Report of the National Advisory Mental Health Council’s Workgroup on

Child and Adolescent Mental Health Intervention Development and Deploym

National 

of Menta

D E P A R T M E N T O F H E A L T H A N D H U M A N S E R V I C E S P U B L I C H E A L T H S E R V I C E N A T I O N A L I N S T I T U T E S O F H E A L T H

Blueprint for Change:

Research on Child and

Adolescent Mental Healt
The National Advisory Mental Health Council Workgroup on Child and Adolescent Mental Health Intervention Development

and Deployment conducted these deliberations and prepared this report.

Recommended Citation: The National Advisory Mental Health Council Workgroup on Child and

Adolescent Mental Health Intervention Development and Deployment.

“Blueprint for Change: Research on Child and Adolescent Mental Health.”

Washington, D.C.: 20001. 

Single copies of this report are available through:

The National Institute of Mental Health

Office of Communications and Public Liaison

6001 Executive Boulevard, Room 8184

Rockville, MD 20892-9663

Telephone: 301-443-4315
Report of the National Advisory Mental Health Council’s Workgroup on

Child and Adolescent Mental Health Intervention Development and Deployment

II

National Institute

of Mental Health

D E P A R T M E N T O F H E A L T H A N D H U M A N S E R V I C E S P U B L I C H E A L T H S E R V I C E N A T I O N A L I N S T I T U T E S O F H E A L T H

Blueprint for Change:

Research on Child and

Adolescent Mental Health
Contents

Acknowledgments ................................................................................................................................... i

Preface ..................................................................................................................................................... iii

Executive Summary and Recommendations ...................................................................................................1

I. A Look Backward: Child and Adolescent Mental Health Intervention Research .................................. 19

A. Historical Context ..................................................................................................................... 19

B. Recent Activities: The Environment Surrounding Child Mental Health ...................................... 24

C. Guiding Principles for the Report .............................................................................................. 25

D. Conceptual Models for the Report............................................................................................ 26

II. A Look Forward: Current Emphases and Future Prospects for

Child and Adolescent Intervention Research ..................................................................................... 33

A. Costs, Financing Policy, and Services Utilization: National Estimates ................................... 33

B. Key Scientific Areas of Research ............................................................................................ 36

1. Basic Neuroscience ............................................................................................................. 36

2. Behavioral Science .............................................................................................................. 41

3. Prevention ......................................................................................................................... 48

4. Psychosocial Interventions .................................................................................................. 52

5. Psychopharmacology .......................................................................................................... 58

6. Combined Interventions and Services Effectiveness ............................................................. 64

7. Dissemination Research and System Improvement: Closing the Loop ................................. 70

III. Infrastructure and Training ................................................................................................................ 77

IV. Future Directions for Child and Adolescent Mental Health Research ................................................. 83

V. Figures ..............................................................................................................................................87

A. NIMH Research and Training Grants, FY 1989-2000, by Number of Grants .............................. 87

B. NIMH Research and Training Grants, FY 1989-2000, by Awarded Amount .............................. 88

C. NIMH Child Training Grants, FY 1989-2000 ............................................................................. 89

D. NIMH Training Grants, FY 1989-2000 ..................................................................................... 90

VI. Appendices ...................................................................................................................................... 91

A. National Estimates of Mental Health Utilization and Expenditures for Children in 1998 .......... 93

B. Clinical Case Study: Childhood-Onset Depression .................................................................... 121

C. Respondents, Training Recommendations from Major Professional Associations ..................... 154

D. National Advisory Mental Health Council ............................................................................... 155

VII. References ........................................................................................................................................158
i

Acknowledgments

We would like to acknowledge the individuals listed below for their contributions to this report.

A special thank-you to all of the members of the National Advisory Mental Health Council Workgroup on

Child and Adolescent Mental Health Intervention Development and Deployment, whose dedication and

hard work made this report a reality:

Chair

Mary Jane England, M.D.

Washington Business Group on Health

Members

William Beardslee, M.D.

Harvard Medical School

Marilyn Benoit, M.D.

Howard University Medical School & Hospital and

Georgetown University Medical Center

Barbara J. Burns, Ph.D.

Duke University Medical Center 

Ron Dahl, M.D.

University of Pittsburgh

Mary L. Durham, Ph.D. 

Kaiser Foundation Hospitals 

Graham Emslie, M.D.

University of Texas, Southwestern 

Medical Center of Dallas 

Michael English, J.D.

Center for Mental Health Services

Substance Abuse and Mental Health Services

Administration

Robert Findling, M.D.

Case Western Reserve University

Robert Friedman, Ph.D.

University of South Florida

Jay Giedd, M.D.

NIMH Intramural Research Program

Regenia Hicks, Ph.D.

Department of Mental Health 

Harris County, Texas

Robert L. Johnson, M.D., F.A.A.P.

New Jersey Medical School

Nadine Kaslow, Ph.D., A.B.P.P.

Emory University School of Medicine

Kelly Kelleher, M.D., M.P.H.

University of Pittsburgh

James Leckman, M.D.

Yale University Medical School

Martha Constantine Paton, Ph.D.

Massachusetts Institute of Technology 

Paul M. Plotsky, Ph.D.

Emory University School of Medicine

John Weisz, Ph.D.

University of California Los Angeles

Roy C. Wilson, M.D. 

Missouri Department of Mental Health

Mark Wolraich, M.D.

Vanderbilt University School of Medicine
ii

Other Contributors to the Report:

Presenters

Deborah C. Beidel, Ph.D., A.B.P.P.

University of Maryland

Michael Davis, Ph.D

Emory University School of Medicine

Mary Dozier, Ph.D.

University of Delaware

Peggy Hill, Ph.D. 

Kempe Prevention Research Center for Family

and Child Health, U. of Colorado, Denver

Isaac Kohane, M.D., Ph.D.

Harvard Medical School

David Olds, Ph.D.

Kempe Prevention Research Center for Family

and Child Health, U. of Colorado, Denver

Sonja Schoenwald, Ph.D.

Medical University of South Carolina

NIMH Staff Director for Report

Kimberly Hoagwood, Ph.D., NIMH

Associate Director for Child & Adolescent Research

NIMH Staff for Report

Serene Olin, Ph.D.

Daisy Whittemore

NIMH Staff Contributors

Cheryl Boyce, Ph.D.

Rhonda Boyd, Ph.D.

Linda Brady, Ph.D.

Lisa Colpe, Ph.D., M.P.H.

Steve Foote, Ph.D.

Junius Gonzales, M.D.

Della Hann, Ph.D.

Themis Hibbs, Ph.D.

Ann Hohmann, Ph.D.

Doreen Koretz, Ph.D.

Israel Lederhendler, Ph.D.

Victoria Levin, M.S.W.

Ann Maney, Ph.D.

Douglas Meinecke, Ph.D.

Eve Moscicki, Sc.D., M.P.H.

Grayson Norquist, M.D., M.S.P.H.

Molly Oliveri, Ph.D.

Jane Pearson, Ph.D.

Kevin Quinn, Ph.D.

Heather Ringeisen, Ph.D.

Agnes Rupp, Ph.D

Karen Shangraw 

Belinda Sims, Ph.D.

David Sommers

Jane Steinberg, Ph.D.

Ellen Stover, Ph.D.

Farris Tuma, Sc.D.

Ben Vitiello, M.D.

Lois Winsky, Ph.D.

Clarissa Wittenberg

With Special Thanks to NIMH Staff:

Karen May, Pamela Mitchell, and 

Catherine West

Consultants

Ellen Frank, Ph.D.

University of Pittsburgh School of Medicine

Megan Gunnar, Ph.D.

University of Minnesota

Robin Peth-Pierce, M.P.A. 

Health Communications Consultant

Roland Sturm, Ph.D. 

RAND Health 

Eva M. Szigethy, M.D., Ph.D. 

Judge Baker Children’s Center
iii

Preface

May 2001

Dear Dr. Hyman:

On behalf of my council colleagues, Drs. Mary Durham and Roy Wilson, it is my pleasure to present to the National

Advisory Mental Health Council (NAMHC) the report of the NAMHC Workgroup on Child and Adolescent Mental Health

Intervention Development and Deployment. Our workgroup has been inspired by the historic amount of public

attention on children’s mental health. This intense interest is apparent in the number of activities that have been

undertaken to illuminate progress and identify problems in this area. 

All these efforts, ranging from White House conferences and Surgeon General reports to private foundation

publications, have arrived at the same conclusion: Findings from research in neurobiology, genetics, behavioral

science, and social science have led to an increased understanding of the complex interactions among genetic and

socioenvironmental factors and their contribution to child and adolescent mental disorders. Further, a promising

number of scientifically proven preventive interventions and treatments are now available. Yet, children, adolescents,

and their families continue to suffer enormous burdens associated with mental illness—burdens that are often

intergenerational. The central problem is that these scientifically proven interventions are not routinely available to

the children and their families who need them. The interventions often fail to take into account the diverse

sociocultural context and settings in which they will be implemented and are consequently not sustainable. At the

same time, the majority of treatments and services children and adolescents receive in the community have either not

been evaluated to determine their effectiveness or are simply ineffective. The gap between research and practice

continues to widen; part of closing the gap entails investigating the best methods for deploying

evidenced-based approaches in real-world settings. 

Our ability to create a promising future for the country depends, in part, on our ability to ensure that all

children have the opportunity to meet their full potential and live healthy, productive lives. Meeting this

challenge will require the work of many people. The research community must partner with families,

providers, policymakers, and Federal agencies providing children’s services, as well as other

stakeholders, to create a knowledge base on interventions and services that is usable, disseminated, and

sustained in the diverse communities where children and their families live. Equally important to this

effort is the need to develop the capacity of the field. A new generation of truly interdisciplinary

researchers must be trained to strengthen the science base on child and adolescent mental health

research and bridge the gaps within and across research, practice, and policy.

We appreciate the opportunity to provide this report. Together with key stakeholders, and with your help,

we hope to chart a new course for the future of child and adolescent mental health research. 

Sincerely,

Mary Jane England, M.D., Chair, NAMHC Workgroup on Child and Adolescent Mental Health Intervention

Development and Deployment
1

Executive Summary and

Recommendations

In the United States today, one in 10 children and

adolescents suffers from mental illness severe

enough to result in significant functional

impairment. Children and adolescents with mental

disorders are at much greater risk for dropping

out of school and suffering long-term

impairments. Recent evidence compiled by the

World Health Organization (WHO) indicates that

by the year 2020, childhood neuropsychiatric

disorders will rise by over 50 percent

internationally to become one of the five most

common causes of morbidity, mortality, and

disability among children. These childhood mental

disorders impose enormous burdens and can have

intergenerational consequences. They reduce the

quality of children’s lives and diminish their

productivity later in life. No other illnesses

damage so many children so seriously. 

In light of the pressing needs of children and

adolescents with mental illness, the NAMHC

recommended to NIMH Director Steven Hyman,

M.D., that a Workgroup on Child and Adolescent

Mental Health Intervention Development and

Deployment be established. Dr. Hyman charged

this group with reviewing research and training,

specifically (1) assessing the status of the NIMH

portfolio and identifying research opportunities in

the development, testing, and deployment of

treatment, service, and preventive interventions

for children and adolescents in the context of

families and communities; (2) assessing the

human resource needs in recruiting, training, and 

retaining child mental health researchers; and 

(3) making recommendations for strategically

targeting research activities and infrastructure

support to stimulate intervention development,

testing, and deployment of research-based

interventions across the child and adolescent

portfolio. This report is the result of their work

over the past year. 

Ten years ago, after the Institute of Medicine

released the report “Research on Children and

Adolescents with Mental, Behavioral and

Developmental Disorders”(IOM, 1989), the NIMH

issued a “National Plan for Research on Child and

Adolescent Mental Disorders,” which helped shape

the current research agenda. As a result of this

national plan, research in the field of child and

adolescent mental health has expanded

dramatically. Much has been learned about the

identification and treatment of mental illness in

children. But many issues remain unresolved.

Stigma continues to be a significant barrier to

mental health treatment for children and their

families, despite public education efforts.

Scientifically proven treatments, services, and

other interventions do exist for some conditions

but are often not completely effective. Most of the

treatments and services that children and

adolescents typically receive have not been

evaluated to determine their efficacy across

developmental periods. Even when clinical trials

have included children and adolescents, the

treatments have rarely been studied for their

effectiveness in the diverse populations and

treatment settings that exist in this country. 
2

Finally, those interventions that have been

adequately tested have not been disseminated to

the children and their families who need them,

nor to the providers who can deliver them.

Services for children are often fragmented, and

many of the traditional service models do not

meet the needs of today’s children and families. In

sum, there is a shortage of evidence-based

treatment, and much of the evidence that does

exist is not being used. As a result, the burden of

mental illness among children and adolescents is

not decreasing. 

In the past few years, this burden has not gone

unnoticed. There has been heightened activity in

this area, launched by the issuance of the

landmark document “Mental Health: A Report of

the Surgeon General” (U.S. Public Health Service,

1999), which included a chapter focused on the

mental health needs of children. This seminal

report marked a turning point in the public focus

on mental health by clearly documenting the

pressing public health need for effective mental

health services and highlighting the scientific

advances that now offer hope for individuals with

mental illness. An offshoot of that effort, “A

Report of the Surgeon General’s Conference on

Children’s Mental Health: A National Action

Agenda” (2000), provided a blueprint for

children’s mental health research, practice, and

policy. In addition, “The Surgeon General’s Call to

Action to Prevent Suicide” (1999) provided a plan

to increase awareness and prevent suicide in the

United States. Several other reports contributed to

this escalating national dialogue, including

“Youth Violence: A Report of the Surgeon General”

(U.S. Public Health Service, 2001), which

reviewed the scientific literature on the cause and

prevention of youth violence; “A Good Beginning”

(Child Mental Health Foundations and Agencies

Network, 2000), a monograph on the importance

of children’s socioemotional school readiness; and

“From Neurons to Neighborhoods: The Science of

Early Childhood Development” (National Research

Council and Institute of Medicine, 2000). 

This intense national interest in children’s mental

health has arisen, in part, from the rapidity of

research advances in neurosciences, genetics,

behavioral sciences, and social sciences. Progress

in developmental neuroscience and genetics, for

example, is beginning to illuminate how the brain

functions at the molecular, cellular, and neural

systems levels. Similar advances have been made

in the basic behavioral sciences and in clinical

treatment and prevention research targeted at

specific childhood disorders. Some of the key

findings that will help guide future research are

listed below; for an overview of advances in the

specific research areas, see Section II.B., Key

Scientific Areas of Research. 

A Decade of Progress: 

Key Findings in Neuroscience,

Behavioral, Prevention, and

Treatment and Services Research

 The impact of genes on behavior is complex;

multiple genetic and nongenetic factors interact to

produce cognitive, emotional, and behavioral

phenotypes. Genes and the environment interact

throughout development in ways that are not

simply additive; for example, genes influence the

nongenetic aspects of development (covariance).

 A child’s environment, both in and out of the

womb, plays a large role in shaping brain

development and subsequent behavior. Studies of

the caregiving environment suggest that extreme

environments (such as abuse and neglect) may

affect brain cell survival, neuron density, and

neurochemical aspects of brain development, as

well as behavioral reactivity to stress in childhood
3

and adulthood. Methods to understand the more

subtle effects of the environment on synapses and

circuits are likely to become available in the near

future.

 Research has demonstrated the remarkable

plasticity of the brain and, in certain neural

systems, the ability of the environment to

influence neural circuitry during childhood.

 Researchers have found that difficulties with

attentional self-regulation can contribute to

behavioral problems and difficulties in school;

research tracing normal development and

individual differences in these regulatory controls

has important implications for advancing

understanding of the causes of a variety of

childhood disorders in which regulatory deficits

are implicated (e.g., attention deficit hyperactivity

disorder [ADHD], mood and anxiety disorders).

 Progress has been made on the identification

of developmental models that describe how

cumulative risk factors contribute to adjustment

problems and mental disorders, including conduct

problems, substance abuse, high-risk sexual

behavior, and depression. Risk factor studies have

identified some potent and malleable targets.

 New methodological designs and statistical

techniques have been developed to strengthen

prevention trials (which are complex by their very

nature) and have provided a conceptual basis for

designing and evaluating prevention programs.

 Effective treatments, both psychosocial and

psychopharmacological, have been developed to

improve outcomes for some children and

adolescents. 

 Research has now documented that

psychosocial interventions and services may also

enhance the impact of pharmacological treatment.

 Advances in medication treatment are

especially promising for several child and

adolescent disorders, including ADHD, obsessivecompulsive disorder (OCD), other anxiety

disorders (generalized anxiety, separation anxiety,

and social phobia), and adolescent depression.

Major studies are currently underway to test the

benefits of psychotherapy, medication, and

combined treatment for selected major mental

disorders affecting youth.

 Medication management and combined

treatments (medication plus behavior therapy) for

children with ADHD have been found to be

effective in targeting core ADHD symptoms.

Combined treatments are effective in improving

non-ADHD symptoms (e.g., disruptive behaviors

and anxiety symptoms) and functional outcomes

(e.g., academic achievement, parent-child

relations, and social skills). 

 Multisystemic therapy (MST), a treatment

approach that addresses both the individual child

and the child’s context, is another promising

intervention. Multiple trials have indicated

beneficial effects of MST for youth with conduct

problems. Positive outcomes include decreasing

externalizing symptoms and improving family

functioning and school attendance. 

 Research has also identified treatments that

are potentially ineffective or, worse yet, harmful. 

Some forms of institutional care do not lead to

lasting improvements after the child is returned to

the community. Some services provided to

delinquent juveniles are also ineffective (e.g., boot

camps and residential programs); peer-groupbased interventions have been found to actually

increase behavior problems among high-risk

adolescents. 

 Research on mental health economics has

provided more accurate data on expenditures for

mental health services in specialty mental health

and general health sectors; 1998 annual

expenditures were $11.75 billion, or about $173

per child. This is nearly a threefold increase from

the 1986 estimate of $3.5 billion (not accounting

for inflation).

 New utilization data indicate that there is an

increase in the rate of outpatient mental health

service use since the 1980’s; however, only 5

percent to 7 percent of children receive some
4

specialty mental health services, in contrast to an

estimated 20 percent with a diagnosable mental

disorder. 

The Challenges: 

Developing Effective Prevention

Programs, Treatments, and Services

In a field as complex as children’s mental health,

developing effective solutions requires coordinated

efforts within and across multiple disciplines. The

research advances highlighted above, coupled

with growing knowledge about clinical

interventions and services afford an opportunity

for interdisciplinary exchange and integration of

knowledge across a range of specialized research

areas. However, several issues complicate efforts

to undertake interdisciplinary work in the field of

child and adolescent mental health. 

DEVELOPMENT

Children’s rapid growth and development greatly

amplifies the complexity of interdisciplinary

research. Integrating this developmental

perspective is critical to advancing research on

child and adolescent mental illness, prevention,

treatment, and services. Childhood is

characterized by change, transition, and

reorganization; understanding the reciprocal

influences between children and their

environments throughout the developmental

trajectory is critical.

SOCIAL CONTEXT

Another issue that impedes progress is the fact that

few of the evidence-based interventions have taken

into account the child’s social context. For

example, the social context has not been studied in

sufficient detail to know whether interventions can

be generalized across populations, settings, or

communities. The majority of studies on child and

adolescent mental health interventions have not

attended to differences in race, ethnicity, culture,

socioeconomic status, community/neighborhood

context, and wider systemic issues. Attending to

these factors is critical, particularly for children and

families living in poverty. Inattention to these

issues becomes most apparent when stakeholders,

including families, providers, payers, and

community leaders, ask about the relevance of

research findings for their communities or

populations. While knowledge about the efficacy of

treatments is increasing at a rapid rate, the

effectiveness and transportability of these

treatments to diverse populations and settings are

less clear. 

DISCIPLINARY INSULARITY

Another challenge is the insularity of the many

disciplines involved in clinical and research

training. This insularity threatens to impede

progress at precisely the time when rich

opportunities for interdisciplinary work exist. For

example, the following disciplines are likely to have

some component of training relevant to the mission

of this report: Psychiatry, pediatrics,

developmental and behavioral pediatrics,

adolescent medicine, nursing, epidemiology,

developmental neuroscience, cognitive and

behavioral neuroscience, social work, clinical

psychology, developmental psychology, and

developmental psychopathology. Other fields that

can contribute significantly include public health,

anthropology, and economics. Because of the rigors

and traditions within each area, it can be extremely

difficult to create training programs that cross these

boundaries.

Clinical care providers (e.g., pediatricians, family

medicine physicians, pediatric nurses, psychiatric

nurses, social workers, and others) are also
5

critical to this partnership. The insularity of

disciplines that presents research barriers also

affects the adoption of research findings in

practice settings; it is unlikely that treatment

practices developed in one discipline will find

their way into other professional disciplines. The

fragmentation of systems serving children with

mental health needs further complicates

interdisciplinary efforts. Thus, clinical providers in

primary care are unlikely to adopt mental health

screening or early intervention methods developed

in child psychology or psychiatry, even though

such knowledge may be critical to child mental

health promotion and early intervention efforts.

Compounding the problem of insularity is the

decline over the past 10 years in the number of

new investigators seeking research careers to

study child and adolescent mental health. Reports

from associations representing child and

adolescent physicians suggest that dwindling

numbers are choosing to enter research careers.

To strengthen the science base on child and

adolescent mental health, the research-training

infrastructure must be enhanced to support a

cadre of investigators who can conduct

interdisciplinary research to bridge the gaps

among research, practice, and policy. 

Overcoming the Obstacles:

Establishing Linkages

Despite these obstacles, the prospects for gaining

a deeper understanding of the complexities of

child and adolescent mental illnesses—what

causes them, what interventions are effective, and

how to get these interventions to those who need

them— are better now than at any time in the

past. This report enters the ongoing national

conversation and proposes the use of new models

for integrating basic research with intervention

development and service delivery. It also

underscores the importance of using a

developmental framework to guide research in

child and adolescent intervention development

and deployment. Two critical action steps must be

taken to move ahead: 

(1) Linkages must be made among

neuroscience, genetics, epidemiology, behavioral

science, and social sciences, and the resulting

interdisciplinary knowledge must be translated

into effective new interventions. 

(2) Scientifically proven interventions must be

disseminated to the clinics, schools, and other

places where children, adolescents, and their

parents can easily access them. This means that

the science base must be made usable. To do so

will require partnerships among scientists,

families, providers, and other stakeholders. 

While many of these issues have been discussed

in other recent reports, among the most important

contributions of this report are the strategies it

provides to overcome the obstacles outlined above

and the direct application of these strategies to

child and adolescent populations. This report

suggests ways to integrate previously isolated

scientific disciplines, with the goals of both

creating an interdisciplinary and well-trained

cadre of child and adolescent researchers and

strengthening the currency of mental health

science. This report also provides strategies for

linking basic science findings to the development

of new interventions and ensuring that they are

positioned within the context of the communities

in which they will ultimately be delivered. Doing

so requires the utilization of a new model of

intervention development, wherein factors

influencing the ultimate dissemination of the

intervention are considered from the start. 
6

PRIORITY AREA 1: BASIC SCIENCE AND THE

DEVELOPMENT OF NEW INTERVENTIONS

The linkages among neuroscience, genetics,

epidemiology, behavioral science, and social

sciences provide opportunities for increasing our

understanding of etiology, attributable risk, and

protective processes (their relative potency,

sequencing, timing, and mechanisms). Such

knowledge is critical for the creation of

developmentally sensitive diagnostic

approaches and theoretically grounded

interventions. One critical piece of knowledge

needed is an understanding of the etiology of

mental illnesses, which can lead to better

identification of “high-risk” groups as the target

for these early interventions, as well as “highrisk” or vulnerable intervals in development.

Despite our appreciation of developmental

perspectives, many evidence-based interventions

for children and adolescents continue to represent

downward extensions of adult models, with

limited consideration of basic knowledge about

how causal mechanisms or processes operate or

may vary across developmental or sociocultural

contexts. Conceptual approaches and

developmental theories are needed to guide

intervention and dissemination efforts.

Information from developmental neuroscience,

behavioral science, and epidemiology should be

used to formulate competing and testable

hypotheses about those developmental processes

that lead to mental disorders. At the same time,

knowledge gleaned from intervention testing and

dissemination research must inform basic

research theory and development.

PRIORITY AREA 2: INTERVENTION

DEVELOPMENT, MOVING FROM EFFICACY TO

EFFECTIVENESS

The current model of treatment development

(typically followed in biomedical science studies)

stipulates that such development begin in

laboratory settings; that highly specific sample

selection criteria be used; that refinement,

manualization or algorithm development, and

delivery be carried out by research staff (as

opposed to practicing clinicians); and that aspects

of the service setting where it is ultimately destined

to land be ignored. This model creates an illusion

that science-based treatments are not meant to be

used or usable. This report suggests that a different

model of intervention development be followed.

