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What are effective treatments for oppositional and defiant behaviors in preadolescents?
Parent training is effective for treating oppositional and defiant behaviors (strength of recommendation [SOR]: A, based on systematic reviews). Parent training programs are standardized, short-term interventions that teach parents specialized strategies—including positive attending, ignoring, the effective use of rewards and punishments, token economies, and time out—to address clinically significant behavior problems. In addition to parent training, other psychosocial interventions (Table) are efficacious in treating oppositional and defiant behavior.
To date, no studies have assessed the efficacy of medication in treating children with pure oppositional defiant disorder (ODD). However, studies have shown amphetamines to be effective for children with ODD and comorbid attention deficit/hyperactivity disorder (ADHD) (SOR: A, based on a meta-analysis).
Evidence summary
Oppositional and defiant behaviors include noncompliance, temper tantrums, arguing, and mild aggression. Children exhibiting these behaviors may have a diagnosis of ODD. Importantly, this review does not examine treatments for children diagnosed with conduct disorder or those exhibiting more deviant behaviors such as serious aggression and delinquency.
Eight well-done systematic reviews examined the effectiveness of parent training programs. Parent training is typically conducted by clinical child psychologists but may also be available through certified parenting educators (see the National Parenting Education Network web page for links to state organizations, at www.ces.ncsu.edu/depts/fcs/npen/). Parent training strategies are also described for parents in books such as Your Defiant Child.1
The most rigorous of the reviews looked at 16 randomized controlled trials that examined the effectiveness of training programs for children between the ages of 3 and 10 years who had “externalizing problems,” including temper tantrums, aggression, and noncompliance.2 All studies included in the review compared a group-based parent training program with a no-treatment wait-list control group and assessed outcomes using a standardized measure of behavior. In studies where sufficient data were provided, effect sizes ranged from 0.6 to 2.9. This indicates that, on a standardized child behavioral measure, parental report of children’s externalizing problems decreased by 0.6 to 2.9 standard deviations from pre- to posttreatment (an effect size of >0.8 is considered large). In the 2 studies that included independent observations of child behavior, the benefits reported by parents were confirmed by these observations.
Although parent training has the strongest evidence as a treatment for oppositional and defiant behavior, other psychosocial treatment interventions have been found by multiple randomized controlled trials to be superior to no treatment or wait-list controls (Table).
In treating oppositional behaviors among children with ADHD and comorbid oppositional defiant disorder or conduct disorder, a meta-analysis identified 28 studies of children age 7 to 15 years that addressed oppositional/aggression-related behaviors within the context of ADHD.8 The analysis found that stimulants are efficacious. The overall weighted effect size (a measure of improvement representing the average effects across all reporters) was 0.89. This indicates that raters saw a change in oppositional behaviors—noncompliance, irritability, and temper tantrums—that corresponded to a drop in scores of approximately 1 standard deviation.
TABLE
Additional ODD treatments supported by randomized controlled trials
| Treatment and representative study | Treatment description | Outcome |
|---|---|---|
| Anger Coping Therapy3 | A 12- to 18-session group cognitive-behavioral and social problem-solving training program. Assessed independently (AC) and with a teacher component (ACTC) | AC and ACTC exhibited reductions in directly observed disruptive and aggressive classroom behavior (P.<.05). |
| SOR: B | No significant differences between AC and ACTC | |
| Problem Solving Skills Training4 | A 20- to 25-session individual child skills training. | 33% (parent report) to 57% (teacher report) of the PSST group and 64%–69% Assessed individually of the PSST+PT |
| group were within the SOR: B | (PSST) and with PT | normal range after treatment. Gains maintained at 1 year. No control group. |
| In an inpatient population, PSST showed greater decreases in externalizing and aggressive behaviors than controls (P.<.01)5 | ||
| Dina Dinosaur Social Emotional and Problem Solving Child Training/ Incredible Years Child Training6 | An 18- to 22-session group skills training program. | PT and PT+CT groups demonstrated fewer mother-reported behavior problems at post-test. Effect sizes: PT vs. control = .89 (P.<.05); PT + CT vs. control = .73 (P.<.05) |
| SOR: B | Assessed as an independent treatment and with PT | One-year follow-up: compared with baseline, 95% of children in the PT+CT group, 74% in the CT group, and 60% in the PT group exhibited at least a 30% reduction in home-observed deviant behaviors. The difference between the PT + CT and PT groups was significant (P.<.01) |
| Incredible Years Teacher Training7 | A classroom teacher training program. | Per parent report, 55% (PT + CT + TT), 59% (PT + TT), 47% (CT + TT) and 20% (control group) had a reduction of 20% or and PT+CT more in behavior problems. The difference between the control group was significant for the PT + CT + TT and PT + TT groups. |
| SOR: B | Assessed with PT, CT | Two-year follow-up: 75% of treated children were within the normal range per parent and teacher reports. No control group. |
| AC = Anger coping therapy; ACTC = Anger coping therapy with teacher consultation; | ||
| CT = Child Training; PSST = Problem Solving Skills Training; | ||
Recommendations from others
Two parent training interventions meet the American Psychological Association’s criteria for well-established treatments.9 These include programs based on Patterson and Gullion’s Living with Children, a short-term, behavioral parent training program, and programs based on WebsterStratton’s Videotape Modeling parent training program. Two additional treatments, Anger Coping Therapy and Problem Solving Skills Training, meet the criteria for “probably efficacious.”
According to the International Consensus Statement on ADHD and Disruptive Behavior Disorders, “pharmacological treatment of pure ODD should not be considered except in cases where aggression is a significant, persistent problem.”10
Psychological interventions for parent and child are essential
Richard C. Fulkerson, MD
Anita R. Webb, PhD
John Peter Smith Family Medicine Residency Program, Fort Worth, Tex
Oppositional and defiant behaviors are a family problem requiring a family solution. Frustrated parents often request a “quick fix,” so this literature review is helpful in defining when medications are not indicated. Psychological interventions for the parents and for the child are essential. An important role for the family physician is to convince parents that their participation is critical in treating this problem. In addition to encouraging referrals to psychological resources in the community and occasionally prescribing medication, another role for the physician is to model parenting skills. The physician can demonstrate the “Tough Love” philosophy of holding the child responsible for unacceptable behavior without rejecting the child or blaming other people. An additional role could be to schedule brief checkup/counseling sessions with the family and child. These roles can be time consuming without necessarily having the assurance that all of them are evidence-based. However, the value of having multiple role options is that family physicians can develop an individualized approach for helping each family, as long as the emphasis remains on parental involvement.
1. Barkley RA, Benton CM. Your Defiant Child: Eight Steps to Better Behavior. New York: Guilford Press; 1998.
2. Barlow J, Stewart-Brown S. Behavior problems and groupbased parent education programs. J Dev Behav Pediatr 2000;21:356-370.
3. Lochman JE, Lampron LB, Gemmer TC, Harris SR, Wyckoff GM. Teacher consultation and cognitive-behavioral interventions with aggressive boys. Psychol Schools 1989;26:179-188.
4. Kazdin AE, Siegel TC, Bass D. Cognitive problem solving skills training and parent management training in the treatment of antisocial behavior in children. J Consult Clin Psychol 1992;60:733-747.
5. Kazdin AE, Esveldt-Dawson K, French NH, Unis AS. Problem-solving skills training and relationship therapy in the treatment of antisocial child behavior. J Consult Clin Psychol 1987;55:76-85.
6. Webster-Stratton C, Reid MJ. Treating conduct problems and strengthening social and emotional competence in young children: the dina dinosaur treatment program. J Emot Behav Disord 2003;11:130-143.
7. Reid MJ, Webster-Stratton C, Hammond M. Follow-up of children who received the incredible years intervention for oppositional-defiant disorder: maintenance and prediction of 2-year outcome. Behav Ther 2003;34:471-491.
8. Connor DF, Glatt SJ, Lopez ID, Jackson D, Melloni RH Jr. Psychopharmacology and aggression. I: A meta-analysis of stimulant effects on overt/covert aggression-related behaviors in ADHD. J Am Acad Child Adolesc Psychiatry 2002;41:253-261.
