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Heather Howard's Subject Files
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3/20 HRCasked Chirs about
bylanten
? epiaysy?
pletiminary -poles chricusion of There players redebate
meeting in time planned
4 pharmaceuticals
Kaiser Perm - mc
notal helps
ins.co. prouding aly . reponsent providers
mental health have
-Insures b/c don't do mental helt
pharcell phar cell
of Beachy t
plan mty of
insurers pharmacists- - action , neh. community me phonnacied
Form sectors
my
1
Jeanne Ireland
224-2831
SG's contact
disparity in
winentioned J charge of pritalic -
Judy Human-
-
4/17
Diane laVoy /
Chilat adolescent Bipolar
Foundatia
hasn't jet heard from Beverly
malare
want to be inited & your
(301)773-6887
Caference
spike of her- - ok not to include
hu IT conference
- she's maintainsled in
Ritalin conference
told her 0 had happened you
Bernard Arons <[email protected]>
03/28/2000 05:59:36 PM
Record Type:
Record
To:
Heather H. Howard/OPD/EOP
CC:
Subject: Children's Mental Health Services Grants
As indicated in our phone conversation, I wanted to share some information about some of our activities.
I'll be happy to provide more if desired.
Bernie Arons
- Nychild.wpd
Center for Mental Health Services (CMHS)
Programs for Children in New York
The Center for Mental Health Services, Substance Abuse and Mental Health Services
Administration, DHHS, provides national leadership in the application of mental health services
research. CMHS activities are designed to improve access and reduce barriers to high-quality
services for people with, or at risk for, serious mental illness, as well as their families and
communities. An important priority at CMHS is to improve services for children with serious
emotional disturbance, to help these children recover or manage their illnesses and build
healthy and productive lives. Another priority is to engage schools and communities in the
effort to reach children with best practices for fostering resilience and preventing violence. The
three major CMHS programs designed to enhance services for children are listed below.
Following these descriptions are program sites funded in New York.
Comprehensive Community Mental Health Services for Children & their Families
Program was designed to expand community service capacity for children with serious
emotional disturbance and their families. Through individualized case planning and
coordination, the Program enables communities to integrate child and family-serving
agencies (such as health, mental health, substance abuse treatment, child welfare,
education, and juvenile justice) into a community-based system of care, while at the
same time involving families in developing and supporting care for their children.
School and Community Action Grant Program was initiated in response to President
Clinton's Call to Action at the 1998 White House Conference on School Safety. This
Program engages community-based organizations in promoting healthy development,
enhancing resilience, and preventing violence, substance abuse, and suicide. The
target population includes preschool and school-aged children and adolescents, and
their families who are at risk of becoming perpetrators, victims, or witnesses of violence.
Grant activities are designed to adopt and adapt evidence-based exemplary practices
for use within and outside schools.
Safe Schools/Healthy Students Initiative is an interDepartmental initiative to address
the
the problem of youth violence. CMHS is collaborating with the Safe and Drug-free
Schools Program in the Department of Education and the Department of Justice to
develop and implement a large grant program, the Safe Schools/Healthy Students
Initiative. Grants have been awarded to 54 local education authorities with formal
partnerships with local mental health and law enforcement agencies. These
partnerships have developed and are implementing comprehensive plans to promote
healthy development, fostering resilience in the face of adversity, and preventing
violence. The plans cover six areas: school safety; alcohol and other drugs and
violence prevention/early intervention programs; school and community mental health
promotion and treatment services; early childhood psychosocial and emotional
development programs; educational reform; and safe school policies.
Programs for Children in New York
Comprehensive Community Mental Health Services for Children & their Families
Program
Westchester County Department of Community Mental Health: The
Westchester Community Network
The five-year Westchester Community Network initiative began in October 1999 with a
goal of developing, implementing and evaluating a family-driven system of care for
children with serious social, emotional, and behavioral difficulties. The Westchester
Community Network will integrate every major service sector in developing a range of
service delivery options, including family resource centers, addition of a mobile clinical
case management team, new and expanded respite opportunities, in-home family
preservation services, wraparound services for juvenile sex offenders and fire setters,
as well as peer and vocational support for youth. Westchester County will unite in
efforts to reduce duplication, streamline county processes, promote coordinated
planning, and develop local community assets. The county also will establish a
partnership with the state in order to sustain the activities under the grant through the
development of a blended funding model through the Children's Special Needs Plan.
The evaluation plan is a longitudinal assessment of the experience of youth and their
families, supplemented by information from program directors and service providers, as
well as from service contact data for children served by the Initiative.
Mott Haven, New York: Families Reaching in Ever New Directions
(FRIENDS)
Mott Haven's Families Reaching in Ever New Directions (FRIENDS) received funding
from CMHS from November 1994 - October 1999. The project has been extended
through a one-year, no-cost extension, ending October 31, 2000. The goal is to
implement a family-driven, integrated system of care to meet the mental health needs
of children with serious emotional disorders and their families. The New York City
Department of Mental Health, the New York City Department of Probation, the New
York City Board of Education, and the New York City Administration for Children
Services have participated in the project. FRIENDS also has involved families in
assisting in everything from developing interagency structure to helping collect data for
national and local evaluation efforts.
School and Community Action Grant Program
Buffalo, New York: Catholic Charities
Catholic Charities, in collaboration with Niagara County Department of Social Services,
Juvenile Probation, and Niagara County schools have engaged in building community
collaboration and consensus to pilot Multisystemic Therapy. The target population is 50
high-risk youth ages 7-11 with the following breakdown: 50% Caucasian, 40% African
American, and 10% Native American. The stakeholders group include the school
superintendent, several service providers from child serving agencies, housing
authority, probation department, police department, health center, department of social
services, special education, and a foster parent. They plan to implement Multisystemic
Therapy starting October 2000 and are actively looking for ways to sustain it.
Cheektowaga, New York: Community Action Partnership
The Community Action Partnership is the lead agency and is actively building
community collaboration with several other local agencies, including the Cheektowaga-
Sloan School District and various community based organizations known as the Family
Services Network. They plan to implement Functional Family, a short term, easily
trainable, well-document program which has been applied successfully to a wide range
of high-risk youth and their families in various contexts, rural, urban, multicultural,
international. Functional Family Therapy involves specific phases and techniques
designed to engage and motivate youth and families, and especially deal with the
intense negative affect (hopelessness, anger) that prevents change.
*
Mastic Beach, New York: William Floyd School District
The William Floyd School District, locates 70 miles east of New York City,
and partnering agencies has been building community support for the implementation
of FAST - Families and Schools Together with elementary children and their families.
Of note, the school district have helped to form a community council of parents and
plans to hire a parent to work on this project. This project has the personal support of
the school superintendent among others.
*
New York, New York: Inwood Community Services, Inc.
Inwood Community Services has been working with IS 52, a middle
school next door, that they have had a relationship with for 16 years to identify 8th
graders who are high-risk for services. The proposed evidence-based practice is
Quantum Opportunities Program. The target population is largely Spanish speaking
and originally form the Dominican Republic. Quantum Opportunities directly address
the problem of dropping out of high school by providing life and academic skills training.
High school participants will receive financial incentives to work in day camps or at
innovative programs of the applicant's local partner agencies.
New York, New York: Isaacs Neighborhood Center
The Isaccs Neighborhood Center is actively engaged in a community
collaboration process to gather support for the implementation of Quit It, a bullying
prevention program. Quit It is a school-wide model directed towards all adults that have
an impact on children in a school setting such as administrators, teachers, guidance
counselors, paraprofessionals, school aides, family workers, and parents. The
implementation of Quit It includes a needs assessment, teacher development, training
for paraprofessionals, family workers, and school aides, parent workshops, pro-social
curriculum implementation, ongoing teacher and parent discussion groups, and
consistent school wide policy on teasing and bullying. The target population are
children ages 5-14.
Poughkeepsie, New York: Mental Health Association, Dutchess
County
County Executive William Steinhaus and Congresswoman Sue Kelly
jointly announced that the Mental Health Association in Dutchess County had received
a grant from SAMHSA to pilot FAST, a program promoting violence prevention and
resilience enhancement among elementary school aged children. Mr. Steinhaus stated
that the pilot program will eventually be replicated throughout Dutchess County, in
urban, suburban, and rural settings. A total of 40-60 families will be enrolled in the
project to bridge the gap between family, school, and children through better
communication and bonding.
Rochester, New York: Primary Mental Health Project Inc.
The Primary Mental Health Project Inc., has been engaged in an intensive
community-wide collaboration. They will pilot the Primary Mental Health Project, a
school-based prevention program, to serve 1st-3rd grade children in two urban
elementary schools, Rochester City School District No. 9 and No. 34. They have
conducted a needs assessment and the support of key stakeholders in the two schools
(parents, administrators, teachers, school mental health professionals) has been
attained. Their implementation and evaluation plan, which includes randomizing
children to the intervention and the wait-control is quite impressive. The Project
Director, Dr. Peter Wyman, is a nationally recognized figure in the field of youth
violence prevention.
Safe Schools/Healthy Students Initiative
Auburn, New York:
This upstate Cayuga County suburban and rural area of the Finger Lakes is a
partnership between the Auburn Enlarged School District, the Cayuga County Health
and Human Services Department and the Auburn (includes county Mental Health
Center) and Port Byron Police Department. The first year grant for $1.8 million will
provide: prenatal and post-partum home visits by nurses and clinical social workers to
75 high-risk families; for school-aged children training on the relationship between
mental health, substance abuse, and violence in families; expanded after-school and
weekend programs; and other appropriate interventions.
Westbury, New York:
This is a partnership between the Board of Cooperative Educational Services of
Nassau County, the South Shore Child Guidance Center and North Shore Child and
Family Guidance Center, and, the Freeport and Westbury Police Departments. Annual
funds of over $500,000 will support comprehensive programs and integrated community
linkages to promote psychosocial and emotional development through an early
childhood program; early intervention and prevention programs and workshops; and a
comprehensive review of safe school policies.
Yonkers, New York:
Over $1.8 million will support partnership activities by the Yonkers City Public
Schools, the County and City Mental Health Department and the Yonkers Police
Department. A comprehensive network, maintained by a multi disciplinary advisory
council. Will provide a continuum of integrated services to meet the developmental
needs of, and enhance resiliency factors in, children through young adulthood. Among
many thrusts the project will replicate a pilot mental health program in at least one high
school.
New SS/HS grants are expected to be announced soon for Dobbs Ferry
($900,000) and Ozone Park ($2.7 million). These grants will provide an impressive
array of initiative services in similar partnerships between the school district, the local
public mental health agency and the local law enforcement agency.
Ann O'Leary
03/22/2000 04:35:35 PM
Record Type:
Record
To:
Christopher C. Jennings/OPD/EOP@EOP, Devorah R. Adler/OPD/EOP@EOP, Trooper
Sanders/OVP@OVP
CC:
Heather H. Howard/OPD/EOP@EOP
Subject: Conference on kids' psych meds
Diane La Voy is an old friend of HRC. She is one of the founders of a new organization, the Child and
Adolescent Bipolar Foundation. If we have follow-up meetings, we should include her. I have also asked
her to contact the SGs office to get involved in the conference.
Forwarded by Ann O'Leary/OPD/EOP on 03/22/2000 04:33 PM
Diane La Voy <[email protected]>
03/20/2000 10:59:48 PM
Record Type:
Record
To:
Ann O'Leary/OPD/EOP
CC:
Subject: Conference on kids' psych meds
Ann,
Following up our conversation, here's a little background on the Child
and Adolescent Bipolar Foundation, whose website is www.bpkids.org.(I'II
try to attach home page below.)
CABF is a new web-based membership organization that informs and
supports families and the professionals treating kids with bipolar
disorder, and advocates for better diagnosis and treatment. We bring
together some of the top people in the field of researching and treating
bipolar disorder in kids, and over 500 families of kids with this
disorder who regularly support each other through electronic lists. Our
Board of Directors, a working board, which actually leads our program
activities, includes leading researchers such as Demitri Papolos and
Barbara Geller, and our Professional Advisory Board, which also actively
supports our program, includes 14 leaders in the field, including Dr.
Kay Redfield Jamison. Our website, which is only two months old, has
already served about two million pages of authoritative information and
support, and has attracted nearly 2000 subscribers to our on-line
newsletter.
I was very glad to learn from you that the NYT article overstated the
conference organizers' concern about "curbing" the use of medications,
and that the concern is centrally on the need for proper diagnosis.
We are especially concerned that sloppy diagnosis is causing many kids
with bpd to be treated as ADHD, and Ritalin is harmful to children with
bipolar disorder. A recent study by Dr. Joseph Biederman of Harvard
found that 20% of kids who are diagnosed as ADHD have the necessary
symptoms for bipolar. Unfortunately, many of them are not given a
proper diagnosis. Those who have bipolar are likely to get much worse,
even psychotic, when taking Ritalin.
We know that those kids who are bipolar must receive mood stabilizers
such as lithium or depakote, and the earlier the better, as well as
other therapy that may be needed. We're very concerned when the topic
is discussed in terms of curbing, the use of drugs, rather than in
terms of proper diagnosis. Most families of children with serious
brain disorders such as bpd find it very hard to obtain affordable
health services as it is.
We agree that there,s a huge need for more research, and as parents
we're painfully aware that none of the drugs we're giving our kids have
been specifically tested for psychiatric use in children. But we
disagree with a statement in today's NYT article in which Dr. Joseph
Coyle of Harvard is quoted as saying, in an AMA journal editorial, that
there,s "no empirical evidence, to support the use of psychotropic drug
treatment in very young children. With regard to bipolar disorder,
there is a vast amount of annecdotal evidence coming from doctors and
families around the country showing that the use of mood stabilizers can
be effective in the treatment of very young children with bipolar
disorders.
Thank you for offering to put me in touch with the right person(s) in
the Surgeon General's Office, which will be organizing the conference
this fall on the diagnosis and treatment of mental illness in young
children.
We would like to assist as appropriate in its planning. As I mentioned,
Dr. Steven Hyman has asked us to participate in a symposium that NIMH is
holding next month (April 25, Chicago) on research needs to address
children with neurobiological disorders. We believe that we can bring
both scientific expertise and the vast experience of our members to the
policy process that Mrs. Clinton has announced.
Thanks again.
Diane La Voy
CABF Teams Coordinator
and Washington Liaison
(301) 773-6887
-
www.bpkids.org
C
Ann O'Leary
03/28/2000 02:34:36 PM
Record Type:
Record
To:
Heather H. Howard/OPD/EOP@EOP
CC:
Subject: Children's Meds. Follow-up
could you please follow-up? thanks.
Forwarded by Ann O'Leary/OPD/EOP on 03/28/2000 02:34 PM
Trooper Sanders@OVP
03/21/2000 11:07
Record Type:
Record
To:
Ann O'Leary/OPD/EOP@EOP
CC:
Subject: Children's Meds. Follow-up
When you get a chance, would you mind calling Dr. Bernie Arons, director of the Center for Mental Health
Services at HHS? He says CMHS is working on a number of children's mental health programs in the field
that are relevant to the children's med. issue. He'd like to make sure you and your office are aware of it.
Mrs. Gore relies heavily on Bernie and he is a really great guy to bring into any follow-up work.
His number is 301/443-0001.
Thank you!
Card
Ann O'Leary
03/28/2000 02:35:36 PM
Record Type:
Record
To:
Trooper Sanders/OVP@OVP
CC:
Heather H. Howard/OPD/EOP@EOP
bcc:
Subject: Re: Bernie Arons
My apologies - I have not. Heather Howard from our staff is going to take the lead on follow-up to Ritalin.
I've asked her to give him a buzz.
Trooper Sanders@OVP
Trooper Sanders @ OVP
03/27/2000 10:41
Record Type:
Record
To:
Ann O'Leary/OPD/EOP@EOP
CC:
Subject: Bernie Arons
Have you had a chance to talk to Bernie Arons at the Center for Mental Health Services re: children's
psych. meds? Thanks.
C
Devorah R. Adler
03/24/2000 11:51:23 AM
Record Type:
Record
To:
Heather H. Howard/OPD/EOP@EOP
CC:
bcc:
Subject: Re: SG's Fall Conference on Children with Behavioral
Beverly Malone. 690-7694
Heather H. Howard
C
Heather H. Howard
03/24/2000 11:50:09 AM
Record Type:
Record
To:
Devorah R. Adler/OPD/EOP@EOP
CC:
Subject: SG's Fall Conference on Children with Behavioral
do you know if there is a contact in the SG's office to whom we can refer people who want to be involved
with the conference?
Salon News I First Lady urges Ritalin caution
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March 20, 2000 I WASHINGTON -- Hillary Rodham Clinton
was launching a White House effort Monday to caution
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The plan -- which reportedly includes new government
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Questions and Answers:
Treatment of Children with Mental Disorders
behavioral or emotional disturbance.
hyperactivity, or social withdrawal, to the
A Note to Parents
Perhaps the most studied, diagnosed, and
attention of the doctor.
There has been recent public concern over
treated childhood-onset mental disorder is
reports that very young children are being
attention deficit hyperactivity disorder
Q: How do I know if my child's
prescribed psychotropic medications.
(ADHD). but even with this disorder there
problems are serious?
Some parents are criticized for giving their
is a need for further research in very
children these medications, while others
young children. Every decision about
A: Many everyday stresses cause changes
are criticized for not doing SO. The studies
treatment should be weighed for risk and
in behavior. The birth of a sibling may
to date are incomplete, and much more
benefit, and each child should be viewed
cause a child to temporarily act much
needs to be learned about young children
individually.
younger. It is important to recognize such
who are treated with medications for all
behavior changes, but also to differentiate
kinds of illnesses. In the field of mental
them from signs of more serious prob-
health, new studies are needed to tell us
Questions and Answers
lems. Problems deserve attention when
what the best treatments are for children
they are severe, persistent. and impact on
with emotional and behavioral
Q: What should I do if I am concerned
daily activities. Seek help for your child if
disturbances. For medications, we must
about mental, behavioral, or
you observe persistent problems such as
also make sure that there are no negative
emotional symptoms in my young
sleep disturbances, changes in appetite,
consequences for the developing brain.
child?
social withdrawal, or fearfulness:
behavior that slips back to an earlier
While there has been progress made in
A: Talk to your child's doctor. Ask
phase such as bed werring; signs of
diagnosing the mental illnesses that begin
distress such as sadness or tearfulness;
questions and find out everything you can
in childhood. children are in a state of
about the behavior or symptoms that
self-destructive behavior such as head
rapid change and growth. and diagnosis
wony you. Every child is different and
banging; or a tendency to have frequent
and treatment of mental disorders must be
even normal development varies from
injuries. In addition, it is essential to
viewed with this in mind. While some
child to child. Sensory processing.
review the development of your child, any
problems are short lived. others are
language. and motor skills are developing
important medical problem he/she might
persistent and very serious, and parents
during early childhood, as well as the
have had, family history of mental
should seek ways to help their children.
ability to relate to parents and to socialize
disorders, physical and psychological
with caregivers and other children. If
traumas or situations that may cause
Not long ago, it was thought that many
your child is in daycare or preschool, ask
stress.
brain disorders such as anxiety disorders,
the caretaker or teacher if your child has
depression, and bipolar disorder began
been showing any worrisome changes in
Q: Whom should I consult to help my
only later in life. We now know they can
behavior, and discuss this with the doctor.
child?
begin in childhood. An estimated 6 to 9
Always bring extreme symptoms, such as
million children and adolescents in the
self-injury, impulsive or aggressive
A: First, consult your child's pediatrician.
United States suffer from a serious
Ask for a complete health examination of
behavior, persistent sadness,
PAGE
behave
I domy
behavioral, or emotional symptoms when
deal of research is needed to determine the
your child. Describe the behaviors that
worry you. Ask whether your child needs
the potential benefits of treatment
effects and benefits of medications in
further evaluation by a specialist in child
outweigh the risks. Some problems are SO
children of all ages. It is important to
severe and persistent that they would
remember that serious untreated mental
behavioral problems. Parents may be
faced with a patchwork of providers.
have serious negative consequences for
disorders themselves negatively impact
Ultimately, a variety of specialists
the child If untreated. and psychosocial
brain development.
including physicians, behavioral
interventions may not always be effective
therapists, and educators may be needed
by themselves. The more extreme the
If my preschool child receives a
to help your child.
problems. the more likely it is that
trupy
diagnosis of a psychiatric disorder,
medication will be prescribed. However,
does this mean that medications have
Q: How are mental disorders
the safety and efficacy of most
to be used?
diagnosed in young children?
psychotropic medications have not yet
been studied in young children. As a
A: No. Psychotropic medications are not
A: Most disorders are diagnosed by
parent you will want to ask many
generally the first option for a preschool
observing signs and symptoms. A skilled
questions and evaluate with your doctor
child with a psychiatric disorder. The first
clinician will consider these signs and
the risks of starting and continuing your
goal is to understand (and if possible. to
symptoms in the context of the child's
child on these medications. Learn
remediate) the factors that may be
developmental level. social and physical
everything you can about the medications
contributing to the condition. The child's
environment, and reports from parents
prescribed for your child. including
own physical and emotional state is key,
and other caretakers or teachers. Very
potential side effects. Learn which side
but many other factors such as parental 1
young children often cannot express their
effects are bothersome but tolerable, and
stress or a changing family environment
thoughts and feelings, which makes
which ones are threatening. In addition.
may influence the child's symptoms.
diagnosis a challenging task. The signs of
learn and keep in mind the goals of
a mental disorder in a young child may be
treatment (e.g., change in specific
Q: How should medication be
quite different from those of an older child
behaviors). Although it has become
included in are overall treatment plan?
or an adult.
common practice, combining multiple
psychotropic medications should be
A: When medication is used, it should not
Q: Won't my child just grow out of
avoided in very young children unless
be the only strategy. There are many
such problems?
absolutely necessary. Any medication
services that you may want to investigate
treatment should proceed with careful
to develop a complete treatment plan for
A: Sometimes yes, but in other cases
monitoring of benefits and adverse effects.
your child. Family support services,
educational classes on parenting
children need help. Problems that are
severe, persistent. and impact on daily
Q: Does medication affect young
strategies. behavior management
activities should be brought to the
children differently from older
techniques, as well as family therapy and
attention of the child's doctor. Great care
children or adults?
other approaches should be considered. If
medication is prescribed, it should be
should be taken to help a child who is
suffering. because mental, behavioral, or
A. Yes. Young children's bodies handle
monitored and evaluated closely and
emotional disorders can affect the way the
medications differently than older
regularly.
1
child grows up.
individuals and this has implications for
dosage. The brains of young children are
Q: Which mental disorders are seen in
in a state of very rapid development, and
children?
Q: Are there situations in which it is
advisable to use psychotropic
animal studies have shown that the
developing neurotransmitter systems can
A: Mental disorders with possible onset in
medications in young children?
be very sensitive to medications. A great
childhood include: anxiety disorders;
A: Psychotropic medications may be
prescribed for young children with mental.
1D:3014432578
PAGE
7/10
attention deficit and disruptive behavior
label" Most medications prescribed for
was tested for efficacy by the
disorders; autism and other pervasive
child mental disorders, including many of
pharmaceutical company that developed
developmental disorders; eating disorders
the newer medications that are proving
it, only children age 6 and above were
(e.g., anorexia nervosa); mood disorders
helpful, are prescribed off label, because
involved; therefore, age 6 was established
(e.g. major depression. bipolar disorder):
only a few of them have been
as the lower age limit for Ritalin. There
schizophrenia; and tic disorders. Enuresis
systematically studied for safety and
is no reason to believe that one
and encopresis may be symptoms of a
efficacy in children. Medications that
medication is safer than the other based
mental disorder.
have not undergone such testing are
on differences in FDA approval.
dispensed with the statement that "safety
Q: Can family events such as a death
and efficacy have not been established in
Q: What medications are used for
in the family, illness in a parent,
children."
which kinds of childhood mental
disorders?
onset of poverty, or divorce cause
symptoms?
Q: Why haven't many medications
been tested in children?
A: There are several major categories of
A: Yes. When a tragedy occurs or some
psychotropic medications: stimulants,
extreme suess hits, every member of a
A: In the past. medications were not
antidepressants. antianxiety agents,
family is affected. even the youngest ones.
studied in children because of ethical
antipsychotics, and mood stabilizers. For
This should also be considered when
concerns about involving children in
medications approved by the FDA for use
evaluating mental, emotional, or
clinical trials. However, this created a
in children. dosages depend on body
behavioral symptoms in a child
new ethnical problem: lack of knowledge
weight and age.
about the best treatments for children.
Q: What difference does it make if a
But in clinical settings, medications are
a
Stimulant Medications: There are four
medication is specifically approved for
being prescribed for children at
stimulant medications that are approved
use in children or not?
increasingly early ages. The NIH and the
for use in the treatment of attention
FDA have begun examining the issue of
deficit hyperactivity disorder (ADHD), the
A: The approval of a medication by the
research on medications in young
most common behavioral disorder of
U.S. Food and Drug Administration (FDA)
children. New research approaches are
childhood. These medications have all
allows for doctors to prescribe the
being considered, and progress is being
been extensively studied and are
medication as they feel appropriate. In
made to require such studies when a
specifically Labeled for pediamic use.
some cases there is extensive clinical
medication is undergoing FDA approval.
Children with ADHD exhibit such
experience in using medications for
symptoms as short attention span.
children or adolescents. However,
Q: Does the FDA approve medications
excessive activity. and impulsivity that
everyone agrees that studies in children
for different age groups among
cause substantial impairment in
would be valuable for finding appropriate
children?
functioning. Stimulant medication should
dosages and learning the effects of
be prescribed only after a careful
medications.
A: Yes. For example, Ricalin® is
evaluation to establish the diagnosis of
approved for children age 6 and older.
ADHD and to rule out other disorders or
Q: What does "off-label" use of a
whereas Dexedrine® is approved for
conditions. Medication treatment should
medication mean?
children as young as 3. The lowest age
be administered and monitored in the
for which the FDA approves a given
context of the overall needs of the child
A: Based on clinical experience and
medication is a function of the policies in
and family, and consideration should be
medication knowledge, a physician may
effect at the time of Initial approval and
given to combining it with behavioral
prescribe to children a medication that has
the specific requests of the drug
therapy. If the child is of school age,
been FDA-approved for use only in adults.
manufacturer. Dexedrine is an older
collaboration with teachers is essentíal.
This use of the medication is called "off
medication than Ritalin. When Ritalin®
D:3014432578
PAGE
8/10
FOR
Stimulant Medications
Brand Name
Generic Name
Approved Age (children)
Adderal
amphetamines
3 and older
Cylert
pemoline
6 and older
Dexedrine
dextro-amphetamine
3 and older
Ritalin
methylphenidate
6 and older
Antidepressant and Antianxiety
medications most widely prescribed for
norepinephrine. SSRIs affect mainly
Medications: These medications follow
these disorders are the selective serotonin
serotonin and have been found to be
the stimulant medications in prevalence
reuptake inhibitors (the SSRIs).
effective in treating depression and
among children and adolescents. They
anxiety without as many side effects as
are used for depression. a disorder
In the human brain, there are many
some older anudepressants. The
recognized only in the last twenty years
"neurouransmitters" that affect the way
following are the most commonly
as a problem for children, and for the
we think, feel, and act. Three of these
prescribed medications for children with
anxiety disorders. including obsessive-
neurotransmitters that antidepressants
depression or anxiety disorders (including
compulsive disorder (OCD). The
influence are serotonin, dopamine, and
OCD).
Antidepressant and Antianxiety Medications
Brand Name
Generic Name
Approved Age (children)
Anafranil
clomipramine
10 and older (for OCD)
Effexor
venlafaxine
Luvox (SSRI)
fluvoxamine
8 and older (for OCD)
Paxil (SSRI)
paroxetine
Prozac (SSRI)
fluoxetine
Serzone (SSRI)
nefazodone
Sinequan
doxepin
12 and older
Tofranil
imipramine
6 and older (for bedwetting)
Wellbutrin
bupropion
Zoloft (SSRI)
sertraline
6 and older (for OCD)
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PAGE
9/10
Antipsychotic Medications: These
conduct disorders. Some of the older
antipsychotics, which have fewer side
medications are used to treat children
antipsychotic medications have specific.
effects, are also being used for children.
with schizophrenia, bipolar disorder,
indications and dose guidelines for
Such use requires close monitoring for
autism, Tourette's syndrome, and severe
children. Some of the newer "atypical"
side effects.
Antipsychotic Medications
Brand Name
Generic Name
Approved Age (children)
Clozaril (atypical)
clozapine
Haldol
haloperidol
3 and older
Risperdal (atypical)
risperidone
Seroquel (atypical)
quetiapine
(generic only)
thioridazine
2 and older
Zyprexa (atypical)
olanzapine
Orap
pimozide
12 and older (for Tourette's syndrome).
Data for age 2 and older
indicate similar safety profile.
Mood Stabilizing Medications: These
with bipolar disorder is ongoing. In
stimulant medications to treat co-
medications are used to treat bipolar
addition, studies are investigating various
occurring ADHD or ADHD-like symptoms
disorder (manic depressive illness).
forms of psychotherapy, including
in a child with bipolar disorder may
However, because there is very limited
cognitive-behavioral therapy, to
worsen manic symptoms. While it can be
data on the safety and efficacy of most
complement medication treatment for this
hard to determine which young patients
mood stabilizers in youth, treatment of
illness in young people.
will become manic, there is a greater
children and adolescents is based mainly
likelihood among children and
on experience with adults. The most
Effective treatment depends on
adolescents who have a family history of
typically used mood stabilizers are lithium
appropriate diagnosis of bipolar disorder
bipolar disorder. If manic symptoms
and valproate (Depakote), which are
in children and adolescents. There is
develop or markedly worsen during
often very effective for controlling mania
some evidence that using antidepressant
antidepressant or stimulant use, a
and preventing recurrences of manic and
medication to weat depression in a person
physician should be consulted
depressive episodes in adults. Research
who has bipolar disorder may induce
immediately, and diagnosis and treatment
on the effectiveness of these and other
manic symptoms if it is taken without a
for bipolar disorder should be considered.
medications in children and adolescents
mood stabilizer. In addition, using
FROM:
ID:3014432578
PAGE 10/10
Mood Stabilizing Medications
Brand Name
Generic Name
Approved Age (children)
Cibalith-S
lithium citrate
12 and older
Depakote
divalproex sodium
2 and older (for seizures)
Eskalith
lithium carbonate
12 and older
Lamictal*
lamotrigine
16 and older (for seizures)
Lithobid
lithium carbonate
12 and older
Neurontin*
gabapentin
12 and older (for seizures)
Tegretol
carbamazepine
any age (for seizures)
Putative mood stablizers
References
For More Information on Mental
Coyle JT, 2000. Psychotropic drug use in
Disorders in Children, Contact:
very young children [editorial]. Journal of
Office of Communications and Public
the American Medical Association, 283:
Liaison, NIMH
1059-1060.
Information Resources and Inquiries
Branch
Physician's Desk Reference (PDR). 1999.
6001 Executive Blvd, Room 8184, MSC
Medical Economics Company,.Montvale,
9663
NJ.
Bethesda, MD 20892-9663
Phone: 301-443-4513
Zito JM. et al., 2000. Trends in the
TTY: 301-443-8431
prescribing of psychotropic medications to
FAX: 301-443-4279
preschoolers. Journal of the American
Mental Health FAX 4U: 301-443-5158
Medical Association, 283: 1025-1030.
E-mail: [email protected]
NIMH home page address:
www.nimh.nth.gov
1.
How can I be sure that my child is accurately diagnosed? Isn't it difficult to diagnose a
mental disorder in very young children?
2.
What criteria or methodology are used to make these diagnoses in very young children?
3.
What types of providers should I take my child to?
4.
Won't my child just grow out of this?
5.
Are there types of normal behavior in children under the age of 7 that are sometimes
misinterpreted to be abnormal? Is this different for girls? For boys?
6.
What are the consequences of not treating my child for their disorder?
QUESTIONS ON MEDICATIONS
1.
How do I know if my child needs medication?
2.
What happens if my child is overmedicated?
3.
What happens if my child is undermedicated?
4.
When appropriately prescribed, what are the common dosage levels by age groups?
5.
Should my'child take medication only when she is in school? Or should she take it for all
waking hours?
6.
Is it a good idea to give my child a break from their medication every once in a while?
7.
Even when appropriately prescribed, are there any health risks associated with the use of
psychotropic drugs in children?
8.
Does it make a difference if a medication is specifically approved for use in children?
Does that increase the risks associated with the use of the drug?
9.
Is there anything my child shouldn't do while he is on this type of medication?
QUESTIONS ON TREATMENT
1.
What are examples of non-medical interventions that help children?
2.
Do therapies or other types of treatments work? How effective are they as compared to
medications?
3.
Are these therapies ever used by themselves? Do they always have to be used together
with medications?
4.
What types of providers specialize in these therapies and treatments?
5.
What does a behavioral therapist do?
6.
What does a family counselor do?
7.
What does a social worker do?
Treatment of Children with Mental Disorders
http://www.nimh.nih.gov/publicat/childqa.cfr
NIMH
Treatment of Children with Mental Disorders
National institute
of Mental Health
DUESTIONS AUSWINS
A Note to Parents
Treatment of
Children with
There has been public concern over reports that very young children are being
Mental Disorders
prescribed psychotropic medications. The studies to date are incomplete, and much
more needs to be learned about young children who are treated with medications for
all kinds of illnesses. In the field of mental health, new studies are needed to tell us
M'Il
what the best treatments are for children with emotional and behavioral
disturbances.
Children are in a state of rapid change and growth during their developmental years.
Diagnosis and treatment of mental disorders must be viewed with these changes in
mind. While some problems are short-lived and don't need treatment, others are
persistent and very serious, and parents should seek professional help for their
children.
Not long ago, it was thought that many brain disorders such as anxiety disorders,
NIH Publication No. 00-4702
depression, and bipolar disorder began only after childhood. We now know they can
Printed September 2000
begin in early childhood. An estimated 1 in 10 children and adolescents in the United
States suffers from mental illness severe enough to cause some level of impairment. Fewer than 1 in 5 of these ill
children receives treatment. Perhaps the most studied, diagnosed, and treated childhood-onset mental disorder is
attention deficit hyperactivity disorder (ADHD), but even with this disorder there is a need for further research in
very young children.
This booklet contains answers to frequently asked questions regarding treatment of children with mental disorders.
Questions and Answers
Q: What should / do if / am concerned about mental, behavioral, or emotional symptoms in my young
child?
A: Talk to your child's doctor. Ask questions and find out everything you can about the behavior or symptoms that
worry you. Every child is different and even normal development varies from child to child. Sensory processing,
language, and motor skills are developing during early childhood, as well as the ability to relate to parents and to
socialize with caregivers and other children. If your child is in daycare or preschool, ask the caretaker or teacher if
your child has been showing any worrisome changes in behavior, and discuss this with your child's doctor.
Q: How do / know if my child's problems are serious?
A: Many everyday stresses cause changes in behavior. The birth of a sibling may cause a child to temporarily act
much younger. It is important to recognize such behavior changes, but also to differentiate them from signs of
more serious problems. Problems deserve attention when they are severe, persistent, and impact on daily
activities. Seek help for your child if you observe problems such as changes in appetite or sleep, social withdrawal,
or fearfulness; behavior that seems to slip back to an earlier phase such as bedwetting; signs of distress such as
sadness or tearfulness; self-destructive behavior such as head banging; or a tendency to have frequent injuries. In
addition, it is essential to review the development of your child, any important medical problem he/she might have
had, family history of mental disorders, and physical and psychological traumas or situations that may cause
stress.
Q: Whom should / consult to help my child?
A: First, consult your child's doctor. Ask for a complete health examination of your child. Describe the behaviors
that worry you. Ask whether your child needs further evaluation by a specialist in child behavioral problems. Such
specialists may include psychiatrists, psychologists, social workers, and behavioral therapists. Educators may also
be needed to help your child.
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Treatment of Children with Mental Disorders
http://www.nimh.nih.gov/publicat/childqa.cfr.
Q: How are mental disorders diagnosed in young children?
A: Similar to adults, disorders are diagnosed by observing signs and symptoms. A skilled professional will consider
these signs and symptoms in the context of the child's developmental level, social and physical environment, and
reports from parents and other caretakers or teachers, and an assessment will be made according to criteria
established by experts. Very young children often cannot express their thoughts and feelings, which makes
diagnosis a challenging task. The signs of a mental disorder in a young child may be quite different from those of
an older child or an adult.
Q: Won't my child get better with time?
A: Sometimes yes, but in other cases children need professional help. Problems that are severe, persistent, and
impact on daily activities should be brought to the attention of the child's doctor. Great care should be taken to
help a child who is suffering, because mental, behavioral, or emotional disorders can affect the way the child
grows up.
Q: Which mental disorders are seen in children?
A: Mental disorders with possible onset in childhood include: anxiety disorders; attention deficit and disruptive
behavior disorders; autism and other pervasive developmental disorders; eating disorders (e.g., anorexia
nervosa), mood disorders (e.g., major depression, bipolar disorder); schizophrenia; and tic disorders. Under some
circumstances, bedwetting and soiling may be symptoms of a mental disorder.
Q: Are there situations in which it is advisable to use psychotropic medications in young children?
A: Psychotropic medications may be prescribed for young children with mental, behavioral, or emotional
symptoms when the potential benefits of treatment outweigh the risks. Some problems are SO severe and
persistent that they would have serious negative consequences for the child if untreated, and psychosocial
interventions may not always be effective by themselves. The safety and efficacy of most psychotropic
medications have not yet been studied in young children. As a parent, you will want to ask many questions and
evaluate with your doctor the risks of starting and continuing your child on these medications. Learn everything you
can about the medications prescribed for your child, including potential side effects. Learn which side effects are
tolerable and which ones are threatening. In addition, learn and keep in mind the goals of a particular treatment
(e.g., change in specific behaviors). Combining multiple psychotropic medications should be avoided in very young
children unless absolutely necessary.
Q: Does medication affect young children differently from older children or adults?
A: Yes. Young children's bodies handle medications differently than older individuals and this has implications for
dosage. The brains of young children are in a state of very rapid development, and animal studies have shown
that the developing neurotransmitter systems can be very sensitive to medications. A great deal of research is still
needed to determine the effects and benefits of medications in children of all ages. Yet it is important to remember
that serious untreated mental disorders themselves negatively impact brain development.
Q: If my preschool child receives a diagnosis of a mental disorder, does this mean that medications have
to be used?
A: No. Psychotropic medications are not generally the first option for a preschool child with a mental disorder. The
first goal is to understand the factors that may be contributing to the condition. The child's own physical and
emotional state is key, but many other factors such as parental stress or a changing family environment may
influence the child's symptoms. Certain psychosocial treatments may be as effective as medication.
Q: How should medication be included in an overall treatment plan?
A: When medication is used, it should not be the only strategy. There are other services that you may want to
investigate for your child. Family support services, educational classes, behavior management techniques, as well
as family therapy and other approaches should be considered. If medication is prescribed, it should be monitored
and evaluated regularly.
Q: What medications are used for which kinds of childhood mental disorders?
A: There are several major categories of psychotropic medications: stimulants, antidepressants, antianxiety
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Treatment of Children with Mental Disorders
http://www.nimh.nih.gov/publicat/childqa.cl.
agents, antipsychotics, and mood stabilizers. For medications approved by the U.S. Food and Drug Administration
(FDA) for use in children, dosages depend on body weight and age. The medications chart in this booklet shows
the most commonly prescribed medications for children with mood or anxiety disorders.
Stimulant Medications: are four stimulant medications that are approved for use in the treatment of attention
deficit hyperactivity disorder (ADHD), the most common behavioral disorder of childhood. These medications have
all been extensively studied and are specifically labeled for pediatric use. Children with ADHD exhibit such
symptoms as short attention span, excessive activity, and impulsivity that cause substantial impairment in
functioning. Stimulant medication should be prescribed only after a careful evaluation to establish the diagnosis of
ADHD and to rule out other disorders or conditions. Medication treatment should be administered and monitored
in the context of the overall needs of the child and family, and consideration should be given to combining it with
behavioral therapy. If the child is of school age, collaboration with teachers is essential.
Antidepressant and Antianxiety Medications: These medications follow the stimulant medications in prevalence
among children and adolescents. They are used for depression, a disorder recognized only in the last twenty years
as a problem for children, and for anxiety disorders, including obsessive-compulsive disorder (OCD). The
medications most widely prescribed for these disorders are the selective serotonin reuptake inhibitors (the SSRIs).
In the human brain, there are many "neurotransmitters" that affect the way we think, feel, and act. Three of these
neurotransmitters that antidepressants influence are serotonin, dopamine, and norepinephrine. SSRIs affect
mainly serotonin and have been found to be effective in treating depression and anxiety without as many side
effects as some older antidepressants.
Antipsychotic Medications: These medications are used to treat children with schizophrenia, bipolar disorder,
autism, Tourette's syndrome, and severe conduct disorders. Some of the older antipsychotic medications have
specific indications and dose guidelines for children. Some of the newer "atypical" antipsychotics, which have
fewer side effects, are also being used for children. Such use requires close monitoring for side effects.
Mood Stabilizing Medications: These medications are used to treat bipolar disorder (manic-depressive illness).
