White House Meeting on Mental Health of Children
Ronald F. Levant, Ed.D., A.B.P.P.
I had the great honor of representing APA at the March 20, 2000, White House meeting on the mental health of children. The meeting was called in response to concerns about the drugging of preschool children generated by a well-publicized study published in the Journal of the American Medical Association (Zito, Safer, dosReis, Gardner, Boles, & Lynch, 2000). This study found a dramatic increase in the prescription of psychotropic medications to pre-school aged children between 1991-1995. The study focused on three major classes of psychotropic drugs (stimulants, antidepressants, and neuroleptics), and two leading drugs (methylphenidate and clonidine). Across three sites, stimulants (and in particular methylphenidate) showed the largest increase, clonidine and antidepressants showed sizable increases, but neuroleptic use increased only slightly. Of particular concern was the predominance of "off-label" use – that is, using drugs which have not been approved either for young children or for the condition for which the drug was prescribed.
This meeting built on the Clinton Administration’s significant accomplishments in the area of mental health, including the first-ever White Conference on Mental Health and the release of the unprecedented Surgeon General’s Report on Mental Health last year, both of which were initiated by Tipper Gore, the President’s Mental Health Advisor.
The meeting was attended by First Lady Hillary Rodham Clinton, Secretary of Health and Human Services Donna Shalala (who, just the previous week had received an Award from APA at the State Leadership Conference), Surgeon General David Satcher, National Institute of Mental Health (NIMH) Director Steven Hyman, Food and Drug Administration (FDA) Commissioner Jane Henney, Assistant Secretary of Education, Office of Special Education and Rehabilitative Services, Judith Huemann, and governance representatives from 14 major mental health, health care, educational and consumer organizations, including, in addition to APA, the American Federation of Teachers, The Federation of Families for Children’s Mental health, The National Mental Health Association, Children and Adults with Attention-Deficit/Hyperactivity Disorder, The Council for Exceptional Children, Children’s Defense Fund, The National Association of School Psychologists, The National Association of School Nurses, The National Association of School Social Workers, the American Academy of Pediatrics, the American Academy of Family Physicians, the American Academy of Child and Adolescent Psychiatry, and the American Psychiatric Association.
The purpose of the meeting was to launch a public-private collaboration to ensure that children with emotional and behavioral conditions are appropriately diagnosed, treated, monitored, and managed by qualified health care professionals, parents and educators. The meeting began with a roundtable discussion of the issues held in the Map Room (the site where President Franklin Roosevelt developed the U.S. strategy for WWII), followed by a press conference in the Roosevelt Room, at which First Lady Hillary Rodham Clinton outlined four new federal initiatives. These include:
(I have included as an Appendix additional information on these initiatives handed out by the White House at the meeting.)
The roundtable discussion was very lively yet quite congenial, with most participants pretty much on the same page. This was undoubtedly due to the compistion of the group, which was largely mental health, educational, and parents groups. There appeared to be consensus that proper diagnosis by qualified professionals was essential; that behavioral, family, and school interventions needed to be tried first in many cases before putting young children on medication, and that these psychosocial interventions should be continued even if the decision is made to do pharmacological treatment; that team work between the home, the school, and the professionals is essential; that much more research is needed; that current "community practice" falls far short of what we know to be good care; and that there was large access issue – e.g, although some children may be over-medicated, there are many more from the lower SES who are not treated at all.
My comments during the roundtable discussion were as follows: Most of the psychoactive drugs prescribed to children (including young children), whether labeled or off-label, are prescribed by primary care generalists, with minimal specific training in mental health diagnosis and treatment, too-often based on a brief interview (as little as 7 minutes, and with 20-30 minutes all too common) with minimal follow-up (1-2 visits per year), sometimes pressured by harried teachers or frustrated parents, conducted in a cost-conscious managed care context. Hence standard community practice deviates significantly from optimal practice (which may account for the fact that in the Multimodal Treatment Study of Children with ADHD [MTA Cooperative Group, 1999] community practice fared so poorly). In addition, there is an access issue: CMHS estimates that 20% or 13.7 million children have a diagnosable mental disorder, of which only 1/3 receive any mental health care. Hence we need to direct our efforts toward the development of a comprehensive plan to change the current practice. While developing such a plan is beyond the scope of my comments, I would like to suggest that this plan include the following elements:
We must understand more about development in early childhood. In short, in order to diagnose young children’s behavior as abnormal, we need to better understand the variations in normal development. As a foundation for making any decisions about diagnosis or treatment, parents, teachers and professionals need research-based information about child development, including the effects of culture, ethnicity, temperament, family structure and dynamics, and specific stressors on children’s behavior. Psychologists and others have done excellent research on normal growth and development, but continued support for research in this area is needed.
