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SCRAPING FOR EVIDENCE

January 1, 2007
by RONALD T. BROWN, PHD
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We have little evidence of the safety and effectiveness of mental health treatments for children

Limited access to mental healthcare, often based on inadequate empirical evidence, leads to inferior care for too many children and adolescents. This dilemma has reached a critical juncture, and the situation must improve or an entire generation of children is at risk of having unmet mental health needs, especially minority children and those from lower-income families (who often have more difficult access issues).

In its final report in August 2006, the American Psychological Association Working Group on Psychotropic Medications for Children and Adolescents (which I chaired) cited many reasons for the current crisis in children's mental healthcare.1 Among them were specific gaps in the evidence base for children's mental health treatments, cuts in Medicaid funding, poor reimbursement for mental health services, and the dearth of clinicians specifically trained to work with children. These limitations and deficiencies have led to the use of interventions (including medications) for which we have insufficient knowledge about efficacy and safety.

Too often writing a prescription has been the easiest or the only available treatment course for a child who presents with an emotional or mental health problem. But data on the safety and effectiveness of psychotropic medication use in children are lacking. For example, despite the paucity of efficacy and safety data on treating children with antipsychotic medications, there was a six-fold increase in the use of antipsychotics to treat children between 1993 and 2002.2 Therefore, questions about these drugs' long-term effects on developing brains have become even more critical.

The working group's report calls for increased use of treatments for children that are based on solid scientific evidence. It also emphasizes the need to balance a treatment's benefits with its potential risks. As many psychosocial treatments have been found to be effective and have better risk profiles than most medications, the working group called for an emphasis on these types of treatments.

Yet the working group found that existing evidence for most mental health treatments for children, both psychosocial and psychopharmacologic, is uneven across disorders, age groups, race, ethnicity, and socioeconomic status. It found that more needs to be known about the interplay of treatment with school and family dynamics, and the effects of treatments on the functional outcomes of academic achievement and peer relationships.

To provide children with more evidence-based care in the long run, the working group recommends:

  • longitudinal studies of treatment efficacy and effectiveness for specific disorders (childhood depression, preschool and adolescent ADHD, adolescent autism, etc.) in terms of targeted symptoms, functional impairments, adaptive functioning, and quality of life across gender, age, racial, and ethnic groups, and for children with comorbid disorders;

  • research to determine the optimal sequencing of treatment components and optimal doses and combinations of psychosocial and psychopharmacologic treatments;

  • research on the role of families, schools, and primary care providers in the development and delivery of mental health services for children, the moderators and mediators of treatment effects, and the factors associated with treatment adherence;

  • increased collaboration across federal agencies involved in or funding child treatment research;

  • public disclosure of all efficacy and safety data from both psychosocial and psychopharmacologic treatment research on child and adolescent disorders; and

  • an emphasis on evidence-based child treatments, including psychosocial and psychopharmacologic interventions, in the training and continuing education of all mental health providers.

In short, the level of psychotropic medication use among children and adolescents exceeds the data available with regard to the safety and efficacy of these medications. In part, the dilemma that we find ourselves in is related to the healthcare crisis in this country, and particularly the generally poor access to psychosocial treatments.

Ronald T. Brown, PhD, is a Professor of Public Health and Dean at Temple University. He served as the Chair of the American Psychological Association Working Group on Psychotropic Medications for Children and Adolescents.

References

  1. American Psychological Association Working Group on Psychoactive Medications for Children and Adolescents. Report of the Working Group on Psychoactive Medications for Children and Adolescents. Psychopharmacological, psychosocial, and combined interventions for childhood disorders: Evidence base, contextual factors, and future directions. Washington, D.C.: American Psychological Association; 2006. Available at: http://www.apa.org/releases/Psycho tropicMedicationsReport.pdf.
  2. Olfson M, Blanco C, Liu L, et al. National trends in the outpatient treatment of children and adolescents with antipsychotic drugs. Arch Gen Psychiatry 2006; 63:679–85.
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