adolescence (Akiskal, 1983; Klein et al., 1997). The
child or adolescent is depressed for most of the day, on
most days, and symptoms continue for several years.
The average duration of a dysthymic period in children
and adolescents is about 4 years (Kovacs et al., 1997a).
Sometimes children are depressed for so long that they
do not recognize their mood as out of the ordinary and
thus may not complain of feeling depressed. Seventy
percent of children and adolescents with dysthymia
eventually experience an episode of major depression®
(Kovacs et al., 1994). When a combination of major
depression and dysthymia occurs, the condition is
referred to as double depression.

Bipolar disorder is a mood disorder in which
episodes of mania alternate with episodes of
depression. Frequently, the condition begins in
adolescence. The first manifestation of bipolar illness
is usually a depressive episode. The first manic features
may not occur for months or even years thereafter, or
may occur either during the first depressive illness or
later, after a symptom-free period (Strober et al., 1995).

The clinical problems of mania are very different

from those of depression. Adolescents with mania or

hypomania feel energetic, confident, and special; they
usually have difficulty sleeping but do not tire; and
they talk a great deal, often speaking very rapidly or
loudly. They may complain that their thoughts are
racing. They may do schoolwork quickly and creatively
but in a disorganized, chaotic fashion. When manic,
adolescents may have exaggerated or even delusional
ideas about their capabilities and importance, may
become overconfident, and may be “fresh” and
uninhibited with others; they start numerous projects
that they do not finish and may engage in reckless or
risky behavior, such as fast driving or unsafe sex.
Sexual preoccupations are increased and may be
associated with promiscuous behavior.

Reactive depression, also known as adjustment
disorder with depressed mood, is the most common
form of mood problem in children and adolescents. In

 

6 Major depression refers to conditions marked by a major
depressive episode, such as major depressive disorder, bipolar
disorder, and related conditions. The word “major” refers to the
number of symptoms. See Chapter 4 for DSM-IV diagnostic criteria.

151

Children and Mental Health

children suffering from reactive depression, depressed
feelings are short-lived and usually occur in response to
some adverse experience, such as a rejection, a slight,
a letdown, or a loss. In contrast, children may feel sad
or lethargic and appear preoccupied for periods as short
as a few hours or as long as 2 weeks. However, mood
improves with a change in activity or an interesting or
pleasant event. These transient mood swings in reaction
to minor environmental adversities are not regarded as
a form of mental disorder.

Conditions Associated Wjth Depression
Roughly two-thirds of children and adolescents with
major depressive disorder also have another mental
disorder (Angold & Costello, 1993; Anderson &
McGee, 1994). The most commonly associated
disorders are dysthymia (see above), an anxiety
disorder, a disruptive or antisocial disorder, or a
substance abuse disorder. When more than one
diagnosis is present, depression is more likely to begin
after the onset of the accompanying disorder, except
when that disorder is substance abuse (Biederman et
al., 1995; Kessler & Walters, 1998). This suggests that,
in some cases, depression may arise in response to the
associated disorder. In other instances, such as the co-
occurrence of conduct disorder and depression, the two
may arise independently in response to inadequate
maternal supervision and control, raising the possibility
that parental behavior may be a risk factor for both
conditions (Downey & Coyne, 1990; Rutter &
Sandberg, 1992; Harrington, 1994).

Prevalence

Major Depression

Population studies show that at any one time between
10 and 15 percent of the child and adolescent
population has some symptoms of depression (Smucker
et al., 1986). The prevalence of the full-fledged
diagnosis of major depression among all children ages
9 to 17 has been estimated at 5 percent (Shaffer et al.,
1996c). Estimates of 1-year prevalence in children
range from 0.4 and 2.5 percent and in adolescents,
considerably higher (in some studies, as high as 8.3
Mental Health: A Report of the Surgeon General

percent) (Anderson & McGee, 1994; Lewinsohn et al.,
1994a; Garrison et al., 1997; Kessler & Walters, 1998).
For purposes of comparison, 1-year prevalence in
adults is about 5.3 percent (Murphy et al., 1988;
Rorsman et al., 1990; Regier et al., 1993).

Dysthymic Disorder

The prevalence of dysthymic disorder in adolescents
has been estimated at around 3 percent (Garrison et al.,
1997). Before puberty, major depressive disorder and
dysthymic disorder are equally common in boys and
girls (Rutter, 1986). But after age 15, depression is

twice as common in girls and women as in boys and

men (Weissman & Klerman, 1977; McGee et al., 1990;
Linehan et al., 1993).

Suicide

In 1996, the age-specific mortality rate from suicide
was 1.6 per 100,000 for 10- to 14-year-olds, 9.5 per
100,000 for 15- to 19-year-olds (i.e., about six times
higher than in the younger age group; in this age group,
boys are about four times as likely to commit suicide
than are girls, while girls are twice as likely to attempt
suicide), compared with 13.6 per 100,000 for 20- to 24-
year-olds (CDC, 1999). Hispanic high school ‘students
are more likely than other students to attempt suicide
(CDC, 1998). There have been some notable changes
in these rates over the past few decades: since the early
1960s, the reported suicide rate among 15- to 19-year-
old males increased threefold but remained stable
among females in that age group and among 10- to 14-
year-olds (National Center for Health Statistics, 1998);
the rate among white adolescent males reached a peak
in the late 1980s (18.0 per 100,000 in 1986) and has
since declined somewhat (16.0 per 100,000 in 1997),
whereas among African American male adolescents,
the rate increased substantially in the same period
(from 7.1 per 100,000 in 1986 to 11.4 per 100,000 in
1997. (CDC, 1998). From 1979 to 1992, the Native
American male adolescent and young adult suicide rate
in Indian Health Service Areas was the highest in the

Nation, with a suicide rate of 62.0 per 100,000
. (Wallace et al., 1996).

152

It has been proposed that the rise in suicidal
behavior among teenage boys results from increased
availability of firearms (Boyd, 1983; Boyd & Moscicki,
1986; Brent et al., 1987; Brent et al. 1991) and
increased substance abuse in the youth population
(Shaffer et al., 1996c; Birckmayer & Hemenway,
1999). However, although the rate of suicide by
firearms increased more than suicide by other methods
(Boyd, 1983; Boyd & Moscicki, 1986; Brent et al.,
1987), suicide rates also increased markedly in many
other countries in Europe, in Australia, and in New
Zealand, where suicide by firearms is rare.

Course and Natural History
Most children with depression experience a recurrence.
Twenty to 40 percent of depressed children relapse
within 2 years, and 70 percent will do so by adulthood
(Garber et al., 1988; Velez et al., 1989; Harrington et
al., 1990; Fleming et al., 1993; Kovacs et al., 1994;
Lewinsohn et al., 1994a; Garrison et al., 1997). The
reasons for relapse are not known, but there is some
evidence that experiencing a depression leaves behind
psychological “scars” that may increase vulnerability
throughout early life (see below).

The age of first onset of depression appears to play
a role in its course. Children who first become
depressed before puberty are at risk for some form of
mental disorder in adulthood, while teenagers who first
become depressed after puberty are most likely to
experience another episode of depression (Harrington
et al., 1990; McCracken, 1992a; Lewinsohn et al.,
1994a, 1994b; Rao et al., 1995). These differences in
outcome suggest that different mechanisms may lead to
superficially similar but inherently different clinical
conditions. Factors that worsen the prognosis for
depressed children and adolescents include depression
occurring in the context of conduct disorder (Harring-
ton et al., 1990; Asarnow et al., 1994) and living in
conflict-ridden families (Asarnow et al., 1994).
Children and particularly adolescents who suffer from
depression are at much greater risk of committing
suicide than are children without depression (Shaffer et
al., 1996b).
The prognosis for dysthymia (Klein et al., 1997a)
is unfavorable, with most patients continuing to feel
depressed and to have social difficulties even after they
have apparently recovered. The prognosis for double
depressives (major depressive disorder plus dysthymia)
is worse than that for either condition alone (Kovacs et
al., 1994).

Twenty to 40 percent of adolescents with depres-
sion eventually develop bipolar disorder. Factors that
predict later bipolar disorder include young age at the
time of the first depressive episode, psychotic features
in the initial depression, a family history of bipolar
illness, and symptoms of hypomania developing during
treatment with antidepressant drugs (Garber et al.,
1988; Strober et al., 1993).

Causes

The precise causes of depression are not known.
Extensive research on adults with depression generally
points to both biological and psychosocial factors
(Kendler, 1995). However, there has been substantially
less research on the causes of depression in children.
and adolescents. Further discussion of the risk factors
for depression can be found in Chapter 4, as well as the

preceding Overview of Risk Factors and. Prevention
section.

Family and Genetic Factors

Much of the research on children and adolescents with
depression has been conducted with those who attend
mental health clinics and with patients who tend to
have the more severe and recurrent forms of
depression, and thus they may not be representative of
all children and adolescents with depression. With this
limitation, research has shown that between 20 and 50
percent of depressed children and adolescents have a
family history of depression (Puig-Antich et al., 1989;
Todd et al., 1993; Williamson et al., 1995; Kovacs,
1997b). Family research has found that children of
depressed parents are more than three times as likely as
children with nondepressed parents to experience a
depressive disorder (see Birmaher et al., 1996a, 1996b
for a review). They also are more vulnerable to other
mental and somatic disorders (Downey & Coyne,

153

Children and Mental Health

1990). Conversely, estimates of the proportion of
depressed parents who have a depressed child or
adolescent vary from approximately one in six to just
under a half (Hammen et al., 1990). It is not clear
whether the relationship between parent and childhood
depression derives from genetic factors, or whether
depressed parents create an environment that increases
the likelihood of a mental disorder developing in their
children (see below).

Gender Differences

One reason advanced to explajn the greater prevalence
of depression in adolescent girls (see above) is that they
are more socially oriented, more dependent on positive
social relationships, and more vulnerable to losses of
social relationships than are boys (Allgood-Merten et
al., 1990). This would increase their vulnerability to the
interpersonal stresses that are common in teenagers.
There is also evidence that the methods girls use to
cope with stress may entail less denial and more
focused and repetitive thinking about the event (Nolen-
Hoeksema & Girgus, 1994). The higher prevalence,
therefore, could be a result of greater vulnerability,
combined with coping mechanisms different than those
of boys.

Biological Factors

Some of the core symptoms of depression, such as
changes in appetite and sleep patterns, are related to the
functions of the hypothalamus. The hypothalamus is, in
turn, closely tied to the function of the pituitary gland.
Abnormalities of pituitary function, such as increased
rates of circulating cortisol and hypo- or hyperthyroid-
ism, are well established features of depression in
adults (Goodwin & Jamison, 1990). However, far less
research has been done in this area among children and
adolescents (see Birmaher et al., 1996a, 1996b fora
review). It is in the ‘neuroendocrine area that most
research has been done on child and adolescent
depression (see Birmaher et al., 1996a, b). In suicidal
adults dysregulation of the serotonergic system is
common (Mann, 1998; Pine et al., 1995), making them
typically impulsive, intense, and given to extreme
reactions. However, little is known about the
Mental Health: A Report of the Surgeon General

association between abnormal serotonin metabolism
and suicidal behavior in children and adolescents.

