Fifty years of preventing and treating childhood behaviour disorders: a systematic review to inform policy and practice

Using Non-Violent Discipline Tools: Evidence Suggesting the Importance of Attunement

Training in non-violent discipline is important to prevent violence against children and ensure that their caregivers remain a safe base for them. This paper aims to deepen understanding of non-violent discipline by exploring attunement as a mechanism in the effectiveness of non-violent discipline tools. Attunement describes the sensitive responsiveness of caregivers towards their children and has been found to be central to the formation of secure attachment bonds and development of self-regulation. It includes understanding or being "in tune with" the child's needs and signals, matching these with appropriate responses. The objective of this paper is to explore attunement in relation to non-violent discipline. Peer-reviewed systematic reviews previously included in a systematic overview of evidence on non-violent discipline options were screened for information relevant to attunement. All reviews were published in English between 1999 and 2018 and offered evidence on at least one non-violent discipline tool. Although no reviews explicitly addressed attunement, evidence was found suggesting its importance in the use and effectiveness of discipline methods. Research directly investigating attunement in discipline is needed.

Oppositional defiant disorder

Oppositional defiant disorder (ODD) is a disruptive behaviour disorder involving an ongoing pattern of angry/irritable mood, argumentative/defiant behaviour and vindictiveness. Onset is typically before 8 years of age, although ODD can be diagnosed in both children and adults. This disorder is associated with substantial social and economic burden, and childhood ODD is one of the most common precursors of other mental health problems that can arise across the lifespan. The population prevalence of ODD is ~3 to 5%. A higher prevalence in males than females has been reported, particularly before adolescence. No single risk factor accounts for ODD. The development of this disorder seems to arise from the interaction of genetic and environmental factors, and mechanisms embedded in social relationships are understood to contribute to its maintenance. The treatment of ODD is often successful, and relatively brief parenting interventions produce large sized treatment effects in early childhood. Accordingly, ODD represents an important focus for research, practice and policy concerning early intervention and prevention in mental health.

Antipsychotics in the Management of Disruptive Behavior Disorders in Children and Adolescents: An Update and Critical Review

Disruptive behaviour disorders (DBDs) in childhood include conduct disorder (CD) and oppositional defiant disorder (ODD). Though psychological therapies are considered to be the first-line treatment for DBDs, many patients require adjunctive pharmacotherapy for the control of specific symptoms, such as aggression. Three prior systematic reviews have examined the evidence for the use of antipsychotics in DBDs and have concluded that their efficacy is marginal and limited by adverse effects. This paper has two objectives: (i) to summarize the findings of existing systematic reviews of antipsychotics for the management of DBDs in children and adolescents (2012-2017), and (ii) to provide an update to these reviews by examining recent clinical trials of antipsychotics in this population, published in the period from 2 January 2017 to 10 October 2022. The PubMed, Scopus and ScienceDirect databases were searched for relevant citations using the search terms "disruptive behaviour disorder", "oppositional defiant disorder", "conduct disorder" and their variants, along with "antipsychotic", "atypical antipsychotic" and the generic names of all currently approved atypical antipsychotics. Six relevant trials were identified during this period, including five randomized controlled trials and one naturalistic open-label trial. These trials were critically evaluated in terms of outcome measures, efficacy and safety. Overall, the data from these trials suggests that of all available antipsychotics, risperidone appears to be effective in the short-term management of DBDs. All available antipsychotics are associated with significant metabolic adverse effects in this population. These results are discussed in the light of global trends towards increasing off-label prescription of antipsychotic medication in children and adolescents and of recent literature on the neuropharmacology of aggression in this patient population. The need for rational, short-term use of these drugs is highlighted, as well as the importance of post-marketing surveillance for long-term or severe adverse events.

Cost-effectiveness of a transdiagnostic psychotherapy program for youth with common mental health problems

OBJECTIVES

Our objective was to evaluate the cost-effectiveness of the transdiagnostic psychotherapy program Mind My Mind (MMM) for youth with common mental health problems using a cost-utility analysis (CUA) framework and data from a randomized controlled trial. Furthermore, we analyzed the impact of the choice of informant for both quality-of-life reporting and preference weights on the Incremental Cost-Effectiveness Ratio (ICER).

