanced Usual Care, and then assessed at four later time points (i.e., post-booster, and 6-, 12- and 24-month booster follow-up). Booster treatment was directed towards addressing individualized problems and some unique developmental issues of adolescence based on the same original protocol content and treatment setting, whereas the Enhanced Usual Care condition involved providing clinical recommendations based on the assessment and an outside referral for services. 

Using hierarchical linear models to analyze the data, the investigators identified improvements for both groups on new (i.e. booster phase) individualized treatment goals. However, there were no significant group differences and few time effects across child, parent, and teacher reports on a broad range of child functioning and impairment outcomes up to two years following re-randomization. Analyses examining the role of putative moderators or predictors (e.g., severity of externalizing behavior, dose of treatment) were likewise non-significant.   

The absence of any booster intervention effects may relate to several considerations.  For example, it is possible that the substantial level of initial improvement that was maintained for three years after acute treatment may have limited the possibility of making even further achievements or experiencing sufficient motivation during the subsequent booster treatment phase.  Where acute treatment has been associated with only limited improvement, more substantial booster phase effects have been found.  A related consideration involves the timing of the booster phase, which occurred three years after acute treatment. Conducting a booster phase three years after acute treatment made it difficult to promote any continuity of care, which has been suggested as a potential mechanism for the impact of a booster intervention, and these children were already in a different developmental period that may have varied from the original need for referral. Another factor may be due to the booster intervention being conducted in the same setting as the child's acute treatment using a modified version of the original intervention protocol in order for it to be more suitable for an older population.  In this case, it is possible that setting or content did not adequately address the children's or family's current service needs or treatment preferences.  It is also worth noting that the dose of booster intervention was briefer than the dose during acute treatment (minimum of 5 hours vs. 15 hours) and was meant to be more flexible in accord with the severity of the child's clinical needs and family's willingness to participate. 

The nature and implications of these findings demonstrate the need for further study of the role and timing of booster treatment and continuity of disruptive behavioral disorders over time. This article is part of a special issue of the Journal of Abnormal Child Psychology edited by Drs. Kolko and Lindhiem.  Click here for the abstract.

Contributors:
David J. Kolko, PhD and Oliver Lindhiem, PhD (Department of Psychiatry, University of Pittsburgh)

Jonathan Hart, PhD (University of Pittsburgh Medical Center)

Oscar G. Bukstein, MD (Department of Psychiatry, University of Texas Health Sciences Center at Houston)