CHILD AND ADOLESCENT MENTAL HEALTH : FORGOTTEN RESEARCH FACTORS

Since the start of the 21st century there has been a considerable increase in the quantity and quality of outcomes research in child and adolescent mental health. But despite this there remain many areas where research knowledge is insufficient to guide practice. Future efforts, research and practice will need to address an issues if we are to meet the ideal of reaching and treating all children and young people with mental health problems.

For some mental health disorders of children and young people there is still a lack of clarity about diagnostic criteria. This makes it difficult to conduct research and to interpret it in order to determine which treatments have the best evidence for effectiveness and cost-effectiveness. It is known that modifying the child’s family environment can yield substantial positive outcomes. The behavioural genetic studies have shown that social and environmental influences play a key role in triggering genetic vulnerabilities or conversely protecting against genetic predispositions. Future research will need to make sophisticated assessments of environmental influence. To help us to better understand how the social environment may counteract genetic risk. It may lead to the development of better preventive and therapeutic interventions and whether a given psychosocial intervention may be suitable or unsuitable for a given child.

Too many studies on which current evidence base rests have significant methodological flaws, such as small sample sizes, failures of replication, or differences in outcome between research and clinical settings. This means that it is often difficult or impossible to generalise findings from research into everyday practice. These problems need to be tackled if we are truly understand which interventions are most effective for the mental health problems of children and young people. We also need to carry out studies with longer follow-up periods to help us to assess. For example, how long pharmacological treatments for Attention deficit/ hyperactivity Disorder (ADHD) or depression should be continued once remission has been achieved or the relative benefits of short-term and extended psychological interventions. As mentioned above, we need to collect data on both what services are offered to children in mental health services and what the outcomes of these interventions are. We are currently lacking a way of integrating information nationally as well as locally across mental health services. For example, we have no way of relating the outcomes of mental health service interventions to educational or often even social mental health service interventions yet. Where children present with mental health problems is more likely to be the consequence of circumstance rather than the characteristics of their presenting problem.

At present, many children and young people do not respond adequately to even the best evidenced mental health treatments. We need to find out more about sub groups who do not respond to mental health treatment and to explore whether better results could be achieved by alternative means. Such that in terms of both different treatments and different settings in which treatment is provided. This could help us to develop care pathways for children and adolescents who present with different mental health problems starting with simpler interventions and moving on to more complex interventions (or combinations of interventions) if the initial ones do not achieve a good outcome. At present, some interventions are being offered that have not been adequately evaluated. For example, systemic therapies. We need to evaluate these treatments more fully and to identify the effective elements that they contain. As it is possible that they may help the ‘poor responders’ to existing evidence based treatments.

We also need more information (from both research and practice) about the adverse outcomes of treatments. In the case of pharmacological treatments, it is already accepted that such adverse effects must be monitored and reported. These reports help to guide marketing authorisations and prescribing decisions. The possibility of adverse outcomes from psychological therapies needs to be investigated and reported with the same diligence. We need to understand more about alternative settings in which treatments may be implemented especially for those children and young people who are not currently reached by existing mental health services. This should include not just physical locations such as schools and community centres but also social contexts. For example involving community leaders, peers and near-peers that is, young people who are slightly older than the young mental health service users.

As unmet need is so high, we need to develop innovative methods of mental health service delivery system for improving mental health literacy in the wider community in the contexts of prevention and intervention.