9. Brestan EV, Eyberg SM. Effective psychosocial treatments of conduct-disordered children and adolescents: 29 years, 82 studies, and 5,272 kids. J Clin Child Psychol 1998;27:180-189.
10. Kutcher S, Aman M, Brooks SJ, et al. International consensus statement on attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs): clinical implications and treatment practice suggestions. Eur Neuropsychopharmacol 2004;14:11-28.
Parent training is effective for treating oppositional and defiant behaviors (strength of recommendation [SOR]: A, based on systematic reviews). Parent training programs are standardized, short-term interventions that teach parents specialized strategies—including positive attending, ignoring, the effective use of rewards and punishments, token economies, and time out—to address clinically significant behavior problems. In addition to parent training, other psychosocial interventions (Table) are efficacious in treating oppositional and defiant behavior.
To date, no studies have assessed the efficacy of medication in treating children with pure oppositional defiant disorder (ODD). However, studies have shown amphetamines to be effective for children with ODD and comorbid attention deficit/hyperactivity disorder (ADHD) (SOR: A, based on a meta-analysis).
Evidence summary
Oppositional and defiant behaviors include noncompliance, temper tantrums, arguing, and mild aggression. Children exhibiting these behaviors may have a diagnosis of ODD. Importantly, this review does not examine treatments for children diagnosed with conduct disorder or those exhibiting more deviant behaviors such as serious aggression and delinquency.
Eight well-done systematic reviews examined the effectiveness of parent training programs. Parent training is typically conducted by clinical child psychologists but may also be available through certified parenting educators (see the National Parenting Education Network web page for links to state organizations, at www.ces.ncsu.edu/depts/fcs/npen/). Parent training strategies are also described for parents in books such as Your Defiant Child.1
The most rigorous of the reviews looked at 16 randomized controlled trials that examined the effectiveness of training programs for children between the ages of 3 and 10 years who had “externalizing problems,” including temper tantrums, aggression, and noncompliance.2 All studies included in the review compared a group-based parent training program with a no-treatment wait-list control group and assessed outcomes using a standardized measure of behavior. In studies where sufficient data were provided, effect sizes ranged from 0.6 to 2.9. This indicates that, on a standardized child behavioral measure, parental report of children’s externalizing problems decreased by 0.6 to 2.9 standard deviations from pre- to posttreatment (an effect size of >0.8 is considered large). In the 2 studies that included independent observations of child behavior, the benefits reported by parents were confirmed by these observations.
Although parent training has the strongest evidence as a treatment for oppositional and defiant behavior, other psychosocial treatment interventions have been found by multiple randomized controlled trials to be superior to no treatment or wait-list controls (Table).
In treating oppositional behaviors among children with ADHD and comorbid oppositional defiant disorder or conduct disorder, a meta-analysis identified 28 studies of children age 7 to 15 years that addressed oppositional/aggression-related behaviors within the context of ADHD.8 The analysis found that stimulants are efficacious. The overall weighted effect size (a measure of improvement representing the average effects across all reporters) was 0.89. This indicates that raters saw a change in oppositional behaviors—noncompliance, irritability, and temper tantrums—that corresponded to a drop in scores of approximately 1 standard deviation.
TABLE
Additional ODD treatments supported by randomized controlled trials
| Treatment and representative study | Treatment description | Outcome |
|---|---|---|
| Anger Coping Therapy3 | A 12- to 18-session group cognitive-behavioral and social problem-solving training program. Assessed independently (AC) and with a teacher component (ACTC) | AC and ACTC exhibited reductions in directly observed disruptive and aggressive classroom behavior (P.<.05). |
| SOR: B | No significant differences between AC and ACTC | |
| Problem Solving Skills Training4 | A 20- to 25-session individual child skills training. | 33% (parent report) to 57% (teacher report) of the PSST group and 64%–69% Assessed individually of the PSST+PT |
| group were within the SOR: B | (PSST) and with PT | normal range after treatment. Gains maintained at 1 year. No control group. |
| In an inpatient population, PSST showed greater decreases in externalizing and aggressive behaviors than controls (P.<.01)5 | ||
| Dina Dinosaur Social Emotional and Problem Solving Child Training/ Incredible Years Child Training6 | An 18- to 22-session group skills training program. | PT and PT+CT groups demonstrated fewer mother-reported behavior problems at post-test. Effect sizes: PT vs. control = .89 (P.<.05); PT + CT vs. control = .73 (P.<.05) |
| SOR: B | Assessed as an independent treatment and with PT | One-year follow-up: compared with baseline, 95% of children in the PT+CT group, 74% in the CT group, and 60% in the PT group exhibited at least a 30% reduction in home-observed deviant behaviors. The difference between the PT + CT and PT groups was significant (P.<.01) |
| Incredible Years Teacher Training7 | A classroom teacher training program. | Per parent report, 55% (PT + CT + TT), 59% (PT + TT), 47% (CT + TT) and 20% (control group) had a reduction of 20% or and PT+CT more in behavior problems. The difference between the control group was significant for the PT + CT + TT and PT + TT groups. |
| SOR: B | Assessed with PT, CT | Two-year follow-up: 75% of treated children were within the normal range per parent and teacher reports. No control group. |
| AC = Anger coping therapy; ACTC = Anger coping therapy with teacher consultation; | ||
| CT = Child Training; PSST = Problem Solving Skills Training; | ||
Recommendations from others
Two parent training interventions meet the American Psychological Association’s criteria for well-established treatments.9 These include programs based on Patterson and Gullion’s Living with Children, a short-term, behavioral parent training program, and programs based on WebsterStratton’s Videotape Modeling parent training program. Two additional treatments, Anger Coping Therapy and Problem Solving Skills Training, meet the criteria for “probably efficacious.”
According to the International Consensus Statement on ADHD and Disruptive Behavior Disorders, “pharmacological treatment of pure ODD should not be considered except in cases where aggression is a significant, persistent problem.”10
Psychological interventions for parent and child are essential
Richard C. Fulkerson, MD
Anita R. Webb, PhD
John Peter Smith Family Medicine Residency Program, Fort Worth, Tex
Oppositional and defiant behaviors are a family problem requiring a family solution. Frustrated parents often request a “quick fix,” so this literature review is helpful in defining when medications are not indicated. Psychological interventions for the parents and for the child are essential. An important role for the family physician is to convince parents that their participation is critical in treating this problem. In addition to encouraging referrals to psychological resources in the community and occasionally prescribing medication, another role for the physician is to model parenting skills. The physician can demonstrate the “Tough Love” philosophy of holding the child responsible for unacceptable behavior without rejecting the child or blaming other people. An additional role could be to schedule brief checkup/counseling sessions with the family and child. These roles can be time consuming without necessarily having the assurance that all of them are evidence-based. However, the value of having multiple role options is that family physicians can develop an individualized approach for helping each family, as long as the emphasis remains on parental involvement.
Parent training is effective for treating oppositional and defiant behaviors (strength of recommendation [SOR]: A, based on systematic reviews). Parent training programs are standardized, short-term interventions that teach parents specialized strategies—including positive attending, ignoring, the effective use of rewards and punishments, token economies, and time out—to address clinically significant behavior problems. In addition to parent training, other psychosocial interventions (Table) are efficacious in treating oppositional and defiant behavior.
To date, no studies have assessed the efficacy of medication in treating children with pure oppositional defiant disorder (ODD). However, studies have shown amphetamines to be effective for children with ODD and comorbid attention deficit/hyperactivity disorder (ADHD) (SOR: A, based on a meta-analysis).
Evidence summary
Oppositional and defiant behaviors include noncompliance, temper tantrums, arguing, and mild aggression. Children exhibiting these behaviors may have a diagnosis of ODD. Importantly, this review does not examine treatments for children diagnosed with conduct disorder or those exhibiting more deviant behaviors such as serious aggression and delinquency.
