Psychiatry · Medical Literature
'Pilot RCT of a new treatment for child conduct problems that have not responded to evidence-based parent training'.
Abstract
Children with conduct problems are at high risk of persisting mental health problems, making them a priority for early intervention. Group-based parent-training is effective but with a substantial failure rate. Based on evidence on the value of involving children, we developed Reflective Interpersonal Therapy for Children and Parents, (RICAP). We report feasibility and outcomes from the first pilot trial of an intervention for children with conduct problems persisting after parent training. In contrast to most studies, we used both parent and teacher report. The sample comprised 105 children and their parents aged 4-10 years inclusive referred to UK Child and Adolescent Mental Health Services (CAMHS) with conduct problems. All were offered the Incredible Years (IY) parent training intervention, and parents provided pre- and post-treatment measures (including CBCL, SDQ). Children still above clinical threshold after IY were randomized either to RICAP or to usual CAMHS treatment (CTAU) with follow up 8 months later. Only those randomized to CTAU could receive school-based interventions. Trial Registration Number: ISRCTN25252940. Feasibility was supported by high retention through the initial IY (102/105) and subsequent RCT phases of the study (58/70 eligible for randomization). The majority of those randomized to RICAP attended for 11/14 or more sessions, reflecting its high acceptability to both children and parents. By parent report RICAP was superior to CTAU on CBCL externalising (d = 0.32) and internalising (d = 0.42) problems, while by teacher report CTAU was superior on SDQ total problems (d = 0.32) and reactive aggression (d = 0.27). We provide first evidence of the feasibility of a design in which non-responders to parent training are randomized to novel intervention or control conditions. Outcomes were different for parent and teacher reports, highlighting for future randomized controlled trials the need to attend to possible reporter and treatment context variations.
Clinical relevance
A substantial proportion of children with conduct disorders fail to achieve clinically meaningful improvement following first-line, evidence-based group parent training, yet this treatment-refractory population has historically lacked a defined, evidence-informed next-step intervention. This pilot RCT addresses that gap by evaluating RICAP — a novel child- and parent-involving therapy — in a UK CAMHS population of 4–10-year-olds who remained above clinical threshold after completing the Incredible Years (IY) programme. Given the well-established trajectory from early-onset conduct problems to persistent psychiatric morbidity, identifying effective sequential or stepped-care interventions is a clinical priority for child and adolescent psychiatrists.
Key findings
1. Feasibility was robustly supported: 102 of 105 enrolled children (97.1%) were retained through the initial IY parent-training phase, and 58 of 70 eligible participants (82.9%) were retained through the subsequent RCT randomization phase, demonstrating acceptable study attrition. 2. Treatment adherence to RICAP was high, with the majority of randomized participants attending 11 or more of 14 sessions (≥78.6% session completion), indicating strong acceptability of the intervention to both children and their parents. 3. By parent report (CBCL), RICAP was superior to control treatment as usual (CTAU) on externalising problems with a small-to-medium effect size (d = 0.32). 4. By parent report (CBCL), RICAP also demonstrated superiority over CTAU on internalising problems with a small-to-medium effect size (d = 0.42), suggesting broader psychopathological benefit beyond conduct symptoms alone. 5. By teacher report (SDQ), CTAU was superior to RICAP on total problems (d = 0.32) and reactive aggression (d = 0.27), a discordant finding that may reflect differential treatment context effects, given that only participants in the CTAU arm were eligible to receive school-based interventions. 6. No confidence intervals or p-values were reported in the abstract, and the sample of children randomized (n ≤ 70) limits the precision and generalizability of effect size estimates; findings should be interpreted as hypothesis-generating for a fully powered RCT.
Practice implications
CAMHS clinicians and child psychiatrists should consider adopting a formal stepped-care framework for pediatric conduct disorders, in which children aged 4–10 who remain above clinical threshold following a completed course of evidence-based group parent training (e.g., Incredible Years) are systematically identified and offered a structured next-step intervention such as RICAP rather than unstructured usual care. When designing or interpreting outcomes in this population, clinicians and researchers must prospectively plan for multi-informant assessment using both parent- and teacher-report measures (e.g., CBCL and SDQ), as reporter and treatment-context discordance — particularly when school-based co-interventions are differentially available — can produce divergent and potentially misleading conclusions about treatment efficacy. Future fully powered RCTs should ensure allocation parity in access to adjunctive school-based interventions across study arms and should pre-specify which informant report constitutes the primary outcome to reduce interpretive ambiguity.