Cognitive Factors

For over two decades there has been considerable
interest in the relationship between a particular
“mindset” or approach to perceiving external events
and a predisposition to depression. The mindset in
question is known as a pessimistic “attribution bias”
(Abramson et al., 1978; Beck, 1987; Hops et al., 1990).
A person with this mindset is one who readily assumes
personal blame for negative events (“All the problems
in the family are my fault”), who expects that one

negative experience is part of a pattern of many other

negative events (“Everything I do is wrong”), and who
believes that a currently negative situation will endure
permanently (“Nothing I do is going to make anything
better”). Such pessimistic individuals take a
characteristically negative view of positive events (i.e.,
that they are a result of someone else’s effort, that they
are isolated events, and that they are unlikely to recur).
Individuals with this mindset react more passively,
helplessly, and ineffectively to negative events than
those without a pessimistic mindset (Seligman, 1975).

There is uncertainty over whether this mindset
precedes depression (and represents a permanent style
of thinking as part of an individual’s personality), is a
manifestation of depression that is only present when
the patient is depressed, and/or is a consequence or
“scar” of a previous, perhaps unnoticed, depressive
episode (Lewinsohn et al., 1981). This pessimistic
mode of thinking does not occur in children under age
5, which could be one of the reasons why depression
and suicide are rare in early childhood (Rholes et al.,
1980; Rotenberg, 1982).

There is evidence that children and adolescents
who previously have been depressed may learn, during
their depression, to interpret events in this fashion. This
may make them prone to react similarly to negative
events experienced after recovery, which could be one
of the reasons why previously depressed children and
adolescents are at continuing risk for depression
(Nolen-Hoeksema et al., 1993).

Perceptions of hopelessness, negative views about
one’s own competence, poor self- esteem, a sense of
responsibility for negative events, and the immutability
of these distorted attributions may contribute to the
hopelessness that has been repeatedly found to be
associated with suicidality (Overholser et al., 1995).

Risk Factors for Suicide and Suicidal Behavior

There is good evidence that over 90 percent of children
and adolescents who commit suicide have a mental
disorder before their death (Shaffer & Craft, 1999). The
most common disorders that predispose to suicide are
some form of mood disorder, with or without
alcoholism or other substance abuse problem, and/or
certain forms of anxiety disorder (Shaffer et al.,
1996b). Psychological postmortem studies also show
that a significant proportion of suicide victims suffered
from an anxiety disorder at the time of their death, but
the number of victims has been too small to yield
precise odds ratios for the calculation of an effect.
Although the rate of suicide is greatly increased in

_ schizophrenia, because of its rarity, it accounts for very

154

few suicides in the child and adolescent age group.

Controlled studies of completed suicide suggest
similar risk factors for boys and girls (Shafii et al.,
1985; Brent et al., 1988; Groholt et al., 1997), but with
marked differences in their relative importance (Shaffer
et al., 1996c).

Among girls, the most significant risk factor is the
presence of major depression, which, in some studies,
increases the risk of suicide 12-fold. The next most
important risk factor is a previous suicide attempt,
which increases the risk approximately threefold.
Among boys, a previous suicide attempt is the most
potent predictor, increasing the rate over 30-fold. It is
followed by depression (increasing the rate by about
12-fold), disruptive behavior (increasing the rate by
twofold), and substance abuse (increasing the rate by
just under twofold) (Shaffer et al., 1996c).

Stressful life events often precede a suicide and/or
suicide attempt (de Wilde et al., 1992; Gould et al.,
1996). As indicated earlier, these stressful life events
include getting into trouble at school or with a law
enforcement agency; a ruptured relationship with a
boyfriend or a girlfriend; or a fight among friends.’
They are rarely a sufficient cause of suicide, but they
can be precipitating factors in young people. —

Controlled studies (Gould et al., 1996; Hollis,
1996) indicate that low levels of communication
between parents and children may act as a significant
risk factor. While family discord, lack of family
warmth, and disturbed parent-child relationship are
commonly associated with child and adolescent
psychopathology (violent behavior, mood disorder,
alcohol and substance abuse disorders) (Brent et al.,
1994; Pfeffer et al., 1994), these factors do not play a
specific role in suicide (Gould et al., 1998).

Evidence has accumulated that supports the
observation that suicide can be facilitated in vulnerable
teens by exposure to real or fictional accounts of
suicide (Velting & Gould, 1997), including media
coverage of suicide, such as intensive reporting of the
suicide of a celebrity, or the fictional representation of
a suicide in a popular movie or TV show. The risk is

especially high in the young, and it lasts for several

weeks (Gould & Shaffer, 1986; Phillips et al., 1989).
The suicide of a prominent person reported on
television or in the newspaper or exposure to some
sympathetic fictional representation of suicide may also
tip the balance and make the at-risk individual feel that
suicide is a reasonable, acceptable, and in some
instances even heroic, decision (Gould & Shaffer,
1986).

The phenomenon of suicide clusters is presumed to
be related to imitation (Davidson, 1989). Suicide
clusters nearly always involve previously disturbed
young people who knew about each other’s death but
rarely knew the other victims personally (Gould,
personal communication, 1999).

 

7 The relationship between sexual orientation, depression, and
suicidal thoughts and behavior is not well understood, Several
studies suggest a link (Faullener & Cranston, 1998; Garofolo et al.,
1998; Garofolo et al., 1999).

Children and Mental Health

Consequences

Both major depressive disorder and dysthymic disorder
are inevitably associated with personal distress, and if
they last a long time or occur repeatedly, they can lead
to a circumscribed life with fewer friends and sources
of support, more stress, and missed educational and job
opportunities (Klein et al., 1997). The psychological
scars of depression include an enduring pessimistic
style of interpreting events, which may increase the risk

_ of further depressive episodes. Impairment is greater

155

for those with dysthymic disorder than for those with
major depression (Klein et dl., 1997a), presumably
because of the longer duration of depression in
dysthymic disorder, which is also a prime risk factor
for suicide. In a 10- to 15-year followup study of 73
adolescents diagnosed with major depression, 7 percent
of the adolescents had committed suicide sometime
later. The depressed adolescents were five times more
likely to have attempted suicide as well, compared with
a control group of age peers without depression
(Weissman et al., 1999).

Treatment

Depression

Psychosocial Interventions

To be deemed effective and approved by the American
Psychological Association, treatments for mental
disorders have to meet very strict criteria. While
interpersonal therapy and systemic family therapy show
promise, they have not been studied sufficiently to
evaluate their effectiveness by these standards.
However, in acomprehensive review article (Kaslow &
Thompson, 1998) that evaluated interventions for
depression in children and adolescents against the
American Psychological Association Task Force
criteria, two forms of cognitive-behavioral therapy
(CBT) were found to be “probably effective
treatments,” although none of the interventions for
depression were deemed, as yet, to meet the
Association’s higher standard for a well-established
intervention.
Mental Health: A Report of the Surgeon General

In studies that focused on relieving symptoms of
depression in preadolescents, only one form of CBT
met the criteria for a probably effective intervention. In
the first study, the relative efficacy of two types of
CBT—12-session group interventions based on either
self-control therapy or behavior-solving therapy—were
compared with a “waiting list” control group (Stark et
al., 1987). Children responded to both CBT inter-
ventions with fewer symptoms of depression and
anxiety, whereas the waiting list group exhibited
minimal change. Because improvement was greatest
with self-control therapy, this intervention was

compared in a later study with a traditional counseling.

condition. Self-control therapy, enhanced by doubling
the number of sessions, entailed social skills training,
assertiveness training, relaxation training and imagery,
and cognitive restructuring. Monthly family meetings
were also added to both the experimental and control
conditions. Children receiving self-control therapy
reported fewer symptoms at 7-month followup (Stark
et al., 1991). .

Among the numerous studies of adolescents
reviewed by Kaslow and Thomson (1998), one form of
CBT—coping skills—was judged probably effi-
cacious. This intervention, based on the “Coping with
Depression” course, was developed originally in
Oregon for adults by Lewinsohn and colleagues
(Lewinsohn et al., 1996) and adapted by Clarke and
colleagues (1992) for school-based programs to treat
adolescent depression. Compared with controls on the
waiting list, adolescents who received CBT had lower
rates of depression, less self-reported depression,
improvement in cognitions, and increased activity
levels (Lewinsohn et al., 1990, 1996). To achieve well-
established status, as defined by the American Psycho-
logical Association Task Force, the intervention has to
be studied by another team of investigators—which has
not as yet been done.

156

Pharmacological Treatment

Prior to 1996, the medications of choice for major
depression in children and adolescents were the
tricyclic antidepressants, a choice based on numerous
studies in adults. However, 13 distinct trials in children
and adolescents failed to demonstrate the efficacy of
tricyclic antidepressants for younger ages. Tricyclic
antidepressants also have a higher risk of toxicity than
selective serotonin reuptake inhibitors (SSRIs) (Walsh
et al., 1994; Kutcher, 1998). The current consensus is
that tricyclic medications are not the medication of
choice for depressed childrefi and adolescents
(Eisenberg, 1996; Fisher & Fisher, 1996).

_ Recent research indicates that young people with
depressive disorders may respond more favorably to
SSRIs than to tricyclic antidepressants. The first SSRI
tested in children and adolescents was fluoxetine. In a
study of 96 outpatients over 8 weeks, 56 percent
receiving fluoxetine and 33 percent receiving placebo
were “much” or “very much” improved on the Clinical
Global Improvement Scale. Benefits were comparable
across age groups. Complete symptom remission
occurred for 31 percent of fluoxetine-treated patients
compared with 23 percent of placebo-treated patients
(Emslie et al., 1997). A recent open trial of fluoxetine
for adolescents hospitalized for treatment of major
depression found it to decrease depression scores more
effectively than imipramine, a tricyclic antidepressant
(Strober et al., 1999), with the further advantage that
fluoxetine was well tolerated.

The safety of a second SSRI, paroxetine, was
demonstrated in a multicenter double-blind placebo-
controlled trial. Paroxetine was compared with
imipramine and placebo in 275 adolescents who met
the DSM-IV criteria for major depression. Preliminary
results indicate that, mostly because of side effects,
one-third of imipramine patients withdrew from the
study, a proportion significantly higher than that for
paroxetine (10 percent) and placebo (7 percent)
(Wagner et al., 1998). One of the co-investigators of
this study noted that paroxetine’ s efficacy was superior
to that of imipramine and placebo on the Clinical
Global Improvement Scale (Graham Emslie, personal
communication, October 1998). However, final
conclusions about the benefit of this second SSRI must
await publication of the outcomes of this multicenter
study.

In summary, psychosocial interventions for
depressed children and adolescents indicate great
promise, with several types of cognitive-behavioral
therapy for the child or adolescent leading the way.
With respect to pharmacotherapy, new studies attest to
the safety and efficacy of two SSRIs. These promising
findings are being extended in the recently begun
NIMH-funded Treatment of Adolescents with
Depression study. .