Eight well-done systematic reviews examined the effectiveness of parent training programs. Parent training is typically conducted by clinical child psychologists but may also be available through certified parenting educators (see the National Parenting Education Network web page for links to state organizations, at www.ces.ncsu.edu/depts/fcs/npen/). Parent training strategies are also described for parents in books such as Your Defiant Child.1
The most rigorous of the reviews looked at 16 randomized controlled trials that examined the effectiveness of training programs for children between the ages of 3 and 10 years who had “externalizing problems,” including temper tantrums, aggression, and noncompliance.2 All studies included in the review compared a group-based parent training program with a no-treatment wait-list control group and assessed outcomes using a standardized measure of behavior. In studies where sufficient data were provided, effect sizes ranged from 0.6 to 2.9. This indicates that, on a standardized child behavioral measure, parental report of children’s externalizing problems decreased by 0.6 to 2.9 standard deviations from pre- to posttreatment (an effect size of >0.8 is considered large). In the 2 studies that included independent observations of child behavior, the benefits reported by parents were confirmed by these observations.
Although parent training has the strongest evidence as a treatment for oppositional and defiant behavior, other psychosocial treatment interventions have been found by multiple randomized controlled trials to be superior to no treatment or wait-list controls (Table).
In treating oppositional behaviors among children with ADHD and comorbid oppositional defiant disorder or conduct disorder, a meta-analysis identified 28 studies of children age 7 to 15 years that addressed oppositional/aggression-related behaviors within the context of ADHD.8 The analysis found that stimulants are efficacious. The overall weighted effect size (a measure of improvement representing the average effects across all reporters) was 0.89. This indicates that raters saw a change in oppositional behaviors—noncompliance, irritability, and temper tantrums—that corresponded to a drop in scores of approximately 1 standard deviation.
TABLE
Additional ODD treatments supported by randomized controlled trials
| Treatment and representative study | Treatment description | Outcome |
|---|---|---|
| Anger Coping Therapy3 | A 12- to 18-session group cognitive-behavioral and social problem-solving training program. Assessed independently (AC) and with a teacher component (ACTC) | AC and ACTC exhibited reductions in directly observed disruptive and aggressive classroom behavior (P.<.05). |
| SOR: B | No significant differences between AC and ACTC | |
| Problem Solving Skills Training4 | A 20- to 25-session individual child skills training. | 33% (parent report) to 57% (teacher report) of the PSST group and 64%–69% Assessed individually of the PSST+PT |
| group were within the SOR: B | (PSST) and with PT | normal range after treatment. Gains maintained at 1 year. No control group. |
| In an inpatient population, PSST showed greater decreases in externalizing and aggressive behaviors than controls (P.<.01)5 | ||
| Dina Dinosaur Social Emotional and Problem Solving Child Training/ Incredible Years Child Training6 | An 18- to 22-session group skills training program. | PT and PT+CT groups demonstrated fewer mother-reported behavior problems at post-test. Effect sizes: PT vs. control = .89 (P.<.05); PT + CT vs. control = .73 (P.<.05) |
| SOR: B | Assessed as an independent treatment and with PT | One-year follow-up: compared with baseline, 95% of children in the PT+CT group, 74% in the CT group, and 60% in the PT group exhibited at least a 30% reduction in home-observed deviant behaviors. The difference between the PT + CT and PT groups was significant (P.<.01) |
| Incredible Years Teacher Training7 | A classroom teacher training program. | Per parent report, 55% (PT + CT + TT), 59% (PT + TT), 47% (CT + TT) and 20% (control group) had a reduction of 20% or and PT+CT more in behavior problems. The difference between the control group was significant for the PT + CT + TT and PT + TT groups. |
| SOR: B | Assessed with PT, CT | Two-year follow-up: 75% of treated children were within the normal range per parent and teacher reports. No control group. |
| AC = Anger coping therapy; ACTC = Anger coping therapy with teacher consultation; | ||
| CT = Child Training; PSST = Problem Solving Skills Training; | ||
Recommendations from others
Two parent training interventions meet the American Psychological Association’s criteria for well-established treatments.9 These include programs based on Patterson and Gullion’s Living with Children, a short-term, behavioral parent training program, and programs based on WebsterStratton’s Videotape Modeling parent training program. Two additional treatments, Anger Coping Therapy and Problem Solving Skills Training, meet the criteria for “probably efficacious.”
According to the International Consensus Statement on ADHD and Disruptive Behavior Disorders, “pharmacological treatment of pure ODD should not be considered except in cases where aggression is a significant, persistent problem.”10
Psychological interventions for parent and child are essential
Richard C. Fulkerson, MD
Anita R. Webb, PhD
John Peter Smith Family Medicine Residency Program, Fort Worth, Tex
Oppositional and defiant behaviors are a family problem requiring a family solution. Frustrated parents often request a “quick fix,” so this literature review is helpful in defining when medications are not indicated. Psychological interventions for the parents and for the child are essential. An important role for the family physician is to convince parents that their participation is critical in treating this problem. In addition to encouraging referrals to psychological resources in the community and occasionally prescribing medication, another role for the physician is to model parenting skills. The physician can demonstrate the “Tough Love” philosophy of holding the child responsible for unacceptable behavior without rejecting the child or blaming other people. An additional role could be to schedule brief checkup/counseling sessions with the family and child. These roles can be time consuming without necessarily having the assurance that all of them are evidence-based. However, the value of having multiple role options is that family physicians can develop an individualized approach for helping each family, as long as the emphasis remains on parental involvement.
1. Barkley RA, Benton CM. Your Defiant Child: Eight Steps to Better Behavior. New York: Guilford Press; 1998.
2. Barlow J, Stewart-Brown S. Behavior problems and groupbased parent education programs. J Dev Behav Pediatr 2000;21:356-370.
3. Lochman JE, Lampron LB, Gemmer TC, Harris SR, Wyckoff GM. Teacher consultation and cognitive-behavioral interventions with aggressive boys. Psychol Schools 1989;26:179-188.
4. Kazdin AE, Siegel TC, Bass D. Cognitive problem solving skills training and parent management training in the treatment of antisocial behavior in children. J Consult Clin Psychol 1992;60:733-747.
5. Kazdin AE, Esveldt-Dawson K, French NH, Unis AS. Problem-solving skills training and relationship therapy in the treatment of antisocial child behavior. J Consult Clin Psychol 1987;55:76-85.
6. Webster-Stratton C, Reid MJ. Treating conduct problems and strengthening social and emotional competence in young children: the dina dinosaur treatment program. J Emot Behav Disord 2003;11:130-143.
7. Reid MJ, Webster-Stratton C, Hammond M. Follow-up of children who received the incredible years intervention for oppositional-defiant disorder: maintenance and prediction of 2-year outcome. Behav Ther 2003;34:471-491.
8. Connor DF, Glatt SJ, Lopez ID, Jackson D, Melloni RH Jr. Psychopharmacology and aggression. I: A meta-analysis of stimulant effects on overt/covert aggression-related behaviors in ADHD. J Am Acad Child Adolesc Psychiatry 2002;41:253-261.
9. Brestan EV, Eyberg SM. Effective psychosocial treatments of conduct-disordered children and adolescents: 29 years, 82 studies, and 5,272 kids. J Clin Child Psychol 1998;27:180-189.
10. Kutcher S, Aman M, Brooks SJ, et al. International consensus statement on attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs): clinical implications and treatment practice suggestions. Eur Neuropsychopharmacol 2004;14:11-28.
1. Barkley RA, Benton CM. Your Defiant Child: Eight Steps to Better Behavior. New York: Guilford Press; 1998.
2. Barlow J, Stewart-Brown S. Behavior problems and groupbased parent education programs. J Dev Behav Pediatr 2000;21:356-370.
3. Lochman JE, Lampron LB, Gemmer TC, Harris SR, Wyckoff GM. Teacher consultation and cognitive-behavioral interventions with aggressive boys. Psychol Schools 1989;26:179-188.
4. Kazdin AE, Siegel TC, Bass D. Cognitive problem solving skills training and parent management training in the treatment of antisocial behavior in children. J Consult Clin Psychol 1992;60:733-747.
5. Kazdin AE, Esveldt-Dawson K, French NH, Unis AS. Problem-solving skills training and relationship therapy in the treatment of antisocial child behavior. J Consult Clin Psychol 1987;55:76-85.
6. Webster-Stratton C, Reid MJ. Treating conduct problems and strengthening social and emotional competence in young children: the dina dinosaur treatment program. J Emot Behav Disord 2003;11:130-143.
