wife withholding prescribed meds

[ADDrus]

I guess my shaking branches and rattling cages is started to get some action. Not from mom, but from the school and the peds doctor. I got a phone call from the school VP and they've agreed to a case conference on S10 and will bring in the school psychologist, his therapist, the teacher, VP, principal and parents that want to show up. Mom hates this stuff and will not want to go, probably won't want to pay the therapists fee to attend, but no matter, I'll pay all of it if I have to. Court order says she pays half, but we'll see.

Peds doc called and left a message that she is trying to get the therapists notes so that's good. Wants me to follow up. That means she's on the ball and looking into the antidepressant thing. To bad it's the weekend and nobody is open to call.

No return call from the family doc.

[*KJ*]

I don't know your wife or have any experience whatsoeva with her difficulties, I had a thought on your last post, and wondered if it'd give your wife the 'control' she seeks, while also helping to move things forward...

Would she consider having a person of her chosing, attend these types of meetings for her. Someone that can obsorb the information and process it without getting stuck on inmaterial things (like emotional battles)????

I do get that much of what she is doing is fighting for the sake of fighting...but as a mom, I do appreciate that she does infact have a voice...even if it happens to be in conflict with everyones elses...it's still her position, ya know????

Trust me I'm not defending her...I am just thinking of how crazy everyone thinks I am because I am refusing the flu shots...I am of the opinion that they just haven't been tested enough, and that god happens to have a better handle on the immune system than big-pharma (plus my son has had some pretty bad reactions). But people think I'm out of my mind for not getting it...the hysteria over the swine flu is insane, in my opinion...

does that make any sense?

So, if there were someone that could represent her opinion, but still be rational...could that help???

[ADDrus]

Originally Posted by *KJ*

I don't know your wife or have any experience whatsoever with her difficulties, I had a thought on your last post, and wondered if it'd give your wife the 'control' she seeks, while also helping to move things forward...
Would she consider having a person of her chosing, attend these types of meetings for her. Someone that can obsorb the information and process it without getting stuck on inmaterial things (like emotional battles)????

It would be very unlikely that she would reliqush control to anybody. She just doesn`t trust anybody and besides, she would have to come to the conclusion and implement the idea herself. I`ve been painted black and anything I say is automatically suspect. Would it help? Maybe, but there is little likelihood she would take counsel from anybody that would advocate for anything other than what she already thought.

Originally Posted by *KJ*

I do get that much of what she is doing is fighting for the sake of fighting...but as a mom, I do appreciate that she does infact have a voice...even if it happens to be in conflict with everyones elses...it's still her position, ya know????

Yup, I don't agree with her opinion, but like everyone else, she's entitled to it. I am also entitled to mine and I am entitled to do everything I can for my son.

Originally Posted by *KJ*

Trust me I'm not defending her...I am just thinking of how crazy everyone thinks I am because I am refusing the flu shots...I am of the opinion that they just haven't been tested enough, and that god happens to have a better handle on the immune system than big-pharma (plus my son has had some pretty bad reactions). But people think I'm out of my mind for not getting it...the hysteria over the swine flu is insane, in my opinion...

does that make any sense?

Yes, that all makes sense. With the amount of controversy in the news reports and the fact that every kid in our local school system has already been out sick in the last 4 weeks, I have no intention of getting a flu shot for my kids. I believe everybody here has already been exposed and this wave has passed us by. I don't have issues with the replication process of the flu vaccine. I believe they used the same process they use for the regular vaccine and it's a process that has been used for years. I doubt, like you, that they've been able to sufficiently test the vaccine against the current strain and that the current strain could mutate so that the vaccine is useless anyway, but this comes down to your choice and that of your children's other parent. If you are in agreement, then it`s not an issue. What do you do if you don't agree though and you both feel strongly that you are advocating in the best interests of your child? This is the question that haunts me. Am I right to continue? At what point is my fight more damaging than just letting it go? Is this fight over custody contributing to the problems that S10 is having and if I had just given in to her needs to control custody, would S10 be better off today? I question my actions daily. What is in the best interests of S10????????

Originally Posted by *KJ*

So, if there were someone that could represent her opinion, but still be rational...could that help???

They're might be and it might help, I just don't see it ever happening.

She appears to be on track with medicating S10 for depression. So how do you reconcile that she would be ok with this and not medicating him for ADD? I can`t, it doesn`t make any sense. After getting my head pharmacist (I work at a company that employees half a dozen) to research the latest studies on treating depression in kids under 12, it seems that stimulants are the medication of choice. So he might end up on the stimulants anyway.

I`ve now signed medical releases for the therapist to talk to the paediatrician and the school, mom needs to sign them also and I`ve informed her that she should do that today when she visits the therapist with S10. She will again be removing him from school for the afternoon so that he can attend his therapists meeting as she refused to schedule appointments for after school, despite the availability of after school appointments. That doesn`t make any sense either.

