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Journal Issue: Children with Disabilities Volume 22 Number 1 Spring 2012

Childhood Health: Trends and Consequences over the Life Course
Liam Delaney James P. Smith

Effect of Interventions in Influencing Lifelong Health: A Focus on Mental Health

Given the prevalence and large long-run effects of childhood mental health conditions such as ADHD and childhood depression, the importance of remediation is readily apparent (see the article in this volume by Mark Stabile and Sara Allin for a more complete treatment of ADHD38). Effective interventions could potentially offset not only the psychological and economic costs experienced by children and their families when children are young but also reduce high costs associated with lifelong psychological problems. Recent studies examining the lives of individuals who have experienced childhood psychological problems indicate lifetime costs in terms of earnings alone that could exceed $500,000.39 Such assessments underestimate total effects because they do not include many costs that spill over to family members, such as treatment costs and mental distress of the family. Many studies have examined the most effective pharmacological, behavioral, and psychological treatments for each of these problems.

Attention-Deficit/Hyperactivity Disorder, or ADHD
ADHD is the most common childhood mental health condition. Treatment for ADHD generally takes the form of pharmacological or behavioral interventions. Several studies have examined effects of stimulant and nonstimulant medication either solely or in combination with other forms of treatment.40 These studies have documented the efficacy of stimulant medications for treatment of ADHD.41 Studies continue to look into the optimal combination of pharmacological and behavioral interventions, and the effectiveness of different types of behavioral interventions and pharmacological treatments.

One of the largest recent examinations of the effectiveness of treatments for ADHD is the National Institute of Mental Health's multimodal study. Researchers studied four groups of children: those who were treated with intensive medication management alone, those who were treated with intensive behavioral treatment alone, those who received a combination of both, and a control group of children who received the care that was routinely available in the community. The fourteen-month follow-up of more than 600 children revealed that both medication and combined conditions were superior to community care.42 Effects, while diminished, were also apparent in a follow-up ten months later.43

While the literature provides strong evidence that appropriately applied stimulant treatment, perhaps in combination with behavioral interventions, can alleviate at least some symptoms of ADHD, there is no way yet of knowing whether these treatments break the link between childhood ADHD onset and the potential adverse effects over the long term. This gap in our knowledge is due largely to the fact that most studies have not followed children treated for ADHD over long periods of time.

Childhood Depression
Childhood depression is another of the more common childhood mental health conditions. For childhood depression, studies have evaluated the effectiveness of various pharmacological, behavioral, and psychological interventions. For the latter two, the use of cognitive behavioral therapy, or CBT (an approach that focuses on patients' understanding of their patterns of thoughts and beliefs and the behaviors that flow from those thoughts), has been widely studied. In general, this literature has suggested that CBT is effective in treating both anxiety and depression. A 2005 Cochrane Literature review, authored by John Cochrane, of CBT treatment for anxiety in children found a 50 percent success rate, higher than in control cases.44 Several experiments and reviews found that CBT is effective in treating child and adolescent depression.45

For pharmacological interventions, several studies examined the use of selective serotonin reuptake inhibitors (SSRIs, commonly prescribed antidepressants) to treat childhood depression. Uncertainty remains about the efficacy of SSRIs in treating childhood depression. Almost all reviews stress the incompleteness of the evidence in terms of drawing conclusions on efficacy. The Cochrane review by S. E. Hetrick and others reviewed twelve trials examining the use of SSRIs in children and concluded that there was little evidence for effectiveness.46 However, several papers and reviews demonstrated the effectiveness of the SSRI fluoxetine for treatment of childhood depression.47 Although fluoxetine, sold as Prozac and under other brand names, is currently FDA-approved for children, unlike some other SSRI medications, debate continues about the potential for increased risk of suicide attempts.48

There is much still to learn about optimal combination of treatments in terms of promoting child mental health. Reviewers are almost unanimous in believing that the existing body of evidence, based largely on short-term and small-scale trials, does not support efforts to draw substantive conclusions regarding overall efficacy. Given evidence on the lifelong effects of childhood psychological problems and the growing number of trials that have tested the efficacy of different treatments, longer-term follow-up studies are needed to examine the effectiveness of these treatments in breaking the link between childhood psychological problems and negative consequences in adulthood. Complex issues also surround how results from clinical trials might be scaled up to the broader population. While CBT has been demonstrated to be effective in treating childhood depression in many trials, the task of rolling out this and other effective treatments to wider and more heterogeneous populations is obviously more difficult than demonstrating effectiveness in single trials.