7. Reid MJ, Webster-Stratton C, Hammond M. Follow-up of children who received the incredible years intervention for oppositional-defiant disorder: maintenance and prediction of 2-year outcome. Behav Ther 2003;34:471-491.
8. Connor DF, Glatt SJ, Lopez ID, Jackson D, Melloni RH Jr. Psychopharmacology and aggression. I: A meta-analysis of stimulant effects on overt/covert aggression-related behaviors in ADHD. J Am Acad Child Adolesc Psychiatry 2002;41:253-261.
9. Brestan EV, Eyberg SM. Effective psychosocial treatments of conduct-disordered children and adolescents: 29 years, 82 studies, and 5,272 kids. J Clin Child Psychol 1998;27:180-189.
10. Kutcher S, Aman M, Brooks SJ, et al. International consensus statement on attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs): clinical implications and treatment practice suggestions. Eur Neuropsychopharmacol 2004;14:11-28.
Evidence-based answers from the Family Physicians Inquiries Network
What are the treatment options for SSRI-related sexual dysfunction?
Substituting bupropion, nefazodone, or mirtazapine is beneficial. (Grade of recommendation: B, randomized controlled trials [RCTs].) Augmentation therapy with amantadine, bupropion, and buspirone is no better than placebo. (Grade of recommendation: B, RCTs.) Augmentation therapy with multiple other agents may be beneficial. (Grade of recommendation: D, open-label nonrandomized studies, case series, and case reports.) SSRI “drug holidays” may also be effective (Table 1). (Grade of recommendation: D, open-label nonrandomized studies.)
TABLE
Summary of treatment options for SSRI-induced sexual dysfunction
| Strategy | Drugs considered | RCT data | Other data |
|---|---|---|---|
| Switch therapy | Bupropion SR, bupropion, mirtazapine, nefazodone | Nefazodone effective | All agents effective in nonrandomized open-label trials |
| Augmentation | Buspirone, amantadine, bupropion, cyproheptadine, dextroamphetamine, granisetron, ginkgo biloba, methylphenidate, mirtazapine, nefazodone, pemoline, sildenafil, yohimbine | Small, transient effect with high-dose buspirone. | Other RCT with buspirone, amantadine, and bupropion showed no difference vs placebo. Most agents effective in nonrandomized open-label trials, case-series, or case reports. Placebo effect unknown |
| Drug holiday | Fluoxetine, paroxetine, sertraline | None available | Improvement in 2 of 4 weekends for sertraline and paroxetine only |
Evidence summary
SSRI-related sexual dysfunction may be dose dependent and diminish with time, but these aspects have not been evaluated prospectively. Data suggest that bupropion, nefazodone, and mirtazapine have little to no effect on sexual functioning.1 Changing from SSRIs to one of these agents may alleviate SSRI-induced sexual dysfunction. In a randomized double-blind study, patients experiencing sexual dysfunction on sertraline improved when switched to nefazodone 400 mg daily.2 Additional open-label nonrandomized studies of all 3 agents suggest improved sexual functioning in 60% to 85% of patients with little to no loss of antidepressant efficacy.1,3,6 The potential for placebo effects makes interpreting these open-label trials more difficult.
Three augmentation therapies have been tested in double-blind placebo-controlled trials. In the first, buspirone augmentation resulted in a statistical improvement in sexual functioning at weeks 2 and 3 of therapy, but not at weeks 1 and 4 (mean dose 48.5 mg per day).7 In the second, adding buspirone 20 to 30 mg per day, amantadine 50 to 100 mg per day, or placebo resulted in equal improvement in women’s sexual function.8 Finally, in a third trial, adding bupropion or placebo showed equal improvement in sexual function.9 Multiple other agents have been tested in open-label nonrandomized studies, case series, and case reports. Most showed a beneficial effect, but results must be interpreted with caution. One open-label nonrandomized study of weekend “drug holidays” showed no benefit for fluoxetine and inconsistent results for paroxetine and sertraline.10
Recommendations from others
Tertiary literature sources recommend the strategies described above.11
Clinical Commentary by Michael Fisher, MD, additional references, search strategy, and detailed evidence table at http://www.fpin.org.
1. Zajecka J, Drouin MA, Yang WH, Horak F, et al. J Clin Psychiatry 2001;62(suppl 3):35-43.2.Allergy 1992;12(suppl):173.-
2. Ferguson JM, Shrivastava RK, Stahl SM, et al. J Clin Psychiatry. 2001;62:24-9.
3. Rosen RC, Lane RM, Menza M. J Clin Psychopharmacol 1999;19:67-85.
4. Gelenberg AJ, Laukes C, McGahuey C, et al. J Clin Psychiatry 2000;61:356-60.
5. Clayton AH, McGarvey EL, Abouesh AI, et al. J Clin Psychiatry 2001;62:185-90.
6. Walker PW, Cole JO, Gardner EA, et al. J Clin Psychiatry 1993;54:459-65.
7. Landen M, Eriksson E, Agren H, et al. J Clin Psychopharmacol 1999;19:268-71
8. Michelson D, Bancroft J, Targum S, et al. Am J Psychiatry 2000;157:239-43.
9. Masand PS, Ashton AK, Gupta S, et al. Am J Psychiatry 2001;158:805-7.
10. Rothschild AJ. Am J Psychiatry 1995;152:1514-6.
11. Marangell LB, Yudofsky SC, Silver JM. Psychopharmacology and electroconvulsive therapy. In: Hales RE, Yudofsky SC, Talbott JA, eds. Textbook of Psychiatry. 3rd ed. Washington, DC: American Psychiatric Press; 1999;1025-132.
Substituting bupropion, nefazodone, or mirtazapine is beneficial. (Grade of recommendation: B, randomized controlled trials [RCTs].) Augmentation therapy with amantadine, bupropion, and buspirone is no better than placebo. (Grade of recommendation: B, RCTs.) Augmentation therapy with multiple other agents may be beneficial. (Grade of recommendation: D, open-label nonrandomized studies, case series, and case reports.) SSRI “drug holidays” may also be effective (Table 1). (Grade of recommendation: D, open-label nonrandomized studies.)
TABLE
Summary of treatment options for SSRI-induced sexual dysfunction
| Strategy | Drugs considered | RCT data | Other data |
|---|---|---|---|
| Switch therapy | Bupropion SR, bupropion, mirtazapine, nefazodone | Nefazodone effective | All agents effective in nonrandomized open-label trials |
| Augmentation | Buspirone, amantadine, bupropion, cyproheptadine, dextroamphetamine, granisetron, ginkgo biloba, methylphenidate, mirtazapine, nefazodone, pemoline, sildenafil, yohimbine | Small, transient effect with high-dose buspirone. | Other RCT with buspirone, amantadine, and bupropion showed no difference vs placebo. Most agents effective in nonrandomized open-label trials, case-series, or case reports. Placebo effect unknown |
| Drug holiday | Fluoxetine, paroxetine, sertraline | None available | Improvement in 2 of 4 weekends for sertraline and paroxetine only |
Evidence summary
SSRI-related sexual dysfunction may be dose dependent and diminish with time, but these aspects have not been evaluated prospectively. Data suggest that bupropion, nefazodone, and mirtazapine have little to no effect on sexual functioning.1 Changing from SSRIs to one of these agents may alleviate SSRI-induced sexual dysfunction. In a randomized double-blind study, patients experiencing sexual dysfunction on sertraline improved when switched to nefazodone 400 mg daily.2 Additional open-label nonrandomized studies of all 3 agents suggest improved sexual functioning in 60% to 85% of patients with little to no loss of antidepressant efficacy.1,3,6 The potential for placebo effects makes interpreting these open-label trials more difficult.
Three augmentation therapies have been tested in double-blind placebo-controlled trials. In the first, buspirone augmentation resulted in a statistical improvement in sexual functioning at weeks 2 and 3 of therapy, but not at weeks 1 and 4 (mean dose 48.5 mg per day).7 In the second, adding buspirone 20 to 30 mg per day, amantadine 50 to 100 mg per day, or placebo resulted in equal improvement in women’s sexual function.8 Finally, in a third trial, adding bupropion or placebo showed equal improvement in sexual function.9 Multiple other agents have been tested in open-label nonrandomized studies, case series, and case reports. Most showed a beneficial effect, but results must be interpreted with caution. One open-label nonrandomized study of weekend “drug holidays” showed no benefit for fluoxetine and inconsistent results for paroxetine and sertraline.10
Recommendations from others
Tertiary literature sources recommend the strategies described above.11
Clinical Commentary by Michael Fisher, MD, additional references, search strategy, and detailed evidence table at http://www.fpin.org.