METHODS

A total of 396 school-aged (6-16 years) youth took part in the 6-month trial carried out in Denmark. CUAs were carried out for the trial period and four one-year extrapolation scenarios. Costs were based on a combination of budget and self-reported costs. Youths and parents were asked to report on the youth's quality-of-life three times during the trial using the Child Health Utility 9D (CHU9D). Parental-reported CHU9D was used in the base case together with preference weights of a youth population. Analyses using self-reported CHU9D and preference weights of an adult population were also carried out.

RESULTS

The analysis of the trial period resulted in an ICER of €170,465. The analyses of the one-year scenarios resulted in ICERs between €23,653 and €50,480. The ICER increased by 24% and 71% compared to the base case when using self-reported CHU9D and adult preference weights, respectively.

CONCLUSION

The MMM intervention has the potential to be cost-effective, but the ICER is dependent on the duration of the treatment effects. Results varied significantly with the choice of informant and the choice of preference weights indicating that both factors should be considered when assessing CUA involving youth.

A health-education intervention to improve outcomes for children with emotional and behavioural difficulties: protocol for a pilot cluster randomised controlled trial

INTRODUCTION

One in seven (14%) children aged 4-17 years old meet criteria for a mental illness over a 12-month period. The majority of these children have difficulty accessing clinical assessment and treatment despite evidence demonstrating the importance of early intervention. Schools are increasingly recognised as universal platforms where children with mental health concerns could be identified and supported. However, educators have limited training or access to clinical support in this area.

METHODS AND ANALYSIS

This study is a pilot cluster randomised controlled trial of a co-designed health and education model aiming to improve educator identification and support of children with emotional and behavioural difficulties. Twelve Victorian government primary schools representing a range of socio-educational communities will be recruited from metropolitan and rural regions, with half of the schools being randomly allocated to the intervention. Caregivers and educators of children in grades 1-3 will be invited to participate. The intervention is likely to involved regular case-based discussions and paediatric support.

ETHICS AND DISSEMINATION

Informed consent will be obtained from each participating school, educator and caregiver. Participants are informed of their voluntary participation and ability to withdrawal at any time. Participant confidentiality will be maintained and data will be secured on a password protected, restricted access database on the Murdoch Children's Research Institute server. Results will be disseminated via peer-reviewed journals and conference presentations. Schools and caregivers will be provided with a report of the study outcomes and implications at the completion of the study.

TRIAL REGISTRATION NUMBER

ACTRN12621000652875.

Editorial Perspective: Adverse childhood events causally contribute to mental illness - we must act now and intervene early

We synthesized critical evidence regarding causal inferences of Adverse Childhood Experience (ACE) exposure and subsequent disease development. Extensive and high-quality research supports causal inferencing and offers a solid ground for policy- and decision-makers interested in translating science into societal action. There is ample evidence supporting system-wide implementation of prevention and treatment even though research on mechanisms needs to and will continue to offer additional insights.

Estimating prevalence of child and youth mental disorder and mental health-related service contacts: a comparison of survey data and linked administrative health data

AIMS

Prevalence estimates of child and youth mental disorder and mental health-related service contacts are needed for policy formulation, research, advocacy and resource allocation. Our aim is to compare prevalence estimates of child and youth mental disorder and mental health-related service contacts derived from general population survey data v. linked administrative health data.

METHODS

Provincially representative 2014 Ontario Child Health Study data were linked to administrative health records for 5563 children and youth aged 4-17 in Ontario. Emotional disorders (mood and anxiety) and attention-deficit/hyperactivity disorder were assessed using a standardised diagnostic interview in the survey and using diagnostic codes in administrative health data. Physician-based mental health-related service contacts were assessed using parent self-reports from the survey and administrative data related to mental health-related diagnostic codes. Prevalence estimates were calculated and compared based on one-sample z-tests and ratios of survey data to administrative data-based prevalence. Sensitivity, specificity and agreement between classifications were compared using κ. Prevalence estimates were calculated by age, sex and geography sub-groups and consistent group differences across data source were counted.

