In a health-care system that too often limits mental health services for children, physicians frequently see psychotropic medication as the best and least expensive treatment, says Ronald T. Brown, PhD, chair of the APA Working Group on Psychotropic Medications for Children and Adolescents, formed two years ago. In fact, a recent study indicates a five-fold increase in the use of antipsychotic drugs in children from 1993 to 2002.

However, as Brown and the other members of the group emphasize in a new report, more research is needed to examine the efficacy and safety of psychotropic medication—and other treatments—for specific disorders in children.

Recent research suggests that up to 15 percent of children and adolescents have a mental disorder that is serious enough to cause some impairment and that only one infive children receive services by appropriately trained mental health professionals. In response to these data, the working group examined and reported on the limited existing research on psychotropic and psycho-social treatment in this age group.

Most of the studies of psychotropic medication, including research intended to guide prescribing to children, have been done with adults, notes Brown, who is also a public health professor and dean at Temple University.

“Clearly the use [of medication] far exceeds any data,” comments Brown. Evidence supports psychosocial interventions such as exposure and response therapy, cognitive-behavioral therapy, multisystemic therapy and habit reversal training—alone or in addition to medication—for several disorders, he adds. The working group calls for a greater emphasis on treatment supported by scientific evidence.

“We do have a solid evidence base for the efficacious treatment of some child and adolescent disorders, but there are many gaps in our knowledge that require more research,” says Cheryl A. King, PhD, working group member and chief psychologist in the psychiatry department at the University of Michigan Medical School.

Diagnosis-specific treatment

The report stresses the need for mental health professionals to balance the benefits of any treatment with its possible risks, recommending that practitioners consider lower-risk alternatives first. After examining the research, the group made recommendations for treating children with several behavioral disorders:

• Attention-deficit hyperactivity disorder. Both behavioral therapy, such as parent education and classroom interventions and pharmacological treatments such as central nervous system stimulants can be effective in acute cases, said the group. Combining them can yield better short-term outcomes than using either alone and also enables the use of lower doses of medication.

• Oppositional defiant disorder and conduct disorder. More research has been conducted on behavioral treatment than on medication. Evidence indicates that psychosocial interventions such as home- and school-based behavior modification and combined or multisystemic therapy can yield significant results, although there is little information on long-term effects. Medication such as lithium and haloperidol can significantly reduce aggression in children with conduct disorder, however haloperidol can have serious side effects. There is little evidence to suggest that medication is effective in treating children with oppositional defiant disorder unless they also have attention-deficit hyperactivity disorder.

• Tourette’s syndrome and tic disorders. Medication such as typical and atypical neuroleptics can be effective, but should be used with caution due to safety and tolerability issues. If prescribed, they should be used in conjunction with behavioral treatments, such as habit reversal training.

• Obsessive-compulsive disorder. Research indicates cognitive behavioral therapy is very effective, but selective serotonin reuptake inhibitors (SSRIs) can also be effective for children who do not show improvement with behavioral therapy alone.

• Anxiety disorders. There is strong evidence for the efficacy of cognitive behavioral therapy, but SSRIs may be effective for children who do not show improvement with behavioral therapy alone.

• Depression and suicidal ideation and behavior. Evidence suggests that children and adolescents with depressive disorders respond well to a wide variety of psychosocial treatments. Fluoxetine—the only medication that has been approved by the Food and Drug Administration for use in children with depression—can be effective for children who don’t respond, but practitioners should monitor patients closely and inform parents about the risk of suicidal ideation or behavior associated with SSRIs. There is almost no research on specific treatments for suicidal children and adolescents. Multisystemic therapy has shown some promise in reducing suicide attempts, but these findings need to be replicated. There are no medication studies that have specifically targeted suicidal children and adolescents.

• Bipolar disorder. Both the psychosocial and pharmacological treatments for this condition require more study. The limited research available suggests psychosocial treatments can be effective and do not have adverse side-effects. Researchers need to conduct short- and long-term studies to clarify the risk-benefit ratio for all psychotropics used to treat bipolar disorder in children and adolescents.

• Schizophrenia spectrum disorders. The disorders are rare in this age group, and evidence on how best to treat them is also limited. Based on what is known, psychosocial interventions that are psycho-educational, cognitive-behavioral and family-based can be effective. Newer antipsychotic medications show promise, but also pose serious risks such as significant weight gain that can cause metabolic disorders such as Type 2 diabetes.

• Anorexia nervosa and bulimia nervosa. There is very little evidence any psychosocial or pharmacological treatments currently being used are effective for anorexia. Psychosocial treatments—particularly cognitive-behavioral therapy—can be effective for bulimia. More research is needed.

• Elimination disorders. Strong evidence supports behavioral treatments, such as a urine alarm. Imipramine can be effective when treating urinary elimination disorders, but it can have significant cardiac side-effects. Synthetic vasopressin nasal spray can also be effective, but once the child stops taking it, he or she will usually start wetting again. Practitioners should work with a child’s pediatrician since elimination disorders often have some physiological foundation.

Future directions

Overall, the working group concludes that more longitudinal studies should be conducted on treatments for specific disorders, focusing on the effects on symptoms, functional impairment and quality of life. The studies should consider gender, age, racial and ethnic groups and children with co-morbid disorders. Future study should also examine sequencing and combining psychosocial and pharmacological treatments, and the roles of family, school and primary-care providers in treatment.

In addition, the group recommends that mental health professionals receive additional training and education in evidence-based pharmacological treatment because practitioners frequently encounter clients on medication. Whether or not they agree with prescribing medication, psychologists still need to know the behavioral effects, says Brown.

The group also concludes that the general public should have full access to all safety and efficacy data uncovered in research: Federal agencies that fund research in children should share information and work together. Both Brown and King see the need for continuing evaluation of mental health treatment in children and adolescents—either through a permanent task force or periodic reconvening of the working group.

Brown also believes psychology—with its emphasis on behavior and skill in assessing quantitative data—can play a uniquely important role in psychotropic research. “Psychology is the study of human behavior, and when you have people who are medicated, you want to understand the mechanisms and actions of the medication and how it affects behavior.”

For more information and to read the full report, visit www.apa.org/releases/PsychotropicMedicationsReport.pdf.

FURTHER READING • Christophersen, E.R. & Mortweet, S.L. (2001). Treatments that work with children: Empirically supported strategies for managing childhood problems. Washington, DC: American Psychological Association. • Hibbs, E.D. & Jensen, P.S. (Eds.). (2004). Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice (2nd ed.). Washington, DC: American Psychological Association. • Phelps, L., Brown, R.T. & Power, T.J. (2001) Pediatric psychopharmacology: Combining medical and psychosocial interventions. Washington, DC: American Psychological Association.