Substituting bupropion, nefazodone, or mirtazapine is beneficial. (Grade of recommendation: B, randomized controlled trials [RCTs].) Augmentation therapy with amantadine, bupropion, and buspirone is no better than placebo. (Grade of recommendation: B, RCTs.) Augmentation therapy with multiple other agents may be beneficial. (Grade of recommendation: D, open-label nonrandomized studies, case series, and case reports.) SSRI “drug holidays” may also be effective (Table 1). (Grade of recommendation: D, open-label nonrandomized studies.)
TABLE
Summary of treatment options for SSRI-induced sexual dysfunction
| Strategy | Drugs considered | RCT data | Other data |
|---|---|---|---|
| Switch therapy | Bupropion SR, bupropion, mirtazapine, nefazodone | Nefazodone effective | All agents effective in nonrandomized open-label trials |
| Augmentation | Buspirone, amantadine, bupropion, cyproheptadine, dextroamphetamine, granisetron, ginkgo biloba, methylphenidate, mirtazapine, nefazodone, pemoline, sildenafil, yohimbine | Small, transient effect with high-dose buspirone. | Other RCT with buspirone, amantadine, and bupropion showed no difference vs placebo. Most agents effective in nonrandomized open-label trials, case-series, or case reports. Placebo effect unknown |
| Drug holiday | Fluoxetine, paroxetine, sertraline | None available | Improvement in 2 of 4 weekends for sertraline and paroxetine only |
Evidence summary
SSRI-related sexual dysfunction may be dose dependent and diminish with time, but these aspects have not been evaluated prospectively. Data suggest that bupropion, nefazodone, and mirtazapine have little to no effect on sexual functioning.1 Changing from SSRIs to one of these agents may alleviate SSRI-induced sexual dysfunction. In a randomized double-blind study, patients experiencing sexual dysfunction on sertraline improved when switched to nefazodone 400 mg daily.2 Additional open-label nonrandomized studies of all 3 agents suggest improved sexual functioning in 60% to 85% of patients with little to no loss of antidepressant efficacy.1,3,6 The potential for placebo effects makes interpreting these open-label trials more difficult.
Three augmentation therapies have been tested in double-blind placebo-controlled trials. In the first, buspirone augmentation resulted in a statistical improvement in sexual functioning at weeks 2 and 3 of therapy, but not at weeks 1 and 4 (mean dose 48.5 mg per day).7 In the second, adding buspirone 20 to 30 mg per day, amantadine 50 to 100 mg per day, or placebo resulted in equal improvement in women’s sexual function.8 Finally, in a third trial, adding bupropion or placebo showed equal improvement in sexual function.9 Multiple other agents have been tested in open-label nonrandomized studies, case series, and case reports. Most showed a beneficial effect, but results must be interpreted with caution. One open-label nonrandomized study of weekend “drug holidays” showed no benefit for fluoxetine and inconsistent results for paroxetine and sertraline.10
Recommendations from others
Tertiary literature sources recommend the strategies described above.11
Clinical Commentary by Michael Fisher, MD, additional references, search strategy, and detailed evidence table at http://www.fpin.org.
1. Zajecka J, Drouin MA, Yang WH, Horak F, et al. J Clin Psychiatry 2001;62(suppl 3):35-43.2.Allergy 1992;12(suppl):173.-
2. Ferguson JM, Shrivastava RK, Stahl SM, et al. J Clin Psychiatry. 2001;62:24-9.
3. Rosen RC, Lane RM, Menza M. J Clin Psychopharmacol 1999;19:67-85.
4. Gelenberg AJ, Laukes C, McGahuey C, et al. J Clin Psychiatry 2000;61:356-60.
5. Clayton AH, McGarvey EL, Abouesh AI, et al. J Clin Psychiatry 2001;62:185-90.
6. Walker PW, Cole JO, Gardner EA, et al. J Clin Psychiatry 1993;54:459-65.
7. Landen M, Eriksson E, Agren H, et al. J Clin Psychopharmacol 1999;19:268-71
8. Michelson D, Bancroft J, Targum S, et al. Am J Psychiatry 2000;157:239-43.
9. Masand PS, Ashton AK, Gupta S, et al. Am J Psychiatry 2001;158:805-7.
10. Rothschild AJ. Am J Psychiatry 1995;152:1514-6.
11. Marangell LB, Yudofsky SC, Silver JM. Psychopharmacology and electroconvulsive therapy. In: Hales RE, Yudofsky SC, Talbott JA, eds. Textbook of Psychiatry. 3rd ed. Washington, DC: American Psychiatric Press; 1999;1025-132.
1. Zajecka J, Drouin MA, Yang WH, Horak F, et al. J Clin Psychiatry 2001;62(suppl 3):35-43.2.Allergy 1992;12(suppl):173.-
2. Ferguson JM, Shrivastava RK, Stahl SM, et al. J Clin Psychiatry. 2001;62:24-9.
3. Rosen RC, Lane RM, Menza M. J Clin Psychopharmacol 1999;19:67-85.
4. Gelenberg AJ, Laukes C, McGahuey C, et al. J Clin Psychiatry 2000;61:356-60.
5. Clayton AH, McGarvey EL, Abouesh AI, et al. J Clin Psychiatry 2001;62:185-90.
6. Walker PW, Cole JO, Gardner EA, et al. J Clin Psychiatry 1993;54:459-65.
7. Landen M, Eriksson E, Agren H, et al. J Clin Psychopharmacol 1999;19:268-71
8. Michelson D, Bancroft J, Targum S, et al. Am J Psychiatry 2000;157:239-43.
9. Masand PS, Ashton AK, Gupta S, et al. Am J Psychiatry 2001;158:805-7.
10. Rothschild AJ. Am J Psychiatry 1995;152:1514-6.
11. Marangell LB, Yudofsky SC, Silver JM. Psychopharmacology and electroconvulsive therapy. In: Hales RE, Yudofsky SC, Talbott JA, eds. Textbook of Psychiatry. 3rd ed. Washington, DC: American Psychiatric Press; 1999;1025-132.
Evidence-based answers from the Family Physicians Inquiries Network
What is the best way to evaluate acute diarrhea?
Limited evidence delineates the relative probabilities of causes of acute diarrhea, typically defined as a diarrheal disease lasting 14 days or fewer, in the developed world. Viruses (rotavirus, Norwalk, and other enteric viruses) are responsible for most cases. Stool culture helps to identify bacterial causes (Salmonella, Shigella, enterotoxic Escherichia coli), especially in patients with fever and bloody stool. A modified 3-day rule (eg, performing only Clostridium difficile toxin tests on low-risk patients who have been hospitalized for 3 or more days) leads to a more rational use of stool cultures without missing cases of clinically significant disease. (Grade of recommendation: D, based on limited studies, reliance on expert opinion, and consensus.)
Evidence summary
More than 2 million cases of infectious diarrhea are documented in the United States annually. Infectious diarrhea is the second leading cause of morbidity and mortality worldwide. Published data have focused on the etiology of diarrhea in the developing world, and more commonly on the clinical evaluation and treatment of patients with diarrhea and dehydration.
