76 Chapter 6
4 Family therapy is fairly frequently used but has hardly been eval-
uated. Judging from clinical experience, it is often useful in fairly
well-functioning families where after only a few sessions parents may
collaborate in setting clear boundaries for their child and improve the
emotional atmosphere; it is less useful for chaotic, disorganised families
who lack coping skills; see Chapter 41.
5 Social work referral. This should be considered if the child or adolescent is
at risk of significant harm, either from abusive or neglectful parenting,
or is so out of control that he/she is a risk to others.
Child- or adolescent-focused
1 Behaviour modificationcan be very effective in modifying one or two
specific antisocial behaviours, but does not usually generalise; see
Chapter 39.
2 Problem-solving skills training and social skills traininghave been shown to
have definite effects but are best combined with parent training.
3 Individual psychotherapyis usually unfruitful as these individuals have
little insight into why they behave the way they do, and there is no trial
evidence to support its use. Furthermore, when they can identify what
is upsetting them, they are not usually in a position to modify it or find
another way of coping. Further, there is risk that outside agencies may
believe that ‘something is being done’ and avoid addressing parenting
and other issues.
4 Medication:
(a)When a child or adolescent has ADHD as well as a disruptive be-
havioural disorder, it may be appropriate to treat their restlessness
and inattention with medication (see Chapter 5). When stimulant
medication reduces restlessness and inattention, it may well reduce
defiance, aggression and anti-social behaviour too. There is no
evidence that stimulants reduce disruptive behaviour in individuals
who do not also have ADHD.
(b) There is some very limited evidence that neuroleptics (‘antipsy-
chotics’) such as aripiprazole and risperidone, and also lithium
may be of value for children and adolescents who have explosive
outbursts in response to minimal provocation, and who have not
responded to appropriate psychological management, but it is very
rarely prescribed for this purpose, and has a wide range of poten-
tially serious side effects.
5 Diet. When diet helps ADHD symptoms, it often reduces irritability too.
In the absence of ADHD, there is no reliable evidence that diet helps
conduct symptoms, although there have been one or two trials, for
example, of oils containing omega fatty acids.
Community-focused
Prevention programmesare currently under evaluation. Effect sizes are
typically modest, although this may be useful for a total population.
They include selective approaches that screen whole populations at