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
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
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
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.
Back to Top
Burns, B. J., Hoagwood, K., & Mrazek, P. J.
(1999). Effective treatment for mental disorders in children
and adolescents. Clinical Child and Family Psychology Review,
Lonigan, C. J., Elbert, Jean C., & Johnson,
S. B. (1998). Empirically supported psychosocial interventions
for children: An overview. Journal of Clinical Child Psychology,
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,
Back to Top