Bipolar Disorder

Pharmacological Treatment
The treatment of bipolar disorder entails treating
symptoms of both depression and mania. For decades,

lithium has been the well-researched mainstay

treatment for mania in adults. Mania in bipolar disorder
of children is also treated with lithium, although the
relevant research on children lags behind that on adults.
Only in recent years have researchers begun to study
lithium in children and adolescents, with good clinical
response. Open trials of lithium were conducted in the
late 1980s (Varanka et al., 1988; Strober et al., 1990).
More recently, lithium proved to be more effective than
placebo in treating adolescents who were bipolar and
substance dependent (Geller et al., 1998).

Children experience the same safety problems with
lithium as do adults: toxicity and impairment of renal
and thyroid functioning (Geller & Luby, 1997).
Lithium is therefore not recommended for families
unable to keep regular appointments that would ensure
monitoring of serum lithium levels and of adverse
events. Patients who discontinue taking the drug have
a high relapse rate (Strober et al., 1990).

As yet, there are no controlled studies on a number
of other psychotropic agents also used clinically in
children and adolescents with bipolar disorder,

157

Children and Mental Health

including valproate, carbamazepine, methylphenidate,
and low-dose chlorpromazine (Campbell & Cueva,
1995; Geller & Luby, 1997).

Suicide

Psychotherapeutic Treatments

Suicidal children and adolescents report feelings of
intense emotional distress involving depression, anger,
anxiety, hopelessness, and worthlessness and an
inability to change problematic, frustrating
circumstances or to find a solution to their problems
(Kienhorst et al., 1995; Ohring et al., 1996). They feel
so distraught that they often respond impulsively to
their despair. Psychotherapeutic techniques aim to
decrease such intolerable feelings and thoughts and to
re-orient the cognitive and emotional perspectives of
the suicidal child or adolescent (Kernberg, 1994;
Spirito, 1997).

Cognitive-behavioral therapy (CBT) may be a
useful intervention, considering that suicidal children
and adolescents often experience negative cognitions
about themselves, their environment, and their futures.
Recent research suggests that CBT may be more
effective than systemic behavior family therapy or
individual nondirective supportive therapy in reducing
depressive symptoms associated with suicidal ideation
(Brent et al., 1997). Such treatment can focus on re-
attribution of precipitating issues for suicidal behavior
and enable the suicidal child or adolescent to rank
stresses and to consider avenues of problem-solving
(Rotheram-Borus et al., 1994; Brent et al., 1997;
Spirito, 1997).

Interpersonal conflicts are important stresses
related to the risk imparted by poor social adjustment
of potentially suicidal children and adolescents.
Treatment of interpersonal strife may significantly
reduce suicidal risk. Recent research into the efficacy
of interpersonal psychotherapy of depressed
adolescents suggests beneficial effects (Kaslow &
Thompson, 1998); it is a treatment that may be
modified to address the risk factor issues related to
interpersonal loss, conflicts, and need for restitution
Mental Health: A Report of the Surgeon General

often reported by children and adolescents with suicidal
tendencies.

A significant class of risk factors for suicide
involves family discord, which is characterized by poor
communication, disagreements, and lack of cohesive
values and goals and of common activities (de Long,
1992; Miller et al., 1992; Wagner, 1997). Suicidal
children and adolescents often feel that they are
isolated within the family, exhibit problems in
independence, and view themselves as expendable to
the family, a perception that is a motivating force for
self-annihilation (Sabbath, 1969; Pfeffer, 1986; Miller
et al., 1992). Family intervention with suicidal children
and adolescents is an important method to decrease
such problems and to enhance effective family
problem-solving and conflict resolution, so that blame
is not directed toward the suicidal child or adolescent.
Cognitive-behavioral approaches with suicidal children
and adolescents and their families aim to reframe their
understanding of family problems, alter the family style
of maladaptive problem-solving techniques, and
encourage positive family interactions (Rotheram-
Borus et al., 1994). Time-limited home-based
intervention to reduce suicidal ideation in children and
adolescents and to improve family functioning has been
reported to have limited efficacy for children and
adolescents without major depressive disorder
(Harrington et al., 1998). Psychoeducational approach-
es to reduce the extent of expressed anger may be
helpful in lowering risk for suicidal behavior in
children and adolescents (Fristad et al., 1996).

Psychopharmacological Treatments

There is a dearth of research on the efficacy of
pharmacological treatments for reducing suicidal
thoughts or preventing suicide in children and
adolescents. Most of the research on pharmacotherapies
has been conducted in adults. In depressed adults,
SSRIs have been found to reduce suicidal ideation
(Letizia et al., 1996; Wernicke et al., 1997) and to
reduce the frequency of suicide attempts in
nondepressed patients who had previously made at least
one suicide attempt (Verkes et al., 1998). In a

158

controlled trial of the experimental neuroleptic drug
flupenthixol, researchers noted a significant reduction
in suicide-attempt behavior in adults who had made
numerous previous attempts (Montgomery &
Montgomery, 1982). Similar studies have yet to be
conducted on adolescents, although trials of SSRIs in
depressed adolescents suggest that these drugs are
effective for treating depression and for reducing
suicidal ideas also in this age group (Emslie et al.,
1997; Ryan & Varma, 1998). Because placebo-
controlled, methodologically appropriate studies of
tricyclic antidepressants have failed to find a significant
effect in depressed children and adolescents (Ryan &
Varma, 1998), it is reasonable to regard SSRIs as a
first-choice medication in treating depressed suicidal
children and adolescents (also see American Academy
of Child and Adolescent Psychiatry, 1998). In contrast
to tricyclic antidepressants, SSRIs have low lethal
potential when taken in overdoses (Ryan & Varma,
1998).

In adults with major depressive disorder, controlled

research suggests that lithium reduces suicide risk

(Thies-Flechtner et al., 1996), but this has not yet been
demonstrated in children and adolescents. Clinicians
should be cautious about prescribing medications that
may reduce self-control, such as the benzodiazapines,
amphetamines, and phenobarbital. These drugs also
have a high lethal potential if taken in overdose
(Carlsten et al., 1996).

Intervention After a Suicidal Death of a Relative,
Friend, or Acquaintance

The suicidal death of a relative or acquaintance may
increase the risk for childhood or adolescent suicidal
behavior and other dysphoric states (Brent et al., 1992,
1994; Pfeffer et al., 1994, 1997; Clark & Goebel,
1996). Major depression, post-traumatic stress disorder,
and suicidal ideation often occur after the death of an
adolescent friend or acquaintance and relative (Brent et
al., 1992, 1994, 1996).

The goal of the clinician is to decrease the
likelihood that a child or adolescent comes to view the
suicidal behavior of the deceased as a coping strategy
in dealing with adversity (Brent et al., 1997). Psycho-
educational counseling may reduce the risk for suicidal
behavior in these circumstances. Intervention is also
needed to decrease the child’s or teen’s personal sense
of guilt, trauma, and social isolation. This treatment can
be given in individual meetings, at group sessions with
other teens, or in conjunction with parents who need
help to support the adaptive capacities of their children
and adolescents. School professionals sometimes offer
programs of this kind and can be invaluable in
identifying grieving friends who may need help.

Community-Based Suicide Prevention

The principal public health approaches to suicide
prevention have been (1) crisis hotlines*, (2) restric-
tions covering access to suicide methods; (3) media
counseling to minimize imitative suicide; (4) indirect
case-finding by educating potential gate-keepers,
teachers, parents, and peers to identify the warning
signs of an impending suicide; (5) direct case-finding
among high school or college students or among the
patients of primary practitioners by screening for
conditions that place teens at risk for suicide; and (6)
training professionals to improve recognition and
treatment of mood disorders. As discussed below, the
level of evidence for these strategies varies. There is
more support for direct case-finding and improved
recognition and treatment of mood disorders than for
the other strategies.

Crisis Hotlines

Although crisis hotlines are available almost every-
where in the United States, research has failed to show
that they reduce the incidence of suicide (Bleach &
Clairborn, 1974; Apsler & Hodas, 1976; Miller et al.,
1984; Shaffer et al., 1990a, 1990b). Possible reasons
for this are that actively suicidal individuals (males and
individuals with an acute mental disturbance) do not
call hotlines because they are acutely disturbed,
preoccupied, or intent on not being deflected from their
intended course of action (Shaffer et al., 1989).
Hotlines are often busy, and there may be a long wait

 

8 Crisis hotlines are only one of the services offered through crisis
services, a topic discussed subsequently.

Children and Mental Health

before a call is answered, so that callers disconnect; the
advice individuals get on calling a hotline may be
stereotyped, inappropriate for an individual’s needs,
and perceived as unhelpful by the caller. Gender
preferences in seeking help result in the large majority

of callers being females, whereas males are at greatest

risk for suicide. While each of these deficiencies is
potentially modifiable, there have been no systematic
attempts to do so.

Method Restriction

Method preference for suicide varies by gender and by
nationality. In the United Sfates, the most common
method for committing suicide is by firearms, and it has
been suggested that reducing firearms availability will
reduce the incidence of suicide (Moscicki, 1995).
However, a natural experiment in Great Britain
suggests this is unlikely. The favored suicide method,
self-asphyxiation with coal gas, became impossible
after the introduction of natural gas. This resulted in a

- marked but short-lived decline in the suicide rate.

159

Within a decade, the suicide rate had returned to
previous levels, and suicides were being committed by
other means (Farberow, 1985). Although reducing
access to firearms with gun-security laws reduces
accidental deaths from firearms (Cummings et al.,
1997), there is no evidence to date that such laws have
a significant impact on suicides attributable to firearms.

Media Counseling

Even though it appears prudent for reporters and editors
to minimize coverage of youth suicide in general and
attention to individual suicides (O’Carroll & Potter,
1994), there is as yet no evidence that these guidelines,
issued by the Centers for Disease Control and
Prevention, are effective in reducing the suicide rate.

Indirect Case-Finding Through Education
Controlled studies have failed to show that classes for

high school students about suicide increase students’
help-seeking behavior when they are troubled or
depressed (Spirito et al., 1988; Shaffer et al., 1991;
Vieland et al., 1991). On the other hand, there is
evidence that previously suicidal adolescents are upset
Mental Health: A Report of the Surgeon General

by exposure to such classes (Shaffer et al., 1990a,
1990b), even though this does not necessarily lead to a
suicide attempt. Such educational programs seem,
therefore, to be both an ineffective mode of case-
finding and to carry with them an unjustified risk of
activating suicidal thoughts.

Direct Case-Finding

Judging from the high response rate to surveys about
suicidal attempts and ideation (National Center for
Health Statistics, 1997), adolescents will provide
accurate information about their own suicidal thoughts
and/or behaviors if asked directly in a nonthreatening
way. A sensible approach to suicide prevention that
needs further study, therefore, is to screen
systematically 15- to 19-year-olds (the age group at
greatest risk) for (1) previous suicide attempts;
(2) recent, serious, suicidal preoccupations; (3) depres-
sion; or (4) complications of substance or alcohol use.
Clearly, screening programs need to go beyond
identifying a teen with a high-risk profile. Youth
identified in this way should be referred for evaluation
and, if necessary, treatment. Contingency arrangements
may need to be made to assist uninsured adolescents
with help if it is needed (Shaffer & Craft, 1999).

