Congressional Briefing on Children’s Mental Health--October 10, 2007
Good afternoon. My name is Bill Pelham. I am a Distinguished Professor of Psychology, Pediatrics, and Psychiatry at the State University of New York at Buffalo and Director of the Center for Children and Families at the university. I am pleased to have the opportunity to speak with you in this briefing about treatments that work, otherwise called evidence-based treatments or practices (EBPs), for childhood mental health. My area of expertise is attention deficit hyperactivity disorder in children, which as you know is one of the most common, publicized, and controversial mental health problems of childhood. My laboratory has developed, evaluated, and implemented many if not most of the leading evidence-based interventions for children with ADHD. I will speak very briefly and generally about evidence-based approaches in childhood mental health, and then describe what an EBP actually looks like for a typical child with ADHD.
You have heard in Drs. Knitzer's and Hoagwood's presentations what evidence-based practices mean in scientific terms, and they have noted that there are many good lists of what treatments for which disorders of childhood have a good basis in scientific evidence (e.g., http://nrepp.samhsa.gov). These lists are produced by government agencies, professional associations, and foundations focused on health and mental health, as well as reviews conducted by mental health professionals in the scientific literature. All mental health problems in children have at least one solid EBP, and most have more than one. Often those EBPs include both psychological (sometimes called psychosocial) and pharmacological (that is, medication) approaches to intervention (see Brown et al, 2007, for a recent summary). Focusing on psychological approaches, it is important to make clear that almost all EBPs for common childhood problems involve concurrently working with three entities--the family (e.g., training the child's parents how to be better at parenting), the schools (e.g., consulting with the child's teacher to develop classroom accommodations), and the child (e.g., to teach skills to help them overcome their difficulties). This means that appropriate utilization of EBPs typically means that different systems (mental health, family, school) need to work seamlessly together to benefit the child.
At the same time, there are many things that therapists can do with families, teachers, and children that are not well grounded in intervention science. For example, some commonly used approaches such as having a child spend an hour weekly in a therapist's office engaging in sand-tray, play therapy, is not an evidence-based approach. Some non-EBPs can actually do considerable harm, as the well-known case of the child in Colorado who died in the process of "rebirthing therapy," which does not have any support in the scientific literature. There is a very real need to increase the number of mental health professionals who are trained to work with children. However, increasing the number of mental health workers or providing for more individual contact hours in healthcare without adequate training will not necessarily lead to improved mental health care for children. What the therapist actually does in those contacts with the child, family, and teacher is the key to beneficial outcomes for the child. Thus, an increase in the work force of mental health professionals needs to proceed hand-in-hand with training in and implementation of treatments that have a scientific evidence base.
I would like to use treatment of ADHD as an example of evidence-based treatments for a specific disorder and describe exactly what a treatment professional does when implementing an EBP with an ADHD child. In addition, I will tell you what we don't do--that is the kinds of things that professionals should not be doing with a child with ADHD because they do not have a scientific evidence base. ADHD is an excellent exemplar because the EBPs include all three of the facets noted above--family, school, and child--as well as medication. Further, the components of EBPs for children with ADHD are very similar to those for many other childhood problems, including conduct problems/aggression, depression, anxiety, and autism.
In your packet is a document titled "Evidence-based Psychosocial Treatment for ADHD Children and Adolescents." It summarizes in what I hope is plain language what parents and teachers and professionals need to know about treating ADHD with an evidence-based approach. It can be downloaded along with many other helpful materials from our Web site at UB. I refer to the packet in my discussion below.
The evidence-based psychological treatment for ADHD involves three components: (1) teaching parents strategies that enable them to better manage and teach their ADHD children; (2) consulting with teachers to develop classroom management strategies that help their ADHD children; (3) teaching skills to ADHD children to enable them to get along better with their peers. Notably, these three domains--interactions with parents, classroom behavior and academics, and peer relationships--are the three areas of daily life functioning in which children with ADHD are most impaired. These three areas are also the keys to improved long-term outcomes (e.g., in adulthood) for ADHD children. That is why we focus on them in treatment.