This new model requires two strands of research

activity: The first strand necessitates a closer

linkage between basic science and clinical realities

(as described in Priority Area 1); the second strand

requires that a focus on the endpoint and its

context—the final resting place for treatment or

service delivery—be folded into the design,

development, refinement, and implementation of

the intervention from the beginning. Furthermore,

such interventions should be developmentally

sensitive and take into account family and

cultural contexts. Finally, in order to explain why

treatments work, it will be important to identify

core ingredients of the intervention, including the

mechanisms that led to therapeutic change and

the processes that influenced outcomes. 

PRIORITY AREA 3: INTERVENTION

DEPLOYMENT, MOVING FROM EFFECTIVENESS

TO DISSEMINATION

For evidence-based interventions to be used in

clinical practice, knowledge about effective

dissemination strategies is needed. The application

of the traditional biomedical model of intervention

development, described above, does not necessarily

lead to interventions that are adaptable, applicable,

or relevant to real-world clinical practices. To

ensure that the current evidence base is

used appropriately, a new genre of scientific effort
7

is needed to better understand factors that

influence the transportability, sustainability, and

usability of interventions for real-world conditions.

Many promising preventive and treatment

interventions have not paid enough attention to

factors that influence family engagement in

services, for example, nor to the broader

socioecological contexts and systemic issues that

influence access to and use of such services. Such

research is critical if the current evidence base on

effective interventions is to be brought to scale,

sustained in service settings, and made accessible

to the children and families in need. 

Interwoven among these priorities is the critical

need to support interdisciplinary training. To

ensure that the next generation of scientists is

prepared to integrate the rapid advances in

multiple disciplines, interdisciplinary training

must be made an integral part of future child and

adolescent mental health research. 

The Future of Child and Adolescent

Mental Health Intervention Research

The development and dissemination of new,

research-based mental health interventions for

children and adolescents will require that scientists

create partnerships with community leaders,

families, providers, and other stakeholders.

Thoughtful scientific partnerships will also need to

be forged across different scientific disciplines if the

power and promise of basic neuroscience and

behavioral science is to be realized through

improvements in clinical care. Significant

challenges exist: The ethical complexities

underlying new research advances will necessitate

careful application of oftentimes elusive principles.

Such complexities must be thoughtfully resolved.

Furthermore, the rapid pace of technological

advances will make it possible to move services

away from traditional settings and into innovative

venues, such as the Web, chat rooms, or other

nonclinic settings. But new technology brings new

scientific and practical challenges, and these, too,

will require careful deliberation. 

This report describes a 10-year plan for advancing

research on child and adolescent mental health

interventions. This report, framed within a public

health perspective and supported by taxpayer

dollars, will have merit only insofar as it leads to

improvements in the quality of care children and

adolescents receive, and thus improvements in the

quality of the lives they lead. The toll that

preventable, untreated, or poorly treated mental

illness takes on children, adolescents, and their

families is profound and unacceptable. In the past

10 years a vast amount of knowledge has been

garnered about the prevention, identification,

treatment of, and services for mental illnesses in

children and adolescents. This knowledge can and

should be used to improve care. But in the next

decade, we must be more exacting. The next

generation of child and adolescent mental health

science will require a transformation of form,

function, and purpose if a true public health

model is to be realized and sustained.

Recommendations 

To mark this new generation of research, the 

next section describes the workgroup’s

recommendations in three broad areas. The first is

the area of interdisciplinary research development

on child and adolescent interventions.

Recommendations in this section are designed to

create interdisciplinary research networks and

establish a forum for the creative exchange of

collaborative research projects to foster new

approaches to common problems. The focus of

these networks should be on targeted problems, the
8

solution to which may lie outside the scope of a

single discipline. The second area is focused on

developing new training initiatives to build a

cadre of high-caliber scientists to tackle future

problems in child and adolescent mental health.

Interdisciplinary research training is needed to

provide multiple perspectives on intractable

problems. Because we recognize that the viability

of such interdisciplinary efforts depends, in part,

on continuing advances in specific scientific

disciplines, the third set of recommendations is

targeted toward advancing programs of research

in particular areas. Implementation of all three

sets of recommendations may have to be staged

and focused to accomplish the goal of disciplined

growth.

I. INTERDISCIPLINARY RESEARCH

DEVELOPMENT IN CHILD AND ADOLESCENT

MENTAL HEALTH

A. CHILD AND ADOLESCENT

INTERDISCIPLINARY RESEARCH NETWORKS

(CAIRN’s)

We recommend that NIMH create support for the

implementation of Child and Adolescent

Interdisciplinary Research Networks (CAIRN’s) to

strengthen and accelerate research on

intervention development and deployment. The

goals of this initiative are to create a series of

interdisciplinary research networks that include

research-training support and to encourage

collaborative research among scientists from

different institutions and disciplines. The primary

purpose of the CAIRN’s will be to introduce new

approaches to common problems and support

collaborative and integrative research activities

across scientific fields.

We recommend that three types of networks be

developed, congruent with the research agenda and

mission of NIMH: (1) Developmental Basic Science

and Clinical Intervention Networks, (2) Treatments

and Services Practice Networks, and (3) Implementing Evidence-based Practice Networks. These

three sets of networks are targeted at different sets

of research problems in the field of child and

adolescent mental disorders. The networks should

be set up flexibly to encourage interdisciplinary and

integrative activities on shared research goals. The

aim of the networks is to provide a framework to

foster the development of integrative research

teams and to provide flexibility for addressing

complex scientific questions. 

1. Developmental Basic Science and Clinical

Intervention Networks (DBCI s)

These networks would focus on linking

developmental processes to basic neuroscience or

behavioral science, with an explicit focus on

creating new assessment models and

interventions. These networks will concentrate on

underdeveloped areas that hold promise for

understanding developmentally sensitive transition

points in children's lives. An overarching goal will

be to map extant knowledge about the functioning

of the brain against current behavioral indices

within a developmental context. The purpose is not

to encourage observational studies of risk factors

but rather to develop testable models for enhancing

etiologic understanding of disorders, to improve

assessment strategies, and to develop new

treatment models. DBCI networks could address

the following research topics:

 Early environment factors (prenatal and

postnatal) that influence the development of

neural systems involved in attention, impulsivity,

and disruptive behavior

 Behavioral and neurobiological deficits in

autistic spectrum disorders (e.g., social cognition

as it relates to brain activity and the development
9

of behavioral and pharmacologic interventions for

improvement of autistic symptoms)

 Neural bases of habitual or repetitive

behaviors 

 Effects of stress on brain and behavior

development as it relates to the regulation and

dysregulation of mood and emotions 

 Extinction of fear and regulation of anxiety

 Interactions among temperament, mood,

emotion, and cognition (e.g., attentional

processing) and their implications for behavioral

and learning difficulties 

2. Treatments and Services Practice

Networks (TSP s)

To encourage interdisciplinary research on the

development of new treatments, Treatments and

Services Practice Networks (TSP’s) should be

created. These networks could provide support to

facilitate the development of culturally sensitive

treatments that are feasible, cost-effective, and

readily disseminated. These networks could

combine basic science expertise with clinical and

services expertise to answer questions related to

improving treatment efficacy, effectiveness, and

delivery within routine practice. These networks

should reflect family, youth, and practitioner

input on questions of interests and outcomes.

Such networks could include (a) treatment

development in partnership with practice

communities to create new interventions within

service settings, (b) the expansion of treatment

trials into routine practice settings, or the (c)

expansion of the Research Units on Pediatric

Psychopharmacology (RUPP’s). TSP’s could

address the following research topics:

 Development of treatment algorithms for

clinical decision-making

 Development of triage guidelines to tailor

severity of clinical problems to dosage, intensity,

or types of treatments or services

 Development of new psychosocial treatments

for delivery within primary care, school-based

health clinic, or other community practice settings

 Development of psychosocial treatments that

attend to the social-ecological environment of the

child and his/her family

3. Implementing Evidence-based Practice

Networks (IEP s)

These networks would focus on linking evidencebased interventions to dissemination, financing,

and policy research. The Implementing Evidencebased Practice Networks (IEP’s) would examine

the application of dissemination and quality

improvement strategies for implementing the

scientific knowledge base on evidence-based

practices for children and adolescents. While the

TSP’s are designed to develop new treatments and

services through connections among basic

scientists and providers, the IEP’s would focus on

studying how empirically supported interventions

that already exist (or will exist) can be effectively

deployed, sustained, and implemented in diverse

communities, with particular attention to costeffectiveness and quality. The translation would

focus on moving efficacy-based findings into a

range of practice settings and specifically on

encouraging interdisciplinary studies among

health economists, behavioral, services and

clinical scientists. Critical to this translation is the

role of youth and families in defining

implementation strategies. The following issues

might be the focus of such networks:

 Use or adaptation of empirically tested

treatments in community clinic settings where

usual care has not previously included such

treatments 

 Application of evidence-based assessment

tools or preventive interventions with young

children 

 Use of evidence based practice in primary

care and in school-based health clinics
10

 Use of depression screening and evidencebased treatment for depression in a variety of

settings

 Implementation of parenting education in

primary care settings

 Studies of factors influencing how

practitioners and families manage youth disorders

and the use of evidence-based treatments

B. OVERALL STRUCTURE AND

CHARACTERISTICS OF NETWORKS

1. We recommend that all three of these

networks include research infrastructure support

to enable trainees and junior faculty to obtain

training and mentorship in the networks. As

feasible, these could be integrated with existing

mechanisms. Additional training

recommendations are described below in Section

II, Interdisciplinary Research Training in Child and

Adolescent Mental Health.

2. We recommend that the proposals submitted

in response to the initiative on CAIRN’s be

reviewed in-house at NIMH and not through the

Center for Scientific Review (CSR). Regardless of

the location of the review, program staff should

work in conjunction with Scientific Review

Administrators (SRA’s) to inform Institutional

Review Groups (IRG’s) about these areas of

emphasis. 

3. Although the three types of networks are

focused on different sets of research problems, we

recommend that the directors of all the networks

meet annually to share research advances, to

strengthen training opportunities among the

networks, and to plan for expansion or refinement

of their interdisciplinary studies. Trainees should

be invited to these annual meetings. 

4. We recommend that NIMH consider cosponsorship from other Federal agencies in

developing and funding these CAIRN’s, where

appropriate. 

II. INTERDISCIPLINARY RESEARCH

TRAINING IN CHILD AND ADOLESCENT

MENTAL HEALTH

A. CAPACITY BUILDING

1. We recommend that NIMH develop a

payback program whereby individuals who pursue

careers in child and adolescent research may

apply for loan forgiveness. 

 

2. We recommend that NIMH develop

additional mechanisms to support mentoring for

new research scientists in child and adolescent

mental health. This program may include funding

for sabbatical leaves or teaching/mentoring time,

provided in the form of supplements to grants.

Funding for teaching/mentoring time is critical

because there are so few clinical investigators, all

with multiple demands on their time.

3. To build the research capacity needed to take

advantage of the promise of interdisciplinary

research, we recommend that NIMH issue a new

initiative for the creation of Child and Adolescent

Interdisciplinary Training Institutes (CITI’s). Basic

requirements would include training or exposure in

at least the following scientific areas: basic

behavioral and neuroscience, epidemiology,

prevention, intervention development, services

research, and health economics. Training seminars,

summer institutes, and intensive coursework on

methodology, statistics, and the range of service

settings where mental health services are typically

delivered (e.g., schools, primary care, community

clinics) would be required. To initiate CITI’s, we

recommend that NIMH establish one or two pilot
11

educational research experiences in interdisciplinary and developmental research with the explicit

focus of encouraging child and adolescent studies.

The overall purpose would be to work out

pragmatic and feasibility issues in detail in at least

one or two universities on how to effectively

integrate basic and clinical training for clinically

oriented investigators. Successful pilot programs

would serve as models for further interdisciplinary

training programs. We also recommend that the

directors of the CITI’s meet annually to discuss 

training initiatives and new programs and to

modify educational objectives as needed. 

4. We recommend that a special announcement

be issued for child and adolescent research

supplements. Modeled along the lines of minority

supplements, they would be used to encourage

investigators in other fields (e.g., adult mental

health, primary care, education, neurology) to

receive training in child and adolescent mental

health and thus increase the numbers of

investigators with expertise in child mental health

research.

5. We recommend that NIMH develop a national

mentorship program to increase the number of

racial/ethnic minorities among NIMH-funded

trainees who can address the unique needs of

minority children. This mentorship program could

include the NIMH Intramural Research faculty.

Such an effort is critical in light of changing

demographics; minority children are increasingly

represented among those with significant mental

health needs.

B. PARTNERSHIPS TO FACILITATE RESEARCH

TRAINING

To enhance child and adolescent research training

activities, NIMH should explore opportunities to

partner with other Federal agencies. Potential

partners include the Maternal and Child Health

Bureau (MCHB) and the Agency for Healthcare

Research and Quality (AHRQ), Health Research and

Services Administration (HRSA); the Center for

Mental Health Services (CMHS) and the Center for

Substance Abuse and Prevention (CSAP), Substance

Abuse and Mental Health Services Administration

(SAMHSA). For example, NIMH should consider

MCHB’s Leadership in Education in Neurodevelopmental Disabilities (LEND) programs as an

avenue for including more of a mental health

perspective. 

III. RECOMMENDATIONS FOR PROGRAM

DEVELOPMENT IN SPECIFIC RESEARCH

AREAS 

A. NEUROSCIENCE 

1. We recommend that databases of rodent and

human brain maps be established and supported. 

We particularly emphasize that these databases

need to have a developmental dimension.

2. We recommend that cross-Institute initiatives

be fostered to establish genomic databases. 

3. We recommend funding program projects to

bring together investigators from a variety of

disciplines to examine the developmental effects of

well-recognized conditions (e.g., stress and the

hypothalamic-pituitary-adrenal axis [HPA] system). 

4. We recommend that technological and

procedural advances be supported that (a) allow

scanning of very young normal children, (b) enable

the development of non-invasive imaging

procedures that can be used on awake behaving

primates, and (c) encourage the development of

functional magnetic resonance imaging (MRI)

which can image potentially powerful rodent

models of genetic disease.
12

5. Integrative approaches to studies of brain

development and function are needed. Examples

include (a) combining techniques of neuroimaging

with simultaneous physiological monitoring and/or

emotional testing, hormonal measurements, and so

on; (b) electrophysiology at both the single-cell and

multiunit levels to study molecular and circuit

regulation in animal models of behavioral

dysfunction; and (c) mutant animal models that

allow researchers to study epigenetic determinants

of brain development (e.g., constitutively

manipulated mice may reveal compensatory

developmental changes relevant to behavior).

6. A major gap exists in the availability of data

relating developmental trajectories across multiple

levels of description, from genetic processes to

behavioral competencies. Data are needed in the

following areas:

 Cross-species differences and correspondences

in neural and behavioral development, the impact

of differing genetic backgrounds, and the validity of

various phenotyping procedures in animals as

behavioral markers of psychopathological

outcomes.

 Gender differences and the putative actions of

gonadal steroids, changes in neurocircuitry with

puberty, and their relationship to cognitive,

behavioral, and emotional regulation during

adolescence.

B. BEHAVIORAL SCIENCE 

1. Research is needed on how different

components of cognition (e.g., attention, language,

memory, social) develop in normative and clinical

groups of children in order to shape intervention

and preventive strategies. This research can

increase our understanding of how children with

cognitive deficits associated with mental illness

may benefit from intervention efforts and perhaps

develop new or compensatory skills. Such studies

have implications for the prevention or

development of more severe impairments or

comorbid conditions.

2. We recommend detailed empirical study of the

specific psychological and behavioral functions that

are impaired in childhood mental disorders. Critical

domains include memory, attention, emotional

processing, emotional expression, social cognitive

capacities, and several dimensions of child

temperament. Specifying the nature of disorders in

terms of these domains will not only improve

nosology, but it will also be critical in making

connections to neural substrates and in identifying

genetic and experiential factors in etiology. As a

result, such an effort will pave the way for the

design and implementation of increasingly welltargeted modes of preventive and treatment

intervention. 

3. We recommend research focused on

developmental, behavioral, and social regulators of

emotions at key transition periods, such as birth

and puberty, and social transitions, such as

daycare and elementary school. 

4. We recommend the development of sciencebased interventions that link the

psychophysiological deficits associated with mental

disorders (e.g., attention, information processing)

with specific functional problems, with the aim of

formulating more effective and targeted

intervention strategies.

5. We recommend that NIMH support the

development of measurements of functioning that

are both culturally sensitive and multidimensional.

New tools and approaches that combine qualitative

and quantitative methods are needed to understand

issues associated with children from diverse

cultures and subcultures. In addition,

measurements are needed that complement
13

traditional symptom-based diagnostic systems

and serve as outcome indicators in intervention,

services, and risk processes research. 

6. We recommend developing measures and

interventions through ethnography. The

diagnostic conundrums that plague childhood

nosology and the pervasive concern about

labeling young children suggest that rigorous

ethnographic or other qualitative methods for

describing mental illness may be particularly

useful in developing interventions that are

sensitive to a variety of living environments,

communities, and cultural contexts. 

7. We recommend new behavioral research to

identify how providers and families manage

children’s disorders and why they do or do not

engage in the most effective practices. Behavioral

science has significant promise to reveal why

treatments are not more widely disseminated,

what factors underlie complex health behaviors,

and the types of decision-making strategies that

guide current practice.

C. PREVENTION 

1. We recommend that attention be paid to

smaller, focused, and intensive longitudinal

studies, informed by basic research. 

2. Given the extensive number of data sets

examining risk and protective factors, we

recommend that a workshop be convened to

identify opportunities for reanalysis of existing

data sets. Examples of questions for such studies

would include areas of attributable risk, predictors

of resilience, interaction of different types/levels of

risks across time, how impairment is affected by

context, and the impact of contextual and cultural

variables on functioning over time.

3. A new emphasis is needed on prevention

effectiveness trials, prevention services, and costeffectiveness of preventive strategies. Studies that

focus on service contexts that facilitate or impede

the sustainability of preventive interventions are

especially needed. 

4. Prevention research trials, by their nature,

require longitudinal follow-up and the use of

fairly sophisticated efforts to determine the effects

of the interventions. Support for methodology

development, especially the analysis of

longitudinal data where the phenomena wax and

wane, is needed via program announcements or

conferences. 

5. Research on relapse prevention, desistance,

and naturally occurring prevention is greatly

needed. 

D. PSYCHOSOCIAL INTERVENTIONS

1. We strongly urge that treatment studies

move beyond assessing outcomes to focus more

attention on the mechanisms or processes that

influence those outcomes. These mechanisms may

involve basic processes at different levels (e.g.,

level of neurotransmitters or stress hormones,

information processing, learning, motivation,

therapeutic alliance) and may be mediated by

therapeutic approaches (e.g., practicing new

behaviors, habituating to external events).

Understanding the mediators and moderators of

outcomes will be important in identifying the

ingredients required for therapeutic change. 

2. We further recommend that treatment

outcome studies assess outcomes beyond child

symptom reduction to include functioning across

various domains (e.g., school functioning, social

interactions, family interactions, adaptive

cognitions) to provide a more comprehensive
14

picture of the benefits of psychosocial

interventions. 

3. We recommend that NIMH promote a

scientific agenda on the generalizability of

psychosocial treatments by targeting funds

toward the development or adaptation of

psychosocial treatments that are implementable in

real-world settings (e.g., schools and primary

care), including the transportability of treatments

with minority populations. Attention to the

impact of development, culture, and context on

the effectiveness of psychosocial treatments must

be a priority. Such efforts will require the

development of new methodologies to address the

issue of increased heterogeneity in effectiveness

trials, treatment fidelity (flexible vs. rigid

adherence to treatment protocols), a clear

definition of “treatment as usual,” and the use of

appropriate comparison groups.

4. We recommend that the psychosocial

treatment program target the critical research

gaps listed below:

 Comorbidity (e.g., substance abuse and

depression, anxiety and depression, medical and

psychiatric disorders)

 Potentially life-threatening conditions (e.g.,

eating disorders, suicide), bipolar disorders,

anxiety spectrum disorders, autism, neglect,

physical and sexual abuse, early-onset

schizophrenia

 Gateway conditions of disorders (e.g.,

oppositional defiant disorder [ODD] as a gateway

to conduct disorders, trauma as a gateway to

post-traumatic stress disorder [PTSD], or ADHD as

a gateway to ODD/conduct disorder/substance

use) to divert onset of more serious disorders or

impairments

 Parental mental illness and its influence on

the prevention and treatment of child and

adolescent mental disorders 

5. We recommend that priority be given to

treatment modalities beyond cognitive behavioral

therapy and behavior therapy (e.g., family therapy,

Internet-based interventions), studies comparing

psychosocial interventions for the same conditions

(e.g., comparing combined treatment involving

parent training and parent-child relationship

therapy vs. child-focused interventions), and

studies that address the issue of sequential

psychosocial treatments and/or combined

psychosocial and psychopharmacology treatments.

6. We recommend that NIMH give funding

priority to studies of common treatments and

services available in the community (e.g.,

wraparound, treatment foster care, residential

care, hospitalization), as they may provide a

promising avenue for discoveries of new

treatment approaches or strategies.

7. Because so few studies have assessed the

long-term outcomes of interventions (beyond 5

years), and because assessments of the costeffectiveness as well as clinical and functional

outcomes are needed to determine the benefits of

treatment and impact on course of illness, we

recommend that NIMH encourage long-term followup studies of treated and untreated populations.

E. PSYCHOPHARMACOLOGY

1. We recommend expansion of the RUPP’s to

include the capacity for launching/conducting large

simple trials to study issues such as comorbidity,

dosing, and safety and efficacy of medication

treatments across diverse cultural populations. 

2. We recommend increased research on the

psychopharmacological management of serious
15

mental illness (e.g., early-onset schizophrenia,

bipolar disorder, eating disorders, severe

depression) and pervasive developmental

disorders (including autism and Tourette’s).

3. We recommend that NIMH support the study

of nonspecific symptoms that are often the targets

of psychopharmacology management in children

(e.g., aggression and sleep problems), but that

have not been measured specifically. Better

assessment measures to identify such symptoms

need to be developed so that the symptoms can be

assessed across disorders, and trials for these

symptoms, independent of disorder diagnosis,

may be considered.

4. Disorder-based efficacy trials for new

medications are currently being conducted for

acute treatment, particularly for medications

under patent protection. However, very few

studies to examine long-term safety and efficacy

are supported. We recommend that NIMH support

such studies.

5. We recommend the development of better

study paradigms on psychopharmacology

effectiveness, including augmentation strategies,

multiple medication strategies, and the use of

algorithmic treatments. Rational approaches to the

management of comorbid disorders, medication

side effects, and treatment resistance are needed. 

6. Studies examining reasons why patients do

or do not follow treatment recommendations are

needed. Further, studies are needed on the impact

of the long-term use of medications, including

their impact on psychosocial functioning. 

7. We recommend supporting basic and clinical

neuroscience research on mechanisms underlying

brain development and the biochemical and

behavioral actions of psychotropic agents in

animals and humans to increase understanding of

drug actions in the developing brain and

individual differences in treatment response (i.e.,

variability in optimal dose levels). Further,

research on brain imaging to identify subtypes of

diagnostic categories may have different

treatment intervention implications. 

8. We recommend that the study of both the

short- and long-term consequences (negative and

positive) of pharmacological interventions

associated with acute, recurrent, and chronic

exposure to psychotropic agents on the developing

brain be a priority for new NIMH initiatives. 

F. COMBINED INTERVENTIONS AND SERVICES

1. We recommend the use of grant supplements

to current service effectiveness projects to

examine factors influencing the adaptability and

sustainability of interventions (e.g., different roles

of family in the research process, strategies for

engaging families, and ways of increasing or

maintaining treatment fidelity).

 

2. We encourage careful attention to issues of

defining, characterizing, and operationalizing

current practice. Currently, researchers largely

ignore usual practice because the variability within

and across practice settings makes these processes

extremely difficult and complex to measure. Yet,

understanding intervention approaches developed

in the field is important, as such approaches often

reflect the needs of children and families and the

constraints of personnel, as well as organizational

and system limitations. Most of these studies will

not be randomized trials because of the nature of

routine practice.

3. We recommend studies that examine how

existing services (e.g., school-based, case

management, mentoring, family support),

combined treatments, and novel delivery

mechanisms (e.g., Internet-based) can be used to
16

augment clinical interventions to meet the

significant needs of children with severe mental

illness or those with multiple problems more

successfully. 

 

4. We recommend studies on the impact of

family engagement and choice regarding the

acceptability of interventions. 

5. We recommend that a mechanism such as a

B/START (Behavioral Science Track Award for

Rapid Transition) be used to establish community

collaboration prior to implementing research

programs. 

6. We recommend that NIMH develop a

national system or a series of regional systems to

track the utilization and costs of child mental

health services. The systematic tracking of broad

indicators of utilization and costs, such as

inpatient days, outpatient utilization by insurance

status, and socioeconomic characteristics, would

allow a more timely recognition of the effects of

major changes in the health care system,

including increasing or decreasing inequities. As

part of these tracking systems, pharmacoeconomic

studies are encouraged. Integration of data

(service use and costs) from other settings likely

to provide a substantial amount of services (e.g.,

the education, juvenile justice, and child welfare

systems) not captured in the existing health

databases is essential. 