Mom also proposed that if S10 should get suspended for anything as the school has alluded to, that she would be the best choice to home school him. I proposed to her that he should be enrolled at a local tutoring center that he has attended in the past. It`s staffed by fully trained teachers and would emulate school, therefore reinforcing the idea that if he acts out inappropriately, he will not be getting a vacation at moms. Mom has no educational training or qualifications.

If anybody else has some suggestions on what to do with S10 if he`s suspended, I`m all ears (or eyes would be more appropriate here )

[*KJ*]

I figured it'd require more flexibility that she would be willing to offer, but just thought there might be enough motivation IF she hated those meetings that much...oh well...crazy thought!

As for suspensions...I think I'd consider some community service of some kind. Not necessarily of the 'scared straight' variety...but more or less as a consequense. Although community service is a noble and kind gesture, I think not having him sit around collecting dust, but rather contributing to society in another form (if his behavior precludes him from doing so for that time period in a 'typical' way). I'm sure your local church or food pantry or other such places would be happy to give him enough to help him get his priorities in line... I know it's really more than that, but I mean as food for thought.

PLUS, I'd get all his work and make sure it's done each day. And eliminate ALL the distractions (TV games, phone, etc).

As for home schooling...yikes, I'd try not to even discuss this, ooops I think I hear your cell ring every time the topic comes up! This way you don't get into a disagreement that she somehow feels compelled to win. Let's just hope he doesn't get expelled! If that happens, I think I'd inlist outsiders to "help" figure out what is in S10's best interest. For example how critical is socializing for him...would he even get that home schooled? things like that.

I do see what you mean about those big conflicts...have you had that level of conversation with your son? I'm sure he'd prefer it if mom & dad got along...I don't mean like that...I mean, does he see the value in your efforts or does it only add more stress.

I think it's a valid question you are having...and of course the whooper on the table, meds, seems to be resolving, so the idea of backing down now likely seems easier...but outside of that, I think it could be telling for you (and his mom) to get his perspective...I'm sure his therapist helps him manage his feelings on it too, which I'm sure goes a long way. But I can certainly see how understanding his perspective could alter your decision, yup, I think it's a good piece of info to gather.

Yes I will continue to pray for your son's success, and everything that is necessary to make that possible!

[ADDrus]

S10's therapist requires a signed medical release form so that she can communicate with the paediatrician, who then would use this information to prescribe the meds for S10.

Guess what?

BPD/NPD mom refused to sign the medical release forms. So now no information goes to the doc and no meds get prescribed and S10 doesn't get the treatment he needs for him.



And the reason she won't sign? She mentioned something about wanting S10 to be seen by another paediatrician. If she wanted him seen by another doctor, why wasn't this brought up anytime since she agreed to meet with this doctor last December? She had a whole year to discuss another doctor as an option. She agreed last year that talking to this doctor was ok. What has changed since then so this doctor should now not be appropriate? At the very least, why wasn't this presented immediately when she discovered that S10 needed meds? Why was it delayed until all the ducks were in a row and everything was in place for S10 to get the help he needed? Why is there still, a day after she refused to sign the medical release form, still not one word of communication from her with what her ideas might be to get S10 timely and appropriate help?

[MGDAD]

Since when does she need a release from both parents? In the US I have a right to seek treatment for my child, and so does my ex. Plus, in the US you have a right for a copy of the file. I can go to any of my childs doctors and get a copy of the file and show it to anyone I want. I dont need my ex's permission for that. Maybe it is different in Canada.

[ADDrus]

I would guess it must be different here. I was told by the peds doctor last year that if the 2 parents do not agree, the docs are supposed to act in the best interests of the patient. IMHO this would mean that the Dr. should release the notes, if she refuses, she is supporting the mom's position. Why is the mom's postion more valid than mine?

[Hoshi]

My sympathies to you and your child. This sounds like a horrid situation. How could your ex-wife not see how she's slowly ruining his childhood?
As an ADD'er who was not diagnosed till adulthood, I personally mourn the loss of the time and the wasting of my potential. I weep for the missed chances and missed happiness. I grieve for what could have been.

[MGDAD]

Are you sure you dont have a right to get a copy of the file? You should put your request in writing. She might be just dodging you.

[*KJ*]

I agree, she shouldn't be withholding documents. Her professional opinion is one thing...withholding information to affect an outcome is manipulative, not professional.

Is this something you should raise with an attorney? Does your son have a court representative of some type? Here we have what is called a guardian ad litem. This person generally is assigned when there is conflict of this type between parents. Their role is really to speak FOR the child. Not to make a decision, but to listen to the childs concerns and speak FOR him and what would seem consistent with his needs.