However, because there is very limited data on the safety and efficacy of most mood stabilizers in youth, treatment
of children and adolescents is based mainly on experience with adults. The most typically used mood stabilizers
are lithium and valproate (Depakote®), which are often very effective for controlling mania and preventing
recurrences of manic and depressive episodes in adults. Research on the effectiveness of these and other
medications in children and adolescents with bipolar disorder is ongoing. In addition, studies are investigating
various forms of psychotherapy, including cognitive-behavioral therapy, to complement medication treatment for
this illness in young people.
Effective treatment depends on appropriate diagnosis of bipolar disorder in children and adolescents. There is
some evidence that using antidepressant medication to treat depression in a person who has bipolar disorder may
induce manic symptoms if it is taken without a mood stabilizer. In addition, using stimulant medications to treat
co-occurring ADHD or ADHD-like symptoms in a child with bipolar disorder may worsen manic symptoms. While it
can be hard to determine which young patients will become manic, there is a greater likelihood among children
and adolescents who have a family history of bipolar disorder. If manic symptoms develop or markedly worsen
during antidepressant or stimulant use, a physician should be consulted immediately, and diagnosis and treatment
for bipolar disorder should be considered.
Q: What difference does it make if a medication is specifically approved for use in children or not?
A: Approval of a medication by the U.S. Food and Drug Administration (FDA) means that adequate data have
been provided to the FDA by the drug manufacturer to show safety and efficacy for a particular therapy in a
particular population. Based on the data, a label indication for the drug is established that includes proper dosage,
potential side effects, and approved age. Doctors prescribe medications as they feel appropriate even if those
uses are not included in the labeling. Although in some cases there is extensive clinical experience in using
medications for children or adolescents, in many cases there is not. Everyone agrees that more studies in children
are needed if we are to know the appropriate dosages, how a drug works in children, and what effects there are on
learning and development.
Q: What does "off-label" use of a medication mean?
A: Many medications that are on the market have not been officially approved by the FDA for use in children.
Treatment of children with these medications is called "off-label" use. For some medications, the off-label use is
supported by data from well-conducted studies in children. For instance, some antidepressant medications have
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http://www.nimh.nih.gov/publicat/childqa.cfr.
been shown to be effective in children and adolescents with depression. For other medications, there are no
controlled studies in children, but only isolated clinical reports. In particular, the use of psychotropic medications in
preschoolers has not been adequately studied and must be considered very carefully by balancing severity of
symptoms, degree of impairment, and potential benefits and risks of treatment.
Q: Why haven't many medications been tested in children?
A: In the past, medications were not studied in children because of ethical concerns about involving children in
clinical trials. However, this created a new problem: lack of knowledge about the best treatments for children. In
clinical settings where children are suffering from mental or behavioral disorders, medications are being
prescribed at increasingly early ages. The FDA has been urging that products be appropriately studied in children
and has offered incentives to drug manufacturers to carry out such testing. The NIH and the FDA are examining
the issue of medication research in children and are developing new research approaches.
Q: Does the FDA approve medications for different age groups among children?
A: Yes. However, this is based on the data provided to the FDA by the drug manufacturer and the policies in effect
at the time of approval. For example, Ritalin® is approved for children age 6 and older, whereas Dexedrine® is
approved for children as young as 3. When Ritalin® was tested for efficacy by its manufacturer, only children age
6 and above were involved; therefore, age 6 was approved as the lower age limit for Ritalin®.
Q: Can events such as a death in the family, illness in a parent, onset of poverty, or divorce cause
symptoms?
A: Yes. When a tragedy occurs or some extreme stress hits, every member of a family is affected, even the
youngest ones. This should also be considered when evaluating mental, emotional, or behavioral symptoms in a
child.
Stimulant Medications
Brand Name
Generic Name
Approved Age
Adderall
amphetamines
3 and older
Concerta
methylphenidate
6 and older
Cylert*
pemoline
6 and older
Dexedrine
dextroamphetamine
3 and older
Dextrostat
dextroamphetamine
3 and older
Ritalin
methylphenidate
6 and older
*
Due to its potential for serious side effects affecting the liver, Cylert should not ordinarily be considered as first
line drug therapy for ADHD.
Antidepressant and Antianxiety Medications
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http://www.nimh.nih.gov/publicat/childqa.cfn
Brand Name
Generic Name
Approved Age
Anafranil
clomipramine
10 and older (for OCD)
BuSpar
buspirone
18 and older
Effexor
venlafaxine
18 and older
Luvox (SSRI)
fluvoxamine
8 and older (for OCD)
Paxil (SSRI)
paroxetine
18 and older
Prozac (SSRI)
fluoxetine
18 and older
Serzone (SSRI)
nefazodone
18 and older
Sinequan
doxepin
12 and older
Tofranil
imipramine
6 and older (for bedwetting)
Wellbutrin
bupropion
18 and older
Zoloft (SSRI)
sertraline
6 and older (for OCD)
Antipsychotic Medications
Brand Name
Generic Name
Approved Age
Clozaril (atypical)
clozapine
18 and older
Haldol
haloperidol
3 and older
Risperdal (atypical)
risperidone
18 and older
Seroquel (atypical)
quetiapine
18 and older
(generic only)
thioridazine
2 and older
Zyprexa (atypical)
olanzapine
18 and older
Orap
pimozide
12 and older (for Tourette's syndrome).
Data for age 2 and older indicate similar safety profile.
Mood Stabilizing Medications
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Brand Name
Generic Name
Approved Age
Cibalith-S
lithium citrate
12 and older
Depakote
divalproex sodium
2 and older (for seizures)
Eskalith
lithium carbonate
12 and older
Lithobid
lithium carbonate
12 and older
Tegretol
carbamazepine
any age (for seizures)
References
Burns BJ, Costello EJ, Angold A, Tweed D, Stangl D, Farmer EM, Erkanli A. Data Watch: children's mental health
service use across service sectors. Health Affairs, 1995; 14(3): 147-59.
Coyle JT. Psychotropic drug use in very young children [editorial]. Journal of the American Medical Association,
2000; 283(8): 1059-60.
Physician's Desk Reference (PDR). Montvale, NJ: Medical Economics Company, 1999.
Shaffer D, Fisher P, Dulcan MK, Davies M, Piacentini J, Schwab-Stone ME, Lahey BB, Bourdon K, Jensen PS,
Bird HR, Canino G, Regier DA. The NIMH diagnostic schedule for children interview version 2.3 (Disc 2.3):
description, acceptability, prevalence, rates, and performance in the MECA study. Journal of the Academy of Child
and Adolescent Psychiatry, 1996; 35(7): 865-77.
Zito JM, Safer DJ, dosReis S, Gardner JF, Botes M, Lynch F. Trends in the prescribing of psychotropic
medications to preschoolers. Journal of the American Medical Association, 2000; 283(8): 1025-30.
For More Information on Mental Disorders in Children, Contact:
Office of Communications and Public Liaison, NIMH
Information Resources and Inquiries Branch
6001 Executive Blvd., Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513
TTY: 301-443-8431
FAX: 301-443-4279
Mental Health FAX 4U: 301-443-5158
E-mail: [email protected]
NIMH home page address: http://www.nimh.nih.gov
NIH-00-4702
September 2000
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For the Public I For Practitioners I For Researchers I Intramural Research
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Treatment of Children with Mental Disorders
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NIMH Public Inquiries
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This page was last updated: October 17, 2000.
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TREATMENT OF YOUNG CHILDREN WITH MENTAL CONDITIONS
When to Get Help
People to Talk To
Learning About Medications
A NOTE TO PARENTS
There has been recent public concern over reports that increasing numbers of very young children are
being prescribed psychotropic medications. Some parents are criticized for giving their children these
medications, while others are criticized for not doing so. New studies are needed to tell us what the best
treatments are for children with emotional and behavioral disturbances.
Although progress has been made in diagnosing the mental illnesses that begin in childhood, children's
brains are in a state of rapid change and growth, and diagnosis and treatment of mental disorders must
be viewed with this in mind. While some problems are short lived, others are persistent and very
serious, and parents should seek help for their children. Treatment decisions should be weighed for
risks and benefits, and each child should be viewed individually.
WHEN TO GET HELP
Changes in behavior can be of real concern to parents. It's important to recognize behavior changes,
but also to differentiate them from signs of more serious problems. All children act out at times as part
of typical development. Some children, however, experience significant changes that may indicate a
more serious problem. But in some cases, children need help. Problems deserve attention when they
are severe, persistent, and impact daily activities. Seek help for your child if you observe persistent
problems such as sleep disturbances, changes in appetite, social withdrawal, or fearfulness; behavior
that slips back to an earlier phase such as bedwetting; signs of depression; erratic and aggressive
behavior, a tendency to be easily distracted or forgetful, or an inability to sustain attention; self-
destructive behavior such as head banging; or a tendency to have frequent injuries. It's important to
address concerns early - mental, behavioral, or emotional disorders affect the way your child grows up.
PEOPLE TO TALK TO IF YOU ARE CONCERNED ABOUT YOUR CHILD
Remember that every child is different, and even normal development varies from child to child. If
your child is in daycare or preschool, ask the teacher if your child has shown any troubling changes in
behavior, and discuss this with your doctor. Ask your doctor questions and find out everything you can
about the behavior or symptoms that worry you. Be sure to tell your doctor about extreme symptoms,
such as self-injury, impulsive or aggressive behavior, hyperactivity, or social withdrawal.
Ask your doctor whether your child needs further evaluation by a specialist in child behavioral
problems. A variety of specialists, including psychiatrists, neurologists, psychologists, behavioral
therapists, social workers and educators may be needed to help your child. Consistent follow-up is
critical to successful treatment.
LEARNING ABOUT MEDICATIONS
The use of medication is not generally the first option for a preschool child with a psychiatric disorder.
When medication is used, it should not be the only strategy. Family support services, educational
classes on parenting strategies, behavior management techniques, and other approaches should be
considered. If medication is prescribed, it should be monitored and evaluated closely and regularly.
There are several categories of medications used for emotional and behavioral disorders: stimulants,
anti-depressants, anti-anxiety agents, anti-psychotics, and mood stabilizers.
Stimulants
There are four stimulant medications that are approved for use in the treatment of attention deficit hyperactivity
disorder (ADHD), the most common behavioral disorder of childhood. Children with ADHD exhibit symptoms
such as short attention span, excessive activity, and impulsivity that cause substantial impairment in functioning.
If the child attends school, collaboration with teachers is essential. These medications are labeled for pediatric use.
Brand Name
Generic Name
Approved Age
Adderal
amphetamines
3 and older
Cyclert
pemoline
6 and older
Dexedrine
dextro-amphetamine
3 and older
Ritalin
methylphenidate
6 and older
Anti-Depressant and Anti-Anxiety Medications
These medications are used for depression and for anxiety disorders, including obsessive compulsive disorder.
Brand Name
clomipramine
8 and older (OCD)
Anafranil
fluovoxamine
12 and older
Luvox
doxepin
6 and older (bedwetting)
Sinequan
imipramine
6 and older (OCD)
Tofranil
sertranline
Zoloft
Approved Age
Generic Name
10 and older (OCD)
Other medications that are used to treat these disorders in children include Effexor (venlafaxine), Paxil
(paroxetine), Prozac (fluoxetine), Serzone (nefazodone), and Wellbutrin (bupropion). They are not labeled for
pediatric use.
Anti Psychotics
These medications are used to treat schizophrenia, bipolar disorder, autism, Tourette's syndrome, and conduct
disorders.
Brand Name
Generic Name
Approved Age
Haldol
Haloperiodol
3 and older
generic only
Thioridazine
2 and older
Orap
Pimozide
12 and older
There are other medications used to treat these disorders in children, including clozaril (clozapine), Risperidal
(risperidone), seroquel (quetiapine), Zyprexa (olanzapine). These drugs are newer (atypical) antipsychotics, and
have fewer side effects. These medications are not labeled for pediatric use.
Mood Stabilizers
These medications are used to treat bipolar disorder (manic depressive illness).
Brand Name
Lamictal
Generic Name
Cibalith-S
Lithobid
lithium citrate
Depakote
Neurontin
divalproex sodium
Eskalith
Tegretol
lithium carbonate
lamotrigine
Approved Age
16 and older (for seizures)
lithium carbonate
12 and older
12 and older
gabapentin
2 and older (for seizures)
12 and older (for seizures)
carbamazepine
12 and older
any age (for seizures)
Research on the effectiveness of these and other medications in children and adolescents with bipolar disorder are
ongoing. In addition, studies are investigating various forms of psychotherapy, including cognitive-behavioral therapy,
to complement medication treatment for this illness in young people.
FOR MORE INFORMATION ON MENTAL DISORDERS IN CHILDREN
CONTACT THE NATIONAL INSTITUTES OF MENTAL HEALTH 301 443 4513 / www.nimh.nih.gov
diafts
TREATMENT OF YOUNG CHILDREN WITH MENTAL DISORDERS
When to Get Help
People to Talk To
Learning About
Medications
A NOTE TO PARENTS
There has been recent public concern over reports that very young children are being prescribed
psychotropic medications. Some parents are criticized for giving their children these medications,
while others are criticized for not doing so. New studies are needed to tell us what the best
treatments are for children with emotional and behavioral disturbances.
Although progress has been made in diagnosing the mental illnesses that begin in childhood,
children are in a state of rapid change and growth, and diagnosis and treatment of mental disorders
must be viewed with this in mind. While some problems are short lived, others are persistent and
very serious, and parents should seek ways to help their children. Treatment decisions should be
weighed for risks and benefits, and each child should be viewed individually.
WHEN TO GET HELP
It's important to recognize behavior changes, but also to differentiate them from signs of more
serious problems. Sometimes, changes in behavior that you find worrisome may be a normal part of
your child's development, and do not need medical attention. But in some cases, children need help.
Problems deserve attention when they are severe, persistent, and impact daily activities. Seek help
for your child if you observe persistent problems such as sleep disturbances, changes in appetite,
social withdrawal, or fearfulness; behavior that slips back to an earlier phase such as bedwetting;
signs of depression; erratic and aggressive behavior, a tendency to be easily distracted or forgetful, or
an inability to sustain attention; self-destructive behavior such as head banging; or a tendency to
have frequent injuries. It's important to address concerns early - mental, behavioral, or emotional
disorders affect the way your child grows up.
PEOPLE TO TALK TO IF YOU ARE CONCERNED ABOUT YOUR CHILD
If you are concerned about your child's behavior, talk to your doctor. Ask questions and find out
everything you can about the behavior or symptoms that worry you. Remember that every child is
different, and even normal development varies from child to child. If your child is in daycare or
preschool, ask the teacher if your child has shown any troubling changes in behavior, and discuss this
with your doctor. Be sure to tell your doctor about extreme symptoms, such as self-injury, impulsive
or aggressive behavior, persistent sadness, hyperactivity, or social withdrawal.
Ask your doctor whether your child needs further evaluation by a specialist in child behavioral
problems. A variety of specialists, including psychiatrists, neurologists, psychologists, and
behavioral therapists, and educators may be needed to help your child. Consistent follow-up is
critical to successful treatment.
LEARNING ABOUT MEDICATIONS
The use of medication is not generally the first option for a preschool child with a psychiatric
disorder. When medication is used, it should not be the only strategy. Family support services,
educational classes on parenting strategies, behavior management techniques, and other approaches
should be considered. If medication is prescribed, it should be monitored and evaluated closely and
regularly. There are several categories of medications used for emotional and behavioral disorders:
stimulants, anti-depressants, anti-anxiety agents, anti-psychotics, and mood stabilizers.
Stimulants
There are four stimulant medications that are approved for use in the treatment of attention deficit
hyperactivity disorder (ADHD), the most common behavioral disorder of childhood. Children with ADHD
exhibit symptoms such as short attention span, excessive activity, and impulsivity that cause substantial
impairment in functioning. If the child attends school, collaboration with teachers is essential. These
medications are labeled for pediatric use.
Brand Name
Generic Name
Approved Age
Adderal
amphetamines
3 and older
Cyclert
pemoline
6 and older
Dexedrine
dextro-amphetamine
3 and older
Ritalin
methylphenidate
6 and older
Anti-Depressant and Anti-Anxiety Medications
These medications are used for depression and for anxiety disorders, including obsessive compulsive disorder.
Brand Name
clomipramine
8 and older (OCD)
Anafranil
fluovoxamine
12 and older
Luvox
doxepin
6 and older (bedwetting)
Sinequan
imipramine
6 and older (OCD)
Tofranil
sertranline
Zoloft
Approved Age
Generic Name
10 and older (OCD)
Other medications that are used to treat these disorders in children include Effexor (venlafaxine), Paxil
(paroxetine), Prozac (fluoxetine), Serzone (nefazodone), and Wellbutrin (bupropion). They are not labeled for
pediatric use.
Anti Psychotics
These medications are used to treat children with schizophrenia, bipolar disorder, autism, Tourette's syndrome,
and severe conduct disorders.
Brand Name
Generic Name
Approved Age
Haldol
Haloperiodol
3 and older
generic only
Thioridazine
2 and older
Orap
Pimozide
12 and older
There are other medications used to treat these disorders in children, including clozaril (clozapine), Risperidal
(risperidone), seroquel (quetiapine), Zyprexa (olanzapine). These drugs are newer (atypical) antipsychotics,
and have fewer side effects. These medications are not labeled for pediatric use.
Mood Stabilizers
These medications are used to treat bipolar disorder (manic depressive illness).
Brand Name
Depakote
Lamictal
Cibalith-S
Eskalith
Lithobid
Neurontin
lamotrigine
2 and older (for seizures)
Tegretol
lithium carbonate
12 and older
Generic Name
gabapentin
16 and older (for seizures)
lithium citrate
carbamazepine
12 and older
divalproex sodium
Approved Age
12 and older (for seizures)
lithium carbonate
12 and older
any age (for seizures)
and me
Research on the effectiveness of these another medications in children and adolescents with bipolar disorder are ongoing.
In addition, studies are investigating various forms of psychotherapy, including cognitive-behavioral therapy, to
complement medication treatment for this illness in young people.
FOR MORE INFORMATION ON MENTAL DISORDERS IN CHILDREN
CONTACT THE NATIONAL INSTITUTES OF MENTAL HEALTH 301 443 4513 / www.nimh.nih.gov
Planning
3/19
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JAMA
Trends in the Prescribing of Psychotropic Medications to Preschoolers
http:/jama.ama-assn.org/issues/v283n8/abs/joc91250.htn
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Vol. 283 No. 8,
February 23, 2000
Original Contribution
OF THIS ARTICLE
Trends in the Prescribing of Psychotropic
View Related
Medications to Preschoolers
Documents
Julie Magno Zito, PhD; Daniel J. Safer, MD; Susan dosReis, PhD;
Return to
James F. Gardner, ScM; Myde Boles, PhD; Frances Lynch, PhD
Table of Contents
Context Recent reports on the use of psychotropic medications for
preschool-aged children with behavioral and emotional disorders
Author/Article
warrant further examination of trends in the type and extent of drug
Information
therapy and sociodemographic correlates.
Objectives To determine the prevalence of psychotropic
medication use in preschool-aged youths and to show utilization
trends across a 5-year span.
Design Ambulatory care prescription records from 2 state Medicaid
programs and a salaried group-model health maintenance
organization (HMO) were used to perform a population-based
analysis of three 1-year cross-sectional data sets (for the years
1991, 1993, and 1995).
Setting and Participants From 1991 to 1995, the number of
enrollees aged 2 through 4 years in a Midwestern state Medicaid
(MWM) program ranged from 146,369 to 158,060; in a mid-Atlantic
state Medicaid (MAM) program, from 34,842 to 54,237; and in an
HMO setting in the Northwest, from 19,107 to 19,322.
Main Outcome Measures Total, age-specific, and gender-specific
utilization prevalences per 1000 enrollees for 3 major psychotropic
drug classes (stimulants, antidepressants, and neuroleptics) and 2
leading psychotherapeutic medications (methylphenidate and
clonidine); rates of increased use of these drugs from 1991 to 1995,
compared across the 3 sites.
Results The 1995 rank order of total prevalence in preschoolers
(per 1000) in the MWM program was: stimulants (12.3), 90% of
which represents methylphenidate (11.1); antidepressants (3.2);
clonidine (2.3); and neuroleptics (0.9). A similar rank order was
observed for the MAM program, while the HMO had nearly 3 times
more clonidine than antidepressant use (1.9 VS 0.7). Sizable
increases in prevalence were noted between 1991 and 1995 across
the 3 sites for clonidine, stimulants, and antidepressants, while
neuroleptic use increased only slightly. Methylphenidate prevalence
in 2 through 4-year-olds increased at each site: MWM, 3-fold; MAM,
Author/Article
1.7-fold; and HMO, 3.1-fold. Decreases occurred in the relative
Information
proportions of previously dominant psychotherapeutic agents in the
stimulant and antidepressant classes, while increases occurred for
newer, less established agents.
Conclusions In all 3 data sources, psychotropic medications
prescribed for preschoolers increased dramatically between 1991
and 1995. The predominance of medications with off-label
1 of 2
3/17/2000 11:52 AM
ends in the Prescribing of Psychotropic Medications to Preschoolers
http://jama.ama-assn.org/issues/v283n8/abs/joc91250.htm.
(uniabeled) indications calls for prospective community-based,
multidimensional outcome studies.
JAMA. 2000;283:1025-1030
Author/Article Information
Author Affiliations: School of Pharmacy (Drs Zito, dosReis, and Mr
Gardner) and School of Medicine (Dr Zito), University of Maryland,
and School of Medicine, Johns Hopkins University (Dr Safer),
Baltimore, Md; and Center for Health Research, Kaiser Permanente,
Portland, Ore (Drs Boles and Lynch).
Corresponding Author and Reprints: Julie Mango Zito, PhD,
University of Maryland, 100 Greene St, Room 5-13, Baltimore, MD
21201 (e-mail: [email protected]).
Funding/Support: This study was supported by funding from the
National Institute of Mental Health, Services Branch (grant R01
MH55259), and the George and Leila Mathers Charitable
Foundation, Mount Kisco, NY.
Previous Presentation: Presented at the American Psychiatric
Association Meeting, Washington, DC, May 19, 1999.
Acknowledgment: Richard E. Johnson, PhD, and Linda Phelps,
MA, provided assistance at several stages in the design or analysis
of this study. Medicaid administrators and research analysts gave
crucial support to bring this study to fruition.
© 2000 American Medical Association. All rights reserved.
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Trends in the Prescribing of Psychotropic Medications to Preschoolers
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Vol. 283 No. 8,
February 23, 2000
Original Contribution
PDF OF THIS ARTICLE
Trends in the Prescribing of Psychotropic
View Related
Medications to Preschoolers
Documents
Julie Magno Zito, PhD; Daniel J. Safer, MD; Susan dosReis, PhD;
James F. Gardner, ScM; Myde Boles, PhD; Frances Lynch, PhD
Return to
Table of Contents
Context Recent reports on the use of psychotropic medications for
preschool-aged children with behavioral and emotional disorders
warrant further examination of trends in the type and extent of drug
ABSTRACT
therapy and sociodemographic correlates.
INTRODUCTION
Objectives To determine the prevalence of psychotropic
METHODS
medication use in preschool-aged youths and to show utilization
trends across a 5-year span.
RESULTS
Design Ambulatory care prescription records from 2 state Medicaid
COMMENT
programs and a salaried group-model health maintenance
organization (HMO) were used to perform a population-based
AUTHOR/ARTICLE
analysis of three 1-year cross-sectional data sets (for the years
INFORMATION
1991, 1993, and 1995).
REFERENCES
Setting and Participants From 1991 to 1995, the number of
enrollees aged 2 through 4 years in a Midwestern state Medicaid
INDEX OF
(MWM) program ranged from 146,369 to 158,060; in a mid-Atlantic
FIGURES AND
state Medicaid (MAM) program, from 34,842 to 54,237; and in an
TABLES
HMO setting in the Northwest, from 19,107 to 19,322.
Main Outcome Measures Total, age-specific, and gender-specific
utilization prevalences per 1000 enrollees for 3 major psychotropic
drug classes (stimulants, antidepressants, and neuroleptics) and 2
leading psychotherapeutic medications (methylphenidate and
clonidine); rates of increased use of these drugs from 1991 to 1995,
compared across the 3 sites.
Results The 1995 rank order of total prevalence in preschoolers
(per 1000) in the MWM program was: stimulants (12.3), 90% of
which represents methylphenidate (11.1); antidepressants (3.2);
clonidine (2.3); and neuroleptics (0.9). A similar rank order was
observed for the MAM program, while the HMO had nearly 3 times
more clonidine than antidepressant use (1.9 VS 0.7). Sizable
increases in prevalence were noted between 1991 and 1995 across
the 3 sites for clonidine, stimulants, and antidepressants, while
neuroleptic use increased only slightly. Methylphenidate prevalence
in 2 through 4-year-olds increased at each site: MWM, 3-fold; MAM,
1.7-fold; and HMO, 3.1-fold. Decreases occurred in the relative
proportions of previously dominant psychotherapeutic agents in the
stimulant and antidepressant classes, while increases occurred for
newer, less established agents.
Conclusions In all 3 data sources, psychotropic medications
prescribed for preschoolers increased dramatically between 1991
and 1995. The predominance of medications with off-label
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(uniabeied) indications calls for prospective community-based,
multidimensional outcome studies.
JAMA. 2000;283:1025-1030
The prevalence of psychotropic medication treatment for children
and adolescents with emotional and behavioral disorders has
ABSTRACT
significantly increased in the United States during the last few
decades, particularly in the last 15 years. Specifically, the 5 through
INTRODUCTION
14-year-old age group has experienced a great increase in stimulant
treatment for attention-deficit/hyperactivity disorder (ADHD), and the
METHODS
15 through 19-year-old age group has had sizable increases in the
use of antidepressant medications. 1,2
RESULTS
Approved and unapproved indications for psychotropic medications
COMMENT
in young children are not extensive. These include: short-term use of
analgesics and sedatives/hypnotics for pain relief; hydroxyzine for
AUTHOR/ARTICLE
situational anxiety associated with medical, presurgical, and dental
INFORMATION
procedures; tricyclic antidepressants for nocturnal enuresis
(6-year-olds and older); and amphetamines for ADHD in those 3
REFERENCES
years old and older. 3 Accordingly, the prevalence of psychotropic
medication treatment for children younger than 5 years old has not
INDEX OF
received much professional attention until recently. 4-6
FIGURES AND
TABLES
Concern about this age group relates to off-label (unlabeled) use, ie,
for treatment indications with little or no proven efficacy and lacking
product package insert labeling information approved by the US
Food and Drug Administration (FDA). 7 One psychiatric newsletter,
citing FDA-compiled marketing data, reported that 3000
prescriptions for fluoxetine hydrochloride were written for children
aged younger than 1 year in 1994.⁸ In a 1998 professional meeting
report, 5 pediatric researchers noted that 57% of 223 Michigan
Medicaid enrollees aged younger than 4 years with a diagnosis of
ADHD received at least 1 psychotropic medication to treat this
condition during a 15-month period in 1995-1996. Of the treatments,
methylphenidate and clonidine were prescribed most often.
Although the use of psychotropic medication in preschool-aged
children compared with older youths is relatively small, the reports
cited argue for additional assessment to more systematically
estimate its use. Consequently, 3 large, computerized data sources
were used to estimate total, age-specific, and gender-specific
psychotropic medication prevalence for 2 through 4-year-olds; to
compare prevalence in the youngest age group with that in older
children and adolescents; and to show utilization trends in the 5-year
span from 1991-1995.
METHODS
Data Sources
Three large data sets were assembled from 2 types of health care
systems. The first 2 are outpatient data sets from 2 geographically
distinct Medicaid populations, 1 in a Midwestern state and 1 in a
ABSTRACT
mid-Atlantic state. The third set of data comes from a group-model
health maintenance organization (HMO) serving a predominantly
INTRODLICTION
in I Inited States
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employed States.
The total enrollments for those younger than age 20 years in 1991
METHODS
and 1995, respectively, are as follows: Midwestern Medicaid
(MWM), 669,164 and 687,722; mid-Atlantic Medicaid (MAM),
RESULTS
165,502 and 248,466; and group-model HMO (HMO), 131,038 and
131,860. These populations included both continuous and
COMMENT
noncontinuous enrollees for each study year. The Medicaid youth
populations were almost entirely eligible under Aid to Families with
AUTHOR/ARTICLE
Dependent Children, and a small proportion qualified because of
INFORMATION
disability status (Supplemental Security Income) or foster care
status. Nonwhites were overrepresented in the Medicaid populations
REFERENCES
and were underrepresented among HMO enrollees according to
general statistical profiles of the settings. 9
INDEX OF
FIGURES AND
Study Measures
TABLES
Psychotropic medication prevalence was defined for each study year
as the frequency of persons with 1 or more HMO pharmacy records
or Medicaid prescription claims for a psychotropic medication class,
subclass, or specific medication per 1000 enrolled youths. Time
trends were assessed across the 5-year span with data from 3
cross-sectional annual analyses (1991, 1993, and 1995).
For age-specific prevalence, children were grouped into 4 age strata
(aged 2-4, 5-9, 10-14, and 15-19 years) according to US census
categories. Data analyses focused on children aged 2 through 4
years. We were unable to investigate psychotropic medication use in
infants 1 year old or younger in the 2 Medicaid populations because
year of birth is recorded in a 2-digit field. Thus, "95" could refer to
someone born in 1895 or 1995. We were unable, therefore, to
distinguish those 1 year old and younger from 100- and
101-year-olds. We do present data on methylphenidate use in
infants 1 year old or younger from the HMO program, as 4-digit
years of birth were available. From 1991-1995, the number of
enrollees aged 2 through 4 years ranged from 146,369 to 158,060 in
the MWM program; from 34,842 to 54,237 in the MAM program, and
from 19,107 to 19,322 in the HMO.
A separate analysis was performed to examine medication use
among preschool-aged children by year of age. Gender-specific
prevalence provided separate prevalence rates for boys and for
girls.
Psychotropic Medications
Three psychotropic medication classes were examined: stimulants
(methylphenidate, other stimulants), antidepressants (selective
serotonin reuptake inhibitors [SSRIs], tricyclic antidepressants
[TCAs], and other antidepressants), and neuroleptics. Selection was
based on the frequent use of stimulants and antidepressants and
ABSTRACT
the public health significance of the use of neuroleptics in the very
young. In addition, 2 specific medications (methylphenidate and
INTRODUCTION
clonidine) were examined because their use alone or as a combined
treatment has increased substantially since the early 1990s. All the
METHODS
drugs were identified using a data dictionary encompassing the
national drug codes for each of the 3 study years. The study was
RESULTS
given an exempt classification by the institutional review
board-expedited review.
COMMENT
AUTHOR/ARTICLE
INFORMATION
RESULTS
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REFERENCES
INDEX OF
FIGURES AND
Total Psychotropic Medication Prevalence
TABLES
The rank order of psychotropic medication prevalence in 1995 for
the MWM program shows that, per 1000 enrollees, stimulants (12.3)
were the leading treatment among those 2 through 4 years old,
followed by antidepressants (3.2), clonidine (2.3), and neuroleptics
(0.9) (Table 1). Within classes, methylphenidate prevalence (11.1
per 1000 enrollees) represented 90% of the stimulant treatment,
while TCA prevalence (2.4 per 1000 enrollees) led the
antidepressant class. A similar ranking of medication prevalence in
1995 was observed for the MAM program, while preschool-aged
children in the HMO had nearly 3 times more clonidine use than
antidepressant use (Table 1).
Pronounced differences in psychotropic prevalence across the 3
sites are apparent from Table 1. Stimulant and antidepressant use
in 1995 was considerably less among preschoolers in the MAM
program and HMO than among those in the MWM program.
Enrollees in the MWM program and in the HMO led in the use of
clonidine, whereas its use in the MAM program was one-half to
two-thirds that of the other sites. Neuroleptic use per 1000 enrollees
in either Medicaid program (0.9 in the MWM program, and 0.5 in the
MAM program) was more common than in the HMO (0.2).
Time Trends in Psychotropic Medication Prevalence Across a
5-Year Span
The rate of psychotropic medication prescribed for preschoolers in
the MWM program increased substantially from 1991-1995. The
increase was greatest for clonidine (28.2-fold), stimulants (3.0-fold),
and antidepressants (2.2-fold). By contrast, neuroleptic use did not
increase substantially during this time. Comparisons of psychotropic
medication between sites showed that trends were similar in all 3
sites, with minor deviations for neuroleptics and antidepressants in
the population enrolled in the HMO (Table 1). Specifically, the
methylphenidate prevalence increase by site was: MWM, 3-fold;
ABSTRACT
MAM, 1.7-fold; and HMO, 3.1-fold. Increases were more dramatic
when the base prevalence was low. For example, methylphenidate
INTRODUCTION
use in the HMO was the lowest of the 3 sites, but its rise from 1.3
per 1000 enrollees in 1991 to 4.0 per 1000 in 1995 represented the
METHODS
largest methylphenidate increase (3.1-fold) across the 3 sites (Table
1).
RESULTS
Age-Specific Methylphenidate Medication Prevalence
COMMENT
Methylphenidate use according to age group in children and
AUTHOR/ARTICLE
adolescents in the MWM program was most prominent for those
INFORMATION
aged 5 through 14 years (Figure 1). By comparison, children 2
through 4 years old were treated at approximately one tenth the rate
REFERENCES
of their 5 through 14-year-old counterparts. The time trend analysis
revealed that those in all 4 age groups experienced increases in the
INDEX OF
use of methylphenidate during the 5-year period. The largest
FIGURES AND
methylphenidate increase (311%) was among 15 through
TABLES
19-year-olds, whereas the 2 through 4-year-olds, like the 5- through
14-year-olds, had a smaller but still substantial increase (169% to
176%). The increase in prevalence within the preschool-aged group
was greater for older children in the MWM program (from 6.9 to 20.8
per 1000 4-year-olds VS 1.1 to 3.5 per 1000 2-year-olds). The
age-specific trends by year of age for those in the MAM program
and HMO were consistent with those in the MWM program (Figure
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1). I here was no methylphenidate use in infants 1 year old or
younger in the HMO population.
Gender-Specific Methylphenidate Medication Prevalence
There was a greater proportional increase in preschool-aged girls
receiving methylphenidate from 1991 through 1995; in the HMO, the
male-to-female ratio decreased from 7:1 to 4:1 during this time. A
similar but less dramatic trend was evident in the MAM program (4:1
in 1991 to 3:1 in 1995). By contrast, the gender ratio for
methylphenidate treatment in the MWM program was stable over
these years (3:1 in 1991 and in 1995).
Changes in Drug Utilization and Off-Label Use
Changes in the use of older agents with a well-established efficacy
profile were observed. For example, despite a general increase in
total stimulant use, methylphenidate use in the MAM program
decreased proportionally by 7% from 1991 to 1995, while the use of
other stimulant medications rose from 15% to 27% of total stimulant
use among preschoolers. In all 3 sites, TCAs were the mainstay of
the antidepressant category in 1991, and their prevalence remained
relatively stable through 1995. By contrast, the use of SSRI
antidepressants increased dramatically at the Medicaid sites,
although by 1995 these drugs comprised only a small proportion of
antidepressants used in the HMO (Figure 2). Thus, antidepressant
use increased, particularly through off-label use, in the
preschool-aged group.
ABSTRACT
INTRODUCTION
METHODS
COMMENT
RESULTS
COMMENT
Several prominent trends characterized the use of psychotropic
medications in preschoolers during the early to mid 1990s. Overall,
AUTHOR/ARTICLE
there were large increases for all study medications (except the
INFORMATION
neuroleptics) and considerable variation according to gender, age,
geographic region, and health care system. These findings are
REFERENCES
remarkable in light of the limited knowledge base that underlies
psychotropic medication use in very young children. 10 Controlled
INDEX OF
clinical studies to evaluate the efficacy and safety of psychotropic
FIGURES AND
medications for preschoolers are rare. 3 Efficacy data are essentially
TABLES
lacking for clonidine and the SSRIs and methylphenidate's adverse
effects for preschool children are more pronounced than for older
youths 11 Consequently, the vast majority of psychotropic
medications prescribed for preschoolers are being used off-label. 7
Specific study findings are discussed below according to 3 major
outcomes: prevalence findings for specific medications; age- and
gender-specific data; and geographic and health care system
variations.
Prevalence Findings
Stimulant treatment in preschoolers increased approximately 3-fold
during the early 1990s. The prominence of stimulant and clonidine
use is consistent with Michigan Medicaid use patterns for children
younger than 4 years with an ADHD diagnosis.⁵ The data show
greater US methylphenidate prevalence for children younger than
age 5 years than was reported in a prevalence study in Western
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Australia (0.26% to 0.64% VS approximately 0.1%). 14 Hypothesized
reasons for the overall increased stimulant use include: (1) a larger
pool of eligible youths because of expanded diagnostic criteria for
ADHD since 1980¹³; (2) more girls being treated for ADHD as
evidenced by the narrowing of the gender ratio even among
preschoolers; (3) greater acceptance of biological treatments for a
behavioral disorder; and (4) the expanded role of school and
preschool health personnel in identifying medical needs. 14
Methylphenidate accounted for the vast majority of stimulant use
(eg, 90% of the 1995 stimulant use in the MWM program). There
was a modest but consistent decrease in the proportion of
methylphenidate use relative to other stimulants across the 3 time
periods. Generalizing from the efficacy and adverse effect
experience of stimulants in older youths to preschoolers is often not
valid, 11 at least partly because of preschoolers' developmental
immaturity.
ABSTRACT
Clonidine had the most dramatic increases, although its use in 1995
INTRODUCTION
was only 15% to 35% of the prevalence rate of stimulants. Clonidine
use is particularly notable because its increased prescribing is
METHODS
occurring without the benefit of rigorous data to support it as a safe
and effective treatment for attentional disorders. Cardiovascular
RESULTS
adverse effects including bradycardia, atrioventricular block, and
syncope with exercise have been reported in children treated with
COMMENT
clonidine in combination with other medications for the treatment of
ADHD and its comorbidities. 15, 16 Problems with abrupt withdrawal
AUTHOR/ARTICLE
producing noradrenergic overdrive have been reported. Its use to
INFORMATION
combat the insomnia associated either with ADHD itself or
secondary to the stimulant treatment of ADHD is new and largely
REFERENCES
uncharted, 17, 18 and its increased use for ADHD since 1991 helps
explain the increased clonidine poisonings in children taking either
INDEX OF
their own medications or that of siblings. 19, 20
FIGURES AND
TABLES
The combined use of clonidine and methylphenidate has been
associated with questions of safety 16, 21 and has been debated. 22
Unfortunately, the present data do not distinguish single vs
concomitant medication use, information vital to understanding how
these agents are being used in children. Such an analysis is better
undertaken in a continuously enrolled cohort so that censored data
do not create artifactual findings. We are currently conducting a
continuously enrolled retrospective cohort study.
Antidepressants were the second most commonly prescribed
psychotropic class of drugs for preschoolers, and their use
increased substantially from 1991-1995. Tricyclic antidepressants
still represent the bulk of early childhood antidepressant use,
although the growth in use of SSRIs was strong in those enrolled in
both Medicaid programs but very modest in those in the HMO. The
proportional decrease in use of TCAs was largely explained by the
recent increase in use of SSRIs, a trend we have previously shown
for older youths² and one that has been documented in adults. 23
The use of TCAs for enuresis is common among 5 through
13-year-olds, 24 but its use in the preschool group is puzzling. It is
also likely that some use of imipramine and desipramine was related
to the treatment of ADHD in preschoolers. 25
Neuroleptic use was infrequent and relatively stable across the study
period. The neuroleptic prevalence rate in this preschool data
showed rates one-tenth to one-half the annual prevalence among 5
through 19-year-olds in Rome from 1986 through 1991. 26 Both the
neuroleptic and antidepressant findings brina new information on
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population-based prevalence and provide some benchmarks to
chart the use of these agents in ambulatory settings. Additional
clinical interpretation, however, awaits prospective outcome studies.
Age- and Gender-Specific Prevalence Findings
ABSTRACT
Preschoolers' use of methylphenidate showed increases similar to
those of 5 through 14-year-olds, suggesting that the expanded use
INTRODUCTION
of this medication for attentional disorders in US youths extends
even to the very young. It is notable that the largest gains in use
METHODS
occurred among high school-aged students (15 through
19-year-olds), a trend that has been documented from county school
RESULTS
survey data. 13
COMMENT
Geographic and Health Care System Variations
AUTHOR/ARTICLE
Disparities in psychotropic medication prevalence data between the
INFORMATION
2 state Medicaid program populations are provocative and suggest
numerous hypotheses. These include differences between the
REFERENCES
states in (1) policies for eligibility or access to continuing care; (2)
the proportion of individuals with emotional or mental disorders that
INDEX OF
may be related to the proportion of youths receiving Supplemental
FIGURES AND
Security Income and foster care in each state; (3) preschool health
TABLES
assessment and referral programs; (4) physician specialty training,
particularly among psychiatrists and primary care providers, with
resultant referral or practice differences; (5) the cultural values that
underlie families' decisions to accept or reject medication for
behavioral or mental disorders; and (6) racial/ethnic population
differences that may affect cultural orientations and beliefs. Also
notable is the finding that the HMO prevalence rates, collectively,
were substantially lower than those of the Medicaid programs. In this
instance, geography and clinical population factors confound the
prevalence findings related to HMO vs Medicaid systems. The
presence of less severely disabled youths in the HMO population is
likely to explain a large part of the differences, but geographic and
patient cultural factors need to be considered as well. Also, the rapid
expansion of Supplemental Security Income benefits since 1990
resulted in more youths with ADHD being eligible for Medicaid
coverage than in previous years. 27
Limitations
The study is limited in several ways. First, the findings may be
generalizable to comparable Medicaid programs and to group-model
HMO enrollees, but the extent to which they may apply to other
treatment settings is unknown. Second, the cross-sectional nature of
the data from the 3 study years do not permit a follow-up of the
natural course of treatment. Until a continuously enrolled cohort is
assembled, descriptive data on the natural course of treatment and
prescription changes over time cannot be adequately assessed.