Aggressive Treatment of Mood Disorders
Preliminary and as yet unreplicated studies in Sweden
(Rihmer et al., 1995) suggest that education of primary
medical practitioners to better identify the
characteristics of mood disorders and to treat these
effectively produced a significant reduction in suicide
and suicide-attempt rates. Although the optimal
treatment of adolescent depression is not yet as well
understood as that of adult depression, this is an option
that may prove to be useful.

Air Force Suicide Prevention Program—A

- Community Approach

Combining many of the approaches for adolescents
described above, the Air Force Surgeon General
developed and implemented a community approach to
suicide prevention for older adolescents and young
adults on active duty. The program involved education

on suicide risk awareness, reducing barriers to mental
health services, and stigma-reducing efforts.”

Other Mental Disorders in Children
and Adolescents

Anxiety Disorders

The combined prevalence of the group of disorders
known as anxiety disorders is higher than that of
virtually all other mental disorders of childhood and
adolescence (Costello et al., 1996). The 1-year
prevalence in children ages 9 to 17 is: 13 percent (Table
3-1). This section furnishes brief overviews of several
anxiety disorders: separation anxiety disorder,
generalized anxiety disorder, social phobia, and
obsessive-compulsive disorder. Treatments for all but
the latter are grouped together below.

Separation Anxiety Disorder
Although separation anxieties are normal among
infants and toddlers, they are not appropriate for older

children or adolescents and may represent symptoms of

160

separation anxiety disorder. To reach the diagnostic
threshold for this disorder, the anxiety or fear must
cause distress or affect social, academic, or job
functioning and must last at least 1 month (DSM-IV).
Children with separation anxiety may cling to their
parent and have difficulty falling asleep by themselves
at night. When separated, they may fear that their
parent will be involved in an accident or taken ill, or in
some other way be “lost” to the child forever. Their
need to stay close to their parent or home may make it
difficult for them to attend school or camp, stay at
friends’ houses, or be in a room by themselves. Fear of
separation can lead to dizziness, nausea, or palpitations
(DSM-IV).

Separation anxiety is often associated with
symptoms of depression, such as sadness, withdrawal,
apathy, or difficulty in concentrating, and such children
often fear that they or a family member might die.

 

* In 1995, prior to implementation, suicide rates were almost 16 per
100,000; following 3 years of exposure to the program, suicide rates
fell to below 2 per 100,000 (Air Force Surgeon General, personal
communication, 1999)
Young children experience nightmares or fears at
bedtime.

About 4 percent of children and young adolescents
suffer from separation anxiety disorder (DSM-IV).
Among those who seek treatment, separation anxiety
disorder is equally distributed between boys and girls.
In survey samples, the disorder is more common in
girls (DSM-IV). The disorder may be overdiagnosed in
children and teenagers . who live in dangerous
neighborhoods and have reasonable fears of leaving
home.

The remission rate with separation anxiety disorder
is high. However, there are periods where the illness is
more severe and other times when it remits. Sometimes
the condition lasts many years or is a precursor to panic
disorder with agoraphobia. Older individuals with
separation anxiety disorder may have difficulty moving
or getting married and may, in turn, worry about
separation from their own children and partner.

The cause of separation anxiety disorder is not
known, although some risk factors have been identified.
Affected children tend to come from families that are
very close-knit. The disorder might develop after a
stress such as death or illness in the family or a move.
Trauma, especially physical or sexual assault, might
bring on the disorder (Goenjian et al., 1995). The
disorder sometimes runs in families, but the precise
role of genetic and environmental factors has not been
established. The etiology of anxiety disorders is more
thoroughly discussed in Chapter 4.

Generalized Anxiety Disorder

Children with generalized anxiety disorder (or
overanxious disorder of childhood) worry excessively
about all manner of upcoming events and occurrences.
They worry unduly about their academic performance
or sporting activities, about being on time, or even
about natural disasters such as earthquakes. The worry
persists even when the child is not being judged and
has always performed well in the past. Because of their
anxiety, children may be overly conforming,
perfectionist, or unsure of themselves. They tend to
redo tasks if there are any imperfections. They tend to
seek approval and need constant reassurance about

161

Children and Mental Health

their performance and their anxieties (DSM-IV). The 1-
year prevalence rate for all generalized anxiety disorder
sufferers of all ages is approximately 3 percent. The
lifetime prevalence rate is about 5 percent (DSM-IV).

About half of all adults seeking treatment for this

disorder report that it began in childhood or

adolescence, but the proportion of children with this
disorder who retain the problem into adulthood is
unknown. The remission rate is not thought to be as
high as that of separation anxiety disorder.

Social Phobia
Children with social phobia (also called social anxiety
disorder) have a persistent fear of being embarrassed in
social situations, during a performance, or if they have
to speak in class or in public, get into conversation with
others, or eat, drink, or write in public. Feelings of
anxiety in these situations produce physical reactions:
palpitations, tremors, sweating, diarrhea, blushing,
muscle tension, etc. Sometimes a full-blown panic
attack ensues; sometimes the reaction is much more
mild. Adolescents and adults are able to recognize that
their fear is unreasonable or excessive, although this
recognition does not prevent the fear. Children,
however, might not recognize that their reaction is
excessive, although they may be afraid that others will
notice their anxiety and consider them odd or babyish.

Young children do not articulate their fears, but
may cry, have tantrums, freeze, cling, appear extremely
timid in strange social settings, shrink from contact
with others, stay on the side during social events, and
try to stay close to familiar adults. They may fall
behind in school, avoid school completely, or avoid
social activities among children their age. The
avoidance of the fearful situations or worry preceding
the feared event may last for weeks and interfere with
the individual’ s daily routine, social life, job, or school.
They may find it impossible to speak in social
situations or in the presence of unfamiliar people (for
review of social phobia, see DSM-IV; Black et al.,
1997).

Social phobia is common, the lifetime prevalence
ranging from 3 to 13 percent, depending on how great
the fear is and on how many different situations induce
Mental Health: A Report of the Surgeon General

the anxiety (DSM-IV; Black et al., 1997). In survey
studies, the majority of those with the disorder were
found to be female (DSM-IV). Often the illness is
lifelong, although it may become less severe or
completely remit. Life events may reassure the
individual or exacerbate the anxiety and disorder.

Treatment of Anxiety

Although anxiety disorders are the most common
disorder of youth, there is relatively little research on
the efficacy of psychotherapy (Kendall et al., 1997).
For childhood phobias, contingency management”? was
the only intervention deemed to be well-established,

according to an evaluation by Ollendick and King —

(1998), which applied the American Psychological
Association Task Force criteria (noted earlier). Several
psychotherapies are probably efficacious for treating
phobias: systematic desensitization''; modeling, based
on research by Bandura and colleagues, which
capitalizes on an observational learning technique
(Bandura, 1971; see also Chapter 2); and several cogni-
tive-behavioral therapy (CBT) approaches (Ollendick
& King, 1998).

CBT, as pioneered by Kendall and colleagues
(Kendall et al., 1992; Kendall, 1994), is deemed by the
American Psychological Association Task Force as
probably efficacious. It has four major components:
recognizing anxious feelings, clarifying cognitions in
anxiety-provoking situations,'? developing a plan for
coping, and evaluating the success of coping strategies.
A more recent study in Australia added a parent
component to CBT, which enhanced reduction in post-
treatment anxiety disorder significantly compared with
CBT alone (Barrett et al., 1996). However, none of the
interventions identified above as well-established or

probably efficacious has, for the most part, been tested
in real-world settings.

 

‘© Contingency management attempts to alter behavior by
manipulating its consequences through the behavioral principles of
shaping, positive reinforcement, and extinction.

‘A technique that trains people to “unlearn” fears by presentation
of fearful stimuli along with nonfearful stimuli.

" This refers to understanding how cognitions are being distorted.

162

In addition, psychodynamic treatment to address:
underlying fears and worries can be helpful, and
behavior therapy may reduce the child’s fear of
separation or of going to school; however, the
experimental support for these approaches is limited.

Preliminary research suggests that selective
serotonin reuptake inhibitors may provide effective
treatment of separation anxiety disorder and other ©
anxiety disorders of childhood and adolescence. Two
large-scale randomized controlled trials are currently
being undertaken (Greenhill, 1998a, 1998b). Neither
tricyclic antidepressants nor benzodiazepines have been
shown to be more effective than placebo in children
(Klein et al., 1992; Bernstein et al., 1998).

Obsessive-Compulsive Disorder
Obsessive-compulsive disorder (OCD), which is
classified in DSM-IV as an anxiety disorder, is
characterized by recurrent, time-consuming obsessive
or compulsive behaviors that cause distress and/or
impairment. The obsessions may be repetitive intrusive
images, thoughts, or impulses. Often the compulsive
behaviors, such as hand-washing or cleaning rituals, are
an attempt to displace the obsessive thoughts
(DSM-IV). Estimates of prevalence range from 0.2 to
0.8 percent in children, and up to 2% of adolescents
(Flament et al., 1998).

There is a strong familial component to OCD, and
there is evidence from twin studies of both genetic
susceptibility and environmental influences. If one twin
has OCD, the other twin is more likely to have OCD if
the children are identical twins rather than fraternal
twin pairs. OCD is increased among first-degree
relatives of children with OCD, particularly among
fathers (Lenane et al., 1990). It does not appear that the
child is simply imitating the relative’s behavior,
because children who develop OCD tend to have
symptoms different from those of relatives with the
disease (Leonard et al., 1997). Many adults with either
childhood- or adolescent-onset of OCD show evidence
of abnormalities in a neural network known as the
orbitofrontal-striatal area (Rauch & Savage, 1997;
Grachev et al., 1998).
Recent research suggests that some children with
OCD develop the condition after experiencing one type
of streptococcal infection (Swedo et al., 1995). This
condition is referred to by the acronym PANDAS,
which stands for Pediatric Autoimmune ’ Neuro-
psychiatric Disorders Associated with Streptococcal
infections. Its hallmark is a sudden and abrupt
exacerbation of OCD symptoms after a strep infection.
This form of OCD occurs when the immune system
generates antibodies to the ‘streptococcal bacteria, and
the antibodies cross-react with the basal ganglia’’ of a
susceptible child, provoking OCD (Garvey et al.,
1998). In other words, the cause of this form of OCD
appears to be antibodies directed against the infection
mistakenly attacking a region of the brain and setting
off an inflammatory reaction.

The selective serotonin reuptake inhibitors appear
effective in ameliorating the symptoms of OCD in
children, although more clinical trials have been done
with adults than with children. Several randomized,
controlled trials revealed SSRIs to be effective in
treating children and adolescents with OCD (Flament
et al., 1985; De Veaugh-Geiss et al., 1992; Riddle et al.,
1992, 1998). The appropriate duration of treatment is
still being studied. Side effects are not inconsequential:
dry mouth, somnolence, dizziness, fatigue, tremors, and
constipation occur -at fairly high rates. Cognitive-
behavioral treatments also have been used to treat OCD
(March et al., 1997), but the evidence is not yet
conclusive.