RESULTS

Disorder prevalence and service contact estimates were significantly higher in survey data in all cases, except for mood disorder. Ratios of survey data to administrative data-based prevalence varied, ranging from 0.80 (mood) to 11.01 (attention-deficit/hyperactivity disorder). Specificity was high (0.98-1.00), sensitivity was low (0.07-0.41) and agreement ranged from slight (κ = 0.13) to moderate (κ = 0.46). Out of 18 sub-group difference comparisons, half were non-significant in either data source. In the remaining nine comparisons, the only significant differences between groups that were consistent across data source were for sex-based differences (attention-deficit/hyperactivity disorder and service contacts). There were no consistent age- or geography-based differences in prevalence across data sources.

CONCLUSIONS

Our findings suggest that conclusions drawn about prevalence, service contacts and sub-group differences in these estimates are dependent on data source. Further research is needed to understand who and what is being captured by each source. Researchers should conduct data linkage where possible to access and compare multiple sources of information.

Systematic identification and stratification of help-seeking school-aged youth with mental health problems: a novel approach to stage-based stepped-care

We investigated whether a novel visitation model for school-aged youth with mental health problems based on a stage-based stepped-care approach facilitated a systematic identification and stratification process without problems with equity in access. The visitation model was developed within the context of evaluating a new transdiagnostic early treatment for youth with anxiety, depressive symptoms, and/or behavioural problems. The model aimed to identify youth with mental health problems requiring an intervention, and to stratify the youth into three groups with increasing severity of problems. This was accomplished using a two-phase stratification process involving a web-based assessment and a semi-structured psychopathological interview of the youth and parents. To assess problems with inequity in access, individual-level socioeconomic data were obtained from national registers with data on both the youth participating in the visitation and the background population. Altogether, 573 youth and their parents took part in the visitation process. Seventy-five (13%) youth had mental health problems below the intervention threshold, 396 (69%) were deemed eligible for the early treatment, and 52 (9%) had symptoms of severe mental health problems. Fifty (9%) youth were excluded for other reasons. Eighty percent of the 396 youth eligible for early treatment fulfilled criteria of a mental disorder. The severity of mental health problems highlights the urgent need for a systematic approach. Potential problems in reaching youth of less resourceful parents, and older youth were identified. These findings can help ensure that actions are taken to avoid equity problems in future mental health care implementations.

"Sometimes I think my frustration is the real issue": A qualitative study of parents' experiences of transformation after a parenting programme

Introduction

Parenting programmes help to alleviate conduct problems in children, but ensuring that all parents feel supported to attend, complete and learn from these programmes has proven difficult. Parents can feel overwhelmed and struggle to change their parenting. This article aims to inform the future refinement of parenting programmes by examining parents’ narratives of how programmes motivated them to change and enabled them to put changes into practice.

Method and results

Forty-two parents, most of whom had attended Incredible Years group sessions, were interviewed about their views and experiences of parenting programmes that focused on positive parenting practices. Analysis of interview transcripts drew on thematic approaches. Parents perceived that parenting programmes helped them to better understand their child and themselves and to let go of anxieties surrounding their child’s behaviour. Better understanding included greater awareness of emotions and of behaviours their child could and could not control. Parents believed this awareness helped them to change the ways that they interacted with their child, which, in turn, helped them and their child to feel calmer. With greater understanding and calmness parents believed they became more able to see for themselves the changes that they could make in their parenting and everyday lives, and to feel more confident in putting these into practice.

Discussion

By supporting parents to reflect on their own and their child’s situation, parents perceived that programmes enabled them to improve interactions with their children without getting stuck in self-blame or feeling overwhelmed. Parents of children whose behaviour remained challenging believed that programmes led to beneficial changes in the way they felt about their child’s behaviours. Enhanced support for reflection by parents could potentially help more families to benefit from parenting programmes.

Prevalence of childhood mental disorders in high-income countries: a systematic review and meta-analysis to inform policymaking

QUESTION

Mental disorders typically start in childhood and persist, causing high individual and collective burdens. To inform policymaking to address children's mental health in high-income countries we aimed to identify updated data on disorder prevalence.

METHODS

We identified epidemiological studies reporting mental disorder prevalence in representative samples of children aged 18 years or younger-including a range of disorders and ages and assessing impairment (searching January 1990 through February 2021). We extracted associated service-use data where studies assessed this. We conducted meta-analyses using a random effects logistic model (using R metafor package).