However, noncontinuously enrolled individuals make up the bulk of
the Medicaid membership. Thus, capturing these annual data
snapshots of both noncontinuous and continuous enrollees is useful
for clinical description. Third, no diagnostic codes were linked to the
medications in this analysis, thus limiting information about why
certain medications were selected. Fourth, computerized data
sources use a limited number of variables to describe the clinical
patterns in the usual practice settings. However, they have the
advantage of describing the usual practice setting without the
ABSTRACT
artificiality and the interference that prospective studies impose on
INTRODUCTION
physicians' decisions about medication and patients' decisions about
treatment. Compared with data from specialty clinic samples, data
from settings 2 far
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METHODS
community provide a ICI
assessment of medication practices, therapy variations, and
RESULTS
treatment. Adding outcome assessments would allow the
effectiveness of the treatments to be evaluated.
COMMENT
Clinical Research Recommendations
AUTHOR/ARTICLE
INFORMATION
Because children's responses to medications are not necessarily
similar to those of adults, systematic and careful outcome research
REFERENCES
specifically needs to be done for them. 7 Two types of studies would
help provide more systematic information on psychotropic drug
INDEX OF
therapy in children. First, epidemiologic (naturalistic) studies could
FIGURES AND
describe youth treatment in major medical settings (eg, traditional
TABLES
preferred provider organizations, Medicaid, salaried medical
group-model HMOs, and other managed care organizations) to
document types of treatments, diagnosis, severity, and time in
treatment and to evaluate clinical outcomes. Outcome measures
could include symptom control; social, day care, and preschool
functioning; parent satisfaction; reasons for initiation and
discontinuation; and adverse drug events, 28 Second, randomized,
double-blind, controlled clinical trials are needed for off-label
indications to evaluate dosages, efficacy, and safety of single and
multiple agents shown to be commonly used or widely
recommended. For disorders that occur very infrequently or
questionable combinations of drug therapy with unknown risks, a
case registry approach may be useful.
Future studies using large databases for clinical descriptive
information should require that the year of birth be stored as a 4-digit
number to avoid misclassification of elders as youths. Finally, youths
in Medicaid programs should be subdivided by type of eligibility (eg,
low income [formerly Aid to Families with Dependent Children, now
called Temporary Assistance for Needy Families], Supplemental
Security Income, or foster care) so that the total treatment
prevalence, which includes children with known disabilities and
major social stressors, will not be unfairly compared with that of less
impaired youths in non-Medicaid populations. 27
Unresolved questions involve the long-term safety of psychotropic
medications, particularly in light of earlier ages of initiation and
longer durations of treatment. While it is reassuring that anecdotal
reports have rarely documented these problems, the possibility of
adverse effects on the developing brain cannot be ruled out. 29
Active surveillance mechanisms for ascertaining subtle changes that
the developing personality may undergo as a result of a
psychotropic drug's impact on brain neurotransmitters should be
developed.
ABSTRACT
INTRODUCTION
Author/Article Information
METHODS
Author Affiliations: School of Pharmacy (Drs Zito, dosReis, and Mr
RESULTS
Gardner) and School of Medicine (Dr Zito), University of Maryland,
and School of Medicine, Johns Hopkins University (Dr Safer),
COMMENT
Baltimore, Md; and Center for Health Research, Kaiser Permanente,
Portland, Ore (Drs Boles and Lynch).
AUTHOR/ARTICLE
INFORMATION
Corresponding Author and Reprints: Julie Mango Zito, PhD,
REFERENCES
University of Maryland, 100 Greene St, Room 5-13, Baltimore, MD
21201 (e-mail: [email protected]).
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INDEX OF
FIGURES AND
Funding/Support: This study was supported by funding from the
TABLES
National Institute of Mental Health, Services Branch (grant R01
MH55259), and the George and Leila Mathers Charitable
Foundation, Mount Kisco, NY.
Previous Presentation: Presented at the American Psychiatric
Association Meeting, Washington, DC, May 19, 1999.
Acknowledgment: Richard E. Johnson, PhD, and Linda Phelps,
MA, provided assistance at several stages in the design or analysis
of this study. Medicaid administrators and research analysts gave
crucial support to bring this study to fruition.
REFERENCES
1.
Safer DJ, Zito JM, Fine EM.
Increased methylphenidate usage for attention deficit disorder in the
1990s.
Pediatrics.
1996;98(6 pt 1):1084-1088.
MEDLINE
2.
Zito JM, dosReis S, Safer DJ, Gardner J.
Trends in psychotropic prescriptions for youths with Medicaid
insurance from a midwestern state: 1987-1995.
Paper presented at: New Clinical Drug Evaluation Unit Meeting;
June 1998; Boca Raton, Fla.
3.
ABSTRACT
Greenhill LL.
The use of psychotropic medication in preschoolers: indications,
INTRODUCTION
safety, and efficacy.
Can J Psychiatry.
METHODS
1998;43:576-581.
MEDLINE
RESULTS
4.
COMMENT
Minde K.
The use of psychotropic medication in preschoolers: some recent
AUTHOR/ARTICLE
developments.
INFORMATION
Can J Psychiatry.
1998;43:571-575.
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INDEX OF
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Rappley MD, Gardiner JC, Mullan PB, Wang J, Alvarez FJ.
TABLES
Psychotropic medications in children ages 1 to 3 with ADHD.
Paper presented at: Pediatric Academic Societies Meeting (Joint
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6.
Pathiyal A, Miwa LJ, Sverdiov LS, Gardner E, Jones JK.
Patterns of methylphenidate use.
Paper presented at: American Societv for Clinical Pharmacology and
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Medication development and testing in children and adolescents:
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MEDLINE
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Grinfeld MJ.
Psychoactive medications and kids: new initiatives launched.
Psychiatric Times.
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Zito JM, Safer DJ, Riddle MA, Johnson RE, Speedie SM, Fox M.
Prevalence variations in psychotropic treatment of children.
J Child Adolesc Psychopharmacol.
1998;8:99-105.
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Jensen PS, Vitiello B, Leonard H, Laughren TP.
Child and adolescent psychopharmacology: expanding the research
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ABSTRACT
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INTRODUCTION
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11.
Firestone P, Musten LM, Pisterman S, Mercer J, Bennett S.
RESULTS
Short-term side effects of stimulant medication are increased in
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COMMENT
double-blind placebo-controlled study.
J Child Adolesc Psychopharmacol.
AUTHOR/ARTICLE
1998;8:13-25.
INFORMATION
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Valentine J, Zubrick S, Sly P.
INDEX OF
National trends in the use of stimulant medication for attention deficit
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hyperactivity disorder.
TABLES
J Paediatr Child Health.
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MEDLINE
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Safer DJ, Zito JM.
Pharmacoepidemiology of methylphenidate and other stimulants for
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Davilla RR, Williams ML, MacDonald JT.
Clarification of policy to address the needs of children with attention
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Memorandum from: US Dept of Education. Washington, DC: US
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Cantwell DP, Swanson J, Connor DF.
Case study: adverse response to clonidine.
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Swanson JM, Flockhart DA, Udrea D, Cantwell DP, Connor DF,
Williams L.
Clonidine in the treatment of ADHD: questions about safety and
efficacy [letter].
J Child Adolesc Psychopharmacol.
1995;5:301-304.
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Prince JB, Wilens TE, Biederman J, Spencer TJ, Wozniak JR.
Clonidine for sleep disturbances associated with attention-deficit
INTRODUCTION
hyperactivity disorder: a systematic chart review of 62 cases.
J Am Acad Child Adolesc Psychiatry.
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1996;35:599-605.
MEDLINE
RESULTS
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COMMENT
Ahmann PA, Waltonen SJ, Olson KA, Theye FW, Van Erem AJ,
LaPlant RJ.
AUTHOR/ARTICLE
Placebo-controlled evaluation of Ritalin side effects.
INFORMATION
Pediatrics.
1993;91:1101-1106.
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Erickson SJ, Duncan A.
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Clonidine poisoning-an emerging problem: epidemiology, clinical
features, management and preventive strategies.
J Paediatr Child Health.
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Kappagoda C, Schell DN, Hanson RM, Hutchins P.
Clonidine overdose in childhood: implications of increased
prescribing.
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1998;34:508-512.
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Popper CW.
Combining methylphenidate and clonidine: pharmacologic questions
and news reports about sudden death.
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1995;5:157-166.
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Combining methylphenidate and clonidine: a clinically sound
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Foxman B, Valdez RB, Brook RH.
Childhood enuresis: prevalence, perceived impact, and prescribed
METHODS
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Pediatrics.
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Geller B, Reising D, Leonard HL, Riddle MA, Walsh BT.
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Critical review of tricyclic antidepressant use in children and
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Prescription of neuroleptics for children and adults in Italy.
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Changing patterns of conditions among children receiving
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SG's Report
Contents, continued
Service Systems and Financing
182
Private Sector
182
Public Sector
183
Children Served by the Public Sector
184
Managed Care in the Public Sector
185
Culturally Appropriate Social Support Services
186
Support and Assistance for Families
187
New Roles for Families in Systems of Care
188
Family Support
188
Family Support Groups
189
Practical Support
190
Integrated System Model
190
Effectiveness of Systems of Care
191
The Fort Bragg Study
191
The Stark County Study
192
Summary: Effectiveness of Systems of Care
193
Conclusions
193
References
194
CHAPTER 3
CHILDREN AND MENTAL HEALTH
S
panning roughly 20 years, childhood and
challenging because of the ongoing process of
adolescence are marked by dramatic changes in
development. The normally developing child hardly
physical, cognitive, and social-emotional skills and
stays the same long enough to make stable
capacities. Mental health in childhood and adolescence
measurements. Adult criteria for illness can be difficult
is defined by the achievement of expected
to apply to children and adolescents, when the signs
developmental cognitive, social, and emotional
and symptoms of mental disorders are often also the
milestones and by secure attachments, satisfying social
characteristics of normal development. For example, a
relationships, and effective coping skills. Mentally
temper tantrum could be an expected behavior in a
healthy children and adolescents enjoy a positive
young child but not in an adult. At some point,
quality of life; function well at home, in school, and in
however, it becomes clearer that certain symptoms and
their communities; and are free of disabling symptoms
behaviors cause great distress and may lead to
of psychopathology (Hoagwood et al., 1996).
dysfunction of children, their family, and others in their
The basic principles for understanding health and
social environment. At these points, it is helpful to
illness discussed in the previous chapter apply to
consider serious deviations from expected cognitive,
children and adolescents, but it is important to
social, and emotional development as "mental
underscore the often heard admonition that "children
disorders." Specific treatments and services are
are not little adults." Even more than is true for adults,
available for children and adolescents with such mental
children must be seen in the context of their social
disorders, but one cannot forget that these disorders
environments, that is, family, peer group, and their
emerge in the context of an ongoing developmental
larger physical and cultural surroundings. Childhood
process and shifting relationships within the family and
mental health is expressed in this context, as children
community. These developmental factors must be
proceed through development.
carefully addressed, if one is to maximize the healthy
Development, characterized by periods of transition
development of children with mental disorders,
and reorganization, is the focus of much research on
promote remediation of associated impairments, and
children and adolescents. Studies focus on normal and
enhance their adult outcomes.
abnormal development, trying to understand and
The developmental perspective helps us understand
predict the forces that will keep children and
how estimated prevalence rates for mental disorders in
adolescents mentally healthy and maintain them on
children and adolescents vary as a function of the
course to become mentally healthy adults. These
degree of impairment that the child experiences in
studies ask what places some at risk for mental illness
association with specific symptom patterns. For
and what protects some but not others, despite exposure
example, the MECA Study (Methodology for
to the same risk factors.
Epidemiology of Mental Disorders in Children and
In addition to studies of normal development and of
Adolescents) estimated that almost 21 percent of U.S.
risk factors, much additional research focuses on
children ages 9 to 17 had a diagnosable mental or
mental illness in childhood and adolescence and what
addictive disorder associated with at least minimum
can be done to prevent or treat it. The science is
impairment (see Table 3-1). When diagnostic criteria
123
Mental Health: A Report of the Surgeon General
Table 3-1. Children and adolescents age 9-17 with
conditions or disorders. Both perspectives are useful.
mental or addictive disorders, combined
Each alone has its limitations, but together they
MECA sample, 6-month (current) prevalence*
constitute a more fully informed approach that spans
(%)
mental health and illness and allows one to design
Anxiety Disorders
13.0
developmentally informed strategies for prevention and
treatment.
Mood Disorders
6.2
Disruptive Disorders
10.3
Normal Development
Substance Use Disorders
2.0
Development is the lifelong process of growth, matur-
ation, and change that unfolds at the fastest pace during
Any Disorder
20.9
childhood and adolescence. An appreciation of normal
*
Disorders include diagnosis-specific impairment and Child
development is crucial to understanding mental health
Global Assessment Scale s70 (mild global impairment)
in children and adolescents and the risks they face in
maintaining mental health. Distortions in the process of
Source: Shaffer et al., 1996a
development may lead to mental disorders. This section
required the presence of significant functional impair-
deals with the normal development of understanding
ment, estimates dropped to 11 percent. This estimate
(cognitive development) in young children and the
translates into a total of 4 million youth who suffer
development of social relationships and temperament.
from a major mental illness that results in significant
impairments at home, at school, and with peers.
Theories of Development
Finally, when extreme functional impairment is the
Historically, the changes that take place in a child's
criterion, the estimates dropped to 5 percent.
psyche between birth and adulthood were largely
Given the process of development, it is not
ignored. Child development first became a subject of
surprising that these disorders in some youth are known
serious inquiry at the beginning of this century but was
to wax and wane, such that some afflicted children
mostly viewed from the perspective of mental disorders
improve as development unfolds, perhaps as a result of
and from the cultural mainstream of Europe and white
healthy influences impinging on them. Similarly, other
America. Some of the "grand theories" of child
youth, formerly only "at risk," may develop full-blown
development, such as that propounded by Sigmund
forms of disorder, as severe and devastating in their
Freud, grew out of this focus, and they unquestionably
impact on the youth and his or her family as are the
drew attention to the importance of child development
analogous conditions that affect adults. Characterizing
in laying the foundation for adult mental health. Even
such disorders as relatively unchangeable under-
those theories that resulted from the observation of
estimates the potential beneficial influences that can
healthy children, such as Piaget's theory of cognitive
redirect a child whose development has gone awry.
development, paid little attention to the relationship
Likewise, characterizing children with mental disorders
between the development of the "inner self" and the
as "only" the victims of negative environmental
environment into which the individual was placed. In
influences that might be fixed if societal factors were
contrast, the interaction of an individual with the
just changed runs the risk of underestimating the
environment was central to the school of thought
severity of these conditions and the need for focused,
known as behaviorism.
intensive clinical interventions for suffering children
Theories of normal development, introduced in
and adolescents. Thus, the science of mental health in
Chapter 2, are presented briefly below, because they
childhood and adolescence is a complex mix of the
form the basis of many current approaches to
study of development and the study of discrete
understanding and treating mental illness and mental
health problems in children and adults. These theories
124
Children and Mental Health
have not achieved the broader objective of explaining
world and that children have a different understanding
how children grow into healthy adults. More study and
of the world than do adults. The principal limitations of
perhaps new theories will be needed to improve our
Piaget's theories are that they are descriptive rather
ability to guide healthy child-rearing with scientific
than explanatory. Furthermore, he neglected variability
evidence.
in development and temperament and did not consider
the crucial interplay between a child's intellectual
Development Viewed as a Series of Stages
development and his or her social experiences (Bidell
Freud and the psychoanalyst Erik Erikson proposed a
& Fischer, 1992).
series of stages of development reflecting the
attainment of biological objectives. The stages are
Behavioral Development
expressed in terms of functioning as an individual and
Other approaches to understanding development are
with others-within the family and the broader social
less focused on the stages of development. Behavioral
environment (particularly in Erikson's theories) (see
psychology focused on observation and measurement,
Chapter 2). Although criticized as unscientific and
explaining development in terms of responses to
relevant primarily to the era and culture in which they
stimuli, such as rewards. Not only did the theories of
were conceived, these theories introduced the
the early pioneers (e.g., Pavlov, Watson, and Skinner)
importance of thinking developmentally, that is, of
generate a number of valuable treatments, but their
considering the ever-changing physical and
focus on precise description set the stage for current
psychological capacities and tasks faced by people as
programs of research based on direct observation.
they age. They emphasized the concept of "maturation"
Social learning theory (Bandura, 1977) emphasized role
and moving through the stages of life, adapting to
models and their impact on children and adolescents as
changing physical capacities and new psychological
they develop. Several important clinical tools came out
and social challenges. And they described mental
of behaviorism (e.g., reinforcement and behavior
health problems associated with failure to achieve
modification) and social learning theory (cognitive-
milestones and objectives in their developmental
behavioral therapy). Both treatment approaches are
schemes.
used effectively with children and adolescents.
These theories have guided generations of
psychodynamic therapists and child development
Social and Language Development
experts. They are important to understand as the
underpinnings of many therapeutic approaches, such as
Parent-Child Relationships
interpersonal therapy, some of which have been
It is common knowledge that infants and, for the most
evaluated and found to be efficacious for some
part, their principal caretakers typically develop a close
conditions. By and large, however, these theories have
bond during the first year of life, and that in the second
rarely been tested empirically.
year of life children become distressed when they are
forcibly separated from their mothers. However, the
Intellectual Development
clinical importance of these bonds was not fully
The Swiss psychologist Jean Piaget also developed a
appreciated until John Bowlby introduced the concept
stage-constructed theory of children's intellectual
of attachment in a report on the effects of maternal
development. Piaget's theory, based on several
deprivation (Bowlby, 1951). Bowlby (1969) postulated
decades' observations of children (Inhelder & Piaget,
that the pattern of an infant's early attachment to
1958), was about how children gradually acquire the
parents would form the basis for all later social
ability to understand the world around them through
relationships. On the basis of his experience with
active engagement with it. He was the first to recognize
disturbed children, he hypothesized that, when the
that infants take an active role in getting to know their
mother was unavailable or only partially available
125
Mental Health: A Report of the Surgeon General
during the first months of the child's life, the
capabilities critical to the development of such skills as
attachment process would be interrupted, leaving
listening and speaking, but they also are fundamental to
enduring emotional scars and predisposing a child to
the acquisition of proficient reading and writing
behavioral problems.
abilities. In turn, children with a variety of speech and
A mother's bond with her child often starts when
language impediments are at increasing risk as their
she feels fetal movements during pregnancy.
language abilities fall behind those of their peers.
Immediately after birth, most, but by no means all,
Caretaker and baby start to communicate with each
mothers experience a surge of affection that is followed
other vocally as well as visually during the first months
by a feeling that the baby belongs to them. This
of life. Many, but not all, developmental psychologists
experience may not occur at all or be delayed under
believe that this early pattern of mother-infant
conditions of addiction or postnatal depression (Robson
reciprocity and interchange is the basis on which
& Kumar, 1980; Kumar, 1997). Yet, like all enduring
subsequent language and communication develop.
relationships, it seems that the relationship between
Various theorists have attempted to explain the
mother and child develops gradually and strengthens
relations between language and cognitive development
over time. Some infants who experience severe neglect
(Vygotsky, 1962; Chomsky, 1965, 1975, 1986; Bruner,
in early life may develop mentally and emotionally
1971; Luria, 1971), but no single theory has achieved
without lasting consequences, for example, if they are
preeminence. While a number of theories address
adopted and their adoptive parents provide sensitive,
language development from different perspectives, all
stable, and enriching care, or if depressed or substance-
theories suggest that language development depends on
abusing mothers recover fully (Koluchova, 1972;
both biological and socio-environmental factors. It is
Dennis, 1973; Downey & Coyne, 1990). Unfortunately,
clear that language competence is a critical aspect of
however, early neglect is all too often the precursor of
children's mental health.
later neglect. When the child remains subject to
deprivation, inadequate or insensitive care, lack of
Relationships With Other Children
affection, low levels of stimulation, and poor education
To be healthy, children must form relationships not
over long periods of time, later adjustment is likely to
only with their parents, but also with siblings and with
be severely compromised (Dennis, 1973; Curtiss,
peers. Peer relationships change over time. In the
1977).
toddler period, children's social skills are very limited;
In general, it appears that the particular caregiver
they spend most of their time playing side by side
with whom infants interact (i.e., biological mother or
rather than with each other in a give-and-take fashion.
another) is less important for the development of good
As children grow, their abilities to form close
social relationships than the fact that infants interact
relationships become highly dependent on their social
over a period of time with someone who is familiar and
skills. These include an ability to interpret and
sensitive (Lamb, 1975; Bowlby, 1988). One of the
understand other children's nonverbal cues, such as
problems in the later development of children who
body language and pitch of voice. Children whose
experience early institutionalization or significant
social skills develop optimally respond to what other
neglect is that there may have been no opportunities for
children say, use eye contact, often mention the other
the caretakers and the infants to establish strong and
child's name, and may use touch to get attention. If
mutual attachments in a reciprocating relationship.
they want to do something that other children oppose,
they can articulate the reasons why their plan is a good
Origins of Language
one. They can suppress their own wishes and desires to
Recent research has established that successful use of
reach a compromise with other children and may be
language and communication is a cornerstone of
willing to change-at least in the presence of another
childhood mental health. Not only are strong language
child-a stated belief or wish. When they are with a
126
Children and Mental Health
group of children they do not know, they are quiet but
& Thomas, 1984; Mitchell, 1993), temperament is
observant until they have a feeling for the structure and
often modified during development, particularly by the
dynamics of the group (Coie & Kuperschmidt, 1983;
interaction with the caregiver. For example, a timid
Dodge, 1983; Putallaz, 1983; Dodge & Feldman, 1990;
child can become bolder with the help of parental
Kagan et al., 1998).
encouragement (Kagan, 1984, 1989). Some traits of
In contrast, children who lack such skills tend to be
temperament, such as attention span, goal orientation,
rejected by other children. Commonly, they are
lack of distractibility, and curiosity, can affect
withdrawn, do not listen well, and offer few if any
cognitive functioning because the more pronounced
reasons for their wishes; they rarely praise others and
these traits are, the better a child will learn (Campos et
find it difficult to join in cooperative activities (Dodge,
al., 1983). Of note, it is not always clear whether
1983). They often exhibit features of oppositional
extremes of temperament should be considered within
defiant or conduct disorder, such as regular fighting,
the spectrum of mental disorder (for example, shyness
dominating and pushing others around, or being
or anxiety) or whether certain forms of temperament
spiteful (Dodge et al., 1990). Social skills improve with
might predispose a child to the development of certain
opportunities to mix with others (Bridgeman, 1981). In
mental disorders.
recent years, knowledge of the importance of children's
acquisition of social skills has led to the development
Developmental Psychopathology
and integration of social skills training components into
a number of successful therapeutic interventions.
Current Developmental Theory Applied to Child
Mental Health and Illness
Temperament
A number of central concepts and guiding assumptions
During the past two decades, as psychologists began to
underpin our current understanding of children's
view the child less as a passive recipient of
mental health and illness. These have been variously
environmental input but rather as an active player in the
defined by different investigators (Sroufe & Rutter,
process, the importance of temperament has become
1984; Cicchetti & Cohen, 1995; Jensen, 1998), but by
better appreciated (Plomin, 1986). Temperament is
and large these tenets are based on the premise that
defined as the repertoire of traits with which each child
psychopathology in childhood arises from the complex,
is born; this repertoire determines how people react to
multilayered interactions of specific characteristics of
the world around them. Such variations in character-
the child (including biological, psychological, and
istics were first described systematically by Anna
genetic factors), his or her environment (including
Freud from her observations of children orphaned by
parent, sibling, and family relations, peer and
the ravages of World War II. She noticed that some
neighborhood factors, school and community factors,
children were affectionate, some wanted to be close but
and the larger social-cultural context), and the specific
were too shy to approach adults, and some were
manner in which these factors interact with and shape
difficult because they were easily angered and
each other over the course of development. Thus, an
frustrated (A. Freud, 1965).
understanding of a child's particular history and past
The first major longitudinal observations on
experiences (including biologic events affecting brain
temperament were begun in the 1950s by Thomas and
development) is essential to unravel the why's and
Chess (1977). They distinguished 10 aspects of
wherefore's of a child's particular behaviors, both
temperament, but there appear to be many different
normal and abnormal.
ways to describe temperamental differences (Goldsmith
While this principle assumes developmental
et al., 1987). Although there is some continuity in
continuities, to the extent that early experiences are
temperamental qualities throughout the life span (Chess
"brought forward" into the current behavior, it is also
127
Mental Health: A Report of the Surgeon General
important to consider developmental discontinuities,
the most important context for developing children is
where qualitative shifts in the child's biological,
their caretaking environment. Research with both
psychological, and social capacities may occur. These
humans and animals has demonstrated that gross
may not be easily discerned or predicted ahead of time
disruptions in this critical parameter have immediate
and may reflect the emergence of new capacities (or
and long-term effects, not just on the young organism's
incapacities) as the child's psychological self, brain,
later social-emotional development but also on physical
and social environment undergo significant
health, long-term morbidity and mortality, later
reorganization.
parenting practices, and even behavioral outcomes of
A second precept underlying an adequate
its offspring. Moreover, context may play a role in the
understanding of children's mental health and illness
definition of what actually constitutes psychopathology
concerns the innate tendencies of the child to adapt to
or health. The same behavior in one setting or culture
his or her environment. This principle of adaptation
might be acceptable and even "normative," whereas it
incorporates and acknowledges children's "self-
may be seen as pathological in another.
righting" and "self-organizing" tendencies; namely, that
Yet another principle central to understanding child
a child within a given context naturally adapts (as much
mental health and illness is that normal and abnormal
as possible) to a particular ecological niche, or when
developmental processes are often separated only by
necessary, modifies that niche to get needs met. When
differences of degree. Thus, supposed differences
environments themselves are highly disordered or
between normal and abnormal behavior may be better
pathological, children's adaptations to such settings
understood by taking into account the differences in the
may also be pathologic, especially when compared with
amount or degree of the particular behavior, or the
children's behaviors within more healthy settings. This
degree of exposure to a particular risk factor.
principle underscores the likelihood that some (but not
Frequently, no sharp distinctions can be made.
all) "pathologic" behavioral syndromes might be best
The virtue of these developmental considerations
characterized as adaptive responses when the child or
when applied to children is that (a) they enable a
adolescent encounters difficult or adverse
broader, more informed search for factors related to the
circumstances. Notably, this ability to adapt
onset of, maintenance of, and recovery from abnormal
behaviorally is reflected at multiple levels, including
forms of child behavior; (b) they help move beyond
the level of brain and nervous system structures
static diagnostic terms that tend to reduce the behaviors
(sometimes called neuroplasticity).
of a complex, developing, adapting, and feeling child to
A third consideration that guides both research-
an oversimplified diagnostic term; (c) they offer a new
based and clinical approaches to understanding child
perspective on potential targets for intervention,
mental health and illness concerns the importance of
whether child-focused or directed toward
age and timing factors. For example, a behavior that
environmental or contextual factors; and (d) they
may be quite normal at one age (e.g., young children's
highlight the possibility of important timing
distress when separated from their primary caretaking
considerations: windows of opportunity during a
figure) can be an important symptom or indicator of
child's development when preventive or treatment
mental illness at another age. Similarly, stressors or risk
interventions may be especially effective.
factors may have no, little, or profound impact,
In the sections that follow, these considerations
depending on the age at which they occur and whether
will help the reader understand the important
they occur alone or with other accumulated risk factors.
differences from chapters focusing principally on
A fourth premise underpinning an adequate
adults, as well as the unique opportunities for
understanding of children's mental health and illness
intervention that occur because of these differences.
)
concerns the importance of the child's context. Perhaps
128
Children and Mental Health
Overview of Risk Factors and
difficult temperament or an inherited predisposition to
Prevention
a mental disorder; external risk factors such as poverty,
Current approaches to understanding the etiology of
deprivation, abuse and neglect; unsatisfactory relation-
mental disorders in childhood are driven by empirical
ships; parental mental health disorder; or exposure to
traumatic events.
advances in neuroscience and behavioral research
rather than by theories. Epidemiological research on the
factors that make children vulnerable to mental illness
Biological Influences on Mental Disorders
It seems likely that the roots of most mental disorders
is important for several reasons: delineating the range
lie in some combination of genetic and environmental
of risk factors for particular mental disorders helps to
factors-the latter may be biological or psychosocial
understand their etiology; the populations most at risk
(Rutter et al., 1999). However, increasing consensus
can be identified; understanding the relative strength of
has emerged that biologic factors exert especially
different risk factors allows for the design of
pronounced influences on several disorders in par-
appropriate prevention programs for children in
ticular, including pervasive developmental disorder
different contexts; and resources can be better allocated
(Piven & O'Leary, 1997), autism (Piven & O'Leary,
to intervene so as to maximize their effectiveness.
1997), and early-onset schizophrenia (McClellan &
Werry, in press). It is also likely that biological factors
Risk Factors
play a large part in the etiology of social phobia (Pine,
There is now good evidence that both biological factors
1997), obsessive-compulsive disorder (Leonard et al.,
and adverse psychosocial experiences during childhood
1997), and other disorders such as Tourette's disorder
influence-but not necessarily "cause"-the mental
(Leckman et al., 1997).
disorders of childhood. Adverse experiences may occur
Two important points about biological factors
at home, at school, or in the community. A stressor or
should be borne in mind. The first is that biological
risk factor may have no, little, or a profound impact,
influences are not necessarily synonymous. with those
depending on individual differences among children
of genetics or inheritance. Biological abnormalities of
and the age at which the child is exposed to it, as well
the central nervous system that influence behavior,
as whether it occurs alone or in association with other
thinking, or feeling can be caused by injury, infection,
risk factors. Although children are influenced by their
poor nutrition, or exposure to toxins, such as lead in the
psychosocial environment, most are inherently resilient
environment. These abnormalities are not inherited.
and can deal with some degree of adversity. However,
Mental disorders that are most likely to have genetic
some children, possibly those with an inherent
components include autism, bipolar disorder,
biological vulnerability (e.g., genes that convey
schizophrenia, and attention-deficit/hyperactivity
susceptibility to an illness), are more likely to be
disorder (ADHD) (National Institute of Mental Health
harmed by an adverse environment, and there are some
[NIMH], 1998). Second, it is erroneous to assume that
environmental adversities, especially those that are
biological and environmental factors are independent of
long-standing or repeated, that seem likely to induce a
each other, when in fact they interact. For example,
mental disorder in all but the hardiest of children. A
traumatic experiences may induce biological changes
recent analysis of risk factors by Kraemer and
that persist. Conversely, children with a biologically
colleagues (1997) has provided a useful framework for
based behavior may modify their environment. For
differentiating among categories of risk and may help
example, low-birth-weight infants who have sustained
point this work in a more productive direction.
brain damage, and thereby become excessively
Risk factors for developing a mental disorder or
irritable, may change the behavior of caretakers in a
experiencing problems in social-emotional
way that adversely affects the caretaker's ability to
development include prenatal damage from exposure to
provide good care. Thus, it is now well documented
alcohol, illegal drugs, and tobacco; low birth weight;
129
Mental Health: A Report of the Surgeon General
that a number of biologic risk factors exert important
the child is raised in an abusive environment (Toth &
effects on brain structure and function and increase the
Cicchetti, 1996), and to later conduct disorder
likelihood of subsequently developing mental dis-
(Sampson & Laub, 1993). The relationship of
orders. These well-established factors include intra-
attachment to mental disorders has been the subject of
uterine exposure to alcohol or cigarette smoke (Nichols
several important review articles (Rutter, 1995; van
& Chen, 1981), perinatal trauma (Whitaker et al.,
IJzendoorn et al., 1995).
1997), environmental exposure to lead (Needleman et
There is controversy as to whether the key
al., 1990), malnutrition of pregnancy, traumatic brain
determinant of "insecure" responses to strange
injury, nonspecific forms of mental retardation, and
situations stems from maternal behavior or from an
specific chromosomal syndromes.
inborn predisposition to respond to an unfamiliar
stranger with avoidant behaviors, such as is found in
Psychosocial Risk Factors
socially phobic children (Belsky & Rovine, 1987;
A landmark study on risks from the environment
Kagan et al., 1988; Thompson et al., 1988; Kagan,
(Rutter & Quinton, 1977) showed that several factors
1994, 1995). Kagan demonstrated that infants who
can endanger a child's mental health. Dysfunctional
were more prone to being active, agitated, and tearful
aspects of family life such as severe parental discord,
at 4 months of age were less spontaneous and sociable
a parent's psychopathology or criminality,
and more likely to show anxiety symptoms at age 4
overcrowding, or large family size can predispose to
(Snidman et al., 1995; Kagan et al., 1998). These
conduct disorders and antisocial personality disorders,
findings are of considerable significance, because long-
especially if the child does not have a loving
term study of such highly reactive, behaviorally
relationship with at least one of the parents (Rutter,
inhibited infants and toddlers has shown that they are
1979). Economic hardship can indirectly increase a
excessively shy and avoidant in early childhood and
child's risk of developing a behavioral disorder because
that this behavior persists and predisposes to later
it may cause behavioral problems in the parents or
anxiety (Biederman et al., 1993). There is also some
increase the risk of child abuse (Dutton, 1986; Link et
controversy as to whether "difficult" temperament in an
al., 1986; Wilson, 1987; Schorr, 1988). Exposure to
infant is an early manifestation of a behavior problem,
acts of violence also is identified as a possible cause of
particularly in children who go on to demonstrate such
stress-related mental health problems (Jenkins & Bell,
problems as conduct disorder (Olds et al., 1999). One
1997). Studies point to poor caregiving practices as
analysis of the attachment literature suggests that
being a risk factor for children of depressed parents
abnormal or insecure forms of attachment are largely
(Zahn-Waxler et al., 1990).
the product of maternal problems, such as depression
The quality of the relationship between infants or
and substance abuse, rather than of individual
children and their primary caregiver, as manifested by
differences in the child (van IJzendoorn et al., 1992).
the security of attachment, has long been felt to be of
The relationship between a child's temperament
paramount importance to mental health across the life
and parenting style is complex (Thomas et al., 1968);
span. In this regard, the relationship between maternal
it may be either protective if it is good or a risk factor
problems and those factors in children that predispose
if it is poor. Thus, a difficult child's chances of
them to form insecure attachments, particularly young
developing mental health problems are much reduced
infants' and toddlers' security of attachment and
if he or she grows up in a family in which there are
temperament style and their impact on the development
clear rules and consistent enforcement (Maziade et al.,
of mood and conduct disorders, is of great interest to
1985), while a child exposed to inconsistent discipline
researchers. Many investigators have taken the view
is at greater risk for later behavior problems (Werner &
that the nature and the outcome of the attachment
Smith, 1992).
process are related to later depression, especially when
130
Children and Mental Health
Family and Genetic Risk Factors
Hilsman, 1992). Depression is also often associated
As noted above in the relationships between
with marital discord, which may have its own adverse
temperament and attachment, in some instances the
effect on children and adolescents. Conversely, the
relative contributions of biologic influences and
behavior of the depressed child or teenager may
environmental influences are difficult to tease apart, a
contribute to family stress as much as being a product
problem that particularly affects studies investigating
of it. The poor academic performance, withdrawal from
the impact of family and genetic influences on risk for
normal peer activities, and lack of energy or motivation
childhood mental disorder. For example, research has
of a depressed teenager may lead to intrusive or
shown that between 20 and 50 percent of depressed
reprimanding reactions from parents that may further
children and adolescents have a family history of
reduce the youngster's self-esteem and optimism.
depression (Puig-Antich et al., 1989; Todd et al., 1993;
The consequences of maternal depression vary with
Williamson et al., 1995; Kovacs, 1997b). The exact
the state of development of the child, and some of the
reasons for this increased risk have not been fully
effects are quite subtle (Cicchetti & Toth, 1998). For
clarified, but experts tend to agree that both factors
example, in infancy, a withdrawn or unresponsive
interact to result in this increased risk (Weissman et al.,
depressed mother may increase an infant's distress, and
1997). Family research has found that children of
an intrusive or hostile depressed mother may lead the
depressed parents are more than three times as likely as
infant to avoid looking at and communicating with her
children of nondepressed parents to experience a
(Cohn et al., 1986). Other studies have shown that if
depressive disorder (see Birmaher et al., 1996a and
infants' smiles are met with a somber or gloomy face,
1996b for review). Parental depression also increases
they respond by showing a similarly somber expression
the risk of anxiety disorders, conduct disorder, and
and then by averting their eyes (Murray et al., 1993).
alcohol dependence (Downey & Coyne, 1990;
During the toddler stage of development, research
Weissman et al., 1997; Wickramaratne & Weissman,
shows that the playful interactions of a toddler with a
1998). The risk is greater if both parents have had a
depressed mother are often briefer and more likely to
depressive illness, if the parents were depressed when
be interrupted (by either the mother or the child) than
they were young, or if a parent had several episodes of
those with a nondepressed parent (Jameson et al.,
depression (Merikangas et al., 1988; Downey & Coyne,
1997). Research has shown that some depressed
1990; McCracken, 1992a, 1992b; Mufson et al., 1992;
mothers are less able to provide structure or to modify
Warner et al., 1995; Wickramaratne & Weissman,
the behavior of excited toddlers, increasing the risk of
1998).
out-of-control behavior, the development of a later
conduct disorder, or later aggressive dealings with
Effects of Parental Depression
peers (Zahn-Waxler et al., 1990; Hay et al., 1992). A
Depressed parents may be withdrawn and lack energy
depressed mother's inability to control a young child's
and consequently pay little attention to, or provide
behavior may result in the child failing to learn
inadequate supervision of, their children. Alternatively,
appropriate skills for settling disputes without reliance
such parents may be excessively irritable and
on aggression.
overcritical, thereby upsetting children, demoralizing
them, and distancing them (Cohn et al., 1986; Field et
Stressful Life Events
al., 1990). At a more subtle level, parents' distress-
The relationship between stressful life events and risk
being pessimistic, tearful, or threatening suicide-is
for child mental disorders is well established (e.g.,
sometimes seen or heard by the child, thereby inducing
Garmezy, 1983; Hammen, 1988; Jensen et al., 1991;
anxiety. Depressed parents may not model effective
Garber & Hilsman, 1992), although this relationship in
coping strategies for stress; instead of "moving on,"
children and adolescents is complicated, perhaps
some provide an example of "giving up" (Garber &
reflecting the impact of individual differences and
131
Mental Health: A Report of the Surgeon General
developmental changes. For example, there is a
Dishion, 1988). In stressed or large families, parents
relationship between stressful life events, such as
have many demands placed on their time and find it
parental death or divorce, and the onset of major
difficult to oversee, or place limits on, their young
depression in young children, especially if they occur
children's behavior. When parental attention is in short
in early childhood and lead to a permanent and negative
supply, young siblings squabbling with each other
change in the child's circumstances. Yet findings are
attract available attention. In such situations, parents
mixed as to whether the same relationship is true for
rarely comment on good or neutral behavior but do pay
depression in midchildhood or in adolescence
attention, even if in a highly critical and negative way,
(Birmaher et al., 1996a and 1996b; Garrison et al.,
when their children start to fight; as a result, the act of
1997).
fighting may be inadvertently rewarded. Thus, any
attention, whether it be praise or physical punishment,
Childhood Maltreatment
increases the likelihood that the behavior is repeated.