While most research on acute diarrhea focuses on infectious causes, noninfectious causes should also be considered (eg, drug-induced diarrhea, inflammatory bowel disease).1 Viral causes are most common; in children, viruses are responsible for 70% to 80% of cases of diarrhea.2 A prospective study of 147 US children with acute, mild diarrhea demonstrated that rectal swabs yielded a positive test for an infectious agent in 60.5% of cases (Table).3
A case-control study of stool cultures for rotavirus in adult patients found that 14% of 683 with diarrhea and 5% of 1115 without diarrhea shed rotavirus.4 A recent systematic review found no published studies about the likelihood of specific diagnoses in children presenting to the hospital with diarrhea.5
Some evidence supports a structured diagnostic strategy for hospitalized patients with acute diarrhea. Using retrospective reviews, Bauer and colleagues6 developed a prediction rule for cases of infectious diarrhea. The “modified 3-day rule” recommends stool cultures for patients with diarrhea beginning more than 3 days after hospitalization only when they fall into 1 of the following groups: patients older than 65 years with permanently altered organ function, those with HIV or neutropenia, those hospitalized during suspected nosocomial outbreaks, and those suspected of nondiarrheal manifestations of enteric infection.6 When the modified rule was applied prospectively, only 2 cases were missed. Both patients were at risk for immunosuppression, although they did not strictly meet the modified criteria. Neither required treatment.6
TABLE 1
Etiologic agents in US children with acute diarrhea
| Infectious agent | Percent |
|---|---|
| Rotavirus | 29.3% |
| Giardia lamblia | 15% |
| Pathogenic Escherichia coli | 15% |
| Multiple agents | 10% |
| Data from Caeiro JP, Mathewson JJ, Smith MA, Jiang ZD, Kaplan MA, Dupont HL. Etiology of outpatient pediatric nondysenteric diarrhea: a multicenter study in the United States. Pediatr Infect Dis J 1999; 18:94–7. | |
Recommendations from others
The Infectious Diseases Society of America’s practice guidelines for the evaluation and treatment of acute diarrhea recommends that stool culture for bacteria (including enterotoxic E coli) should be considered in patients with community- or travel-acquired diarrhea, especially when fever or bloody stool is present. In hospitalized patients, only toxin tests for C difficile are recommended. Testing for acute parasitic diseases should be reserved only for patients whose symptoms persist after 7 days.1
Clinical Commentary by Les Hall, MD, at http://www.fpin.org.
1. Guerrant RL, Van Gilder T, Steiner TS, et al. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis 2001;32:331-51.
2. Merrick N, Davidson B, Fox S. Treatment of acute gastroenteritis: too much and too little care. Clin Pediatr (Phila) 1996;35:429-35.
3. Caeiro JP, Mathewson JJ, Smith MA, Jiang ZD, Kaplan MA, Dupont HL. Etiology of outpatient pediatric nondysenteric diarrhea: a multicenter study in the United States. Pediatr Infect Dis J 1999;18:94-7.
4. Nakajima H, Nakagomi T, Kamisawa T, et al. Winter seasonality and rotavirus diarrhoea in adults. Lancet 2001;357(9272):1950.-
5. Armon K, Stephenson T, MacFaul R, Eccleston P, Werneke U. An evidence and consensus based guideline for acute diarrhoea management. Arch Dis Child 2001;85:132-42.
6. Bauer TM, Lalvani A, Fehrenbach J, et al. Derivation and validation of guidelines for stool cultures for enteropathogenic bacteria other than Clostridium difficile in hospitalized adults. JAMA 2001;285:313-9.
Limited evidence delineates the relative probabilities of causes of acute diarrhea, typically defined as a diarrheal disease lasting 14 days or fewer, in the developed world. Viruses (rotavirus, Norwalk, and other enteric viruses) are responsible for most cases. Stool culture helps to identify bacterial causes (Salmonella, Shigella, enterotoxic Escherichia coli), especially in patients with fever and bloody stool. A modified 3-day rule (eg, performing only Clostridium difficile toxin tests on low-risk patients who have been hospitalized for 3 or more days) leads to a more rational use of stool cultures without missing cases of clinically significant disease. (Grade of recommendation: D, based on limited studies, reliance on expert opinion, and consensus.)
Evidence summary
More than 2 million cases of infectious diarrhea are documented in the United States annually. Infectious diarrhea is the second leading cause of morbidity and mortality worldwide. Published data have focused on the etiology of diarrhea in the developing world, and more commonly on the clinical evaluation and treatment of patients with diarrhea and dehydration.
While most research on acute diarrhea focuses on infectious causes, noninfectious causes should also be considered (eg, drug-induced diarrhea, inflammatory bowel disease).1 Viral causes are most common; in children, viruses are responsible for 70% to 80% of cases of diarrhea.2 A prospective study of 147 US children with acute, mild diarrhea demonstrated that rectal swabs yielded a positive test for an infectious agent in 60.5% of cases (Table).3
A case-control study of stool cultures for rotavirus in adult patients found that 14% of 683 with diarrhea and 5% of 1115 without diarrhea shed rotavirus.4 A recent systematic review found no published studies about the likelihood of specific diagnoses in children presenting to the hospital with diarrhea.5
Some evidence supports a structured diagnostic strategy for hospitalized patients with acute diarrhea. Using retrospective reviews, Bauer and colleagues6 developed a prediction rule for cases of infectious diarrhea. The “modified 3-day rule” recommends stool cultures for patients with diarrhea beginning more than 3 days after hospitalization only when they fall into 1 of the following groups: patients older than 65 years with permanently altered organ function, those with HIV or neutropenia, those hospitalized during suspected nosocomial outbreaks, and those suspected of nondiarrheal manifestations of enteric infection.6 When the modified rule was applied prospectively, only 2 cases were missed. Both patients were at risk for immunosuppression, although they did not strictly meet the modified criteria. Neither required treatment.6
TABLE 1
Etiologic agents in US children with acute diarrhea
| Infectious agent | Percent |
|---|---|
| Rotavirus | 29.3% |
| Giardia lamblia | 15% |
| Pathogenic Escherichia coli | 15% |
| Multiple agents | 10% |
| Data from Caeiro JP, Mathewson JJ, Smith MA, Jiang ZD, Kaplan MA, Dupont HL. Etiology of outpatient pediatric nondysenteric diarrhea: a multicenter study in the United States. Pediatr Infect Dis J 1999; 18:94–7. | |
Recommendations from others
The Infectious Diseases Society of America’s practice guidelines for the evaluation and treatment of acute diarrhea recommends that stool culture for bacteria (including enterotoxic E coli) should be considered in patients with community- or travel-acquired diarrhea, especially when fever or bloody stool is present. In hospitalized patients, only toxin tests for C difficile are recommended. Testing for acute parasitic diseases should be reserved only for patients whose symptoms persist after 7 days.1
Clinical Commentary by Les Hall, MD, at http://www.fpin.org.
Limited evidence delineates the relative probabilities of causes of acute diarrhea, typically defined as a diarrheal disease lasting 14 days or fewer, in the developed world. Viruses (rotavirus, Norwalk, and other enteric viruses) are responsible for most cases. Stool culture helps to identify bacterial causes (Salmonella, Shigella, enterotoxic Escherichia coli), especially in patients with fever and bloody stool. A modified 3-day rule (eg, performing only Clostridium difficile toxin tests on low-risk patients who have been hospitalized for 3 or more days) leads to a more rational use of stool cultures without missing cases of clinically significant disease. (Grade of recommendation: D, based on limited studies, reliance on expert opinion, and consensus.)
Evidence summary
More than 2 million cases of infectious diarrhea are documented in the United States annually. Infectious diarrhea is the second leading cause of morbidity and mortality worldwide. Published data have focused on the etiology of diarrhea in the developing world, and more commonly on the clinical evaluation and treatment of patients with diarrhea and dehydration.