FINDINGS

Fourteen studies in 11 countries met inclusion criteria, published from 2003 to 2020 with a pooled sample of 61 545 children aged 4-18 years, including eight reporting service use. (All data were collected pre-COVID-19.) Overall prevalence of any childhood mental disorder was 12.7% (95% CI 10.1% to 15.9%; I²=99.1%). Significant heterogeneity pertained to diagnostic measurement and study location. Anxiety (5.2%), attention-deficit/hyperactivity (3.7%), oppositional defiant (3.3%), substance use (2.3%), conduct (1.3%) and depressive (1.3%) disorders were the most common. Among children with mental disorders, only 44.2% (95% CI 37.6% to 50.9%) received any services for these conditions.

CONCLUSIONS

An estimated one in eight children have mental disorders at any given time, causing symptoms and impairment, therefore requiring treatment. Yet even in high-income countries, most children with mental disorders are not receiving services for these conditions. We discuss the implications, particularly the need to substantially increase public investments in effective interventions. We also discuss the policy urgency, given the emerging increases in childhood mental health problems since the onset of the COVID-19 pandemic (PROSPERO CRD42020157262).

Association between child/adolescent overweight/obesity and conduct disorder: A systematic review and meta-analysis

BACKGROUND

Research findings of the association and its pattern between obesity and psychiatric/psychological comorbidities are not consistent across the types of comorbidities or the study subgroups.

OBJECTIVES

We aimed to perform meta-analysis of cross-sectional studies and longitudinal studies analysing obesity as a risk factor for conduct disorder in order to assess the association between child/adolescent overweight/obesity and conduct disorder.

METHODS

Systematic literature search, study selection and data extraction were performed independently by the two authors. Data were analysed by Comprehensive Meta-analysis software.

RESULTS

Analysis of 13 high-quality cross-sectional studies including 79 027 children and adolescents indicated a significant association between overweight/obesity and conduct disorder among children and adolescents (OR 1.32 [95% CI, 1.18-1.49], I² = 86.68), with no publication bias. Subgroup analyses yielded a significant difference (P < .01) between boys and girls. Analysis of four low- to moderate-quality longitudinal studies (OR 1.11 [95% CI, 0.89-1.38], I² = 57.69) showed no prospective association between overweight/obesity and conduct disorder. Subgroup analysis according to gender revealed a significant positive association for boys and negative association for girls.

CONCLUSIONS

Based on the high-quality cross-sectional data, overweight and obesity are associated with conduct disorder among children and adolescents, affecting boys more frequently than girls. Results of the longitudinal analysis indicated possible association in boys, while girls seem to be protected from conduct disorder. However, these results are very unreliable, indicating the need of well-designed longitudinal studies to elucidate the pattern of association between these disorders.

Effectiveness of Transdiagnostic Cognitive-Behavioral Psychotherapy Compared With Management as Usual for Youth With Common Mental Health Problems: A Randomized Clinical Trial

IMPORTANCE

Behavioral therapy and cognitive-behavioral therapy (CBT) programs targeting a single class of problems have not been widely implemented. The population of youths with common mental health problems is markedly undertreated.

OBJECTIVE

To determine the effectiveness of a new transdiagnostic CBT program (Mind My Mind [MMM]) compared with management as usual (MAU) in youths with emotional and behavioral problems below the threshold for referral to mental health care.

DESIGN, SETTING, AND PARTICIPANTS

This pragmatic, multisite, randomized clinical trial of MMM vs MAU was conducted from September 7, 2017, to August 28, 2019, including 8 weeks of postintervention follow-up, in 4 municipalities in Denmark. Consecutive help-seeking youths were randomized (1:1) to the MMM or the MAU group. Main inclusion criteria were age 6 to 16 years and anxiety, depressive symptoms, and/or behavioral disturbances as a primary problem. Data were analyzed from August 12 to October 25, 2019.

INTERVENTIONS

The MMM intervention consisted of 9 to 13 weekly, individually adapted sessions of manualized CBT delivered by local psychologists. The MAU group received 2 care coordination visits to enhance usual care.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in mental health problems reported by parents at week 18, using the Strengths and Difficulties Questionnaire (SDQ) Impact scale (range, 0-10 points, with higher scores indicating greater severity of distress and impairment). Primary and secondary outcomes were assessed in the intention-to-treat population at week 18. Maintenance effects were assessed at week 26.