The parenting component involves meetings with parents--typically held in a clinic or school--in which basic strategies for effective parenting are taught to parents. This can be done individually or, more efficiently, in group settings. The basic format common to all of the evidence based parenting programs, several of which are noted in our handout, is a series of 8-16 weekly sessions in which skills are taught and then parents have a homework assignment of implementing the strategy they have been taught (e.g., praising a child for following a parent's request or command, time out for noncompliance). Most programs are quite interactive, relying on parent-parent and parent-therapist interaction to facilitate the learning process. Learning how to give effective commands and how to use "when…then" contingencies (when you have done your homework, then you may watch television) consistently are key skills taught. Why do we need to teach such skills to parents of children with ADHD and other mental health problems? Because none of us who are parents received any training in how to raise children before we became parents! We simply produced a child and then learned to parent by trial and error. Unfortunately, the learning curve for parents of a child with a mental health problem is very steep, and they need assistance early in learning how to be effective parents.
Concurrently with parenting work, ADHD children are enrolled in a group social skills program in which they receive extensive instruction and monitored practice in how to get along better with other children. The most effective programs involve training during activities that are the venue for peer interactions--children's games--and are often more rather than less intensive--e.g., summer camps rather than a few clinic-based sessions. Typically, paraprofessionals (e.g., college students, school aides) run these programs to minimize cost.
While the parents and children are in treatment, someone (e.g., therapist, school psychologist, parent) works with the child's teacher to establish and implement school-based programs that are analogous to those that parents are learning to do at home. One of the most common of these is a Daily Report Card, which is depicted on p. 6 in the handout. ADHD children cannot delay gratification for the 9 weeks between report cards typical for other children. They need explicit goals--both academic and behavioral--that "followed classroom rules") and described in daily feedback to the child and parents. Parents then provide consequences at home for positive Daily Reports (e.g., special time with Dad for a good day in school). Other modifications to classroom routine and instruction may be necessary. Fortunately, ADHD children are entitled to a variety of accommodations in school under IDEA, and teachers can effectively implement these programs for sustained periods of time.
Finally, as our handout illustrates, medication is often an adjunctive treatment for children with ADHD. Most parents prefer to begin treatment with psychological and educational approaches, and research shows clearly that if this approach is taken, medication can be avoided for most children. In this approach, medication is added as an adjunct when necessary. A chart describing this treatment approach is the last page of the handout. The addition of medication means that the treatment team for the parents and teachers also needs to interface with or be joined by the physician who prescribes the medication. Such interdisciplinary coordination is central to EBP for children with ADHD.
Of the four components discussed, medication is very widely used for ADHD and has been increasing in use over the past decade. Classroom management programs are widely available in schools, though not consistently applied to ADHD children. Behavioral parent training is the single most well-validated EBP for ADHD and many other disorders of childhood and arguably the key to treating most childhood MH disorders. However, it is much less widely available than medication, primarily due to reimbursement issues in both public and private healthcare systems. The least widely available of these components is the social skills training described earlier that is also central to improving outcomes--similarly limited by reimbursement practices and by the structure of the traditional mental health approach of office-based therapy.
The lack of availability of these psychological EBPs for childhood mental health problems is a serious public health issue that contributes to the dramatically escalating numbers of children being treated with medication. Increasing the availability and use of these psychological approaches to treating ADHD and other childhood mental health disorders should be a major goal of improving interventions for childhood mental health. Although the presence of a large pharmaceutical industry guarantees the development, dissemination, and availability of medications for ADHD, as well as all other childhood mental health disorders, there is no comparable entity that plays a similar role for psychological approaches to treatment. The federal government must play this role. Seven years ago, the Surgeon General held a meeting about children's mental health. One of the recommendations was for the federal government to "Create an oversight system [analogous to the FDA] to identify and approve scientifically-based [psychosocial] prevention and treatment interventions, promote their use, and monitor their implementation (USPHS, 2000)." That recommendation remains as relevant and important today as it was then.
Thank you for your time today. I hope your have found these comments helpful.