While most research on acute diarrhea focuses on infectious causes, noninfectious causes should also be considered (eg, drug-induced diarrhea, inflammatory bowel disease).1 Viral causes are most common; in children, viruses are responsible for 70% to 80% of cases of diarrhea.2 A prospective study of 147 US children with acute, mild diarrhea demonstrated that rectal swabs yielded a positive test for an infectious agent in 60.5% of cases (Table).3
A case-control study of stool cultures for rotavirus in adult patients found that 14% of 683 with diarrhea and 5% of 1115 without diarrhea shed rotavirus.4 A recent systematic review found no published studies about the likelihood of specific diagnoses in children presenting to the hospital with diarrhea.5
Some evidence supports a structured diagnostic strategy for hospitalized patients with acute diarrhea. Using retrospective reviews, Bauer and colleagues6 developed a prediction rule for cases of infectious diarrhea. The “modified 3-day rule” recommends stool cultures for patients with diarrhea beginning more than 3 days after hospitalization only when they fall into 1 of the following groups: patients older than 65 years with permanently altered organ function, those with HIV or neutropenia, those hospitalized during suspected nosocomial outbreaks, and those suspected of nondiarrheal manifestations of enteric infection.6 When the modified rule was applied prospectively, only 2 cases were missed. Both patients were at risk for immunosuppression, although they did not strictly meet the modified criteria. Neither required treatment.6
TABLE 1
Etiologic agents in US children with acute diarrhea
| Infectious agent | Percent |
|---|---|
| Rotavirus | 29.3% |
| Giardia lamblia | 15% |
| Pathogenic Escherichia coli | 15% |
| Multiple agents | 10% |
| Data from Caeiro JP, Mathewson JJ, Smith MA, Jiang ZD, Kaplan MA, Dupont HL. Etiology of outpatient pediatric nondysenteric diarrhea: a multicenter study in the United States. Pediatr Infect Dis J 1999; 18:94–7. | |
Recommendations from others
The Infectious Diseases Society of America’s practice guidelines for the evaluation and treatment of acute diarrhea recommends that stool culture for bacteria (including enterotoxic E coli) should be considered in patients with community- or travel-acquired diarrhea, especially when fever or bloody stool is present. In hospitalized patients, only toxin tests for C difficile are recommended. Testing for acute parasitic diseases should be reserved only for patients whose symptoms persist after 7 days.1
Clinical Commentary by Les Hall, MD, at http://www.fpin.org.
1. Guerrant RL, Van Gilder T, Steiner TS, et al. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis 2001;32:331-51.
2. Merrick N, Davidson B, Fox S. Treatment of acute gastroenteritis: too much and too little care. Clin Pediatr (Phila) 1996;35:429-35.
3. Caeiro JP, Mathewson JJ, Smith MA, Jiang ZD, Kaplan MA, Dupont HL. Etiology of outpatient pediatric nondysenteric diarrhea: a multicenter study in the United States. Pediatr Infect Dis J 1999;18:94-7.
4. Nakajima H, Nakagomi T, Kamisawa T, et al. Winter seasonality and rotavirus diarrhoea in adults. Lancet 2001;357(9272):1950.-
5. Armon K, Stephenson T, MacFaul R, Eccleston P, Werneke U. An evidence and consensus based guideline for acute diarrhoea management. Arch Dis Child 2001;85:132-42.
6. Bauer TM, Lalvani A, Fehrenbach J, et al. Derivation and validation of guidelines for stool cultures for enteropathogenic bacteria other than Clostridium difficile in hospitalized adults. JAMA 2001;285:313-9.
1. Guerrant RL, Van Gilder T, Steiner TS, et al. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis 2001;32:331-51.
2. Merrick N, Davidson B, Fox S. Treatment of acute gastroenteritis: too much and too little care. Clin Pediatr (Phila) 1996;35:429-35.
3. Caeiro JP, Mathewson JJ, Smith MA, Jiang ZD, Kaplan MA, Dupont HL. Etiology of outpatient pediatric nondysenteric diarrhea: a multicenter study in the United States. Pediatr Infect Dis J 1999;18:94-7.
4. Nakajima H, Nakagomi T, Kamisawa T, et al. Winter seasonality and rotavirus diarrhoea in adults. Lancet 2001;357(9272):1950.-
5. Armon K, Stephenson T, MacFaul R, Eccleston P, Werneke U. An evidence and consensus based guideline for acute diarrhoea management. Arch Dis Child 2001;85:132-42.
6. Bauer TM, Lalvani A, Fehrenbach J, et al. Derivation and validation of guidelines for stool cultures for enteropathogenic bacteria other than Clostridium difficile in hospitalized adults. JAMA 2001;285:313-9.
Evidence-based answers from the Family Physicians Inquiries Network
What are the indications for tonsillectomy in children?
Tonsillectomy with or without adenoidectomy is minimally effective when combined with tympanostomy tube placement in preventing recurrent otitis media in the 3 years following surgery. The risks of surgery must be weighed against potential benefit. (Grade of recommendation: B, based on low-quality randomized controlled trials [RCTs]). The evidence supporting tonsillectomy for recurrence of sore throat is controversial.1 There is insufficient evidence to recommend other potential indications (Table). (Grade of recommendation: C, based on case series.)
TABLE
INDICATIONS FOR TONSILLECTOMY
| Potential Indication | Evidence of Effectiveness? | Grade of Recommendation | |
|---|---|---|---|
| Preventing recurrent otitis media in the 3 years following surgery | Yes, small effect size | B (RCTs, case series) | |
| Preventing recurrent sore throat caused by tonsillitis | No | B (systematic review of flawed RCTs) | |
| Preventing recurrent peritonsillar abscess | No | C (case series, consensus statements) | |
| Treating sleep apnea in children | No | C (case series2) | |
| Treating IgA nephropathy | No | C (case series) | |
| Treating guttate psoriasis | No | C (case series3) | |
| Treating nocturnal enuresis | No | C (case series) | |
| IgA denotes immunoglobulin A; RCTs, randomized controlled trials. | |||
Evidence summary
Cochrane: “There is no evidence from randomized controlled trials to guide the clinician in formulating the indications for surgery in adults or children.”1 The few existing trials are complicated by differences in treatment and control groups at baseline and by differential complication rates in groups receiving tonsillectomy or adenotonsillectomy. For example, 2 RCTs showed minimal effect at 1 year and no effect at 3 years of follow-up in preventing recurrent sore throat.2,3 However, 1 of these could not be critically appraised because it was published in abstract format only.
Two other trials of tonsillectomy and adenotonsillectomy in children, both with and without tympanostomy tube placement, have shown a small, brief reduction in episodes of recurrent otitis.4-6 In the largest study,6 controls had a mean of 2.1 episodes of recurrent otitis media in the first postoperative year while those undergoing adenotonsillectomy had had 1.8 episodes (P= .25) and those undergoing adenoidectomy had 1.4 episodes (P< .001). However, these benefits did not persist beyond the first year. Several case series report no evidence of effectiveness of tonsillectomy for immunoglobulin A (IgA) nephropathy, psoriasis, or nocturnal enuresis.
Recommendations from others
The Infectious Diseases Society of America states: “Surgical removal of the tonsils may be considered for the rare patient whose symptomatic episodes [of strep pharyngitis] do not diminish in frequency over time and for whom no alternative explanation for the recurrent pharyngitis is evident. Tonsillectomy may decrease recurrences of symptomatic pharyngitis in selected patients, but only for a limited period of time.”4
The American Academy of Pediatrics position is as follows: “Tonsillectomy, either alone or with adenoidectomy, has not been found effective for treatment of otitis media with effusion.”5 The Scottish Intercollegiate Guidelines Network (SIGN): “The following are recommended as reasonable indications for consideration of tonsillectomy in both children and adults, based on the current level of knowledge, clinical observation in the field and the results of clinical audit.” According to SIGN, patients should meet all these criteria: sore throats are caused by tonsillitis; 5 or more episodes of sore throat per year; symptoms have lasted for at least 1 year; and the episodes of sore throat “are disabling and prevent normal functioning.”7
Clinical Commentary by Jeff Belden, MD, at http://www.fpin.org.
1. Burton MJ, Towler B, Glasziou P. Cochrane Database of Systematic Reviews, Issue 2, 2001. Oxford, England: Update Software.
2. Paradise JL, Bluestone CD, Bachman RZ, et al. N Engl J Med 1984;310:674-83.
3. Paradise JL, Bluestone CD, Rogers KD, et al. Pediatr Res 1992;31:126A.-
4. Bisno AL, Gerber MA, Gwaltney JM, Jr, et al [abstract]. Clin Infect Dis 1997;25:574-83.
5. American Academy of Pediatrics. Pediatrics 1994;94:766-73.
6. Paradise JL, Bluestone CD, Colborn DK, et al. JAMA 1999;282:945-53.
7. Scottish Intercollegiate Guidelines Network, Scottish Cancer Therapy Network. SIGN publication no. 34; January 1999.
Tonsillectomy with or without adenoidectomy is minimally effective when combined with tympanostomy tube placement in preventing recurrent otitis media in the 3 years following surgery. The risks of surgery must be weighed against potential benefit. (Grade of recommendation: B, based on low-quality randomized controlled trials [RCTs]). The evidence supporting tonsillectomy for recurrence of sore throat is controversial.1 There is insufficient evidence to recommend other potential indications (Table). (Grade of recommendation: C, based on case series.)