RESULTS

A total of 396 youths (mean [SD] age, 10.3 [2.4] years; 206 [52.0%] boys) were randomized to MMM (n = 197) or MAU (n = 199), with primary outcome data available in 177 (89.8%) and 167 (83.9%), respectively, at 18 weeks. The SDQ Impact score decreased by 2.34 points with MMM and 1.23 with MAU, from initial scores of 4.12 and 4.21, respectively (between-group difference, 1.10 [95% CI, 0.75-1.45]; P < .001; Cohen d = 0.60). Number of responders (≥1-point reduction in SDQ Impact score) was greater with MMM than with MAU (144 of 197 [73.1%] vs 93 of 199 [46.7%]; number needed to treat, 4 [95% CI, 3-6]). Secondary outcomes indicated statistically significant benefits in parent-reported changes of anxiety, depressive symptoms, daily functioning, school attendance, and the principal problem. All benefits were maintained at week 26 except for school attendance.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, the scalable transdiagnostic cognitive-behavioral intervention MMM outperformed MAU in a community setting on multiple, clinically relevant domains in youth with emotional and behavioral problems.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03535805.

Informing the personalisation of interventions for parents of children with conduct problems: a qualitative study

BACKGROUND

Parenting programmes aim to alleviate behavioural problems in children, including conduct disorder. This study was part of a multi-phase mixed-methods project seeking to extend the reach of parenting programmes for the treatment of conduct problems through developing an evidence base to inform a personalised approach. It explored the narratives of parents of children with behavioural and conduct problems about parenting programmes to identify how such programmes could be personalised in order to extend their reach to parents and children who do not currently benefit.

METHODS

Face-to-face semi-structured interviews with a purposive sample of 42 parents, who had different experiences of parenting programmes. Interviews were conversational and informed by a topic guide. Analysis of transcripts of audio-recorded interviews drew on inductive thematic approaches and was framed largely within a phenomenological perspective.

RESULTS

Parents' accounts demonstrated three themes: 1) a personalised approach needs to include the child; 2) a supportive school matters; and, 3) the programme needs to feel personal. Parents were more likely to have a positive experience at a parenting programme, and for their child to demonstrate positive behavioural changes, when they felt their concerns were validated within the group and they also felt supported by the child's teachers. Parents whose children had been assessed prior to undertaking the programme were also more likely to perceive the programme to be beneficial, compared to parents who felt their child's individual issues were never considered.

CONCLUSIONS

Our findings point to the potential for personalised approaches to extend the reach of parenting programmes to parents and children who do not currently benefit from such programmes. Important in personalising parenting programmes is assessing children before parents are referred, to directly work with children as well as parents, and to work collaboratively with parents and children to identify which families are most suited to group support or one-to-one support and how this may change depending on circumstances.

Topographies and functions of emerging problem behavior and appropriate requests in neurotypical preschoolers

The current study builds on a small but growing body of research evaluating the formal and functional characteristics of emerging problem behavior before it becomes harmful and requires costly treatment. The researchers tested 21 preschool children's sensitivity to establishing operations that commonly precede severe problem behavior. Sensitivity tests were embedded in a small group play context to optimize safety, efficiency, and ecological validity. The tests screened several levels of problem-behavior severity as well as the presence of adaptive alternatives (i.e., communication) to problem behavior. Overall, outcomes suggested sources of reinforcement for minor- and moderate-severity problem behavior in 86% of children. Only 17% of children exhibiting problem behavior also engaged in appropriate requests in the same condition(s) as problem behavior. The present data are compared to published functional analyses of severe behavior. The results are discussed as a preliminary step towards a function-based model of risk identification and behavioral prevention of severe problem behavior.

Changes in the Prevalence of Child and Youth Mental Disorders and Perceived Need for Professional Help between 1983 and 2014: Evidence from the Ontario Child Health Study

OBJECTIVES

To examine: 1) changes in the prevalence of mental disorders and perceived need for professional help among children (ages 4 to 11) and youth (ages 12 to 16) between 1983 and 2014 in Ontario and 2) whether these changes vary by age and sex, urban-rural residency, poverty, lone-parent status, and immigrant background.

METHODS

The 1983 ( n = 2836) and 2014 ( n = 5785) Ontario Child Health Studies are provincially representative cross-sectional surveys with identical self-report checklist measures of conduct disorder, hyperactivity, and emotional disorder, as well as perceived need for professional help, assessed by integrating parent and teacher responses (ages 4 to 11) and parent and youth responses (ages 12 to 16).