Autism

Autism, the most common of the pervasive develop-
mental disorders (with a prevalence of 10 to 12
children per 10,000 [Bryson & Smith, 1998]), is
characterized by severely compromised ability to
engage in, and by a lack of interest in, social
interactions. It has roots in both structural brain
abnormalities and genetic predispositions, according to
family studies and studies of brain anatomy. The search
for genes that predispose to autism is considered an

 

3 Basal ganglia are groups of neurons responsible for motor and
impulse control, attention, and regulation of-mood and behavior.

Children and Mental Health

extremely high research priority for the National
Institute of Mental Health (NIMH, 1998). Although the
reported association between autism and obstetrical
hazard may be due to genetic factors (Bailey et al.,
1995), there is evidence that several different causes of
toxic or infectious damage to the central nervous
system during early development also may contribute
to autism. Autism has been reported in children with
fetal’ alcohol syndrome (Aronson et al., 1997), in
children who were infected with rubella during

_ pregnancy (Chess et al., 1978), and in children whose

163

mothers took a variety of medications that are known to
damage the fetus (Williams &-Hersh, 1997).

Cognitive deficits in social perception likely result
from abnormalities in neural circuitry. Children with
autism have been studied with several imaging
techniques, but no strongly consistent findings have
emerged, although abnormalities in the cerebellum and
limbic system (Rapin & Katzman, 1998) and larger
brains (Piven, 1997) have been reported. In one small
study (Zilbovicius et al., 1995), evidence of delayed
maturation of the frontal cortex was found. The
evidence for genetic influences include a much greater
concordance in identical than in fraternal twins (Cook,
1998).

Treatment

Because autism is a severe, chronic developmental
disorder, which results in significant lifelong disability,
the goal of treatment is to promote the child’s social
and language development and minimize behaviors that
interfere with the child’s functioning and learning.
Intensive, sustained special education programs and
behavior therapy early in life can increase the ability of
the child with autism to acquire language and ability to
learn. Special education programs in highly structured
environments appear to help the child acquire self-care,
social, and job skills. Only in the past decade have
studies shown positive outcomes for very young
children with autism. Given the severity of the
impairment, high intensity of service needs, and costs
(both human and financial), there has been an ongoing
search for effective treatment.
Mental Health: A Report of the Surgeon General

Thirty years of research demonstrated the efficacy
of applied behavioral methods in reducing inap-
propriate behavior and in increasing communication,
learning, and appropriate social behavior. A well-
designed study of a psychosocial intervention was
carried out by Lovaas and colleagues (Lovaas, 1987;
McEachin et al., 1993). Nineteen children with autism
were treated intensively with behavior therapy for 2
years and compared with two control groups. Followup
of the experimental group in first grade, in late
childhood, and in adolescence found that nearly half
the experimental group but almost none of the children
in the matched control group were able to participate in

regular schooling. Up to this point, a number of other ~

research groups have provided at least a partial
replication of the Lovaas model (see Rogers, 1998).

Several uncontrolled studies of comprehensive
center-based programs have been conducted, focusing
on language development and other developmental
skills. A comprehensive model, Treatment and
Education of Autistic and Related Communication
Handicapped Children (TEACCH), demonstrated short-
term gains for preschoolers with autism who received
daily TEACCH home-teaching sessions, compared with
a matched control group (Ozonoff & Cathcart, 1998).
A review of other comprehensive, centet-based
programs has been conducted, focusing on elements
considered critical to school-based programs, including
minimum hours of service and necessary curricular
components (Dawson & Osterling, 1997).

The antipsychotic drug, haloperidol, has been
shown to be superior to placebo in the treatment of
autism (Perry et al., 1989; Locascio et al., 1991),
although a significant number of children develop
dyskinesias'* as a side effect (Campbell et al., 1997).
Two of the SSRIs, clomipramine (Gordon et al., 1993)
and fluoxetine (McDougle et al., 1996), have been
tested, with positive results, except in young autistic
_ children, in whom clomipramine was not found to be
therapeutic, and who experienced untoward side effects
(Sanchez et al., 1996). Of note, preliminary studies of

 

'4 Dyskinesia is an impairment of voluntary movement, such that it
becomes fragmentary or incomplete.

164

some of the newer antipsychotic drugs suggest that they
may have fewer side effects than conventional
antipsychotics such as haloperidol, but controlled
studies are needed before firm conclusions can be
drawn about any possible advantages in safety and
efficacy over traditional agents.

Disruptive Disorders
Disruptive disorders, such as oppositional defiant
disorder and conduct disorder, are characterized by
antisocial behavior and, as such, seem to be a collection
of behaviors rather than a coherent pattern of mental
dysfunction. These behaviors are also frequently found
in children who suffer from attention-deficit/hyper-
activity disorder, another disruptive disorder, which is
discussed separately in this chapter. Children who
develop the more serious conduct disorders often show
signs of these disorders at an earlier age. Although it is
common fora very young children to snatch something
they want from another child, this kind of behavior may
herald a more generally aggressive behavior and be the
first sign of an emerging oppositional defiant or
conduct disorder if it occurs by the ages of 4 or 5 and
later. However, not every oppositional defiant child
develops conduct disorder, and the difficult behaviors
associated with these conditions often remit.
Oppositional defiant disorder (ODD) is diagnosed
when a child displays a persistent or consistent pattern
of defiance, disobedience, and hostility toward various
authority figures including parents, teachers, and other
adults. ODD is characterized by such problem
behaviors as persistent fighting and arguing, being
touchy or easily annoyed, and deliberately annoying or
being spiteful or vindictive to other people. Children
with ODD may repeatedly lose their temper, argue with
adults, deliberately refuse to comply with requests or
rules of adults, blame others for their own mistakes,
and be repeatedly angry and resentful. Stubbornness
and testing of limits are common. These behaviors
cause significant difficulties with family and friends
and at school or work (DSM-IV; Weiner, 1997).
Oppositional defiant disorder is sometimes a precursor
of conduct disorder (DSM-IV).
In different studies, estimates of the prevalence of
ODD have ranged from 1 to 6 percent, depending on
the population sample and the way the disorder was
evaluated, but not depending on diagnostic criteria.
Rates are lower when impairment criteria are more
strict and when information is obtained from teachers
and parents rather than from the children alone (Shaffer
et al., 1996a). Before puberty, the condition is more
common in boys, but after puberty the rates in both
genders are equal.

In preschool boys, high reactivity, difficulty being
soothed, and high motor activity may indicate risk for
the disorder. Marital discord, disrupted child care with
a succession of different caregivers, and inconsistent,
unsupervised child-rearing may contribute to the
condition.

Children or adolescents with conduct disorder
behave aggressively by fighting, bullying, intimidating,
physically assaulting, sexually coercing, and/or being
cruel to people or animals. Vandalism with deliberate
destruction of property, for example, setting fires or
smashing windows, is common, as are theft; truancy;
early tobacco, alcohol, and substance use and abuse;
and precocious sexual activity. Girls with a conduct
disorder are prone to running away from home and may
become involved in prostitution. The behavior
interferes with performance at school or work, so that
individuals with this disorder rarely perform at the level
predicted by their IQ or age. Their relationships with
peers and adults are often poor. They have higher
injury rates and are prone to school expulsion and
problems with the law. Sexually transmitted diseases
are common. If they have been removed from home,
they may have difficulty staying in an adoptive or
foster family or group home, and this may further
complicate their development. Rates of depression,
suicidal thoughts, suicide attempts, and suicide itself
are all higher in children diagnosed with a conduct
disorder (Shaffer et al., 1996b).

The prevalence of conduct disorder in 9- to 17-
year-olds in the community varies from 1 to 4 percent,
depending on how the disorder is defined (Shaffer et
al., 1996a). Children with an early onset of the
disorder, i.e., onset before age 10, are predominantly

165

Children and Mental Health

male. The disorder appears to be more common in
cities than in rural areas (DSM-IV). Those with early
onset have a worse prognosis and are at higher risk for
adult antisocial personality disorder (DSM-IV; Rutter
& Giller, 1984; Hendren & Mullen, 1997). Between a
quarter and a half of highly antisocial children become
antisocial adults.

The etiology of conduct disorder is not fully
known. Studies of twins and adopted children suggest
that conduct disorder has both biological (including
genetic) and psychosocial components (Hendren &
Mullen, 1997). Social risk factors for conduct disorder
include early maternal rejection, separation from
parents with no adequate alternative caregiver
available, early institutionalization, family neglect,
abuse or violence, parents’ psychiatric illness, parental
marital discord, large family size, crowding, and
poverty (Loeber & Stouthamer-Loeber, 1986). These
factors are thought to lead to a lack of attachment to the
parents or to the family unit and eventually to lack of
regard for the rules and rewards of society (Sampson &
Laub, 1993). Physical risk factors for conduct disorder
include neurological damage caused by birth
complications or low birthweight, attention-
deficit/hyperactivity disorder, fearlessness and stim-
ulation-seeking behavior, learning impairments,
autonomic underarousal, and insensitivity to physical
pain and punishment. A child with both social
deprivation and any of these neurological conditions is
most susceptible to conduct disorder (Raine et al.,
1998).

Since many of the risk factors for conduct disorder
emerge in the first years of life, intervention must begin
very early. Recently, screening instruments have been
developed to enable earlier identification of risk factors
and signs of conduct disorder in young children (Feil et
al., 1995). Studies have shown a correlation between
the behavior and attributes of 3-year-olds and the
aggressive behavior of these children at ages 11 to 13
(Raine et al., 1998). Measurements of aggressive
behaviors have been shown to be stable over time
(Sampson & Laub, 1993). Training parents of high-risk
children how to deal with the children’s demands may
help. Parents may need to be taught to reinforce
Mental Health: A Report of the Surgeon General

appropriate behaviors and not harshly punish
transgressing ones, and encouraged to find ways to
increase the strength of the emotional ties between
parent and child. Working with high-risk children on
social interaction and providing academic help to
reduce rates of school failure can help prevent some of
the negative educational consequences of conduct
disorder (Johnson & Breckenridge, 1982).

Treatment

Several psychosocial interventions can effectively
reduce antisocial behavior in disruptive disorders. A
recent review of psychosocial treatments for children

and adolescents identified 82 studies conducted .

between 1966 and 1995 involving 5,272 youth (Brestan
& Eyberg, 1998). The criterion for inclusion was that
the child was in treatment for conduct problem
behavior, based on displaying a symptom of conduct
disorder or oppositional defiant disorder, rather than on
a DSM diagnosis of either, although children did meet
DSM criteria for one of these conditions in about one-
third of the studies.
By applying criteria established by the American
Psychological Association Task Force (see earlier) to
the 82 studies, two treatments met criteria for well-
established treatment and 10 for probably efficacious
treatment. Two well-established treatments, both di-
rected at training parents, succeeded in reducing
problem behaviors. The two treatments were a parent
training program based on the manual Living With
Children (Bernal et al., 1980) and a videotape modeling
parent training (Spaccarelli et al., 1992). The first
teaches parents to reward desirable behaviors and
ignore or punish deviant behaviors, based on principles
of operant conditioning. The second provides a series
of videotapes covering parent-training lessons, after
which a therapist leads a group discussion of the
videotape lessons. The identification of 12 treatments
as well-established or probably efficacious is very
encouraging because of the potential to intervene
effectively with youth at high risk of poor outcomes. A
new and promising approach for the treatment of
conduct disorder is multisystemic therapy, an intensive

166

home- and family-focused treatment that is described
under Home-Based Services.

