Tuesday, October 28, 2008

Child mental health: Why progress is so slow

(My most recent column for ChristianWeek )

Last column (September 15, 2008) featured tips from psychology and neuroscience for doing the best possible job in schoolwork. The skinny: For normal levels of achievement, self-discipline and sleep matter far more than IQ.

But what about truly troubled kids? Kids with mental problems like anxiety, ADHD, disruptive behavior, or pervasive development disorders? Parents, pastors, and youth leaders might be interested to learn of a recent hard-hitting editorial in Nature Neuroscience (September 2008) highlighted a “Credibility crisis in pediatric psychiatry.” It is a warning that there are no simple, short-term answers to these problems on the horizon.

Briefly, the editors said, “Our understanding of the neurobiology and treatment of psychiatric illness in children remains poor. Prominent psychiatrists have now been accused of concealing the extent of their financial ties to the drug industry. We urgently need to encourage more science in this area and we need vigorous regulation to restore some neutrality to the field.” What’s behind that?

First, as the editors implied, it is often difficult to identify or treat childhood mental disorders. For one thing, children are always growing and changing, and learning to cope and relate—and they mature at their own pace. They may not be able to communicate clearly. And even if we are pretty sure about what is wrong, we don’t always know what to do about it. And by the time we develop an effective approach, the problem may have changed.

Here are some other problems they identify: Drugs are usually tested on adults, but the findings do not necessarily translate well to children. Their long term effects on brain development and function are not known. One research problem is that, whereas drugs for physical conditions can be tested on animals first, there are often no useful animal models for specifically human mental problems.

The issue that sparked the “credibility crisis” mentioned above was that psychiatrists who prescribe anti-psychotic drugs may have financial ties to the drug industry, in the form of, for example, consulting fees or ownership of shares. In one instance, Stanford University recently removed its chairman of psychiatry as a principal investigator of an antidepressant in a study paid for by the US National Institute of Mental Health. It determined that he had undisclosed ties to the drug company whose product was being investigated.

A subtler problem is this: Many drugs are prescribed for children off-label. But there is little incentive for the drug company to sponsor expensive large trials to determine whether they work for children. If studies show that a drug does not work, it should not be prescribed, but no useful substitute may be available.

Here is another problem: A scientifically based trial must have a placebo group—a group that thinks it is getting the medication, but actually isn’t. Here is the reason: A large proportion of the placebo group will get better, partly because the subjects believe they are receiving a treatment. These results must be subtracted from the results in the control group, to determine the difference the medication itself made, as opposed to the power of suggestion. Adult participants in a clinical trial are told up front that they might be randomly assigned to the placebo group. According to surveys, few subjects actually believe they are in the placebo group. But because they are informed adults and they gave consent, what they believe is beside the point. However, children cannot give valid consent to participate in a clinical trial. So the risk that many children are in the placebo group—and therefore may not be receiving a medication that could actually help them—is an ethical dilemma. It could become a legal dilemma too, if tragedy occurs.

For these and other reasons, there are few or no obvious solutions to child mental health problems. Many parents may echo the father in Mark 9:17-29, “ ... Teacher, I brought you my son, who is possessed by a spirit ... I asked your disciples to drive out the spirit, but they could not.” Knowing in advance that this will sound trite to some desperate parents, one must mind Jesus’s word (v29), “This kind can come out only by prayer.” The good news is that prayer does help, though we do not often see its results immediately, only in retrospect.

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