Acronym Key

ADHD attention-deficit/hyperactivity disorder
CBCL Child Behavior Checklist
CBT cognitive behavior therapy
CD conduct disorder
DK don't know
MST multisystemic therapy
ODD oppositional defiant disorder
PTSD posttraumatic stress disorder
RCT randomized clinical trial
SED severe emotional disorder

Introduction

The Duke University team was invited by the National Institute on Drug Abuse (NIDA) to prepare an annotated bibliography on the evidence base for treatments of selected childhood mental disorders. The intent of this review was twofold: (1) to identify efficacious/effective interventions for the treatment of childhood psychiatric disorders that could potentially reduce the risk for substance abuse disorders in adolescence or young adulthood; and (2) to identify recent intervention studies that merit followup research to examine outcomes relative to their impact on subsequent substance use, abuse, or dependence in adolescence and beyond. This review is in response to interest by NIDA, and the field, in whether early treatment of childhood mental disorders can prevent later substance abuse problems.

To achieve the above aims, NIDA provided a list of childhood mental health disorders that may be linked to later substance abuse: (1) attention-deficit/hyperactivity disorder (ADHD); (2) major depression; (3) disruptive behavior disorders; (4) anxiety disorders; and (5) posttraumatic stress disorder (PTSD). Although classified as an anxiety disorder, PTSD was reviewed separately.

Literature searches were conducted on treatments for each of the above disorders or related symptoms. Eligible studies were identified primarily through searches of the Medline and PsycINFO databases. To be included in this review, a study had to: (1) focus on one of the above childhood mental health disorders or related symptoms; (2) be a controlled design, either a randomized clinical trial (RCT), a quasi-experimental design, a within-subject crossover design, or a multiple baseline design; (3) target children in the 6-12 age range, although studies that extended the age range to also include younger or older youth were not excluded; and (4) be published between 1985 and 1999, although some earlier studies were included if more recent research on a promising intervention had not been conducted. Variations in these inclusion criteria are delineated in the overview section for each disorder. An important caveat is that treatment studies that addressed multiple or unspecified disorders were not included because of the focus on diagnostic-specific interventions. The review focused on outpatient care; therefore, studies of residential or institutional treatment (e.g., treatment foster care, group homes, residential treatment centers, and hospitals) were not included.

Matrices for each disorder (tables 1-5) include the following topic headings: study design/description, target population, demographic characteristics, outcomes, and comments. Within each matrix, studies have been organized into three sections: psychosocial, psychopharmacological, and adjunctive (psychosocial plus psychopharmacological) interventions.

A summary of the treatment research for each disorder or related symptoms identified above is presented briefly in the following text, and annotated specific studies are included in the matrices. The evidence base here does not appear to be as strong as what was reported in the Report of the Surgeon General on Mental Health (DHHS, 1999; see also Burns, Hoagwood, & Mrazek, 1999; Weisz & Jensen, 1999). This is because the treatment studies of adolescents were included there and not here. A link between interventions for the selected mental disorders and substance abuse outcomes was not found in most of the studies presented here. This is not unexpected due to the age 12 cutoff, which is younger than when most substance use or abuse begins. Two further and related issues emerge: (1) measures of substance use are not commonly included in treatment studies of mental disorders in children; and (2) most treatment studies do not follow children into adolescence where the risk for substance use is greater and detection of substance problems (or the lack thereof) could be identified. An exception with respect to measures of substance use and long-term followup is the research on multisystemic therapy for disruptive behavior disorders.

This review shows that within the existing evidence base for each disorder, psychosocial interventions include an array of behavioral approaches. The psychopharmacology evidence base is clearly strongest for ADHD, weaker for other disorders, and virtually nonexistent for anxiety disorders and PTSD (with the exception of obsessive-compulsive disorder). Adjunctive studies examining psychosocial and psychopharmacological interventions were rare, with the largest and most sophisticated for ADHD.

This review and bibliography provide a considerable, but brief, collection of information in a single document on the status of controlled treatment research for selected disorders. The matrices can be quickly scanned to obtain details about specific studies (e.g., sample size, gender and racial/ethnic distribution, and outcomes). Therefore, each matrix provides a starting point for determining known benefits of a specified intervention for a given disorder, which may be useful for identifying interventions with the potential for preventing later substance use problems. Moreover, the matrices offer a way to identify successful interventions that have been tested in reasonably large and well-conducted studies. These interventions might be candidates for assessing substance abuse outcomes via followup studies as participants age into adolescence or young adulthood. Substance abuse outcome comparisons for youth in experimental and control conditions could then be done.

An additional comment and caveat is related to the question of what constitutes evidence. In preparing this report, careful attention was given to study selection and accurate abstraction. However, it is possible that relevant studies may have been missed. In addition, clarification about what works will require application of standards to the existing evidence base. Standards of evidence such as those developed by the Society of Clinical Psychology (Lonigan, Elbert, & Johnson, 1998) may require, for example, multiple trials of an intervention or findings reported by multiple teams of investigators, before an intervention can be added to the evidence base.

In conclusion, for policymakers and investigators to utilize the information in this report for decisionmaking about further research, multiple issues will require attention. In addition to establishing criteria to assess the adequacy of the evidence base for specific disorders, the utility of these studies for specific target populations (e.g., age, gender, racial/ethnic groups) will require consideration. This is particularly an issue where the representation of such groups has not been addressed in the existing literature. In addition, further understanding of risk factors and prevention strategies for substance use problems will be required to address decisions about future research on mental health interventions.

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References

Burns, B. J., Hoagwood, K., & Mrazek, P. J. (1999). Effective treatment for mental disorders in children and adolescents. Clinical Child and Family Psychology Review, 2, 199-254.

Lonigan, C. J., Elbert, Jean C., & Johnson, S. B. (1998). Empirically supported psychosocial interventions for children: An overview. Journal of Clinical Child Psychology, 27, 138-145.

U. S. Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

Weisz, J. R., & Jensen, P. S. (1999). Efficacy and effectiveness of child and adolescent psychotherapy and pharmacotherapy. Mental Health Services Research, 1, 125-157.

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