We need better information about appropriate diagnoses for young children. There is little empirical research on diagnostic assessment of very young children. We know little about measuring current behavior in preschoolers or about predicting their future behavior. Even some measures of intelligence, which tend to be more stable than those of behavior, show low correlations between those taken in the preschool years and those taken later in life. Hence diagnoses of preschoolers must be made with great caution and research is urgently needed in the diagnostic assessment of behavioral problems in early childhood.
Psychological and pharmacological interventions with children need equal attention. While pharmacotherapy has been an effective treatment for many children, psychological interventions also have demonstrated efficacy. Parents, teachers and health care practitioners must be better informed about both types of interventions and how they can be used together in "combination therapy" (Sammons & Levant, 1999; indeed the Multimodal Treatment Study of Children with ADHD [MTA Cooperative Group, 1999] found that the very best results were obtained with combination therapy). As part of this educational effort we need to ensure that only qualified professionals conduct mental health diagnosis and treatment. It is of great concern that health care insurance and managed care procedures too often preclude appropriate behavioral interventions in favor of psychotropic medications. This latter point is so important because we know so little about the impact of psychotropic drugs on the young child’s developing brain. We also know very little about the degree to which gains made while taking psychotropic medications are sustained after medication usage is discontinued. For this reason more research is needed on the short and long term effects of medication, psychological interventions, and combination therapy on children, particularly preschoolers.
As always, I welcome your thoughts on this column. You can most easily contact me via email: Rlevant@aol.com
The MTA Cooperative Group (1999). A 14 month randomized clinical trail of treatment strategies for attention-deficit/hyperactivity disrorder. Archives of General Psychiatry, 56, 1073-1086.
Sammons, M., & Levant, R. F. (1999). Combined psychosocial and pharmacological treatments : Introduction. Clinical Psychology in Medical Settings, 6, 1-10
Zito, J. M., Safer, D. J., dosReis, S., Gardner, J. F., Boles, M. & Lynch, F. (2000). Trends in the prescribing of psychotropic medications to preschoolers. Journal of the American Medical Association, 283, 1025-1030.
- The release of a new, easy to understand fact sheet for parents about the treatment of children with emotional and behavioral conditions.
- Funding to the tune of $5 million by NIMH of a study of the effects of psychotropic medication on children under the age of seven.
- The initiation of a process at the FDA to improve pediatric labeling information for young children.
- A national conference on Treatment of Children with Behavioral and Mental Disorders to be held this fall, sponsored by Surgeon General David Satcher. In response to concerns expressed during the roundtable discussion that many issues needed to be taken up with the health care insurance/managed care and pharmaceutical industries, the First Lady indicated that this conference would also include representatives from these industries. Exactly how a fruitful discussion will take place is at this point not clear.
Appendix: Information on White House Initiatives
INAPPROPRIATE DIAGNOSIS AND TREATMENT OF BEHAVIORAL AND EMOTIONAL CONDITIONS IN CHILDREN HAVE ADVERSE CONSEQUENCES. While progress has been made in diagnosing and treating these conditions, justifiable concerns have been raised about the inappropriate (both over and under) utilization of medications such as Ritalin, clonidine, and Prozac in very young children. Just as important, there is a lack of understanding amongst parents, teachers, and health professionals about the best diagnostic, pharmacological, and behavioral interventions now available. Recent studies published in the Journal of the American Medical Association reviewing selected provider data over a five year period found that:
NEW ACTION TO ENSURE BETTER DIAGNOSIS, TREATMENT, AND MANAGEMENT OF CHILDREN WITH EMOTIONAL AND BEHAVIORAL CONDITIONS. At today’s meeting, the First Lady will announce a series of public and private actions designed to address the challenges posed by children with emotional and behavioral conditions. Federal actions she will outline include:
- Failure to treat emotional and behavioral disorders can have severe life-long consequences. Studies suggest that many children with untreated emotional and behavioral conditions fail to reach their full potential. Untreated mental illness has a negative impact on the developing brain, causing lifelong emotional and social damage. Children with these types of problems are at significantly higher risk for anti-social activities later on than those without behavioral problems. It is evident that an accurate early diagnosis, education, support, and medication, if necessary, can overcome many early problems and help prevent long-term negative behavior.
- The number of preschoolers on anti-depressants increased by over 200 percent. The number of children on tri-cyclic anti-depressants, often used to control bedwetting, increased 220 percent over five years. Given the difficulty of diagnosing depression in children this young and the relative normalcy of bedwetting in children this young, the increase in the use of this drug in preschoolers is troubling.