7. New technologies will change care

dramatically over the next decade. In addition,

delivery of care is moving away from clinic-based

models and toward models of patient-centered

family care delivered in out-of-office settings,

including on the Internet, in the home, in the

school, in primary care and other settings. Because

this trend is likely to continue, we recommend that

studies of nontraditional delivery of services be 

encouraged and supported through program

announcements or special funding initiatives.

G. DISSEMINATION RESEARCH AND SYSTEM

IMPROVEMENT

1. We recommend that investigators be strongly

encouraged to conduct dissemination studies in

public sector mental health sites, collaborating

with other child-serving sectors. Because of the

major activities of the Center for Mental Health

Services (CMHS) in promoting systems of care

through its Comprehensive Community Mental

Health Services for Children and Their Families

Program, we strongly endorse the NIMH Program

Announcement (PA-00-135), “Effectiveness,

Practice, and Implementation in CMHS’ Children’s

Service Sites.” This program announcement is

sensitive to the need to disseminate evidencebased clinical practice to very high-risk youth

receiving services in public sector programs.

However, to facilitate meaningful research in

these public sector sites, a major technical

assistance effort will be necessary to bring

together investigators and service sites.

2. We recommend that priority be given to

research on the factors that facilitate or impede

the transportability or sustainability of evidencebased treatments. Factors identified may include

extra-organizational factors (e.g., stakeholder

involvement, triage system), organizational

factors, practitioner behavior factors (e.g.,

attitudes and readiness to change), and family

and child characteristics (e.g., attitudes,

preferences, or co-occurring disorders) as they are

related to dissemination and uptake of effective

clinical services. Such factors may guide the

development of incentives to optimize the use and

sustainability of evidence-based treatments. Such

research is especially needed in communities or

populations where disparities in access to mental
17

health care are prevalent, including minority

communities and the uninsured.

3. We recommend that NIMH consider the use

of Small Business Innovation Research program

funds for deployment, method/analysis

development, or dissemination research to

develop new commercial products and potentially

expand the range, function, and effectiveness of

therapeutic services.

4. We support continued partnerships with

other Federal agencies in order to capitalize on

their dissemination arms. These agencies include

those of the U.S. Department of Health and

Human Services (HHS)—CMHS/SAMSHA,

AHRQ/HRSA, MCHB/HRSA, the Administration for

Children and Families, and other NIH

Institutes—the Office of Special Education and

Rehabilitative Services, Department of Education;

and the Office of Juvenile Justice and Delinquency

Prevention, Department of Justice, to carry

forward research advances in both policy and

practice arenas.

5. A highly visible national dissemination effort

is needed. We recommend the creation of a

Dissemination Center. The research focus of this

center would include dissemination and

sustainability studies, with a special focus on

understanding the validity of evidence-based

treatments for minority populations. In order to

conduct these studies, theoretical and empirical

literature on organizational and practice change

will need to be critically and creatively addressed,

and different approaches to diffusion will need to

be tested. Initial work by the center would be to

identify experts in the change process from other

fields and to utilize them in adopting or adapting

the complex provision of mental health care

services for targeted children and families. 

IV. NIMH OVERSIGHT OF

RECOMMENDATIONS: MONITORING

PROGRESS 

A. ETHICAL ISSUES

1. Because of the difficult ethical issues

surrounding studies of child and adolescent

mental health and the paucity of scientific studies

on informed consent, confidentiality, and risk

assessment with which to guide investigators, we

recommend that priority be given to these issues

through workshops, program announcements,

and special funding initiatives.

B. GOVERNANCE AND MONITORING OF

RECOMMENDATIONS

1. We recommend that the Associate Director

for Child and Adolescent Mental Health Research

at NIMH report annually to the National Advisory

Mental Health Council (NAMHC) about the

implementation of these recommendations. In

particular, a report should be provided on changes

in the scope of and funding for child and

adolescent research. 

2. We recommend that special consideration be

given to elevating funding priorities for child and

adolescent grants that reflect the interdisciplinary

linkages underscored and highlighted in this

report. The objective of these initiatives is to

create bridges among differing research traditions,

and to do so well will require sustained support.

C. ADMINISTRATIVE OVERSIGHT WITHIN NIMH

1. Because the NIMH Child and Adolescent

Research Consortium (CARC) has been highly

successful in setting research priorities that cross

the divisional structure at NIMH and in

encouraging creative initiatives to foster children's
18

mental health, we recommend that the NIMH

CARC be retained and fully supported. 

2. To increase administrative capacity within

NIMH, we recommend that consideration be given

to retaining individual expert consultants, as

needed, to provide advice to the NIMH director

about research directions and priorities in child

and adolescent mental health.
19

I. A Look Backward:

Child and Adolescent Mental Health

Intervention Research

A. Historical Context

The first English book on pediatrics is considered

to be “The Boke of Chyldren” by Thomas Phaire,

published in 1544. Phaire included a lengthy list

of "perilous diseases" of children, including,

among other illnesses, "apostume of the brayne"

(most likely meningitis), bad dreams, and colic.

According to Neal Postman in “The Disappearance

of Childhood” (1994), Phaire’s book heralded the

notion of childhood itself, marking one of the first

occasions when childhood as a concept was

distinguished as a period of development separate

from adulthood.

The concept of childhood mental illnesses,

however, did not arise until the late 19th century,

and they were typically not seen as unique to

children or distinguishable from adult

manifestations of mental illnesses until the early

part of the 20th century. William Healy established

the first child guidance clinic in the United States in

1909. Healy advocated for both the “team

approach” and the “child’s own story” in treatment

and research (Snodgrass, 1984). The first Englishlanguage text on child psychiatry was published in

1935 (Kanner, 1935; Sanua, 1990). Autism and

ADHD (then known as hyperkinesis) were

recognized as childhood disorders in the 1940’s

and childhood depression in the 1950’s. In the

1970's, during a WHO seminar on the classification

of mental disorders for the International

Classification of Diseases (ICD), the coding scheme

for clinical syndromes in child psychiatry was first

suggested. This first multiaxial scheme for children

was developed and evaluated in 1975 (Rutter,

Shaffer, & Shepherd, 1975) and formed the basis

for subsequent classification and refinement in the

Diagnostic and Statistical Manual of Mental

Disorders (DSM) of the American Psychiatric

Association. The United States was required by

international treaty to use the ICD for maintaining

statistics, and so the DSM for the past three decades

has used criteria similar to those used in the ICD. 

The DSM is generally deemed to be an

authoritative compendium of diagnostic categories

for mental illness. It was not until the third

edition of the DSM (American Psychiatric

Association, 1980) that child and adolescent

mental disorders were assigned a separate and

distinct section within that classification system.

This edition of the DSM was widely read; by 1990

more than 2,300 scientific articles referred to it in

title or abstract (Kirk & Kuchins, 1992). The DSM

established boundaries over the domain of

psychiatric classification and consequently

controlled discourse about mental illness,

structured research directions, and established the
20

parameters of knowledge, including theoretical

understanding, about mental illness. 

The recognition that children and adolescents

suffer from mental illnesses is thus a very recent

phenomenon. The development of treatments,

services, and preventive approaches to risk for

these disorders is even more recent. However, in

the past two decades, stemming in part from the

rapid advances in psychopharmacology, in

adaptations of adult psychosocial treatments for

use with children, and the advent of communitybased rather than institutionally based care, the

knowledge base on treatments, services, and

prevention programs has greatly expanded. In

addition, tremendous progress has occurred in

mapping and cloning genes for diseases that follow

Mendelian patterns in families. However, the

discovery of the genes that influence susceptibility

to more complex diseases such as neurobehavioral

disorders has proceeded slowly. The lack of one-toone correspondence between genotype and

phenotype, and the etiological complexity of

common mental disorders such as ADHD, anxiety

disorders, mood disorders, and schizophrenia,

present considerable challenges for researchers. 

In order to harness the avalanche of genomic

information being generated from new and

evolving molecular technologies, innovative

quantitative methods are being developed to foster

genome-wide analyses. With these new methods

under development to map genes for complex

diseases, the field of genetics shows promise of

providing insights into the biological

underpinnings of these diseases, which will

advance current diagnostic, prevention, and

treatment efforts. Such insights are critical to

understanding how genes contribute to

vulnerability or resistance, affect the severity or

course of illness, and interact with environmental

factors that modify their expression or course.

These advances are especially critical for children

with neurobehavioral disorders because early onset

of such diseases tends to be associated with a

greater genetic load. With the growing research

focused on the genetic control of the developing

brain structure and system, as well as the powerful

technology that continues to evolve and provide

access to the developing brain, unprecedented

opportunities for understanding the etiology of

mental disorders, and hence ways to divert adverse

developmental trajectories, have been created.

In the past 10 years, families of children with

mental illnesses and consumers have taken a much

more active role in treatment delivery and service

planning. The importance of attending to and

engaging families in every aspect of mental health

services has become the sine qua non of treatment

and care plans. Not only does such engagement

represent the only defensible moral platform from

which to consider the needs of families and

children, it also represents recognition of the fact

that solutions to child and adolescent mental

illness require the partnership of professionals,

families, scientists, and youth themselves. 

Treatments for childhood disorders such as conduct

problems, anxiety disorders, adolescent depression,

OCD, and ADHD have been the primary targets of

recent study. In the past 2 years, five reviews of

treatment and service studies have been published,

summarizing hundreds of studies, most conducted

since 1980 (Burns, Hoagwood, & Mrazek, 1999;

Child Mental Health Foundations and Agencies

Network, 2000; Journal of the American Academy of

Child and Adolescent Psychiatry, 1999; Journal of

Clinical Child Psychology, 1998; Weisz & Jensen,

1999). These reviews span a host of interventions,

including preventive approaches for behavioral

problems that may emerge into full-blown

disorders, medication and behavioral treatments for

attention deficit disorders, and services for

multiproblem children. The availability of a range

of treatments, prevention programs, and services
21

for children with functional impairments is thus a

new phenomenon. It suggests that the situation

for families whose children are at risk, or who

have developed mental illness, is not hopeless. A

scientifically defensible corpus of treatments,

services, and preventive interventions now exists.

Yet, despite this progress, the burden of childhood

mental health problems is not lessening. Report

after report cite the fact that childhood mental

health problems and illnesses are common, are on

the rise, and impose serious burdens on children

and families alike (Achenbach & Howell, 1993;

Burns et al., 1995; Knitzer, 1982; Murray &

Lopez, 1996; Roberts, Attkisson, & Rosenblatt,

1998; National Advisory Mental Health Council,

1990; Shaffer et al., 1996; U.S. Public Health

Service, 1999). The level of unmet needs for

services is as high as ever, despite two decades of

treatment development and mental health service

delivery (Burns et al., 1995; Sturm, Ringel, Bao,

Stein, Kapur, Zhang, & Zeng et al., in press; also,

see appendix A). There are probably a number of

reasons why the burden has not lightened.

STIGMA

The reasons for the continued and pervasive level

of unaddressed mental health needs among young

people in this country are many. One perpetual

impediment has been the existence of attitudinal

bias or stigma toward mental illness. Mental

illnesses have not been accorded the same level of

credibility as other health disabilities, yet there is

no scientific justification for this difference.

Stigma continues to affect families whose children

experience mental illness by creating a culture of

suspicion, discrimination, fear of mental health

problems, blaming the parents, and very real

concerns about treatment confidentiality and

restriction of insurance coverage. 

FRAGMENTATION OF SOCIAL INSTITUTIONS

The social institutions primarily responsible for

providing mental health support—schools, mental

health clinics, and hospitals—remain fragmented

and entrenched in models of service delivery that

do not match child and family realities. Specialty

mental health treatments still tend to be delivered

in offices rather than in homes, schools, or health

settings. Children with unrecognized mental

health problems are still sent to out-of-home

placements, often miles away from their families,

rather than being treated in communities. The

lack of availability and infrastructure support for

treatments, prevention programs, and services is

as high as it was in the early 1980's (U.S. Public

Health Service, 2000).

HEALTH DISPARITIES

The disparities between minority children and the

majority population in health status and access to

care have been a source of significant concern

(American Academy of Pediatrics, 1994). Mental

disorders appear to have equivalent incidence and

prevalence across majority and minority

populations. However, they may exert a

disproportionate impact on racial and ethnic

minority groups (NIMH, 2001). This disproportion

is evidenced by uneven access to services, poorer

treatment, and worse mental health outcomes

among minority populations. According to

evidence recently presented at the Surgeon

General's Conference on Children's Mental Health

(U.S. Public Health Service, 2000), this finding

holds for both children and adolescents. Among

this population, unmet need for specialty mental

health care is high, and there are substantial

ethnic disparities in access to such care (Wells,

unpublished data). Racial, ethnic, and cultural

differences influence the expression and

identification of the need for services (e.g.,
22

caregiver expectations), quality of care (e.g.,

whether or not children receive medication),

referral bias or access to appropriate care (e.g.,

referral to school services or specialty care settings

vs. justice or welfare systems for similar

problems), the diagnostic process (e.g., lack of

culturally competent providers), and hence

subsequent care and poorer health outcomes.

Similarly, children whose parents are in chronic

poverty or who have experienced severe economic

losses are at a greater risk for anxiety, depression,

and antisocial behaviors (McLeod & Shanahan,

1996; Samaan, 2000). 

RESOURCES 

Many treatments and services children and their

families receive have not been examined or

evaluated. A significant proportion of the mental

health dollar for children continues to go to

treatments and services that have been shown to

be largely ineffective or have not been shown to

be effective. The question of how to redirect costly

residential, hospital, and outpatient (when not

evidence-based) resources into more effective care

is both a research and a policy issue. The

challenge of implementing science-based

treatments and services rests not only on good

dissemination but also on the realignment of

resources to ensure that children and families in

need receive the most appropriate care in a timely

manner. This requires the research community to

partner with families, providers, and other mental

health stakeholders and policymakers to realign

current resources to ensure that the science base

on treatments and services is usable,

implementable, disseminated, and sustained in

the communities where children live.

RESEARCH GAPS

It is significant to note that the evidence base on 

the effectiveness of preventive programs 

and treatments for specifiable disorders and

services is growing but uneven. Although there is

strong evidence for the treatment of many

disorders, for others, particularly eating disorders,

PTSD, autism and co-occurring conditions, the

evidence is minimal. Despite the existence of a

growing body of interventions for children, when

questions arise as to the extent to which such

interventions will match the unique

configurations of particular communities,

populations, or real-world clinical practices, the

limits of the evidence base become apparent.

Meta-analytic work has revealed that the effects

of psychosocial treatments are as strong for

children as they are for adults (Weisz & Weiss,

1993; Weisz, Weiss, Alicke, & Klotz, 1987; Weisz,

Weiss, Han, Granger, & Morton, 1995), yet the

vast majority of studies on the effectiveness of

psychosocial treatments have been conducted in

controlled laboratory settings, rather than in the

crucible of real-world practices (Weisz, Donenberg,

Han & Weiss, 1995; Weisz, Weiss, & Donenberg,

1992). Consequently, the extent to which these

Evidence-based Treatments

In the field of children’s mental health science

and service deliver, the term evidence-based

refers to a body of knowledge, obtained through

carefully implemented scientific methods, about

the prevalence, incidence, or risk for mental

disordres or about the impact of treatments or

services on mental health problems.

It is a shorthand term denoting the quality,

robutsness, and validity of the scientific

evidence that can be brought to bear on

questions of etiology, distribution, or risk for

disorders or on outcomes of care for children

with mental health problems.
23

evidence-based practices can be transported

into the panoply of practice settings is largely

unknown. 

An additional limitation of the science base on

childhood interventions is that for the most part, it

is not used. In some cases, a particular treatment

has become a standard of care across the country,

even though it has produced few positive effects

and even negative outcomes for children and

adolescents (e.g., the use of group homes or

residential treatment centers vs. therapeutic foster

care for treating severely delinquent youths). In

addition, prevention programs, treatments, and

services are not being made accessible quickly

enough to children who need help and their

families (Burns et al., 1995; Forness & Hoagwood,

1993). Services are not routinely available because

of long waiting lists and restrictions in mental

health coverage (Friedman, 1992; Wells,

unpublished data).

One factor that contributes to the lack of use of

evidence-based treatments in naturalistic practice is

the pace of their creation: Scientific study of

interventions takes time. To properly conduct these

studies, a careful sequencing of thought and

analysis is required. The current models for

scientific progress, however, may be excessively

linear and may not be taking advantage of

opportunities to develop interventions in the

contexts into which they will ultimately be

embedded. For example, new models of treatment

and service development include attention to

features of service contexts (e.g., pediatric health

settings, schools, and Head Start programs) that

are important to sustaining and perpetuating the

quality and fidelity of treatments, as opposed to

waiting until the intervention has passed through

all phases of scientific testing and development.

Building a clinically relevant and strong base of

knowledge about effective interventions for

children with mental disorders depends on two

factors: One is knowledge about the intervention’s

generalizability, impact, and effect on diverse

populations; the other is knowledge about the

etiologic pathways by which illnesses become

manifest. The scientific foundation for knowledge

about etiology often arises from basic science or

epidemiological studies, which may be able to trace

at genetic, molecular, neuronal, or anatomical

levels the precursors and pathways to the

phenomena we call childhood mental illnesses.

Unfortunately, however, as this report will discuss

in detail, the opportunities to connect basic

neuroscience and behavioral science to the

development of new assessment approaches,

treatments, or preventions within social contexts

have been largely ignored. The rapid pace of

discovery in the basic sciences makes this an

opportune moment for such translation. 

ETHICAL ISSUES

Finally, complex issues pervade studies of child and

adolescent mental health. The shadow of past

scientific misconduct, as well as scientific

inattention to the important issues of race,

ethnicity, culture, and context, have compromised

the ability of science to improve public health for

children. In the area of child and adolescent mental

health, the ethical issues that are most commonly

fraught with dilemma and debate are consent by

proxy; balancing risks and benefits, especially for

vulnerable populations of children for whom

knowledge about risk is very slight (i.e., minority

youth, very young children, and children who have

been abused or neglected); and the complex role of

parents and parent substitutes (such as the State)

in granting consent for minors. Other ethical

concerns involve ensuring truly informed consent

across different populations and systems and

attending to racial/ethnic differences in values,

attitudes, history, and experiences with science.
24

B. Recent Activities: 

The Environment Surrounding 

Child Mental Health

Over the past several years, a series of nationallevel activities focused on children’s mental health

has taken place. In December 1999, the Office of

the Surgeon General released its first-ever report on

mental health, with one chapter focused solely on

the mental health needs of children (U.S. Public

Health Service, 1999). This seminal report marked

a critical turning point in the public focus on

mental health. Years ago, people with mental

illness were doomed to live without prospect for

active and productive lives; this report highlighted

the scientific advances that now offer hope for

people with mental illness and put mental health

issues in the forefront of the public health agenda.

A public-private White House conference was also

held to improve the diagnosis and treatment of

children with emotional and behavioral conditions

(White House Conference, 2000). This conference

was triggered by an article in the Journal of the

American Medical Association (Zito, Safer, dosReis,

Gardner, Boles, & Lynch, 2000) that reported a

dramatic increase in the use of psychotropic

medication in preschoolers between 1991 and

1995. The findings from this study raised public

concern that very young children, who are in a

state of rapid change and growth during their

developmental years, are being prescribed potent

psychotropic medications even though few data are

available on their use. More alarming, the safety

and efficacy of these drugs have not been tested in

children under the age of 6, and many have not

been tested in children under the age of 16. The

controversy around psychotropic drug use in very

young children raised serious concerns about the

appropriate diagnosis and treatment of emotional

and behavioral difficulties in children and about the

need to take steps to ensure that these children

receive appropriate care.

Two other meetings were held to address this

issue: The Surgeon General’s Conference on

Children’s Mental Health, and the NIMH/Food and

Drug Administration meeting on

Psychopharmacology for Young Children: Clinical

Needs and Research Opportunities. The

recommendations from these meetings formed the

basis of the “Report of the Surgeon General’s

Conference on Children’s Mental Health: A

National Action Agenda” (U.S. Public Health

Service, 2000). This report, an offshoot of the

first-ever “Surgeon General’s Report on Mental

Health,” highlighted the public health crisis in

mental health for children and adolescents and

outlined an overarching vision and specific goals

to elevate mental health—and the treatment of

mental disorders—to a major public health

concern. The recommendations bridged the gaps

among research, practice, and policy. Specifically,

the report called for continued research to

develop, disseminate, and implement sciencebased prevention and treatment services in the

field of children’s mental health. In addition, it

included other goals pertinent to this report: 

 Promote public awareness of children’s

mental health issues and reduce stigma

associated with mental health

 Improve the assessment of and recognition

of mental health needs in children 

 Eliminate racial/ethnic and socioeconomic

disparities in access to mental health services

 Increase access to and coordination of

mental health services 

In addition, two significant reports focusing on

related issues have been released over the past

year. In October 2000, the National Research

Council and Institute of Medicine released “From

Neurons to Neighborhoods: Science of Early
25

Childhood Interventions.” The report reviewed the

explosion of research in neurobiological,

behavioral, and social sciences and addressed how

the country as a whole could use this knowledge

about early childhood development to improve

children’s well-being and, in so doing, optimize

human capital and ensure the ongoing vitality of

the country. In September 2000, the Child Mental

Health Foundations and Agencies Network (FAN)

released the report “A Good Beginning,” which

indicated that social and emotional school

readiness is critical for young children’s early

school success—and may even set the stage for

success later in life (Child Mental Health

Foundations and Agencies Network, 2000). 

Together, all of these activities highlight our

current knowledge base, as well as the enormous

gaps among research, practice, and policy.

However, this momentum can be harnessed to

improve both the evidence base and its use so that

service delivery is equitable, just, and effective.

Revised models of treatment development are

needed to strengthen the evidence base and

ensure its uptake. 

C. Guiding Principles for the Report

In January 2000, the National Advisory Mental

Health Council (NAMHC) Workgroup on Child and

Adolescent Mental Health Intervention

Development and Deployment was established

with the following charge from NIMH Director

Steven Hyman, M.D.: 

 Assess the status of the NIMH portfolio and

identify research opportunities in the

development, testing, and deployment of

treatments, services, and preventive interventions

for children and adolescents in the context of

families and communities

 Assess the human resource needs in

recruiting, training, and retaining child mental

health researchers

 Make recommendations for strategically

targeting research activities and infrastructure

support to stimulate intervention development,

testing, and deployment of research-based

interventions across the child and adolescent

portfolio

Previous Council reports, including “Translating

Behavioral Science into Action” (NAMHC

Behavioral Science Workgroup, 2000), have

addressed the problem of the lack of

connectedness between basic behavioral science

and services. Other reports, such as “Bridging

Science to Service,” have dealt with the problem of

connecting science to service delivery (NAMHC

Clinical Treatment and Services Research

Workgroup, 1999). Those reports have yielded

many useful recommendations, some of which are

repeated in this report. However, the applicability

of those reports to child mental health issues is

complex because of some unique aspects of

children, their development, and their contexts,

which are valuable to consider. In response to

these challenges, the workgroup has framed the

following guiding principles, which undergird the

thought, interpretation, and recommendations of

this report:

 Developmental processes are core to

understanding child mental illness prevention,

treatment, and services. Childhood is

characterized by rapid change, transition, and

reorganization, and understanding the reciprocal

influences between children and their

environments throughout their developmental

trajectory is critical. 

 Context is critical in understanding childhood

mental illnesses. The etiology and course of mental
26

illnesses, including the processes mediating and

moderating the expression of symptoms, cannot be

understood without reference to the various

contexts in which a child lives (e.g., family, peer

group, school, community) and sociocultural

ecology. The most effective management of

childhood mental illnesses and preventive

strategies must take into account this context and

address the needs of children and their families

throughout the child’s development.

 Empirical science must underlie both

practice and policy. To provide the most effective

interventions possible for the prevention and

treatment of childhood mental illnesses, the

science base must be linked to practice and used

to direct policy, so as to reduce the disparities and

gaps in access to effective interventions. 

 Interdisciplinary research is key to

advancing the understanding of children's mental

health. The rapid advances in various disciplines

of science highlight exciting opportunities for

integrating a broad knowledge base to advance

etiologic understanding of child and adolescent

mental health. 

 Children’s mental disorders are often

chronic. Consequently, evidence-based treatments,

prevention programs, and services must be

positioned permanently in communities to provide

care, over time, to children and their families. 

 Equity in care for children’s mental health is

essential. Compelling scientific evidence on the

critical importance of children’s mental health for

learning and development indicates the need for

the health system to address children’s mental

health in the same way that it addresses physical

health.

D. Conceptual Models 

for the Report

Two broad conceptual models, shown in Figures 1

and 2, also guide the development of this report.

The first model addresses the relationship

between basic science and child mental health

services. The second model describes a

developmental framework linking neuroscience,

behavioral science, and intervention across the

life span. In this section, we describe each model

and its relevance to the themes of the report.