Child abuse is a very widespread problem; it is
estimated that over 3 million children are maltreated
Correlations and Interactions Among Risk
every year in the United States (National Committee to
Factors
Prevent Child Abuse, 1995). Physical abuse is
Recent evidence suggests that social/environmental risk
associated with insecure attachment (Main & Solomon,
factors may combine with physical risk factors of the
1990), psychiatric disorders such as post-traumatic
child, such as neurological damage caused by birth
stress disorder, conduct disorder, ADHD (Famularo et
complications or low birth-weight, fearlessness and
al., 1992), depression (Kaufman, 1991), and impaired
stimulation-seeking behavior, learning impairments,
social functioning with peers (Salzinger et al., 1993).
autonomic underarousal, and insensitivity to physical
Psychological maltreatment is believed to occur more
pain and punishment (Raine et al., 1996, 1997, 1998).
frequently than physical maltreatment (Cicchetti &
However, testing models of the impact of risk factor
Carlson, 1989); it is associated with depression,
interactions for the development of mental disorders is
conduct disorder, and delinquency (Kazdin et al., 1985)
difficult, because some of the risk factors are difficult
and can impair social and cognitive functioning in
to measure. Thus, the trend these days is to move away
children (Smetana & Kelly, 1989).
from the consideration of individual risk factors toward
identifying measurable risk factors and their com-
Peer and Sibling Influences
binations and incorporating all of them into a single
The influence of maladaptive peers can be very
model that can be tested (Patterson, 1996).
damaging to a child and greatly increases the likelihood
The next section describes a series of preventive
of adverse outcomes such as delinquency, particularly
interventions directed against the environmental risk
if the child comes from a family beset by many
factors described above.
stressors (Friday & Hage, 1976; Loeber & Farrington,
1998). One way to reduce antisocial behavior in
Prevention
adolescents is to encourage such youths to interact with
Childhood is an important time to prevent mental
better adapted youths under the supervision of a mental
disorders and to promote healthy development, because
health worker (Feldman et al., 1983). Sibling rivalry is
many adult mental disorders have related antecedent
a common component of family life and, especially in
problems in childhood. Thus, it is logical to try to
the presence of other risk factors, may contribute to
intervene early in children's lives before problems are
family stresses (Patterson & Dishion, 1988). Although
established and become more refractory. The field of
almost universal, in the presence of other risk factors it
prevention has now developed to the point that
may be the origin of aggressive behavior that
reduction of risk, prevention of onset, and early
eventually extends beyond the family (Patterson &
intervention are realistic possibilities. Scientific
132
Children and Mental Health
methodologies in prevention are increasingly
young children, adolescents, and/or their caregivers,
sophisticated, and the results from high-quality
addressing the risk factors described above.
research trials are as credible as those in other areas of
biomedical and psychosocial science. There is a
Project Head Start
growing recognition that prevention does work; for
Project Head Start, though generally conceived of as an
example, improving parenting skills through training
early childhood intervention program, is probably this
can substantially reduce antisocial behavior in children
country's best known prevention program. In 1965,
(Patterson et al., 1993).
when it was designed and first implemented in 2,500
The wider human services and law enforcement
communities, Head Start's target population was
communities, not just the mental health community,
economically disadvantaged preschool children. Its
have made prevention a priority. Policymakers and
goal was to improve the social competence of these
service providers in health, education, social services,
children through an 8-week comprehensive intervention
and juvenile justice have become invested in
that included a center-based component and a home
intervening early in children's lives: they have come to
visit by community aides, focusing on social, health,
appreciate that mental health is inexorably linked with
and education services (Karoly et al., 1998). A number
general health, child care, and success in the classroom
of psychologists, most notably Jerome Bruner (1971),
and inversely related to involvement in the juvenile
argued that children can be trained to think in a more
justice system. It is also perceived that investment in
logical way and that the development of logic is not
prevention may be cost-effective. Although much
entirely predetermined. Bruner's views were very
research still needs to be done, communities and
influential in launching early intervention programs
managed health care organizations eager to develop,
such as Head Start. There is now ample evidence that,
maintain, and measure empirically supported
by providing an appropriately stimulating environment,
preventive interventions are encouraged to use a risk
significant advances in knowledge and reasoning
and evidence-based framework developed by the
ability can be achieved.
National Mental Health Association (Mrazek, 1998).
The program has served over 15 million children
Some forms of primary prevention are so familiar
and has cost $31 billion since its inception (General
that they are no longer thought of as mental health
Accounting Office, 1997). It has changed in many ways
prevention activities, when, in fact, they are. For
in the intervening years, and there now is considerable
example, vaccination against measles prevents its
program variation across localities (Zigler & Styfco,
neurobehavioral complications; safe sex practices and
1993). Early evaluations of Head Start showed
maternal screening prevent newborn infections such as
promising results in terms of higher IQ scores, but over
syphilis and HIV, which also have neurobehavioral
the years many of the findings have met with criticism
manifestations. Efforts to control alcohol use during
and skepticism. The reason is that there has been no
pregnancy help prevent fetal alcohol syndrome
national randomized controlled trial to evaluate the
(Stratton et al., 1996). All these conditions may
program as originally designed (Karoly et al., 1998).
produce mental disorders in children.
Repeated evaluations of Head Start programs that
This section describes several exemplary
did not employ such a rigorous design (Berrento-
interventions that focus on enhancing mental health and
Clement et al., 1984; Seitz et al., 1985; Lee et al., 1990;
primary prevention of behavior problems and mental
Yoshikawa, 1995) have shown that, although focused
health disorders. Prevention of a disorder or its
early education can improve test scores, the advantage
recurrence or exacerbation is discussed together with
is short-lived. The test scores of children of comparable
that disorder in other sections of this chapter.
ability who do not receive early childhood education
Prevention strategies usually target high-risk infants,
quickly catch up with those who have been in Head
Start programs (Lee et al., 1990). Yet there appear to be
133
Mental Health: A Report of the Surgeon General
more enduring academic outcomes. A review of 36
supplement the school's basic curriculum. There were
studies of Head Start and other early childhood
significant positive effects from the two-phase
programs found them to lower enrollment in special
intervention on intellectual development and academic
education and to enhance rates of high school
achievement, and these effects were maintained
graduation and promotion to the next grade level
through age 12, which was 4 years after the
(Barnett, 1995). Head Start and other forms of early
intervention ended.
education offer arguably even more important benefits,
which do not become apparent until children are older.
Infant Health and Development Program
The advantages are mainly social, rather than cognitive,
The Infant Health and Development Program (IHDP)
and include better peer relations, less truancy, and less
also began at birth and continued for several years and
antisocial behavior (Berrento-Clement et al., 1984;
was also designed for low-birth-weight and premature
Provence, 1985; Seitz et al., 1985; Webster-Stratton,
infants (McCarton et al., 1997²). The intervention was
1998; Weikart, 1998). Although important from a
provided until the children reached 3 years of age. It
societal perspective, it is not known whether these very
included pediatric care, home visits, parent group
significant benefits are due to direct effects on the child
meetings, and center-based schooling 5 days a week
or to the parent education programs that often accom-
from 12 months of age to 3 years. At the end of the
pany Head Start programs (Zigler & Styfco, 1993).
intervention, the group receiving it had significantly
higher mean IQ scores than did the control group. Of
Carolina Abecedarian Project
note, although children's behavior problems were not
The Carolina Abecedarian Project is an example of an
targeted by the intervention, mothers of children in the
early educational intervention for high-risk children
intervention group reported significantly fewer
that has been tested more rigorously than Head Start in
behavior problems than those in the control group.
well-designed, randomized, and controlled trials. It
addresses the issue of the timing of the intervention,
Elmira Prenatal/Early Infancy Project
that is, when an intervention should begin and how
The Elmira Prenatal/Early Infancy Project is an
long it should continue. Unlike Head Start, children
excellent example of a preventive intervention that
were enrolled in this program at birth and remained in
targeted an at-risk population to prevent the onset of a
it for several years.
series of health, social, and mental health problems in
In the Carolina Abecedarian Project, children who
children and in their mothers (Olds et al., 1998 and
had been identified at birth as being at high risk for
previous years³). This study warrants special attention
school failure on the basis of social and economic
because of its positive and enduring findings,
variables were enrolled in a child-centered prevention-
randomized, controlled design, cost-benefit analysis,
oriented intervention program delivered in a day care
and unusually long-term follow up of 15 years. The
setting from infancy to age 5 (Campbell & Ramey,
study began by focusing on pregnant women bearing
1994¹). The preschool intervention operated 8 hours a
their first child in a small, semirural county in upstate
day for 50 weeks a year and included an infant
New York. The children of these women were
curriculum to enhance development and parent
considered high risk because of their mother's young
activities. At elementary school age, a second
maternal age, single-parent status, or low socio-
intervention was provided: the children, who were then
economic level. There were four study groups to which
in kindergarten, received 15 home visits a year for 3
years from a teacher who prepared a home program to
2 Also see IHDP, 1990; Ramey et al., 1992; Brooks-Gunn et al.,
1994a, 1994b; Casey et al., 1994.
I Also see Ramey et al., 1984; Ramey & Campbell, 1984; Horacek
3 Also see Olds et al., 1986a, 1986b, 1988, 1993, 1994a, 1994b,
et al., 1987; Martin et al., 1990.
1995, and 1997.
134
Children and Mental Health
random assignment was made. The first group received
of the program was recovered with a dividend of $180
developmental screening at ages 1 and 2; the second
per family.
group received screening and free transportation to
Fifteen years after the birth of the index child (13
health care; the third group received screening,
years after termination of the intervention), women
transportation, and nurse home visits once every 2
who were visited by nurses during pregnancy and
weeks during pregnancy; and the fourth group received
infancy had significantly fewer subsequent preg-
all of the above plus continued home visits by a nurse
nancies, less use of welfare, fewer verified reports of
on a diminishing schedule until the infants were 24
abuse and neglect, fewer behavioral impairments due to
months of age. The intervention focused on parent
use of alcohol and other drugs, and fewer arrests. Their
education, enhancement of the women's informal
children, now adolescents, reported fewer instances of
support systems, and linkage with community services.
running away, fewer arrests, fewer convictions and
Women in both groups receiving home visits from
violations of probation, fewer lifetime sex partners,
nurses had many positive behavioral outcomes
fewer cigarettes smoked per day, and fewer days having
compared with groups that received screening only or
consumed alcohol in the last 6 months. The parents of
screening plus transportation. Among the women at
these adolescents reported that their children had fewer
highest risk for caregiver dysfunction, those who were
behavioral problems related to use of alcohol and other
visited by a nurse had fewer instances of verified child
drugs.
abuse and neglect during the first 2 years of their
children's lives. They were observed in their homes to
Primary Mental Health Project
restrict and punish their children less frequently, and
The Primary Mental Health Project (PMHP) is a 42-
they provided more appropriate play materials. There
year-old program for early detection and prevention of
were no differences between groups in the rates of new
young children's school adjustment problems. PMHP
cases of child abuse and neglect or in the children's
currently operates in approximately 2,000 schools in
intellectual functioning in the period when the children
700 school districts nationally and internationally.
were 25 to 48 months of age. However, nurse-visited
Seven states in the United States are implementing the
children had fewer behavioral and parental coping
program systematically, based on authorizing
problems (as noted in the physician record). Nurse-
legislation and state appropriations.
visited mothers were observed to be more involved
PMHP has four key elements: (1) a focus on
with their children than were mothers in the
primary grade children; (2) systematic use of brief
comparison groups.
objective screening measures for early identification of
A cost-benefit analysis estimated program costs
children in need; (3) use of carefully selected, trained,
(direct costs of nurse visitation, costs of services to
closely supervised nonprofessionals (called child
which nurses linked families, and costs of
associates) to establish a caring and trusting
transportation) and benefits (cost outcomes presumed
relationship with children; and (4) a changing role for
to be affected by the program through improved
the school professionals that features selection,
maternal and child functioning, such as less use of Aid
training, and supervision of child associates, early
to Families With Dependent Children, Medicaid, food
systematic screening, and functioning as program
stamps, child protective services, and greater tax
coordinator, liaison, and consultant to parents, teachers
revenues generated by women's working). Taking a
and other school personnel.
time point of 2 years after the program ended, the net
The PMHP model has been applied flexibly to
cost of the program for the sample as a whole was
diverse ethnic and sociodemographic groups in settings
$1,582 per family, but for low-income families, the cost
where help is most needed. Over 30 program evaluation
studies, including several at the state level, underscore
135
Mental Health: A Report of the Surgeon General
the program's efficacy (Cowen et al., 1996). Significant
development of the child. According to these
improvements were detected in children's grades,
principles, a mental disorder results from the inter-
achievement test scores, and adjustment ratings by
action of a child and his or her environment. Thus,
teachers and child associates. PMHP represents a
mental illness often does not lie within the child alone.
successful mental health intervention that does not
Within the conceptual framework and language of
require highly trained and skilled mental health
integrative neuroscience, the mental disorder is an
professionals.
"emergent property" of the transaction with the
environment. Proper assessment of a child's mood,
Other Prevention Programs and Strategies
thought, and behaviors demands a simultaneous
These and other prevention trials demonstrate that
consideration of nature and nurture, genes and
positive adaptation and social-emotional well-being in
environment, and biology and psychosocial influences.
children and youth can be enhanced, and that risk
These relationships are reciprocal. The brain shapes
factors for behavioral and emotional disorders can be
behavior, and learning shapes the brain.
reduced, by intervening in home, school, day care, and
Mental disorders must be considered within the
other settings. Programs have focused not only on
context of the family and peers, school, home, and
mental health problems but also on other problem
community. Taking the social-cultural environment into
behaviors (Botvin et al., 1995; St. Lawrence et al.,
consideration is essential to understanding mental
1995; Kellam & Anthony, 1998).
disorders in children and adolescents, as it is in adults.
Other prevention trials are showing similar
However, the changing nature of these environments,
benefits. For example, a large-scale, four-site school-
coupled with the progressively unfolding processes of
and home-based prevention trial, known as FastTrack,
brain development, makes the emphasis on context, as
has shown clear benefits in reducing behavior problems
well as development, more complex and more central
among high-risk children, as well as in reducing needs
in child mental health (Jensen & Hoagwood, 1997).
for and use of special education, which has substantial
Thus, developmental psychopathology encourages
cost-effectiveness implications (Conduct Problems
consideration of the transactions between the individual
Prevention Research Group, 1999a, 1999b). Another
and the social and physical environment at the same
trial is now under way to test the efficacy of a
time that signs and symptoms of mental disorder are
preventive intervention provided to adolescents whose
considered. Moreover, focusing on diagnostic labels
parents are currently being treated for depression
alone provides too limited a view of mental disorders
within a health maintenance organization (Clark et al.,
in children and adolescents.
1998). Treatment of mood disorders also has potential
effectiveness for the primary prevention of suicide, as
General Categories of Mental Disorders of
explained in the later section on Depression and
Children
Suicide in Children and Adolescents.
Mental disorders with onset in childhood and
adolescence are listed in Table 3-2 as they appear in
Overview of Mental Disorders in
DSM-IV. These disorders fall into a number of broad
Children
categories, most of which apply not just to children but
across the entire life span: anxiety disorders; attention-
A consideration of developmental principles enhances
deficit and disruptive behavior disorders; autism and
understanding of mental illness in children and
other pervasive developmental disorders; eating
adolescents by reconciling the concept of mental
disorders (e.g., anorexia nervosa); elimination disorders
disorder as a stable state or condition with the ongoing
136
Children and Mental Health
Table 3-2.
Selected mental disorders of childhood and
severe learning difficulties and impaired intelligence.
adolescence from the DSM-IV
The disorders in this category include the pervasive
Anxiety Disorders
developmental disorders, autism, Asperger's disorder,
Attention-Deficit and Disruptive Behavior Disorders
and Rett's disorder (DSM-IV).
It is not uncommon for a child to have more than
Autism and Other Pervasive Developmental
one disorder or to have disorders from more than one of
Disorders
these groups. Thus, children with pervasive
Eating Disorders
developmental disorders often suffer from ADHD.
Elimination Disorders
Children with a conduct disorder are often depressed,
Learning and Communication Disorders
and the various anxiety disorders may co-occur with
mood disorders. Learning disorders are common in all
Mood Disorders (e.g., Depressive Disorders)
these conditions, as are alcohol and other substance use
Schizophrenia
disorders (DSM-IV).
Tic Disorders
Assessment and Diagnosis
(e.g., enuresis, encopresis); learning and communi-
As with adults, assessment of the mental function of
cation disorders; mood disorders (e.g., major depres-
children has several important goals: to learn the
sive disorder, bipolar disorder); schizophrenia; and tic
unique functional characteristics of each individual
disorders (Tourette's disorder). Several of the more
(sometimes called formulation) and to diagnose signs
common childhood conditions are described below.
and symptoms that suggest the presence of a mental
Disorders of anxiety and mood are characterized by
disorder. Case formulation helps the clinician
the repeated experience of intense internal or emotional
understand the child in the context of family and
distress over a period of months or years. Feelings
community. Diagnosis helps identify children who may
associated with these conditions may be those of
have a mental disorder with an expected pattern of
unreasonable fear and anxiety, lasting depression, low
distress and limitation, course, and recovery. Both
self-esteem, or worthlessness. Syndromes of depression
processes are useful in planning for treatment and
and anxiety very commonly co-occur in children. The
supportive care. Both are helpful in developing a
disorders in this broad group include separation anxiety
treatment plan.
disorder, generalized anxiety disorder, post-traumatic
Even with the aid of widely used diagnostic
stress disorder, obsessive-compulsive disorder, major
classification systems such as DSM-IV (see Chapter 2),
depressive disorder, dysthymia, and bipolar disorder
diagnosis and diagnostic classification present a greater
(DSM-IV).
challenge with children than with adults for several
Children who suffer from attention-deficit disorder,
reasons. Children are often unable to verbalize thoughts
disruptive disorder, and oppositional defiant disorder
and feelings. Clinicians by necessity become more
may be inattentive, hyperactive, aggressive, and/or
reliant on parents, teachers, and other professionals,
defiant; they may repeatedly defy the societal rules of
who may be unable to assess these mental processes in
the child's own cultural group or disrupt a well-ordered
children. Children's normal development also presents
environment such as a school classroom.
an ever-changing backdrop that complicates clinical
Children with autism and other pervasive
presentation. As previously noted, some behaviors may
developmental disorders often suffer from disordered
be quite normal at one age but suggest mental illness at
cognition or thinking and have difficulty understanding
another age. Finally, the criteria for diagnosing most
and using language, understanding the feelings of
mental disorders in children are derived from those for
others, or, more generally, understanding the world
adults, even though relatively little research attention
around them. Such disorders are often associated with
has been paid to the validity of these criteria in
137
Mental Health: A Report of the Surgeon General
children. Expression, manifestation, and course of a
teachers, pediatricians, and hospital records. The
disorder in children might be very different from those
mental health professional also makes observations of
in adults. The boundaries between normal and
the child's or teenager's behavior and patterns of
abnormal are less distinct and those between one
speech. Very often, additional testing is requested to
diagnosis and another are fluid.
assess the child's or youth's intelligence and learning
Thus, the field of childhood mental health
abilities. Information about symptoms can be obtained
historically downplayed diagnosis. This trend began to
more reliably by direct questioning (Gittelman-Klein,
change in the 1980s, in part as a result of developing
1978; Gittelman, 1985).
practice guidelines and tougher reimbursement
A full evaluation may take several hours. By that
standards (Lonigan et al., 1998) and more appropriate
time, the professional should have a good
diagnostic categories and criteria (DSM III, III-R, and
understanding of how the child is functioning at home,
IV). The body of accumulated research on treatment
at school, and in society and some understanding of the
and services referred to throughout this chapter reflects
family's characteristics. With this information, the
the past emphasis on the efficacy of treatments,
child or adolescent psychiatrist, clinical psychologist,
sometimes with and sometimes independently of
or social worker can suggest further investigations and,
diagnosis.
if needed, initiate treatment of the child and provide
Most disorders are diagnosed by their manifesta-
counseling to parents and teachers on how to best assist
tions, that is, by symptoms and signs, as well as
the child or teenager to overcome problems.
functional impairment (see Chapter 2). A diagnosis is
There is a dearth of child psychiatrists, appro-
made when the combination and intensity of symptoms
priately trained clinical child psychologists, or social
and signs meet the criteria for a disorder listed in DSM-
workers (Thomas & Holzer, 1999). Furthermore, many
IV. However, diagnosis of childhood mental disorders,
barriers remain that prevent children, teenagers, and
as noted earlier, is rarely an easy task. Many of the
their parents from seeking help from the small number
symptoms, such as outbursts of aggression, difficulty in
of specially trained professionals who are available.
paying attention, fearfulness or shyness, difficulties in
This places a burden on pediatricians, family
understanding language, food fads, or distress of a child
physicians, and other gatekeepers (such as school
when habitual behaviors are interfered with, are normal
counselors and primary child care workers) to identify
in young children and may occur sporadically
children for referral and treatment decisions. These
throughout childhood. Well-trained clinicians
gatekeepers are unlikely to have the time and
overcome this problem by determining whether a given
specialized training to do an evaluation requiring
symptom is occurring with an unexpected frequency,
several hours. Their responsibility often is to "triage"
lasting for an unexpected length of time, or is occurring
cases, that is, refer children who need further
at an unexpected point in development. Clinicians with
evaluation to specialists. Many, however, are involved
less experience may either overdiagnose normal
in treating children and adolescents. They may be
behavior as a disorder or miss a diagnosis by failing to
greatly aided by various diagnostic aids such as brief
recognize abnormal behavior. Inaccurate diagnoses are
questionnaires that can be completed in the waiting
more likely in children with mild forms of a disorder.
room of the pediatrician, the school counseling office,
or some other community setting. Ideally, these
Evaluation Process
screening questionnaires would be accompanied by a
When conducted by a mental health professional, the
clear guide on interpreting results and identifying what
evaluation process usually consists of gathering
kind of score or behavior would normally indicate a
information from several sources: the child, parents,
need for referral to a professional.
138
Children and Mental Health
Some of the questionnaires that specifically address
Treatment Strategies
mood disorders are shown in Figure 3-1. Other ques-
Children and adolescents receive most of the traditional
tionnaires, such as the Adolescent Antisocial Self-
treatments described in Chapter 2, particularly psycho-
Report Behavior Checklist (Kulik et al., 1968), the
social treatments, such as psychotherapies, and various
Eyberg Child Behavior Inventory (Eyberg & Robinson,
medications. Specific psychosocial and pharma-
1983), and the Family Interaction Coding Pattern
cological treatment approaches are described in
(Patterson, 1982), assess antisocial behavior. Adults
subsequent sections on specific mental disorders. Much
and teachers can use instruments such as the Child
of the research, however, has been conducted on adults,
Behavior Checklist (Achenbach & Edelbrock, 1983) to
with results extrapolated to children. Some of the
assess a relatively full range of behavioral and
treatments, such as interactive or play therapy with
emotional symptoms and disorders from the perspective
young children, are unique to clinical work with this
of adult informants. The Minnesota Multiphasic
group, while others, such as individual psychotherapy
Personality Inventory-2 (MMPI-2; Hathaway &
with adolescents, are similar to clinical work with
McKinley, 1989) and the Millon Adolescent Personal-
adults. Many of the treatment interventions have been
Figure 3-1. Questionnaires used to assess childhood mood disorders
Title
Source
The Children's Depression Inventory
Kovacs, 1985
(CDI)
Beck Depression Inventory
Beck, Ward, Mendelson, Mock, & Erbaugh, 1961
(BDI)
Reynolds Adolescent Depression Scale
Reynolds, 1986
(RADS)
Children's Depression Scale
Tisher & Lang, 1983
(CDS)
Center for Epidemiological Studies of Depression
Radloff, 1977
(CES-D)
Kandel Depression Scale
Kandel & Davies, 1982
(KDS)
Zung Self-Rating Depression Scale
Zung, 1965
(SDS)
Diagnostic Interview Schedule for Children
Shaffer & Fisher, 1998
(DISC)
ity Inventory (MAPI) (Millon et al., 1982)
"packaged" together in particular arrangements for
questionnaires may be used with adolescents to assess
delivery in specific clinical settings.
normal and abnormal personality function.
More attention is being paid to the value of
The advent of highly structured, computer-driven
multimodal therapies, that is, the combination of
assessment tools, such as the NIMH Diagnostic
pharmacological and psychosocial therapies. While
Interview Schedule for Children, which comes in a
research is limited, multimodal studies have shown
spoken version that can be given through headphones
benefits for treatment of ADHD (see later section),
to children and/or their parents (Shaffer et al., 1996a),
anxiety (Kearney & Silverman, 1998), and depression.
promises to greatly improve the ability of professionals
Tempering the value of psychotherapy as well as
outside of the mental health field to obtain robust
pharmacotherapy, which is discussed below, is that the
diagnostic information, which can guide them in
efficacy of these therapies in the research setting is
decisions about further referral or treatment.
greater than that in the real world. The problem of the
139
Mental Health: A Report of the Surgeon General
gap between research and clinical practice is discussed
well-controlled studies have been performed for each
in greater depth elsewhere in this chapter and in
disorder. To meet the criteria for a Well-Established
Chapter 2.
Psychosocial Intervention, there must be at least two
well-conducted group-design studies conducted by
Psychotherapy
different teams of researchers, among other criteria.⁴
The major types of psychotherapy for children are
Hereafter, these criteria are referred to as the American
supportive, psychodynamic, cognitive-behavioral, inter-
Psychological Association Task Force Criteria.
personal, and family systemic. With the exception of
Some other general points are warranted about the
the latter, these therapies originally were developed for
value of psychotherapies for children. Psychotherapies
adults and then tailored for use in children.
are especially important alternatives for those children
Most psychotherapies are deemed effective for
who are unable to tolerate, or whose parents prefer
children and adolescents because they improve more
them not to take, medications. They also are important
than with no treatment, as discussed later in this
for conditions for which there are no medications with
chapter under Treatment Interventions (Casey &
well-documented efficacy. They also are pivotal for
Berman, 1985; Hazelrigg et al., 1987; Weisz et al.,
families under stress from a child's mental disorder.
1987; Kazdin et al., 1990; Baer & Nietzel, 1991;
Therapies can serve to reduce stress in parents and
Grossman & Hughes, 1992; Shadish et al., 1993; Weisz
siblings and teach parents strategies for managing
& Weiss, 1993; Weisz et al., 1995). But despite this
symptoms of the mental disorder in their child (see
strong body of research on children comparing
later sections on Disruptive Disorders and Home-Based
treatment with no treatment, far less attention has been
Services).
paid to, and guidance provided about, the efficacy of a
given psychotherapy for a specific diagnosis (Lonigan
Psychopharmacology
et al., 1998). In other words, it is not clear which
Dramatic increases have occurred over the past decade
therapies are best for which conditions. The American
in the use of pharmacological therapies for children and
Psychological Association sought to rectify this
adolescents with mental disorders, but research has
problem by convening two task forces, the second of
lagged behind the surge in their use (Jensen et al.,
which exhaustively reviewed the professional literature
1999). Our gaps in knowledge span three areas in
to evaluate the strength of the evidence for treating
particular. First, for most prescribed medications, there
individual disorders in children. The second task force
are no studies of safety and efficacy for children and
refined two sets of criteria against which to evaluate the
adolescents. This is true for medications for mental
evidence: the first, and more rigorous, set of criteria
disorders as well as for somatic disorders. Depending
was for Well-Established Psychosocial Interventions,
on the specific medication, evidence may be lacking for
while the other was for Probably Efficacious Psycho-
short-term, or most commonly, for long-term safety and
social Interventions (Lonigan et al., 1998). The
efficacy. The problem is even more pronounced with
findings of the task force's comprehensive evaluation
newer medications, most of which have been
were published, disorder by disorder, in an entire issue
introduced into the market for adults. Only in the case
of the Journal of Clinical Child Psychology in June
of psychostimulants for ADHD is there an adequate
1998. While findings relating to individual disorders
body of research on their safety and efficacy in children
are presented in the next section of this chapter, this
and adolescents, albeit short-term information only
was the overarching conclusion:
"
the majority of
(Greenhill et al., 1998) (see later section on ADHD).
these [psychosocial] interventions do not meet criteria
Second, there is often limited information about
for the highest level of empirical support, the well-
pharmacokinetics, that is, drug concentrations in body
established criteria" (Lonigan et al., 1998). The
problem, according to these authors, is that too few
4 The criteria are listed in Chapter 1.
140
Children and Mental Health
fluids and tissues over time (Clein & Riddle, 1996).
through off-label prescribing. The problem has been
Most of what is known about pharmacokinetics comes
significant enough to have galvanized Congress into
from studies of adults. But pediatric pharmacokinetic
passing legislation, the FDA Modernization Act of
studies are crucial to identifying the appropriate dose
1997, to create financial incentives for drug sponsors to
and dose frequency for children of different ages and
conduct research with pediatric subjects [FDA, 1999
body sizes. Third, the combined effectiveness of
Title 21 USC 505A(g)]. The FDA Modernization Act
pharmacological and psychosocial treatments, that is,
may help alleviate this problem, but it is too early to
multimodal treatments, is seldom studied. Multimodal
tell.
treatments have the potential to yield dose reductions
Despite the relative lack of information concerning
in pharmacological treatments, thereby improving the
safety and efficacy of psychotropic agents in children,
side-effect profile, parental acceptance, and patient
six scientific reviews have been completed recently;
compliance.
these reviews comprehensively surveyed all available
The dearth of research on children and adolescents
published research concerning the safety and efficacy
has allowed for widespread "off-label" use of
of psychotropic medication, focusing on six general
medications. This means that, for this population,
classes of medication: the psychostimulants (Greenhill
physicians who are prescribing a given drug do not
et al., 1998), the mood stabilizers and antimanic agents
have the benefit of research and drug labeling
(Ryan et al., 1999), the selective serotonin reuptake
information developed by the sponsor and approved by
inhibitors (SSRIs) (Emslie et al., 1999), antidepressants
the Food and Drug Administration (FDA). Under U.S.
(Geller et al., 1998), antipsychotic agents (Campbell et
food and drug law, a drug is approved by the FDA only
al., 1999), and other miscellaneous agents (Riddle et
for a defined population. Yet after its approval and
al., 1998).
market availability, physicians are at liberty to
Review of this comprehensive body of research
prescribe it for anyone, even though the sponsor only is
evidence indicates strong support for the safety and
allowed to market the drug for the approved population
efficacy of several classes of agents for several
conditions, specifically, SSRIs for childhood/
(which typically is adults) (FDA, 1998). Fortunately,
adolescent obsessive-compulsive disorder, and the
there is a large body of clinical experience with
psychostimulants for ADHD. For many other disorders
children and adolescents to guide prescribing practices,
and medications, however, information from rigorously
despite few controlled studies (Green, 1996).
controlled trials is sparse or altogether absent (see
There are several reasons for the paucity of
Figure 3-2). Further, only in the area of ADHD is in-
research on medications for children and adolescents.
formation now emerging on longer term safety and
One is greater caution on the part of both the medical
efficacy, as well as on the merits of combining
profession and parents to experiment with children or
psychopharmacologic and psychotherapeutic
to prescribe drugs with potentially serious side effects.
treatments.
Another reason is the need for compliance with dosing
Given the inadequacy of efficacy data for most
requirements of the clinical trial protocol. When
nonstimulant psychotropics, studies are needed for the
children are research subjects, enforcing compliance is
majority of agents. However, efficacy data appear to be
generally perceived to be more difficult. Researchers
most urgently needed for SSRIs, mood stabilizers, and
must rely on parents to assess the degree of
novel antipsychotics, since the level of usage of these
compliance. A final reason is the cost of research. Once
medications appears to be highest among the growing
drugs have reached the market for adults, pharmaceuti-
list of psychotropic medications used in youth (Fisher
cal companies have fewer financial incentives to
& Fisher, 1996). In contrast to adult psycho-
conduct expensive and methodologically demanding
pharmacology that is focusing on differential efficacy
studies with children, to whom drugs may be given
and speed of onset of these categories of psychotropics,
141
Mental Health: A Report of the Surgeon General
Figure 3-2. Grading the Level of Evidence for Efficacy of Psychotropic Drugs in Children
Estimated
Frequency
Level of Supporting Data
of Use
Short-Term
Long-Term
Short-Term
Long-Term
Category
Indication
Efficacy
Efficacy
Safety
Safety
Rank
Stimulants
ADHD
A
B
A
A
1
Selective Serotonin
Major depression
B
C
A
C
Reuptake Inhibitors
OCD
A
C
A
C
2
Anxiety disorders
C
C
C
C
Central Adrenergic
Tourette syndrome
B
C
B
C
3
Agonists
ADHD
C
C
C
C
Valproate and
Bipolar disorders
C
C
A
A
4
Carbamazepine
Aggressive conduct
C
C
A
A
Tricyclic
Major depression
C
C
B
B
5
Antidepressants
ADHD
B
C
B
B
Benzodiazepines
Anxiety disorders
C
C
C
C
6
Antipsychotics
Childhood schizophrenia
and psychoses
B
C
C
B
7
Tourette syndrome
A
C
B
B
Lithium
Bipolar disorders
B
C
B
C
8
Aggressive conduct
B
C
C
C
Key: A = ≥ 2 randomized controlled trials (RCTs).
B = At least 1 RCT.
C = Clinical opinion, case reports, and uncontrolled trials.
Source: Jensen et al., 1999
pediatric psychopharmacology needs basic studies of
(see Table 3-3). Although these problems usually occur
efficacy.
together, one may be present without the other to
Additional information on specific medication
qualify for a diagnosis (DSM-IV). Inattention or
treatment is presented in the succeeding sections,
attention deficit may not become apparent until a child
providing more detailed discussion of particular
enters the challenging environment of elementary
disorders. Indepth information is presented on two
school. Such children then have difficulty paying
disorders where a great deal of research has been done,
attention to details and are easily distracted by other
namely, ADHD and major depressive disorder,
events that are occurring at the same time; they find it
followed by briefer discussions of other childhood
difficult and unpleasant to finish their schoolwork; they
mental disorders.
put off anything that requires a sustained mental effort;
they are prone to make careless mistakes, and are
Attention-Deficit/Hyperactivity
disorganized, losing their school books and assign-
Disorder
ments; they appear not to listen when spoken to and
As its name implies, attention-deficit/hyperactivity
often fail to follow through on tasks (DSM-IV; Waslick
& Greenhill, 1997).
disorder (ADHD) is characterized by two distinct sets
of symptoms: inattention and hyperactivity-impulsivity
142
Children and Mental Health
Table 3-3. DSM-IV criteria for Attention-Deficit/Hyperactivity Disorder
A. Either (1) or (2):
(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that
is maladaptive and inconsistent with developmental level:
Inattention
(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other
activities
(b) often has difficulty sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the
workplace (not due to oppositional behavior or failure to understand instructions)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as
schoolwork or homework)
(g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or
tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities
(2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months
to a degree that is maladaptive and inconsistent with developmental level:
Hyperactivity
(a) often fidgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other situations in which remaining seated is expected
(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults,
may be limited to subjective feelings of restlessness)
(d) often has difficulty playing or engaging in leisure activities quietly
(e) is often "on the go" or often acts as if "driven by a motor"
(f) often talks excessively
Impulsivity
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into conversations or games)
B. Some hyperactive-impulsive or inattentive symptoms that cause impairment were present before age 7 years.
C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational
functioning.
E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder,
schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder
(e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).
143
Mental Health: A Report of the Surgeon General
The symptoms of hyperactivity may be apparent in
some teens who have had severe ADHD since middle
very young preschoolers and are nearly always present
childhood experience periods of anxiety or depression.
before the age of 7 (Halperin et al., 1993; Waslick &
This seems to be especially common in children whose
Greenhill, 1997). Such symptoms include fidgeting,
predominant symptom is inattention (Morgan et al.,
squirming around when seated, and having to get up
1996). Excellent reviews of ADHD can be found in
frequently to walk or run around. Hyperactive children
DSM-IV and other sources.⁵
have difficulty playing quietly, and they may talk
excessively. They often behave in an inappropriate and
Prevalence
uninhibited way, blurting out answers in class before
ADHD, which is the most commonly diagnosed
the teacher's question has been completed, not waiting
behavioral disorder of childhood, occurs in 3 to 5
their turn, and interrupting often or intruding on others'
percent of school-age children in a 6-month period
conversations or games (Waslick & Greenhill, 1997).
(Anderson et al., 1987; Bird et al., 1988; Esser et al.,
Many of these symptoms occur from time to time
1990; Pelham et al., 1992; Shaffer et al., 1996c;
in normal children. However, in children with ADHD
Wolraich et al., 1996). Pediatricians report that
they occur very frequently and in several settings, at
approximately 4 percent of their patients have ADHD
home and at school, or when visiting with friends, and
(Wolraich et al., 1990), but in practice the diagnosis is
they interfere with the child's functioning. Children
often made in children who meet some, but not all, of
suffering from ADHD may perform poorly at school;
the criteria recommended in DSM-IV (Wolraich et al.,
they may be unpopular with their peers, if other
1990) (see also Treatment later in this section). Boys
children perceive them as being unusual or a nuisance;
are four times more likely to have the illness than girls
and their behavior can present significant challenges
are (Ross & Ross, 1982). The disorder is found in all
for parents, leading some to be overly harsh (DSM-IV).
cultures, although prevalences differ; differences are
Inattention tends to persist through childhood and
thought to stem more from differences in diagnostic
adolescence into adulthood, while the symptoms of
criteria than from differences in presentation
motor hyperactivity and impulsivity tend to diminish
(DSM-IV).
with age. Many children with ADHD develop learning
difficulties that may not improve with treatment
Causes
(Mannuzza et al., 1993). Hyperactive behavior is often
The exact etiology of ADHD is unknown, although
associated with the development of other disruptive
neurotransmitter deficits, genetics, and perinatal
disorders, particularly conduct and oppositional-defiant
complications have been implicated. In the early post-
disorder (see Disruptive Disorders). The reason for the
World War II years, a number of pediatricians,
relationship is not known. Some believe that the
neurologists, and child psychiatrists noted that brain-
impulsivity and heedlessness associated with ADHD
damaged children were often hyperactive (Strauss &
interfere with social learning or with close social bonds
Lehtinen, 1947; Eisenberg, 1957; Laufer & Denhoff,
with parents in a way that predisposes to the
1957). These observations led to the diagnostic concept
development of behavior disorders (Barkley, 1998).
of "minimal brain damage" (Wender, 1971), which was
Even though a great many children with this
thought to be characterized by hyperactivity, inat-
disorder ultimately adjust (Mannuzza et al., 1998),
tention, learning difficulties, and a wide variety of
some-especially those with an associated conduct or
behavior problems. However, large epidemiological
oppositional-defiant disorder-are more likely to drop
studies (Rutter & Quinton, 1977) of grossly brain-
out of school and fare more poorly in their later careers
damaged children with cerebral palsy, epilepsy, and so
than children without ADHD. As they grow older,
5 Taylor, 1994; Cantwell, 1996; Waslick & Greenhill, 1997;
Barkley, 1998; and NIH Consensus Statement 110, 1998.
144
Children and Mental Health
forth, did not find an excess of hyperactivity, and more
chromosome 11 and the dopamine-transporter gene
recent imaging studies have found no evidence of gross
(DATI) on chromosome 5 (Cook et al., 1995; Smalley
brain damage in children with ADHD (Swanson et al.,
et al., 1998). Several studies have found evidence that
1998). The past view that ADHD is a form of minimal
children with ADHD have genetic variations in one of
brain damage has therefore been abandoned by experts.
the dopamine-receptor genes (DRD4), although the
Many brain-damaged children are, if anything,
largest of these studies suggests that the presence of
significantly underactive.
such a variation is associated with only a modest
In the late 1970s, it was postulated that the core
increase in the risk of developing ADHD (Smalley et
problem in hyperkinetic children was one of inattention
al., 1998). Several other studies have found evidence
(Douglas & Peters, 1979). This view led, in 1980, to
for abnormalities of the dopamine-transporter gene
the adoption, in the official DSM-III (American
(DAT1) in children with very severe forms of ADHD
Psychiatric Association, 1980) nomenclature, of the
(Cook et al., 1995; Gill et al., 1997; Waldman et al.,
new diagnostic label attention-deficit disorder.
1998).
Because the symptoms of ADHD respond well to
Yet for most children with ADHD, the overall
treatment with stimulants, and because stimulants
effects of these gene abnormalities appear small,
increase the availability of the neurotransmitter
suggesting that nongenetic factors also are important.
dopamine, the "dopamine hypothesis" has gained a
Although none of the many imaging studies have found
wide following. The dopamine hypothesis posits that
evidence of gross brain damage, some investigators
ADHD is due to inadequate availability of dopamine in
have suggested that exposure to toxins, such as lead, or
the central nervous system. The neurotransmitter
episodes of oxygen deprivation for the fetus, as may
dopamine plays a key role in initiating purposive
occur during some complications of pregnancy, may
movement, increasing motivation and alertness,
adversely affect dopamine-rich areas of the brain.
reducing appetite, and inducing insomnia, effects that
These theories support observations that hyperactivity
are often seen when a child responds well to
and inattention are more common in children whose
methylphenidate. The dopamine hypothesis has thus
mothers smoked during pregnancy (Nichols & Chen,
driven much of the recent research into the causes of
1981), in children who have been exposed to high
ADHD.
quantities of lead (Needleman et al., 1990), and in
The fact that ADHD runs in families suggests that
children who had a lack of oxygen in the neonatal
inheritance is an important risk factor. Between 10 and
period (Whittaker et al., 1997).
35 percent of children with ADHD have a first-degree
Some investigators have noted that the parents of
relative with past or present ADHD. Approximately
hyperactive children are often overintrusive and
one-half of parents who had ADHD have a child with
overcontrolling (Carlson et al., 1995). It has therefore
the disorder (Biederman et al., 1995). Over the past
been suggested that such parental behavior is another
decade, a large number of twin studies have shown that,
possible risk factor for ADHD. However, others have
when ADHD is present in one twin, it is significantly
noted that, when children are treated with
more likely also to be present in an identical twin than
methylphenidate, there is a reduction in parental
in a fraternal twin (Goodman & Stevenson, 1989).
negativity and intrusiveness. This suggests that the
These findings have led geneticists to estimate that
observed overintrusive and overcontrolling behavior of
genes are important in a high proportion of children
the parent is a response to the child's behavior rather
with ADHD.
than the cause (Barkley et al., 1985).
