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QUESTION: Which psychological, psychopharmacological and adjunctive treatments in childhood have the potential to prevent substance abuse disorders in adolescence?
Design
Systematic review with narrative synthesis and standardised effect sizes.
Data sources
The authors searched Medline, PsycInfo and the reference lists of identified articles. Expert reviewers suggested additional studies. The authors identified 18 studies of children with depressive disorders and 33 studies of children with anxiety disorder from the electronic searches.
Study selection
Controlled studies of treatments for children aged 6–12 years with depressive or anxiety disorders were eligible if they were published in peer reviewed English language journals between 1985–2001.
Data extraction
The authors did not describe methods for assessing study quality or extracting data.
Main results
Psychosocial interventions for depression:
the authors identified 6 studies of psychosocial interventions for childhood depression. The evidence suggests that cognitive-behavioural therapy and other active interventions may reduce depressive symptoms in children compared with no treatment or wait list controls.
Psychopharmacological interventions for depression:
the authors identified 5 randomised trials of antidepressants, 4 of which focused on tricycle antidepressants. Tricyclic antidepressants may be of limited benefit and should not be considered as first line therapy. It was not possible to draw conclusions about selective reuptake inhibitors in childhood depression as only one high quality study was identified.
Psychosocial interventions for anxiety:
the authors identified 21 controlled studies of psychosocial interventions for simple phobias, generalised anxiety disorder, separation anxiety disorder, social phobia, post traumatic stress disorder, selective mutism, and refusal to attend school. The evidence suggests that systematic desensitisation, contingency management and cognitive-behavioural therapies are effective for a number of phobias and anxiety disorders. There is less evidence about interventions for post traumatic stress disorder.
Psychopharmacological interventions for anxiety:
the authors identified 8 studies on psychopharmacological interventions for obsessive compulsive disorder, separation anxiety, avoidant and overanxious disorder, and other anxiety disorders. Fluoxetine, sertraline and fluvoxamine appear effective for childhood obsessive compulsive disorder. There is less evidence about the effectiveness of medications for other anxiety disorders.
None of the studies reviewed included substance abuse outcomes.
Conclusions
A number of behavioural, cognitive-behavioural, and pharmacological interventions are associated with reduced childhood depression, phobias, and anxiety disorders. It is unclear whether treating childhood internalising disorders prevents substance abuse in adolescence.
COMMENTARY
These two reviews examine whether treating internalising and externalising disorders in 6–12 year old children decreases the likelihood of substance abuse in adolescence and young adulthood. The authors investigated both psychosocial and psychopharmacological treatments. They provide detailed tables listing the characteristics of individual studies. The overall conclusion is that there are insufficient data to establish a preventative link between treating childhood disorders and substance abuse in adolescence.
The reviews underscore an important and yet to be exploited agenda, namely, evaluating the broader and long term impact of treating children effectively. Substance abuse and a variety of other social, emotional, behavioural, and medical problems might be influenced by treating childhood disorders effectively.
The paucity of long term follow up is a cogent complaint in child, adolescent, and adult therapy literature. There are many obstacles, including retaining a large and not too biased cohort, obtaining funding for long term follow up, and maintaining a control or standard treatment group as a comparison. These reviews highlight the importance of follow up in light of the possible, but yet to be investigated, implications for preventing other disorders and presumably reducing service use. The reviews are likely to prompt research to address this topic.
A key issue is whether and how to move from understanding risk factors to planning intervention strategies. Internalising and externalising disorders among children are precursors of, and comorbid with, substance abuse. This could mean that intervening in the disorders would impact on substance abuse, but it could also mean that it would not. Identifying risk factors and correlates is an interesting and useful point of departure, but many risk factors have no causal role in the onset or maintenance of a problem. The reviews sensitise us to the implications of child treatment, the urgent need to assess broader outcomes beyond the focus of the intervention, and the important role that treatment may play in prevention.
Footnotes
Source of funding: National Institute on Drug Abuse, Bethesda, Maryland, USA.
For correspondence: S Compton, Duke Child and Family Study Center, Duke University Medical Center, Durham, North Carolina, USA. scompton{at}acpub.duke.edu