CYCLICAL FEEDBACK MODEL

A primary goal of this report is to describe,

illustrate, and encourage the application of a

model for the links between basic science and the

provision of mental health services to children

and adolescents. This model, depicted in Figure 1,

envisions a cyclical sequence of processes. The

sequence we envision is never expected to reach a

terminus at which all the answers are known and

all service interventions are perfected. Instead,

any report on the state of the field, at any time,

will be a snapshot of a moving target; the body of

scientific evidence and the collection of specific

“best interventions” will change continually. For

this reason, we do not attempt here to provide an

exhaustive list of the most important findings of

basic science or the best-supported interventions.

Instead, our goal—in the model and throughout

the report—is to describe a model, or strategy, for

building knowledge and building interventions by

maintaining a strong linkage between science and

practice. Implicit in the model, and throughout

this report, is our view that best practice in

mental health requires a close connection to the

state of the science and that best science requires

ongoing feedback from real-world experience. 
27

Figure 1 begins with Basic Research and Theory.

This box encompasses basic science with both

human and infrahuman species in such fields as

learning, development, and neurobiology. In the

model, concepts and findings in these fields are

used to stimulate Research on Intervention

Development and Refinement. Such research may

include psychosocial treatments, medications,

combined psychosocial-pharmacological

interventions, and prevention programs targeting

mental health. 

Note that the arrow between basic research and

research on intervention development is

bidirectional, reflecting our view that basic

research may both inform and be informed by

intervention development research. This

bidirectional influence characterizes all pairs of

elements or steps in the model, reflecting our view

that the connections between science and practice

are neither unidirectional nor linear.

Research on intervention development and

refinement typically leads to Research on

Intervention Testing. Within this box, we envision

a continuum of methods, ranging from carefully

controlled university experiments with recruited

symptomatic youth to randomized trials with

clinically referred youth treated in service settings

by practicing clinicians. Where a particular study

falls along the continuum will be dictated in part

by the level of development of the intervention

and the goals of the researcher. However, one

conclusion emerging from our discussions is that

there has been too little research to date on

developing and testing interventions in the

clinical settings for which they are ultimately

intended; this situation has weakened prospects

for effective dissemination.

Another element of the model is the Review and

Synthesis of Research Findings to Identify

Interventions that Work. Here we refer to efforts

by reviewers to apply rules of evidence to the

clinical trials literature so as to identify specific,

empirically supported or evidence-based

interventions. Relevant procedures may include

systematic literature reviews, meta-analyses, and

efforts by various committees and task forces to

code studies for their methodological adequacy

and gauge the level of support they provide for

various interventions. It is not our purpose to

produce a comprehensive list of such

interventions, but we refer interested readers to a

relevant report on child psychosocial treatments

that began the process of compiling a list

(Lonigan, Elbert, & Johnson, 1998). 

A fifth process highlighted in the model is

Intervention Deployment. Included here are efforts

to take evidence-based interventions into the field

and encourage their use by providers, paired with

efforts to understand the process, the outcome,

and factors that may influence whether the

interventions are adopted, whether they are used

appropriately, and whether they are beneficial.

Thoughtful research addressing these questions

about deployment, and what makes it succeed or

fail, will certainly require input from providers,

community partners, parents and other

caregivers, and the children and adolescents the

interventions are intended to help. As the diagram

suggests, the model holds that information gained

via research on deployment should be used to

inform each of the other four processes described

in the model: Basic Research and Theory,

Research on Intervention Development and

Refinement, Research on Intervention Testing,

and Review and Synthesis of Research Findings to

Identify Interventions that Work.

Finally, we consider the multidirectionality and

multisequentiality of the model. The spatial layout

of the model may suggest a unidirectional

sequence in which basic research and theory leads

to research on development and refinement of a

29

specific intervention, then to intervention testing.

This is followed by review and synthesis that

identifies the intervention as empirically

supported in multiple studies, at which point the

intervention is deployed in service settings.

Although this sequence may unfold in some cases,

we do not see such a linear progression as

essential to progress in the field, and we suspect

that it may be unduly limiting. For example, a

strong argument can be made that, for some

interventions, deployment and outcome

assessment in service settings should be a part of

intervention development and testing so that

problems in treatment delivery in real-world

settings may be identified and solved early in the

evolution of the intervention. The general point is

that the model shown in Figure 1 depicts

processes that are needed to keep science and

practice linked, but the order of these processes

may be quite varied from one intervention to

another, and there may be considerable blending

of these processes as interventions are envisioned,

developed, tested, and disseminated.

Critical to this cyclic feedback model is the

involvement of youth, family, providers, and

community input at every level of the process to

ensure the credibility of the interventions

developed. Further, policymakers responsible for

the organization and financing of children’s

service systems should be involved if the

interventions are ultimately to be relevant to the

needs of these systems. 

DEVELOPMENTAL FRAMEWORK: LINKING

BASIC SCIENCE TO INTERVENTIONS

The second conceptual model guiding this report

is depicted in Figure 2. As the figure illustrates, a

developmental perspective is essential to the task

of linking basic neuroscience, behavioral science,

and opportunities for intervention. The figure

shows a developmental trajectory across stages

beginning with conception and gestation, passing

through childhood and adolescence, and

progressing into adulthood. Across this trajectory,

developmental competencies (e.g., physical skills,

cognitive abilities, emotional and behavioral

regulation) take shape. The growth of these

competencies is not a smooth course involving

uniform increments, but rather a series of spurts

and plateaus. This "bumpy" course of maturation

is reflected in the irregular growth curve shown

above the developmental stages. 

The darkened circles along the timeline represent

the interplay of biological and behavioral

development at multiple points in development. In

the preschool years, for example, biological

changes such as myelination, dendritic and

axonal arborization, neurogenesis, synaptic

stabilization, and sculpting of neural circuits are

associated with behavioral changes such as

improved regulation of attention and affect,

impulse control, and task focus. These changes

set the stage for subsequent learning in school

settings and for new kinds of social relationships

involving empathy and cooperation. These points

of biological-behavioral interface represented by

the darkened circles along the curve are

particularly important to the developmental model

and to this report. They illustrate what we believe

are exciting opportunities for cross-pollination

among neuroscientists, behavioral scientists, and

intervention researchers. Enriched collaboration

among these disciplines could stimulate a new

generation of biobehavioral developmental theory

and research and, in turn, new models of

prevention and treatment. 

New models of prevention and treatment are

needed for diverse forms of risk processes and

competencies. We offer a few illustrations in

Figure 2, indicated by the letter R. Of course, each

form of risk process can be seen as one end of a 

31

continuum, at the other end of which is a

particular form of competence. A range of

developmental outcomes may accrue from the

various risk processes and competencies. As an

example, low birth weight, irritable temperament

in infancy coupled with caregiver stress,

attentional deficits, and poor frustration tolerance

at school age may confer negative outcomes such

as ADHD, learning disabilities, and associated

difficulties in peer relations. By contrast, similar

early risk processes and neurobehavioral

vulnerabilities may be mediated by

responsive/sensitive caregiving, enhancing the

infant’s frustration tolerance so that by school

age, the child is able to persevere on tasks,

cooperate with peers and teachers, and become

confident and socially adept even in the face of

challenges. 

A central idea is that at each point in

development, biological, behavioral, and

environmental processes carry potential risks and

potential opportunities for the development of

new adaptive skills. An overarching goal of this

report is to identify strategies for enriching our

understanding of these developmental processes

and their interplay, and to foster the development

and deployment of interventions that can reduce

risk and maximize adaptive skills. Throughout

this report, we provide a few examples of

evidence-based interventions (Science Cases in

Point) to explain aspects of the conceptual models

and developmental framework. A clinical case

study of childhood-onset depression (see appendix

B) is used to illustrate how knowledge generated

from interdisciplinary research can be

meaningfully brought to bear on clinical practice.
33

II. A Look Forward:

Current Emphases and Future Prospects

for Child and Adolescent Intervention

Research

A. Costs, Financing Policy, and

Services Utilization: National

Estimates

Shifting evidence-based interventions into realworld settings will likely be an expensive

endeavor. Before estimating the costs of this

effort, the current resource context must first be

understood. That is:

How much money is being spent for the 

provision of specialty mental health services

for children and what kinds of services are 

provided in the United States today?

These funding amounts do not need to remain

fixed, even if that were feasible. Instead, what is

needed is a starting place to assess the

relationship between mental health dollars

expended and the number of youth served. A

complete estimate is not likely to be attainable,

owing to missing information about costs (both

direct and indirect) and services provided in other

critical child-serving sectors (i.e., education, child

welfare, and juvenile justice systems). Treatment

dollars and service use in those sectors are

significant, given very high rates of need in youth

involved with child welfare (up to 50 percent) and

juvenile justice (up to 80 percent) systems. Many

of the youth in those sectors are high-end or highcost service users, and the research base for

treating this critical subpopulation is more limited

than for youth with single disorders. Additional

questions that arise out of the relationship

between resources and the services provided

include: 

 What are the characteristics of treated

youth—age, ethnicity, and insurance status?

 How much care do they receive?

 In what settings is care provided?

Such information can offer a gauge for

considering policies governing fiscal and clinical

practices relative to unmet need, including access

to care and appropriate provision of care. The

service utilization data constitute a measure of

access, and that rate, when contrasted with

epidemiological estimates of mental health need,

creates a measure of unmet need. More

challenging is the creation of the link between

data on current services use and the

appropriateness of care (or the practice of

evidence-based treatment), since this link relies on

treatment and services research not reviewed here 
34

but available in “Mental Health: A Report of the

Surgeon General” (U.S. Public Health Service,

1999). Nonetheless, cost and utilization

information about the resources used for

interventions that lack evidence (i.e., much of the

outpatient and most of the institutional care

provided) opens the door to consider strategies

(policy, training, research) for directing existing

resources toward interventions that can more

effectively benefit children, families, and society.

In this section, recent national estimates of the

direct costs of children’s mental health services

and service-use patterns for child mental health

services are presented.

COSTS OF MENTAL HEALTH SERVICES

Sturm and colleagues (in press; also, see appendix

A) have produced the first national estimate since

the 1980’s of child mental health expenditures in

the specialty mental health and general health

sectors. Utilizing the most recent sources of

national, regional, and/or State data (including

those that are population- or insurance-based),

they estimated the annual expenditure at around

$11.75 billion. This is nearly a threefold increase

from the 1986 estimate of $3.5 billion (not

accounting for inflation); this increase may be

somewhat less after accounting for inflation, but

because the 1986 estimate lacked information

about (1) children ages 0-11, (2) primary

care/mental health services, (3) psychotropic

medications, and (4) private practice, this new

estimate is likely to be more complete and accurate.

Key findings from this report include the following:

 Based on three national surveys fielded

between 1996 and 1998, between 5 percent and 7

percent of children used any mental health

specialty services in a year. This average rate is

similar to the rate among adults, but it obscures

the major differences across age groups. Only 1 to

2 percent of preschoolers used any services; the

average rates increased in older children—6 to 8

percent of children ages 6 to11, and 8 to 9 percent

of adolescents ages 12 to 17.

 There is substantial variation in mental health

service use by type of insurance, ranging from 8.4

percent for Medicaid enrollees to 4.0 percent for the

uninsured. The intensity of outpatient care (number

of visits) differs similarly. Specialty mental health

estimates per 1,000 children per year range from

1,300 visits for Medicaid, 462 visits for private

insurance, 391 visits for other types of insurance,

and 366 visits for the uninsured.

 Mental health utilization varies across

racial/ethnic groups. Among white, black,

Hispanic, and other youth, Hispanics are the least

likely of all groups to access specialty care (5

percent), even though they and black children

have the highest rates of need (10.5 percent),

according to measures in the National Health

Interview Survey (NHIS). Approximately 7 percent

of the families with a child with need (based on

NHIS measures) claimed financial barriers as the

reason for not getting any mental health care.

 More than half of all outpatient specialty

mental health services for children with private

insurance are provided out-of-plan. The education

sector likely provides a substantial portion of

these services. 

 Regarding inpatient mental health care,

between 0.2 percent and 0.3 percent of children

ages 1 to 17 use inpatient mental health services in

community hospitals. This rate is much lower than

the 0.6 percent rate for adults. Across all insurance

types, adults and adolescents have more inpatient

days per 1,000 population than do young children.

Among the privately insured and the uninsured,

adolescents have higher inpatient service use than

adults. In contrast, among the publicly insured,
35

inpatient days per 1,000 population are

significantly higher for adults than for

adolescents. 

 Annually, 4.3 percent of children receive

psychotropic medication, and utilization is

concentrated among older children, with 5 percent

of children ages 6 to 11 and 5.6 percent of

adolescents on psychotropic medication; only 0.7

percent of children ages 1 to 5 used any such

medication.

 Total 1998 treatment expenditures for

children are estimated to be approximately $11.75

billion, or about $173 per child. Adolescents ages

12 to 17 account for 59 percent of the total, and

also have the highest expenditure per child at

$291; children ages 6 to 11 account for 34

percent of the total at $165 per child, and children

ages 1 to 5 account for 7 percent of the total at

$39 per child.

 Across service expenditures, outpatient

services account for 57 percent ($6.7 billion),

inpatient services for 33 percent ($3.9 billion),

psychotropic medications for 9 percent ($1.1

billion), and other services for 1 percent ($0.1

billion) of the total.

 Across children’s insurance status, children

with private insurance account for 47 percent

($5.5 billion), Medicaid enrollees for 24 percent

($2.8 billion), children with other public insurance

for 3 percent ($0.4 billion), and the uninsured for

5 percent ($0.6 billion) of the total. State/local

expenditures (21 percent or $2.5 billion) could not

be allocated by child insurance status. 

 Total 1998 expenditures on psychotropic

medications for children are estimated to be $1.1

billion. The largest proportion of expenditures was

for stimulants, which accounted for slightly over

40 percent of the total. Antidepressants made the 

second largest contribution to these costs,

accounting for 33 percent of the total.

Observations about these data are both

encouraging and discouraging. On the positive

side, there is an increase in the rate of outpatient

mental health service use since the 1980’s. This

rate is still, however, well below the estimated

need for care; only 5 to 7 percent of children

receive some specialty mental health services, in

contrast to an estimated 20 percent with a

diagnosable mental disorder (U.S. Public Health

Service, 1999). There has been a significant

decrease in the proportion of mental health

dollars spent on institutional care since the last

national estimate of costs and service use (Burns,

1991), but the rate of hospital use has changed

little since 1986. The reduction in the percentage

of institutional care costs is largely attributable to

reductions in length of stay, second to discounting

inpatient rates, and third to other factors such as

the rise in outpatient treatment. 

The finding here is that of a reduced proportion of

the mental health dollar being spent on

institutional care. In absolute value, the cost of

institutional care has actually doubled (not

adjusted for inflation) since the 1986 estimate

(Burns, 1991). Despite the decrease in this

proportion, the fact that one-third, or $3.9 billion,

is used for institutional care (and this does not

include residential care reimbursed by child welfare

or education, or detention in juvenile justice) raises

a serious question about the availability of

evidence-based community alternatives to hospital

care. The question of how to redirect both hospital

and outpatient resources (when not evidencebased) into more effective care is both a research

and policy issue. Further, studies to identify the

necessary and appropriate use of inpatient care are

needed, as are studies to examine the relationship

between the availability of comprehensive

community-based services and the use of inpatient
36

treatment. Stronger evidence of cost-effectiveness of

community-based interventions could also be of 

use to policymakers considering changes in

reimbursement and treatment strategies.

Access to any type of mental health service

appears to be a problem for the multiple groups

identified above. Medicaid coverage is clearly

instrumental in creating access to services; of

note is that uninsured youth receive care at half

the rate of their Medicaid counterparts.

Preschool-age children rarely receive any care,

and racial disparities in service use persist

despite higher rates of need. The preceding

access issues require attention to understand

their origins (e.g., lack of culturally competent

and developmentally appropriate services,

stigma, or lack of insurance coverage) and to

identify strategies for overcoming them. The

variation in the number of specialty mental

health visits based on type of insurance raises an

appropriateness of care question. Although the

adequacy of care cannot be fully determined

without more information about the specific type

and amount of care per treated child, it is clear

that uninsured and privately insured youth are

at a disadvantage compared with Medicaidinsured youth.

B. Key Scientific Areas of Research

To illustrate the potential of the science base for

improving mental health care for children,

adolescents, and their families, this section

systematically highlights progress from key

scientific areas, including basic neuroscience,

behavioral science, prevention, treatments, and

services. Each subsection delineates

opportunities for crossing the boundaries to link

knowledge bases, identifies obstacles that

present research challenges, and outlines specific

recommendations for knowledge development

within each area that can facilitate

interdisciplinary efforts to solve targeted

problems in child and adolescent mental health. 

1. BASIC NEUROSCIENCE 

PROGRESS

Basic developmental neuroscience research

involves examining childhood alterations in

molecular, cellular, and integrative brain

functions that are responsible for the development

and/or expression of complex mental disorders.

The major goal of such research is to translate

and integrate findings from basic neuroscience

into clinical investigations in order to develop and

test specific hypotheses about the neurobiological

substrates and etiologies of complex mental

disorders. Such investigations include early-life

neural antecedents of disorders that are expressed

later in life, neural substrates of disorders that

appear during childhood, neural circuitry activity,

and genomic manipulations. 

In the prolonged dialogue about the crisis in

children’s mental health, it is easy to identify the

pressing need for the societal prevention,

identification, and development of interventions.

The deficiencies in the latter are frequently so

staggering that even the brightest scenarios for

solutions from basic neuroscience research seem

likely to make only small contributions toward the

alleviation of the problems. However, research into

the environmental and genetic interactions that

bring about brain and behavioral development

must run in parallel with psychological and

sociological solutions to the problems faced by

children in our society if lasting solutions to these

problems are to be achieved. Knowledge pertaining

to the natural history and organic nature of mental

illness and to its etiology during childhood will be

fundamentally important in establishing credible

milestones of improvement as a result of behavioral
37

intervention. Such knowledge is also vitally

important for accurately diagnosing mental illness

and developing early interventions. In addition, the

identification of the biological bases of emotional

and cognitive dysfunction should help to alleviate

the social stigma associated with poor mental

health. This stigma curbs societal efforts to provide

both adequate child-care and medical coverage, and

also keeps families from seeking professional help

even when medical coverage is available. 

After nearly four decades of research into the

cellular and molecular bases of brain

development, there is one unassailable

conclusion: The developing child’s environment,

both in utero and ex utero, plays a large role in

shaping his or her brain circuitry and subsequent

behavioral performance. Poor nutrition, physical

or emotional abuse, neglect that produces

prolonged stress, substance abuse, and

environments that do not evoke active

participation have been shown to produce

detrimental effects on brain cell survival, neuron

density, brain vascularization, and the normal

development of brain circuitry. For many of these

risk factors, there are strong data supporting

behavioral correlates of these anatomical and

physiological changes. It is very reasonable to

expect that even if, having survived some of these

insults, a child matures into a competent adult,

there is a high probability that he or she will

suffer some emotional or cognitive handicap that

prevents optimal function. This is a waste of

human resources. 

It also has been demonstrated that the early

plasticity of brain circuitry can play a positive role

in optimizing the brain for the environment in

which it develops. This has been most

dramatically illustrated in functional imaging

studies of individuals born with sensory deficits

and therefore forced to use other modalities for

the basic skills of reading or speaking. Brain

regions not normally utilized in such skills are

incorporated into new brain circuits. However,

this adaptation occurs only if the unusual

modalities are utilized for these purposes during

early childhood. Such findings suggest that a

mechanistic understanding, or even a behavioral,

time-line keyed map of functional human brain

development could help educators and clinicians

to develop far more efficient strategies for using

brain plasticity to facilitate learning or to aid in

recovery from disease or trauma.

A growing number of linkage studies of families

with emotional disorders and breeding studies of

animals also make it clear that the genetic

makeup of an individual will play a role in the

behavioral and cognitive outcome of nongenetic

effects on brain development. Genetic

manipulation is one of many potential techniques

for creating animal models of mental illness, and

such work has revealed critically important

information about disease processes at the

cellular and molecular levels. Unfortunately, in

almost all instances, the way the genetic program

of brain development interacts with epigenetic or

environmental factors is not understood. Despite

the explosion in neuroscience research within the

past decade, we are still far from understanding

the brain loci that are altered or involved when

behaviors involving perception, projection,

learning, memory, and emotion are performed,

even in adults. We are even further from

understanding how these areas change or evolve

as children’s cognitive abilities develop. 

Some animal research has begun to illuminate the

interplay between genes and environmental

factors. Francis and colleagues (1999) at McGill

University have found that normal variations in

maternal care predict patterns of maternal care

displayed by the adult offspring. In the rat,

variations in maternal care (measured as

frequency and duration of licking and grooming
38

behaviors) appear to influence the development of

behavioral and endocrine responses to stress in

the offspring. Remarkably, they found that if the

pups born to low licking and grooming mothers

were cross-fostered by high licking and grooming

mothers, these pups grew up to be high licking

and grooming mothers. The opposite was also

true: The pups born to high licking and grooming

mothers when cross-fostered by low licking and

grooming mothers grew up to be low licking and

grooming mothers. The results of cross-fostering

studies reported here provide evidence for (1) a

causal relationship between maternal behavior

and stress reactivity in the offspring and (2) the

transmission of such individual differences in

maternal behavior from one generation of females

to the next. Moreover, an environmental

manipulation imposed during early development

that alters maternal behavior can then affect the

pattern of transmission in subsequent

generations. It is important to note that the low

licking mothers and pups showed heightened

stress responsivity as adults and were more

anxious and fearful of novel environments. Taken

together, these findings indicate that variations in

maternal care can serve as the basis for a

nongenomic behavioral transmission of individual

differences in stress reactivity across generations.

The next phase of this research is seeking to

identify critical behavioral and neurochemical

changes associated with the effects of early

environment on later susceptibility to adverse

effects of stress. These studies are relevant to

understanding predisposing factors contributing

to the development of anxiety and depression in

humans. 

This line of research is directly in line with Field’s

work on tactile stimulation. She found that

infants of withdrawn, depressed mothers show

dysregulation as early as the neonatal period

(unresponsive behavior, low activity level,

indeterminate sleep, low vagal tone, right frontal

electroencephalogram [EEG] activation, elevated

norepinephrine, and low dopamine levels). Infants

of mothers who remain depressed for 1 year after

birth have a distinct profile of behavioral, 

physiologic, and biochemical dysregulation. Their

mothers also have a distinct profile that can be

used to target those in need of intervention (Field,

1998). These interventions may include mood

induction, massage therapy, interaction coaching,

and natural buffers such as nondepressed fathers

and caregivers. The next phase of this research

will work on identifying infants of depressed

mothers who are most at risk, as well as

suggesting specific interventions for the depressed

mother-infant dyads with a different profile. 

This line of work is also consistent with

Hammen’s and Kendler’s work on depression,

which shows the relevance of stressful life events

on the development and recurrence of depression

(Hammen, Henry & Daley, 2000; Kendler et al.,

1995; Kendler, Karkowski, & Prescott, 1999;

Kendler, Kessler, Neale, Heath, & Eaves, 1993;

Kendler, Thornton, & Gardner, 2000; Kessler,

1997). For example, Hammen and colleagues

(2000) tested a stress-sensitization version of a

diathesis-stress approach to depression. In a 2-

year longitudinal follow-up design, exposure to

stressful life events was examined in young

women in the transition to adulthood. The

authors hypothesized that those who had

experienced one or more significant childhood

adversities would have a lower threshold for

developing a depressive reaction to stressors.

Results indicated that women with exposure to

one or more childhood adversities—such as

family violence, parent psychopathology, or

alcoholism—were more likely to become

depressed following less total stress than women

without such adversity. The results could not be

accounted for by chronic stress or prior

depression. Both biological and psychological

sensitization mechanisms may be speculated to
39

play a role, but the actual mechanisms of stress

sensitization remain to be explored.

CROSSING THE BOUNDARIES

Future neuroscience research is focusing on the

etiologic role of genes and key environmental

factors to understand how genes and the

environment interact to produce illness, and to

clarify how these risk factors differentially affect

gender, stage of development, and cultural/ethnic

groups. Insight will be gained into the role of

genetic and environmental factors in the etiology

of comorbidity. In addition, the development of

multivariate genetic models, which include

specified environmental risk factors, will provide

realistic etiologic models that incorporate all

major risk-factor domains. To do this, models of

pathogenesis are needed that can be refined and

tested both in the laboratory and in the

community. 

NIMH has already begun to support some efforts

to facilitate the translation of basic science

knowledge. Several innovative networks have

been brought together through a translational

research initiative. One such network is

investigating the links between glucocorticoid and

early experiences in rodents and its potential for

helping to explicate disorders related to early

adverse conditions in humans. The network

comprises animal researchers, developmental

psychologists, psychiatrists, and mental health

services researchers who have met over the past 2

years to examine the relation between stress and

the hypothalamic-pituitary-adrenal axis (HPA).

After a thorough discussion of ideas, the group

identified potential linkages and is now

developing feasible research studies that take

advantage of the advances at the interface of

basic animal models, neuroscience, and services

research to begin to clarify how behavioral and

biological factors may interact in the etiology,

course, and amelioration of psychopathology. 