RESULTS

The overall prevalence of perceived need for professional help increased from 6.8% to 18.9% among 4- to 16-year-olds. An increase in any disorder among children (15.4% to 19.6%) was attributable to increases in hyperactivity among males (8.9% to 15.7%). Although the prevalence of any disorder did not change among youth, conduct disorder decreased (7.2% to 2.5%) while emotional disorder increased (9.2% to 13.2%). The prevalence of any disorder increased more in rural and small to medium urban areas versus large urban areas. The prevalence of any disorder decreased for children and youth in immigrant but not nonimmigrant families.

CONCLUSIONS

Although there have been decreases in the prevalence of conduct disorder, increases in other mental disorders and perceived need for professional help underscore the continued need for effective prevention and intervention programs.

A National Comparison of Suicide Among Medicaid and Non-Medicaid Youth

INTRODUCTION

In the U.S., youth enrolled in Medicaid experience more risk factors for suicide, such as mental illness, than youth not enrolled in Medicaid. To inform a national suicide prevention strategy, this study presents suicide rates in a sample of youth enrolled in Medicaid and compares them with rates in the non-Medicaid population.

METHODS

Data sources were death certificate data matched with Medicaid data from 16 states, and the Web-based Injury Statistics Query and Reporting System. Deaths by suicide that occurred between 2009 and 2013 by youth aged 10 to 18 years were identified for Medicaid and non-Medicaid groups. Age-, gender-, and cause-specific mortality rates were calculated separately for both groups. Standardized mortality ratios were calculated to compare rates, and standardized mortality ratio 95% CIs were estimated with Poisson regressions. The data were analyzed in 2018.

RESULTS

A substantial proportion (39%) of the total number of deaths by suicide (N=4,045) in youth occurred among those enrolled in Medicaid. The overall suicide rate did not significantly differ between groups (standardized mortality ratio=0.96, 95% CI=0.90, 1.03). However, compared with the non-Medicaid group, the suicide rate in the Medicaid group was significantly higher among youth aged 10 to 14 years (standardized mortality ratio=1.28, 95% CI=1.11, 1.47), females (regardless of age; standardized mortality ratio=1.14, 95% CI=1.01, 1.29), and those who died by hanging (standardized mortality ratio=1.26, 95% CI=1.16, 1.38).

CONCLUSIONS

The population-based profile of suicide among youth enrolled in Medicaid differs from the profile of youth not enrolled in Medicaid, confirming the importance of Medicaid as a "boundaried" suicide prevention setting.

The Economic Case for the Prevention of Mental Illness

Poor mental health has profound economic consequences. Given the burden of poor mental health, the economic case for preventing mental illness and promoting better mental health may be very strong, but too often prevention attracts little attention and few resources. This article describes the potential role that can be played by economic evidence alongside experimental trials and observational studies, or through modeling, to substantiate the need for increased investment in prevention. It illustrates areas of action across the life course where there is already a good economic case. It also suggests some further areas of substantive public health concern, with promising effectiveness evidence, that may benefit from economic analysis. Financial and economic barriers to implementation are then presented, and strategies to address the barriers and increase investment in the prevention of mental illness are suggested.

What do we really know about PRN use in agitated children with mental health conditions: a clinical review

What is the evidence that 'pro re nata' (PRN) medication is effective for ending agitated outbursts in children and adolescents in psychiatric emergency rooms or inpatient units? Literature search was performed for studies of PRN medication use in children and adolescents that included an outcome measure. One randomised controlled trial, three prospective studies and six retrospective studies that included some outcome measure were identified. Outcome measures were heterogeneous, and frequently did not use standardised metrics assessing agitation level to measure effectiveness. The single small Randomized Controlled Trial (RTC) does not find a difference between placebo and medication, and outcomes of other studies do not control for potential placebo effect of the intervention itself as opposed to the medication. There is insufficient evidence to support the common practice of PRN medications for the management of acute agitation, and no data with which to inform clinical practice, such as which medicines and doses are helpful for specific populations or situations. Psychiatrists have no evidence-based medication interventions for acutely managing agitated outbursts in children and adolescents.