In other words (without knowing much of your wife's thoughts)...they might hear your son mention that he'd like to try the meds to see if it helps his functioning at school. Also hear your desire for the same thing, and then read a statement from the doctor saying that his presentation is consistent with children that respond well to meds. This person would also likely hear comments from key people at school about his difficulties as well as your wife's opinion to not medicate.

This information would not beused to make a decision, but more or less to assess the conflicting issues and the pressure that the child is managing. All of this would be presented to the court with a recommendation that would be in line with the childs needs.

Likely, since his doc was recommending meds, and it's been shown that these meds can help with the specifc issues hampering his success at schol, and a trial would resolve the big question: "Will it help?" and your son is open to it (whether he says this for your beneift and something else for your wife is up for investigation though) it's likely this would be the logical next step...but you never know, the proess could reveal something that you are unaware of and a different recommendation could be made.

Anyhoo...is there some type of person like this there? From what I understand the court needs to appoint this person when conflicts like this arise.

ADDrus, can you share the information that you got from the pharmacists. Just curious about what they suggested. Thanks.

[ADDrus]

Hi KJ,

I am trying to eliminate the conflict. Yes a GAL could be appointed and it has been discussed on a number of occasions and was in my original filing. At this point, the court would probably not allow it and prefer to wait for the CE report that should be done soon. It should be done already, but mom keeps delaying her appointments, missing them, and just not helping finish the process. Big surprise there. We were told 12 weeks to complete when it was started at the beginning of July. There is a zero likelihood of the report being completed by Christmas.

[ADDrus]

S P E C I A L A R T I C L E
Drs. McClellan and Werry have compiled a snapshot of the status of our field with respect to evidencebased
treatment. This is an unusual feature for the Journal, although our psychology colleagues have
completed a similar task in a more comprehensive format. I would appreciate your feedback on whether
you find the concept and/or the format useful in your clinical work and teaching.
M.K.D.
Evidence-Based Treatments in Child and Adolescent
Psychiatry: An Inventory

JON M. M

CCLELLAN, M.D., AND JOHN SCOTT WERRY, M.D.

ABSTRACT

Objective:

To provide a list of evidence-based psychopharmacology and psychotherapy treatments for child psychiatry.

Method:

Published reviews and Medline searches were examined to generate a list of treatments supported by randomized

controlled trials.

Results: For psychopharmacology, the best evidence to date supports the use of stimulant

medications for attention-deficit/hyperactivity disorder and selective serotonin reuptake inhibitors (SSRIs) for obsessivecompulsive

disorder. There is also reasonable evidence addressing SSRIs for anxiety disorders and moderate to severe

major depressive disorder, and risperidone for autism. The psychosocial interventions best supported by well-designed

studies are cognitive-behavioral and behavioral interventions, especially for mood, anxiety, and behavioral disorders.

Family-based and systems of care interventions also have been found effective.

Conclusions: Although the number of

evidence-based treatments for child psychiatry is growing, much of clinical practice remains based on the adult literature

and traditional models of care. Challenges toward adopting evidence-based practices are discussed.

J. Am. Acad. Child

Adolesc. Psychiatry,

Evidence-based medicine refers to the use of intervention
strategies for which there is scientific evidence supporting

their effectiveness and safety for a given
indication and population. The notion that treatments
should be scientifically validated seems at face value
obvious. Professional, consumer, and regulatory bodies
have advocated that evidence-based therapies be
adopted as standard clinical practice. However, efforts
to encourage clinicians and teaching programs to use

evidence-based interventions have not always been successful.

The purpose of this review is to outline the

areas in child psychiatry for which evidence-based practices

exist, as well as to discuss the broader issues of

using and implementing such practices.

ISSUES RELATING TO EVIDENCE

There are several issues and challenges in the development

and adoption of evidence-based medicine as

the standard of care for child psychiatry.

Level of Evidential Proof

What evidence implies “evidence-based”? Randomized

controlled research designs with adequate sample

sizes and defined study populations are generally required

(The Cochrane Collaboration, 2002). Other

important criteria include whether study findings have

been independently replicated, thus ensuring the results

are due to the effectiveness of the intervention

rather than the investigator. Also, the treatment needs

to be definable (e.g., a medication protocol or psychotherapy

manual) so that different clinicians can provide

the same intervention reliably.

Representative Sampling

Many studies use narrowly defined exclusion criteria

to address the question of efficacy for a specific population;

therefore, results may not reflect the more common

clinical situations seen in everyday practice.

Variations in diagnostic comorbidity, severity, associated

risk factors, and cultural/social variables all influence

treatment decisions and effectiveness. Diagnostic

comorbidity is the rule for childhood psychopathology.

Current psychiatric diagnostic nosology for youth requires

further validation and leaves many complicated

cases less than adequately characterized (McClellan and

Werry, 2000).