Research to pinpoint abnormal genes is honing in
on two genes: a dopamine-receptor (DRD) gene on
145
Mental Health: A Report of the Surgeon General
Treatment
(see reviews by Barkley, 1990; Pelham, 1993; Swanson
The American Academy of Child and Adolescent
et al., 1993, 1995b; Greenhill et al., 1998; Cantwell,
Psychiatry (AACAP) published "practice parameters"
1996a; Spencer et al., 1996.) However, psychostimu-
(i.e., guidelines for clinical practice) on the diagnosis
lants do not appear to achieve long-term changes in
and treatment of ADHD. The AACAP parameters
outcomes such as peer relationships, social or academic
include an extensive literature review, detailed
skills, or school achievement (Pelham et al., 1998).
descriptions of the clinical presentation of the disorder,
Children who do not respond to one stimulant may
and recommendations for treatment. The practice
respond to another (Elia et al., 1991; Elia & Rapoport,
parameters state that "the cornerstones of treatment are
1991). Children should be reevaluated without the
support and education of parents, appropriate school
medication to see if stimulant treatment is still
placement, and pharmacology" (AACAP, 1991). These
indicated. Many families choose to have their child
practice parameters evolved out of research relating to
take a "drug holiday" on weekends and vacations to
two major types of treatment: pharmacological
reduce overall exposure, but the utility of this strategy
treatment and psychosocial treatment, particularly
has not been demonstrated (AACAP, 1991).
behavioral modification, as well as multimodal
treatment, the combination of psychosocial and
Dosing
pharmacological treatments.
Stimulants are usually started at a low dose and
adjusted weekly (AACAP, 1991). A recent study
Pharmacological Treatment
demonstrated that the practice of dosing
Psychostimulants
methylphenidate on the basis of body weight fails to
Pharmacological treatment with psychostimulants is the
predict the optimal dose of medication (Rapport &
most widely studied treatment for ADHD. Stimulant
Denney, 1997). One of the goals of the recently
treatment has been used for childhood behavioral
completed NIMH Multimodal Treatment Study of
disorders since the 1930s (Bradley, 1937).
ADHD (described more fully below) was to develop
Psychostimulants are highly effective for 75 to 90
medication strategies to guide "best dose," dose
percent of children with ADHD. At least four separate
changes, management of side effects, and integration
psychostimulant medications consistently reduce the
with other treatments (Greenhill et al., 1996).
core features of ADHD in literally hundreds of
randomized controlled trials: methylphenidate, dextro-
Side Effects
amphetamine, pemoline, and a mixture of amphetamine
Common stimulant side effects include insomnia,
salts (Spencer et al., 1995; Greenhill, 1998a, 1998b;
decreased appetite, stomach aches, headaches, and
Greenhill et al., 1998).
jitteriness. Some children may develop tics, but a recent
These medications are metabolized, leave the body
study suggests that they disappear with continued
fairly quickly, and work for 1 to 4 hours. Administra-
treatment (Gadow et al., 1995). Rebound activation
tion is timed to meet the child's school schedule, to
(i.e., a sudden increase in attention deficit and
help the child pay attention and meet his or her
hyperactivity) has been noted anecdotally after the
academic demands, and to mitigate side effects. These
child's last dose of medication wears off (Johnston et
medications have their greatest effects on symptoms of
al., 1988). Most of the side effects are mild, recede over
hyperactivity, impulsivity, and inattention and the
time, and respond to dose changes. Children rarely
associated features of defiance, aggression, and
experience cognitive impairment, which, if it does
oppositionality. They also improve classroom
occur, can be resolved with reduction or cessation of
performance and behavior and promote increased
the drug (Cantwell, 1996). A few cases of psychosis
interaction with teachers, parents, and peers. Small
have been reported. Pemoline has been associated with
effects were found on learning and school achievement
hepatotoxicity, so monitoring of liver function is
146
Children and Mental Health
necessary. Two studies have shown no long-term
symptoms of children with ADHD (Milich & Pelham,
effects of stimulants on later height or weight (Klein &
1986).
Mannuzza, 1988; Vincent et al., 1990). Nonetheless,
regular precautionary monitoring of weight and height
Psychosocial Treatment
for children on stimulants is recommended.
Important options for the management of ADHD are
psychosocial treatments, particularly in the form of
Other Medications
training in behavioral techniques for parents and
For children with ADHD who do not respond to
teachers. Behavioral techniques, which are described
stimulants (10 to 30 percent) or cannot tolerate the side
more fully below, typically employ "time-out," point
effects, there are other useful medications. The
systems and contingent attention (adults reinforcing
antidepressant bupropion has been found to be superior
appropriate behavior by paying attention to it).
to placebo, although the response is not as strong as
Psychosocial treatments are useful for the child who
that found with stimulants (Cantwell, 1998). Bupropion
does not respond to medication at all or for whom the
can also be used as an adjunct to augment stimulant
therapeutic benefits of the medication have worn off
treatment. Well-controlled trials have shown tricyclic
and for the child who responds only partially to
antidepressants to be superior to placebo but less
medication or cannot tolerate medication. In addition,
effective than stimulants (Elia et al., 1991; Elia &
some families express a strong preference not to use
Rapoport, 1991). Reports of sudden death of a few
medication. Even children who are receiving
children in the early 1990s on the tricyclic compound
medication may continue to have residual ADHD
desipramine led to great caution with the use of
symptoms or symptoms from other disorders, such as
tricyclics in children (Riddle et al., 1991).
oppositional defiant disorder or depression, which
Considerable controversy surrounds the use of
make specialized child management skills necessary
central alpha-adrenergic blocking drugs, such as
and helpful (see next section, Multimodal Treatments).
clonidine and guanfacine, to treat ADHD. There is
Furthermore, children with ADHD can present a
some evidence that clonidine is effective for ADHD
challenge that puts significant stress on the family.
when it occurs with a tic disorder (Hunt, 1987; Hunt et
Skills training for parents can help reduce this stress on
al., 1990, 1995). Caution is warranted in view of the
parents and siblings.
four cases of sudden death that have been reported in
children taking methylphenidate and clonidine together
Behavioral Approaches
and of a number of reports of nonfatal cardiac side
The main psychosocial treatments for ADHD are
effects in children taking clonidine alone or in
behavioral training for parent and teacher, as well as
combination (Swanson et al., 1995a).
systematic programs of contingency management (this
Neuroleptics have been found to be occasionally
behavioral technique is described in more detail in the
effective (Green, 1995), yet the risk of movements
Treatment section later in this chapter). Of these
disorders, such as tardive dyskinesia, makes their use
options, systematic programs of intensive contingency
problematic. Lithium, fenfluramine, or benzodiazapines
management conducted in specialized classrooms or
have not been found to be effective treatments for
summer camps with the setting controlled by highly
ADHD (Cantwell, 1996a; Green, 1995), nor have
trained individuals is the most effective (Abramowitz
SSRIs, such as fluoxetine (Goldman et al., 1998).
et al., 1992; Carlson et al., 1992; Pelham & Hoza,
Furthermore, more than 20 studies have shown that
1996). The efficacy of behavioral training of teachers
dietary manipulation (e.g., the Feingold diet) is not
is well-established, while the evidence for parent
efficacious (Mattes & Gittelman, 1981), and controlled
training is less solid, according to the criteria, noted
studies failed to demonstrate that sugar exacerbates the
earlier, promulgated by the American Psychological
147
Mental Health: A Report of the Surgeon General
Association Task Force (Pelham et al., 1998). There is,
Psychoeducation
however, indirect support for the effectiveness of
Although there are no studies evaluating the efficacy of
parent training in the literature, demonstrating the
psychoeducation as a treatment modality for ADHD,
efficacy of parent training for children with
providing information to parents, children, and teachers
oppositional defiant disorder who share many
about ADHD and treatment options is considered
characteristics with children who have ADHD (see
critical in the development of a comprehensive
section on Disruptive Disorders).
treatment plan (AACAP, 1991). Educational
A number of studies have compared parent training
accommodations for children with ADHD are federally
(Gittelman et al., 1980; Firestone et al., 1986; Horn et
mandated, and mental health providers are required to
al., 1987, 1990, 1991; Pelham et al., 1988) or school-
ensure that patients and families have access to
based behavioral modification (Gittelman et al., 1980;
adequate and appropriate educational resources.
Pelham et al., 1988) with the use of stimulants. Most of
Organizations such as Children and Adults with
the studies are of outpatient behavioral therapy
Attention Deficit Disorder (CHADD) and the National
programs in which parents meet in groups and are
Attention Deficit Disorder Association can be helpful
taught behavioral techniques such as time out, point
sources of information and support for families.
systems, and contingent attention. Teachers are taught
similar classroom strategies, as well as the use of a
Multimodal Treatments
daily report card for parents that evaluates the child's
Many researchers and families have long suspected that
in-school behavior. The improvements in the symptoms
multimodal treatment-medication used together with
of ADHD achieved with psychosocial treatments are
multiple psychosocial interventions in multiple
not as large as those found with psychostimulants
settings-should be more effective than medication
(Pelham et al., 1998). Behavioral interventions tend to
alone. Multimodal treatment has thus been used in the
improve targeted behaviors or skills but are not as
absence of empirical support (Hechtman, 1993). To
helpful in reducing the core symptoms of inattention,
determine whether multimodal treatment is indeed
hyperactivity, or impulsivity. Questions remain about
effective, the recent NIMH Multimodal Treatment
the effectiveness of these treatments in other settings.
Study of ADHD (called the MTA Study) examined
To be fully effective, treatments for ADHD need to be
three experimental conditions: medication management
conducted across settings (school, home, community)
alone, behavioral treatment alone, or a combination of
and by different people (e.g., parents, teachers,
medication and behavioral treatments. The study
therapists)-aconsistency a and comprehensiveness that
compared the effectiveness of these three treatment
can be hard to achieve.
modes with each other and with standard care provided
in the community (the control group). The behavioral
Cognitive-Behavioral Therapy
treatment condition consisted of parent training, a
Cognitive-behavioral therapy (CBT), primarily training
school intervention, and a summer treatment program.
in problem solving and social skills, has not been
The MTA Study was also designed to determine the
shown to provide clinically important changes in
relative benefits of these treatments over time (Richters
behavior and academic performance of children with
et al., 1995). All subjects were treated for 14 months
ADHD (Pelham et al., 1998). However, CBT might be
and then followed for an additional 22 months.
helpful in treating symptoms of accompanying
Results of the MTA Study comparing the 14-month
disorders such as oppositional defiant disorder,
outcomes of 579 children randomly assigned to one of
depression, or anxiety disorders (Abikoff, 1985;
the four treatment conditions were presented in the fall
Hinshaw & Ehardt, 1991; Lochman, 1992).
of 1998 (MTA Cooperative Group, 1998). At 14
months, medication and the combination treatment
were generally more effective than the behavioral
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Children and Mental Health
treatment alone or the control treatment. Notably, the
younger girls with ADHD, who were underdiagnosed
combined treatment resulted in significant improve-
in the past, are being identified and treated.
ment over the control condition in six outcome
Nonetheless, some of the increase in use may
areas-social skills, parent child relations, internalizing
reflect inappropriate diagnosis and treatment. In one
(e.g., anxiety) symptoms, reading achievement,
study, the rate of stimulant treatment was twice the rate
oppositional and/or aggressive symptoms, and parent
of parent-reported ADHD, based on a standardized
and/or consumer satisfaction-whereas the single
psychiatric interview (Angold & Costello, 1998). While
forms of treatment (medication or behavior therapy)
many children who do meet the full criteria for ADHD
were each superior to the control condition in only one
are not being treated, the majority of children and
to two of these domains. The conclusions from this
adolescents who are receiving stimulants did not fully
major study are that carefully managed and monitored
meet the criteria. These findings may reflect a failure of
stimulant medication, alone or combined with
proper, comprehensive evaluation and diagnosis rather
behavioral treatment, is effective for ADHD over a
than a failure of the diagnostic criteria, which are clear
period of 14 months. Addition of behavioral treatment
and validated by research (Angold & Costello, 1998).
yields no additional benefits for core ADHD symptoms
A diagnosis of ADHD requires the presence of
but appears to provide some additional benefits for
impairing ADHD symptoms in multiple settings for at
non-ADHD-symptom outcomes.
least 6 months. Although fidgeting and not paying
attention are normal, common childhood behaviors,
Treatment Controversies
DSM-IV criteria reserve a diagnosis of ADHD for
children in whom such frequent behavior produces
Overprescription of Stimulants
persistent and pervasive dysfunction. An adequate
Concerns have been raised that children, particularly
diagnostic evaluation requires histories to be taken
active boys, are being overdiagnosed with ADHD and
from multiple sources (parents, child, teachers), a
thus are receiving psychostimulants unnecessarily.
medical evaluation of general and neurological health,
However, recent reports found little evidence of
a full cognitive assessment including school history,
overdiagnosis of ADHD or overprescription of
use of parent and teacher rating scales, and all
stimulant medications (Goldman et al., 1998; Jensen et
necessary adjunct evaluation (such as assessment of
al., 1999). Indeed, fewer children (2 to 3 percent of
speech, language). These evaluations take time and
school-aged children) are being treated for ADHD than
require multiple clinical skills. Regrettably, there is a
suffer from it. Treatment rates are much lower for
dearth of appropriately trained professionals.
selected groups such as girls, minorities, and children
Family practitioners are more likely than either
receiving care though public service systems (Bussing
pediatricians or psychiatrists to prescribe stimulants
et al., 1998a, 1998b). However, there have been major
and less likely to use diagnostic services, provide
increases in the number of stimulant prescriptions since
mental health counseling, or provide followup care
1989 (Hoagwood et al., 1998), and methylphenidate is
(Hoagwood et al., 1998). The American Academy of
being manufactured at 2.5 times the rate of a decade
Pediatrics published a policy statement in 1996 on the
ago (Goldman et al., 1998). Most researchers believe
use of medication for children with attentional
that much of the increased use of stimulants reflects
disorders, concluding that use of medication should not
better diagnosis and more effective treatment of a
be considered the complete treatment program for
prevalent disorder. Medical and public awareness of
children with ADHD and should be prescribed only
the problem of ADHD has grown considerably, leading
after a careful evaluation (American Academy of
to longer treatment, fewer interruptions in treatment,
Pediatrics Committee on Children With Disabilities and
and increased treatment of adults. Adolescents and
Committee on Drugs, 1996).
149
Mental Health: A Report of the Surgeon General
Safety of Long-Term Stimulant Use
suicide cannot be defined as a mental disorder, the
Even though the MTA Study found no safety issues
various risk factors-especially the presence of mood
over a 14-month period (Greenhill et al., 1998),
disorders-that predispose young people to such
concerns have been raised about the longer term safety
behavior are given special emphasis in this section, as
of stimulant treatment. Since ADHD has an early onset
is a discussion of the effectiveness of various forms of
and requires an extended course of treatment, research
treatment. The evidence is strong that over 90 percent
is needed to examine the long-term safety of treatment
of children and adolescents who commit suicide have
and to investigate whether other forms of treatment
a mental disorder, as explained later in this section.
could be combined with psychostimulants to lower
Major depressive disorder is a serious condition
their dose as well as to reduce other problem behaviors
characterized by one or more major depressive
found with ADHD. Such combined treatments could be
episodes. In children and adolescents, an episode lasts
targeted for symptoms of disorders that often
on average from 7 to 9 months (Birmaher et al., 1996a,
accompany ADHD, such as conduct disorder, substance
1996b) and has many clinical features similar to those
abuse, and learning disabilities, and could be targeted
in adults. Depressed children are sad, they lose interest
to improve overall functioning (Laufer, 1971;
in activities that used to please them, and they criticize
Gittelman et al., 1985).
themselves and feel that others criticize them. They feel
Because stimulants are also drugs of abuse and
unloved, pessimistic, or even hopeless about the future;
because children with ADHD are at increased risk for
they think that life is not worth living, and thoughts of
a substance abuse disorder, concerns have also been
suicide may be present. Depressed children and
raised about the potential for abuse of stimulants by
adolescents are often irritable, and their irritability may
children taking the medication or diversion of the drug
lead to aggressive behavior. They are indecisive, have
to others. While stimulants clearly have abuse
problems concentrating, and may lack energy or
potential, the rate of lifetime nonmedical methyl-
motivation; they may neglect their appearance and
phenidate use has not significantly increased since
hygiene; and their normal sleep patterns are disturbed
methylphenidate was introduced as a treatment for
(DSM-IV).
ADHD, suggesting that abuse is not a major problem
Despite some similarities, childhood depression
(Goldman et al., 1998). Case reports describing abuse
differs in important ways from adult depression.
by children prescribed stimulants for ADHD are rare
Psychotic features do not occur as often in depressed
(Hechtman, 1985).
children and adolescents, and when they occur,
auditory hallucinations are more common than
Depression and Suicide in Children
delusions (Ryan et al., 1987; Birmaher et al., 1996a,
and Adolescents
1996b). Associated anxiety symptoms, such as fears of
In children and adolescents, the most frequently
separation or reluctance to meet people, and somatic
diagnosed mood disorders are major depressive
symptoms, such as general aches and pains,
disorder, dysthymic disorder, and bipolar disorder.
stomachaches, and headaches, are more common in
Because mood disorders such as depression
depressed children and adolescents than in adults with
substantially increase the risk of suicide, suicidal
depression (Kolvin et al., 1991; Birmaher et al., 1996a,
behavior is a matter of serious concern for clinicians
1996b).
who deal with the mental health problems of children
Dysthymic disorder is a mood disorder like major
and adolescents. The incidence of suicide attempts
depressive disorder, but it has fewer symptoms and is
reaches a peak during the midadolescent years, and
more chronic. Because of its persistent nature, the
mortality from suicide, which increases steadily
disorder is especially likely to interfere with normal
through the teens, is the third leading cause of death at
adjustment. The onset of dysthymic disorder (also
that age (CDC, 1999; Hoyert et al., 1999). Although
called dysthymia) is usually in childhood or
150
Children and Mental Health
adolescence (Akiskal, 1983; Klein et al., 1997). The
children suffering from reactive depression, depressed
child or adolescent is depressed for most of the day, on
feelings are short-lived and usually occur in response to
most days, and symptoms continue for several years.
some adverse experience, such as a rejection, a slight,
The average duration of a dysthymic period in children
a letdown, or a loss. In contrast, children may feel sad
and adolescents is about 4 years (Kovacs et al., 1997a).
or lethargic and appear preoccupied for periods as short
Sometimes children are depressed for so long that they
as a few hours or as long as 2 weeks. However, mood
do not recognize their mood as out of the ordinary and
improves with a change in activity or an interesting or
thus may not complain of feeling depressed. Seventy
pleasant event. These transient mood swings in reaction
percent of children and adolescents with dysthymia
to minor environmental adversities are not regarded as
eventually experience an episode of major depression⁶
a form of mental disorder.
(Kovacs et al., 1994). When a combination of major
depression and dysthymia occurs, the condition is
Conditions Associated With Depression
referred to as double depression.
Roughly two-thirds of children and adolescents with
Bipolar disorder is a mood disorder in which
major depressive disorder also have another mental
episodes of mania alternate with episodes of
disorder (Angold & Costello, 1993; Anderson &
depression. Frequently, the condition begins in
McGee, 1994). The most commonly associated
adolescence. The first manifestation of bipolar illness
disorders are dysthymia (see above), an anxiety
is usually a depressive episode. The first manic features
disorder, a disruptive or antisocial disorder, or a
may not occur for months or even years thereafter, or
substance abuse disorder. When more than one
may occur either during the first depressive illness or
diagnosis is present, depression is more likely to begin
later, after a symptom-free period (Strober et al., 1995).
after the onset of the accompanying disorder, except
The clinical problems of mania are very different
when that disorder is substance abuse (Biederman et
from those of depression. Adolescents with mania or
al., 1995; Kessler & Walters, 1998). This suggests that,
hypomania feel energetic, confident, and special; they
in some cases, depression may arise in response to the
usually have difficulty sleeping but do not tire; and
associated disorder. In other instances, such as the co-
they talk a great deal, often speaking very rapidly or
occurrence of conduct disorder and depression, the two
loudly. They may complain that their thoughts are
may arise independently in response to inadequate
racing. They may do schoolwork quickly and creatively
maternal supervision and control, raising the possibility
but in a disorganized, chaotic fashion. When manic,
that parental behavior may be a risk factor for both
adolescents may have exaggerated or even delusional
conditions (Downey & Coyne, 1990; Rutter &
ideas about their capabilities and importance, may
Sandberg, 1992; Harrington, 1994).
become overconfident, and may be "fresh" and
uninhibited with others; they start numerous projects
Prevalence
that they do not finish and may engage in reckless or
risky behavior, such as fast driving or unsafe sex.
Major Depression
Sexual preoccupations are increased and may be
Population studies show that at any one time between
associated with promiscuous behavior.
10 and 15 percent of the child and adolescent
Reactive depression, also known as adjustment
population has some symptoms of depression (Smucker
disorder with depressed mood, is the most common
et al., 1986). The prevalence of the full-fledged
form of mood problem in children and adolescents. In
diagnosis of major depression among all children ages
9 to 17 has been estimated at 5 percent (Shaffer et al.,
1996c). Estimates of 1-year prevalence in children
6 Major depression refers to conditions marked by a major
depressive episode, such as major depressive disorder, bipolar
range from 0.4 and 2.5 percent and in adolescents,
disorder, and related conditions. The word "major" refers to the
considerably higher (in some studies, as high as 8.3
number of symptoms. See Chapter 4 for DSM-IV diagnostic criteria.
151
Mental Health: A Report of the Surgeon General
percent) (Anderson & McGee, 1994; Lewinsohn et al.,
It has been proposed that the rise in suicidal
1994a; Garrison et al., 1997; Kessler & Walters, 1998).
behavior among teenage boys results from increased
For purposes of comparison, 1-year prevalence in
availability of firearms (Boyd, 1983; Boyd & Moscicki,
adults is about 5.3 percent (Murphy et al., 1988;
1986; Brent et al., 1987; Brent et al., 1991) and
Rorsman et al., 1990; Regier et al., 1993).
increased substance abuse in the youth population
(Shaffer et al., 1996c; Birckmayer & Hemenway,
Dysthymic Disorder
1999). However, although the rate of suicide by
The prevalence of dysthymic disorder in adolescents
firearms increased more than suicide by other methods
has been estimated at around 3 percent (Garrison et al.,
(Boyd, 1983; Boyd & Moscicki, 1986; Brent et al.,
1997). Before puberty, major depressive disorder and
1987), suicide rates also increased markedly in many
dysthymic disorder are equally common in boys and
other countries in Europe, in Australia, and in New
girls (Rutter, 1986). But after age 15, depression is
Zealand, where suicide by firearms is rare.
twice as common in girls and women as in boys and
men (Weissman & Klerman, 1977; McGee et al., 1990;
Course and Natural History
Linehan et al., 1993).
Most children with depression experience a recurrence.
Twenty to 40 percent of depressed children relapse
Suicide
within 2 years, and 70 percent will do so by adulthood
In 1996, the age-specific mortality rate from suicide
(Garber et al., 1988; Velez et al., 1989; Harrington et
was 1.6 per 100,000 for 10- to 14-year-olds, 9.5 per
al., 1990; Fleming et al., 1993; Kovacs et al., 1994;
100,000 for 15- to 19-year-olds (i.e., about six times
Lewinsohn et al., 1994a; Garrison et al., 1997). The
higher than in the younger age group; in this age group,
reasons for relapse are not known, but there is some
boys are about four times as likely to commit suicide
evidence that experiencing a depression leaves behind
than are girls, while girls are twice as likely to attempt
psychological "scars" that may increase vulnerability
suicide), compared with 13.6 per 100,000 for 20- to 24-
throughout early life (see below).
year-olds (CDC, 1999). Hispanic high school students
The age of first onset of depression appears to play
are more likely than other students to attempt suicide
a role in its course. Children who first become
(CDC, 1998). There have been some notable changes
depressed before puberty are at risk for some form of
in these rates over the past few decades: since the early
mental disorder in adulthood, while teenagers who first
1960s, the reported suicide rate among 15- to 19-year-
become depressed after puberty are most likely to
old males increased threefold but remained stable
experience another episode of depression (Harrington
among females in that age group and among 10- to 14-
et al., 1990; McCracken, 1992a; Lewinsohn et al.,
year-olds (National Center for Health Statistics, 1998);
1994a, 1994b; Rao et al., 1995). These differences in
the rate among white adolescent males reached a peak
outcome suggest that different mechanisms may lead to
in the late 1980s (18.0 per 100,000 in 1986) and has
superficially similar but inherently different clinical
since declined somewhat (16.0 per 100,000 in 1997),
conditions. Factors that worsen the prognosis for
whereas among African American male adolescents,
depressed children and adolescents include depression
the rate increased substantially in the same period
occurring in the context of conduct disorder (Harring-
(from 7.1 per 100,000 in 1986 to 11.4 per 100,000 in
ton et al., 1990; Asarnow et al., 1994) and living in
1997 (CDC, 1998). From 1979 to 1992, the Native
conflict-ridden families (Asarnow et al., 1994).
American male adolescent and young adult suicide rate
Children and particularly adolescents who suffer from
in Indian Health Service Areas was the highest in the
depression are at much greater risk of committing
Nation, with a suicide rate of 62.0 per 100,000
suicide than are children without depression (Shaffer et
(Wallace et al., 1996).
al., 1996b).
152
Children and Mental Health
The prognosis for dysthymia (Klein et al., 1997a)
1990). Conversely, estimates of the proportion of
is unfavorable, with most patients continuing to feel
depressed parents who have a depressed child or
depressed and to have social difficulties even after they
adolescent vary from approximately one in six to just
have apparently recovered. The prognosis for double
under a half (Hammen et al., 1990). It is not clear
depressives (major depressive disorder plus dysthymia)
whether the relationship between parent and childhood
is worse than that for either condition alone (Kovacs et
depression derives from genetic factors, or whether
al., 1994).
depressed parents create an environment that increases
Twenty to 40 percent of adolescents with depres-
the likelihood of a mental disorder developing in their
sion eventually develop bipolar disorder. Factors that
children (see below).
predict later bipolar disorder include young age at the
time of the first depressive episode, psychotic features
Gender Differences
in the initial depression, a family history of bipolar
One reason advanced to explain the greater prevalence
illness, and symptoms of hypomania developing during
of depression in adolescent girls (see above) is that they
treatment with antidepressant drugs (Garber et al.,
are more socially oriented, more dependent on positive
1988; Strober et al., 1993).
social relationships, and more vulnerable to losses of
social relationships than are boys (Allgood-Merten et
Causes
al., 1990). This would increase their vulnerability to the
The precise causes of depression are not known.
interpersonal stresses that are common in teenagers.
Extensive research on adults with depression generally
There is also evidence that the methods girls use to
points to both biological and psychosocial factors
cope with stress may entail less denial and more
(Kendler, 1995). However, there has been substantially
focused and repetitive thinking about the event (Nolen-
less research on the causes of depression in children
Hoeksema & Girgus, 1994). The higher prevalence,
and adolescents. Further discussion of the risk factors
therefore, could be a result of greater vulnerability,
for depression can be found in Chapter 4, as well as the
combined with coping mechanisms different than those
preceding Overview of Risk Factors and Prevention
of boys.
section.
Biological Factors
Some of the core symptoms of depression, such as
Family and Genetic Factors
Much of the research on children and adolescents with
changes in appetite and sleep patterns, are-related to the
depression has been conducted with those who attend
functions of the hypothalamus. The hypothalamus is, in
mental health clinics and with patients who tend to
turn, closely tied to the function of the pituitary gland.
have the more severe and recurrent forms of
Abnormalities of pituitary function, such as increased
depression, and thus they may not be representative of
rates of circulating cortisol and hypo- or hyperthyroid-
all children and adolescents with depression. With this
ism, are well established features of depression in
limitation, research has shown that between 20 and 50
adults (Goodwin & Jamison, 1990). However, far less
percent of depressed children and adolescents have a
research has been done in this area among children and
family history of depression (Puig-Antich et al., 1989;
adolescents (see Birmaher et al., 1996a, 1996b for a
Todd et al., 1993; Williamson et al., 1995; Kovacs,
review). It is in the neuroendocrine area that most
research has been done on child and adolescent
1997b). Family research has found that children of
depressed parents are more than three times as likely as
depression (see Birmaher et al., 1996a, b). In suicidal
children with nondepressed parents to experience a
adults dysregulation of the serotonergic system is
depressive disorder (see Birmaher et al., 1996a, 1996b
common (Mann, 1998; Pine et al., 1995), making them
for a review). They also are more vulnerable to other
typically impulsive, intense, and given to extreme
mental and somatic disorders (Downey & Coyne,
reactions. However, little is known about the
153
Mental Health: A Report of the Surgeon General
association between abnormal serotonin metabolism
Perceptions of hopelessness, negative views about
and suicidal behavior in children and adolescents.
one's own competence, poor self- esteem, a sense of
responsibility for negative events, and the immutability
Cognitive Factors
of these distorted attributions may contribute to the
For over two decades there has been considerable
hopelessness that has been repeatedly found to be
interest in the relationship between a particular
associated with suicidality (Overholser et al., 1995).
"mindset" or approach to perceiving external events
and a predisposition to depression. The mindset in
Risk Factors for Suicide and Suicidal Behavior
question is known as a pessimistic "attribution bias"
There is good evidence that over 90 percent of children
(Abramson et al., 1978; Beck, 1987; Hops et al., 1990).
and adolescents who commit suicide have a mental
A person with this mindset is one who readily assumes
disorder before their death (Shaffer & Craft, 1999). The
personal blame for negative events ("All the problems
most common disorders that predispose to suicide are
in the family are my fault"), who expects that one
some form of mood disorder, with or without
negative experience is part of a pattern of many other
alcoholism or other substance abuse problem, and/or
negative events ("Everything I do is wrong"), and who
certain forms of anxiety disorder (Shaffer et al.,
believes that a currently negative situation will endure
1996b). Psychological postmortem studies also show
permanently ("Nothing I do is going to make anything
that a significant proportion of suicide victims suffered
better"). Such pessimistic individuals take a
from an anxiety disorder at the time of their death, but
characteristically negative view of positive events (i.e.,
the number of victims has been too small to yield
that they are a result of someone else's effort, that they
precise odds ratios for the calculation of an effect.
are isolated events, and that they are unlikely to recur).
Although the rate of suicide is greatly increased in
Individuals with this mindset react more passively,
schizophrenia, because of its rarity, it accounts for very
helplessly, and ineffectively to negative events than
few suicides in the child and adolescent age group.
those without a pessimistic mindset (Seligman, 1975).
Controlled studies of completed suicide suggest
There is uncertainty over whether this mindset
similar risk factors for boys and girls (Shafii et al.,
precedes depression (and represents a permanent style
1985; Brent et al., 1988; Groholt et al., 1997), but with
of thinking as part of an individual's personality), is a
marked differences in their relative importance (Shaffer
manifestation of depression that is only present when
et al., 1996c).
the patient is depressed, and/or is a consequence or
Among girls, the most significant risk factor is the
"scar" of a previous, perhaps unnoticed, depressive
presence of major depression, which, in some studies,
episode (Lewinsohn et al., 1981). This pessimistic
increases the risk of suicide 12-fold. The next most
mode of thinking does not occur in children under age
important risk factor is a previous suicide attempt,
5, which could be one of the reasons why depression
which increases the risk approximately threefold.
and suicide are rare in early childhood (Rholes et al.,
Among boys, a previous suicide attempt is the most
1980; Rotenberg, 1982).
potent predictor, increasing the rate over 30-fold. It is
There is evidence that children and adolescents
followed by depression (increasing the rate by about
who previously have been depressed may learn, during
12-fold), disruptive behavior (increasing the rate by
their depression, to interpret events in this fashion. This
twofold), and substance abuse (increasing the rate by
may make them prone to react similarly to negative
just under twofold) (Shaffer et al., 1996c).
events experienced after recovery, which could be one
Stressful life events often precede a suicide and/or
of the reasons why previously depressed children and
suicide attempt (de Wilde et al., 1992; Gould et al.,
adolescents are at continuing risk for depression
1996). As indicated earlier, these stressful life events
(Nolen-Hoeksema et al., 1993).
include getting into trouble at school or with a law
154
Children and Mental Health
enforcement agency; a ruptured relationship with a
Consequences
boyfriend or a girlfriend; or a fight among friends.⁷
Both major depressive disorder and dysthymic disorder
They are rarely a sufficient cause of suicide, but they
are inevitably associated with personal distress, and if
can be precipitating factors in young people.
they last a long time or occur repeatedly, they can lead
Controlled studies (Gould et al., 1996; Hollis,
to a circumscribed life with fewer friends and sources
1996) indicate that low levels of communication
of support, more stress, and missed educational and job
between parents and children may act as a significant
opportunities (Klein et al., 1997). The psychological
risk factor. While family discord, lack of family
scars of depression include an enduring pessimistic
warmth, and disturbed parent-child relationship are
style of interpreting events, which may increase the risk
commonly associated with child and adolescent
of further depressive episodes. Impairment is greater
psychopathology (violent behavior, mood disorder,
for those with dysthymic disorder than for those with
alcohol and substance abuse disorders) (Brent et al.,
major depression (Klein et al., 1997a), presumably
1994; Pfeffer et al., 1994), these factors do not play a
because of the longer duration of depression in
specific role in suicide (Gould et al., 1998).
dysthymic disorder, which is also a prime risk factor
Evidence has accumulated that supports the
for suicide. In a 10- to 15-year followup study of 73
observation that suicide can be facilitated in vulnerable
adolescents diagnosed with major depression, 7 percent
teens by exposure to real or fictional accounts of
of the adolescents had committed suicide sometime
suicide (Velting & Gould, 1997), including media
later. The depressed adolescents were five times more
coverage of suicide, such as intensive reporting of the
likely to have attempted suicide as well, compared with
suicide of a celebrity, or the fictional representation of
a control group of age peers without depression
a suicide in a popular movie or TV show. The risk is
(Weissman et al., 1999).
especially high in the young, and it lasts for several
weeks (Gould & Shaffer, 1986; Phillips et al., 1989).
Treatment
The suicide of a prominent person reported on
television or in the newspaper or exposure to some
Depression
sympathetic fictional representation of suicide may also
Psychosocial Interventions
tip the balance and make the at-risk individual feel that
To be deemed effective and approved by the American
suicide is a reasonable, acceptable, and in some
Psychological Association, treatments for mental
instances even heroic, decision (Gould & Shaffer,
disorders have to meet very strict criteria. While
1986).
interpersonal therapy and systemic family therapy show
The phenomenon of suicide clusters is presumed to
promise, they have not been studied sufficiently to
be related to imitation (Davidson, 1989). Suicide
evaluate their effectiveness by these standards.
clusters nearly always involve previously disturbed
However, in a comprehensive review article (Kaslow &
young people who knew about each other's death but
Thompson, 1998) that evaluated interventions for
rarely knew the other victims personally (Gould,
depression in children and adolescents against the
personal communication, 1999).
American Psychological Association Task Force
criteria, two forms of cognitive-behavioral therapy
(CBT) were found to be "probably effective
treatments," although none of the interventions for
depression were deemed, as yet, to meet the
7 The relationship between sexual orientation, depression, and
Association's higher standard for a well-established
suicidal thoughts and behavior is not well understood. Several
intervention.
studies suggest a link (Faullener & Cranston, 1998; Garofolo et al.,
1998; Garofolo et al., 1999).
155
Mental Health: A Report of the Surgeon General
In studies that focused on relieving symptoms of
Pharmacological Treatment
depression in preadolescents, only one form of CBT
Prior to 1996, the medications of choice for major
met the criteria for a probably effective intervention. In
depression in children and adolescents were the
the first study, the relative efficacy of two types of
tricyclic antidepressants, a choice based on numerous
CBT-12-session group interventions based on either
studies in adults. However, 13 distinct trials in children
self-control therapy or behavior-solving therapy-were
and adolescents failed to demonstrate the efficacy of
compared with a "waiting list" control group (Stark et
tricyclic antidepressants for younger ages. Tricyclic
al., 1987). Children responded to both CBT inter-
antidepressants also have a higher risk of toxicity than
ventions with fewer symptoms of depression and
selective serotonin reuptake inhibitors (SSRIs) (Walsh
anxiety, whereas the waiting list group exhibited
et al., 1994; Kutcher, 1998). The current consensus is
minimal change. Because improvement was greatest
that tricyclic medications are not the medication of
with self-control therapy, this intervention was
choice for depressed children and adolescents
compared in a later study with a traditional counseling
(Eisenberg, 1996; Fisher & Fisher, 1996).
condition. Self-control therapy, enhanced by doubling
Recent research indicates that young people with
the number of sessions, entailed social skills training,
depressive disorders may respond more favorably to
assertiveness training, relaxation training and imagery,
SSRIs than to tricyclic antidepressants. The first SSRI
and cognitive restructuring. Monthly family meetings
tested in children and adolescents was fluoxetine. In a
were also added to both the experimental and control
study of 96 outpatients over 8 weeks, 56 percent
conditions. Children receiving self-control therapy
receiving fluoxetine and 33 percent receiving placebo
reported fewer symptoms at 7-month followup (Stark
were "much" or "very much" improved on the Clinical
et al., 1991).
Global Improvement Scale. Benefits were comparable
Among the numerous studies of adolescents
across age groups. Complete symptom remission
reviewed by Kaslow and Thomson (1998), one form of
occurred for 31 percent of fluoxetine-treated patients
CBT-coping skills-was judged probably effi-
compared with 23 percent of placebo-treated patients
cacious. This intervention, based on the "Coping with
(Emslie et al., 1997). A recent open trial of fluoxetine
Depression" course, was developed originally in
for adolescents hospitalized for treatment of major
Oregon for adults by Lewinsohn and colleagues
depression found it to decrease depression scores more
(Lewinsohn et al., 1996) and adapted by Clarke and
effectively than imipramine, a tricyclic antidepressant
(Strober et al., 1999), with the further advantage that
colleagues (1992) for school-based programs to treat
fluoxetine was well tolerated.
adolescent depression. Compared with controls on the
The safety of a second SSRI, paroxetine, was
waiting list, adolescents who received CBT had lower
demonstrated in a multicenter double-blind placebo-
rates of depression, less self-reported depression,
controlled trial. Paroxetine was compared with
improvement in cognitions, and increased activity
imipramine and placebo in 275 adolescents who met
levels (Lewinsohn et al., 1990, 1996). To achieve well-
the DSM-IV criteria for major depression. Preliminary
established status, as defined by the American Psycho-
results indicate that, mostly because of side effects,
logical Association Task Force, the intervention has to
one-third of imipramine patients withdrew from the
be studied by another team of investigators-which has
study, a proportion significantly higher than that for
not as yet been done.
paroxetine (10 percent) and placebo (7 percent)
(Wagner et al., 1998). One of the co-investigators of
this study noted that paroxetine's efficacy was superior
156
Children and Mental Health
to that of imipramine and placebo on the Clinical
including valproate, carbamazepine, methylphenidate,
Global Improvement Scale (Graham Emslie, personal
and low-dose chlorpromazine (Campbell & Cueva,
communication, October 1998). However, final
1995; Geller & Luby, 1997).
conclusions about the benefit of this second SSRI must
await publication of the outcomes of this multicenter
Suicide
study.
In summary, psychosocial interventions for
Psychotherapeutic Treatments
depressed children and adolescents indicate great
Suicidal children and adolescents report feelings of
promise, with several types of cognitive-behavioral
intense emotional distress involving depression, anger,
therapy for the child or adolescent leading the way.
anxiety, hopelessness, and worthlessness and an
With respect to pharmacotherapy, new studies attest to
inability to change problematic, frustrating
the safety and efficacy of two SSRIs. These promising
circumstances or to find a solution to their problems
findings are being extended in the recently begun
(Kienhorst et al., 1995; Ohring et al., 1996). They feel
NIMH-funded Treatment of Adolescents with
so distraught that they often respond impulsively to
Depression study.
their despair. Psychotherapeutic techniques aim to
decrease such intolerable feelings and thoughts and to
Bipolar Disorder
re-orient the cognitive and emotional perspectives of
the suicidal child or adolescent (Kernberg, 1994;
Pharmacological Treatment
Spirito, 1997).
The treatment of bipolar disorder entails treating
Cognitive-behavioral therapy (CBT) may be a
symptoms of both depression and mania. For decades,
useful intervention, considering that suicidal children
lithium has been the well-researched mainstay
and adolescents often experience negative cognitions
treatment for mania in adults. Mania in bipolar disorder
about themselves, their environment, and their futures.
of children is also treated with lithium, although the
Recent research suggests that CBT may be more
relevant research on children lags behind that on adults.
effective than systemic behavior family therapy or
Only in recent years have researchers begun to study
individual nondirective supportive therapy in reducing
lithium in children and adolescents, with good clinical
depressive symptoms associated with suicidal ideation
response. Open trials of lithium were conducted in the
(Brent et al., 1997). Such treatment can focus on re-
late 1980s (Varanka et al., 1988; Strober et al., 1990).
attribution of precipitating issues for suicidal behavior
More recently, lithium proved to be more effective than
and enable the suicidal child or adolescent to rank
placebo in treating adolescents who were bipolar and
stresses and to consider avenues of problem-solving
substance dependent (Geller et al., 1998).