OBSTACLES AND GAPS

Broadly speaking, there are four reasons why

progress in this area is slow. First, there is still

relatively little innovative interaction between

clinical research and basic neuroscience research

focused on animal models. For example, a review

of the NIMH research portfolio shows many

studies dealing with the genetics, physiological

correlates, environmental determinants, and

occasionally gender differences of psychological

disorders such as depression, borderline

personality disorder, anxiety disorder, tic

disorders, schizophrenia, and autism. All of these

disorders affect children or have their onset in

adolescence. However, studies are needed using

certain animal models of behaviors that have

some of the correlates of the human condition in

order to study the cellular and circuit basis of the

dysfunction. This cross-disciplinary work, or

translational research, may ultimately provide

more accurate explication of brain dysfuntions

that lead to mental illness. 

Even in tractable animal models, such as the

rodent, where the vast majority of cellular and

genetic approaches to brain development are

possible, relatively few investigators are using

interdisciplinary approaches to study the

mechanisms through which activity on an altered

hormonal milieu regulates the development of

brain synapses and circuits. In addition, there are

relatively few good normative data on the

development of children’s brains (neuroimaging,

emotional regulation, EEG asymmetry, sensory

process event-related potentials) and even fewer

that tie brain development to controlled studies of

behavioral development. With the ability to use

imaging in children comes the opportunity to

study the development of a number of relevant
40

aspects of cognition (e.g., attention, memory,

affect regulation, and inhibitory control). These all

have tie-ins, directly or indirectly, to behaviors or

disease-based "misbehaviors."

The slow progress in this area is highlighted by

gaps in the current portfolio. For example, most

work on activity-dependent brain development

has been closely tied to the sensory periphery,

whereas work on the epigenetic determinants of

limbic system development has been relatively

neglected. Even with work on the mature brain,

studies correlating the performance of affectassociated tasks with electrophysiological

recordings in awake behaving primates are

exceptionally scarce. Yet, such work will be key to

linking humans and tractable animal models. In

addition, despite the great advances in mouse

genetics, there has been relatively little

development of behavioral tasks or neurological

assays that help to decipher the circuit defects in

these animals. There have been very few studies

seeking to understand how the brain alters its

normal development to adjust for these defects.

Given all the activity in genetic linkage studies of

human dysfunctions, whose goal is to find the

genes responsible for dysfunction, it is

exceptionally important to develop approaches

using genetically altered mice to determine how

brain development and behavior adjust to these

primary lesions.

RECOMMENDATIONS FOR BASIC

NEUROSCIENCE RESEARCH 

1. We recommend that databases of rodent and

human brain maps be established and supported. 

We particularly emphasize that these databases

need to have a developmental dimension.

2. We recommend that cross-Institute

initiatives be fostered to establish genomic

databases. 

3. We recommend funding program projects to

bring together investigators from a variety of

disciplines to examine the developmental effects

of well-recognized conditions (e.g., stress and the

HPA system). 

4. We recommend that technological and

procedural advances should be supported that 

(a) allow scanning of very young normal children,

(b) enable the development of noninvasive

imaging that can be used on awake behaving

primates, and (c) encourage the development of

functional magnetic resonance imaging (MRI),

which can image potentially powerful rodent

models of genetic disease.

5. Integrative approaches to studies of brain

development and function are needed. Examples

include (a) combining techniques of neuroimaging

with simultaneous physiological monitoring

and/or emotional testing, hormonal

measurements, and so on; (b) electrophysiology at

both the single-cell and multiunit levels to study

molecular and circuit regulation in animals

models of behavioral dysfunction; and (c) mutant

animal models that allow researchers to study

epigenetic determinants of brain development

(e.g., constitutively manipulated mice may reveal

compensatory developmental changes relevant to

behavior).

6. A major gap exists in the availability of data

relating developmental trajectories across multiple

levels of description, from genetic processes to

behavioral competencies. Data are needed in the

following areas:

 Cross-species differences and

correspondences in neural and behavioral

development, the impact of differing genetic

backgrounds, and the validity of various

phenotyping procedures in animals as behavioral

markers of psychopathological outcomes.
41

 Gender differences and the putative actions

of gonadal steroids, changes in neurocircuitry

with puberty, and their relationship to cognitive,

behavioral, and emotional regulation during

adolescence.

2. BEHAVIORAL SCIENCE

PROGRESS

Over the past 5 years, the NAMHC has developed

two reports on basic behavioral science research.

The first report, “Basic Behavioral Science

Research for Mental Health” (NAMHC, 1995),

highlighted past achievements and outlined the

future trajectory of basic behavioral science within

NIMH. The second report, “Translating Behavioral

Science into Action” (NAMHC’s Behavioral Science

Workgroup, 2000), focused on ways to enhance

the potential contributions of behavioral science

and how the critical insights offered by such

research might be used to develop intervention

and deployment research. 

An extensive body of behavioral science research

has identified the specificity and variability of

basic behavioral processes in normal populations

and has developed a range of methodologies and

technologies for such research. Applying these

sophisticated measurement technologies to

clinical populations may lead to refined diagnosis

and more precisely identified points of

intervention. Illustrated here is research progress

on normative processes that have implications for

child and adolescent mental disorders. 

Significant advances have been made in our

understanding of the cognitive capacities of

children, particularly those of infants and young

children. For example, in mapping the structure of

infant memory, very young infants’ memory

capacities have been found to be independent of

verbal ability and not to involve conscious

awareness (Rovee-Collier, 1997). Further, the

general organization of memory in young infants

is the same as that in adults, where memory

development primarily involves the acquisition of

new information rather than an entirely new

structure for organizing information. This work

provides a foundation for designing new tests for

developmental disorders that can be administered

early in life when interventions are likely to be

most effective. 

An emerging body of evidence on the interrelation

among temperament, mood, emotions, and

cognition has implications for the etiology and

course of illness. A good example of such research

is the study of infant temperament, which is

defined as the constitutionally based patterns of

sociability, activity, physiological reactivity,

emotionality, and self-regulation that can be

identified very early in development.

Temperament is influenced over time by heredity,

maturational processes, and experience, and

provides a substrate for individual personality.

Basic knowledge on infant temperament has been

augmented by research on how social and

psychobiological substrates of affect may

contribute to individual differences. For example,

a number of projects in the current NIMH portfolio

focus on measures of temperament and emotion

and examine the links between them and early

social factors, individual child characteristics, and

physiological measures. Research examining the

early development of attentional systems and how

this development relates to the control of action

and emotion has implications for improving the

understanding of developmental problems in

attention regulation. For example, studies are

examining ways in which the executive attention

network linked to frontal lobe development plays

a role in the development of higher cognitive

capacities and in the self-regulation of emotional

states and action (Rothbart, MH43361). Because

attentional self-regulation can contribute to 
42

Science Case in Point: Sleep Regulation and Pubertal Maturation

Studies of sleep/wake regulation exemplify the opportunities afforded by combining knowledge about biologic maturation (puberty),

behavioral changes, and social influences such that the findings have implications for social policy. The fundamental issue is that many

adolescents obtain insuffcient amounts of sleep at a time in development (pubertal maturation) when the biological need for sleep

increases. Insufficient sleep can contribute to serious emotional and behavioral health consequences that include short-term as well as

possible long-term effects. Progress in understanding the causes of sleep deprivation (and ultimately strategies for early intervention)

has been informed significantly by research examining interactions between biologic systems, behavioral patterns, and social and

cultural influences within a developmental perspective. Scientific progress includes these main points, made below:

At a time in development (pubertal maturation) when the physiological need for sleep increases, many adolescents are obtaining less

sleep on school nights, largely as a result of late bedtimes combined with early school start times (Carskadon, 1999). The shift to later

bedtime in early adolescence is, at least in part, related to maturational changes near puberty that cause a shift in the circadian system

(biological clock) resulting in a biologically based tendency to stay up later and sleep in later (a shift from a more “lark” pattern to an

“owl” pattern during pubertal development)(Carskadon et al., 1993). These biological tendencies (activated by pubertal maturation)

interact strongly with behavioral/social factors in several important ways, including (1) less parental control over bedtime, (2) access to

highly arousing stimuli (TV, movies, video games) and social interactions (telephone and Internet) late at night, (3) peer influences

toward later bedtime, (4) access to stimulating substances (e.g., caffeine, nicotine), and (5) stress, anxiety, and worries that interfere

with falling asleep. In combination, these factors lead to sleep-onset times that occur at late hours (Carskadon et al., 1993). Thus, the

strong tendency for adolescents to adopt very late schedules (bedtime and wake time) results in a shift of the circadian system, which

adapts more quickly to phase delays than to phase advances (thus it is very difficult for adolescents to shift back to the early bedtimes

and rise times for school) (Carskadon, 1999). Despite an average bedtime between 11 p.m. and midnight, most high school students

must wake up between 6 and 6:30 a.m. on school days. It is not infrequent for high school students to obtain less than 6 hours of sleep

on school nights at a time in development when they typically require 8 to 9.5 hours of sleep per night (Carskadon, 1999). Individual

differences in anxiety, biologic clock, sleep needs, and social context can greatly amplify the affective and behavioral consequences of

insufficient sleep and erratic sleep/wake schedules (Dahl, 1999).

The short- and long-term consequences of insufficient sleep at this point in development are not fully understood. Preliminary data

clearly indicate a negative impact on school performance and learning, as well as decrements in mood and self-regulatory abilities. 

More specifically, sleep deprivation is associated with irritability, poor concentration, and emotional lability, all of which create

additional stress in the lives of many adolescents. Sleep deprivation can also increase stimulant use during the day (e.g., caffeine or

nicotine), as well as extensive catch-up sleep on the weekends by sleeping in very late in the morning (which further interferes with the

slowly adapting circadian systems, resulting in jet-lag like symptoms when the adolescent tries to shift back to an early wake-up time

for school days). Sleep deprivation, mood disturbance, and impaired concentration and self-regulatory skills can spiral into more

severe symptoms of impairment in school and social functioning, which further erodes mood (Dahl, 1999).

Some policy-level decisions are already being enacted to address aspects of these problems; one such policy is adopting later start

times for high schools. Prelimary results from a controlled study of Minnesota school districts that have adopted later start times have

been encouraging, with improved grades and mood ratings in the first year after these changes were made (Wahlstrom et al., 1999). 

Larger studies are currently in progress. Educational programs for adolescents are also being developed (similar to the nutrition

education programs enacted in the past 20 years). However, large-scale policy changes and early clinical interventions focused on

sleep and circadian aspects of adolescent health will require a great deal more interdisciplinary developmental research to better

understand these complex issues.
43

behavioral problems and difficulties in school,

research tracing the normal development of and

individual differences in these controls has

implications for advancing etiologic

understanding of a variety of childhood disorders

in which regulatory deficits are implicated (e.g.,

ADHD, mood and anxiety disorders). This work

needs to be extended to include clinical

populations, both to test the generalizability of

the basic findings and to clarify how, and in

which dimension, children with certain illnesses

or symptoms express these regulatory functions in

different ways. It will also increase the

understanding of how behaviors, symptoms, and

disabilities actually cluster across disorders. 

Advances in the area of basic behavioral research

involve our understanding of contextual

influences on the development of personality or

behavioral traits. Contextual issues play a critical

role in the development, onset, and maintenance

of mental illness in children. For example, studies

have demonstrated that children with difficult

temperaments may push the caregiver away, and

with the caregiver less available, the child may

develop soothing strategies that do not involve

the caregiver. Nevertheless, mothers of such

infants can be taught to effectively regulate the

infant’s distress. Mothers who were trained to

soothe their distress-prone infants and taught

how to play with them were able to foster more

positive affect and greater involvement of their

children with them, with resulting benefits for

their children in terms of attachment and

sophistication of play (Van den Boom, 1994;

1995). 

To better understand the social processes involved

in mother-child transmission of affect, Fogel

(Fogel, MH57669) is examining the development

of emotion and attention in the context of a

dyadic (mother-infant) relationship. Using a

process design called relational-historical

approach, this study is documenting the process

by which individual differences in patterns of

attention and emotion arise developmentally in

infants’ social relationships with mothers. This

study will include the observation of normally

developing mother-infant dyads across key

developmental transitions in the first 2 years of life,

and also a larger group of dyads at risk for

developmental disorders, who will then be followed

longitudinally. One of the goals of this study is to

understand the dynamic processes that regulate

developmental change and the origins of individual

differences in attention-emotion couplings. Such

research is a step forward in exploring how the

interaction of socialization and maturation of

infants’ motor and cognitive abilities affects their

ability to regulate their emotions. 

Another example of the influence of contextual

factors relates to the widely documented gender

difference in depression, which begins to appear

during adolescence. Biological as well as social

and personality factors have been implicated. A

recent, large-scale NIMH study simultaneously

explored the social and personality differences

that could account for the gender difference

(Nolen-Hoeksema, Larson, & Grayson, 1999).

Findings suggest that social factors (e.g., sexual

abuse, lower income, inequities in distribution of

work), child care, and personality factors (e.g.,

lower levels of mastery and a greater tendency to

ruminate when depressed) were found to mediate

the effects of gender. When these variables were

controlled, gender difference in depression became

minimal. These findings suggest that the

increased incidence of depression among

adolescent girls is likely due to factors that

socialize them to be more emotionally expressive

and to adopt internalizing coping strategies.

Gender socialization processes prior to

adolescence that may increase girls’ vulnerability

to adolescent transitions (from elementary school

to junior high) and thereby contribute to gender
44

differences in depression have been identified. For

example, girls are more likely to engage in selfevaluative mechanisms, which heighten

vulnerability to depressive and anxiety symptoms.

Further, mothers were found to exert greater

control and decreased autonomy-granting over

girls than boys (Pomerantz & Ruble, 1998). Social

psychological theory suggests that this type of

control is likely to undermine a sense of mastery

and self-reliance that is crucial for coping with

failures and disruptions, such as those

experienced during school transitions. Such

findings have implications for understanding the

processes by which parental control influences

girls’ perception of mastery and self-evaluation.

Further, they have implications for developing

interventions that could help decrease

vulnerability to depressive symptoms. 

CROSSING THE BOUNDARIES

As previously noted, our understanding of the

relative contributions of biological and

environmental/contextual factors to the

development of mental disorders is not complete.

Recent expansion of knowledge in basic science,

in conjunction with advances in behavioral

science, can advance our etiologic understanding

of mental illness, and hence have potential for

prevention and treatment. We highlight below

some of the opportunities for crossing the

boundaries between behavioral science, basic

neuroscience research, and intervention research. 

Genetics and Behavior. The growing base of

research on the genetic control of the developing

brain structure and system, coupled with the everevolving, powerful technology that provides access

to the developing brain, offers an unprecedented

opportunity for understanding the etiology of

mental disorders and, hence, ways to divert adverse

developmental trajectories. The understanding of

how these brain areas evolve as children’s cognitive

abilities develop and transact with both genetic and

epigenetic factors and influence the course of

mental illness is an important research area. This

area of research is complicated by the fact that

mental disorders do not stem from errors in single

genes. Furthermore, genes and the environment

interact in complex ways over the developmental

course of a mental illness. One vital task is to

complete careful behavioral and biological

descriptions of the behavioral phenotypes of

specific subsets of mental disorders, including how

they are expressed. Behavioral technologies from

psychometrics and behavioral genetics are critical

to the study of the sources of genetic and

environmental variation and vital to dissecting and

understanding the range of hypothesized

phenotypes. 

Managing Mental Illness. Because limited

information is available about the short- and

long-term safety and efficacy of psychoactive

agents on the developing brain, the use of

behavioral strategies is often the first line of

intervention approach in the management of

symptoms in children. Even when psychoactive

agents are prescribed, there is evidence for

including a behavioral component as part of the

treatment protocol (MTA Cooperative Group,

1999a; 1999b). The examination of the long-term

functional impact of such behavioral interventions

is needed to further our understanding of disorder

management.

Further, the impact of childhood-onset mental

disorders has significant social implications for

family members, as well as for school adjustment.

The symptoms of mental disorders interfere with

the development of social skills, and the social

ostracization that is so often associated with

mental illness further deprives children of precious

opportunities to practice and develop needed skills

to interact and cope with their social environment.

Behavioral methods are needed that examine
45

school-based interventions to help such children

develop the requisite social skills for successful, if

not non-traumatizing, peer relationships. 

Brain Plasticity and Behavior. Adult behavioral

treatment outcomes have found functional brain

changes that are associated with positive

behavioral outcomes (Baxter et al., 1992). For

example, patients with OCD were found to

demonstrate normalized position emission

tomography in relevant brain regions after

treatment with effective behavior modification.

These changes were also associated with

successful drug therapy (Schwartz et al., 1996).

These findings have important implications for

children and adolescents, in whom the

tremendous malleability of the developing brain

suggests even greater potential for identifying

important behavioral time lines to target

interventions and for understanding what level of

intervention is needed to affect change and

facilitate recovery.

Biobehavioral Development and Mental

Disorders. Behavioral science offers a rich

description of risk factors associated with the

onset of mental disorders, and the behavioral

course of some child mental disorders has been

described (e.g., conduct disorder, autism,

depression). Focusing on some well-defined areas

of risk factor research may offer opportunities for

translating this knowledge into developmental

neuroscience research. An example of these

opportunities is the risk factor research

establishing that offspring of mothers who give

birth earlier in life are more likely to exhibit

externalizing behavior problems during childhood

and adolescence (Hann & Borek, in press).

Following early (prenatal through 30 months of

age) in-home intervention programs, the mothers

were found to be less impaired by substance use

and less likely to neglect or abuse their offspring.

In addition, the offspring of such young high-risk

mothers had reduced rates of arrest, substance

abuse, and number of sexual partners (Olds et al.,

1986; Olds et al., 1997). It should be possible to

use animal models to manipulate maternal age,

fostering conditions (including cross-fostering

condition with older mothers), maternal stress

during pregnancy, and nicotine exposure to

examine subsequent impulsivity, motor activity,

and susceptibility to self-administration of drugs

in their offspring. Variations in maternal care can

also be examined. The use of transgenic and

knockout mice to manipulate the genetic makeup

of the animals would add a further refinement. It

might be worth examining basal cortisol levels

and various autonomic indices in these animals

as well, given the associations observed in

humans between these variables and disruptive

and antisocial behaviors. 

OBSTACLES AND GAPS

Although efforts at translating behavioral science

into action have been initiated through some

collaborative work, the many research

opportunities that intersect the areas of basic

behavioral and intervention science are hampered

by a lack of communication across disciplines,

across levels of inquiry, across departments and

schools, sometimes across NIMH organizational

lines, and across researchers, providers, and

consumers. Within the area of behavioral science,

some of the specific challenges include the

following: 

 Developing scientifically valid and reliable

measurements and methods. Traditional,

category-focused diagnostic systems based on

adult mental illness have not translated well for

studying child disorders. There are few validated

diagnostic categories in very young children. The

threshold and boundaries for some disorders in

children continue to be hotly debated (e.g., bipolar

disorder). Further, the high degree of diagnostic
46

overlap among disorders raises questions about

nosology. Developing measurement systems that

blend symptom-based indicators with processbased indicators would allow for a richer

understanding of the individual child and his/her

context, thereby allowing a better scientific

understanding of the complex interplay of process

and symptom and the development of finergrained intervention approaches. This is

particularly important in children, in whom

diagnostic classification alone may be difficult or

complicated and of limited use in developing or

guiding interventions. 

 Measuring function. Assessment of

functioning has lagged considerably behind the

assessment of clinical symptoms in mental illness.

The serious economic and societal burden of

childhood and adolescent mental illness requires

the development of tools that can aid researchers,

policymakers, and other mental health

stakeholders in accurately assessing the form and

frequency of functional impairments and

projecting future health care needs and costs.

Functional assessments are also particularly

salient for children, as manifestations of

symptoms are often complicated by the rapid

developmental processes characteristic of

childhood, and do not always fit into categorical

classifications of mental disorders. Consequently,

it is more useful and valid to study mental health

and illness in children in terms of functional or

adaptive abilities rather than solely relying on the

traditional categorical approach, which has

limited utility, especially in young children. 

Theoretical perspectives and limited tools are

available in the behavioral sciences for examining

issues related to functioning, including peer

influence, emotion regulation, cognition, and selfconcept. Research in the area of functioning needs

to take advantage of available resources by

linking to behavioral theory and methods. For

example, some research has documented specific

cognitive and psychophysiological deficits

associated with mental disorders (e.g., attention,

information processing), but there is little

understanding of how these deficits are related to

specific functional problems or how such

problems may be addressed by rehabilitative

approaches. Consequently, many rehabilitative

interventions are not grounded in research, and

there is wide variation in how well these

interventions help specific individuals with

specific deficits. Some ongoing mental health

research that focuses on or includes functioning is

beginning to make these links, but most research

to date does not. 

 Contextual influences. There is some

evidence that social, cultural, psychological, and

market factors influence children’s vulnerability to

risk, experience and reporting of symptoms,

course of illness, the diagnostic process, access to

quality care, responses to interventions, and

health outcomes (Takeuchi, Uehara & Maramba,

1999; Vera, Alegria, Freeman, Robles, Pescosolido

& Pena, 1998). The main and interactive effects of

such context variables, individually and in

combination, need to be identified and assessed to

aid in designing and/or developing interventions

appropriate to the needs and circumstances of

children suffering from mental disorders and their

families. Yet, these social and cultural contexts

are not well configured into current paradigms of

research. At the individual level, knowledge of

how social and cultural contexts influence

individual risk for mental illness and how such

characteristics affect behavioral responses to

intervention can inform the development and

design of new interventions. Further, behavioral

research can help identify strategies to better

understand the role of providers as service

ombudsmen for the child and family. Behavioral

strategies are needed to help providers from

different systems (e.g., schools, primary care)
47

engage youth and families and to understand the

factors that influence treatment acceptability. At

the sociocultural level, knowledge of how

ethnicity, culture, language, socioeconomic class,

family and social networks, and neighborhood or

community affect risk, diagnosis, and intervention

is critical. At the organizational level, knowledge

of how policies, incentive structures, and cultures

at all levels of health/mental health organizations

and institutions affect the behavior of those

providing care and of those receiving it, including

the outcomes of care, is needed. Given the

country’s cultural diversity, a better

understanding of how these contextual factors

affect the mental health services system is needed.

New approaches are needed to deliver culturally

appropriate care to the disenfranchised and the

destitute, for whom mainstream approaches are

often too expensive, foreign, and centralized. 

RECOMMENDATIONS FOR BEHAVIORAL

RESEARCH

Current gaps in our knowledge highlight how

basic behavioral science research is critical and

can increase our understanding of risk,

prevention, treatment, rehabilitation, and the

organization, delivery, and use of mental health

services. Below, research opportunities for linking

basic research to clinical applications are listed: 

1. Research is needed on how different

components of cognition (e.g., attention, language,

memory, social) develop in normative and clinical

groups of children in order to shape intervention

and preventive strategies. This research can

increase our understanding of how children with

cognitive deficits associated with mental illness

may benefit from intervention efforts and develop

new or compensatory skills. Such studies have

implications for the prevention or development of

more severe impairments or comorbid conditions.

2. We recommend detailed empirical study of

the specific psychological and behavioral

functions that are impaired in childhood mental

disorders. Critical domains include memory,

attention, emotional processing, emotional

expression, social cognitive capacities, and several

dimensions of child temperament. Specifying the

nature of disorder in terms of these domains will

not only improve nosology, but it will also be

critical in making connections to neural

substrates and in identifying genetic and

experiential factors in etiology. As a result, such

an effort will pave the way for the design and

implementation of increasingly well-targeted

modes of preventive and treatment intervention. 

3. We recommend research focused on

developmental, behavioral, and social regulators

of emotions at key transition periods, such as

birth and puberty, and social transitions, such as

daycare and elementary school. 

4. We recommend the development of sciencebased interventions that link the psychophysiological deficits associated with mental

disorders (e.g., attention, information processing)

with specific functional problems, with the aim of

formulating more effective and targeted

intervention strategies.

5. We recommend that NIMH support the

development of measurements of functioning that

are both culturally sensitive and

multidimensional. New tools and approaches that

combine qualitative and quantitative methods are

needed to understand issues associated with

children from diverse cultures and subcultures. In

addition, measurements are needed that

complement traditional symptom-based diagnostic

systems and serve as outcome indicators in

intervention, services, and risk processes research. 
48

6. We recommend developing measures and

interventions through ethnography. The

diagnostic conundrums that plague childhood

nosology and the pervasive concern about

labeling young children suggest that rigorous

ethnographic or other qualitative methods for

describing mental illness may be particularly

useful in developing interventions that are

sensitive to a variety of living environments,

communities, and cultural contexts. 

7. We recommend new behavioral research to

identify how providers and families manage

children’s disorders and why they do or do not

engage in the most effective practices. Behavioral

science has significant promise to reveal why

treatments are not more widely disseminated,

what factors underlie complex health behaviors,

and the types of decision-making strategies that

guide current practice.

3. PREVENTION

PROGRESS

Basic science for prevention is the study of both

normal development and the development of

psychopathology at the molecular, individual,

community, and large-scale programmatic levels

(i.e., State or Federal policy). Such study is critical

to the development of preventive interventions.