Despite strong enthusiasm for improving care for
conduct-disordered youth, there are important groups of
children, specifically girls and ethnic minority
populations, who were not sufficiently represented in
these studies to ensure that the identified treatments
work for them. Other issues raised by Brestan and
Eyberg (1998) are cost-effectiveness, the sufficiency of
a given intervention, effectiveness over time, and the
prevention of relapse.

No drugs have been demonstrated to be
consistently effective in treating conduct disorder,
although four drugs have been tested. Lithium and
methylphenidate have been found (one double-blind
placebo trial each) to reduce aggressiveness effectively
in children with conduct disorder (Campbell et al.,
1995; Klein et al., 1997b), but in two subsequent
studies with the same design, the positive findings for
lithium could not be reproduced (Rifkin et al., 1989;
Klein, 1991). In one of the latter studies, methyl-
phenidate was superior to lithium and placebo. A third
drug, carbamazepine, was found in a pilot study to be
effective, but multiple side effects were also reported
(Kafantaris et al., 1992). The fourth drug, clonidine,
was explored in an open trial, in which 15 of 17
patients showed a significant decrease in aggressive
behavior, but there were also significant side effects
that would require monitoring of cardiovascular and
blood pressure parameters (Kemph et al., 1993).

Substance Use Disorders in Adolescents

Since the early 1990s there has been a “sharp
resurgence” in the misuse of alcohol and other drugs by
adolescents (Johnston et al., 1996). A recent review,
focusing particularly on substance abuse and
dependence, synthesizes research findings of the past
decade (Weinberg et al., 1998). The authors review
epidemiology, course, etiology, treatment, and
prevention and discuss comorbidity with other mental
disorders in adolescents. All of these issues are
important to public health, but none is more relevant to
this report than the co-occurrence of alcohol and other
substance use disorders with other mental disorders in
adolescents.

According to the National Comorbidity Study, 41
to 65 percent of individuals with a lifetime substance
abuse disorder also have a lifetime history of at least
one mental disorder, and about 51 percent of those with
one or more lifetime mental disorders also have a
lifetime history of at least one substance use disorder
(Kessler et al., 1996). The rates are highest in the 15-to
24-year-old age group (Kessler et al., 1994). The cross-
sectional data on association do not permit any
conclusion about causality or clinical prediction
(Kessler et al., 1996), but an appealing theory suggests
that a subgroup of the population abuses drugs in an
effort to self-medicate for the co-occurring mental
disorder. Little is actually known about the role of
mental disorders in increasing the risk of children and
adolescents for misuse of alcohol and other drugs.
Stress appears to play a role in both the process of
addiction and the development of many of the
comorbid conditions. .

The review by Weinberg and colleagues (1998)
provides more detail on epidemiology and assessment
of alcohol and other drug use in adolescents and
describes several effective treatment approaches for
these problems. A meta-analysis and literature review
(Stanton & Shadish, 1997) concluded that family-
oriented therapies were superior to other treatment
approaches and enhanced the effectiveness of other
treatments. Multisystemic family therapy, discussed
elsewhere in this chapter, is effective in reducing
alcohol and other substance use and other severe
behavioral problems among adolescents (Pickrel &
Henggeler, 1996).

Eating Disorders

Eating disorders are serious, sometimes life-
threatening, conditions that tend to be chronic (Herzog
et al., 1999). They usually arise in adolescence and
disproportionately affect females. About 3 percent of
young women have one of the three main eating
disorders: anorexia nervosa, bulimia nervosa, or binge-
eating disorder (Becker et al., 1999). Binge-eating
disorder is a newly recognized condition featuring

167

Children and Mental Health

episodic uncontrolled consumption, without
compensatory activities, such as vomiting or laxative
abuse, to avert weight gain (Devlin, 1996). Bulimia, in
contrast, is marked by both binge eating and by
compensatory activities. Anorexia nervosa is
characterized by low body weight (< 85 percent of
expected weight), intense fear of weight gain, and an
inaccurate perception of body weight or shape
(DSM-IV). Its mean age of onset is 17 years (DSM-IV).

The causes of eating disorders are not known with
precision but are thought to be a combination of
genetic, neurochemical, psychodevelopmental, and
sociocultural factors (Becker et al., 1999; Kaye et al.,
1999). Comorbid mental disorders are exceedingly
common, but interrelationships are poorly understood.
Comorbid disorders include affective disorders
(especially depression), anxiety disorders, substance
abuse, and personality disorders (Herzog et al., 1996).
Anorexia nervosa has the most severe consequence,
with a mortality rate of 0.56 percent per year (or 5.6
percent per decade) (Sullivan, 1995), arate higher than
that of almost all other mental disorders (Herzog et al.,
1996). Mortality is from starvation, suicide, or
electrolyte imbalance (DSM-IV). The mortality rate
from anorexia nervosa is 12 times higher than that for
other young women in the population (Sullivan , 1995).

Treatment of eating disorders entails psychotherapy
and pharmacotherapy, either alone or in combination.
Treatment of comorbid mental disorders also is
important, as is treatment of medical complications.
There are some controlled studies of the efficacy of
specific treatments for adults with bulimia and binge-
eating disorder (Devlin, 1996), but fewer for anorexia
nervosa (Kaye et al., 1999). Controlled studies in
adolescents are rare for any eating disorder (Steiner and
Lock, 1998). Pharmacological studies in young adult
women found conflicting evidence of benefit from
antidepressants for anorexia and some reduction in the
frequency of binge eating and purging with tricyclic
antidepressants, monoamine oxidase inhibitors, and
SSRIs (see Jimerson et al., 1993; J acobi et al., 1997).
Studies mostly of adult women find cognitive-
behavioral therapy and interpersonal therapy to be
effective for bulimia and binge-eating disorder
Mental Health: A Report of the Surgeon General

(Fairburn et al., 1993; Devlin, 1996; Becker et al.,
1999). Clearly, more research is warranted for the
treatment of eating disorders, especially because a
sizable proportion of those with eating disorders have
limited response to treatment (Kaye et al., 1999).

Services Interventions

Treatment Interventions

This section examines the effectiveness of such
treatment interventions as outpatient, partial
hospitalization/day, residential, inpatient treatments,

and medication. Much of the research on their

effectiveness deals with children’s outcomes largely
independent of diagnosis. As noted earlier in this
chapter (see Treatment Strategies), practitioners and
researchers previously shied away from diagnosis
because of the inherent difficulty of making a
diagnosis, concerns about labeling children, and the
limited usefulness of DSM classifications for children.
Each intervention was developed to treat a host of
mental health conditions in children and adolescents.
Each also was delivered in a wide range of settings.
Over time, the combination of interventions and
settings, with the exception of medication, became
conceptualized as “treatments,” which stimulated
research on their effectiveness (Goldman, 1998). They
are not, however, treatments in the conventional sense
of the term because they are less specific than other
treatments with respect to indications, intensity (i.e.,
~ “dose”), and elements of the intervention. There is little
research describing treatment in actual clinical settings.

Outpatient Treatment

The term “outpatient treatment” covers a large variety
of therapeutic approaches, with most falling into the
broad theoretical categories of the psychodynamic,
interpersonal, and behavioral psychotherapy.
Outpatient psychotherapy is the most common form of
treatment for children and adolescents, utilized
annually by an estimated 5 to 10 percent of children
and their families in the United States (Burns et al.,
1998). It is also the most extensively studied
intervention and, with over 300 studies, has the

168

strongest research base (Weisz et al., 1998). Outpatient
therapy is offered to individuals, groups, or families,
usually in a clinic or private office. The duration of
treatment varies from 6 to 12 weekly sessions to a year
or longer. Newer outpatient interventions (e.g., case
management, home-based therapy) that were developed
more recently for youth with severe disorders are
provided with greater frequency (i.e., daily) in the
home, school, or community. Those interventions are
reviewed later in this chapter.

The strongest support for the effectiveness of
outpatient treatment comes fronf a series of meta-
analyses. Meta-analyses are an important type of
research methodology, described in Chapter 1, that
enable one to combine research findings from separate
studies. Nine meta-analyses, published between 1985
and 1995, probed the effectiveness of research on
individual, group, and family therapy for children and
adolescents (Casey & Berman, 1985; Hazelrigg et al.,
1987; Weisz et al., 1987; Kazdin et al., 1990; Baer &
Nietzel, 1991; Grossman & Hughes 1992; Shadish et
al., 1993; Weisz & Weiss, 1993; Weisz et al., 1995).
Although these meta-analyses vary in time period, age
groups, and meta-analytic approach, they were largely
restricted to studies of treatment given in a research
clinical setting, and their findings are relatively
consistent. The major findings indicated that the
improvements with outpatient therapy are greater than
those achieved without treatment; the treatment is
highly effective, as was found in meta-analyses of
adults (Brown, 1987); and the effects of treatment are
similar, whether applied to problems such as anxiety,
depression, or withdrawal (internalizing problems) or
to hyperactivity and aggression (externalizing
problems) (Kazdin, 1996).

Given strong evidence of efficacy for outpatient
treatment, the question of applicability to real-world
settings has been examined. A meta-analysis was
performed on studies of the effectiveness of various
types of outpatient treatment, regardless of whether
their efficacy had been established through research
(Weisz et al., 1995). The researchers were able to
identify only nine studies of treated children in
nonresearch clinical settings where therapy was a
regular service of the clinic and was carried out by
practicing clinicians. Those nine studies demonstrated
little or no effect. Clearly, real-world therapy was
found to be less effective than that provided through a
research protocol. A variety of factors may account for
the gap, including less attention in real-world settings
to careful matching of patients with treatments, less
adherence to a treatment protocol, and less followup
care.

Partial Hospitalization/Day Treatment

Partial hospitalization, also called day treatment and
partial care, has been a growing treatment modality for
youth with mental disorders. Research on partial
hospitalization as an alternative to inpatient treatment
generally finds benefit from a structured daily
environment that allows youth to return home at night
to be with their family and peers.

Partial hospitalization is a specialized and intensive
form of treatment that is less restrictive than inpatient
care but is more intensive than the usual types of
outpatient care (i.e., individual, family, or group

treatment). The most frequently used type of partial

hospitalization is an integrated curriculum combining
education, counseling, and family interventions. The
setting, be it a hospital, school, or clinic, may be tied to
the theoretical orientation of the treatment, which
ranges from psychoanalytic to behavioral. Partial
hospitalization has also been used as a transitional
service after either psychiatric hospitalization or
residential treatment, at the point when the child no
longer needs 24-hour care but is not ready to be
integrated into the school system. It also is used to
prevent institutional placement.

