WASHINGTON UPDATE:
White House Meeting on Mental Health of Children

Ronald F. Levant, Ed.D., A.B.P.P.

I had the great honor of representing APA at the March 20, 2000, White House meeting on the mental health of children. The meeting was called in response to concerns about the drugging of preschool children generated by a well-publicized study published in the Journal of the American Medical Association (Zito, Safer, dosReis, Gardner, Boles, & Lynch, 2000). This study found a dramatic increase in the prescription of psychotropic medications to pre-school aged children between 1991-1995. The study focused on three major classes of psychotropic drugs (stimulants, antidepressants, and neuroleptics), and two leading drugs (methylphenidate and clonidine). Across three sites, stimulants (and in particular methylphenidate) showed the largest increase, clonidine and antidepressants showed sizable increases, but neuroleptic use increased only slightly. Of particular concern was the predominance of "off-label" use – that is, using drugs which have not been approved either for young children or for the condition for which the drug was prescribed.

This meeting built on the Clinton Administration’s significant accomplishments in the area of mental health, including the first-ever White Conference on Mental Health and the release of the unprecedented Surgeon General’s Report on Mental Health last year, both of which were initiated by Tipper Gore, the President’s Mental Health Advisor.

The meeting was attended by First Lady Hillary Rodham Clinton, Secretary of Health and Human Services Donna Shalala (who, just the previous week had received an Award from APA at the State Leadership Conference), Surgeon General David Satcher, National Institute of Mental Health (NIMH) Director Steven Hyman, Food and Drug Administration (FDA) Commissioner Jane Henney, Assistant Secretary of Education, Office of Special Education and Rehabilitative Services, Judith Huemann, and governance representatives from 14 major mental health, health care, educational and consumer organizations, including, in addition to APA, the American Federation of Teachers, The Federation of Families for Children’s Mental health, The National Mental Health Association, Children and Adults with Attention-Deficit/Hyperactivity Disorder, The Council for Exceptional Children, Children’s Defense Fund, The National Association of School Psychologists, The National Association of School Nurses, The National Association of School Social Workers, the American Academy of Pediatrics, the American Academy of Family Physicians, the American Academy of Child and Adolescent Psychiatry, and the American Psychiatric Association.

The purpose of the meeting was to launch a public-private collaboration to ensure that children with emotional and behavioral conditions are appropriately diagnosed, treated, monitored, and managed by qualified health care professionals, parents and educators. The meeting began with a roundtable discussion of the issues held in the Map Room (the site where President Franklin Roosevelt developed the U.S. strategy for WWII), followed by a press conference in the Roosevelt Room, at which First Lady Hillary Rodham Clinton outlined four new federal initiatives. These include:

  1. The release of a new, easy to understand fact sheet for parents about the treatment of children with emotional and behavioral conditions.
  2. Funding to the tune of $5 million by NIMH of a study of the effects of psychotropic medication on children under the age of seven.
  3. The initiation of a process at the FDA to improve pediatric labeling information for young children.
  4. A national conference on Treatment of Children with Behavioral and Mental Disorders to be held this fall, sponsored by Surgeon General David Satcher. In response to concerns expressed during the roundtable discussion that many issues needed to be taken up with the health care insurance/managed care and pharmaceutical industries, the First Lady indicated that this conference would also include representatives from these industries. Exactly how a fruitful discussion will take place is at this point not clear.

(I have included as an Appendix additional information on these initiatives handed out by the White House at the meeting.)

The roundtable discussion was very lively yet quite congenial, with most participants pretty much on the same page. This was undoubtedly due to the compistion of the group, which was largely mental health, educational, and parents groups. There appeared to be consensus that proper diagnosis by qualified professionals was essential; that behavioral, family, and school interventions needed to be tried first in many cases before putting young children on medication, and that these psychosocial interventions should be continued even if the decision is made to do pharmacological treatment; that team work between the home, the school, and the professionals is essential; that much more research is needed; that current "community practice" falls far short of what we know to be good care; and that there was large access issue – e.g, although some children may be over-medicated, there are many more from the lower SES who are not treated at all.