Therapist Factors

Interpersonal elements are important tenets of healing,

yet the effectiveness of therapy must be based on

more than persona. Although the patient

–therapist relationship

is a critical component of a successful outcome,

it is important to distinguish between the

effectiveness of the treatment versus that of the therapist.

Therapies that rely on charisma or the patient

–

therapist relationship may generate undeserved name

and fame but ultimately may not generalize to other

practitioners.

Applicability of Adult Evidence

Much of child psychiatry practice, especially psychopharmacology,

stems from the adult literature. Presumptions

that treatments are safe and effective in

adolescents and children are generally based on assumptions

regarding the continuity of the disorder.

While probably warranted in many cases, this assumption

needs to be better examined for many disorders,

especially given the difficulty at times of extrapolating

adult diagnostic criteria for children.

METHOD

Given the broad nature of the task, we narrowed the search to

published reviews, supplemented with more recent studies. The

American Academy of Child and Adolescent Psychiatry (AACAP)

’s

Practice Parameters, the Journal

’s 10-Year Reviews, a special section

on pediatric psychopharmacology edited by Vitiello et al. (1999) in

this

Journal, two series of reviews on empirically supported treatments

published in 1998 and 2001 in the

Journal of Clinical Child

Psychology

, and a review by Fonagy (2000) of psychotherapy were

particularly helpful. More recent publications were identified using

Medline, with the last literature search conducted in June 2003. It

is inevitable that we will have missed some important papers, especially

non-English publications or recently published works. This

review is intended to be a list rather than a manual of how to use

the various interventions.

We limited the review to randomized controlled trials of either

psychopharmacological or psychotherapeutic interventions. In

weighting the support of the current literature, we assessed the

number of studies available (with greater support given to protocols

replicated by different sites and authors), sample sizes, relevance of

comparison groups, and availability of manual-based approaches.

These reflect the criteria published by the Task Force on Psychological

Intervention Guidelines (American Psychological Association,

1995).

PHARMACOLOGY

Tables 1 through 5 outline the current research support

with regard to controlled clinical trials. We will

outline the content briefly and by medication class

rather than by diagnosis.

Stimulants

The effectiveness of stimulants for the short-term

treatment of attention-deficit/hyperactivity disorder

(ADHD) is well documented and constitutes the largest

body of evidential literature in child psychiatry

pharmacology. By 1996, there were 161 randomized

controlled trials (RCTs) published, including 5 preschool,

150 school-age, 7 adolescent, and 9 adult studies

(AACAP, 2001; Greenhill et al., 1999). Improvement

occurred in 65% to 75% of the 5,899 patients

randomized to stimulants compared to only 5%

to 30% of those assigned to placebo. Studies consistently

noted a positive response for core ADHD symptoms,

and some reported improved compliance and

reduced aggression. Methylphenidate is the best studied,

followed by dextroamphetamine and pemoline.

Controlled studies also support the efficacy of the

mixed amphetamine salts (McCracken et al., 2003;

Pelham et al., 1999; Pliszka et al., 2000; Swanson et al.,

1998). Stimulant medications are FDA-approved for

use with ADHD (methylphenidate for ages 6 years and

older, dextroamphetamine for ages 3 and older).

The vast majority of studies examining the benefits

of stimulant treatment have been short-term trials,

most lasting less than 12 weeks. There are a few prospective,

longer RCTs, with durations of 12 to 24

months (Gillberg et al., 1997; Richters et al., 1995;

Schachar et al., 1997). The largest of these, the NIMH

Multimodal Treatment Study of Attention Deficit

–

Hyperactivity Disorder (MTA study), showed that

stimulants (either by themselves or in combination

with behavioral treatments) lead to stable, long-term

EVIDENCE-BASED TREATMENTS

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:12, DECEMBER 2003

1389

improvements in ADHD symptoms as long as the drug

continues to be taken (Jensen et al., 2001, The MTA

Cooperative Group, 1999).

Stimulant Slow-Release Forms.

The short duration of

standard stimulants has resulted in considerable efforts

to develop longer-acting preparations. Historically the

effectiveness of these agents has not been as great, presumably

due to variations in pharmacodynamics and

receptor activity (AACAP, 2002). However, newer

preparations with delivery systems that attempt to

mimic the pharmacodynamics of standard stimulants

have been shown to be effective (Greenhill et al., 2002;

Wolraich et al., 2001).

Alternative to Stimulant Medications.

Atomoxetine is

a noradrenergic reuptake inhibitor that has been found

helpful for ADHD in both children and adults (Kratochvil

et al., 2002). Advantages include the fact that it

provides 24-hour coverage with single day dosing and

is not a drug of abuse. Atomoxetine is FDA-approved

for treating ADHD in children 6 years of age and older.

Antidepressants

The antidepressant literature is outlined in Tables 1

through 3.

SSRIs.

