Welcome to Part Five of our Summer 2013 blog series…Ten Questions Parents and Caregivers Ask About Kids and Medication. In this segment, we’ll review the question: When should parents consider non-medical treatment first?
Lost in the controversy swirling around the numbers of kids in the U.S. receiving prescription medication for ADHD, anxiety, depression, mood disorders and aggressive behavior is the reality that non-medical treatment is often the most appropriate first step for the majority of children and teens entering the mental health delivery system. Many mental health conditions are commonly seen in kids for which medication generally isn’t the first step in a well-developed treatment plan. Today, we’ll look at some situations when parents and clinicians might consider non-medical treatment alternatives first.
Kids and teens with depression of mild to moderate severity, without suicidal thinking. Education, case management and brief, supportive treatment has been shown to be as effective as cognitive-behavioral therapy (CPT) or interpersonal therapy for kids with mind depression. Quoting from the American Academy of Child and Adolescent Psychiatry’s (AACAP) practice parameter for the treatment of depression…
“Thus, it is reasonable, in a patient with a mild or brief depression, mild psychosocial impairment and the lack of any clinically significant suicidality or psychosis, to begin treatment with education, support and case management related to environmental stressors in the family and school. It is expected to observe response after 4 to 6 weeks of supportive therapy.”
Kids with Obsessive-Compulsive Disorder (OCD) without first degree relatives with OCD (although concomitant medication may be necessary in severe cases). In the POTS (Pediatric OCD Treatment) study, CBT was superior to placebo, while sertraline was not. The rate of clinical remission for combined treatment (CBT plus sertraline) was 53.6%; for CBT alone, 39.3%; for sertraline alone, 21.4%; and for placebo, 3.6%. A secondary analysis of the study data demonstrated that kids with a family history of OCD had more than a sixfold decrease in the effect size of CBT monotherapy relative to their counterparts in CBT without a family history of OCD.
Because of the findings of the POTS study, AACAP recommended the following…When possible, CBT is the first line treatment for mild to moderate cases of OCD in children.
Anxiety Disorders (especially phobias)…Since the publication of the most recent AACAP Practice Parameters in 2007, results from the CAMS (Child and Adolescent Anxiety Multimodal Study) have demonstrated that combination therapy (CBT plus medication) is the most effective treatment approach to kids and teens with anxiety. Nevertheless, 60% of kids in the study assigned to the CBT-only treatment group responded positively to treatment within twelve weeks, compared to 23% of kids receiving placebo, 55% receiving sertraline alone, and 81% receiving combination treatment. Per the current practice parameters…
Until evidence from comparative studies inform clinical practice, treatment of childhood anxiety disorders of mild severity should begin with psychotherapy. Valid reasons for combining medication and treatment with psychotherapy include the following: need for acute symptom reduction in a moderately to severely anxious child, a comorbid disorder that requires concurrent treatment, and partial response to psychotherapy and potential for improved outcome with combined treatment
Post-Traumatic Stress Disorder (PTSD). Again, per the AACAP Practice Parameter for the Assessment and Treatment of Children and Adolescents With Posttraumatic Stress Disorder…
“Trauma-Focused Psychotherapies Should Be Considered First-Line Treatments for Children and Adolescents With PTSD.”
Preschoolers with ADHD. The US Agency for Healthcare Research and Quality recently sponsored a comparative effectiveness review of interventions for preschoolers at risk for attention-deficit/hyperactivity disorder (ADHD) that was published this past April in Pediatrics.
RESULTS: Fifty-five studies were examined. Only studies examining Parent Behavior Training (PBT) interventions could be pooled statistically using meta-analysis. Eight “good” studies examined PBT, total n = 424; Stength of evidence (SOE) was high for improved child behavior, standardized mean difference = –0.68 (95% confidence interval: –0.88 to –0.47), with minimal heterogeneity among studies. Only 1 good study evaluated methylphenidate, total n = 114; therefore, SOE for methylphenidate was low. Combined home and school/day care interventions showed inconsistent results. The literature reported adverse effects for methylphenidate but not for PBT.
CONCLUSIONS: With more studies consistently documenting effectiveness, PBT interventions have greater evidence of effectiveness than methylphenidate for treatment of preschoolers at risk for ADHD.
We have some truly fabulous tools to assist parents of kids with mental illness in doing their “due diligence” in evaluating treatment recommendations professionals suggest for their children. One of my favorites is the website for the National Library of Medicine. One last tip for parents…really good clinicians enjoy fielding questions from educated parents and don’t feel threatened when parents are well-read. Don’t be afraid to ask about non-medical treatment approaches!
Photo courtesy of http://www.freedigitalphotos.net
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