(Rotheram-Borus et al., 1994; Brent et al., 1997;
Children experience the same safety problems with
Spirito, 1997).
lithium as do adults: toxicity and impairment of renal
Interpersonal conflicts are important stresses
and thyroid functioning (Geller & Luby, 1997).
related to the risk imparted by poor social adjustment
Lithium is therefore not recommended for families
of potentially suicidal children and adolescents.
unable to keep regular appointments that would ensure
Treatment of interpersonal strife may significantly
monitoring of serum lithium levels and of adverse
reduce suicidal risk. Recent research into the efficacy
events. Patients who discontinue taking the drug have
of interpersonal psychotherapy of depressed
a high relapse rate (Strober et al., 1990).
adolescents suggests beneficial effects (Kaslow &
As yet, there are no controlled studies on a number
Thompson, 1998); it is a treatment that may be
of other psychotropic agents also used clinically in
modified to address the risk factor issues related to
children and adolescents with bipolar disorder,
interpersonal loss, conflicts, and need for restitution
157
Mental Health: A Report of the Surgeon General
often reported by children and adolescents with suicidal
controlled trial of the experimental neuroleptic drug
tendencies.
flupenthixol, researchers noted a significant reduction
A significant class of risk factors for suicide
in suicide-attempt behavior in adults who had made
involves family discord, which is characterized by poor
numerous previous attempts (Montgomery &
communication, disagreements, and lack of cohesive
Montgomery, 1982). Similar studies have yet to be
values and goals and of common activities (de Long,
conducted on adolescents, although trials of SSRIs in
1992; Miller et al., 1992; Wagner, 1997). Suicidal
depressed adolescents suggest that these drugs are
children and adolescents often feel that they are
effective for treating depression and for reducing
isolated within the family, exhibit problems in
suicidal ideas also in this age group (Emslie et al.,
independence, and view themselves as expendable to
1997; Ryan & Varma, 1998). Because placebo-
the family, a perception that is a motivating force for
controlled, methodologically appropriate studies of
self-annihilation (Sabbath, 1969; Pfeffer, 1986; Miller
tricyclic antidepressants have failed to find a significant
et al., 1992). Family intervention with suicidal children
effect in depressed children and adolescents (Ryan &
and adolescents is an important method to decrease
Varma, 1998), it is reasonable to regard SSRIs as a
such problems and to enhance effective family
first-choice medication in treating depressed suicidal
problem-solving and conflict resolution, so that blame
children and adolescents (also see American Academy
is not directed toward the suicidal child or adolescent.
of Child and Adolescent Psychiatry, 1998). In contrast
Cognitive-behavioral approaches with suicidal children
to tricyclic antidepressants, SSRIs have low lethal
and adolescents and their families aim to reframe their
potential when taken in overdoses (Ryan & Varma,
understanding of family problems, alter the family style
1998).
of maladaptive problem-solving techniques, and
In adults with major depressive disorder, controlled
encourage positive family interactions (Rotheram-
research suggests that lithium reduces suicide risk
Borus et al., 1994). Time-limited home-based
(Thies-Flechtner et al., 1996), but this has not yet been
intervention to reduce suicidal ideation in children and
demonstrated in children and adolescents. Clinicians
adolescents and to improve family functioning has been
should be cautious about prescribing medications that
reported to have limited efficacy for children and
may reduce self-control, such as the benzodiazapines,
adolescents without major depressive disorder
amphetamines, and phenobarbital. These drugs also
(Harrington et al., 1998). Psychoeducational approach-
have a high lethal potential if taken in overdose
es to reduce the extent of expressed anger may be
(Carlsten et al., 1996).
helpful in lowering risk for suicidal behavior in
children and adolescents (Fristad et al., 1996).
Intervention After a Suicidal Death of a Relative,
Friend, or Acquaintance
Psychopharmacological Treatments
The suicidal death of a relative or acquaintance may
increase the risk for childhood or adolescent suicidal
There is a dearth of research on the efficacy of
pharmacological treatments for reducing suicidal
behavior and other dysphoric states (Brent et al., 1992,
1994; Pfeffer et al., 1994, 1997; Clark & Goebel,
thoughts or preventing suicide in children and
adolescents. Most of the research on pharmacotherapies
1996). Major depression, post-traumatic stress disorder,
and suicidal ideation often occur after the death of an
has been conducted in adults. In depressed adults,
SSRIs have been found to reduce suicidal ideation
adolescent friend or acquaintance and relative (Brent et
al., 1992, 1994, 1996).
(Letizia et al., 1996; Wernicke et al., 1997) and to
The goal of the clinician is to decrease the
reduce the frequency of suicide attempts in
likelihood that a child or adolescent comes to view the
nondepressed patients who had previously made at least
suicidal behavior of the deceased as a coping strategy
one suicide attempt (Verkes et al., 1998). In a
in dealing with adversity (Brent et al., 1997). Psycho-
158
Children and Mental Health
educational counseling may reduce the risk for suicidal
before a call is answered, so that callers disconnect; the
behavior in these circumstances. Intervention is also
advice individuals get on calling a hotline may be
needed to decrease the child's or teen's personal sense
stereotyped, inappropriate for an individual's needs,
of guilt, trauma, and social isolation. This treatment can
and perceived as unhelpful by the caller. Gender
be given in individual meetings, at group sessions with
preferences in seeking help result in the large majority
other teens, or in conjunction with parents who need
of callers being females, whereas males are at greatest
help to support the adaptive capacities of their children
risk for suicide. While each of these deficiencies is
and adolescents. School professionals sometimes offer
potentially modifiable, there have been no systematic
programs of this kind and can be invaluable in
attempts to do so.
identifying grieving friends who may need help.
Method Restriction
Community-Based Suicide Prevention
Method preference for suicide varies by gender and by
The principal public health approaches to suicide
nationality. In the United States, the most common
prevention have been (1) crisis hotlines⁸; (2) restric-
method for committing suicide is by firearms, and it has
tions covering access to suicide methods; (3) media
been suggested that reducing firearms availability will
counseling to minimize imitative suicide; (4) indirect
reduce the incidence of suicide (Moscicki, 1995).
case-finding by educating potential gate-keepers,
However, a natural experiment in Great Britain
teachers, parents, and peers to identify the warning
suggests this is unlikely. The favored suicide method,
signs of an impending suicide; (5) direct case-finding
self-asphyxiation with coal gas, became impossible
among high school or college students or among the
after the introduction of natural gas. This resulted in a
patients of primary practitioners by screening for
marked but short-lived decline in the suicide rate.
conditions that place teens at risk for suicide; and (6)
Within a decade, the suicide rate had returned to
training professionals to improve recognition and
previous levels, and suicides were being committed by
treatment of mood disorders. As discussed below, the
other means (Farberow, 1985). Although reducing
level of evidence for these strategies varies. There is
access to firearms with gun-security laws reduces
more support for direct case-finding and improved
accidental deaths from firearms (Cummings et al.,
recognition and treatment of mood disorders than for
1997), there is no evidence to date that such laws have
the other strategies.
a significant impact on suicides attributable to firearms.
Crisis Hotlines
Media Counseling
Although crisis hotlines are available almost every-
Even though it appears prudent for reporters and editors
where in the United States, research has failed to show
to minimize coverage of youth suicide in general and
that they reduce the incidence of suicide (Bleach &
attention to individual suicides (O'Carroll & Potter,
Clairborn, 1974; Apsler & Hodas, 1976; Miller et al.,
1994), there is as yet no evidence that these guidelines,
1984; Shaffer et al., 1990a, 1990b). Possible reasons
issued by the Centers for Disease Control and
for this are that actively suicidal individuals (males and
Prevention, are effective in reducing the suicide rate.
individuals with an acute mental disturbance) do not
call hotlines because they are acutely disturbed,
Indirect Case-Finding Through Education
preoccupied, or intent on not being deflected from their
Controlled studies have failed to show that classes for
intended course of action (Shaffer et al., 1989).
high school students about suicide increase students'
Hotlines are often busy, and there may be a long wait
help-seeking behavior when they are troubled or
depressed (Spirito et al., 1988; Shaffer et al., 1991;
Vieland et al., 1991). On the other hand, there is
8 Crisis hotlines are only one of the services offered through crisis
evidence that previously suicidal adolescents are upset
services, a topic discussed subsequently.
159
Mental Health: A Report of the Surgeon General
by exposure to such classes (Shaffer et al., 1990a,
on suicide risk awareness, reducing barriers to mental
1990b), even though this does not necessarily lead to a
health services, and stigma-reducing efforts.⁹
suicide attempt. Such educational programs seem,
therefore, to be both an ineffective mode of case-
Other Mental Disorders in Children
finding and to carry with them an unjustified risk of
and Adolescents
activating suicidal thoughts.
Anxiety Disorders
Direct Case-Finding
The combined prevalence of the group of disorders
Judging from the high response rate to surveys about
known as anxiety disorders is higher than that of
suicidal attempts and ideation (National Center for
virtually all other mental disorders of childhood and
Health Statistics, 1997), adolescents will provide
adolescence (Costello et al., 1996). The 1-year
accurate information about their own suicidal thoughts
prevalence in children ages 9 to 17 is 13 percent (Table
and/or behaviors if asked directly in a nonthreatening
3-1). This section furnishes brief overviews of several
way. A sensible approach to suicide prevention that
anxiety disorders: separation anxiety disorder,
needs further study, therefore, is to screen
generalized anxiety disorder, social phobia, and
systematically 15- to 19-year-olds (the age group at
obsessive-compulsive disorder. Treatments for all but
greatest risk) for (1) previous suicide attempts;
the latter are grouped together below.
(2) recent, serious, suicidal preoccupations; (3) depres-
sion; or (4) complications of substance or alcohol use.
Separation Anxiety Disorder
Clearly, screening programs need to go beyond
Although separation anxieties are normal among
identifying a teen with a high-risk profile. Youth
infants and toddlers, they are not appropriate for older
identified in this way should be referred for evaluation
children or adolescents and may represent symptoms of
and, if necessary, treatment. Contingency arrangements
separation anxiety disorder. To reach the diagnostic
may need to be made to assist uninsured adolescents
threshold for this disorder, the anxiety or fear must
with help if it is needed (Shaffer & Craft, 1999).
cause distress or affect social, academic, or job
functioning and must last at least 1 month (DSM-IV).
Aggressive Treatment of Mood Disorders
Children with separation anxiety may cling to their
Preliminary and as yet unreplicated studies in Sweden
parent and have difficulty falling asleep by themselves
(Rihmer et al., 1995) suggest that education of primary
at night. When separated, they may fear that their
medical practitioners to better identify the
parent will be involved in an accident or taken ill, or in
characteristics of mood disorders and to treat these
some other way be "lost" to the child forever. Their
effectively produced a significant reduction in suicide
need to stay close to their parent or home may make it
and suicide-attempt rates. Although the optimal
difficult for them to attend school or camp, stay at
treatment of adolescent depression is not yet as well
friends' houses, or be in a room by themselves. Fear of
understood as that of adult depression, this is an option
separation can lead to dizziness, nausea, or palpitations
that may prove to be useful.
(DSM-IV).
Separation anxiety is often associated with
Air Force Suicide Prevention Program-A
symptoms of depression, such as sadness, withdrawal,
Community Approach
Combining many of the approaches for adolescents
apathy, or difficulty in concentrating, and such children
often fear that they or a family member might die.
described above, the Air Force Surgeon General
developed and implemented a community approach to
suicide prevention for older adolescents and young
9 In 1995, prior to implementation, suicide rates were almost 16 per
100,000; following 3 years of exposure to the program, suicide rates
adults on active duty. The program involved education
fell to below 2 per 100,000 (Air Force Surgeon General, personal
communication, 1999)
160
Children and Mental Health
Young children experience nightmares or fears at
their performance and their anxieties (DSM-IV). The 1-
bedtime.
year prevalence rate for all generalized anxiety disorder
About 4 percent of children and young adolescents
sufferers of all ages is approximately 3 percent. The
suffer from separation anxiety disorder (DSM-IV).
lifetime prevalence rate is about 5 percent (DSM-IV).
Among those who seek treatment, separation anxiety
About half of all adults seeking treatment for this
disorder is equally distributed between boys and girls.
disorder report that it began in childhood or
In survey samples, the disorder is more common in
adolescence, but the proportion of children with this
girls (DSM-IV). The disorder may be overdiagnosed in
disorder who retain the problem into adulthood is
children and teenagers who live in dangerous
unknown. The remission rate is not thought to be as
neighborhoods and have reasonable fears of leaving
high as that of separation anxiety disorder.
home.
The remission rate with separation anxiety disorder
Social Phobia
is high. However, there are periods where the illness is
Children with social phobia (also called social anxiety
more severe and other times when it remits. Sometimes
disorder) have a persistent fear of being embarrassed in
the condition lasts many years or is a precursor to panic
social situations, during a performance, or if they have
disorder with agoraphobia. Older individuals with
to speak in class or in public, get into conversation with
separation anxiety disorder may have difficulty moving
others, or eat, drink, or write in public. Feelings of
or getting married and may, in turn, worry about
anxiety in these situations produce physical reactions:
separation from their own children and partner.
palpitations, tremors, sweating, diarrhea, blushing,
The cause of separation anxiety disorder is not
muscle tension, etc. Sometimes a full-blown panic
known, although some risk factors have been identified.
attack ensues; sometimes the reaction is much more
Affected children tend to come from families that are
mild. Adolescents and adults are able to recognize that
very close-knit. The disorder might develop after a
their fear is unreasonable or excessive, although this
stress such as death or illness in the family or a move.
recognition does not prevent the fear. Children,
Trauma, especially physical or sexual assault, might
however, might not recognize that their reaction is
bring on the disorder (Goenjian et al., 1995). The
excessive, although they may be afraid that others will
disorder sometimes runs in families, but the precise
notice their anxiety and consider them odd or babyish.
role of genetic and environmental factors has not been
Young children do not articulate their fears, but
established. The etiology of anxiety disorders is more
may cry, have tantrums, freeze, cling, appear extremely
thoroughly discussed in Chapter 4.
timid in strange social settings, shrink from contact
with others, stay on the side during social events, and
Generalized Anxiety Disorder
try to stay close to familiar adults. They may fall
Children with generalized anxiety disorder (or
behind in school, avoid school completely, or avoid
overanxious disorder of childhood) worry excessively
social activities among children their age. The
about all manner of upcoming events and occurrences.
avoidance of the fearful situations or worry preceding
They worry unduly about their academic performance
the feared event may last for weeks and interfere with
or sporting activities, about being on time, or even
the individual's daily routine, social life, job, or school.
about natural disasters such as earthquakes. The worry
They may find it impossible to speak in social
persists even when the child is not being judged and
situations or in the presence of unfamiliar people (for
has always performed well in the past. Because of their
review of social phobia, see DSM-IV; Black et al.,
anxiety, children may be overly conforming,
1997).
perfectionist, or unsure of themselves. They tend to
Social phobia is common, the lifetime prevalence
redo tasks if there are any imperfections. They tend to
ranging from 3 to 13 percent, depending on how great
seek approval and need constant reassurance about
the fear is and on how many different situations induce
161
Mental Health: A Report of the Surgeon General
the anxiety (DSM-IV; Black et al., 1997). In survey
In addition, psychodynamic treatment to address
studies, the majority of those with the disorder were
underlying fears and worries can be helpful, and
found to be female (DSM-IV). Often the illness is
behavior therapy may reduce the child's fear of
lifelong, although it may become less severe or
separation or of going to school; however, the
completely remit. Life events may reassure the
experimental support for these approaches is limited.
individual or exacerbate the anxiety and disorder.
Preliminary research suggests that selective
serotonin reuptake inhibitors may provide effective
Treatment of Anxiety
treatment of separation anxiety disorder and other
Although anxiety disorders are the most common
anxiety disorders of childhood and adolescence. Two
disorder of youth, there is relatively little research on
large-scale randomized controlled trials are currently
the efficacy of psychotherapy (Kendall et al., 1997).
being undertaken (Greenhill, 1998a, 1998b). Neither
For childhood phobias, contingency management¹⁰ was
tricyclic antidepressants nor benzodiazepines have been
the only intervention deemed to be well-established,
shown to be more effective than placebo in children
according to an evaluation by Ollendick and King
(Klein et al., 1992; Bernstein et al., 1998).
(1998), which applied the American Psychological
Association Task Force criteria (noted earlier). Several
Obsessive-Compulsive Disorder
psychotherapies are probably efficacious for treating
Obsessive-compulsive disorder (OCD), which is
phobias: systematic desensitization¹; modeling, based
classified in DSM-IV as an anxiety disorder, is
on research by Bandura and colleagues, which
characterized by recurrent, time-consuming obsessive
capitalizes on an observational learning technique
or compulsive behaviors that cause distress and/or
(Bandura, 1971; see also Chapter 2); and several cogni-
impairment. The obsessions may be repetitive intrusive
tive-behavioral therapy (CBT) approaches (Ollendick
images, thoughts, or impulses. Often the compulsive
& King, 1998).
behaviors, such as hand-washing or cleaning rituals, are
CBT, as pioneered by Kendall and colleagues
an attempt to displace the obsessive thoughts
(Kendall et al., 1992; Kendall, 1994), is deemed by the
(DSM-IV). Estimates of prevalence range from 0.2 to
American Psychological Association Task Force as
0.8 percent in children, and up to 2% of adolescents
probably efficacious. It has four major components:
(Flament et al., 1998).
recognizing anxious feelings, clarifying cognitions in
There is a strong familial component to OCD, and
anxiety-provoking situations, 12 developing a plan for
there is evidence from twin studies of both genetic
coping, and evaluating the success of coping strategies.
susceptibility and environmental influences. If one twin
A more recent study in Australia added a parent
has OCD, the other twin is more likely to have OCD if
component to CBT, which enhanced reduction in post-
the children are identical twins rather than fraternal
treatment anxiety disorder significantly compared with
twin pairs. OCD is increased among first-degree
CBT alone (Barrett et al., 1996). However, none of the
relatives of children with OCD, particularly among
interventions identified above as well-established or
fathers (Lenane et al., 1990). It does not appear that the
probably efficacious has, for the most part, been tested
child is simply imitating the relative's behavior,
in real-world settings.
because children who develop OCD tend to have
symptoms different from those of relatives with the
disease (Leonard et al., 1997). Many adults with either
10 Contingency management attempts to alter behavior by
childhood- or adolescent-onset of OCD show evidence
manipulating its consequences through the behavioral principles of
of abnormalities in a neural network known as the
shaping, positive reinforcement, and extinction.
orbitofrontal-striatal area (Rauch & Savage, 1997;
11 A technique that trains people to "unlearn" fears by presentation
Grachev et al., 1998).
of fearful stimuli along with nonfearful stimuli.
12 This refers to understanding how cognitions are being distorted.
162
Children and Mental Health
Recent research suggests that some children with
extremely high research priority for the National
OCD develop the condition after experiencing one type
Institute of Mental Health (NIMH, 1998). Although the
of streptococcal infection (Swedo et al., 1995). This
reported association between autism and obstetrical
condition is referred to by the acronym PANDAS,
hazard may be due to genetic factors (Bailey et al.,
which stands for Pediatric Autoimmune Neuro-
1995), there is evidence that several different causes of
psychiatric Disorders Associated with Streptococcal
toxic or infectious damage to the central nervous
infections. Its hallmark is a sudden and abrupt
system during early development also may contribute
exacerbation of OCD symptoms after a strep infection.
to autism. Autism has been reported in children with
This form of OCD occurs when the immune system
fetal alcohol syndrome (Aronson et al., 1997), in
generates antibodies to the streptococcal bacteria, and
children who were infected with rubella during
the antibodies cross-react with the basal ganglia¹³ of a
pregnancy (Chess et al., 1978), and in children whose
susceptible child, provoking OCD (Garvey et al.,
mothers took a variety of medications that are known to
1998). In other words, the cause of this form of OCD
damage the fetus (Williams & Hersh, 1997).
appears to be antibodies directed against the infection
Cognitive deficits in social perception likely result
mistakenly attacking a region of the brain and setting
from abnormalities in neural circuitry. Children with
off an inflammatory reaction.
autism have been studied with several imaging
The selective serotonin reuptake inhibitors appear
techniques, but no strongly consistent findings have
effective in ameliorating the symptoms of OCD in
emerged, although abnormalities in the cerebellum and
children, although more clinical trials have been done
limbic system (Rapin & Katzman, 1998) and larger
with adults than with children. Several randomized,
brains (Piven, 1997) have been reported. In one small
controlled trials revealed SSRIs to be effective in
study (Zilbovicius et al., 1995), evidence of delayed
treating children and adolescents with OCD (Flament
maturation of the frontal cortex was found. The
et al., 1985; eVeaugh-Geiss et al., 1992; Riddle et al.,
evidence for genetic influences include a much greater
1992, 1998). The appropriate duration of treatment is
concordance in identical than in fraternal twins (Cook,
still being studied. Side effects are not inconsequential:
1998).
dry mouth, somnolence, dizziness, fatigue, tremors, and
constipation occur at fairly high rates. Cognitive-
Treatment
behavioral treatments also have been used to treat OCD
Because autism is a severe, chronic developmental
(March et al., 1997), but the evidence is not yet
disorder, which results in significant lifelong disability,
conclusive.
the goal of treatment is to promote the child's social
and language development and minimize behaviors that
Autism
interfere with the child's functioning and learning.
Autism, the most common of the pervasive develop-
Intensive, sustained special education programs and
mental disorders (with a prevalence of 10 to 12
behavior therapy early in life can increase the ability of
children per 10,000 [Bryson & Smith, 1998]), is
the child with autism to acquire language and ability to
characterized by severely compromised ability to
learn. Special education programs in highly structured
engage in, and by a lack of interest in, social
environments appear to help the child acquire self-care,
interactions. It has roots in both structural brain
social, and job skills. Only in the past decade have
abnormalities and genetic predispositions, according to
studies shown positive outcomes for very young
family studies and studies of brain anatomy. The search
children with autism. Given the severity of the
for genes that predispose to autism is considered an
impairment, high intensity of service needs, and costs
(both human and financial), there has been an ongoing
search for effective treatment.
13 Basal ganglia are groups of neurons responsible for motor and
impulse control, attention, and regulation of mood and behavior.
163
Mental Health: A Report of the Surgeon General
Thirty years of research demonstrated the efficacy
some of the newer antipsychotic drugs suggest that they
of applied behavioral methods in reducing inap-
may have fewer side effects than conventional
propriate behavior and in increasing communication,
antipsychotics such as haloperidol, but controlled
learning, and appropriate social behavior. A well-
studies are needed before firm conclusions can be
designed study of a psychosocial intervention was
drawn about any possible advantages in safety and
carried out by Lovaas and colleagues (Lovaas, 1987;
efficacy over traditional agents.
McEachin et al., 1993). Nineteen children with autism
were treated intensively with behavior therapy for 2
Disruptive Disorders
years and compared with two control groups. Followup
Disruptive disorders, such as oppositional defiant
of the experimental group in first grade, in late
disorder and conduct disorder, are characterized by
childhood, and in adolescence found that nearly half
antisocial behavior and, as such, seem to be a collection
the experimental group but almost none of the children
of behaviors rather than a coherent pattern of mental
in the matched control group were able to participate in
dysfunction. These behaviors are also frequently found
regular schooling. Up to this point, a number of other
in children who suffer from attention-deficit/hyper-
research groups have provided at least a partial
activity disorder, another disruptive disorder, which is
replication of the Lovaas model (see Rogers, 1998).
discussed separately in this chapter. Children who
Several uncontrolled studies of comprehensive
develop the more serious conduct disorders often show
center-based programs have been conducted, focusing
signs of these disorders at an earlier age. Although it is
on language development and other developmental
common for a very young children to snatch something
skills. A comprehensive model, Treatment and
they want from another child, this kind of behavior may
Education of Autistic and Related Communication
herald a more generally aggressive behavior and be the
Handicapped Children (TEACCH), demonstrated short-
first sign of an emerging oppositional defiant or
term gains for preschoolers with autism who received
conduct disorder if it occurs by the ages of 4 or 5 and
daily TEACCH home-teaching sessions, compared with
later. However, not every oppositional defiant child
a matched control group (Ozonoff & Cathcart, 1998).
develops conduct disorder, and the difficult behaviors
A review of other comprehensive, center-based
associated with these conditions often remit.
programs has been conducted, focusing on elements
Oppositional defiant disorder (ODD) is diagnosed
considered critical to school-based programs, including
when a child displays a persistent or consistent pattern
minimum hours of service and necessary curricular
of defiance, disobedience, and hostility toward various
components (Dawson & Osterling, 1997).
authority figures including parents, teachers, and other
The antipsychotic drug, haloperidol, has been
adults. ODD is characterized by such problem
shown to be superior to placebo in the treatment of
behaviors as persistent fighting and arguing, being
autism (Perry et al., 1989; Locascio et al., 1991),
touchy or easily annoyed, and deliberately annoying or
although a significant number of children develop
being spiteful or vindictive to other people. Children
dyskinesias¹⁴ as a side effect (Campbell et al., 1997).
with ODD may repeatedly lose their temper, argue with
Two of the SSRIs, clomipramine (Gordon et al., 1993)
adults, deliberately refuse to comply with requests or
and fluoxetine (McDougle et al., 1996), have been
rules of adults, blame others for their own mistakes,
tested, with positive results, except in young autistic
and be repeatedly angry and resentful. Stubbornness
children, in whom clomipramine was not found to be
and testing of limits are common. These behaviors
therapeutic, and who experienced untoward side effects
cause significant difficulties with family and friends
(Sanchez et al., 1996). Of note, preliminary studies of
and at school or work (DSM-IV; Weiner, 1997).
Oppositional defiant disorder is sometimes a precursor
of conduct disorder (DSM-IV).
14 Dyskinesia is an impairment of voluntary movement, such that it
becomes fragmentary or incomplete.
164
Children and Mental Health
In different studies, estimates of the prevalence of
male. The disorder appears to be more common in
ODD have ranged from 1 to 6 percent, depending on
cities than in rural areas (DSM-IV). Those with early
the population sample and the way the disorder was
onset have a worse prognosis and are at higher risk for
evaluated, but not depending on diagnostic criteria.
adult antisocial personality disorder (DSM-IV; Rutter
Rates are lower when impairment criteria are more
& Giller, 1984; Hendren & Mullen, 1997). Between a
strict and when information is obtained from teachers
quarter and a half of highly antisocial children become
and parents rather than from the children alone (Shaffer
antisocial adults.
et al., 1996a). Before puberty, the condition is more
The etiology of conduct disorder is not fully
common in boys, but after puberty the rates in both
known. Studies of twins and adopted children suggest
genders are equal.
that conduct disorder has both biological (including
In preschool boys, high reactivity, difficulty being
genetic) and psychosocial components (Hendren &
soothed, and high motor activity may indicate risk for
Mullen, 1997). Social risk factors for conduct disorder
the disorder. Marital discord, disrupted child care with
include early maternal rejection, separation from
a succession of different caregivers, and inconsistent,
parents with no adequate alternative caregiver
unsupervised child-rearing may contribute to the
available, early institutionalization, family neglect,
condition.
abuse or violence, parents' psychiatric illness, parental
Children or adolescents with conduct disorder
marital discord, large family size, crowding, and
behave aggressively by fighting, bullying, intimidating,
poverty (Loeber & Stouthamer-Loeber, 1986). These
physically assaulting, sexually coercing, and/or being
factors are thought to lead to a lack of attachment to the
cruel to people or animals. Vandalism with deliberate
parents or to the family unit and eventually to lack of
destruction of property, for example, setting fires or
regard for the rules and rewards of society (Sampson &
smashing windows, is common, as are theft; truancy;
Laub, 1993). Physical risk factors for conduct disorder
early tobacco, alcohol, and substance use and abuse;
include neurological damage caused by birth
and precocious sexual activity. Girls with a conduct
complications or low birthweight, attention-
disorder are prone to running away from home and may
deficit/hyperactivity disorder, fearlessness and stim-
become involved in prostitution. The behavior
ulation-seeking behavior, learning impairments,
interferes with performance at school or work, so that
autonomic underarousal, and insensitivity to physical
individuals with this disorder rarely perform at the level
pain and punishment. A child with both social
predicted by their IQ or age. Their relationships with
deprivation and any of these neurological conditions is
peers and adults are often poor. They have higher
most susceptible to conduct disorder (Raine et al.,
injury rates and are prone to school expulsion and
1998).
problems with the law. Sexually transmitted diseases
Since many of the risk factors for conduct disorder
are common. If they have been removed from home,
emerge in the first years of life, intervention must begin
they may have difficulty staying in an adoptive or
very early. Recently, screening instruments have been
foster family or group home, and this may further
developed to enable earlier identification of risk factors
complicate their development. Rates of depression,
and signs of conduct disorder in young children (Feil et
suicidal thoughts, suicide attempts, and suicide itself
al., 1995). Studies have shown a correlation between
are all higher in children diagnosed with a conduct
the behavior and attributes of 3-year-olds and the
disorder (Shaffer et al., 1996b).
aggressive behavior of these children at ages 11 to 13
The prevalence of conduct disorder in 9- to 17-
(Raine et al., 1998). Measurements of aggressive
year-olds in the community varies from 1 to 4 percent,
behaviors have been shown to be stable over time
depending on how the disorder is defined (Shaffer et
(Sampson & Laub, 1993). Training parents of high-risk
al., 1996a). Children with an early onset of the
children how to deal with the children's demands may
disorder, i.e., onset before age 10, are predominantly
help. Parents may need to be taught to reinforce
165
Mental Health: A Report of the Surgeon General
appropriate behaviors and not harshly punish
home- and family-focused treatment that is described
transgressing ones, and encouraged to find ways to
under Home-Based Services.
increase the strength of the emotional ties between
Despite strong enthusiasm for improving care for
parent and child. Working with high-risk children on
conduct-disordered youth, there are important groups of
social interaction and providing academic help to
children, specifically girls and ethnic minority
reduce rates of school failure can help prevent some of
populations, who were not sufficiently represented in
the negative educational consequences of conduct
these studies to ensure that the identified treatments
disorder (Johnson & Breckenridge, 1982).
work for them. Other issues raised by Brestan and
Eyberg (1998) are cost-effectiveness, the sufficiency of
Treatment
a given intervention, effectiveness over time, and the
Several psychosocial interventions can effectively
prevention of relapse.
reduce antisocial behavior in disruptive disorders. A
No drugs have been demonstrated to be
recent review of psychosocial treatments for children
consistently effective in treating conduct disorder,
and adolescents identified 82 studies conducted
although four drugs have been tested. Lithium and
between 1966 and 1995 involving 5,272 youth (Brestan
methylphenidate have been found (one double-blind
& Eyberg, 1998). The criterion for inclusion was that
placebo trial each) to reduce aggressiveness effectively
the child was in treatment for conduct problem
in children with conduct disorder (Campbell et al.,
behavior, based on displaying a symptom of conduct
1995; Klein et al., 1997b), but in two subsequent
disorder or oppositional defiant disorder, rather than on
studies with the same design, the positive findings for
a DSM diagnosis of either, although children did meet
lithium could not be reproduced (Rifkin et al., 1989;
DSM criteria for one of these conditions in about one-
Klein, 1991). In one of the latter studies, methyl-
third of the studies.
phenidate was superior to lithium and placebo. A third
By applying criteria established by the American
drug, carbamazepine, was found in a pilot study to be
Psychological Association Task Force (see earlier) to
effective, but multiple side effects were also reported
the 82 studies, two treatments met criteria for well-
(Kafantaris et al., 1992). The fourth drug, clonidine,
established treatment and 10 for probably efficacious
was explored in an open trial, in which 15 of 17
treatment. Two well-established treatments, both di-
patients showed a significant decrease in aggressive
rected at training parents, succeeded in reducing
behavior, but there were also significant side effects
problem behaviors. The two treatments were a parent
that would require monitoring of cardiovascular and
training program based on the manual Living With
blood pressure parameters (Kemph et al., 1993).
Children (Bernal et al., 1980) and a videotape modeling
parent training (Spaccarelli et al., 1992). The first
Substance Use Disorders in Adolescents
teaches parents to reward desirable behaviors and
Since the early 1990s there has been a "sharp
ignore or punish deviant behaviors, based on principles
resurgence" in the misuse of alcohol and other drugs by
of operant conditioning. The second provides a series
adolescents (Johnston et al., 1996). A recent review,
of videotapes covering parent-training lessons, after
focusing particularly on substance abuse and
which a therapist leads a group discussion of the
dependence, synthesizes research findings of the past
videotape lessons. The identification of 12 treatments
decade (Weinberg et al., 1998). The authors review
as well-established or probably efficacious is very
epidemiology, course, etiology, treatment, and
encouraging because of the potential to intervene
prevention and discuss comorbidity with other mental
effectively with youth at high risk of poor outcomes. A
disorders in adolescents. All of these issues are
new and promising approach for the treatment of
important to public health, but none is more relevant to
conduct disorder is multisystemic therapy, an intensive
this report than the co-occurrence of alcohol and other
166
Children and Mental Health
substance use disorders with other mental disorders in
episodic uncontrolled consumption, without
adolescents.
compensatory activities, such as vomiting or laxative
According to the National Comorbidity Study, 41
abuse, to avert weight gain (Devlin, 1996). Bulimia, in
to 65 percent of individuals with a lifetime substance
contrast, is marked by both binge eating and by
abuse disorder also have a lifetime history of at least
compensatory activities. Anorexia nervosa is
one mental disorder, and about 51 percent of those with
characterized by low body weight (< 85 percent of
one or more lifetime mental disorders also have a
expected weight), intense fear of weight gain, and an
lifetime history of at least one substance use disorder
inaccurate perception of body weight or shape
(Kessler et al., 1996). The rates are highest in the 15- to
(DSM-IV). Its mean age of onset is 17 years (DSM-IV).
24-year-old age group (Kessler et al., 1994). The cross-
The causes of eating disorders are not known with
sectional data on association do not permit any
precision but are thought to be a combination of
conclusion about causality or clinical prediction
genetic, neurochemical, psychodevelopmental, and
(Kessler et al., 1996), but an appealing theory suggests
sociocultural factors (Becker et al., 1999; Kaye et al.,
that a subgroup of the population abuses drugs in an
1999). Comorbid mental disorders are exceedingly
effort to self-medicate for the co-occurring mental
common, but interrelationships are poorly understood.
disorder. Little is actually known about the role of
Comorbid disorders include affective disorders
mental disorders in increasing the risk of children and
(especially depression), anxiety disorders, substance
adolescents for misuse of alcohol and other drugs.
abuse, and personality disorders (Herzog et al., 1996).
Stress appears to play a role in both the process of
Anorexia nervosa has the most severe consequence,
addiction and the development of many of the
with a mortality rate of 0.56 percent per year (or 5.6
comorbid conditions.
percent per decade) (Sullivan, 1995), a rate higher than
The review by Weinberg and colleagues (1998)
that of almost all other mental disorders (Herzog et al.,
provides more detail on epidemiology and assessment
1996). Mortality is from starvation, suicide, or
of alcohol and other drug use in adolescents and
electrolyte imbalance (DSM-IV). The mortality rate
describes several effective treatment approaches for
from anorexia nervosa is 12 times higher than that for
these problems. A meta-analysis and literature review
other young women in the population (Sullivan, 1995).
(Stanton & Shadish, 1997) concluded that family-
Treatment of eating disorders entails psychotherapy
oriented therapies were superior to other treatment
and pharmacotherapy, either alone or in combination.
approaches and enhanced the effectiveness of other
Treatment of comorbid mental disorders also is
treatments. Multisystemic family therapy, discussed
important, as is treatment of medical complications.
elsewhere in this chapter, is effective in reducing
There are some controlled studies of the efficacy of
alcohol and other substance use and other severe
specific treatments for adults with bulimia and binge-
behavioral problems among adolescents (Pickrel &
eating disorder (Devlin, 1996), but fewer for anorexia
Henggeler, 1996).
nervosa (Kaye et al., 1999). Controlled studies in
adolescents are rare for any eating disorder (Steiner and
Eating Disorders
Lock, 1998). Pharmacological studies in young adult
Eating disorders are serious, sometimes life-
women found conflicting evidence of benefit from
threatening, conditions that tend to be chronic (Herzog
antidepressants for anorexia and some reduction in the
et al., 1999). They usually arise in adolescence and
frequency of binge eating and purging with tricyclic
disproportionately affect females. About 3 percent of
antidepressants, monoamine oxidase inhibitors, and
young women have one of the three main eating
SSRIs (see Jimerson et al., 1993; Jacobi et al., 1997).
disorders: anorexia nervosa, bulimia nervosa, or binge-
Studies mostly of adult women find cognitive-
eating disorder (Becker et al., 1999). Binge-eating
behavioral therapy and interpersonal therapy to be
disorder is a newly recognized condition featuring
effective for bulimia and binge-eating disorder
167
Mental Health: A Report of the Surgeon General
(Fairburn et al., 1993; Devlin, 1996; Becker et al.,
strongest research base (Weisz et al., 1998). Outpatient
1999). Clearly, more research is warranted for the
therapy is offered to individuals, groups, or families,
treatment of eating disorders, especially because a
usually in a clinic or private office. The duration of
sizable proportion of those with eating disorders have
treatment varies from 6 to 12 weekly sessions to a year
limited response to treatment (Kaye et al., 1999).
or longer. Newer outpatient interventions (e.g., case
management, home-based therapy) that were developed
Services Interventions
more recently for youth with severe disorders are
provided with greater frequency (i.e., daily) in the
Treatment Interventions
home, school, or community. Those interventions are
This section examines the effectiveness of such
reviewed later in this chapter.
treatment interventions as outpatient, partial
The strongest support for the effectiveness of
hospitalization/day, residential, inpatient treatments,
outpatient treatment comes from a series of meta-
and medication. Much of the research on their
analyses. Meta-analyses are an important type of
effectiveness deals with children's outcomes largely
research methodology, described in Chapter 1, that
independent of diagnosis. As noted earlier in this
enable one to combine research findings from separate
chapter (see Treatment Strategies), practitioners and
studies. Nine meta-analyses, published between 1985
researchers previously shied away from diagnosis
and 1995, probed the effectiveness of research on
because of the inherent difficulty of making a
individual, group, and family therapy for children and
diagnosis, concerns about labeling children, and the
adolescents (Casey & Berman, 1985; Hazelrigg et al.,
limited usefulness of DSM classifications for children.
1987; Weisz et al., 1987; Kazdin et al., 1990; Baer &
Each intervention was developed to treat a host of
Nietzel, 1991; Grossman & Hughes 1992; Shadish et
mental health conditions in children and adolescents.
al., 1993; Weisz & Weiss, 1993; Weisz et al., 1995).
Each also was delivered in a wide range of settings.