TABLE
INDICATIONS FOR TONSILLECTOMY
| Potential Indication | Evidence of Effectiveness? | Grade of Recommendation | |
|---|---|---|---|
| Preventing recurrent otitis media in the 3 years following surgery | Yes, small effect size | B (RCTs, case series) | |
| Preventing recurrent sore throat caused by tonsillitis | No | B (systematic review of flawed RCTs) | |
| Preventing recurrent peritonsillar abscess | No | C (case series, consensus statements) | |
| Treating sleep apnea in children | No | C (case series2) | |
| Treating IgA nephropathy | No | C (case series) | |
| Treating guttate psoriasis | No | C (case series3) | |
| Treating nocturnal enuresis | No | C (case series) | |
| IgA denotes immunoglobulin A; RCTs, randomized controlled trials. | |||
Evidence summary
Cochrane: “There is no evidence from randomized controlled trials to guide the clinician in formulating the indications for surgery in adults or children.”1 The few existing trials are complicated by differences in treatment and control groups at baseline and by differential complication rates in groups receiving tonsillectomy or adenotonsillectomy. For example, 2 RCTs showed minimal effect at 1 year and no effect at 3 years of follow-up in preventing recurrent sore throat.2,3 However, 1 of these could not be critically appraised because it was published in abstract format only.
Two other trials of tonsillectomy and adenotonsillectomy in children, both with and without tympanostomy tube placement, have shown a small, brief reduction in episodes of recurrent otitis.4-6 In the largest study,6 controls had a mean of 2.1 episodes of recurrent otitis media in the first postoperative year while those undergoing adenotonsillectomy had had 1.8 episodes (P= .25) and those undergoing adenoidectomy had 1.4 episodes (P< .001). However, these benefits did not persist beyond the first year. Several case series report no evidence of effectiveness of tonsillectomy for immunoglobulin A (IgA) nephropathy, psoriasis, or nocturnal enuresis.
Recommendations from others
The Infectious Diseases Society of America states: “Surgical removal of the tonsils may be considered for the rare patient whose symptomatic episodes [of strep pharyngitis] do not diminish in frequency over time and for whom no alternative explanation for the recurrent pharyngitis is evident. Tonsillectomy may decrease recurrences of symptomatic pharyngitis in selected patients, but only for a limited period of time.”4
The American Academy of Pediatrics position is as follows: “Tonsillectomy, either alone or with adenoidectomy, has not been found effective for treatment of otitis media with effusion.”5 The Scottish Intercollegiate Guidelines Network (SIGN): “The following are recommended as reasonable indications for consideration of tonsillectomy in both children and adults, based on the current level of knowledge, clinical observation in the field and the results of clinical audit.” According to SIGN, patients should meet all these criteria: sore throats are caused by tonsillitis; 5 or more episodes of sore throat per year; symptoms have lasted for at least 1 year; and the episodes of sore throat “are disabling and prevent normal functioning.”7
Clinical Commentary by Jeff Belden, MD, at http://www.fpin.org.
Tonsillectomy with or without adenoidectomy is minimally effective when combined with tympanostomy tube placement in preventing recurrent otitis media in the 3 years following surgery. The risks of surgery must be weighed against potential benefit. (Grade of recommendation: B, based on low-quality randomized controlled trials [RCTs]). The evidence supporting tonsillectomy for recurrence of sore throat is controversial.1 There is insufficient evidence to recommend other potential indications (Table). (Grade of recommendation: C, based on case series.)
TABLE
INDICATIONS FOR TONSILLECTOMY
| Potential Indication | Evidence of Effectiveness? | Grade of Recommendation | |
|---|---|---|---|
| Preventing recurrent otitis media in the 3 years following surgery | Yes, small effect size | B (RCTs, case series) | |
| Preventing recurrent sore throat caused by tonsillitis | No | B (systematic review of flawed RCTs) | |
| Preventing recurrent peritonsillar abscess | No | C (case series, consensus statements) | |
| Treating sleep apnea in children | No | C (case series2) | |
| Treating IgA nephropathy | No | C (case series) | |
| Treating guttate psoriasis | No | C (case series3) | |
| Treating nocturnal enuresis | No | C (case series) | |
| IgA denotes immunoglobulin A; RCTs, randomized controlled trials. | |||
Evidence summary
Cochrane: “There is no evidence from randomized controlled trials to guide the clinician in formulating the indications for surgery in adults or children.”1 The few existing trials are complicated by differences in treatment and control groups at baseline and by differential complication rates in groups receiving tonsillectomy or adenotonsillectomy. For example, 2 RCTs showed minimal effect at 1 year and no effect at 3 years of follow-up in preventing recurrent sore throat.2,3 However, 1 of these could not be critically appraised because it was published in abstract format only.
Two other trials of tonsillectomy and adenotonsillectomy in children, both with and without tympanostomy tube placement, have shown a small, brief reduction in episodes of recurrent otitis.4-6 In the largest study,6 controls had a mean of 2.1 episodes of recurrent otitis media in the first postoperative year while those undergoing adenotonsillectomy had had 1.8 episodes (P= .25) and those undergoing adenoidectomy had 1.4 episodes (P< .001). However, these benefits did not persist beyond the first year. Several case series report no evidence of effectiveness of tonsillectomy for immunoglobulin A (IgA) nephropathy, psoriasis, or nocturnal enuresis.
Recommendations from others
The Infectious Diseases Society of America states: “Surgical removal of the tonsils may be considered for the rare patient whose symptomatic episodes [of strep pharyngitis] do not diminish in frequency over time and for whom no alternative explanation for the recurrent pharyngitis is evident. Tonsillectomy may decrease recurrences of symptomatic pharyngitis in selected patients, but only for a limited period of time.”4
The American Academy of Pediatrics position is as follows: “Tonsillectomy, either alone or with adenoidectomy, has not been found effective for treatment of otitis media with effusion.”5 The Scottish Intercollegiate Guidelines Network (SIGN): “The following are recommended as reasonable indications for consideration of tonsillectomy in both children and adults, based on the current level of knowledge, clinical observation in the field and the results of clinical audit.” According to SIGN, patients should meet all these criteria: sore throats are caused by tonsillitis; 5 or more episodes of sore throat per year; symptoms have lasted for at least 1 year; and the episodes of sore throat “are disabling and prevent normal functioning.”7
Clinical Commentary by Jeff Belden, MD, at http://www.fpin.org.
1. Burton MJ, Towler B, Glasziou P. Cochrane Database of Systematic Reviews, Issue 2, 2001. Oxford, England: Update Software.
2. Paradise JL, Bluestone CD, Bachman RZ, et al. N Engl J Med 1984;310:674-83.
3. Paradise JL, Bluestone CD, Rogers KD, et al. Pediatr Res 1992;31:126A.-
4. Bisno AL, Gerber MA, Gwaltney JM, Jr, et al [abstract]. Clin Infect Dis 1997;25:574-83.
5. American Academy of Pediatrics. Pediatrics 1994;94:766-73.
6. Paradise JL, Bluestone CD, Colborn DK, et al. JAMA 1999;282:945-53.
7. Scottish Intercollegiate Guidelines Network, Scottish Cancer Therapy Network. SIGN publication no. 34; January 1999.
1. Burton MJ, Towler B, Glasziou P. Cochrane Database of Systematic Reviews, Issue 2, 2001. Oxford, England: Update Software.
2. Paradise JL, Bluestone CD, Bachman RZ, et al. N Engl J Med 1984;310:674-83.
3. Paradise JL, Bluestone CD, Rogers KD, et al. Pediatr Res 1992;31:126A.-
4. Bisno AL, Gerber MA, Gwaltney JM, Jr, et al [abstract]. Clin Infect Dis 1997;25:574-83.
5. American Academy of Pediatrics. Pediatrics 1994;94:766-73.
6. Paradise JL, Bluestone CD, Colborn DK, et al. JAMA 1999;282:945-53.
7. Scottish Intercollegiate Guidelines Network, Scottish Cancer Therapy Network. SIGN publication no. 34; January 1999.
Evidence-based answers from the Family Physicians Inquiries Network