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Children's Behavioral And Mental Health Problems

Children's Behavioral And Mental Health Problems
Limited access to services for children and adolescents with behavioral problems or mental illness often leads to inadequate care and therapy based on insufficient scientific evidence of safety and effectiveness, concludes a report by the American Psychological Association (APA) released recently.

As per the report, a product of the APA Working Group on Psychotropic Medications for Children and Adolescents, gaps in the scientific knowledge concerning which therapys work best for specific diagnoses and patients, a dearth of clinicians specifically trained to work with children, cuts in Medicaid funding, and poor reimbursement for mental health services leads to a number of children being treated with medicine despite limited efficacy and safety for their use especially with children.

Research published earlier this year showed a five-fold increase in the use of antipsychotic drugs to treat behavioral and emotional problems in children and adolescents from 1993 to 2002.

"This entire state of affairs is in part correlation to our health care system's failure to provide sufficiently for children, especially in the area of pediatric mental health care," states Ronald T. Brown, PhD, chair of the APA Working Group and Professor of Public Health and Dean at Temple University. "As a result, much of the care provided to children for mental health issues has been limited to medicine even though a number of psychosocial therapys have been found to be effective and some with better risk profiles. Psychosocial therapys, however, can be more labor intensive and more expensive." .

The Working Group's report identifies and calls attention to several "notable gaps" in the knowledge base upon which psychotropics are currently being prescribed, including anti-depressants and anti-psychotics. The report furthermore notes that current evidence for both psychosocial and psychopharmacologcial therapys are "uneven across disorders, age groups, and other defining characteristics of race, ethnicity, and socioeconomic status".

"Furthermore," the report states, "data are lacking concerning the long-term effects of the majority of therapys, both psychosocial and psychopharmacological, as well as their effects on functional outcomes" such as academic achievement and peer relationships.

Finally, the report notes that the lack of availability of all pharmaceutical data on psychotropics and their effects prevents the news media and the public from a full understanding of which therapys work, which do not, and the possible adverse side effects of some medications.

Among its recommendations, the report calls for:
  • Longitudinal studies of therapy efficacy and effectiveness for specific disorders (childhood depression, preschool and adolescent ADHD, adolescent autism, etc.) in terms of targeted symptoms, functional impairments, adaptive functioning and quality of life across gender, age, racial and ethnic groups, and for children with comorbid disorders.
  • Research to determine the optimal sequencing of therapy components as well as optimal doses and combinations of psychosocial and psychopharmacological therapys.
  • Research on the role of families, school, and primary care providers in the development and delivery of mental health services for children, the moderators and mediators of therapy effects, and the factors that are linked to therapy adherence.
  • Increased collaboration across federal funding agencies involved in child therapy research, including National Institutes of Mental Health, National Institute of Child Health and Human Development, National Institutes of Natural Sciences, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, the Substance Abuse and Mental Health Services Administration and Institute for Education Science.
  • Public disclosure of all efficacy and safety data emanating from both psychosocial and psychopharmacological therapy research on child and adolescent disorders.
  • An emphasis on evidence-based child therapys, including psychosocial and psychopharmacological interventions in the training and continuing education of all mental health providers.

"Systematic reimbursement for evidence-based psychosocial and psychopharmacological therapys must be established," the report concludes. "Current funding and administrative mechanisms often encourage the use of medicine or non-evidence based psychosocial therapys over empirically based psychosocial therapys. Finally, mental health services for youth are provided across many different service sectors, either simultaneously or sequentially, and collaborative care is often hampered by cost, discipline, and administrative barriers".

Best therapy depends on diagnosis and balances risks and benefits
In addition to the aforementioned global needs for an evidence base, appropriately trained providers and good access to care, the Working Group looked at the evidentiary base for numerous therapys currently in use for children and adolescents with behavioral and mental health problems.

The report recommends that decisions about first line of therapy options should be guided by the need to balance the anticipated benefits of the therapy with its possible harms, including the absence of therapy. Safer therapys with demonstrated efficacy should be considered first before any use of other therapys with less favorable risk profiles.

This diagnosis-by-diagnosis review of the literature reached a general conclusion that much more studies are needed, as well as a few specific conclusions - pending further research - about current therapy practices for each illness:

Attention Deficit Hyperactivity Disorder -- Behavioral therapys, psychopharmacological therapys, and a combination of the two all have solid evidence for acute efficacy. Behavioral therapys have the most favorable risk:benefit ratio, suggesting they be first line interventions. Combining behaviorally based therapys with medicine can yield better short-term outcomes than either therapy alone and the combination enables lower doses of medicine to be used.

Oppositional Defiant Disorder and Conduct Disorder - Based on evidence showing better results with psychosocial interventions, such interventions should be the first line therapy and tried before psychotropic medications.

Tourettes and Tic Disorders - Drug therapy should be used cautiously due to safety and tolerability issues. If medications are used, keep doses low to decrease the risks of adverse side effects and use in combination with behavioral therapys such as habit reversal training (HRT).

Obsessive Compulsive Disorder -- Evidence supports the use of cognitive behavioral treatment as the first line therapy. Medication should be added only if necessary.

Anxiety Disorders - There is good evidence to support cognitive behavioral treatment (CBT) as a first line therapy and CBT does not pose the risks that some medicine therapys do. However, therapy with SSRI medicine is also a viable choice for children who are unable to engage in CBT or do not show improvement during such therapy.

Depression/Suicidailty - A therapy strategy designed to minimize risks would involve sequential use of psychosocial interventions and close monitoring, followed by medicine (fluoxetine is the only medicine approved by the FDA for treating depression in children) for those children and adolescents who do not respond to psychosocial therapys. If a child is to be treated with medication, his or her parents must be fully informed of the potential risks and benefits.

Bipolar Disorder - Both psychosocial and psychopharmacologic therapys for bipolar disorder require more study. The limited research suggests psychosocial therapys are beneficial and do not present adverse side-effects. Short- and long-term medicine trials are needed to clarify the risk:benefit ratio for all medications used to treat bipolar disorder.

Schizophrenia Spectrum Disorders - These disorders are rare in children and adolescents; empirical evidence of how best to treat these disorders in young people is also very limited. However, based on the little research that does exist, psychosocial interventions that are psychoeducational, family-based, and cognitive-behavioral are suggested. Newer pharmacologic agents hold promise but also carry the risk of adverse side-effects.

Anorexia Nervosa and Bulimia Nervosa - For anorexia nervosa, there is a general lack of evidence of effectiveness for both the psychosocial interventions as well as the pharmacologic interventions currently in use. For bulimia nervosa, psychosocial interventions, especially CBT, appear to have more scientific support and a more favorable risk:benefit ratio compared with medications. Future research needs to be done to determine the effectiveness of specific forms of therapys or therapy combinations.

Elimination Disorders - The efficacy of behavioral therapys, such as the use of a urine alarm, is well documented in the research literature. There is little or no evidence of the effectiveness of drug therapys for elimination disorders; there is concern about the safety of such medicine based therapys. Because elimination disorders often have some kind of physiological foundation, mental health practitioners should partner with a pediatrician when assessing and managing enuresis and encopresis.

Posted by: JoAnn    Source

Did you know?
Limited access to services for children and adolescents with behavioral problems or mental illness often leads to inadequate care and therapy based on insufficient scientific evidence of safety and effectiveness, concludes a report by the American Psychological Association (APA) released recently. Children's Behavioral And Mental Health Problems

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