Currently, the best evidence supports the use

of selective serotonin reuptake inhibitors (SSRIs) and

clomipramine for obsessive-compulsive disorder

(OCD) (Emslie et al., 1999). Fluvoxamine and sertraline

received FDA approval for use in pediatric OCD

in 1997 (down to 8 and 6 years of age, respectively).

There are also studies supporting the use of SSRIs for

the treatment of other anxiety disorders (Birmaher et

al., 2003; Research Unit on Pediatric Psychopharmacology

Anxiety Study, 2001).

The efficacy of antidepressants for major affective

disorder has been a difficult issue for child psychiatry.

Despite the belief that it is the same illness as in adults,

it was only recently that double-blind placebocontrolled

trials demonstrated a therapeutic response.

These studies support the use of fluoxetine (Emslie et

al., 1997; Emslie et al., 2002) and paroxetine (Keller et

al., 2000) for moderate to severe persistent depression.

Braconnier et al. (2003) found similar efficacy between

paroxetine and clomipramine but did not include a

placebo control. Prior studies, including several with

tricyclic antidepressants, failed to find a positive response,

primarily due to high placebo response rates.

This is an area where the adult literature has not translated

well to juveniles. Several methodological reasons

have been hypothesized for this: studies including

youths with only mild depression; placebo-type therapeutic

effects of the concomitant supportive and

psychoeducational interventions; and possibly developmental

differences in drug response or metabolism.

There may also be syndromic differences between depression

in youths and that classically diagnosed in

adults. At this time, SSRIs are the first medication

choice for depression in youths, though not necessarily

the first-choice treatment (AACAP, 1997).

Heterocyclic Antidepressants.

While not yet of demonstrated

efficacy in anxiety (except OCD) or mood

disorders, bupropion and the tricyclic antidepressants

(TCAs) have been found to be effective for ADHD

(Emslie et al., 1999; Geller et al., 1999). Given the

concerns regarding TCAs

’ side effect profile (most importantly

the issue of cardiotoxicity), bupropion is

probably a better first option, though evidence supporting

its efficacy is limited. Finally, several controlled

studies support the use of TCAs for enuresis (Geller et

al., 1999), though its effect is strictly symptomatic, not

curative.

Neuroleptics (Antipsychotics)

There are very few studies examining the effectiveness

of antipsychotics in early-onset psychotic disorders,

none of which looks at the most commonly used atypi-

cal agents (there are studies underway to address this

area). Thus, at this time the treatment of schizophrenia

spectrum disorders in youth with antipsychotic agents is

primarily justified by the adult literature (AACAP, 2002).

The majority of studies with neuroleptics have addressed

other disorders or problems, including autism

and pervasive developmental disorders, mental retardation,

tic disorders, and disruptive behaviors. To date,

the best evidence is probably for autism. A multisite

study coordinated through the RUPP network (Mc-

Cracken et al., 2002) found risperidone helpful for

aggression and self-injurious behaviors in youths with

autistic disorder. Similar findings were previously

noted 30 years ago with low doses of higher-potency

agents (e.g., haloperidol). Neuroleptics do not reverse

the core symptoms of autism. Similar responses are also

noted in youths with mental retardation with externalizing

behaviors (Baumeister et al., 1998; Buitelaar et

al., 2001). Unfortunately, antipsychotic agents historically

were often overprescribed in individuals with

mental retardation and developmental disorders. If

used, low-dose studies suggest an advantage over higher

doses (Campbell et al., 1978).

Antipsychotic agents also are helpful for reducing

tics and aggressive behavior (Table 4). Potential side

effects may outweigh potential benefits, although the

long-term ramifications of conduct disorder, and the

improved safety profile of the atypical agents, make

these agents more viable for disruptive behavior disorders.

[ADDrus]

Mood Stabilizers


The use of mood stabilizers in youth has increased


greatly in clinical practice despite the lack of controlled


trials (Ryan et al., 1999). This is in part due to more


youths being diagnosed with bipolar disorder, an area


of some controversy (AACAP, 1997; Geller and Luby,


1997; NIMH, 2001). To date, there are only a few


studies examining the efficacy of lithium in youths with


bipolar disorder (or manic-like symptoms) (Table 5).


Lithium is FDA-approved for treating bipolar disorder


in youths ages 12 years and older. There are also a few


studies demonstrating lithium


’s effectiveness at decreasing

explosive behavior in boys with conduct disorder


(Campbell et al., 1984; 1995).


There are no controlled studies to date documenting


the efficacy of the anticonvulsants used as mood stabilizers


for bipolar disorder in youth. DelBello et al.


(2002) found that quetiapine plus valproate worked


better than valproate alone for acute mania in adolescents.


There is one study supporting the use of valproate


for explosive behaviors (Donovan et al., 2000). The


few controlled studies examining the efficacy of carbamazepine


for ADHD symptoms and/or aggression produced


mixed results (Table 5).