Overall, the research literature points to positive
gains from adolescent use of day treatment, but most of
the studies are uncontrolled. Gains relate to academic
and behavioral improvement; reduction in, or delay of,
hospital and residential placement; and a return to
regular school for about 75 percent of patients (Baenen
et al., 1986; Gabel & Finn, 1986). Day treatment
programs are not being used as frequently as they might
be because third-party payers are reluctant to support
this form of treatment. They claim that the modality is

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Children and Mental Health

ambiguous, that it induces demand among those who
would not otherwise seek treatment, and that its length,
treatment outcomes, and costs are unpredictable (Kiser
et al., 1986). Research’ is needed to address these
issues.

To date, the only controlled study of partial
hospitalization compared outcomes for young children
(ages 5 to 12) with disruptive behavior disorders who
received intensive day treatment with children who
received traditional outpatient treatment services (in
fact, a waiting list control) (Grizenko et al., 1993). The
results at 6 months favored day treatment in reducing
behavior problems, decreasing symptoms, and improv-
ing family functioning.

Findings from uncontrolled studies of partial
hospitalization are informative, although not conclu-
sive. Based on approximately 20 studies, multiple
benefits have been reported even over the long term
(see reviews by Kutash & Rivera, 1996; Grizenko,
1997). In general, child behavior and family
functioning improve following partial hospitalization.
Findings for improved academic achievement are
mixed and possibly suggest that implementation of
school-based models should be considered. About
three-fourths of youth are reintegrated into regular
school, often with the help of special education or other
school- or community-based services. Several
uncontrolled studies found that day treatment could
prevent youth from entering other costly placements
(particularly inpatient and residential treatment
centers), which suggests that partial hospitalization
may reduce overall costs of treatment (Kutash &
Rivera, 1996). Finally, family participation during and
following day treatment is essential to obtaining and
maintaining results (Kutash & Rivera, 1996).

Residential Treatment Centers

Residential treatment centers are the second most
restrictive form of care (next to inpatient
hospitalization) for children with severe mental
disorders. Although used by a relatively small
percentage (8 percent) of treated children, nearly one-
fourth of the national outlay on child mental health is
spent on care in these settings (Burns et al., 1998).
Mental Health: A Report of the Surgeon General

However, there is only weak evidence for their
effectiveness.

A residential treatment center (RTC) is a licensed
24-hour facility (although not licensed as a hospital),
which offers mental health treatment. The types of
treatment vary widely; the major categories are
psychoanalytic, psychoeducational, behavioral
management, group therapies, medication management,
and peer-cultural. Settings range from structured ones,
resembling psychiatric hospitals, to those that are more
like group homes or halfway houses. While formerly
for long-term treatment (e.g., a year or more), RTCs

under managed care are now serving more seriously

disturbed youth for as briefly as 1 month for intensive
evaluation and stabilization.

Concerns about residential care primarily relate to
criteria for admission; inconsistency of community-
based treatment established in the 1980s; the costliness
of such services (Friedman & Street, 1985); the risks of
treatment, including failure to learn behavior needed in
the community; the possibility of trauma associated
with the separation from the family; difficulty
reentering the family or even abandonment by the
family; victimization by RTC staff; and learning of
antisocial or bizarre behavior from intensive exposure
to other disturbed children (Barker, 1998). These
concerns are discussed below.

In the past, admission to an RTC has been justified
on the basis of community protection, child protection,
and benefits of residential treatment per se (Barker,
1982). However, none of these justifications have stood
up to research scrutiny. In particular, youth who display
seriously violent and aggressive behavior do not appear
to improve in such settings, according to limited
evidence (Joshi & Rosenberg, 1997). One possible
reason is that association with delinquent or deviant
peers is a major risk factor for later behavior problems
(Loeber & Farrington, 1998). Moreover, community
interventions that target change in peer associations
have been found to be highly effective at breaking
contact with violent peers and reducing aggressive
behaviors (Henggeler et al., 1998). Although removal
from the community for a time may be necessary for
‘some, there is evidence that highly targeted behavioral

170

interventions provided on an outpatient basis can
ameliorate such behaviors (Brestan & Eyberg, 1998).
For children in the second category (i.e., those needing
protection from themselves because of suicide attempts,
severe substance use, abuse, or persistent running
away), it is possible that a brief hospitalization for an
acute crisis or intensive community-based services may
be more appropriate than an RTC. An intensive long-
term program such as an RTC with a high staff to child
ratio may be of benefit to some children, especially
when sufficient supportive services are not available in
their communities. In short, there is a compelling need
to clarify criteria for admission to RTCs (Wells, 1991).
Previous criteria have been replaced and strengthened
(i.e., with an emphasis on resources needed after
discharge) by the National Association of Psychiatric
Treatment Centers for Children (1990).

The evidence for outcomes of residential treatment
comes from research published largely in the 1970s and
1980s and, with three exceptions, consists of
uncontrolled studies (see Curry, 1991).

Of the three controlled studies of RTCs, the first
evaluated a program called Project Re-Education (Re-
Ed). Project Re-Ed, a model of residential treatment
developed in the 1960s, focuses on training teacher-
counselors, who are backed up by consultant mental
health specialists. Project Re-Ed schools are located
within communities, facilitating therapeutic work with
the family and allowing the child to go home on
weekends. Camping also is an important component of
the program, inspired by the Outward Bound Schools
in England. The first published study of Project Re-Ed
compared outcomes for adolescent males in Project Re-
Ed with untreated disturbed adolescents and with
nondisturbed adolescents. Treated adolescents
improved in self-esteem, control of impulsiveness, and
internal control compared with untreated adolescents,
according to ratings by Project Re-Ed staff and by
families (Weinstein, 1974). A 1988 followup study of
Project Re-Ed found that when adjustment outcomes
were maintained at 6 months after discharge from
Project Re-Ed, those outcomes were predicted more by
community factors at admission (e.g., condition of the
family and school, supportiveness of the local
community) than by client factors (e.g., diagnosis,
school achievement, age, IQ). This suggested that
interventions in the child’s community might be as
effective as placement in the treatment setting (Lewis,
1988).

The only other controlled study compared an RTC
with therapeutic foster care through the Parent
Therapist Program. Both client groups shared
comparable backgrounds and made similar progress in
their respective treatment program. However, the
residential treatment cost twice as much as therapeutic
foster care (Rubenstein et al., 1978).

Despite strong caveats about the quality,
sophistication, and import of uncontrolled studies,
several consistent findings have emerged. For most
children (60 to 80 percent), gains are reported in areas
such as clinical status, academic skills, and peer
relationships. Whether gains are sustained following
treatment appears to depend on the supportiveness of
the child’s post-discharge environment (Wells, 1991).
Several studies of single institutions report main-
tenance of benefits from 1 to 5 years later (Blackman et
al., 1991; Joshi & Rosenberg, 1997). In contrast, a large
longitudinal six-state study of children in publicly
funded RTCs found at the 7-year followup that 75
percent of youth treated at an RTC had been either
readmitted to a mental health facility (about 45 percent)
or incarcerated in a correctional setting (about 30
percent) (Greenbaum et al., 1998).

In summary, youth who are placed in RTCs clearly
constitute a difficult population to treat effectively. The
outcomes of not providing residential care are
unknown. Transferring gains from a residential setting
back into the community may be difficult without clear
coordination between RTC staff and community
services, particularly schools, medical care, or
community clinics. Typically, this type of coordination
or aftercare service is not available upon discharge. The
research on RTCs is not very enlightening about the
potential to substitute RTC care for other levels of care,
as this requires comparisons with other interventions.
Given the limitations of current research, it is
premature to endorse the effectiveness of residential
treatment for adolescents. Moreover, research is needed

Children and Mental Health

to identify those groups of children and adolescents for
whom the benefits of residential care outweigh the
potential risks.

Inpatient Treatment

Inpatient hospitalization is the most restrictive type of
care in the continuum of mental health services for
children and adolescents. Questions about excessive
and inappropriate use of hospitals were raised in the
early 1980s (Knitzer, 1982) and clearly documented

” thereafter in rising admission rates from the 1980s into

171

the mid-1990s, without evidence of increased social or
clinical need for such treatment (Weller et al., 1995).
Inpatient care consumes about half of child mental
health resources, based on the latest estimate available
(Burns, 1991), but it is the clinical intervention with the
weakest research support. Nevertheless, because some
children with severe disorders do require a highly
restrictive treatment environment, hospitals are
expected to remain an integral component of mental
health care (Singh et al., 1994). More concerted
attention to the risks and benefits of hospital use is
critical, however, along with development of
community-based alternative services.

Research on inpatient treatment mostly consists of
uncontrolled studies (Curry, 1991). Factors that are
likely to predict benefit have been identified from such
studies. Beneficial factors were found to include higher
child intelligence; the quality of family functioning and
family involvement in treatment; specific
characteristics of treatment (e.g., completion of
treatment program and planned discharge); and the use
of aftercare services. Neither age nor gender affected
prognosis after hospitalization. The prognosis was poor
for several clinical characteristics, including children
with a psychotic diagnosis and antisocial features with
conduct disorder (Kutash & Rivera, 1996).

Only three controlled studies evaluated the
effectiveness of inpatient treatment: one that random-
ized antisocial children to specific interventions on an
inpatient unit (Kazdin et al., 1987a, 1987b) and two
older clinical trials (Flomenhaft, 1974; Winsberg et al.,
1980). All three studies demonstrated that community
care was at least as effective as inpatient treatment.
Mental Health: A Report of the Surgeon General

More recently there have been preliminary
favorable findings from a randomized trial of inpatient
treatment versus multisystemic therapy (MST), an
intensive home-based intervention. For example, MST
was more effective than psychiatric hospitalization in
reducing antisocial behavior, improving family
structure and cohesion, improving social relationships,
and keeping children in school and out of institutions
(after the initial period when the control group was in
the hospital). Hospitalized youth reported improved
self-esteem, and youth in both treatment conditions
showed comparable decreases in emotional distress
(Henggeler et al., 1998). A great deal more research is
needed on inpatient hospitalization, as it is by far the
costliest and most restrictive form of care. Recent
changes in health care management have resulted in
short lengths of stay for children and adolescents.
Preliminary results from the study of MST indicate that
intensive home-based services may be a viable
alternative to hospitalization. However, even when
such services are available, there may be a need for
brief 24-hour stabilization units for handling crises (see
Crisis Services).

Newer Community-Based Interventions '
Since the 1980s, the field of children’s mental health
has witnessed a shift from institutional to community-
based interventions. The forces behind this
transformation are presented in a subsequent section,
Service Delivery. This section attempts to answer the
question of whether community-based interventions are
effective. It covers a range of comprehensive
community-based interventions, including case
management, home-based services, therapeutic foster
care, therapeutic group homes, and crisis services.
Although the evidence for the benefits of some of these
services is uneven at best, even uncontrolled studies
offer a starting point for studying the effectiveness and
feasibility of their implementation. Many of the
evaluations to date offer a first glimpse into the benefits
of these services and the extent to which they may be
‘valuable for further examination. Of these inter-
ventions, the most convincing evidence of effectiveness

172

is for home-based services and therapeutic foster care,
as discussed below.

