Evidence-based medical care has become the clarion for safe and improved clinical intervention. However, limited access to services for children and adolescents with behavioral problems or mental illness often leads to inadequate care and treatment based on insufficient scientific evidence of safety and effectiveness.
The findings are contained in a report released today by the American Psychological Association (APA) .
According to the report, a product of the APA Working Group on Psychotropic Medications for Children and Adolescents, gaps in the scientific knowledge concerning which treatments work best for specific diagnoses and patients, a dearth of clinicians specifically trained to work with children, cuts in Medicaid funding, and poor reimbursement for mental health services leads to many children being treated with medication despite limited efficacy and safety for their use particularly with children.
Research published earlier this year showed a five-fold increase in the use of antipsychotic drugs to treat behavioral and emotional problems in children and adolescents from 1993 to 2002.
“This entire state of affairs is in part related to our health care system’s failure to provide sufficiently for children, particularly in the area of pediatric mental health care,” states Ronald T. Brown, PhD, chair of the APA Working Group and Professor of Public Health and Dean at Temple University. “As a result, much of the care provided to children for mental health issues has been limited to medication even though many psychosocial treatments have been found to be effective and some with better risk profiles. Psychosocial treatments, however, can be more labor intensive and more expensive.”
The Working Group’s report identifies and calls attention to several “notable gaps” in the knowledge base upon which psychotropics are currently being prescribed, including anti-depressants and anti-psychotics. The report furthermore notes that existing evidence for both psychosocial and psychopharmacologcial treatments are “uneven across disorders, age groups, and other defining characteristics of race, ethnicity, and socioeconomic status”.
“Furthermore,” the report states, “data are lacking concerning the long-term effects of the majority of treatments, both psychosocial and psychopharmacological, as well as their effects on functional outcomes” such as academic achievement and peer relationships.
Finally, the report notes that the lack of availability of all pharmaceutical data on psychotropics and their effects prevents the news media and the public from a full understanding of which treatments work, which do not, and the possible adverse side effects of some medications.
Among its recommendations, the report calls for:
• 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 as well as optimal doses and combinations of psychosocial and psychopharmacological treatments.
• Research on the role of families, school, 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 that are associated with treatment adherence.
• Increased collaboration across federal funding agencies involved in child treatment research, including National Institutes of Mental Health, National Institute of Child Health and Human Development, National Institutes of Natural Sciences, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, the Substance Abuse and Mental Health Services Administration and Institute for Education Science.
• Public disclosure of all efficacy and safety data emanating from both psychosocial and psychopharmacological treatment research on child and adolescent disorders.
• An emphasis on evidence-based child treatments, including psychosocial and psychopharmacological interventions in the training and continuing education of all mental health providers.
“Systematic reimbursement for evidence-based psychosocial and psychopharmacological treatments must be established,” the report concludes. “Current funding and administrative mechanisms often encourage the use of medication or non-evidence based psychosocial treatments over empirically based psychosocial treatments. Finally, mental health services for youth are provided across a number of different service sectors, either simultaneously or sequentially, and collaborative care is often hampered by cost, discipline, and administrative barriers.”
Best treatment depends on diagnosis and balances risks and benefits
In addition to the aforementioned global needs for an evidence base, appropriately trained providers and good access to care, the Working Group looked at the evidentiary base for numerous treatments currently in use for children and adolescents with behavioral and mental health problems.
The report recommends that decisions about first line of treatment options should be guided by the need to balance the anticipated benefits of the treatment with its possible harms, including the absence of treatment. Safer treatments with demonstrated efficacy should be considered first before any use of other treatments with less favorable risk profiles.
This diagnosis-by-diagnosis review of the literature reached a general conclusion that much more research is needed, as well as a few specific conclusions – pending further research – about current treatment practices for each illness:
Attention Deficit Hyperactivity Disorder — Behavioral treatments, psychopharmacological treatments, and a combination of the two all have solid evidence for acute efficacy. Behavioral treatments have the most favorable risk:benefit ratio, suggesting they be first line interventions. Combining behaviorally based treatments with medication can yield better short-term outcomes than either treatment alone and the combination enables lower doses of medication to be used.
Oppositional Defiant Disorder and Conduct Disorder – Based on evidence showing better results with psychosocial interventions, such interventions should be the first line treatment and tried before psychotropic medications.
Tourettes and Tic Disorders – Drug treatment should be used cautiously due to safety and tolerability issues. If medications are used, keep doses low to decrease the risks of adverse side effects and use in combination with behavioral treatments such as habit reversal training (HRT).
Obsessive Compulsive Disorder — Evidence supports the use of cognitive behavioral therapy as the first line treatment. Medication should be added only if necessary.
Anxiety Disorders – There is strong evidence to support cognitive behavioral therapy (CBT) as a first line treatment and CBT does not pose the risks that some medication treatments do. However, treatment with SSRI medication is also a viable choice for children who are unable to engage in CBT or do not show improvement during such treatment.
Depression/Suicidailty – A treatment strategy designed to minimize risks would involve sequential use of psychosocial interventions and close monitoring, followed by medication (fluoxetine is the only medication approved by the FDA for treating depression in children) for those children and adolescents who do not respond to psychosocial treatments. If a child is to be treated with medication, his or her parents must be fully informed of the potential risks and benefits.
Bipolar Disorder – Both psychosocial and psychopharmacologic treatments for bipolar disorder require more study. The limited research suggests psychosocial treatments are beneficial and do not present adverse side-effects. Short- and long-term medication trials are needed to clarify the risk:benefit ratio for all medications used to treat bipolar disorder.
Schizophrenia Spectrum Disorders – These disorders are rare in children and adolescents; empirical evidence of how best to treat these disorders in young people is also very limited. However, based on the little research that does exist, psychosocial interventions that are psychoeducational, family-based, and cognitive-behavioral are suggested. Newer pharmacologic agents hold promise but also carry the risk of adverse side-effects.
Anorexia Nervosa and Bulimia Nervosa – For anorexia nervosa, there is a general lack of evidence of effectiveness for both the psychosocial interventions as well as the pharmacologic interventions currently in use. For bulimia nervosa, psychosocial interventions, particularly CBT, appear to have more scientific support and a more favorable risk:benefit ratio compared with medications. Future research needs to be done to determine the effectiveness of specific forms of treatments or treatment combinations.
Elimination Disorders – The efficacy of behavioral treatments, such as the use of a urine alarm, is well documented in the research literature. There is little or no evidence of the effectiveness of drug treatments for elimination disorders; there is concern about the safety of such medication based treatments. Because elimination disorders often have some kind of physiological foundation, mental health practitioners should partner with a pediatrician when assessing and managing enuresis and encopresis.
Full text of the article is available from the APA Public Affairs Office or at http://www.apa.org/releases/PsychotropicMedicationsReport.pdf