Although these meta-analyses vary in time period, age
Over time, the combination of interventions and
groups, and meta-analytic approach, they were largely
settings, with the exception of medication, became
restricted to studies of treatment given in a research
conceptualized as "treatments," which stimulated
clinical setting, and their findings are relatively
research on their effectiveness (Goldman, 1998). They
consistent. The major findings indicated that the
are not, however, treatments in the conventional sense
improvements with outpatient therapy are greater than
of the term because they are less specific than other
those achieved without treatment; the treatment is
treatments with respect to indications, intensity (i.e.,
highly effective, as was found in meta-analyses of
"dose"), and elements of the intervention. There is little
adults (Brown, 1987); and the effects of treatment are
research describing treatment in actual clinical settings.
similar, whether applied to problems such as anxiety,
depression, or withdrawal (internalizing problems) or
Outpatient Treatment
to hyperactivity and aggression (externalizing
The term "outpatient treatment" covers a large variety
problems) (Kazdin, 1996).
of therapeutic approaches, with most falling into the
Given strong evidence of efficacy for outpatient
broad theoretical categories of the psychodynamic,
treatment, the question of applicability to real-world
interpersonal, and behavioral psychotherapy.
settings has been examined. A meta-analysis was
Outpatient psychotherapy is the most common form of
performed on studies of the effectiveness of various
treatment for children and adolescents, utilized
types of outpatient treatment, regardless of whether
annually by an estimated 5 to 10 percent of children
their efficacy had been established through research
and their families in the United States (Burns et al.,
(Weisz et al., 1995). The researchers were able to
1998). It is also the most extensively studied
identify only nine studies of treated children in
intervention and, with over 300 studies, has the
nonresearch clinical settings where therapy was a
168
Children and Mental Health
regular service of the clinic and was carried out by
ambiguous, that it induces demand among those who
practicing clinicians. Those nine studies demonstrated
would not otherwise seek treatment, and that its length,
little or no effect. Clearly, real-world therapy was
treatment outcomes, and costs are unpredictable (Kiser
found to be less effective than that provided through a
et al., 1986). Research is needed to address these
research protocol. A variety of factors may account for
issues.
the gap, including less attention in real-world settings
To date, the only controlled study of partial
to careful matching of patients with treatments, less
hospitalization compared outcomes for young children
adherence to a treatment protocol, and less followup
(ages 5 to 12) with disruptive behavior disorders who
care.
received intensive day treatment with childrent who
received traditional outpatient treatment services (in
Partial Hospitalization/Day Treatment
fact, a waiting list control) (Grizenko et al., 1993). The
Partial hospitalization, also called day treatment and
results at 6 months favored day treatment in reducing
partial care, has been a growing treatment modality for
behavior problems, decreasing symptoms, and improv-
youth with mental disorders. Research on partial
ing family functioning.
hospitalization as an alternative to inpatient treatment
Findings from uncontrolled studies of partial
generally finds benefit from a structured daily
hospitalization are informative, although not conclu-
environment that allows youth to return home at night
sive. Based on approximately 20 studies, multiple
to be with their family and peers.
benefits have been reported even over the long term
Partial hospitalization is a specialized and intensive
(see reviews by Kutash & Rivera, 1996; Grizenko,
form of treatment that is less restrictive than inpatient
1997). In general, child behavior and family
care but is more intensive than the usual types of
functioning improve following partial hospitalization.
outpatient care (i.e., individual, family, or group
Findings for improved academic achievement are
treatment). The most frequently used type of partial
mixed and possibly suggest that implementation of
hospitalization is an integrated curriculum combining
school-based models should be considered. About
education, counseling, and family interventions. The
three-fourths of youth are reintegrated into regular
setting, be it a hospital, school, or clinic, may be tied to
school, often with the help of special education or other
the theoretical orientation of the treatment, which
school- or community-based services. Several
ranges from psychoanalytic to behavioral. Partial
uncontrolled studies found that day treatment could
hospitalization has also been used as a transitional
prevent youth from entering other costly placements
service after either psychiatric hospitalization or
(particularly inpatient and residential treatment
residential treatment, at the point when the child no
centers), which suggests that partial hospitalization
longer needs 24-hour care but is not ready to be
may reduce overall costs of treatment (Kutash &
integrated into the school system. It also is used to
Rivera, 1996). Finally, family participation during and
prevent institutional placement.
following day treatment is essential to obtaining and
Overall, the research literature points to positive
maintaining results (Kutash & Rivera, 1996).
gains from adolescent use of day treatment, but most of
the studies are uncontrolled. Gains relate to academic
Residential Treatment Centers
and behavioral improvement; reduction in, or delay of,
Residential treatment centers are the second most
hospital and residential placement; and a return to
restrictive form of care (next to inpatient
regular school for about 75 percent of patients (Baenen
hospitalization) for children with severe mental
et al., 1986; Gabel & Finn, 1986). Day treatment
disorders. Although used by a relatively small
programs are not being used as frequently as they might
percentage (8 percent) of treated children, nearly one-
be because third-party payers are reluctant to support
fourth of the national outlay on child mental health is
this form of treatment. They claim that the modality is
spent on care in these settings (Burns et al., 1998).
169
Mental Health: A Report of the Surgeon General
However, there is only weak evidence for their
interventions provided on an outpatient basis can
effectiveness.
ameliorate such behaviors (Brestan & Eyberg, 1998).
A residential treatment center (RTC) is a licensed
For children in the second category (i.e., those needing
24-hour facility (although not licensed as a hospital),
protection from themselves because of suicide attempts,
which offers mental health treatment. The types of
severe substance use, abuse, or persistent running
treatment vary widely; the major categories are
away), it is possible that a brief hospitalization for an
psychoanalytic, psychoeducational, behavioral
acute crisis or intensive community-based services may
management, group therapies, medication management,
be more appropriate than an RTC. An intensive long-
and peer-cultural. Settings range from structured ones,
term program such as an RTC with a high staff to child
resembling psychiatric hospitals, to those that are more
ratio may be of benefit to some children, especially
like group homes or halfway houses. While formerly
when sufficient supportive services are not available in
for long-term treatment (e.g., a year or more), RTCs
their communities. In short, there is a compelling need
under managed care are now serving more seriously
to clarify criteria for admission to RTCs (Wells, 1991).
disturbed youth for as briefly as 1 month for intensive
Previous criteria have been replaced and strengthened
evaluation and stabilization.
(i.e., with an emphasis on resources needed after
Concerns about residential care primarily relate to
discharge) by the National Association of Psychiatric
criteria for admission; inconsistency of community-
Treatment Centers for Children (1990).
based treatment established in the 1980s; the costliness
The evidence for outcomes of residential treatment
of such services (Friedman & Street, 1985); the risks of
comes from research published largely in the 1970s and
treatment, including failure to learn behavior needed in
1980s and, with three exceptions, consists of
the community; the possibility of trauma associated
uncontrolled studies (see Curry, 1991).
with the separation from the family; difficulty
Of the three controlled studies of RTCs, the first
reentering the family or even abandonment by the
evaluated a program called Project Re-Education (Re-
family; victimization by RTC staff; and learning of
Ed). Project Re-Ed, a model of residential treatment
antisocial or bizarre behavior from intensive exposure
developed in the 1960s, focuses on training teacher-
to other disturbed children (Barker, 1998). These
counselors, who are backed up by consultant mental
concerns are discussed below.
health specialists. Project Re-Ed schools are located
In the past, admission to an RTC has been justified
within communities, facilitating therapeutic work with
on the basis of community protection, child protection,
the family and allowing the child to go home on
and benefits of residential treatment per se (Barker,
weekends. Camping also is an important component of
1982). However, none of these justifications have stood
the program, inspired by the Outward Bound Schools
up to research scrutiny. In particular, youth who display
in England. The first published study of Project Re-Ed
seriously violent and aggressive behavior do not appear
compared outcomes for adolescent males in Project Re-
to improve in such settings, according to limited
Ed with untreated disturbed adolescents and with
evidence (Joshi & Rosenberg, 1997). One possible
nondisturbed adolescents. Treated adolescents
reason is that association with delinquent or deviant
improved in self-esteem, control of impulsiveness, and
peers is a major risk factor for later behavior problems
internal control compared with untreated adolescents,
(Loeber & Farrington, 1998). Moreover, community
according to ratings by Project Re-Ed staff and by
interventions that target change in peer associations
families (Weinstein, 1974). A 1988 followup study of
have been found to be highly effective at breaking
Project Re-Ed found that when adjustment outcomes
contact with violent peers and reducing aggressive
were maintained at 6 months after discharge from
behaviors (Henggeler et al., 1998). Although removal
Project Re-Ed, those outcomes were predicted more by
from the community for a time may be necessary for
community factors at admission (e.g., condition of the
some, there is evidence that highly targeted behavioral
family and school, supportiveness of the local
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Children and Mental Health
community) than by client factors (e.g., diagnosis,
to identify those groups of children and adolescents for
school achievement, age, IQ). This suggested that
whom the benefits of residential care outweigh the
interventions in the child's community might be as
potential risks.
effective as placement in the treatment setting (Lewis,
1988).
Inpatient Treatment
The only other controlled study compared an RTC
Inpatient hospitalization is the most restrictive type of
with therapeutic foster care through the Parent
care in the continuum of mental health services for
Therapist Program. Both client groups shared
children and adolescents. Questions about excessive
comparable backgrounds and made similar progress in
and inappropriate use of hospitals were raised in the
their respective treatment program. However, the
early 1980s (Knitzer, 1982) and clearly documented
residential treatment cost twice as much as therapeutic
thereafter in rising admission rates from the 1980s into
foster care (Rubenstein et al., 1978).
the mid-1990s, without evidence of increased social or
Despite strong caveats about the quality,
clinical need for such treatment (Weller et al., 1995).
sophistication, and import of uncontrolled studies,
Inpatient care consumes about half of child mental
several consistent findings have emerged. For most
health resources, based on the latest estimate available
children (60 to 80 percent), gains are reported in areas
(Burns, 1991), but it is the clinical intervention with the
such as clinical status, academic skills, and peer
weakest research support. Nevertheless, because some
relationships. Whether gains are sustained following
children with severe disorders do require a highly
treatment appears to depend on the supportiveness of
restrictive treatment environment, hospitals are
the child's post-discharge environment (Wells, 1991).
expected to remain an integral component of mental
Several studies of single institutions report main-
health care (Singh et al., 1994). More concerted
tenance of benefits from 1 to 5 years later (Blackman et
attention to the risks and benefits of hospital use is
al., 1991; Joshi & Rosenberg, 1997). In contrast, a large
critical, however, along with development of
longitudinal six-state study of children in publicly
community-based alternative services.
funded RTCs found at the 7-year followup that 75
Research on inpatient treatment mostly consists of
percent of youth treated at an RTC had been either
uncontrolled studies (Curry, 1991). Factors that are
readmitted to a mental health facility (about 45 percent)
likely to predict benefit have been identified from such
or incarcerated in a correctional setting (about 30
studies. Beneficial factors were found to include higher
percent) (Greenbaum et al., 1998).
child intelligence; the quality of family functioning and
In summary, youth who are placed in RTCs clearly
family involvement in treatment; specific
constitute a difficult population to treat effectively. The
characteristics of treatment (e.g., completion of
outcomes of not providing residential care are
treatment program and planned discharge); and the use
unknown. Transferring gains from a residential setting
of aftercare services. Neither age nor gender affected
back into the community may be difficult without clear
prognosis after hospitalization. The prognosis was poor
coordination between RTC staff and community
for several clinical characteristics, including children
services, particularly schools, medical care, or
with a psychotic diagnosis and antisocial features with
community clinics. Typically, this type of coordination
conduct disorder (Kutash & Rivera, 1996).
or aftercare service is not available upon discharge. The
Only three controlled studies evaluated the
research on RTCs is not very enlightening about the
effectiveness of inpatient treatment: one that random-
potential to substitute RTC care for other levels of care,
ized antisocial children to specific interventions on an
as this requires comparisons with other interventions.
inpatient unit (Kazdin et al., 1987a, 1987b) and two
Given the limitations of current research, it is
older clinical trials (Flomenhaft, 1974; Winsberg et al.,
premature to endorse the effectiveness of residential
1980). All three studies demonstrated that community
treatment for adolescents. Moreover, research is needed
care was at least as effective as inpatient treatment.
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Mental Health: A Report of the Surgeon General
More recently there have been preliminary
is for home-based services and therapeutic foster care,
favorable findings from a randomized trial of inpatient
as discussed below.
treatment versus multisystemic therapy (MST), an
There is a special emphasis throughout this section
intensive home-based intervention. For example, MST
on "children with serious emotional disturbances," as
was more effective than psychiatric hospitalization in
many of these community-based services are targeted
reducing antisocial behavior, improving family
to this population of the most serious severely affected
structure and cohesion, improving social relationships,
children. The term serious emotional disturbance refers
and keeping children in school and out of institutions
to a diagnosed mental health problem that substantially
(after the initial period when the control group was in
disrupts a child's ability to function socially,
the hospital). Hospitalized youth reported improved
academically, and emotionally. It is not a formal
self-esteem, and youth in both treatment conditions
DSM-IV diagnosis but rather a term that has been used
showed comparable decreases in emotional distress
both within states and at the Federal level to identify a
(Henggeler et al., 1998). A great deal more research is
population of children with significant functional
needed on inpatient hospitalization, as it is by far the
impairment due to mental, emotional, and behavioral
costliest and most restrictive form of care. Recent
problems who have a high need for services. The
changes in health care management have resulted in
official definition of children with serious emotional
short lengths of stay for children and adolescents.
disturbance adopted by the Substance Abuse and
Preliminary results from the study of MST indicate that
Mental Health Services Administration is "persons
intensive home-based services may be a viable
from birth up to age 18 who currently or at any time
alternative to hospitalization. However, even when
during the past year had a diagnosable mental,
such services are available, there may be a need for
behavioral, or emotional disorder of sufficient duration
brief 24-hour stabilization units for handling crises (see
to meet diagnostic criteria specified within the DSM-
Crisis Services).
III-R, and that resulted in functional impairment which
substantially interferes with or limits the child's role or
Newer Community-Based Interventions
functioning in family, school, or community activities"
Since the 1980s, the field of children's mental health
(SAMHSA, 1993, p. 29425). 15 The term is used in a
has witnessed a shift from institutional to community-
variety of Federal statutes in reference to children
based interventions. The forces behind this
fitting that description and does not signify any
transformation are presented in a subsequent section,
particular diagnosis per se; rather, it is a legal term that
Service Delivery. This section attempts to answer the
triggers a host of mandated services to meet the needs
question of whether community-based interventions are
of these children (see Service Delivery section).
effective. It covers a range of comprehensive
community-based interventions, including case
Case Management
management, home-based services, therapeutic foster
Case management is an important and widespread
care, therapeutic group homes, and crisis services.
component of mental health services, especially for
Although the evidence for the benefits of some of these
children with serious emotional disturbances. The main
services is uneven at best, even uncontrolled studies
purpose of case management is to coordinate the
offer a starting point for studying the effectiveness and
provision of services for individual children and their
feasibility of their implementation. Many of the
families who require services from multiple service
evaluations to date offer a first glimpse into the benefits
providers. Case managers take on roles ranging from
of these services and the extent to which they may be
brokers of services to providers of clinical services.
valuable for further examination. Of these inter-
ventions, the most convincing evidence of effectiveness
15 This definition is also used with newer diagnostic systems, such
as DSM-IV.
172
Children and Mental Health
There is a considerable amount of variation in models
found that children in the program spent significantly
of case management. In one important model, called
more days in the community between episodes of
"wraparound," case managers involve families in a
psychiatric hospitalization and were hospitalized for
participatory process of developing an individualized
fewer days than before enrollment (Evans et al., 1994).
plan focusing on individual and family strengths in
A subsequent study evaluated a random sample of 199
multiple life domains. Research on wraparound is still
children enrolled in CYICM (Evans et al., 1996b).
in its early stages (Burns & Goldman, 1999).
Findings at 3-year followup indicated significant
There have been controlled studies of three
behavioral improvements and decreases in unmet
programs that used case managers who work
medical, recreational, and educational needs compared
individually rather than as part of an interdisciplinary
with findings at enrollment. As in the previous study,
team (discussed later). In one study of the Partner's
children who had been in CYICM for 2 years had spent
Project in Oregon, case management was compared
fewer days in psychiatric hospitals and more days in
with "usual services," which did not include case
community settings during the intervals between
management (Gratton et al., 1995). The authors found
hospitalizations. This study went further to compare
at 1-year followup that children in the Partner's Project
their hospital utilization with that by children not
scored significantly higher on measures of social
enrolled in the program. Although CYICM clients spent
competence and had received more individualized,
more days in psychiatric hospitals before enrollment,
comprehensive services, and a greater degree of service
they used inpatient services after enrollment
coordination.
significantly less than did non-enrollees. CYICM
The second study compared the outcomes of
clients' hospital admissions declined fivefold after
intensive case management and regular case
enrollment whereas among non-enrollees the decline in
management for mentally ill homeless children in
admission rates was less than half that value. This
Seattle (Cauce et al., 1994). The case managers in the
difference translated into a savings of almost
intensive condition had lower caseloads, were required
$8,000,000 for New York State, where the project took
to spend more hours supervising the youth, had flexible
place.
funds (for clothing, transportation, etc.) at their
Some research has investigated the effects of
disposal, spent more hours in consultation with
extending case management on children with a dual
psychologists, and were of higher educational status.
diagnosis of a mental disorder and a substance abuse
After 1 year, the study found that both groups showed
problem. Within the CYICM program, researchers
substantial yet similar improvement in mental health
looked at whether adolescents with mental disorders
and social adjustment.
and substance abuse problems derived comparable
A model known as Children and Youth Intensive
benefits from the program as did those without
Case Management (CYICM) was evaluated in two
substance abuse problems (Evans et al., 1992). No
controlled studies. The program has been described as
significant differences were found in the average
an Expanded Broker Model, which means that the case
number of inpatient admissions both before and after
manager, in addition to brokering services, is
enrollment. There was also no significant difference
responsible for assessment, planning, linking, and
between groups in the average decrease from pre- to
advocating on behalf of the youth and family. Case
postenrollment in the number of days spent in
managers, with caseloads of 10 children, are given
hospitals. These results indicate that case management
$2,000 of flexible funds per child each year to purchase
can be as effective for youth presenting with substance
treatment and ancillary services (e.g., transportation
abuse problems as for youth presenting with other
and educational aids). In the first study, the authors
psychiatric disorders.
173
Mental Health: A Report of the Surgeon General
Team Approaches to Case Management
The findings at 18 months (or at discharge) indicated
Several studies assessed the value of case management
that children in FCICM had significantly fewer
as part of a treatment team. In a randomized trial in
behavioral symptoms and significantly greater
North Carolina (Burns et al., 1996), youth served by an
improvements in overall functioning than those in
interdisciplinary treatment team led by a case manager
Family-Based Treatment. In addition, the average
were compared with a control group of youth served by
annual cost of FCICM was less than half that of
a treatment team led by their primary clinician in the
Family-Based Treatment.
role of case manager (also called clinician case
The Fostering Individualized Assistance Program
manager). At 1-year followup, case managers in the
(FIAP) is an example of case management provided
experimental group reported spending significantly
through a wraparound approach. The effectiveness of
more time with their clients, as well as significantly
this model, which used clinical case managers, was
more time on the core functions of case management
compared with standard foster care in a randomized
(e.g., outreach; assessment of strengths, needs, and
trial involving 131 children and their families (Clark et
resources; service planning and monitoring; linking,
al., 1998). The most important duty of the FIAP case
referral, and advocacy; and crisis intervention). The
managers was to arrange monthly team meetings for the
experimental group also remained in the case-managed
monitoring of individualized service plans. Although
program longer, spent fewer days in psychiatric
both groups showed significant improvement in their
hospitals, and received more community-based services
behavioral adjustment over a 3½-year period, children
and a more comprehensive array of services. Although
in the FIAP group were less likely to change
both groups showed similar clinical and functional
placements, and boys in the group reported better social
improvements, parents of youth in the experimental
adjustment and fewer delinquencies. Older youth in the
group reported more satisfaction with the service
group were more likely to maintain placements in
system. The study concluded that traditional case
homes of relatives and less likely to run away. Youth in
managers, rather than clinician case managers, provide
FIAP were also absent from school less often and spent
a more cost-effective method for attaining positive
fewer days suspended from school. Overall, youth in
behavioral outcomes and access to mental health
the FIAP group showed more improvement than did
services.
youth in standard foster care. Multiple uncontrolled
Another example of a team approach to case
studies of case management using a wraparound
management is the Family Centered Intensive Case
approach were summarized in a recent monograph
Management (FCICM) program. This was originally
focusing on the wraparound process (Burns &
created as a variation of Child and Youth Intensive
Goldman, 1999). Overall, the reviewed studies,
Case Management in New York, with the later addition
although using uncontrolled methods, offer emerging
of a wraparound approach. The wraparound approach
evidence of the potential effectiveness of case
is based on a belief that the child and family should be
management using a wraparound process.
placed at the center of an array of coordinated health
While evidence is limited and many of the positive
and mental health, educational, and other social welfare
outcomes focus on service use rather than clinical
services and resources, which a case manager wraps
status, there is some indication that case management
around the patient and family. In a randomized trial,
is an effective intervention for youth with serious
children were assigned to either FCICM or Family-
emotional disturbances. Studies in this area are difficult
Based Treatment (Evans et al., 1996a). Family-Based
to conduct because of resource limitations and of
Treatment included training, support, and respite care
varying approaches to case management. Agreement on
for foster families but did not include case managers.
standards for specific case management models is
174
Children and Mental Health
needed in order to proceed with efficient and reliable
The findings are presented below according to their
controlled research in this area. In addition, future
organizational sponsorship by either child welfare or
research needs to address the issue of cost-
juvenile justice system.
effectiveness, as some evidence presented above has
shown savings from less utilization of institutional care.
Family Preservation Programs Under the Child
Welfare System
Home-Based Services
Within the child welfare system, particularly effective
This section describes the strong record of
family reunification programs were the Homebuilders
effectiveness for home-based services, which provide
Program in Tacoma, Washington, which was designed
very intensive services within the homes of children
to reunify abused and neglected children with their
and youth with serious emotional disturbances. A major
families by providing family-based services (Fraser et
goal is to prevent an out-of-home placement (i.e., in
al., 1996), and the family reunification programs in
foster care, residential, or inpatient treatment). Home-
Washington State and in Utah (Pecora et al., 1991).
based services are usually provided through the child
Studies suggested that 75 to 90 percent of the children
welfare, juvenile justice, and/or mental health systems.
and adolescents who participated in such programs
They are also referred to as in-home services, family
subsequently did not require placement outside the
preservation services, family-centered services, family-
home. The youths' verbal and physical aggression
based services, or intensive family services.
decreased, and cost of services was reduced (Hinckley
Stroul (1988) identified three major goals of home-
& Ellis, 1985). The success of these family
based services: to preserve the family's integrity and
preservation programs is based on the following:
prevent unnecessary out-of-home placements; to put
services are delivered in a home and community
adolescents and their families in touch with community
setting; family members are viewed as colleagues in
agencies and individuals, thus creating an outside
defining a service plan; back-up services are available
support system; and to strengthen the family's coping
24 hours a day; skills are built according to the
skills and capacity to function effectively in the
individual needs of family members; marital and family
community after crisis treatment is completed. The
interventions are offered; community services are
specific services provided most often include
efficiently coordinated; and assistance with basic needs
evaluation, assessment, counseling, skills training, and
such as food, housing, and clothing is given (Fraser et
coordination of services. The historical evolution of
al., 1997).
home-based services is discussed further under Support
and Assistance for Families in Service Delivery.
Multisystemic Therapy
The evidence for the benefits of home-based
Multisystemic therapy programs within the juvenile
services was recently evaluated in a meta-analysis of
justice system have demonstrated effectiveness. MST
controlled studies only (Fraser et al., 1997). The
is an intensive, short-term, home- and family-focused
analysis referred to home-based services as "family
treatment approach for youth with severe emotional
preservation services"; these were sponsored either by
disturbances. MST was originally based on risk factors
the child welfare or juvenile justice systems. For 22
that were identified in the published literature and was
studies the authors analyzed specific measures such as
designed for delinquents. MST intervenes directly in
out-of-home placement, family reunification, arrest,
the youth's family, peer group, school, and
incarceration, and hospitalization, with the control
neighborhood by identifying and targeting factors that
group defined as youth receiving "usual" or "routine"
contribute to the youth's problem behaviors. The main
services. While a majority of the studies demonstrated
goal of MST is to develop skills in both parents and
marginal gains in effectiveness, other services appeared
community organizations affecting the youth that will
to be significantly more effective than usual services.
endure after brief (3 to 4 months) and intensive
175
Mental Health: A Report of the Surgeon General
treatment. MST was constructed around a set of
children who are dangerous to themselves and who do
principles that were put into practice and then
not respond as quickly to treatment as the delinquent
expanded upon in a manual (Henggeler et al., 1998).
youth in previous studies. The efficacy of MST was
Elaborate training, supervision, and monitoring for
demonstrated in real-world settings but only by one
treatment adherence make this an exemplary approach.
group of investigators; thus, the results need to be
Furthermore, publication of an MST manual and the
reproduced by others and future effectiveness research
high level of clinical training in MST distinguish this
needs to determine whether the same benefits can be
model from other types of family preservation services.
demonstrated with less support from experts.
The efficacy of MST has been established in three
randomized clinical trials for delinquents within the
Therapeutic Foster Care
juvenile justice system. The first of these studies took
Therapeutic foster care is considered the least
place in Memphis, Tennessee, and revealed that MST
restrictive form of out-of-home therapeutic placement
was more effective than usual community services in
for children with severe emotional disorders. Care is
decreasing adolescent behavioral problems and in
delivered in private homes with specially trained foster
improving family relations (Henggeler et al., 1986).
parents. The combination of family-based care with
The second was conducted in Simpsonville, South
specialized treatment interventions creates "a
Carolina, and compared outcomes for 84 juvenile
therapeutic environment in the context of a nurturant
offenders randomly assigned to either MST or usual
family home" (Stroul & Friedman, 1988). These
services. At 59 weeks after referral, youth who had
programs, which are often funded jointly by child
received MST had fewer arrests and self-reported
welfare and mental health agencies, are responsible for
offenses and had spent an average of 10 fewer weeks
arranging for foster parent training and oversight.
incarcerated than did the youth in usual services. In
Although the research base is modest compared with
addition, families served by MST reported increased
other widely used interventions, some studies have
family cohesion and decreased youth aggression in peer
reported positive outcomes, mostly related to
relations (Henggeler et al., 1992). In the third study,
behavioral improvements and movement to even less
MST was compared with individual therapy in
restrictive living environments, such as traditional
Columbia, Missouri, and was found to be more
foster care or in-home placement.
effective in ameliorating adjustment problems in
While therapeutic foster care programs vary
individual family members. A 4-year followup of
considerably, they have some features in common.
rearrest data indicated that MST was more effective
Children are placed with foster parents who are trained
than individual therapy in preventing future criminal
to work with children with special needs. Usually, each
behavior, including violent offenses (Borduin et al.,
foster home takes one child at a time, and caseloads of
1995). Studies found improved behavior, fewer arrests,
supervisors in agencies overseeing the program remain
and lower costs. These findings encouraged the
small. In addition, therapeutic foster parents are given
investigators to test the effectiveness of MST in other
a higher stipend than that given to traditional foster
organizational settings (e.g., child welfare and mental
parents, and they receive extensive preservice training
health), allowing them to target other clinical
and in-service supervision and support. Frequent
populations, including youthful sex offenders (Borduin
contact between case managers or care coordinators
et al., 1990), abused and neglected youth (Brunk et al.,
and the treatment family is expected, and additional
1987), and child psychiatric inpatients (see Inpatient
resources and traditional mental health services may be
Treatment section). Initial results are promising for
provided as needed.
youth receiving MST instead of psychiatric
Therapeutic foster care programs are inexpensive
hospitalizations (Henggeler et al., 1998). As expected,
to start (few requirements for facilities or salaried staff)
some adjustments to MST are required to handle
and have lower costs than more restrictive programs. In
176
Children and Mental Health
Ontario, a study found that therapeutic foster care cost
Three programs also reported followup data, indicating
half that of residential treatment center placement for
that about 70 percent of youth treated in therapeutic
the same period of time (Rubenstein et al., 1978).
foster homes remained in less restrictive settings for a
There have been four efficacy studies, each with
substantial amount of time after treatment.
randomized, controlled designs. In the first study, 20
It is clear from these studies that therapeutic foster
youths who had been previously hospitalized were
care produces better outcomes at lower costs than more
assigned to either therapeutic foster care or other out-
restrictive types of placement. Furthermore, with the
of-hospital settings, such as residential treatment
fairly recent development of standards for therapeutic
centers or homes of relatives. The youths in therapeutic
foster care, as well as a standards review instrument
foster care showed more improvements in behavior and
(Foster Family-Based Treatment Association, 1995),
lower rates of reinstitutionalization, and the costs were
services can be monitored for quality and fidelity to the
lower than those in other settings (Chamberlain &
therapeutic approach, making it easier to ascertain if
Reid, 1991). In another study, which concentrated on
the approach taken produces the favorable outcomes.
youths with histories of chronic delinquency, those in
therapeutic foster care were incarcerated less frequently
Therapeutic Group Homes
and for fewer days per episode than youths in other
For adolescents with serious emotional disturbances the
residential placements. Thus, at 2-year followup, 44
therapeutic group home provides an environment
percent fewer children in therapeutic foster care were
conducive to learning social and psychological skills.
incarcerated (Chamberlain & Weinrott, 1990). In a
This intervention is provided by specially trained staff
third study, outcomes for children in therapeutic foster
in homes located in the community, where local
care were compared with those of children in standard
schools can be attended. Each home typically serves 5
foster care. Children in therapeutic foster care were less
to 10 clients and provides an array of therapeutic
likely during a 2-year study to run away or to be
interventions. Although the types and combinations of
incarcerated and showed greater emotional and
treatment vary, individual psychotherapy, group
behavioral adjustment (Clark et al., 1994). In the most
therapy, and behavior modification are usually
recent study, therapeutic foster care was compared with
included.
group care: children receiving the former showed
There are two major models of therapeutic group
significantly fewer criminal referrals, returned to live
homes. The first is the teaching family model,
with relatives more often, ran away less often, and were
developed at the University of Kansas, then moved to
confined to detention or training schools less often
Boys Town in Omaha, Nebraska (Phillips et al., 1974).
(Chamberlain & Reid, 1998).
The second is the Charley model, developed at the
All four studies of treatment effectiveness showed
Menninger Clinic. Both models use their staff as the
that youths in therapeutic foster care made significant
key agents for change in the disturbed youth; selection
improvements in adjustment, self-esteem, sense of
and training of the staff are emphasized. Both models
identity, and aggressive behavior. In addition, gains
employ couples who live at the homes 24 hours a day.
were sustained for some time after leaving the
The teaching family model emphasizes structured
therapeutic foster home (Bogart, 1988; Hawkins et al.,
behavioral interventions through teaching new skills
1989; Chamberlain & Reid, 1991).
and positively reinforcing improved behavior. Other
There are also promising indications from
group homes use individual psychotherapy and group
uncontrolled studies. Looking at 18 reports from 12
interaction.
therapeutic foster care programs across the country,
There is a dearth of research on the effectiveness of
Kutash and Rivera (1996) concluded that between
therapeutic group home programs targeted toward
about 60 and 90 percent of youth treated in therapeutic
emotionally disturbed adolescents. These homes have
foster homes are discharged to less restrictive settings.
been developed primarily for children under the care of
177
Mental Health: A Report of the Surgeon General
juvenile justice or social welfare. A dissertation
programs would benefit from assessing alternative
(Roose, 1987) studied the outcomes of 20 adolescents
strategies for treatment after discharge from group
treated in a group home. Adolescents with severe
homes.
character pathology or major psychiatric disorders were
not admitted. Twenty group home adolescents were
Crisis Services
compared with 20 untreated adolescents. At an 18-
Crisis services are used in emergency situations either
month followup, 90 percent of the treated group had
to furnish immediate and sufficient care or to serve as
fair or good functioning, defined by improved
a transition to longer term care within the mental health
relationships with parents, peers, and fellow workers.
system. These services are extremely important because
Only 45 percent of the untreated group achieved similar
many youth enter the mental health service system at a
functioning. The treated group experienced a
point of crisis. Crisis services include three basic
significant decrease in psychopathology, while the
components: (1) evaluation and assessment, (2) crisis
untreated group did not.
intervention and stabilization, and (3) followup
Therapeutic group homes were compared with
planning. The goals of crisis services include
therapeutic foster care in two studies. The first study
intervening immediately, providing brief and intensive
found equivalent gains for youth in the two
treatment, involving families in treatment, linking
interventions, but group home placement was twice as
clients and families with other community support
costly as therapeutic foster care (Rubenstein et al.,
services, and averting visits to the emergency
1978). A second study, a randomized clinical trial,
department or hospitalization by stabilizing the crisis
compared the outcomes for 79 males with histories of
situation in the most normal setting for the adolescent.
juvenile delinquency placed in either group homes or
Crisis services include telephone hotlines, crisis group
therapeutic foster homes (Chamberlain & Reid, 1998).
homes, walk-in crisis intervention services, runaway
The boys treated in therapeutic foster homes had
shelters, mobile crisis teams, and therapeutic foster
significantly fewer criminal referrals and returned more
homes when used for short-term crisis placements.
often to live with relatives, suggesting this to be a more
Crisis programs are small in order to facilitate close
effective intervention. The implication of these studies
relationships among the staff, child, and family. Crisis
is that if therapeutic foster care is available, and if the
staff are required to have skills and experience in the
foster parents are willing to take youth with serious
areas of assessment, emergency treatment, and family
behavioral problems, therapeutic foster care may be a
support. Short-term services are provided, with the staff
better treatment choice for youth who previously would
meeting more frequently with the client at the outset of
have been placed in group homes.
the crisis. A typical treatment plan consists of 10
Existing research suggests that therapeutic group
sessions over a period of 4 to 6 weeks. Crisis services
home programs produce positive gains in adolescents
usually are available 24 hours a day, 7 days a week
while they are in the home, but the limited research
(Goldman, 1988).
available reveals that these changes are seldom
Research on crisis services consists exclusively of
maintained after discharge (Kirigin et al., 1982). The
uncontrolled studies. Kutash and Rivera (1996)
conclusion may be similar to that for residential
reviewed 12 studies with pre-post¹⁶ designs. Positive
treatment center placement: long-term outcomes appear
behavioral and adjustment outcomes for youth
to be related to the extent of services and support after
presenting to crisis programs and emergency
discharge. Adolescents who have been placed in
departments across the country were reported in all of
therapeutic group homes because of mental disorders
frequently have histories of multiple prior placements
(particularly in foster homes), a situation that is
16 Pre-post design: a research design in which a measure is
associated with a poor prognosis. Thus, future
compared on the same individual research subjects before and after
an intervention.
178
Children and Mental Health
the studies. Most programs also demonstrated the
Service Delivery
capacity to prevent institutionalization.
The focus of this section is on service systems-their
The most recent studies examine three different
origins, nature, and financing and also their
models: a mobile crisis team, short-term residential
effectiveness, delivery, and utilization-rather than on
services, and intensive in-home service. The first study
individual interventions and treatments, which were
examined the Youth Emergency Services (YES)
covered in previous sections of this chapter.
program in New York. This program included a mobile
About 20 years ago it became clear that children
crisis team that sent clinicians directly to the scene of
and families were failing to receive adequate care from
the crisis. The data showed that YES prevented
the public sector, whose services were fragmented,
emergency department visits and out-of-home
inadequate, and overreliant on institutional care. As a
placements (Shulman & Athey, 1993).
result, the emphasis of service delivery has shifted to
A second crisis program, in Suffolk County, New
systems of care that are designed to provide culturally
York, involved short-term residential services. In a
competent, coordinated services; community-based
study of 100 children served by the program over a 2-
services; new financing arrangements in the private and
year period, more than 80 percent were discharged in
public sectors; family participation in decisionmaking
less than 15 days. Most were diverted from inpatient
about care for their children; and individualized care
hospitalization, and inpatient admissions to the state
drawing on treatment and social supports called
children's psychiatric center for Suffolk County were
wraparound services, described above. Thus, there has
reduced by 20 percent after the program was
been progress in transforming the nature of service
established (Schweitzer & Dubey, 1994).
delivery and its financing, but the central question of
In the third study, records were analyzed from a
the effectiveness of systems of care has not yet been
large sample of youth (nearly 700) presenting to the
resolved.
Home Based Crisis Intervention (HBCI) program in
At the outset, it is important to note that while
New York over a 4-year period. Youth received short-
systems of care are designed to provide the appropriate
term, intensive, in-home emergency services. After an
level of services for all children, it is children with
average service episode of 36 days, 95 percent of the
serious emotional disturbances, particularly children
youth were referred to, or enrolled in, other services
who are involved in multiple service sectors, who are
(Boothroyd et al., 1995). The HBCI program was
likely to benefit the most. There are approximately 6
established at eight locations across the State of New
million to 9 million children and adolescents in the
York. Overall, programs with more access to
United States with serious emotional disturbances
community resources reported shorter average lengths
(Friedman et al., 1996a; Lavigne et al., 1996),
of services.
accounting for 9 to 13 percent of all children (Friedman
Although crisis and emergency services represent
et al., 1996a; Friedman et al., 1998).
a promising intervention, the research done so far only
The system for delivering mental health services to
includes uncontrolled studies, limiting the conclusions
children and their families is complex, sometimes to the
that can be drawn. Kutash and Rivera (1996)
point of inscrutability-a patchwork of providers,
recommend additional effectiveness research using
interventions, and payers. Much of the complexity
controlled study designs and comparing differences
stems from the multiple pathways into treatment and
between the various types of crisis services. Finally,
the multiple funding streams for services. However,
there remains a need for investigation of cost-
once care has begun, the interventions and settings
effectiveness as well as an exploration of the
themselves are generally the same as those covered in
integration of crisis services into systems of care.
previous sections of this chapter.
179
Mental Health: A Report of the Surgeon General
Service Utilization
The study by Burns and colleagues also showed
This section presents research findings about the
where children were receiving treatment. Of those who
utilization of mental health services by children and
received services and had both a diagnosis and
adolescents. The foremost finding is that most children
impaired functioning, about 40 percent received
in need of mental health services do not get them.
services in the specialty mental health sector, about 70
Another finding refutes the common perception that
percent received services from the schools, about 11
children who do not need specialty mental health
percent from the health sector, about 16 percent from
services are more likely to receive such services than
the child welfare sector, and about 4 percent from the
those who really do need them. This section also
juvenile justice sector. For nearly half the children with
discusses children's high dropout rates from treatment
serious emotional disturbances who received services,
and the significance of this problem for children of
the public school system was the sole provider (Burns
different cultural backgrounds.
et al., 1995). After reviewing these findings and the
findings from other studies, Hoagwood and Erwin
Utilization in Relation to Need
(1997) also concluded that schools were the primary
The conclusion that a high proportion of young people
providers of mental health services for children.
with a diagnosable mental disorder do not receive any
mental health services at all (Burns et al., 1995; Leaf et
Early Termination of Treatment
al., 1996) reinforces an earlier report by the U.S. Office
Among children and adolescents who begin treatment,
of Technology Assessment (1986), which indicated that
the dropout rate is high, although estimates vary
approximately 70 percent of children and adolescents
considerably. According to Kazdin and colleagues
in need of treatment do not receive mental health
(1997), 40 to 60 percent of families who begin
services. Only one in five children with a serious
treatment terminate it prematurely. Armbruster and
emotional disturbance used mental health specialty
Fallon (1994) found that the great majority of children
services, although twice as many such children
who enter outpatient treatment attend for only one or
received some form of mental health intervention
two sessions. One of the explanations for the high
(Burns et al., 1995). Thus, about 75 to 80 percent fail to
dropout rate and for failure to keep the first
receive specialty services, and the majority of these
appointment is that referrals are often made not by
children fail to receive any services at all, as reported
children and adolescents or their families, but by
by their families. The most likely reasons for
schools, courts, or other agencies. Most of the research
underutilization relate to the perceptions that treatments
on dropping out has focused exclusively on examining
are not relevant or are too demanding or that stigma is
demographic or diagnostic correlates of dropping out,
associated with mental health services; the reluctance
and few researchers have directly asked the children or
of parents and children to seek treatment;
their parents about their reasons for discontinuing
dissatisfaction with services; and the cost of treatment
treatment.
(Pavuluri et al., 1996; Kazdin et al., 1997).
There are a number of effective interventions to
Studies do, however, demonstrate a clear and
reduce dropout from treatment and to increase
strong relationship between use of services and
enrollment and retention (Szapocznik et al., 1988;
presence of a diagnosis and/or presence of impaired
McKay et al., 1996; Santisteban et al., 1996). Offering
functioning. In the study by Leaf and colleagues
services in the schools improves treatment access
(1996), young people with both a diagnosis and
(Catron & Weiss, 1994). A variety of case management
impaired functioning were 6.8 times more likely to see
approaches can also improve engagement of low-
a specialist than were those with no diagnosis and a
income families in the treatment of their children
higher level of functioning.
(Burns et al., 1996; Koroloff et al., 1996a; Lambert &
Guthrie, 1996).
180
Children and Mental Health
Poverty and Utilization
child behavioral and emotional problems as disturbed
Poverty status has been associated with both dropping
(Weisz & Weiss, 1991). Differences also have been
out of services and shorter lengths of treatment
found across cultural groups in their beliefs about
(Hoberman, 1992). This relationship between
whether these child problems are likely to improve in
underutilization of mental health services and poverty
the absence of professional support. Weisz and Weiss
is especially significant for minority children and
(1991) have also identified cultural differences in the
families. Youths receiving community mental health
power of various children's behavioral and emotional
services supported by public agencies tend to be male,
problems to motivate a parent's search for professional
poor, and referred by social agencies (Canino et al.,
help.
1986; Costello & Janiszewski, 1990). Furthermore,
Differences also arise indirectly from the
investigators have found this pattern particularly true
multiplicity of service systems with authority and
for African Americans as compared with Caucasians.
responsibility for protecting the well-being of children.
Hoberman (1992) has found that 90 percent of African
These systems have different criteria for initiating
American youths entering the mental health system live
treatment and different patterns of utilization. African
in poverty.
American children and youth are considerably more
likely than those of other ethnic groups to enter the
Culture and Utilization
child welfare system (National Research Council,
Although it is clear that an insufficient number of
1993). Their greater chances of having parents
children receive mental health services, it is not clear
compelled to surrender them or of suffering abuse or
whether utilization of services varies by race or
neglect lead them in greater numbers to be referred to
ethnicity. The majority of studies have found that
child welfare authorities, to be placed out-of-home, and
African Americans tend to use some mental health
to be involved with the child welfare system longer.
services, particularly inpatient care, more than would
Studies in one California county have found that
be expected from their proportion in the population.