Anxiolytics


The few double-blind placebo-controlled trials examining


the effectiveness of benzodiazepines for childhood


anxiety disorders have not documented


significant efficacy, in part due to a high placebo response


rate (Graae et al., 1994; Simeon et al., 1992).


There are no controlled studies examining the effectiveness


of buspirone or


-adrenergic blockers in this

age group.


Other Medications


Although the


-adrenergic agonists are commonly

used for ADHD and behavioral problems, there are


only a few small controlled studies demonstrating the


effectiveness of clonidine for ADHD (Hunt et al.,


1985; Riddle et al., 1999). One multisite controlled


trial found that clonidine, and clonidine plus methylphenidate,


improved both tics and ADHD symptoms


(The Tourette


’s Syndrome Study Group, 2002). In this

study, combined therapy worked best for ADHD


symptoms. Other double-blind trials examining the efficacy


of clonidine for tics and/or behavioral difficulties


in patients with Tourette


’s disorder have produced

mixed results (Borison et al., 1982; Goetz et al., 1987;


Leckman et al., 1991; Singer et al., 1995). There is one


controlled study showing that guanfacine is helpful for


tic disorders plus ADHD symptoms (Scahill et al., 2001).


The opiate antagonist naltrexone was initially


thought to be helpful for autism (Riddle et al., 1999).


However, four controlled trials found no benefit for


core autistic symptoms or self-injurious behaviors, although


the medication may help reduce hyperactivity


in this population (Campbell et al., 1993; Herman et


al., 1993; Kolmen et al., 1997; Willemsen-Swinkels et


al., 1995).


Summary


To date, in pediatric psychopharmacology, there is


substantial empirical evidence supporting stimulant


medications for ADHD, and SSRIs for OCD. Well-


designed multisite trials also support the use of SSRIs


for major depression (moderate to severe persistent


cases) and childhood anxiety disorders, and risperidone


for behavioral disturbances in youth with autism. Beyond


that, the majority of clinical practice is supported


by few controlled studies and is primarily justified by


the adult literature, case reports, and/or clinical lore.


Further, the literature examining medication therapies


for comorbid conditions is sparse, and that justifying


polypharmacy nonexistent.


In general, the psychopharmacology literature in


youth is limited by small sample sizes, narrow diagnostic


inclusion criteria, and short duration of treatment.


Fortunately, recent efforts by the NIH to develop large


cooperative multisite designs have helped address these


concerns. Significant placebo response rates in studies


of anxiety and depressive disorders have also been an


issue. This raises unique concerns when justifying clinical


practice on open-label trials, since positive findings


cannot be assumed due to medications.


PSYCHOSOCIAL INTERVENTIONS


Psychotherapy remains a mainstay of psychiatric


treatment. Unfortunately, the existing evidence suggests


that the widely used traditional psychotherapies


are not effective in youth (Weiss et al., 1999, 2000;


Weisz and Jensen, 2001). Conversely, although research-


based psychotherapeutic interventions have


documented effectiveness, they are generally not used


in clinical practice.


Four meta-analytic studies of psychotherapy research


(Casey and Berman, 1985; Kazdin et al., 1990; Weisz


et al., 1987; 1995) note positive outcomes with medium


to large effect sizes when compared to no treatment


or active control groups. These reviews examined


over 300 studies dating from 1952 to 1993 (Lonigan et


al., 1998), with ages of subjects ranging from 2 to 18


years (the youngest children were involved with parenting


interventions) (Weisz et al., 1995). Behavioral


therapies had greater effects than nonbehavioral. These


meta-analytic studies examined psychotherapies without


regard for diagnosis or other clinical issues. Thus,


the remainder of this section will focus on specific


interventions.


Cognitive-Behavioral Therapies


Cognitive-behavioral therapies (CBTs) are the psychosocial


treatments best supported by the literature,


with effectiveness noted for a number of different illnesses


and symptom states. The specific protocols and


strategies vary somewhat by study and targeted condition.


For depression (Asarnow et al., 2001; Kaslow and


Thompson, 1998), CBT was found to be effective


compared to wait list controls (Clarke et al., 1999;


Lewinsohn et al., 1996), systemic family therapy or


nondirective supportive therapy (Brent et al., 1997),


and relaxation therapy (Wood et al., 1996). Cognitivebehavioral


or psychoeducational therapies found to be


helpful for children with elevated depression rating


scores (versus a depressive disorder) include self-control


and behavioral problem solving (Stark et al., 1987),


relaxation training and self-modeling (Kahn et al.,


1990), cognitive training and/or social problem solving


(Gillham et al., 1995; Jaycox et al., 1994), and primary


and secondary control enhancement (Weisz et al.,


1997). In adolescents with high depression symptom


ratings, Reynolds and Coats (1986) found that CBT


and relaxation therapy were both superior to controls.


