The number of research-supported treatments for mental health problems in youth has increased substantially over the last decade. However, because patient populations are more complicated and diverse than research samples (and also because clinicians are not always trained in, or willing to use, evidence-based modalities), the justification for most practice is based on the adult literature or clinical consensus. Ultimately, pediatric mental health services need to be defined by research, rather than the current state whereby studies, if done at all, are initiated to justify existing practices. Variability in diagnostic and treatment practices, coupled with a lack of research, makes it is difficult to stipulate which practices fall within or outside consensus or community standards.
The limited validity for most childhood psychiatric disorders further complicates this issue (McClellan and Werry, 2000). Many studies use narrowly defined exclusion criteria to address the question of efficacy for a specific condition. Therefore, results may not reflect the more common clinical situations seen in everyday practice. Diagnostic comorbidity, associated risk factors and cultural/social variables all influence treatment decisions and effectiveness.
Future research needs include establishing the effectiveness of commonly used unstudied interventions; determining the effectiveness of evidence-based treatments in nonacademic clinical settings and populations; and developing methods for promoting the use of existing evidence-based practices in community settings. Complicated treatment algorithms should be incorporated into study designs, such as systematically combining pharmaco- and psychotherapy to address more complex cases. The potential influences of relevant clinical, family, community and social-service factors on the type, dose and/or timing of specific interventions also need to be examined. Finally, efforts are needed to better understand how to train evidence-based practitioners, since maintaining treatment fidelity in community settings is a major challenge.
Dr. McClellan is associate professor of psychiatry at the University of Washington in Seattle.
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Brestan EV, Eyberg SM (1998), Effective psychosocial treatments of conduct-disordered children and adolescents: 29 years, 82 studies, and 5,272 kids. J Clin Child Psychol 27(2):180-189 [see comments].