Introduction

There has been an increased recognition of the prevalence and substantial morbidity associated with child and adolescent mental disorders. Estimates suggest that up to 15% of children and adolescents suffer from a mental disorder of sufficient severity to cause some level of functional impairment (Roberts, Atkinson, & Rosenblatt, 1998; Shaffer, Fisher, Dulcan, & Davies, 1996). Of concern are data indicating that only one in five of these children receive services provided by appropriately trained mental health professionals (Burns et al., 1995; Centers for Disease Control, 2004; U.S. Department of Health and Human Services, 1999). For many of these interventions, the short-term efficacy for decreasing symptoms is fairly well demonstrated. Evidence supporting the acute impact of treatment on daily life functioning and the long-term impact on both symptoms and other functional outcomes is less well documented.

Given a recent increase in the number of efficacy studies of psychosocial, psychopharmacological, and combined interventions for mental health disorders in youth, including several recent clinical trials sponsored by the National Institutes of Health (NIH) (Vitiello, 2006), and growing public recognition of the existence of these disorders, the APA Working Group on Psychotropic Medications for Children and Adolescents was charged with reviewing the literature and preparing a comprehensive report on the current state of knowledge concerning the effective use, sequencing, and integration of psychotropic medications and psychosocial interventions for children and adolescents. In preparing its report, the working group reviewed the existing literature in peer-reviewed journals (included as part of MEDLINE and PsycINFO), as well as Food and Drug Administration (FDA) data concerning safety. For the psychological disorders most prevalent in children and adolescents, the various psychosocial, psychotropic, and combination treatments were reviewed, including the effect of each therapy, the strength of evidence for its efficacy, and the limitations and side effects of each treatment in the short- and the long-term. An Efficacy Summary Table for treatments targeting each type of child psychopathology appears at the end of each section.

Disorders included in the report are attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD), Tourette and tic disorder, obsessive–compulsive disorder (OCD), anxiety disorders, depression and suicidality, bipolar disorder, schizophrenia spectrum disorder, autism spectrum disorder, and elimination disorders. Information regarding specific psychosocial, psychopharmalogical, and combined treatments for each disorder can be found in the main report.

Safety
Especially salient to this review are issues of safety, particularly with respect to psychotropic medications in the pediatric population. Within childhood populations, there are vast developmental differences that influence physiological, cognitive, behavioral, and affective functioning. The unique issues in child and adolescent psychopharmacology must be considered when prescribing and monitoring medication effects at home and at school. The acceptability of the risk–benefit profile for any intervention involves value judgments as to the cost of harm-related and psychiatric-related adverse events. Recent safety concerns about antidepressants in the pediatric population illustrate several of the ethical issues related to clinical research and the dissemination of findings. For many other psychotropic agents, issues of safety have not been explored, particularly for long-term usage.
Diversity
Issues of diversity, including gender, race/ethnicity, sexual orientation, physical disability, socioeconomic status, culture, and religious preference may moderate response to treatment and influence treatment choice and adherence. There is, however, a paucity of data concerning these possible moderators. Where there are published data with regard to treatment efficacy, the working group has taken care to review these studies. Further research examining treatment effects and outcomes by diversity variables is necessary.
Conclusions

Despite recent advances in treatment research, significant knowledge gaps remain. The evidence base for treatment efficacy is somewhat uneven across disorders, with some of the most severe mental health conditions of childhood, including bipolar disorder and schizophrenia, receiving proportionally less attention from treatment researchers. Most of the evidence for efficacy is limited to acute symptomatic improvement, with only limited attention paid to functional outcomes, long-term durability, and safety of treatments. Few studies have been conducted in practice settings, and little is known about the therapeutic benefits of intervention under usual, or real-life, conditions. The benefits of some behavioral treatments have been well documented through numerous single-subject design studies and group crossover designs for some low-prevalence disorders, although there is a relative dearth of well-controlled randomized clinical trials supporting their effectiveness. The interpretation of study findings for a number of disorders is also limited by specific design features, including inadequate statistical power, choice of control group, and lack of an intent-to-treat analytical strategy.

Relatively few studies have addressed the sequencing and integration of different interventions—that is, which of the treatment alternatives should be first-line—and little empirical evidence is available to guide the management of initial treatment nonresponders. In spite of the high rates of diagnostic comorbidity in childhood, few studies have addressed the treatment of youngsters with multiple disorders or other complex presentations.

It is the opinion of the working group that the decision about which treatment to use first be in general guided by the balance between anticipated benefits and possible harms of treatment choices (including absence of treatment), which should be the most favorable to the child. It is recommended that the safest treatments with demonstrated efficacy be considered first before considering other treatments with less favorable side effect profiles. For most of the disorders reviewed herein, there are psychosocial treatments that are solidly grounded in empirical support as stand-alone treatments. The preponderance of available evidence indicates that psychosocial treatments are safer than psychoactive medications. Thus, the working group recommends that in most cases psychosocial interventions be considered first. The acute and long-term safety and efficacy data that are available for each disorder will be central to this determination.

It should also be acknowledged that there are cultural and individual differences about how to weigh safety and efficacy data, and consumers (i.e., families) might weigh them differently. Ultimately, it is the families’ decision about which treatments to employ and in which order. A clinician’s role is to provide the family with the most up-to date evidence, as it becomes available, regarding short- and long-term risks and benefits of the treatments. As the evidence base continues to grow, the ultimate goal will be to provide information that will allow families to apply their own preferences about how to weigh safety and efficacy in order to make an informed choice with regard to treatment on behalf of their child.

Recommendations

A summary of each section is provided below. Specific recommendations for each category can be found in the main report.

Research and Funding
To advance knowledge in the field and improve the lives of children and adolescents and their families, it is recommended that researchers, research funding organizations, and other stakeholders, including those who establish funding priorities, work together to strengthen the evidence base for the treatment of child and adolescent psychopathology.

Professional Education
It is recommended that (a) predoctoral training of professional psychologists include a broadbased education in the various evidence-based treatments discussed in this review, (b) postdoctoral training further the development of skills in the implementation of evidence-based psychosocial interventions and general knowledge of evidence-based psychopharmacological and psychosocial treatments, and (c) continuing education for child and adolescent practitioners and training faculty emphasize contemporary evidence-based strategies in the treatment and management of childhood disorders.

Public Education
To improve recognition and understanding of childhood mental illness and its treatment, it is recommended that professional organizations, the medical community, federal agencies, foundations, private industry, health care organizations, accrediting bodies, and other stakeholders commit to educating the public about these disorders and appropriate treatments that have been empirically demonstrated to be both safe and effective.

Service Delivery
It is recommended that policymakers, professional organizations, educational and training institutions, and providers develop policy and implement practices ensuring that youth with mental health disorders are identified and have access to evidence-based (to be consistent with above and APA policy), safe, reimbursable treatments.

Task Force members

Chair: Ronald T. Brown, PhD, ABPP
Temple University

David Antonuccio, PhD, ABPP
University of Nevada School of Medicine

George J. DuPaul, PhD
Lehigh University

Mary Fristad, PhD, ABPP
Ohio State University

Cheryl A. King, PhD, ABPP
University of Michigan

Laurel K. Leslie, MD, MPH
Children’s Hospital of San Diego

William E. Pelham Jr., PhD
University at Buffalo, The State University of New York

John Piacentini, PhD, ABPP
University of California, Los Angeles

Benedetto Vitiello, MD
National Institute of Mental Health

APA Staff, Children, Youth, and Families Office
Mary Campbell, Director

Gabriele McCormick

Efua Andoh