There are some studies of CBT in juvenile depression


where response rates did not differ between the


active treatment and control arms (Clarke et al., 2002;


Liddle and Spence, 1990; Marcotte and Baron, 1993;


Vostanis et al., 1996). The inclusion of subjects with


only mild depression may have influenced these findings


(Asarnow et al., 2001).


For anxiety disorders, cognitive-behavioral strategies


using self-instruction training are helpful for childhood


phobias (Ollendick and King, 1998). CBT is effective


for overanxious, generalized anxiety or separation anxiety


disorder (Barrett et al., 1996; Kendall, 1994; Kendall


et al., 1997; Manassis et al., 2002). Family-based


CBT strategies are also beneficial (Barrett et al., 1996;


Shortt et al., 2001).


For OCD, De Haan et al. (1998) found that youths


with OCD randomized to behavioral therapy did as


well or better than those randomized to clomipramine.


For posttraumatic stress disorder (PTSD), CBT strategies


were superior to nonspecific therapy for reducing


symptoms in sexually or physically abused children


(Cohen and Mannarino, 1997; Deblinger et al., 1999,


2001; King et al., 2000; Kolko, 1996). Further randomized


controlled trials are needed to confirm the


utility of CBT for both OCD and PTSD.


For ADHD, cognitive-behavioral strategies (i.e.,


promoting improved self-control though problemsolving


strategies; Hinshaw and Erhardt, 1991) have


not been consistently found to be helpful in controlled


studies. These strategies may be useful when combined


with other multimodal treatment programs (Pelham et


McCLELLAN AND WERRY


1394


J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:12, DECEMBER 2003

al., 1998). For conduct disorder, there are a number of


studies showing that interventions focusing on the cognitive


processes underlying conduct problems are helpful


(Kazdin, 2000). These include problem-solving


training (Kazdin et al., 1987a,b; Kazdin et al., 1992),


anger management strategies (Lochman et al., 1984,


1989), assertiveness training (Huey and Rank, 1984),


and rational-emotive therapy (Block, 1978).


Behavioral Interventions


This literature overlaps some with CBT. For childhood


phobias


, behavioral interventions, including in

vivo desensitization, filmed modeling, and live modeling,


are helpful compared to wait list controls (Ollendick


and King, 1998). However, small sample sizes,


lack of comparison between different treatment modalities,


a lack of treatment manuals, and the use of


nonclinical samples limit these findings.


For ADHD


, there is some support for behavioral

classroom interventions and behavioral parent training


that involve training parents or teachers in contingency


management and behavioral intervention strategies.


Improvement has been noted in ADHD rating scales


and observed behavior (Pelham et al., 1998). Preschoolers


benefit without the need for medications


(Sonuga-Barke et al., 2001). However, behavioral strategies


are generally less effective than medications alone


(AACAP, 1997), and the improvement may not generalize


to other settings nor persist beyond the period of


treatment (Pelham et al., 1998). Finally, since these


programs require intensive parental/teacher involvement


and are time-consuming, treatment adherence


and compliance are issues.


Interpersonal Therapy


Interpersonal therapy has been shown to be effective


for depressed adults. There are two controlled studies


supporting the use of interpersonal therapy in depressed


adolescents (Mufson et al., 1999; Rossello and


Bernal, 1999).


Family and Parenting Interventions


In addition to the studies noted above, the effectiveness


of family interventions has been established in


some important areas, most notably conduct disorder.


Parent training programs have been developed to improve


parent


–child interactions, enhance parenting

effectiveness, and reduce coercive interactions. Videotaped


modeling parent training (Scott et al., 2001;


Spaccarelli et al., 1992; Webster-Stratton 1984, 1994)


provides instruction to parents in therapist-led groups.


The focus is generally on younger children (ages 4


–8

years) whohave behavioral difficulties and/or meet the


criteria for conduct disorder or oppositional defiant


disorder. Patterson


’s (1974) behavioral family intervention

is designed to instruct parents on monitoring and


reducing deviant behaviors using operant principals of


behavioral change. Several controlled studies have


found these methods superior to either standard treatment


(e.g., psychodynamic therapy, client-centered


therapy) or no treatment in reducing noncompliance


and problem behaviors (Alexander and Parsons, 1973;


Bernal et al., 1980; Firestone et al., 1980; Wiltz and


Patterson, 1974). Other studies also have shown behaviorally


based parent


–child and parenting therapies

to be effective (Eyberg et al., 1995; Hamilton and Mac-


Quiddy, 1984; McNeil et al., 1991; Peed et al., 1977;


Wells and Egan, 1988; Zangwill, 1983).