Preventive interventions offer opportunities to test

fundamental mechanisms about either the

causation of the disease or, alternatively, the

avoidance of poor outcomes in the face of risk.

One fundamental test of whether a mechanism is

truly understood is whether preventive

interventions can alter the expression of disorder. 

While prevention has not historically been

regarded as an essential part of research,

particularly within mental health, three recent

developments have substantially changed that

perspective. First, there are now a number of

longitudinal and developmental investigations

that provide vital information about development

and, in particular, the identification of sensitive

periods, the balance between risk and protective

factors, and vulnerabilities (both genetic and

environmental). Findings from these studies

provide the necessary scientific basis from which

to mount preventive intervention efforts. Second,

preventive intervention investigations are

somewhat more difficult than cross-sectional

analyses, or even short-term randomized trials,

because they require the demonstration that

effects are sustained over several years. Recently,

both methodological designs and statistical

analytic techniques have been devised to provide

the conceptual bases for designing and evaluating

prevention programs. Third, a number of

prevention trials have proved successful, either

significantly reducing risk factors for disorders or

changing the course of the illness in its early

state. As for clinical treatment studies, the next

frontier is the testing of prevention designs in

effectiveness trials. Some preventive intervention

strategies, such as nurse home-visitation

programs and multisystemic family therapy, are

already in the effectiveness testing stage, while

others, such as prevention interventions for

depression, are in the efficacy testing stage.

The subject of prevention research has been

reviewed in several major reports. In 1996, “A

Plan for Prevention Research for the National

Institute of Mental Health” (NIMH Advisory

Mental Health Council Prevention Research

Steering Committee and the Institute of Medicine

Committee on Prevention of Mental Disorders,

1996) summarized two previous reports: “The

Prevention of Mental Disorders: A National

Research Agenda” (NIMH Advisory Mental Health

Council Prevention Research Steering Committee,

1993) and “Reducing the Risks for Mental
49

Disorders: Frontiers for Preventive Intervention

Research” (Mrazek & Haggerty, 1994). In 1998,

“Priorities for Prevention Research at National

Institute of Mental Health" (National Advisory

Mental Health Council Workgroup on Mental

Disorders Prevention Research, 1998) was

developed to review the NIMH research portfolio

on the prevention of mental disorders, identify

research gaps and opportunities, and indicate

priorities for future research. The commonalities

among these reports were recognized, and there

was a strong endorsement of the need for (1)

continued exploration of the interface between

potentially modifiable biological and psychosocial

risk and protective factors, (2) outcomeprevention research focused on risk reduction,

and (3) broader collaboration among scientific

disciplines and the dissemination of existing

approaches. 

CROSSING THE BOUNDARIES

The most recent report on prevention research,

“Priorities for Prevention Research” (NAMHC

Workgroup on Mental Disorders Prevention

Research, 1998), recommended several steps to

advance the science of prevention research. The

report recommended broadening the definition of

prevention factors to focus more fully on basic

biological, psychosocial, and social-cultural risk

factors. The report also suggested that the

prevention of relapse, co-occurring illnesses,

disability, and the consequences of severe mental

illness be considered within the prevention rubric.

Further, the report emphasized the critical

importance of integrating knowledge across

disciplines, as well as integrating prevention

research across all phases of research, including

preintervention, intervention, and services

research. 

Opportunities for integrating prevention research

into intervention research are delineated by

Pearson and Koretz (in press). First, prevention

trial designs can offer strategies for treatment

research design. Prevention trials are embedded in

defined populations (Kellam, Koretz, & Moscicki,

1999) and allow for the analysis of mediators and

moderators of the effects of intervention (e.g.,

recruitment, retention, level of intervention

received). As treatment research moves toward a

public health model with greater emphasis on

effectiveness, service delivery, and dissemination,

the use of epidemiologically based trial designs, in

which target populations are defined on the basis

of samples representative of the populations

seeking treatment or services, will be critical. Such

designs will allow less biased ways to understand

challenging treatment research issues, such as

treatment refusal, dropout, and relapse.

Second, sophisticated analytic models have been

developed to deal with longitudinal data in

prevention research, which allow for multiple

assessments across time, taking into account

baseline trajectories (Brown & Liao, 1999; Curran &

Muthen, 1999). These analytic models will be

particularly useful to child intervention researchers

who are interested in understanding the long-term

effects of intervention in the context of

developmental processes and their impact on the

course of the disorder. Further, epidemiologicallybased samples have the advantage of avoiding

referral biases inherent in most traditional clinical

trials. Such analytic models have also delineated

approaches to delivering interventions to

appropriate individuals in a “unified” manner so

that multiple components of certain interventions

could either be staged sequentially or delivered

simultaneously (Brown & Liao, 1999). 

Third, prevention trials embedded in existing

communities and institutions (e.g., school-based

prevention efforts) can offer insights into
50

approaches for collaborating with various systems

(e.g., Harachi et al., 1996). Such collaborative

relationships are essential if intervention

researchers are to develop effective treatments that

can ultimately be transported, used, and sustained

in communities. Such prevention trials require

collaboration among community representatives

and researchers to identify common goals, and are

typically based on multilevel intervention strategies

that have been shown to be effective for early,

proximal risk factors (e.g., intervention with first

graders [Ialongo et al., 1999]) and difficult-to-treat

populations (e.g., juvenile delinquents [Henggeler

et al., 1996; 1999]). Such multilevel approaches

can be useful as treatment research moves beyond

interventions for targeting single disorders and

considers combined treatments and services to

address more heterogeneous groups of children.

Fourth, in addition to categorizing prevention

efforts according to levels of risk (universal,

selected, and indicated [Gordon, 1983; 1987]),

recent recommendations to broaden prevention

efforts to include comorbidity, disability (primary,

secondary, and tertiary prevention), and relapse

prevention (NAMHC Workgroup on Mental

Disorders Prevention Research, 1998) have

implications for future treatment intervention

efforts. Such efforts include research to understand

how to reduce the incidence of co-occurring

psychiatric disorders (e.g., depression with anxiety)

or psychiatric conditions with medical disorders

(e.g., depression with asthma), decrease the onset

of more severe impairments or disorders (e.g.,

conduct disorder with ADHD), and reduce relapse of

future episodes (e.g., depression) through

appropriate management of stress or adverse

experiences. 

Ultimately, preventive intervention trials offer one

of the best scientific tests for understanding the

mechanisms of causation of disease or the

emergence into health. The recognition and

examination of multiple influences on

developmental plasticity is key for future scientific

advances in the study of preventive interventions

for children. 

OBSTACLES AND GAPS

To date, prevention programs, for the most part,

have focused on efficacy studies, and each

addresses a specific developmental epoch, with

little continuity across the life span. Current

strategies tend to focus on individual-level

processes, rather than on the broader context of

school, family, and community. There is a need for

population-based cohort studies, studies of highrisk individuals, and studies of high-risk families.

The NIMH research portfolio must be realigned to

reflect the public health significance of the disorders

targeted, with an emphasis on different cultural

perspectives and a focus on the differing ways

individuals from diverse backgrounds respond to

similar stressors. 

Limited attention has been devoted to effectiveness

studies, with little attempt to coordinate different

researchers working on the same problem, such as

the prevention of depression. Specifically, there is a

lack of preventive services research. Gaps include a

lack of focus on the prevention of anxiety and

depression across the life span, opportunities for

the prevention of ADHD, and new approaches to

prevention intervention research. One critical

research area includes broadening disorders in

populations targeted for prevention research, with

a greater focus on comorbidity and developing a

preventive services research program.

Prevention research trials, by their nature, require

longitudinal follow-up and fairly sophisticated

effects from interventions. The translation of this

sophisticated methodology used in efficacy studies

to large effectiveness trials and programmatic
51

efforts has yet to take place. Furthermore,

historically, those who have focused on severe

mental illness in adults have tended not to focus on

early-life interventions that may, in general,

increase the resources and readiness of a child and

family to cope with whatever comes, but that are

not directly linked to later outcomes. This is

partially because those doing early interventions

have not looked primarily at mental health

outcomes. The need must be recognized for

intervention programs across the life span--not just

for support in the few years before the onset of

major mental illness in early adulthood.

The translation from efficacy to effectiveness is not

an easy one. As one example, there is new evidence

from the work of David Olds and colleagues (1999)

that nurse home visitation delivered in the first 2

years of an infant’s life to a first-time adolescent

mother can make quite a significant difference,

even 15 years later, in terms of health outcomes for

the infant and mother (see Science Case in Point).

However, there are also many nurse homevisitation programs that do not yield similar

results. In fact, after Olds’ initial research in Elmira,

New York, there was an attempt to replicate the

program using paraprofessionals. The results were

less dramatic (Olds et al., 1999). This finding

emphasizes the fact that mental health outcomes

such as substance abuse or physical abuse of

children can, in fact, be affected by interventions

early in life when they are delivered with attention

to the fidelity of the implementation. It also

emphasizes that the translation to large

effectiveness trials is a difficult and arduous task

that requires sustained programmatic focus and

support if prevention research is ultimately to have

an impact on public health. As illustrated later in

the case study on childhood-onset depression

(appendix B), the recent efficacy data about the

prevention of depression, although modest in

scope, offer considerable promise. Little work has

been done to provide models about how to take

such programs to scale, particularly with

awareness of cultural and community influences. 

To return to the fundamental scientific principle:

Prevention trials offer one of the best ways of

testing the mechanisms of action in moving toward

either psychopathology or health, so prevention

research is a legitimate and necessary part of any

fundamental, longitudinal, developmental, childbased, scientific investigation. 

 

RECOMMENDATIONS FOR PREVENTION

RESEARCH

1. We recommend that attention be paid to

smaller, focused, and intensive longitudinal

studies, informed by basic research. 

2. Given the extensive number of data sets

examining risk and protective factors, we

recommend that a workshop be convened to

identify opportunities for reanalysis of existing data

sets. Examples of questions for such studies would

include areas of attributable risk, predictors of

resilience, interaction of different types/levels of

risks across time, how impairment is affected by

context, and the impact of contextual and cultural

variables on functioning over time.

3. A new emphasis is needed on prevention

effectiveness trials, prevention services, and costeffectiveness of preventive strategies. Studies that

focus on service contexts that facilitate or impede

the sustainability of preventive interventions are

especially needed. 

4. Prevention research trials, by their nature,

require longitudinal follow-up and the use of fairly

sophisticated efforts to determine the effects of the

interventions. Support for methodology

development, especially the analysis of

longitudinal data where the phenomena wax and
52

wane, is needed via program announcements or

conferences. 

5. Research on relapse prevention, desistance,

and naturally occurring prevention is greatly

needed. 

4. PSYCHOSOCIAL INTERVENTIONS

PROGRESS

Reviews of the past 25 years of clinical trials of

child psychosocial interventions have consistently

pointed to beneficial effects of treatment over no

treatment (Casey & Berman, 1985; Kazdin et al.,

1990; Weisz et al., 1987; 1995). Further, the

effects of these treatments are quite strong and

comparable to those found in adult psychotherapy

(Lambert & Bergin, 1994; Smith & Glass, 1977).

Outcome studies continue to emerge, with

ongoing improvements in the quality of design

and method (Durlak et al., 1995). In the past

decade alone, an estimated 500 controlled

treatment outcome studies of psychotherapy for

children and adolescents have been conducted

(Kazdin, 2000a). Recent reviews of psychosocial

interventions have been published, with some

efforts made to identify specific empirically

supported psychosocial interventions for children

(Burns, Hoagwood, & Mrazek, 1999; Journal of

Clinical Child Psychology, 1998; Weisz & Jensen,

1999). Criteria for assessing what constitutes an

evidence base have been offered. Kazdin (1999,

2000a) described critical domains that constitute

such criteria: A theory to relate a hypothesized

mechanism to the clinical problem, basic research

to assess the validity of the mechanisms,

preliminary outcome evidence to demonstrate that

a therapeutic approach changes the relevant

outcomes, and process-outcome connections that

display the relationships between process change

and clinical outcomes. 

Guidelines for clinical practice have been

developed to take into account this body of

empirical evidence (American Academy of Child

and Adolescent Psychiatry, 1998). More specific

operational criteria have been proposed by a task

force of the American Psychological Association

(APA) to identify well-established and probably

efficacious treatments (Lonigan, Elbert, &

Johnson, 1998). The criteria for "well-established"

therapies require at least two scientifically

defensible group-design studies conducted by

different investigative teams, or more than nine

single-case design studies, treatment manuals,1

and strong experimental designs. Therapies

designated as "probably efficacious" generally

require at least two studies demonstrating the

intervention to be more effective than a notreatment control group, or several single-case

design studies demonstrating their impact, as well

as manuals that prescribe therapy.

Efforts to distinguish what does and does not work

are very important, as treatments vary in their level

of efficacy, may be ineffective, or, worse yet, may be

harmful. Through such efforts, approximately two

dozen specific treatments have been identified as

efficacious for various conditions in children,

including ADHD, anxiety disorders, oppositionaldefiant disorder, conduct disorder, and depression

(Chambless et al., 1998; Lonigan, Elbert, &

Johnson, 1998). Some examples of these treatments

include reinforced practice and participant

modeling for fears and phobias; behavioral parent

training and classroom behavior modification for

ADHD; cognitive behavioral therapy for anxiety and

depression; interpersonal therapy for depression;

and anger-control training, problem-solving skills 

1

 Treatment manuals provide a way to specify the

intervention procedures, and can range from those that

are highly prescriptive (with specific session-by-session

activities) to those that provide a general framework for

a treatment approach.
53

Science Case in Point: Preventive Intervention Nurse Home-Visitation Models

The theoretical model of David Olds’ nurse home-visitation program exemplifies a comprehensive approach to intervening with high-risk

families to prevent negative consequences to infants. This program, grounded in epidemiology and theories of child development and

behavioral change, emphasizes the importance of (1) reducing children’s neurodevelopmental impairment (including emotion and behavioral

dysregulation and cognitive impairment) through the improvement of prenatal health-related behaviors, (2) reducing the dysfunctional care

of the child, which compromises health and development, and (3) increasing the economic self-sufficiency of the parents by helping them

plan future pregnancies, find work, and eventually, decrease reliance on welfare. The development and testing of this model was further

complemented by a cumulative sequence of field trials, with replication of findings in diverse populations, and current efforts to scale up

the program across the country.

During a home visitation, nurses make an effort to help mothers and other family members improve their health behaviors and the care of

the child and enrich the parent’s personal development. They provide child development information, parenting education, parental social

support, parent leadership training, screening, and referrals for a period of 30 months. Evidence for standardization of treatment includes

detailed record-keeping forms, visit-by-visit protocols, case reviews, and extensive staff training. Essentially the same program (refined over

the years) was tested in three sites to ascertain the generalizability of findings: a small semirural county in Elmira, New York (n=400), and

two urban areas serving minority families in Memphis, Tennessee (n=1138) and Denver, Colorado (n=735), where the trial is still

underway. This program of research is characterized by strong sample retention and measurement of outcomes; many outcomes were

collected on institutionally archived data, such as medical, criminal, Aid to Families with Dependent Children program (now called the

Temporary Assistance to Needy Families program), and child abuse records. Multiple informants of child behavior problems (parent and

teacher) were used at older ages, although these sources did not always corroborate the findings of reductions in child-reported arrests at

15 years with corresponding reductions in delinquent acts.

Results have been published from the Elmira and Memphis trials (Olds et al., 1999). In both trials, families received a little over 50 percent

of the scheduled visits. Evaluation results have been reported most fully from the Elmira site. As with many preventive interventions, the

outcomes of this study were not limited to the risks for mental health or behavioral outcomes examined in this review. Researchers found

reduced incidences of child abuse and neglect in the intervention vs. the control group when the children were 2 and 15 years of age (Olds

et al., 1986; Olds et al., 1997). When children were 15 years of age, mothers in the intervention group were also reported to be less impaired

by drug and alcohol use over the 15-year period following the birth of the first child compared with mothers in the control group (Olds et

al., 1997). Moreover, the 15-year-old children had over 50 percent fewer arrests, 69 percent fewer convictions for the original crime or

probation violations, 28 percent less use of cigarettes, 56 percent less use of alcohol, and 63 percent fewer sexual partners (Olds et al.,

1998). Many corroborating effects were found in related aspects of maternal and child functioning. Many of the early beneficial effects found

in Elmira were reproduced in the Memphis replication, although the treatment versus control differences generally were not as large as those

in Elmira. Based on the two completed trials, this program was found to benefit the neediest families (low-income, unmarried women), with

little benefit for the broader population (Olds et al., 1999).

Economic analyses by the RAND Corporation (Karoly et al., 1998) have shown that the investment in the service is recovered with dividends

by the fourth year of the child’s life when it is focused on low-income families (Olds et al., 1993), with an estimated four dollars saved for

every dollar invested (Karoly et al., 1998). Based on the high-quality study design and program implementation, positive short- and longterm effects and replication, this intervention is deemed appropriate for dissemination. The program is currently being replicated in

nonresearch settings, and evaluations are being conducted to determine the extent to which the program is being conducted with fidelity

to the model tested in the randomized trials.
54

training, multisystemic therapy, delinquency

prevention, and parent-child interaction treatment

for conduct problems.

In the past 5 years, there has been a concerted

effort by the clinical treatment research field to

move beyond small-scale efficacy trials to broaderbased effectiveness studies (Hoagwood, Jensen,

Petti, & Burns, 1996). This emphasis on the

translation from efficacy to effectiveness has

resulted in an increase in studies that focus on

more heterogeneous populations, more "real-world"

settings (e.g., pediatricians’ offices), and a wider

range of outcomes with which to investigate the

applicability of the treatment under consideration.

Further, effectiveness studies are increasingly

attending to the use of treatment manuals to codify

procedures (Kazdin, 2000b), issues of treatment

fidelity (e.g., Schoenwald, Brown & Henggeler,

2000c), and assessment and maintenance of

therapeutic change (e.g., through an after-care

program that monitors children and families and

provides periodic treatment sessions, as needed, to

maintain treatment gains, prevent relapse, and

reduce the need for and use of additional services

following treatment (Kazdin, MH59029). Some

efforts are also underway to adapt, develop, and

test treatment approaches with specific cultural

groups (e.g., Rossello & Bernal, 1999).

More recent efforts at NIMH to encourage an

expanded treatment research agenda with a public

health focus have cautioned against the dichotomy

between efficacy and effectivenesstreatment

designs. In efforts to broaden the scope of clinical

research studies, the terms efficacy and

effectiveness have become buzzwords, resulting in

inconsistent use of terminology. As a result,

effectiveness research may mean many different

things. Rather than focusing on the strengths and

weaknesses of each type of design, the next frontier

of treatment research calls for new and innovative

methods, including mixed-modality approaches

(e.g., combined treatments—see Section B.6.

Combined Interventions and Services Effectiveness),

paradigms that include both experimental and

observational work, and hybrid treatment study

designs that combine the careful controls of efficacy

trials and the flexibility of effectiveness paradigms

(Miklowitz & Clarkin, 1999; Norquist, Lebowitz, &

Hyman, 1999). 

The significant progress in this area indicates that

clinical psychosocial treatments have much to offer.

They offer the prospect of enhancing the quality of

children’s development and reducing the risk for

short- and long-term impairment. They also offer

the potential to provide alternatives or

complements to pharmacological interventions that

parents and children may view more positively. In a

related vein, psychosocial interventions may also

enhance the impact of pharmacological treatment.

As interdisciplinary research in child mental health

progresses, documented brain changes that occur in

children in response to psychosocial interventions

may inform our understanding of underlying

neurobiological mechanisms and biobehavioral

processes.

CROSSING THE BOUNDARIES

If the impressive advances in child and adolescent

psychosocial treatment research are to be

effectively applied and used in service settings,

such progress must be accompanied by a

systematic plan to guide treatment development,

future progress, and evaluation. The question of

“what treatment, by whom, is most effective for

this individual with that specific problem, under

which set of circumstances” may not be applicable

owing to the number of therapeutic techniques

under use, the number of child disorders, and the

wide range of factors that can influence treatment

outcome—all of which may vary depending on

when treatment is applied in the course of
55

development (Kazdin, 2000a). To make significant

advances in the field of child and adolescent

psychosocial research, Kazdin (2000a) proposed a

research plan that is consistent with the goals of

this report. Broadly, this plan emphasizes the need

to (1) connect treatment development with what we

know from basic science (including developmental

psychopathology), (2) understand the mechanisms

or processes by which therapeutic change occurs

and factors that influence the change, (3) broaden

the range of questions (beyond treatment

techniques and global conceptual approaches), and

(4) expand the range of outcome criteria to evaluate

treatment effectiveness (including differential

outcomes by subtypes that may or may not be

linked to DSM diagnoses). Weisz (2000) further

argued for the need to move beyond serial efficacy

studies to achieve this research agenda. To ensure

that research for treatments will be used in clinical

practice, Weisz proposed a Clinic-based Treatment

Development Model in which the development and

testing of treatments are moved at an early stage

into clinical practice to ensure a more complete

understanding of the processes and mechanisms of

therapeutic change. 

These conceptual contributions are critical; this

report highlights the urgent need for these and

other critical linkages to be made in order to focus

the field of child and adolescent mental health

intervention research. To date, most psychosocial

interventions developed have largely ignored the

tremendous amount of knowledge in basic

science. For example, a recent review of the NIMH

portfolio on ADHD revealed that literature on the

development of executive functions and

regulation of attention and impulse control exists

within the basic science. Yet virtually none of this

research has been connected to the development

of interventions for children diagnosed with

ADHD. With some exceptions, most current

treatment paradigms (e.g., cognitive behavioral

therapy [CBT]) for children have been modeled

after adult studies, with limited attention to

developmental or contextual issues or solid

theoretical conceptualization of the disorder based

on developmental psychopathology, basic

neuroscience, or behavioral science theory. The

rapidly evolving knowledge from basic science

should be harnessed more systematically to guide

intervention development. Yet etiologic

understanding does not guarantee an effective

treatment (Kazdin, 2000a). While basic research

continues to increase understanding of etiologies

that can guide treatment development, effective

treatments can be identified. Such treatment

outcome studies can, in turn, inform basic

research. The knowledge of the processes and

mechanisms by which such treatments lead to

therapeutic change can help basic researchers

identify potential variables that may be involved

in the etiology, maintenance, and recurrence of

child and adolescent disorders. 

Another critical linkage involves harnessing

knowledge from the services and dissemination

research areas (see this report, Section II.B., 6.

and 7.). Services and dissemination research

offers crucial information on the factors critical to

successful transportation of interventions—

information that can be integrated into treatment

development, right from the start, to ensure that

interventions can be used and sustained. At the

same time, psychosocial intervention outcome

studies can also inform services and

dissemination research by providing clues about

the facets of treatments that are critical to ensure

beneficial outcomes, delineating the conditions

and parameters under which interventions are

most likely to succeed and identifying the

processes and principles by which treatments may

be augmented to enhance their success across

diverse populations and settings. 
56

OBSTACLES AND GAPS

Despite the sheer quantity of studies in

psychosocial outcome research for children and

adolescents, the direction of research in this area

has been criticized for a neglect of theory, a lack of

distinction between theories of onset of dysfunction

and therapeutic change, and the lack of progression

of knowledge from description to explanation and

from risk factors to causal agents (Kazdin, 1999).

Although some empirically supported treatments

can be shown to reliably produce change, the

processes by which such change occurs are not well

understood. The complex relations among multiple,

dynamic, and (often) confounding influences and

clinical outcomes pose significant conceptual

challenges for understanding the nature of clinical

disorders and therapeutic change. These challenges

are further complicated by constraints of current

statistical models, which limit assessments of these

complex relationships (e.g., assessing multiple

constructs at multiple levels at multiple points

across the developmental trajectory). 

Another challenge in psychosocial intervention

research relates to the development of

interventions that are generalizable. With a few

exceptions, the majority of treatment development

research has been focused on single, specific

disorders and tested on nonclinically referred

children. The applicability of scientifically proven

treatments to diverse populations and settings is

frequently challenged. At the same time, a metaanalysis summarizing the limited literature on

treatment effects in clinical practice (as opposed to

research settings) found almost no difference

between treatment and no-treatment conditions

(Weisz et al., 1995). Thus, whether conclusions

drawn from treatment research developed in

research settings can be applied to clinical practice

remains an open question (Weisz, Weiss, &

Donenberg, 1992). 

As noted earlier, task forces have been brought

together by different professional associations and

private foundations to develop guidelines and

criteria for evidence-based interventions. Despite

increased attention to empirically supported

treatments, there is not yet clear consensus about

what constitutes evidence-based treatments. For

example, the thoughtful criteria developed by the

APA task force have not been widely adopted, in

part because of several limitations. The criteria

were based on multiple subjective judgments, and

there was no common outcome metric across the

studies (Weisz & Hawley, 1998). In addition, many

such studies fail to describe effects adequately.