There is a special emphasis throughout this section
on “children with serious emotional disturbances,” as
many of these community-based services are targeted
to this population of the most serious severely affected
children. The term serious emotional disturbance refers
to a diagnosed mental health problem that substantially
disrupts a child’s ability to function socially,
academically, and emotionally. It is not a formal
DSM-IV diagnosis but rather a term that has been used
both within states and at the Federal level to identify a
population of children with significant functional
impairment due to mental, emotional, and behavioral
problems who have a high need for services. The
official definition of children with serious emotional
disturbance adopted by the Substance Abuse and
Mental Health Services Administration is “persons
from birth up to age 18 who currently or at any time
during the past year had a diagnosable mental,
behavioral, or emotional disorder of sufficient duration
to meet diagnostic criteria specified within the DSM-
I-R, and that resulted in functional impairment which
substantially interferes with or limits the child’s role or
functioning in family, school, or community activities”
(SAMHSA, 1993, p. 29425).'5 The term is used in a
variety of Federal statutes in reference to children
fitting that description and does not signify any
particular diagnosis per se; rather, itis a legal term that
triggers a host of mandated services to meet the needs
of these children (see Service Delivery section).

Case Management

Case management is an important and widespread
component of mental health services, especially for
children with serious emotional disturbances. The main
purpose of case management is to coordinate the
provision of services for individual children and their
families who require services from multiple service
providers. Case managers take on roles ranging from
brokers of services to providers of clinical services.

 

'5 This definition is also used with newer diagnostic systems, such
as DSM-IV.
There is a considerable amount of variation in models
of case management. In one important model, called
“wraparound,” case managers involve families in a
participatory process of developing an individualized
plan focusing on individual and family strengths in
multiple life domains. Research on wraparound is still
in its early stages (Burns & Goldman, 1999).

There have been controlled studies of three
programs that used case managers who work
individually rather than as part of an interdisciplinary
team (discussed later). In one study of the Partner’s
Project in Oregon, case management was compared
with “usual services,” which did not include case
-management (Gratton et al., 1995). The authors found
at 1-year followup that children in the Partner’ s Project
scored significantly higher on measures of social
competence and had received more individualized,
comprehensive services, and a greater degree of service
coordination.

The second study compared the outcomes of
intensive case management and regular case
management for mentally ill homeless children in
Seattle (Cauce et al., 1994). The case managers in the
intensive condition had lower caseloads, were required
to spend more hours supervising the youth, had flexible
funds (for clothing, transportation, etc.) at their
disposal, spent more hours in consultation with
psychologists, and were of higher educational status.
After 1 year, the study found that both groups showed
substantial yet similar improvement in mental health
and social adjustment.

A model known as Children and Youth Intensive
Case Management (CYICM) was evaluated in two
controlled studies. The program has been described as
an Expanded Broker Model, which means that the case
manager, in addition to brokering services, is
responsible for assessment, planning, linking, and
advocating on behalf of the youth and family. Case
managers, with caseloads of 10 children, are given
$2,000 of flexible funds per child each year to purchase
treatment and ancillary services (e.g., transportation
and educational aids). In the first study, the authors

173

Children and Mental Health

found that children in the program spent significantly
more days in the community between episodes of
psychiatric hospitalization and were hospitalized for
fewer days than before enrollment (Evans et al., 1994).
A subsequent study evaluated a random sample of 199
children enrolled in CYICM (Evans et al., 1996b).
Findings at 3-year followup indicated significant
behavioral improvements and decreases in unmet
medical, recreational, and educational needs compared
with findings at enrollment. As in the previous study,
children who had been in CYICM for 2 years had spent
fewer days in psychiatric hospitals and more days in
community settings during the intervals between
hospitalizations. This study went further to compare
their hospital utilization with that by children. not
enrolled in the program. Although CYICM clients spent
more days in psychiatric hospitals before enrollment,
they. used inpatient services after enrollment
significantly less than did non-enrollees. CYICM
clients’ hospital admissions declined fivefold after
enrollment whereas among non-enrollees the decline in
admission rates was less than half that value. This
difference translated into a savings of almost
$8,000,000 for New York State, where the project took
place.

Some research has investigated the effects of
extending case management on children with a dual
diagnosis of a mental disorder and a substance abuse
problem. Within the CYICM program, researchers
looked at whether adolescents with mental disorders
and substance abuse problems derived comparable
benefits from the program as did those without
substance abuse problems (Evans et al., 1992). No
significant differences were found in the average
number of inpatient admissions both before and after
enrollment. There was also no significant difference
between groups in the average decrease from pre- to
postenrollment in the number of days spent in
hospitals. These results indicate that case management
can be as effective for youth presenting with substance
abuse problems as for youth presenting with other
psychiatric disorders.
Mental Health: A Report of the Surgeon General

Team Approaches to Case Management
Several studies assessed the value of case management

as part of a treatment team. In a randomized trial in
North Carolina (Burns et al., 1996), youth served by an
interdisciplinary treatment team led by a case manager
were compared with a control group of youth served by
a treatment team led by their primary clinician in the
role of case manager (also called clinician case
manager). At 1-year followup, case managers in the
experimental group reported spending significantly
more time with their clients, as well as significantly
more time on the core functions of case management
(e.g., outreach; assessment of strengths, needs, and
resources; service planning and monitoring; linking,
referral, and advocacy; and crisis intervention). The
experimental group also remained in the case-managed
program longer, spent fewer days in psychiatric
hospitals, and received more community-based services
and a more comprehensive array of services. Although
both groups showed similar clinical and functional
improvements, parents of youth in the experimental
group reported more satisfaction with the service
system. The study concluded that traditional case
managers, rather than clinician case managers, provide
a more cost-effective method for attaining positive
behavioral outcomes and access to mental health
services.

Another example of a team approach to case
management is the Family Centered Intensive Case
Management (FCICM) program. This was originally
created as a variation of Child and Youth Intensive
Case Management in New York, with the later addition
_ of a wraparound approach. The wraparound approach
is based on a belief that the child and family should be
placed at the center of an array of coordinated health
and mental health, educational, and other social welfare
services and resources, which a case manager wraps
around the patient and family. In a randomized trial,
children were assigned to either FCICM or Family-
Based Treatment (Evans et al., 1996a). Family-Based
Treatment included training, support, and respite care
for foster families but did not include case managers.

174

The findings at 18 months (or at discharge) indicated
that children in FCICM had significantly fewer
behavioral symptoms and significantly greater
improvements in overall functioning than those in
Family-Based Treatment. In addition, the average
annual cost of FCICM was less than half that of
Family-Based Treatment.

The Fostering Individualized Assistance Program
(FIAP) is an example of case management provided
through a wraparound approach. The effectiveness of
this model, which used clinical case managers, was
compared with standard foster care in a randomized
trial involving 131 children and their families (Clark et
al., 1998). The most important duty of the FIAP case
managers was to arrange monthly team meetings for the
monitoring of individualized service plans. Although
both groups showed significant improvement in their
behavioral adjustment over a 3-year period, children
in the FIAP group were less likely to change
placements, and boys in the group reported better social
adjustment and fewer delinquencies. Older youth in the
group were more likely to maintain placements in
homes of relatives and less likely to run away. Youth in
FIAP were also absent from school less often and spent
fewer days suspended from school. Overall, youth in
the FIAP group showed more improvement than did
youth in standard foster care. Multiple uncontrolled
studies of case management using a wraparound
approach were summarized in a recent monograph
focusing on the wraparound process (Burns &
Goldman, 1999). Overall, the reviewed studies,
although using uncontrolled methods, offer emerging
evidence of the potential effectiveness of case
management using a wraparound process.

While evidence is limited and many of the positive
outcomes focus on service use rather than clinical
status, there is some indication that case management
is an effective intervention for youth with serious
emotional disturbances. Studies in this area are difficult
to conduct because of resource limitations and of
varying approaches to case management. Agreement on
standards for specific case management models is
needed in order to proceed with efficient and reliable
controlled research in this area. In addition, future
research needs to address the issue of cost-
effectiveness, as some evidence presented above has
shown savings from less utilization of institutional care.

Home-Based Services

This section describes the strong record of
effectiveness for home-based services, which provide
very intensive services within the homes of children
and youth with serious emotional disturbances. A major
goal is to prevent an out-of-home placement (i.e., in
foster care, residential, or inpatient treatment). Home-
based services are usually provided through the child
welfare, juvenile justice, and/or mental health systems.
They are also referred to as in-home services, family
preservation services, family-centered services, family-
based services, or intensive family services.

Stroul (1988) identified three major goals of home-
based services: to preserve the family’s integrity and
prevent unnecessary out-of-home placements; to put
adolescents and their families in touch with community
agencies and individuals, thus creating an outside
support system; and to strengthen the family’s coping
skills and capacity to function effectively in the
community after crisis treatment is completed. The
specific services provided most often include
evaluation, assessment, counseling, skills training, and
coordination of services. The historical evolution of
home-based services is discussed further under Support
and Assistance for Families in Service Delivery.

The evidence for the benefits of home-based
services was recently evaluated in a meta-analysis of
controlled studies only (Fraser et al., 1997). The
analysis referred to home-based services as “family
preservation services”; these were sponsored either by
the child welfare or juvenile justice systems. For 22
studies the authors analyzed specific measures such as
out-of-home placement, family reunification, arrest,
incarceration, and hospitalization, with the control
group defined as youth receiving “usual” or “routine”
services. While a majority of the studies demonstrated
marginal gains in effectiveness, other services appeared
to be significantly more effective than usual services.

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Children and Mental Health

The findings are presented below according to their
organizational sponsorship by either child welfare or
juvenile justice system.

Family Preservation Programs Under the Child
Welfare System

Within the child welfare system, particularly effective

family reunification programs were the Homebuilders
Program in Tacoma, Washington, which was designed
to reunify abused and neglected children with their
families by providing family-based services (Fraser et
al., 1996), and the family reunification programs in
Washington State and in Utah (Pecora et al., 1991).
Studies suggested that 75 to 90 percent of the children
and adolescents who participated in such programs
subsequently did not require placement outside the
home. The youths’ verbal and physical aggression
decreased, and cost of services was reduced (Hinckley
& Ellis, 1985). The success of these family
preservation programs is based on the following:
services are delivered in a home and community
setting; family members are viewed as colleagues in
defining a service plan; back-up services are available
24 hours a day; skills are built according to the
individual needs of family members; marital and family
interventions are offered; community services are
efficiently coordinated; and assistance with basic needs

such as food, housing, and clothing is given (Fraser et
al., 1997).

Multisystemic Therapy

Multisystemic therapy programs within the juvenile
justice system have demonstrated effectiveness. MST
is an intensive, short-term, home- and family-focused
treatment approach for youth with severe emotional
disturbances. MST was originally based on risk factors
that were identified in the published literature and was
designed for delinquents. MST intervenes directly in
the youth’s family, peer group, school, and
neighborhood by identifying and targeting factors that
contribute to the youth’s problem behaviors. The main
goal of MST is to develop skills in both parents and
community organizations affecting the youth that will
endure after brief (3 to 4 months) and intensive