In addition, parenting interventions and family


therapy/psychoeducation have been shown to be helpful


for anxiety disorders (Barrett et al., 1996) and eating


disorders (Crisp et al., 1991; Eisler et al., 1997;


Geist et al., 2000; Robin et al., 1999).


Systemic Multimodal Interventions


Given the complex nature of childhood psychiatric


disorders, it is not surprising that multifaceted approaches


using comprehensive intervention strategies


have been helpful for a number of disorders. For conduct


disorder (and other associated comorbid conditions),


multisystemic therapy (Borduin et al., 1995;


Henggeler et al., 1992) uses aggressive case management,


comprehensive psychiatric services, and targeted


family interventions to maintain youths in their home


communities. Multisystemic therapy has been shown


to be superior to incarceration, psychiatric hospitalization,


and other treatments and is more cost-effective.


However, its effects were found to dissipate over a 12-


to 16-month period (Henggeler et al., 2003). Multisystemic


therapy also has been found helpful for youths


with substance abuse problems (Henggeler et al.,


1999a, 2002), and those in psychiatric crisis


(Henggeler et al., 1999b; Schoenwald et al., 2000),


though effects in the former were mixed.


For ADHD, although the core symptoms respond


well to medications alone, the combination of medications


plus intensive psychosocial behavioral interventions


provides significant benefit for commonly


associated difficulties, including comorbid mood, anxi-


EVIDENCE-BASED TREATMENTS


J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:12, DECEMBER 2003


1395

ety, and/or behavioral disorders, social skills, and/or


academic problems (Greene and Ablon, 2001; Jensen


et al., 2001; Wells, 2001). These data support the addition


of intensive behavioral interventions for complicated


or comorbid cases.


The Reaching Educators, Children and Parents (RECAP)


program is a school-based program that provides


individual, group, classroom, teacher, and parenting


interventions. This program was developed to address


the clinical reality that most emotionally disturbed


youths have problems in a number of domains of functioning.


The curricula incorporate strategies shown to


be effective with other psychotherapies: problemsolving


skills, coping skills, and parent training. RECAP


was shown to improve internalizing and


externalizing problems in fourth-grade students compared


to no treatment controls (Weiss et al., 2003).


Summary


The existing literature supports the use of psychotherapeutic


interventions, particularly cognitivebehavioral


and psychoeducational strategies, for child


and adolescent mood, anxiety, and behavioral disorders.


Family-based and systems of care interventions


are also important. Further work is needed to replicate


findings across multiple sites with larger samples. Research


is also needed to identify how factors related to


the therapy, the child, or the surrounding environment


influence treatment decisions and/or outcome (Kazdin,


2001). Moreover, these interventions need to be better


studied in real-world settings to determine how well


positive findings generalize to clinical populations.


DISCUSSION


Fortunately, there are an increasing number of available


research-supported treatments for treating mental


health problems in youth. However, most of child psychiatry


practice is not evidence-based, in part because


patient populations are much more complicated and


diverse than research samples, and in part because clinicians


are not always trained in, or willing to use,


evidence-based modalities. This is a major public


health issue, since approximately 20% of children and


adolescents suffer from significant emotional difficulties.


Some would argue that until diagnostic and treatment


interventions are better established, we should


not be providing unsubstantiated care. Others more


cavalier assert that the lack of evidence justifies using


whatever treatment any clinician deems is appropriate.


Most practitioners recognize the limitations and work


to combine the limited research with community standards


and common sense in defining treatment plans.


Nevertheless, there is great variability between clinicians


and between different communities and different


disciplines. The notion of a well-defined standard of care


for most childhood psychiatric cases remains elusive.


Research efforts are needed in a variety of areas,


including establishing the effectiveness of commonly


used unstudied practices, determining the effectiveness


of evidence-based treatments in nonacademic clinical


settings and populations, and developing methods for


promoting the use of existing evidence-based practices


in clinical settings. Ideally, child psychiatry will evolve


to the point where standard interventions are defined


by research, versus the current state where research, if


done at all, typically is initiated to justify existing practices.


In the absence of science, clinical opinion dictates


practice. While clinical experience is important, the


history of medicine, including psychiatry, is paved with


what are now considered unacceptable or even barbaric


practices. Even within the current era, many of the


practices being promoted 20 years ago are no longer in


vogue. Although there is a tendency to look back with


either bemusement or disdain at our forbears, were


they really so much more na


ïve and foolish than current

practitioners? Given that we still suffer faddish


waves of unsupportable treatments (e.g., holding


therapy, facilitated communication) and idiosyncratic


diagnostic practices, caution and humility are indicated


when assessing our current standards of care.


Disclosure: Dr. McClellan is a primary investigator for a research study


funded by Pfizer and in the last year served as a consultant to Eli Lilly


and AstraZeneca.

[ADDrus]

Happy Reading KJ, sorry for the formatting issues, the original is a PDF and about 3 times as long with the tables and the references.