- The number of children under the age of five on clonidine increased exponentially. The 28-fold increase in children using clonidine, used in children with attention deficit disorders or children exhibiting disruptive behaviors, is notable, as the increase in its use occurred without research ensuring that it is safe and effective. Adverse effects, including rapid or irregular heartbeat and fainting, have been reported in children using the drug with other medications for attention-deficit disorder.
- The number of children aged two through four taking stimulants such as Ritalin more than doubled. The vast majority of preschoolers taking stimulants were on Ritalin to treat attention deficit disorders – as many as ninety percent in one study – and the number of these children increased by 150 percent over a five year period. Although there are a disproportionate number of boys taking medication for attention deficit disorders as opposed to girls (a ratio of 4:1), the number of girls being diagnosed and treated with attention deficit disorders increased over this time period; in one study, the proportion of girls taking stimulants increased by 60 percent.
- Many children are inappropriately diagnosed and treated. Studies indicate wide geographic and ethnic variation in the numbers of children receiving psychotropic drugs such as Ritalin. In one study, the percentage of children receiving Ritalin was as high as 10 percent – 2 to 3 times as high as the expected rate of attention deficit disorder. The percentage of boys receiving medication for attention deficit disorder in the fifth grade was as high as 20 percent. Other research indicates racial variations as well; a study of one Maryland HMO indicated that African-American children were 2.5 times less likely to receive Ritalin as white children. This wide variation in treatment patterns supports the need for more research to determine appropriate treatment protocols for children with emotional and behavioral disorders. Although little is known about the effects of over medication on children, unnecessary use of these medications can have adverse effects on the developing brain and the emotional and social development of young children.
- More research is necessary to ensure informed treatment decisions. Many of the drugs being prescribed for very young children have not been tested in children under the age of 16; few have been tested for children under the age of six. More research is necessary to ensure that providers and parents have necessary information, especially about the impact of medication on brain development, to make appropriate treatment decisions.
- Initiation of a process for the development of pediatric labeling information for psychotropic drugs used in young children. Today, FDA will announce that it will work with its Pediatric Advisory Committee to design research protocols that will be used to develop new pediatric dosage information to be included on the labels of drugs such as methylphenidate, clonidine, and other drugs increasingly used in young children. These studies, which will begin after national research goals have been identified, will be designed to address ethical and scientific issues associated with the studies on this population.
- Announcement that NIMH will dedicate more than $5 million to research on attention deficit disorder and Ritalin use in preschoolers. Today, the National Institute of Mental Health announced that it plans to invest more than $5 million in research on the use of medication to treat attention deficit disorder in preschool children. This research will assemble the latest information on the use of these drugs and identify discrepancies between clinical practice and current scientific evidence.
- New efforts to provide parents with up-to-date information on the appropriate diagnosis and treatment of children with emotional and behavioral conditions. This week, NIMH will release a new fact sheet to help parents of children with behavioral and emotional conditions understand the treatment options available and guide them in their decision-making process. This fact sheet includes easy to understand information on when to include medication in an overall treatment plan; how to help determine if a child’s problems are serious; and when and how to get help. The Department of Education will also release an information kit on ways for teachers and parents of children with attention deficit disorders.
- A national Conference on the Diagnosis and Treatment of Children with Behavioral and Mental Disorders. This fall, the Office of the Surgeon General, together with NIMH and FDA, will coordinate a Conference on Treatment of Children with Behavioral and Mental Conditions. This national conference, which will build on the success of the recent White House Conference on Mental Health chaired by Tipper Gore, and the Surgeon General’s Report on Mental Health, will include representatives of provider, consumer advocacy, and education communities. Topics of discussion include: developing research on treatments and services that can be used by providers nationwide; how best to determine the efficacy and safety of medications in young children; and ways to address the difficulty of accurate diagnosis in preschoolers. The Surgeon General will also release a report on children’s mental health by the end of the year.
Ronald F. Levant, Ed.D., A.B.P.P., is Recording Secretary of the American
Psychological Association. He was the Chair of the APA Committee for the
Advancement of Professional Practice (CAPP) from 1993-95, a member of the
Board of Directors of Division 42 (1991-94), and a member of the APA Board of
Directors (1995-97). He is Dean, Center for Psychological Studies, Nova
Southeastern University, Fort Lauderdale, FL.Reprinted with permission of the author.
CURRENT TOPICS IN PSYCHOLOGY Surgeon General's Conference (9-2000)