African American youths are overrepresented in
However, research findings are conflicting, probably
arrests, detention, and incarceration in the juvenile
due to divergent methodological approaches (Attkisson
justice system, and in the schools they are
et al., 1995; McCabe et al., 1998; Quinn & Epstein,
overrepresented in educational classes for the severely
1998). Furthermore, as Attkisson and colleagues (1995)
emotionally disturbed. Hispanic/Latino children and
point out, consistent with the study by McCabe and
youths are no more likely than whites to come under
colleagues (1998), it is difficult to interpret these
supervision of the child welfare system but, once
findings in the absence of epidemiologic data on the
involved, remain longer. They are also more likely than
prevalence of a mental disorder in different racial and
whites to be detained in juvenile justice facilities
ethnic groups. Recent reviews of epidemiological
(McCabe et al., 1998).
findings concluded that present data are inadequate to
As a group, Hispanic/Latino and African American
determine the relationship between race or ethnicity
children more often leave mental health services
and prevalence of a mental disorder (Friedman et al.,
prematurely than do Caucasian children (Sue et al.,
1996b; Roberts et al., 1998).
1991; Bui & Takeuchi, 1992; Takeuchi et al., 1993;
The task of understanding treatment patterns is
Viale-Val et al., 1984). Many factors contribute to
made even more difficult because there are racial and
premature termination, such as insensitivity of mental
ethnic differences in family preferences and family-
health providers to the culture of children and families
initiated patterns of help-seeking (see also Culturally
(Woodward et al., 1992). In general, even after
Appropriate Social Support Services). For example,
demonstrated success with middle-class Caucasians,
parents from various cultural backgrounds have been
mental health treatments should not be applied without
found to differ in the degree to which they identify
181
Mental Health: A Report of the Surgeon General
culturally appropriate modification to people from
entails outpatient counseling, medication treatments,
other cultures and races (Rosado & Elias, 1993).
and short-term inpatient hospitalization. Under more
Specialized programs and supports linked with the
generous insurance plans, including some managed
culture of the community being served have been found
care plans, intermediate services, such as crisis respite
to be successful in promoting favorable patterns of
and day hospitalization (also called partial
service utilization for all ages (Snowden & Hu, 1997).
hospitalization or day treatment), are becoming more
It is becoming clear that the children and families
popular although more traditional insurance plans
served by mental health programs designed to be linked
continue to restrict their use. The drive to reduce the
to community cultures are less likely to drop out of
cost of inpatient care is sparking an expansion in the
treatment compared with similar families in mainstream
range of services supported by the private sector.
programs (Takeuchi et al., 1995). For example, Asian
When children and adolescents have complex and
American children at an Asian community- or culture-
long-term mental health problems, required services are
focused program were found to use more services, drop
not usually covered by private sector insurance plans.
out less often, and improve more than did Asian
Families must either pay for the services themselves or
American children at mainstream programs (Yeh et al.,
obtain the services through the public sector. In many
1994).
states, parents are forced to give up custody of their
In summarizing the relationship between race and
children to the state child welfare system in order to
ethnicity, need for service, and use of service, Isaacs-
obtain needed residential services (Cohen et al., 1991).
Shockley and colleagues (1996) raised the concern that
This unfortunate choice results from a limited supply of
minority children are less likely to receive the care they
public sector services and special requirements for
need than nonminority children-a concern that should
gaining access to them.
energize advocacy for the development of systems of
Over the past decade, managed care has become a
care tailored to the needs of distinct cultures (Cross et
major payer for private health care. Managed care
provision of mental health services emerged partially in
al., 1989; Hernandez & Isaacs, 1998).
response to the overutilization of costly inpatient
hospitalization by adolescents in the 1980s (Lourie et
Service Systems and Financing
al., 1996). The purpose of managed care has been to
In the past, mental health services paid for by the
control spiraling mental health service costs, mostly by
private sector were viewed as separate entities from
limiting hospital stays and rigorously managing
those funded by the public sector, particularly since the
outpatient service usage (Stroul et al., 1998). Managed
public sector only paid for services that it itself
care can offer advantages in terms of cost-effective
delivered. As this section explains below, the
services to meet the needs of children with flexible
distinction between public and private sectors has been
benefits. It may also lead to denial of needed treatment.
blurred by the advent of publicly supported payment
While its potential negative effect on the efficacy of
systems such as Medicaid and grants of public funds to
mental health care delivered under its aegis is a hotly
private organizations and providers. Now in the public
debated issue, for the most part managed care furnishes
sector, services are paid for with governmental
the same traditional services available under fee-for-
resources but delivered either by public or private
service insurance. The drive for efficiency, however,
organizations in institutional or community-based
has led to the introduction of intermediate services
settings.
designed to divert children from hospitalization.
Managed care has shortened hospital stays and
Private Sector
The private sector uses a health insurance model that
increased the use of short-term therapy models (Eisen
reimburses for acute medical problems. Under this
et al., 1995; Merrick, 1998). Managed care also has
traditional model, mental health coverage usually
lowered reimbursements for services provided by both
182
Children and Mental Health
individual professionals and institutions. This has been
without individualized wraparound provisions, early
accompanied by the construction of provider networks,
intervention programs, crisis stabilization, in-home
under which professionals and institutions agree to
therapy, and day programs. Since there has never been
accept lower than customary fees as a tradeoff for
a mandate to states to provide mental health services to
access to patients in the network.
children and adolescents, the state or local support for
such services has been variable. Thus, one might find
Public Sector
a well-supported, innovative array of mental health
Mental health services provided by the public sector are
services for children in one state or community, and
more wide-ranging than those supported by the private
almost no services in the next. The new State Child
sector, and the types of payers are more diverse. Some
Health Insurance Program (CHIP) is an attempt by
public agencies, such as Medicaid and state and local
Congress to address the health care needs of low-
departments of mental health, are mandated to support
income, uninsured children. States have great flexibility
mental health services. Others provide mental health
in their approach to coverage, and it remains to be seen
services to satisfy mandates in special education,
how they will deal with mental health services.
juvenile justice, and child welfare, among others.
States and communities have sweeping mandates to
Medicaid is a major source of funding for mental
serve children and adolescents in schools and under
health and related support services. For the most part,
child welfare and juvenile service auspices. Many of
Medicaid has supported the traditional mix of
these state and community programs, however, lack the
outpatient and inpatient services. However, unlike
expertise to recognize, refer, or treat mental health
private sector insurance, Medicaid also funds long-term
problems that trigger mandated services. When they do
services for those children who need more intensive or
recognize problems, some of the needed mental health
restrictive services, often through hospitalizations and
services are paid for by Medicaid, by the federal
residential treatments. Some states cover in-home
Maternal and Child Block Grant, or by a state or local
services, school-based services, and case management
mental health authority; often, however, they are not.
through a variety of Medicaid options. Medicaid also
Under these circumstances, the school, welfare, or
supports the Early Periodic Screening, Diagnosis, and
juvenile justice agency ends up paying the bill for the
Treatment (EPSDT) program.
mental health services.
Trapped between the private and public sectors is
Under the Federal special education law, the
a group of uninsured individuals and families who do
Individuals with Disabilities Education Act¹⁷ (IDEA;
not qualify for the public sector programs, cannot
see also New Roles for Families in Systems of Care),
afford to pay for services themselves, and have no
school systems are mandated to provide special
access to private health insurance. The American
education services to children and adolescents whose
Academy of Pediatrics estimates that in 1999 there will
disabilities interfere with their education. When these
be 11 million uninsured children, about 3 million of
disabilities take the form of serious emotional or
whom do not qualify for existing public programs
behavioral disturbances, school systems are required to
(American Academy of Pediatrics website
respond through assessment, counseling, behavior
www.aap.org). State and local mental health authorities
management, and special classes or schools. When
fund some mental health services for these children,
school systems lack sufficient capacity to meet such
often offered through the same community mental
needs directly, school funds are used to send children
health centers that are funded by Medicaid. Mental
and youths to specialized private day schools or to
health departments in some jurisdictions also fund a
long-term residential schools, even if such schools are
broader array of mental health services than the
out of the child's state or community. In this way,
traditional acute service package. These "intermediate"
services include intensive case management with and
17 Public Law 94-142; Public Law 101-476; Public Law 105-17.
183
Mental Health: A Report of the Surgeon General
school systems support an extensive array of mental
levels of services. Many of these agencies arose
health services in the public and private sectors.
historically for another purpose, only to recognize later
Preschool children with developmental and
that mental disorders cause, contribute to, or are effects
emotional disabilities are covered by some state and
of the problem being addressed. In the past, these
local legislation. Services for them also are mandated
sectors operated somewhat autonomously, with little
under IDEA. Whereas some states coordinate this
ongoing interaction. Catalyzed by the NMHA's
education-based mandate through school systems,
Invisible Children's Project (NMHA, 1987, 1993), the
others administer the preschool programs through
combined impetus of Federal policies and managed
mental health or developmental disability agencies, an
care more recently has begun to forge their integration.
interagency coordinating body, or other state agency.
Two recent review articles examined the
Child welfare agencies in states and communities
characteristics of children served in public systems.
also have powerful mandates to protect children and to
Based on an appraisal of six prior studies, it was
ensure that they receive the services they need,
concluded that, in addition to emotional and behavioral
including mental health services. Child welfare
functioning, these young people have problems in life
agencies primarily serve poor children who are
domains such as intellectual and educational
separated from their parents because they are orphaned,
performance and social and adaptive behavior
abandoned, abused, or neglected. Although many
(Friedman et al., 1996b). Frequently, such children and
mental health services are provided either under
their families have contact not only with the mental
Medicaid or through state and locally supported
health system, but also with special education, child
community mental health centers, many are not and are
welfare, and juvenile justice (Landrum et al., 1995;
paid for directly by child welfare agencies. This
Duchnowski et al., 1998; Greenbaum et al., 1998; Quinn
happens most often when children and adolescents have
& Epstein, 1998).
severe, complicated conditions. As with education
It is estimated that in a 1-year period more than
agencies, when funding is not available through
700,000 children nationwide are in out-of-home
Medicaid or other mental health funds, child welfare
placements, mostly under the supervision of either the
agencies directly pay for group home care, therapeutic
child welfare or to some extent the juvenile justice
foster care, or residential treatment.
system (Glisson, 1996). Also, during the 1996-1997
The same is true for juvenile justice agencies,
school year more than 400,000 emotionally disturbed
which have strong mandates to protect children and the
children and youths between the ages of 6 and 21 were
public. Many children and adolescents in the juvenile
served in the public schools nationwide (U.S.
justice system have serious mental health problems.
Department of Education, 1997). This is just under
Beyond the more traditional "training schools" and
1 percent of the school enrollment for ages 6 to 17, and
"detention centers," run by state and local juvenile
8.5 percent of all children with disabilities receiving
authorities, respectively, these agencies also purchase
any kind of special education service (Oswald &
care from the same group home, therapeutic foster care,
Coutinho, 1995; U.S. Department of Education, 1997).
and residential providers as do child welfare agencies.
These figures and percentages have remained relatively
constant since national data were first collected about
Children Served by the Public Sector
20 years ago, although there are great variations
Children needing services are identified under the
between states. For example, in 1992-1993, 0.4 percent
auspices of five distinct types of service sectors:
of school-enrolled children in Mississippi were
schools, juvenile justice, child welfare, general health,
identified as having a serious emotional disturbance
and mental health agencies. These agencies are mostly
compared with 2.08 percent in Connecticut (Coker et
publicly supported, each with different mandates to
al., 1998).
serve various groups and to provide somewhat varied
184
Children and Mental Health
In addition to children with a serious emotional
substantially cut, with youths being discharged from
disturbance served by the special education system,
the hospital before adequate personal and/or
children served by child welfare and juvenile justice
community safety plans can be instituted. Child welfare
systems also have need for mental health services
and juvenile justice agencies have been compelled to
(Friedman & Kutash, 1986; Cohen et al., 1990;
create and pay for services to support those children
Greenbaum et al., 1991, 1998; Otto et al., 1992; Glisson,
who are no longer kept in hospitals. Thus, while
1996; Claussen et al., 1998), because they are much
Medicaid's mental health costs may be decreasing in
more likely to have emotional and behavioral disorders
such cases, there may be a substantial cost increase to
than is the general population (Duchnowski et al.,
the other agencies involved, resulting in little if any
1998; Quinn & Epstein, 1998). Thus, the emphasis on
overall cost saving (Stroul et al., 1998).
interagency community-based systems of care is
Similarly, management of only the Medicaid
warranted and essential (see Integrated System Model).
portion of a complex funding system that includes
Medicaid, mental health, special education, child
Managed Care in the Public Sector
welfare, and juvenile justice funds not only creates the
Since 1992, managed care has begun to penetrate the
cost-shifting described above, but also underestimates
public sector (Essock & Goldman, 1995). The prime
the need to manage the funds spent by all agencies.
impetus for this has been an attempt to control the costs
Demonstration programs of managed care strategies for
of Medicaid, in both the general health and mental
children and adolescents with severe emotional
health arenas. Since Medicaid appears, on the surface,
disturbances have included the creation of an
to be similar to a private health insurance plan,
interagency funding pool, shared by all affected
administrators of state Medicaid programs have
agencies, to meet the full range of needs of this
recently implemented managed care approaches and
population. Under the demonstration program, the
structures to reduce health care costs. However,
funds in such a pool are capitated¹⁸ to ensure that the
Medicaid populations tend to have a higher prevalence
most appropriate services are purchased, regardless of
of children with serious emotional disturbance than that
which agency's mandate they come under. In this way,
seen in privately insured populations. Those children
long-term, complex care can be offered in an efficient
generally need longer-term care (Friedman et al.,
way that reduces costs for all of the involved child and
1996b; Broskowski & Harshbarger, 1998). Managed
youth agencies.
care strategies, which developed in the private sector,
An excellent example of an approach in a managed
are geared toward a relatively low utilization of mental
care setting is "Wraparound Milwaukee," one of the
health services by a population whose mental health
Center for Mental Health Services' Comprehensive
needs tend to be short term and acute in nature. As a
Community Mental Health Services for Children and
result, the kinds of cost-cutting measures used by
Their Families Programs (Stroul et al., 1998; Goldman
managed care organizations, such as reduction of
& Faw, 1998). Wraparound Milwaukee, a coordinated
hospital days and encouragement of short-term
system of community-based care and resources for
outpatient therapies, have not worked as well in the
families of children with severe emotional, behavioral,
public sector with seriously emotionally disturbed
and mental health problems, is operated by the Children
children as they have in the private sector (Stroul et al.,
and Adolescent Services Branch of the Milwaukee
1998).
County Mental Health Division. The features of this
Advocates express concern that the restrictions of
care management model are a provider network that
public managed care on mental health services shift
furnishes an array of mental health and child welfare
costs of diagnosis and treatment to other agencies, a
services; an individualized plan of care; a care
process known as cost-shifting. Under public managed
care, hospitalization for mental disorders is being
18 Capitation: a fixed sum per individual per month.
185
Mental Health: A Report of the Surgeon General
coordinator management system to ensure that services
provided in Chapter 2.) If they are culturally
are coordinated, monitored, and evaluated; a Mobile
appropriate, services can transcend mental health's
Urgent Treatment Team to provide crisis intervention
focus on the "identified client" to embrace the
services; a managed care approach including
community, cultural, and family context of a client
preauthorization of services and service monitoring;
(Szapocznik & Kurtines, 1993; Hernandez et al., 1998).
and a reinvestment strategy in which dollars saved from
According to Greenbaum (1998), considering a client's
decreased use of inpatient or residential care are
context is important because people who live close to
invested in increased service capacity.
each other frequently have developed ways of coping
Since its inception in 1994, one of the goals of the
with similar personal problems. Becoming aware of
program has been to blend funding streams.
these natural systems and adapting formal services to
Wraparound Milwaukee operates as a behavioral health
be congruent with them are ways to make services more
care "carve-out"19 that blends funds from a monthly
accessible and useful to diverse populations.
capitation rate from Medicaid, a case rate from county
Community- and neighborhood-based social net-
child welfare and juvenile justice funds, and a Center
works act as important resources for easing emotional
for Mental Health Services child mental health services
stress and for facilitating the process of seeking
grant. The Wraparound Milwaukee capitated rate of
professional help (Saunders, 1996). Often natural social
approximately $4,300 covers all mental health and
supports ameliorate emotional distress and have been
substance abuse services, including inpatient
found to reduce the need for formal mental health
hospitalization. Additional funds from child welfare
treatment (Linn & McGranahan, 1980; Birkel &
and/or juvenile justice are used for children with
Reppucci, 1983; Cohen & Wills, 1985). According to
serious emotional disturbances in the child welfare and
Saunders (1996), obtaining social support is not a
juvenile justice systems in Milwaukee County to cover
single event but rather an ongoing process. In general,
residential treatment, foster care, group home and
people use their neighborhood and familial supports
shelter care costs, and nontraditional mental health
many times before they decide they have a problem and
community services (e.g., mentors, job coaches, after-
determine what type of help they will seek (Rew et al.,
school programs). Wraparound Milwaukee is at "full
1997). A key to the success of mental health programs
risk" for all services costs, meaning it is responsible for
is how well they use and are connected with
charges in excess of the capitated rate. The average
established, accepted, credible community supports.
monthly costs, including administrative costs, are
The more this is the case, the less likely families view
$3,400 per child. Medicaid-eligible children constituted
such help as threatening and as carrying stigma; this is
80 percent of the population served by the program in
particularly true for families who are members of racial
1998.
and ethnic minority groups (Bentelspacher et al., 1994).
Minority parents are more likely than nonminority
Culturally Appropriate Social Support
parents to seek input regarding their children from
Services
family and community contacts (Briones et al., 1990;
One of the fundamental requirements of culturally
Hoberman, 1992). In a study by McMiller and Weisz
appropriate services is for mental health providers to
(1996), two-thirds of the parents of minority children
identify and then to work in concert with natural
did not seek help from professionals and agencies as
support systems within the diverse communities they
their first choice. For example, in Hispanic/Latino
serve (Greenbaum, 1998). (Background information on
families, important decisions related to health and
cultural diversity and culturally competent services is
mental health are often made by the entire family
network rather than by individuals (Council of
Scientific Affairs, 1991). According to Ruiz (1993),
19 Carve-out: separation of funding for mental health services and
health care settings that are not modified to work with
their management from those of general health.
186
Children and Mental Health
Hispanic/Latino family networks find that their clients
(Friesen & Stephens, 1998). In 1982, a particularly
do not comply with medical advice; as a result, their
incisive description of the problems faced by families
health status can be compromised.
raising children with emotional or behavioral disorders
In sum, mental health programs attempting to serve
was published. It concluded that parents received little
diverse populations must incorporate an understanding
assistance in finding services for their children and
of culture, traditions, beliefs, and culture-specific
were either ignored or coerced by public agencies;
family interactions into their design (Dasen et al., 1988)
respite and support services to relieve the stress on
and form working partnerships with communities in
parents were unavailable; parents with children needing
order to become successful (Kretzman & McKnight,
residential care were compelled to give up custody to
1993). Ultimately, the solution offered by professionals
get them placed; and few advocacy efforts were aimed
and the process of problem resolution or treatment
at relieving their problems (Knitzer, 1982).
should be consistent with, or at least tolerable to, the
Over the past two decades, however, recognition
natural supportive environments that reflect clients'
and response to the plight of families have become
values and help-seeking behaviors (Lee, 1996).
increasingly widespread. The role of families has been
Such partnerships sometimes fail, however,
redefined as that of a partner in care. Furthermore,
because they concentrate on neighborhood and
there was growing awareness of the difficulties families
community problems. According to Kretzman and
faced because services are provided by so many
McKnight (1993), this approach often reinforces the
different public sources. In addition to problems with
negative stereotypes of violent, drug- and gang-ridden,
coordination, parents and caregivers encountered
and poverty-stricken communities. A more effective
conflicting requirements, different atmospheres and
alternative approach to working with communities is to
expectations, and contradictory messages from system
focus on community strengths (Kretzman & McKnight,
to system, office to office, and provider to provider
1993). This approach works best when community
(Knitzer, 1982). Although some agencies began to
residents themselves are interested in participating in
provide families with training, information, education,
the partnership. Mental health providers who approach
and financial assistance, there was often a gap between
minority communities in a paternalistic manner fail to
what families needed and what agencies provided.
engage residents and fail to recognize whether the
Also, service agencies themselves began to recognize
community wants their assistance (Gutierrez-Mayka &
that putting children into institutions may not have
Contreras-Neira, 1998). Service providers who attend
served the child, the family, or the state and that
to the wishes of community residents are more likely to
keeping a child with his or her family could reduce the
be respectful in their delivery of services, a respect that
ever-growing costs of institutionalization (Stroul,
is a prerequisite to cultural responsiveness and
1993a, 1993b). Emerging awareness of these foregoing
competence in service planning and delivery to diverse
problems galvanized advocacy for a better way to care
communities (Gutierrez-Mayka & Contreras-Neira,
for children with emotional and behavioral disorders.
1998).
Reforms were instituted in many Federal programs, as
discussed later in this section.
Support and Assistance for Families
According to Knitzer and colleagues (1993), family
Any parent or guardian of a child with an emotional or
participation promotes four changes in the way children
behavioral disorder can testify to the challenging,
are served: increased focus on families; provision of
sometimes overwhelming, task of caring for and raising
services in natural settings; greater cultural sensitivity;
such a child. In the past, support from public agencies
and a community-based system of care. Research is
has been inadequate and disjointed. Compounding the
accumulating that family participation improves the
problem was the view that parents were partly, if not
process of delivering services and their outcomes. For
completely, to blame for their child's condition
example, Koren and coworkers (1997) found that, for
187
Mental Health: A Report of the Surgeon General
children with serious mental health problems, the more
et al., 1991; Briggs et al., 1994; also see Integrated
the family participates in planning services, the better
System Model). Such organizations were funded to
family members feel their children's needs are being
develop statewide networks of information and support
met; participation in service planning also helps service
for families, to coordinate with other organizations that
coordination. Curtis and Singh (1996) and Thompson
shared common goals, and to promote needed changes.
and colleagues (1997) also found that family
Currently, Federal funding for 22 statewide family
involvement in services was a determinant of the level
organizations is provided through the Child and Family
of parental empowerment, that is, how much control
Branch, Center for Mental Health Services, Substance
parents felt they had over their children's treatment.
Abuse and Mental Health Services Administration.
Support and technical assistance to community-level
New Roles for Families in Systems of Care
family organizations are also provided by the
Over the past two decades, the Federal government
Federation of Families for Children's Mental Health,
established a series of initiatives to support families.
the National Alliance for the Mentally III, and other
Parents were given progressively greater roles as
family-run consumer organizations.
decisionmakers with the passage of the Education of
the Handicapped Act in 1975 and its successor
Family Support
legislation, the Individuals with Disabilities Education
Family support is defined here as the assistance given
Acts of 1991 and 1997. For simplicity, these pieces of
to families to cope with the extra stresses that
legislation are collectively referred to hereinafter as the
accompany caring for a child with emotional
IDEA Act. This act requires parent involvement in
disabilities. In addition to the stress of raising a child
decisions about educating children with disabilities. It
with an emotional disability, families often face other
guarantees that all children with disabilities receive
difficulties such as poverty, joblessness, substance
free and appropriate public education. It also provides
abuse, and victimization. Family support often helps
funding assistance to states for implementation.
keep families together by assisting them with the
A novel approach taken by some community-level
practicalities of living and by attending to the needs of
systems of care to encouraging nvolvement of families
all family members (Will, 1998). The main goal of
is to train and hire family members into a wide range of
family support services is to strengthen adults in their
well-paying, career-ladder jobs as outreach workers,
roles as parents, nurturers, and providers (Weissbourd
service coordinators (sometimes called case managers),
& Kagan, 1989). Too often, family support services are
and direct support services providers. These positions
not available within local communities.
are critical to achieving major program goals because
Natural support systems are often diminished for
they make it possible for children and families to
families of children with serious emotional, behavioral,
remain together and to participate in the more clinical
or physical disorders or handicaps because of the
components of their service plan. Family members are
stigma of, or embarrassment about, their child's
also employed as supervisors of services, involved in
problems, or because caregivers have insufficient
hiring staff, providing them with orientation and on-
energy to reach out to others. Not surprisingly, most
the-job training (e.g., of case managers), overseeing
parents report that limited social support decreases
their work, and evaluating their performance. They also
their quality of life (Crowley & Kazdin, 1998) and that
participate in research.
they feel less competent, more depressed, worried, and
Beginning in 1989, the Child and Adolescent
tired and have more problems with spouses and other
Service System Program, a component of the Center for
family relationships than other parents (Farmer et al.,
Mental Health Services, began providing some support
1997), although a few families do feel enriched by
for statewide family organizations through a series of
caring for these children (Yatchmenoff et al., 1998).
funding and technical assistance mechanisms (Koroloff
188
Children and Mental Health
In a national survey of parents of children with an
diagnoses, such as conduct disorder (see section on
emotional or behavioral disorder, 72 percent of
Selected Mental Disorders in Children).
respondents indicated that emotional support
(irrespective of its form) was the most helpful aspect of
Family Support Groups
family support services (Friesen, 1990). Benefits
The primary focus of family support groups is to
included increased access to information, improved
provide information and emotional support to members
problem-solving skills, and more positive views about
who share a common problem or concern (e.g.,
parenting and their children's behavior (Friesen &
disability, substance abuse, bereavement). Support
Koroloff, 1990).
groups for families of children with emotional or
Family support services occur in several forms:
behavioral disorders are expanding. Although there is
assistance with daily tasks and psychosocial support
a wide variation in membership, format, and duration
and counseling; informal or professional provision of
of these groups, most share some characteristics.
services; and practical support such as housing
Usually, from 4 to 20 parents meet regularly to discuss
assistance, food stamps, income support, or respite care
the problems and issues associated with parenting a
(i.e., temporary relief for family members caring for
child with emotional and behavioral disorders and to
individuals with disabilities).
provide mutual encouragement and suggestions for
Efforts to stop blaming parents for children's
dealing with problematic situations. Support services
problems have resulted in parents becoming viewed
may be informal, organized, and parent led and are
less as patients than as partners, actively involved in
often associated with organizations such as the
every phase of the treatment process (e.g., home-based
National Mental Health Association, Children and
care, case management) and as a resource for their
Adults with Attention Deficit Disorders, the National
children, as discussed above. For the self-help and
Alliance for the Mentally III, or the Federation of
professionally led family support services described
Families for Children's Mental Health. Mental health
subsequently, parents may function either as partners or
professionals may also participate in support groups
as providers. As "partners," parents act as a resource,
(Koroloff & Friesen, 1991).
active contributor, or decisionmaker; as "providers,"
It was found that support groups for parents of
they are viewed as contributing to the welfare and
children hospitalized with mental illness make parents
growth of other members of the family.
feel more positive about themselves and increase their
Results of research on the effectiveness of family
understanding of and communication with their
services are only beginning to appear, in the form of
children (Dreier & Lewis, 1991). Participation in a six-
some controlled studies and evaluations of support
session education and support group for parents of
services for families of children with emotional and
adolescents with schizophrenia led to increased
behavioral disorders (although there is a larger
relaxation and concentration, less worry, changed
literature on families whose children have other types
attitudes toward discipline, and greater ease in
of disability and illness). Although this database on
discussing feelings. The support from parents in similar
family support programs is still limited, many positive
situations was highly valued (Sheridan & Moore,
effects have been reported. The following paragraphs
1991).
cover family support groups as well as concrete
Another approach to support for parents of children
services. For the latter, only two types of interventions,
receiving mental health services is education:
respite care and the family associate, are included.
knowledge of the services; skills needed to interact
Family therapy is covered in this chapter under
with the system; and the caregivers' confidence in their
Outpatient Treatment. Furthermore, several forms of
ability to collaborate with service providers (self-
parent training were found to be effective for individual
efficacy). A training curriculum for parents was tested
in a randomized controlled trial involving more than
189
Mental Health: A Report of the Surgeon General
200 parents who either did or did not receive the
complex and interrelated needs, as indicated earlier
training curriculum. Three-month and 1-year followup
(Friedman et al., 1996a, 1996b; Quinn & Epstein,
results demonstrated significant improvement in
1998). In 1984, the Child and Adolescent Service
parents' knowledge and self-efficacy with the training
System Program (CASSP) was launched to respond to
curriculum, whereas there was no effect on the mental
the fragmentation of public services (Stroul &
health status of their children, service use, or caregiver
Friedman, 1986). It was funded by the services
involvement in treatment (Heflinger & Bickman, 1996;
component of the National Institute of Mental Health,
Bickman et al., 1998).
which later became the Center for Mental Health
Services under the Alcohol and Drug Abuse and
Practical Support
Mental Health Administration Reorganization Act of
Respite care is a type of concrete support that provides
1992 (Public Law 102-321).
temporary relief to family caregivers. An investigation
CASSP recognized the need for public- sector
of the benefit of respite care is under way in New York
programs to become more integrated in their attempts
in families with children at risk of hospital placement.
to meet more fully and efficiently the needs of children
When respite care was available, families preferred in-
and adolescents with a serious emotional disturbance
home to out-of-home care. The younger the children,
and their families. This Federal program pioneered the
the greater the child's functional impairment, and the
concept of a "system of care" for this population, as
fewer the social supports (Boothroyd et al., 1998), the
delineated by Stroul and Friedman (1986, 1996). A
more respite care was used. Outcomes have not yet
system of care, described further below, is a
been reported.
comprehensive approach to coordinating and delivering
Another form of concrete support is exemplified by
a far-reaching array of services from multiple agencies.
the Family Associate Intervention, which was
All 50 states and numerous communities have received
developed in Oregon. It appears to be an inexpensive
CASSP grants to improve the organization of their
way to assist children in actually obtaining care after
response to the mental health needs of the most
they have been identified as needing care. The goal is
severely affected children and adolescents. Although
to use paraprofessionals (known as family associates),
CASSP principles have become a standard for program
rather than professionals, to facilitate entry into an
design, many communities do not offer comprehensive
often intimidating service system. In a controlled study,
services according to the CASSP model.
family associates were found to be effective in helping
CASSP provided the conceptual framework for the
families initiate mental health service use. Families
Robert Wood Johnson Foundation's Mental Health
receiving this support service were more likely to make
Services Program for Youth and the Annie E. Casey
and keep a first appointment at the mental health clinic.
Foundation's Urban Mental Health Initiative. These
The effectiveness of the intervention was moderate but
foundation programs were devoted to the development
sufficient to encourage further development of such a
of local interagency models (Cole, 1990). They were
low-cost intervention (Koroloff et al., 1996b; Elliot et
followed in 1992 by the authorization for what was to
al., 1998).
become the largest Federal program for child mental
health, the Comprehensive Community Mental Health
Integrated System Model
Services for Children and Their Families Program (also
Within the public mental health system, the 1980s and
known as the Children's Services Program), sponsored
1990s have seen an increased emphasis on developing
by the Center for Mental Health Services (Public Law
interagency community-based systems of care (Stroul
102-321).
& Friedman, 1986). This focus is driven by awareness
The Children's Services Program provides grants
that a large number of children are served in systems
to states, communities, territories, and Indian tribes and
other than mental health, as well as by children's
tribal organizations to improve and expand systems of
190
Children and Mental Health
care to meet the needs of approximately 6.3 million
Although findings are encouraging, their effectiveness
children and adolescents with serious emotional
has not yet been demonstrated conclusively, largely
disturbance and their families. The program now
because evaluation studies have not had a control
supports 45 sites across the country.
group. Most evaluations indicate that systems of care
Built on the principles of CASSP, the Children's
reduce rates of reinstitutionalization after discharge
Services Program promotes the development of service
from residential settings, reduce out-of-state place-
delivery systems through a "system of care" approach.
ments of children, and improve other individual
The system of care approach embraced by this initiative
outcomes such as number of behavior problems and
is defined as a comprehensive spectrum of mental
satisfaction with services. After reviewing findings
health and other services and supports organized into a
from the demonstration project of the Robert Wood
coordinated network to meet the diverse and changing
Johnson Foundation, their own work in Vermont,
needs of children and adolescents with serious
research in California and Alaska, and early findings
emotional disturbance and their families (Stroul &
from the Fort Bragg evaluation, Bruns, Burchard, and
Friedman, 1996). The system of care model is based on
Yoe (1995) conclude that "initial findings are encourag-
three main elements: (1) the mental health service
ing, especially with the history of disappointing results
system must be driven by the needs and the preferences
of outcome studies for child and adolescent services"
of the child and family; (2) the locus and management
(p. 325). Details are available in the individual studies
of services must be within a multiagency collaborative
(Attkisson et al., 1997; Illback et al., 1998; Santarcan-
environment, grounded in a strong community base;
gelo et al., 1998).
and (3) the services offered, the agencies participating,
Reviews (Stroul, 1993a, 1993b; Rosenblatt, 1998) of
and the programs generated must be responsive to
uncontrolled studies of community-based systems of
children's different cultural backgrounds. The
care showed that young people with serious emotional
Children's Services Program requires a national cross-
disturbances who were served under community-based
site evaluation, which has been continuously
systems of care consistently showed improvement
implemented since the spring of 1994. Preliminary
across a range of outcomes. However, most of these
evidence from the uncontrolled evaluation indicates
studies used a so-called pre-post evaluation design that
some improvements in outcomes, such as fewer law
does not answer the question of whether the changes
enforcement contacts and better school grades, living
occurring over time (pre to post) are a consequence of
arrangements, and mental health status. As part of the
the intervention or of the passage of time itself. Indeed,
evaluation, comparisons are being made between
when comparison groups are studied, such as in the
system of care sites and comparable communities
Fort Bragg demonstration project, results tend to be
without systems of care (Holden et al., 1999).
less favorable (see below).
Effectiveness of Systems of Care
The Fort Bragg Study
The previous sections have highlighted the trans-
The Fort Bragg study, conducted by Bickman and his
formations that have taken place since the early 1980s
colleagues (Bickman et al., 1995; Bickman, 1996a;
to create comprehensive, interagency, community-
Hamner et al., 1997), merits detailed discussion
based systems of care. This section reviews the
findings of research into the effectiveness of such
because of the basic issues it raises and the controversy
systems of care as compared with more traditional
it engendered. The Fort Bragg study is an evaluation of
a large-scale system change project initiated by the
systems.
Several studies on the effectiveness of systems of
State of North Carolina and the Department of Defense
care have been conducted in recent years (Stroul,
in the early 1990s; it was designed to determine what
1993a, 1993b; Bruns et al., 1995; Rosenblatt, 1998).
systemic, clinical, and functional outcomes could be
191
Mental Health: A Report of the Surgeon General
achieved if a wide range of individualized and family-
behavioral functioning), and the cost was considerably
centered services were provided without any barriers to
greater at Fort Bragg.
their availability. The project involved replacing the
The interpretation of the results by the project's
traditional CHAMPUS benefit for children who were
principal investigator has generated much discussion
military dependents in the Fort Bragg area with a
and controversy in the children's mental health field,
continuum of care that included a broad range of
both in support of and questioning the study's
services, a single point of entry, comprehensive
conclusions (Friedman & Burns, 1996; Behar, 1997;
assessments, and no copayment or benefit limit. The
Feldman, 1997; Hoagwood, 1997; Lourie, 1997; Pires,
provider agency at Fort Bragg was reimbursed for
1997; Saxe & Cross, 1997; Sechrest & Walsh, 1997;
costs. The impact of this change on children was
Weisz et al., 1997). Most of the controversy surrounds
assessed by comparing outcomes at Fort Bragg with
study interpretation, implementation, methodology, and
those at two other military installations in the Southeast
the interpretation of the cost data (Behar, 1997;
where the traditional CHAMPUS benefit package
Feldman, 1997; Heflinger & Northrup, 1997;
remained in effect. The comparison sites restricted
Langmeyer, 1997). Furthermore, it has been pointed out
services to outpatient treatment, placement in a
that Fort Bragg was not a multiagency community-
residential treatment center, or treatment in an inpatient
based system of care (Friedman & Burns, 1996), a
hospital setting; regular copayment and benefit limits
point that has been acknowledged by the principal
were in effect at the comparison sites.
investigator of the study (Bickman, 1996b). Overall,
Over a 3-year period, the evaluators collected
despite the controversy surrounding it, the Fort Bragg
service use, cost, satisfaction, clinical, and functional
evaluation has challenged the notion that changes at the
data for 984 young people served either at Fort Bragg
system level have consequences at the practice level
(574) or the comparison sites (410). Overall, there were
and, ultimately, improve outcomes for children and
a number of favorable findings for the demonstration
families. The results have stimulated an increased focus
site at Fort Bragg: access for children was increased;
on practice-level issues.
children referred for services were indeed in need of
help; parents and adolescents were more satisfied with
The Stark County Study
the services they received than were parents and
The shift in focus to the practice level is being re-
adolescents at the comparison sites; children received
inforced by results from another study by Bickman and
services sooner; care was provided in less restrictive
colleagues (1997, 1999) of children with emotional
environments; there was heavy use of intermediate-
disturbances who were served in Stark County, Ohio.
level services; fewer clients received only one session
In this study, participating children were served within
of outpatient treatment; overall, children stayed in
the public mental health system by a multiagency
treatment longer (although the length of stay in
system of care; this was in contrast to the Fort Bragg
hospitals and residential treatment centers was shorter);
sample of military dependents seen in a mental health-
and there were fewer disruptions in services (Bickman,
funded and -operated continuum of care. Children and
1996a). Thus, the major findings were that the
families who consented to participate in the study were
expanded continuum of care resulted in greater access,
randomly assigned to one of two groups. The first
higher satisfaction with services by patients, and less
group was immediately eligible to receive services
use of inpatient hospitalization and residential
within the existing community-based system of care in
treatment. Bickman also concluded, however, that
Stark County. Families in the second group were
despite the fact that the intervention was well
required to seek services on their own rather than to
implemented at Fort Bragg, there were no differences
receive them within the system of care. The major
between sites in clinical outcomes (emotional-
differences in services provided were that significantly
192
Children and Mental Health
more children and families in the system of care group
4. Mental disorders and mental health problems
received case management and home visits than those
appear in families of all social classes and of all
in the comparison group. Findings indicate no
backgrounds. No one is immune. Yet there are
differences in clinical or functional status 12 months
children who are at greatest risk by virtue of a
after intake. These results are similar to those of the
broad array of factors. These include physical
Fort Bragg study and suggest that attention should be
problems; intellectual disabilities (retardation); low
paid to the effectiveness of services delivered within
birth weight; family history of mental and addictive
systems of care rather than only to the organization of
disorders; multigenerational poverty; and caregiver
these systems.
separation or abuse and neglect.
5. Preventive interventions have been shown to be
Summary: Effectiveness of Systems of Care
effective in reducing the impact of risk factors for
Collectively, the results of the evaluations of systems
mental disorders and improving social and
of care suggest that they are effective in achieving
emotional development by providing, for example,
important system improvements, such as reducing use
educational programs for young children, parent-
of residential placements, and out-of-state placements,
education programs, and nurse home visits.
and in achieving improvements in functional behavior.
6. A range of efficacious psychosocial and
There also are indications that parents are more
pharmacologic treatments exists for many mental
satisfied in systems of care than in more traditional
disorders in children, including attention-
service delivery systems. The effect of systems of care
deficit/hyperactivity disorder, depression, and the
on cost is not yet clear, however. Nor has it yet been
disruptive disorders.
demonstrated that services delivered within a system of
7. Research is under way to demonstrate the
care will result in better clinical outcomes than services
effectiveness of most treatments for children in
delivered within more traditional systems. There is
actual practice settings (as opposed to evidence of
clearly a need for more attention to be paid to the
"efficacy" in controlled research settings), and
relationship between changes at the system level and
significant barriers exist to receipt of treatment.
changes at the practice level.
8. Primary care and the schools are major settings for
the potential recognition of mental disorders in
Conclusions
children and adolescents, yet trained staff are
1. Childhood is characterized by periods of transition
limited, as are options for referral to specialty care.
and reorganization, making it critical to assess the
9. The multiple problems associated with "serious
emotional disturbance" in children and adolescents
mental health of children and adolescents in the
context of familial, social, and cultural
are best addressed with a "systems" approach in
expectations about age-appropriate thoughts,
which multiple service sectors work in an
emotions, and behavior.
organized, collaborative way. Research on the
2. The range of what is considered "normal" is wide;
effectiveness of systems of care shows positive
still, children and adolescents can and do develop
results for system outcomes and functional
mental disorders that are more severe than the "ups
outcomes for children; however, the relationship
and downs" in the usual course of development.
between changes at the system level and clinical
outcomes is still unclear.
3. Approximately one in five children and adoles-
cents experiences the signs and symptoms of a
10. Families have become essential partners in the
DSM-IV disorder during the course of a year, but
delivery of mental health services for children and
adolescents.
only about 5 percent of all children experience
what professionals term "extreme functional im-
11. Cultural differences exacerbate the general
pairment."
problems of access to appropriate mental health
193
Mental Health: A Report of the Surgeon General
services. Culturally appropriate services have been
Anderson, J. C., & McGee, R. (1994). Comorbidity of
designed but are not widely available.
depression in children and adolescents. In W. M.
Reynolds & H. F. Johnson (Eds.), Handbook of
depression in children and adolescents (pp. 581-601).
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