Positive results are typically described as significant

differences between groups, between pre- and posttests, or by magnitude of effect. The level to which

interventions raise functioning in relation to

"normal" or "typical" children is often not known or

described. Further, the majority of the interventions

identified by the task force as having demonstrated

efficacy consist of brief behavioral or cognitive

behavioral interventions for specific disorders. This

is in marked contrast to the theoretical orientation

of many clinicians. The focus of psychosocial

intervention research on "pure" forms of

intervention is in striking contrast to most clinical

practice, where intervention approaches often

emphasize processes with wide applicability across

disorders rather than specific dysfunctions (e.g.,

maladaptive family processes and distorted

cognitions) and techniques that are eclectic or

multimodal in nature (Kazdin, 2000a). The use of

treatment manuals that rigidly fix treatments is

seldom directly applicable to the problems

presented by clinically referred children, who often

have more severe, chronic, and comorbid

conditions, and who come from less advantageous

environments. 

The disconnect between treatment research and

clinical practice is related to several issues.

Treatment research for children has typically
57

involved conducting such studies within

controlled and somewhat rarefied environments,

such as university laboratories. Studies of

conventional treatments delivered in clinics and

clinical programs have demonstrated much

weaker effects (Weisz et al., 1995). There has

been an implicit assumption that once the

laboratory studies of the efficacy of treatments

have been completed, the results will be usable

and relevant outside of these laboratories. But as

Weisz and colleagues have noted (Kazdin &

Weisz, 1998; Weisz, 2000; Weisz et al., 1993),

there are numerous differences between the

conditions of most research settings and the

conditions in which everyday treatment is

delivered. These differences may mean that

treatments developed through efficacy trials may

need adaptation to fit into many clinics and other

service settings. The challenge of addressing the

discrepancy between treatments as tested within

controlled environments and treatments or

services as tested within real-world clinics or

community settings has been identified as a major

impediment to closing the gap between science

and practice (Burns, 1999; Burns, Hoagwood, &

Mrazek, 1999; Hoagwood, Hibbs, Brent, & Jensen,

1995; Jensen, Hoagwood, & Petti, 1996; Jensen,

Hoagwood, & Trickett, 1999; Kazdin & Weisz,

1998; Weisz et al., 1993). Understanding the

mechanisms by which these empirically supported

treatments lead to beneficial outcomes, as well as

the factors that moderate treatment outcomes,

will be critical to increasing their transportability. 

Finally, barriers to the use of evidence-based

interventions have not been adequately considered

in intervention development. For example,

economic factors and their feasibility (e.g.,

treatment cost, training cost, and reimbursement)

are often not taken into account in intervention

development research. Yet, if providers are not

trained or reimbursed for evidence-based

treatments, those treatments will not be practiced.

Similarly, if families are unable to accept a certain

type of treatment, outcomes will not be successful.

In the current health care climate of cost

containment, identifying core elements of

interventions that potentiate the outcomes of

interest is important so that buyers of services can

make informed choices to improve triage and

increase the efficiency of services. Studies are

needed to answer, for example, questions about

those components of cognitive-behavior therapies,

family therapies, home-visitation programs, or

parent management programs that are core to

obtaining certain outcomes. Studies are needed that

deconstruct or dismantle therapies into elements

that eventuate certain positive outcomes and that

are practically amenable to being taught to mental

health care providers, including teachers, health

care paraprofessionals, and others in the field.

RECOMMENDATIONS FOR PSYCHOSOCIAL

INTERVENTIONS

1. We strongly urge that treatment studies

move beyond assessing outcomes to focus more

attention on the mechanisms or processes that

influence those outcomes. These mechanisms may

involve basic processes at different levels (e.g.,

level of neurotransmitters or stress hormones,

information processing, learning, motivation,

therapeutic alliance) and may be mediated by

therapeutic approaches (e.g., practicing new

behaviors, habituating to external events).

Understanding the mediators and moderators of

outcomes will be important in identifying the

ingredients required for therapeutic change. 

2. We further recommend that treatment

outcome studies assess outcomes beyond child

symptom reduction to include functioning across

various domains (e.g., school functioning, social

interactions, family interactions, adaptive

cognitions) to provide a more comprehensive
58

picture of the benefits of psychosocial

interventions. 

3. We recommend that NIMH promote a

scientific agenda on the generalizability of

psychosocial treatments by targeting funds

toward the development or adaptation of

psychosocial treatments that are implementable in

real-world settings (e.g., schools and primary

care), including the transportability of treatments

with minority populations. Attention to the

impact of development, culture, and context on

the effectiveness of psychosocial treatments must

be a priority. Such efforts will require the

development of new methodologies to address the

issue of increased heterogeneity in effectiveness

trials, treatment fidelity (flexible vs. rigid

adherence to treatment protocols), a clear

definition of “treatment as usual,” and the use of

appropriate comparison groups.

4. We recommend that the psychosocial

treatment program target the critical research

gaps listed below:

 Comorbidity (e.g., substance abuse and

depression, anxiety and depression, medical and

psychiatric disorders)

 Potentially life-threatening conditions (e.g.,

eating disorders, suicide), bipolar disorders,

anxiety spectrum disorders, autism, neglect,

physical and sexual abuse, early-onset

schizophrenia

 Gateway conditions of disorders (e.g.,

oppositional defiant disorder [ODD] as a gateway

to conduct disorders, trauma as a gateway to

post-traumatic stress disorder [PTSD], or ADHD as

a gateway to ODD/conduct disorder/substance

use) to divert onset of more serious disorders or

impairments

 Parental mental illness and its influence on

the prevention and treatment of child and

adolescent mental disorders 

5. We recommend that priority be given to

treatment modalities beyond cognitive behavioral

therapy and behavior therapy (e.g., family therapy,

Internet-based interventions), studies comparing

psychosocial interventions for the same conditions

(e.g., comparing combined treatment involving

parent training and parent-child relationship

therapy vs. child-focused interventions), and

studies that address the issue of sequential

psychosocial treatments and/or combined

psychosocial and psychopharmacology treatments. 

6. We recommend that NIMH give funding

priority to studies of common treatments and

services available in the community (e.g.,

wraparound, treatment foster care, residential

care, hospitalization), as they may provide a

promising avenue for discoveries of new

treatment approaches or strategies.

7. Because so few studies have assessed the

long-term outcomes of interventions (beyond 5

years), and because assessments of the costeffectiveness as well as clinical and functional

outcomes are needed to determine the benefits of

treatment and impact on course of illness, we

recommend that NIMH encourage long-term followup studies of treated and untreated populations.

5. PSYCHOPHARMACOLOGY

PROGRESS

As in other areas of child research, the changes in

clinical practice in child and adolescent psychiatry

have far outpaced the emergence of research data.

Compared with those for adults, relatively few

psychotropic drugs have been approved specifically
59

for the treatment of pediatric childhood disorders.

The small number of approved indications in

pediatric psychopharmacology is problematic

because clinical decisions are not guided by a

scientific knowledge base for the majority of

childhood psychiatric disturbances and symptoms. 

Since the early 1990’s, substantial progress has

been made in conducting high-quality scientific

studies on the role and benefits of medications for

the treatment of childhood mental disorders.

Consequently, a sizable scientific evidence base is

becoming available to help providers and parents

make informed choices about medication treatment

options, whether such medicines are used alone or

combined with psychotherapies. One major

advance is the newfound appreciation that children

can suffer from psychiatric disorders and that some

of these disorders can be reliably diagnosed in

children. The difference lies in the diagnostic

process, in which multiple informants are required.

While more work is still required to increase the

reliability of assessment instruments for certain

syndromes, the field is sufficiently advanced that

clinical trials have been launched. Advances in

medication treatments are especially promising for

several disorders, including ADHD, OCD, and

childhood anxiety disorders. In addition, major

studies are currently underway to test the benefits

of psychotherapeutic, medication, and combined

treatments for ADHD in preschoolers, major

depression in adolescents, and OCD. Similar sizable

trials and substantial efforts are also being

conducted in the areas of youth bipolar disorder,

autism, and other major mental disorders affecting

youth.

Federal and Industry Developments

Two recent initiatives, the 1997 Food and Drug

Administration Modernization Act (FDAMA) and

the 1998 Pediatric Rule, have been particularly

important in stimulating greater interest in

developing psychopharmacology for children and

adolescents. The FDAMA gives the FDA authority to

require that certain studies be done in children for

both new drug applications and already-approved

drugs that companies plan to develop for new

indications in adults. FDAMA is a voluntary

program that gives a financial incentive (an

additional 6 months of patent exclusivity) for

companies to study both new and currently

marketed drugs in children. Under FDAMA, nine

written requests have been issued for three

psychiatric disorders in pediatric patients—major

depressive disorder, OCD, and generalized anxiety

disorder. Under the Pediatric Rule, studies have

been requested for PTSD, social anxiety disorder,

mania, and premenstrual dysphoric disorder. Other

conditions that are currently under consideration

for issuing written requests and requiring studies

under the Pediatric Rule include schizophrenia,

panic disorder, conduct disorder, and ADHD (for

children under 6 years of age) (Laughren, 2000).

The increased research activity in child and

adolescent populations by the pharmaceutical

industry can be further enhanced in several ways.

Dissemination of study data in peer-reviewed

journals is not always a priority in these studies.

Therefore, valuable information is not always

shared with the scientific community and

providers. Prompt dissemination of study results,

even negative studies, should be encouraged.

Improved cooperation among investigators,

clinicians, parents, patients, and government

agencies (scientific and regulatory) may allow for

large studies to have more “depth” than simply

safety and efficacy.

Methodological Advances:

Drug Metabolism Studies. Until recently, very few

drug metabolism studies were performed in

children. There is a growing appreciation that doseranging, pharmacokinetic studies can be effectively

implemented to develop rational medication dosing

strategies for children. Single-dose studies do not
60

examine with adequate rigor how medications are

processed in the body. Consequently, investigators

are examining drug metabolism to dose

psychotropic agents in children more accurately

and safely. Further research is needed into the

determinants of clinical response

(pharmacodynamics), tolerability, and betweenpatient variability in optimal dose levels.

Protocol Development. Some “standard” protocols

to test the efficacy of psychotropic drugs over the

short term have been developed for a few

disorders, including ADHD, depression, and OCD.

In addition, the Research Units on Pediatric

Psychopharmacology (RUPP) centers have

implemented methods for the study of anxiety and

autistic disorders. Currently, accepted protocols do

not exist for bipolar disorder, schizophrenia,

PTSD, and certain other conditions. With the

exception of the MTA study, consensus about

effectiveness studies needs to be developed. Longterm safety studies tracking large cohorts of

patients should be a priority, considering the

number of children and adolescents receiving

psychotropic medications and the chronic,

recurrent, and disabling nature of many

psychiatric disorders. In addition, studies of

comorbid disorders and combination

pharmacotherapy are needed in light of the

number of children receiving concomitant

medication treatments.

Advances by Condition:

Much is now known about how to treat many of

the mental illnesses that befall children and

adolescents. Of all of the childhood-onset

psychiatric disorders, ADHD is the most widely

studied, with a plethora of literature on the shortterm effects of medications on ADHD now

available. Recently, results were released from the

MTA study, an effectiveness trial that considered

the roles of state-of-the-art pharmacotherapy,

psychosocial interventions, and their combination

(MTA Cooperative Group, 1999a, 1999b; see also

Science Case in Point). Currently, a six-site NIMH

study (Preschoolers with ADHD Treatment Study

[PATS]) is assessing the safety and efficacy of

methylphenidate in young children. 

Despite the high prevalence and frequency of their

use, no antidepressants are currently labeled for

use in childhood depressive disorders. Several

efficacy and safety studies are now underway. An

NIMH-funded study (Treatment of Resistant

Depression in Adolescents [TORDIA]) will test the

effects of pharmacological and combined

pharmacological and psychotherapeutic treatment

strategies for adolescents who have failed to

respond to an adequate course of selective

serotonin reuptake inhibitors (SSRI’s). The TORDIA

study should help determine the utility of

psychotherapy and pharmacotherapy (SSRI) alone

and in combination. Controversy continues about

the accurate diagnosis of bipolar disorder in young

children, although consensus is beginning to

emerge (NIMH Research Roundtable on Prepubertal

Bipolar Disorder, in press). Difficulties in diagnoses

have resulted in limited psychopharmacological

trials. However, several small, open-label trials

have been conducted, although many include

heterogeneous groups of children, which may

confound results. In addition, an acute NIMHsponsored efficacy trial has begun and several

maintenance trials are underway to study the

efficacy of mood stabilizers for bipolar disorder in

children and adolescents. Research on diagnostic

assessment, outcome measures, combination

therapy studies, long-term safety studies, and

maintenance trials are sorely needed. Research

determining the short-term efficacy of

antidepressants for young patients with anxiety

disorders has been conducted largely by the

RUPP’s. OCD is the best-studied of the anxiety

disorders, as evidenced by FDA approval of three

psychotropic agents over the past 10 years; further

study is needed on the impact of trauma and PTSD. 
61

Few data about effective treatments for

schizophrenia and related conditions in children

and adolescents are available. With the exception

of two small studies (Findling et al., 2000; Kumra

et al., 1996), there are no controlled data about the

use of new-generation antipsychotics in youths.

Only modest amounts of short-term treatment data

are available for children and adolescents with

autistic disorder/pervasive developmental disorder.

An acute and maintenance trial for young people

with this condition is currently being undertaken by

the RUPP’s, and new models have been developed

to examine the effectiveness of medications in this

population. 

Yet, as with other disorders, combination

pharmacotherapy and long-term safety studies with

large numbers of patients are still lacking. Further

studies are needed to assess how these

scientifically proven treatments can be successfully

transported and sustained in real-world practices.

There is a need to better understand the factors

contributing to the use or lack of use of efficacious

treatments in the real world, including individual,

familial, provider/organizational, systemic, and

societal factors.

CROSSING THE BOUNDARIES

To date, most pharmacologic drugs have been

studied in open trials. The limitations of available

safety data from randomized controlled trials

(RCT’s), and the difficulties of mounting sizable

trials in children and adolescents, suggest the need

to augment our knowledge in other ways.

Knowledge from several areas of basic science is

particularly relevant. Longitudinal

pharmacoepidemiological studies in children are

needed to better understand the long-term risks or

benefits associated with psychotropics.

Experimental data garnered through the

development of animal models can be important in

examining the developmental impact of both

psychotropic drugs and illness during sensitive

periods of neurodevelopment. Fundamental

research on the mechanisms underlying and

influencing brain development, neuronal signaling,

synaptic plasticity, signal transduction pathways,

and the biochemical and behavioral actions of

therapeutic agents in animals and humans have

important implications for the understanding of

individual differences in treatment response.

Knowledge about the mechanisms of action of

therapeutic interventions can also have important

implications for the development of new

medications for treatment of childhood disorders.

OBSTACLES AND GAPS

Pediatric psychopharmacology is no longer in its

infancy; it is taking the small, tentative steps of a

toddler. Yet, several issues continue to impede

progress in this area. The safety of psychotropic

drugs is a concern—children are growing and

developing and, hence, are perceived to be more

vulnerable to drug effects. Current assessment

methods are not well developed, and preclinical

models to assess possibly subtle developmental

effects are inadequate. Moreover, the

ascertainment of adverse events is a particular

challenge, especially in young children. Optimal

approaches for studying the safety of psychotropics

in children are needed. Another difficulty relates to

diagnosing young children. Debate continues

around whether or not diagnoses such as ADHD,

major depressive disorder, and other psychiatric

diagnoses that are well accepted in older children

are meaningful in younger children. An alternative

view is that much of the prescribing of

psychotropics in preschoolers, especially for

conditions other than ADHD, represents treatment

of nonspecific symptoms such as aggression or selfinjurious behavior. If so, are these nonspecific

symptoms reasonable targets for research? 
62

Methodological paradigms of pediatric

psychopharmacology are limited and are often

modeled after adult studies. Issues of comorbidity,

polypharmacy, the effects on neuro-ontology, and

the impact of combining medications with

behavioral or other nonpsychopharmacological

treatments need to be considered in study designs

that should both rigorously test medications and

carefully consider both the risks and the potential

benefits of psychotropic agents. Many psychiatric

disorders are chronic, recurrent, and impairing. For

example, relapse and recurrence of depression in

children is equal to or surpasses that in adults

(Emslie et al., 1998). Yet there are no controlled

data on the effectiveness of antidepressants in

preventing relapse or recurrence. Study designs

that look beyond acute treatment to examine the

long-term safety and efficacy and the impact of

treatment on the natural course of illness are

needed. Specific gaps include the lack of adequate

clinical trials that examine how best to treat

patients with subclinical disorders such as

depressive disorder not otherwise specified,

dysthymia, or major depression with genetic high

risk for bipolar disorder, and youths with comorbid

psychiatric or medical conditions (e.g., substance

abuse, diabetes, asthma). 

Other areas that need development include the use

of psychopharmacology to treat substance abuse in

teenagers, psychopharmacological management of

neglect, physical and sexual abuse, and pervasive

developmental disorders. Studies on the

psychopharmacological management of nonspecific

psychiatric symptoms are also needed. There is a

growing recognition that there is a group of

children who are physically aggressive who do not

suffer from a mood or anxiety disorder. Future

work should help to characterize this group and

develop and further examine outcome measures to

observe the effects of therapies, including

medications. Another set of psychiatric symptoms

relates to sleep disturbance. Difficulties with sleep

may be quite problematic for children and

teenagers. Some sleep problems may be due to

medical conditions or prescribed agents. Although

soporifics are commonly used in these children, few

data exist about their use.

RECOMMENDATIONS FOR

PSYCHOPHARMACOLOGY

1. We recommend expansion of the RUPP’s to

include the capacity for launching/conducting large

simple trials to study issues such as comorbidity,

dosing, and safety and efficacy of medication

treatments across diverse cultural populations. 

2. We recommend increased research on the

psychopharmacological management of serious

mental illness (e.g., early-onset schizophrenia,

bipolar disorder, eating disorders, severe

depression) and pervasive developmental disorders

(including autism and Tourette’s).

3. We recommend that NIMH support the study

of nonspecific symptoms that are often the targets

of psychopharmacological management in children

(e.g., aggression and sleep problems) but that have

not been measured specifically. Better assessment

measures to identify such symptoms need to be

developed so that the symptoms can be assessed

across disorders. Trials for these symptoms,

independent of disorder, may be considered.

4. Disorder-based efficacy trials for new

medications are currently being conducted for acute

treatment, particularly for medications under

patent protection. However, very few studies that

examine long-term safety and efficacy are

supported. We recommend that NIMH support such

studies.

5. We recommend the development of better

study paradigms on psychopharmacology 
63

Science Case in Point: Multimodal Treatment for ADHD

Significant public concerns about stimulant medication, wide variations in treatment practices, and lack of evidence to guide long-term

management of ADHD led to the development of the NIMH Collaborative Multisite Multimodal Treatment Study of Children with ADHD (MTA).

This 5-year study of treatment of ADHD and its associated comorbid conditions examined the long-term effectiveness of medication versus

behavioral treatment versus combined treatment, and compared these results to routine community care. Using a parallel-groups design,

576 children (7 to 9 years of age) with ADHD were recruited across six sites and randomized to four treatment conditions: Medication alone,

psychosocial treatment alone, a combination of the two, and community comparison. This study was designed to provide a large enough

sample size to address the multiple questions about treatment strategies for ADHD, namely, to determine what treatments (medication,

behavioral treatment, parent training, school-based intervention) would benefit which children (comorbid conditions, gender, family

background), in what domain of functioning (cognitive, academic, behavior, social skills, family relations), for how long, and to what extent.

The findings: Medication management and combined treatment were superior to behavioral treatment alone and to routine community care

in targeting core ADHD symptoms for up to 14 months. Although medication management yielded the most improvement in core ADHD

symptoms, the combined treatment was necessary to produce results consistently superior to routine community care for addressing nonADHD symptoms (oppositionality/aggression and internalizing symptoms) and functional outcomes (achievement, parent-child relations,

and social skills)(MTA Cooperative Group, 1999a; 1999b). Furthermore, the combined treatment allowed children to be successfully treated

over the course of the study with lower doses of medication compared to the medication management group.

Overall, these findings held across all six research sites, despite substantial cross-site differences in sample demographics. Therefore, the

study’s results appear to be applicable and generalizable to a wide range of children. Despite the scientific evidence and availability of the

state-of-the-art treatments utilized in this research protocol, such treatments are not readily available in the real world. Differences in quality

and intensity of the treatment regimens between study protocol and real-world treatments account for superior improvements seen in children

treated as part of the study. Further studies are needed to assess how these scientifically proven treatments can be transported to and

sustained in real-world practices. There is a need to better understand the factors contributing to the use or lack of use of efficacious

treatments in the real world, including individual, familial, provider/organizational, systemic, and societal factors.

A couple of surprising findings emerged from this study. First, despite the superiority of medication management on core ADHD symptoms,

teachers and parents indicated higher levels of satisfaction with treatments that included the behavioral therapy component. Second, even

though routine community treatment usually included medication, treatment effects were inferior to the medication management alone. This

discrepancy is related to the quality and intensity of the medication management treatment, including longer and more regular visits, closer

monitoring of side effects, more frequent and higher dosing, and regular contact with teachers whose input was used to adjust the child’s

treatment. Third, contrary to expectations about the superiority of combined treatment on parenting and family stress, combined treatment

did not produce significantly better effects on family stress variables than either medication or behavior management alone. All three MTA

treatment protocols did not differ significantly from the community treatment on family stress, although they were more effective in

decreasing negative and/or ineffective parenting (Wells et al., 2000). However, combined treatment, and not behavior management alone,

was necessary to produce improvement in children’s social skills and reduction in disruptive behaviors in school. This effect was mediated

by decreases in negative or ineffective parental discipline (Hinshaw et al., 2000). This finding suggests the need to appreciate the complexity

of the interrelationships among the various types of interventions.
64

effectiveness, including augmentation strategies,

multiple medication strategies, and the use of

algorithmic treatments. Rational approaches to

the management of comorbid disorders,

medication side effects, and treatment resistance

are needed. 

6. Studies examining reasons why patients do

or do not follow treatment recommendations are

needed. Further, studies are needed on the impact

of the long-term use of medications, including

their impact on psychosocial functioning. 

7. We recommend supporting basic and clinical

neuroscience research on mechanisms underlying

brain development and the biochemical and

behavioral actions of psychotropic agents in

animals and humans to increase understanding of

drug actions in the developing brain and

individual differences in treatment response (i.e.,

variability in optimal dose levels). Further,

research on brain imaging to identify subtypes of

diagnostic categories may have different

treatment intervention implications.

 8. We recommend that the study of both the

short- and long-term consequences (negative and

positive) of pharmacological interventions

associated with acute, recurrent, and chronic

exposure to psychotropic agents on the developing

brain be a priority for new NIMH initiatives. 

6. COMBINED INTERVENTIONS AND

SERVICES EFFECTIVENESS

PROGRESS

A 25-year history of clinical trials of psychosocial

treatments for a range of child and adolescent

disorders has culminated in several landmark

meta-analytic studies (Weisz, Weiss, Alicke, &

Klotz, 1987; Weisz & Weiss, 1993; Weisz, Weiss,

Granger, & Morton, 1995); see Section II.B.4.

Psychosocial Interventions, for further discussion.

These meta-analyses have concluded that

psychosocial treatments for children and

adolescents do indeed improve outcomes, and that

the mean effect size for these therapies is

analogous to those found in similar analyses of

adult psychotherapies. In a related vein, several

hundred trials of stimulant treatments in pediatric

psychopharmacology have been launched in this

same time frame (Jensen et al., 1999), and these

studies have found that such treatments are safe

and efficacious for children with pronounced

problems of attention regulation and impulse

control. Yet most children who receive care in

communities receive a combination of services

(see the Clinical Case Study: Childhood-Onset

Depression, appendix B, as an example). Those

with serious problems often have a variety of

needs, some of which are in the mental health

sphere and some of which are not. These services

may include a variety of behavioral, interpersonal,

or group therapies and medications, as well as a

broad range of school-, home-, or communitybased services targeted toward the child’s ecology. 

Only in the past 8 years has careful attention been

paid to the relative effectiveness of medication or

psychosocial/behavioral treatments singly or in

combination, and only for two disorders of

childhood and adolescence—ADHD (MTA

Cooperative Group, 1999a; 1999b) and adolescent

depression (the Treatment of Adolescent

Depression Study [TADS]). These studies represent

important advances in the science of children’s

mental health because they offer the opportunity

to compare outcomes associated with different

types, levels, intensities, and dosages of

treatments. These studies can thus yield

important policy-relevant data that can inform

treatment planning decisions at local, State, or

Federal levels (Burns, 1999). 
65

Beyond specific treatments for specific disorders, a

broad array of community-based services exist,

which, in the past 15 years, have become

increasingly available to families of children or

adolescents with serious emotional disturbances.

In large part originating from two prominent

reports, “Unclaimed Children” (Knitzer, 1982) and

the “Systems of Care” monograph (Stroul &

Friedman, 1988), concerted Federal attention has

been paid to encouraging partnerships among

local leaders of mental health, general health,

education, child welfare, juvenile justice, and

substance abuse agencies, strong family

involvement, and a less fragmented and more

seamless systems of care (Friedman, 2001). The

“systems of care model” developed by Stroul and

Friedman (1988) emphasized individualized,

comprehensive care in response to the varied and

multiple needs of children and families. This

model articulated a series of principles that were

centered on maintaining children within their

communities, coordinating services, involving

families centrally in delivery and planning of

treatments and services, and ensuring the cultural

relevance of services provided. 