My comments during the roundtable discussion were as follows: Most of the psychoactive drugs prescribed to children (including young children), whether labeled or off-label, are prescribed by primary care generalists, with minimal specific training in mental health diagnosis and treatment, too-often based on a brief interview (as little as 7 minutes, and with 20-30 minutes all too common) with minimal follow-up (1-2 visits per year), sometimes pressured by harried teachers or frustrated parents, conducted in a cost-conscious managed care context. Hence standard community practice deviates significantly from optimal practice (which may account for the fact that in the Multimodal Treatment Study of Children with ADHD [MTA Cooperative Group, 1999] community practice fared so poorly). In addition, there is an access issue: CMHS estimates that 20% or 13.7 million children have a diagnosable mental disorder, of which only 1/3 receive any mental health care. Hence we need to direct our efforts toward the development of a comprehensive plan to change the current practice. While developing such a plan is beyond the scope of my comments, I would like to suggest that this plan include the following elements:

We must understand more about development in early childhood. In short, in order to diagnose young children’s behavior as abnormal, we need to better understand the variations in normal development. As a foundation for making any decisions about diagnosis or treatment, parents, teachers and professionals need research-based information about child development, including the effects of culture, ethnicity, temperament, family structure and dynamics, and specific stressors on children’s behavior. Psychologists and others have done excellent research on normal growth and development, but continued support for research in this area is needed.

We need better information about appropriate diagnoses for young children. There is little empirical research on diagnostic assessment of very young children. We know little about measuring current behavior in preschoolers or about predicting their future behavior. Even some measures of intelligence, which tend to be more stable than those of behavior, show low correlations between those taken in the preschool years and those taken later in life. Hence diagnoses of preschoolers must be made with great caution and research is urgently needed in the diagnostic assessment of behavioral problems in early childhood.

Psychological and pharmacological interventions with children need equal attention. While pharmacotherapy has been an effective treatment for many children, psychological interventions also have demonstrated efficacy. Parents, teachers and health care practitioners must be better informed about both types of interventions and how they can be used together in "combination therapy" (Sammons & Levant, 1999; indeed the Multimodal Treatment Study of Children with ADHD [MTA Cooperative Group, 1999] found that the very best results were obtained with combination therapy). As part of this educational effort we need to ensure that only qualified professionals conduct mental health diagnosis and treatment. It is of great concern that health care insurance and managed care procedures too often preclude appropriate behavioral interventions in favor of psychotropic medications. This latter point is so important because we know so little about the impact of psychotropic drugs on the young child’s developing brain. We also know very little about the degree to which gains made while taking psychotropic medications are sustained after medication usage is discontinued. For this reason more research is needed on the short and long term effects of medication, psychological interventions, and combination therapy on children, particularly preschoolers.

As always, I welcome your thoughts on this column. You can most easily contact me via email: Rlevant@aol.com

References

The MTA Cooperative Group (1999). A 14 month randomized clinical trail of treatment strategies for attention-deficit/hyperactivity disrorder. Archives of General Psychiatry, 56, 1073-1086.

Sammons, M., & Levant, R. F. (1999). Combined psychosocial and pharmacological treatments : Introduction. Clinical Psychology in Medical Settings, 6, 1-10

Zito, J. M., Safer, D. J., dosReis, S., Gardner, J. F., Boles, M. & Lynch, F. (2000). Trends in the prescribing of psychotropic medications to preschoolers. Journal of the American Medical Association, 283, 1025-1030.

Appendix: Information on White House Initiatives

INAPPROPRIATE DIAGNOSIS AND TREATMENT OF BEHAVIORAL AND EMOTIONAL CONDITIONS IN CHILDREN HAVE ADVERSE CONSEQUENCES. While progress has been made in diagnosing and treating these conditions, justifiable concerns have been raised about the inappropriate (both over and under) utilization of medications such as Ritalin, clonidine, and Prozac in very young children. Just as important, there is a lack of understanding amongst parents, teachers, and health professionals about the best diagnostic, pharmacological, and behavioral interventions now available. Recent studies published in the Journal of the American Medical Association reviewing selected provider data over a five year period found that:

NEW ACTION TO ENSURE BETTER DIAGNOSIS, TREATMENT, AND MANAGEMENT OF CHILDREN WITH EMOTIONAL AND BEHAVIORAL CONDITIONS. At today’s meeting, the First Lady will announce a series of public and private actions designed to address the challenges posed by children with emotional and behavioral conditions. Federal actions she will outline include:

Ronald F. Levant, Ed.D., A.B.P.P., is Recording Secretary of the American Psychological Association. He was the Chair of the APA Committee for the Advancement of Professional Practice (CAPP) from 1993-95, a member of the Board of Directors of Division 42 (1991-94), and a member of the APA Board of Directors (1995-97). He is Dean, Center for Psychological Studies, Nova Southeastern University, Fort Lauderdale, FL.

Reprinted with permission of the author.

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