Assessment and Treatment of Oppositional Behaviour,Conduct Problems,and Aggression in Children and Adolescents: Creation and Dissemination of a National Curriculum

Dear Editor:

Children with disruptive behaviour include those with attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD). Childhood disruptive and aggressive behaviour is a major risk factor for the development of criminality in adolescence and adulthood ¹ and negatively influences quality of life for children and their families. ² Families and clinicians often struggle with how to address severe behavioural problems in children. Four Canadian pharmacoepidemiologic studies have found a substantial increase in the use of antipsychotics in this population, ^{3 –6} prescribed by psychiatrists, paediatricians, and family physicians. A survey of Canadian graduates of paediatrics residency training programmes revealed that paediatricians felt least prepared for child psychiatry and behavioural paediatrics in their practice. ⁷ Our group has endeavoured to address this training need through the creation of a national curriculum for residents in paediatrics, psychiatry, and child and adolescent psychiatry (CAP) on the assessment and treatment of oppositional behaviour, conduct problems, and aggression in children and adolescents. Our ultimate goal is to improve health outcomes for these patients through standardised, evidence-based education of residents.

The first step of the project was a Canadian Institutes of Health Research–funded meeting of researchers, practitioners, and knowledge users. Our meeting brought together the Canadian Paediatric Society (CPS), the College of Family Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, and residency education programs across the country to develop educational goals for the curriculum based on objectives of training by specialty. We performed a needs assessment confirming that physicians had knowledge needs in the assessment of disruptive and aggressive behaviour, making recommendations for psychosocial therapies, choosing appropriate pharmacological interventions, and appropriate drug safety monitoring. Our group reviewed evidence-based resources upon which to base the curriculum and identified the Center for Education and Research on Mental Health Therapeutics ^8,9 and Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotic Medications in Children ¹⁰ guidelines as appropriate foundations.

Funding from the SickKids Foundation and Royal Bank of Canada Knowledge Translation Fund allowed us to develop more specific pharmacotherapy guidelines and to create the curriculum. The Canadian Guidelines on Pharmacotherapy for Disruptive and Aggressive Behaviour in Children and Adolescents with ADHD, ODD, or CD were published in the Canadian Journal of Psychiatry in 2015. ^{11 –13} The guidelines recommend the use of ADHD medications first-line, usually starting with psychostimulants, for disruptive and aggressive behaviour in children with ADHD, with or without ODD or CD, when psychosocial therapies have been inadequate. Risperidone was the only other medication supported by at least moderate-quality evidence. However, because of its major side effect burden, risperidone received only a conditional recommendation. No other antipsychotic received a recommendation in favour of use for this indication.

As residents in family medicine, paediatrics, psychiatry, and CAP have different educational needs in this area, we created basic and advanced versions of our curriculum. The curriculum includes slide sets, videos, small group exercises, evaluation materials, and key references. In 2014-2015, it was piloted at The Hospital for Sick Children with residents in paediatrics (basic) and residents in adolescent medicine, developmental paediatrics, psychiatry, and CAP (advanced). For both versions of the curriculum, median scores improved substantially on the posttest compared to the pretest. Detailed feedback from the residents led to the creation of updated videos demonstrating the content and structure of parent- and child-based group therapy, as well as the creation of the interactive small group exercises.

Once the curriculum content was finalised, we worked with the CPS to develop and copy edit our slide sets and have them professionally translated into French. We recruited paediatricians and psychiatrists from every medical school in Canada to attend a full-day “Train-the-Trainer” event. At this event, we described the evolution of our project, presented the curriculum, and provided guidance on how to teach it. We also created a website (www.readycanada.org) where all the curriculum materials can be openly accessed and used for teaching, and we encourage any interested clinician or educator to access and disseminate the resources contained there. On a survey following the event, all participants indicated that they were likely or highly likely to teach the curriculum at their university and that they felt prepared or very prepared to do so.

Our ultimate goal in creating this curriculum is to promote the implementation of evidence-based guidelines to improve the quality of care and health outcomes of children and adolescents with disruptive and aggressive behaviour. We believe that this project is relevant to a wide range of physicians treating children and adolescents and ultimately will result in greater implementation of nonpharmacological interventions, as well as more judicious and carefully monitored use of antipsychotics.

Tamara Pringsheim, MD Department of Clinical Neuroscience, Psychiatry, Pediatrics, and Community Health Sciences University of Calgary, Calgary, Alberta [e-mail] Brendan Andrade, PhD Department of Psychiatry, University of Toronto Toronto, Ontario Asif Doja, MD Department of Pediatrics, University of Ottawa Ottawa, Ontario Daniel A. Gorman, MD Department of Psychiatry, University of Toronto Toronto, Ontario