Yet the research base on the systems of care has

lagged behind the policy emphasis on creating

such systems of care. The systems of care model

was the focus of a series of studies in the early

1990’s that were undertaken to assess the degree

to which reform of the system would influence

changes in practice and therefore lead to clinical

improvements. The initial studies focused on

comparing a continuum of care model, called the

Fort Bragg Demonstration Project, with usual

service delivery models (Bickman, 1996a). A

follow-up study, which included random

assignment to a system of care model or to usual

care, was conducted in Stark County (Bickman et

al., 1999). Both studies demonstrated that system

coordination alone did improve access to services

and satisfaction, and modestly improved

functioning. System coordination also reduced the

use of hospitalizations or other restrictive forms of

care (Bickman et al., 1999; Bickman, 2000;

Bickman, 1996b; Lambert & Guthrie, 1996).

However, clinical outcomes for children (e.g.,

symptom reduction) were the same whether

children were receiving coordinated services

through systems of care or usual services, and the

cost was considerably higher for systems of care. 

As a result of these findings, scientific emphasis

was shifted away from general studies of

"systemness" to the clinical effectiveness of services

within these systems of care and especially to the

types, dosage, and intensity of treatments delivered

(Henggeler et al., 1997; Hoagwood, 1997; Weisz,

1997). In particular, the transportability of

efficacious clinical treatments into mental health

services has become a central focus of new efforts,

as has attention to the range of clinical, functional,

and service outcomes (Burns, 1999; Hoagwood,

Jensen, Petti, & Burns, 1996; Jensen, Hoagwood, &

Petti, 1996). Further, greater attention has been

paid to the fidelity of implementation of “systems of

care” principles at the practice level.

In the past 2 years, several reviews of the evidence

base on the effectiveness of specific services have

been completed (Burns, Hoagwood, & Mrazek,

1999; Weisz & Jensen, 1999). In general, these

reviews have revealed the existence of empirically

validated interventions such as intensive case

management, therapeutic foster care, home-based

therapies, especially multisystemic therapies (MST)

and nurse home-visitation models. Studies of

intensive case management, therapeutic foster care,

and MST demonstrate that there are alternatives to

lengthy inpatient treatment that can help maintain

a child within his or her community setting.

Adequate supervision, therapist training, and

institutional program support are essential to

successful outcomes from these services (Burns,

1999; Chamberlain & Reid, 1991; Schoenwald et
66

al., 2000a). Given the particularly high financial

expenses associated with psychiatric

hospitalizations and incarcerations, findings

related to the cost savings of these approaches have

been especially important in service planning

efforts. 

In addition to these services, progress has been

made in identifying a range of school-based

interventions that have been found to be effective.

Children identified in school as being in need of

mental health services are more likely to actually

enter and receive them when the services are

offered in school, as opposed to within the

community (Catron, Weiss, & Bahr, 1994).

Although schools do not primarily focus on the

delivery of mental health services, academic-related

functional impairments and logistical accessibility

make schools a logical and important point of

access for interventions and services for children

with emotional or behavior problems. Some of the

empirically supported treatments for childhood

behavior problems have been conducted and found

to be effective in school settings. These treatments

include targeted classroom-based contingency

management to reduce the incidence of disruptive

behaviors in children diagnosed with ADHD

(Pelham, Wheeler, & Chronis, 1998) and in children

diagnosed with other conduct problems (Brestan &

Eyberg, 1998), and behavioral consultation with

teachers to help accommodate difficult students in

the classroom (Fuchs, Fuchs, & Bahr, 1990). 

School-based preventive interventions designed to

target children at risk for emotional or behavior

problems have also been shown to reduce

symptoms and increase positive coping strategies;

they include cognitive group interventions to

modify adolescents’ depressive thinking (Clarke et

al., 1995) and social problem-solving skills for

elementary school-aged children at risk for

depression (Jaycox, Reivich, Gillham, & Seligman,

1994). Finally, there is evidence of school-based

preventive interventions that reduce the risk for

conduct problems, such as interventions that

involve multiple components, targeting classroom,

home, and peer environments (Conduct Problems

Research Group, 1999; Reid, Eddy, Fetrow, &

Stoolmiller, 1999). 

CROSSING THE BOUNDARIES

A series of trials is currently underway to evaluate

a range of services. These trials are likely to yield

important information in the next few years. They

include family psychoeducational and support

programs, school-based wraparound services, and

clinic-based treatments for depression and anxiety

disorders, among others (Burns & Hoagwood, in

press).

In addition to the progress that is being made on

the impact of treatments and services on child and

adolescent functioning, significant advances have

been made in understanding factors related to

engaging families in treatments. Unless families are

motivated and able to access effective services, the

evidence base will be unused. Studies have been

launched to better understand those factors that

influence access, dropping out of care, and

engagement (Armbruster & Fallon, 1994;

Greenbaum, Dedrick, Friedman, Kutash, Brown,

Lardieri, & Pugh, 1998; Kazdin, Holland, &

Crowley, 1997; Weisz, Weiss, & Langermeyer,

1987; 1989). Unfortunately, there is increasing

evidence that children who are from especially

vulnerable populations (e.g., children of single

mothers, children living in poverty, minority

children) and those with the most serious

presenting problems are less likely to stay in

treatment past the first session and more likely to

discontinue services prematurely (Kazdin &

Mazurick, 1994). Models for enhancing a family’s

service engagement have demonstrated decreased

rates of premature treatment termination when

such models are used (Santisteban, et al., 1996;
67

Szapocznik, et al., 1988). A similar engagement

intervention has been used among inner-city,

primarily minority families to increase attendance

at initial mental health service appointments

(McKay, McCadam, & Gonzales, 1996; McKay,

Stoewe, McCadam, & Gonzales, 1998). These

preliminary efforts at increasing engagement are

particularly noteworthy given the research that

supports the importance of involving children’s

caretakers in mental health treatment. For

instance, family participation during and following

day-treatment hospitalizations (Kutash & Rivera,

1995) and inpatient hospitalizations (Pfeifer &

Strzelecki, 1990) has been shown to be essential to

obtaining and maintaining positive outcomes.

Consequently, continued efforts to increase mental

health service engagement and entry are necessary. 

Finally, an important body of work is uncovering

potentially ineffective treatments. As pointed out

by Weisz and Hawley (1998), null or even

negative effects can be instructional but,

unfortunately, are often not reported. The recent

report “Youth Violence: A Report of the Surgeon

General” (U.S. Public Health Service, 2001)

estimates that many of the services provided to

delinquent juveniles have little or no evidence

base. Worse yet, a recent study indicated that peer

group-based interventions might actually increase

behavior problems among high-risk adolescents

(Dishion, McCord, & Poulin, 1999). In addition,

despite their prevalent use in mental health

settings, there is little empirical justification for

the use of nonbehavioral psychotherapies to treat

disruptive behavior disorders (Weisz, Donenberg,

Han, & Weiss, 1995). Finally, common treatments

for children with complex emotional and behavior

problems are group homes and inpatient

hospitalization (Burns, Hoagwood, & Mrazek,

1999). Yet existing research indicates that

improvements are not maintained once the child

is returned to the community (Kirigin,

Braukmann, Atwater, & Wolf, 1982). The lesson

to be learned from these examples is that in some

cases, it is wrong to assume that some treatment

or service is better than nothing at all.

OBSTACLES AND GAPS

While progress in creating an evidence base on

combined treatments and services has been rapid

in the past 10 years, the need to link clinical

treatments more forcefully to service provision is

underscored by the fact that most of the services

available in most communities have no empirical

support behind them (English, in press). Further,

the number of children with untreated mental

illnesses is as high now as it was 20 years ago

(U.S. Public Health Service, 2000).

To address the significant unmet mental health

needs of children and their families, the

traditional paradigm for creating an evidence base

on the clinical safety, efficacy, and utility of

treatments must be revisited. The traditional

paradigm involves conducting a series of

controlled laboratory trials, with dissemination,

implementation, and deployment appended at the

end of the process. This model, called the ClinicBased Treatment Development Model, may not be

well-suited to ultimate use in clinics or

community settings, because many of the realworld factors that researchers consider “nuisance

variables”— and therefore rule out or control

experimentally— are precisely those variables that

need to be understood and addressed if treatments

are to work well in real-world practice (Weisz,

2000). These variables, or real-world exigencies

(e.g., providers too overwhelmed to learn a new

treatment protocol, comorbidity, parent substance

abuse or pathology, and life stressors that lead to

early terminations or no-shows), may need to be

directly addressed within the development,

refinement, and testing of treatments and services

if these interventions are to be maximally

effective. 
68

The critical need for comprehensive and intensive

services as alternatives to institutional care is

supported by recent evidence documenting the

benefits of multiple interventions (Burns,

Hoagwood, & Mrazek, 1999). Treatments with

strong evidence for youth with severe emotional

disorders include MST, intensive case

management, and treatment foster care; for a

number of other treatments, there is at least one

randomized clinical trial (e.g., mentoring, family

education and support). The availability of these

interventions across the country is minimal, as is

experience in these settings with the diagnosticspecific psychosocial and psychopharmacological

treatments. Research is needed to determine if

these evidence-based interventions are effective in

the community, to address how to adapt or modify

such interventions as necessary, and to learn how

to transport and sustain them in the community.

The emphasis on providing such services where

children live suggests the need to locate these

services in public sector settings such as education,

primary care, juvenile justice, and child welfare, as

well as in mental health settings.

RECOMMENDATIONS FOR COMBINED

INTERVENTIONS, SERVICE EFFECTIVENESS, AND

TRANSPORTABILITY 

1. We recommend the use of grant supplements

to current service effectiveness projects to examine

factors influencing the adaptability and

sustainability of interventions (e.g., different roles

of family in the research process, strategies for

engaging families, and ways of increasing or

maintaining treatment fidelity).

 

2. We encourage careful attention to issues of

defining, characterizing, and operationalizing

current practice. Currently, researchers largely

ignore usual practice because the variability within

and across practice settings makes these processes

extremely difficult and complex to measure. Yet,

understanding intervention approaches developed

in the field is important, as such approaches often

reflect the needs of children and families and the

constraints of personnel, as well as organizational

and system limitations. Most of these studies will

not be randomized trials because of the nature of

routine practice.

3. We recommend studies that examine how

existing services (e.g., school-based, case

management, mentoring, family support),

combined treatments, and novel delivery

mechanisms (e.g., Internet-based) can be used to

augment clinical interventions to meet the

significant needs of children with severe mental

illness or those with multiple problems more

successfully.

4. We recommend studies on the impact of

family engagement and choice regarding the

acceptability of interventions.

5. We recommend that a mechanism such as a

B/START (Behavioral Science Track Award for

Rapid Transition) be used to establish community 

collaboration prior to implementing research

programs. 

6. We recommend that NIMH develop a national

system or a series of regional systems to track the

utilization and costs of child mental health services.

The systematic tracking of broad indicators of

utilization and costs, such as inpatient days,

outpatient utilization by insurance status, and

socioeconomic characteristics would allow a more

timely recognition of the effects of major changes in

the health care system, including increasing or

decreasing inequities. As part of these tracking

systems, pharmacoeconomic studies are

encouraged. Integration of data (service use and

costs) from other settings likely to provide a

substantial amount of services (e.g., the education,
69

juvenile justice, and child welfare systems) not

captured in the existing health databases is

essential. An increased focus on the role of private

insurance in covering mental health services for

children could provide important lessons.

Traditionally, most of the information about

behavioral health care has come from the public

system. But privately insured children account for

the largest proportion of the population with

mental health expenditures. Even so, some of the

most costly treatments continue to be paid for

with public funds. Finally, this tracking initiative

could facilitate the development of a conceptual

integration to link policies (e.g., parity) and

market forces (e.g., growth of managed care) to

service use, processes of care, and outcomes. In

the absence of a more complex model based on a

national data system, health care debates will be

informed by simple descriptive comparisons (e.g., 

outcomes by financing system) and extrapolations

based on isolated studies.

Science Case in Point: Multisystemic Therapy (MST)

Multiple randomized trials have shown beneficial effects of an intervention approach called multisystemic therapy (MST) with

youngsters who show serious antisocial behavior. Most of the youths in these trials have been arrested multiple times prior to

treatment, and MST has been shown to markedly reduce rates of subsequent arrest. The approach involves efforts to work with both the

individual youngster and several elements of the youngster’s environment, to create conditions in which antisocial behavior will be

reduced and prosocial behavior increased. For example, the MST therapist may work with parents on their skills in youth monitoring

and discipline, as well as rewarding appropriate behavior. The therapist may also work with teachers and other school staff, and with the

family’s neighbors and friends, to create conditions in which youth behavior will be monitored closely and appropriate behavior

encouraged and supported. The intervention is heavily focused on environmental change, but also can involve individual work with the

youth. The therapist’s time is spent in the settings where the youth and family spend time; therapists do not even have private offices.

MST, as described by Henggeler and colleagues (Henggeler, Schoenwald, Borduin, Rowland,& Cunningham, 1998), was heavily

influenced by general systems theory (von Bertalanffy, 1968) and social ecology theory (Bronfenbrenner, 1979) as applied to diverse

empirical findings on the causes and correlates of behavioral and mental health problems in youth. The early work on MST involved

efforts to apply the basic principles via traditional therapy office visits in an urban setting, but the treatment developers were increasingly

frustrated by client attendance problems and limited access to information on their young clients’ environments. To cope, Henggeler

and colleagues developed an environmentally focused intervention approach in which the therapists went to the child and family rather

than requiring office visits. The resulting approach to intervention, MST, has now been tested and found beneficial in a series of

randomized trials (described in Henggeler et al., 1998). Systematic reviews have identified multiple trials showing beneficial effects of

MST for youth conduct problems and antisocial behavior (e.g., Brestan & Eyberg, 1998; Kazdin & Weisz, 1998). MST, modified for use

with youths presenting with psychiatric emergencies, can also serve as a clinically viable alternative to inpatient psychiatric

hospitalization, with positive outcomes including decreasing externalizing symptoms and improving family functioning and school

attendance (Schoenwald et al., 2000b). Preliminary evidence of efficacy with families referred for physicial abuse of youth (Brunk,

Henggeler, & Whelan, 1987) is being further investigated in a newly funded clinical trial comparing MST with parent-training

approaches following substantiated reports of physical abuse (Swenson, MH60663). In general, the clinical trials already completed

involve some elements of deployment in that many of the youngsters treated have arrest records, have been referred to MST by the

juvenile justice system, and are clients of multiple systems. In most of the trials, State or local agency stakeholders were directly

involved as consultants to the study. While the earlier trials generally used university-employed project staff, this has changed with the

later trials, and actual providers in community agencies have been trained—and in some cases, retrained—to deliver MST. The next

step in the deployment agenda involves studying the transportability of MST by testing the effects of organizational climate on the ability

of real-world clinical therapists to adhere to MST principles and ultimately to effect positive outcomes for children (Schoenwald,

MH59138; Schoenwald et al., 2000a).
70

7. New technologies will change care

dramatically over the next decade. In addition,

delivery of care is moving away from clinic-based

models and toward models of patient-centered

family care delivered in out-of-office settings,

including on the Internet, in the home, in the

school, in primary care and other settings. Because

this trend is likely to continue, we recommend that

studies of nontraditional delivery of services be

encouraged and supported through program

announcements or special funding initiatives.

7. DISSEMINATION RESEARCH AND

SYSTEM IMPROVEMENT: CLOSING THE

LOOP 

PROGRESS

Long-standing concern about the fragmentation of

mental health services for children, adolescents, 

and their families has led to a series of major

national initiatives and calls for reform. Foremost

has been the “systems of care” movement (see

Section II.B.6. Combined Interventions and

Services Effectiveness) which advocates

coordinated services for children and families,

attention to family-centered services, and

adherence to cultural relevance in service and

treatment planning. As indicated in the previous

section, the systems of care studies demonstrated

that system coordination alone did improve access

to services and satisfaction, and modestly

improved functioning. System coordination also

reduced the use of hospitalizations or other

restrictive forms of care (Bickman et al., 1999;

Bickman, 2000; Bickman, 1996b; Lambert &

Guthrie, 1996). However, clinical outcomes for

children (e.g., symptom reduction) were the same

whether children were receiving coordinated

services through systems of care or usual services,

and the cost was considerably higher for systems

of care. Yet, the multiple problems associated with

children who have serious emotional disturbance

may best be addressed with a “systems” approach

in which multiple service sectors work in an

organized, collaborative way. 

These findings have led to a reorientation of

systems research in three major directions.

Increased attention has been paid to the

effectiveness of services within systems of care

and especially to the types, dosage, and intensity

of treatments delivered (Henggeler et al., 1997;

Hoagwood, 1997; Weisz, 1997). This redirection

is described in the previous section. There has

also been a focus on the features of

organizations—especially child welfare agencies

and, to a lesser extent, schools—that impede or

facilitate the delivery of effective treatments or

services. Much of this work has arisen from the

studies of Glisson and colleagues (1998), who

developed models and measures of organizational

culture and climate. Glisson has determined that

these features predict psychosocial outcomes for

children in the custody of the State. These

findings have led to greater attention to the

characteristics of organizations within systems of

care that may be malleable and that may affect

the ability of providers to deliver effective mental

health care to children (Hohmann, 1999;

Schoenwald & Hoagwood, 2001). Further, the

relationship between the system level and the

practice level must be clarified, including the need

to assess treatment intervention fidelity. 

Attention to systems change has redirected

research toward questions about the

sustainability and disseminability of effective

services within practice settings. Burns and

colleagues (1999) argued that the continuing,

well-documented, and persistent unmet need for

mental health care among children and

adolescents in this country necessitates a timely

response by those in both the scientific and

practitioner fields. She proposed the creation of a
71

research agenda on clinical interventions for

youth to accomplish four tasks: (1) synthesize

(through reviews of the evidence base) the status

of science on promising interventions, (2) assess

quality indicators of outcomes to improve

standards of clinical practice, (3) evaluate

outcome measures, and (4) develop a new

research phase model for connecting research to

practice. Important to this effort is not only

identifying the evidence base on service

effectiveness but also attending to the models of

dissemination that will enable it to be used in

clinical practice. The aim is to address historically

intractable problems through learning how to

shift relevant evidence-based interventions to

youth with the most severe disorders. Critical

activities will include (1) establishing criteria for

interventions to be disseminated, (2) developing

“user-friendly” training and supervisory and

quality monitoring materials, and (3) conducting

dissemination research to test theoretical and

empirical approaches for changing practitioner

and organizational behavior. 

A comprehensive dissemination and knowledge

transfer program would involve all three of these

classes of activities. It would require that research

findings, after having successfully gone through

rigorous scientific peer review procedures, be

provided in formats and language appropriate for

other audiences, such as providers and

consumers. Above and beyond the preparation of

appropriate materials, a comprehensive and

effective dissemination effort requires an

interpersonal component. The National Center for

the Dissemination of Disability Research (NCDDR)

(1996) reported that perhaps the most consistent

and ubiquitous finding in the literature on

knowledge utilization is the primacy of personal

interaction, and Crandall (1989) indicated that

“adequate materials and procedural guidelines,

coupled with responsive, in-person assistance

during later implementation, are imperative for

maximum success.” This finding is consistent

with the finding that credibility of the source of

information is critical for knowledge utilization.

“Credibility” refers to both the level of perceived

expertness and trustworthiness (NCDDR, 1996).

Personal interaction is very important for

promoting a level of trust that is more likely to

result in utilization of research findings.

The implications are that even with advances in

technology, in the complex area of interventions

for child mental health disorders, effective

knowledge transfer is labor-intensive and

expensive. Researchers who have developed

successful interventions need to be prepared to

respond to requests for assistance and to

proactively generate interest from groups that

may implement the intervention with high fidelity

to its principles and processes. Agencies such as

NIMH and CMHS that are interested in promoting

the use of evidence-based interventions in

children’s mental health need to identify

mechanisms to study and support this process.

CROSSING THE BOUNDARIES

It is increasingly clear that a goal of public health

science is ensuring that science-based services are

embedded into everyday practice and used by all.

Doing so necessitates new areas of

investigation— what might be called

dissemination and implementation science—to

understand how best to position and sustain

effective services in communities and identify

factors that impede this positioning. Achieving

this goal requires both a new genre of study and

persistent attention to questions about why

services are effective. Toward this end, scientists

must engage families, providers, and other mental

health stakeholders to increase the likelihood that

the research is relevant to their needs and will

produce findings that are credible and

scientifically valid. 
72

Changing Practitioner Behaviors

As knowledge about treatments and services with

known outcomes becomes more widely available

(e.g., combination or medication therapies for

children with ADHD), it will be important to

understand how best to change practitioner

behaviors so that this knowledge will be used.

Different strategies are likely to be needed for

changing the behaviors of providers from different

disciplines. Professional associations (e.g., the

American Academy of Child Psychiatry, the

American Academy of Pediatrics) have developed

practice guidelines, but adoption of these

guidelines into everyday practice may necessitate

studies of characteristics of the practice

environment, history of the professional discipline,

or credentialing traditions that impede or facilitate

such adoption. Approaches such as academic

detailing, widely used by the pharmaceutical

industry (Baro et al., 1998; Freemantle et al.,

2000), or use of key opinion leaders within

communities (Kelly et al., 1993) may be valuable

approaches for changing practice. For example,

theories of social diffusion suggest that adoption of

new strategies or behaviors (such as cessation of

smoking or eating a healthier diet) depend in part

on the social value attached to the opinions of

leaders who encourage such changes. The impact of

opinion leadership with reference to children’s

mental health treatments or services could be

examined for its applicability to a range of services,

providers, and service environments.

Changing Organizational Behaviors

As work by Glisson and Himmelgarn (1988) has

shown, the organizational culture and context

within which mental health providers work directly

influences the attitudes, motivations, and

behaviors of providers, and consequently indirectly

influences child outcomes. Studies of the impact of

organizational culture and climate on sustaining

the fidelity of the therapeutic process and outcomes

need to be conducted if science-based services are

to be maintained within community-based

agencies, schools, or health care settings. Studies

are also needed to identify aspects of the practice

environment that facilitate therapists fidelity to

treatment. In addition, it will be important to

examine those proximal features of the practice

environment that influence the clinician/patient

relationship and why some clinicians are motivated

to change and adopt new strategies and others are

not. To conduct such research, partnerships among

scientists, providers, and agency administrators

must be initiated from the very beginning. 

Amplification of Interventions to Increase

Organizational or Community Fit

A substantial knowledge base on school mental

health services (Rones & Hoagwood, 2000) and

psychosocial treatments for children exists in the

literature (Kazdin, 2000b; Weisz et al., 1995;

Weisz, Huey, & Weersing, 1998). Yet for the most

part, these services have no sustaining power

within schools, clinics, or agencies beyond the

tenure of their creators. They come and go as grant

support, faculty members, and faculty interests

come and go. Studies of the augmentations are

needed that will help to maintain scientifically

driven services within a range of agencies and

organizations. Augmented models, such as

additions of wraparound services to core prevention

programs, neighborhood resource centers, or

additions of case management to after-school

programs, may increase the likelihood that these

services will be sustained.

Adaptation of Treatments to Increase

Organizational or Community Fit

Because there now exists a knowledge base of

hundreds of treatment studies demonstrating

improved outcomes for children with a range of

behavioral, emotional, or psychiatric problems,

extension of this knowledge into a range of

community settings would be valuable. However,

to date, little attention has been paid to the kinds of
73

adaptations needed to make these treatments

practical and feasible for use in community

settings. Because much of the knowledge about

treatment efficacy has been developed in academic

settings, a new generation of research is needed to

address questions such as how far to adapt a

manualized therapy for use within a mental health

clinic (given that most children will attend only

four or five sessions), what kinds of outcomes to

assess when a treatment is embedded in a new

service setting, or how to engage families in

tailoring a treatment to enable it to match familial

or cultural values and experiences. It will also be

important to develop research-based triage

standards to determine when children’s mental

health needs are best managed by persons with

different levels of mental health training. In

addition, issues about whether to treat co-occurring

disorders sequentially or simultaneously will need

to be addressed for children with mental health and

substance abuse problems. 

Deconstruction of Interventions to Identify Core

Potencies 

Studies that deconstruct or dismantle therapies into

elements that eventuate certain outcomes and that

are practically amenable to being taught to mental

health care providers (e.g., nurse providers,

teachers, health care paraprofessionals) are sorely

needed. A related issue is identifying the dosage of

a given service that is needed to obtain a particular

outcome. In part, the issue of appropriate dosage is

being urged forward by the exigencies of health

care accountability. The notion of service dose

cannot be made meaningful until (1) the services

themselves are well-specified, (2) the active

ingredients composing the service can be specified,

and (3) appropriate statistical scaling methods of

dosage are used (Hoagwood, 2000).

Measurement Development: Functioning and

Impairment

Measurement of child mental health outcomes has

been dominated by attention to syndromes,

problem areas, and diagnoses. Yet of greater

importance to most health care administrators,

teachers, parents, and front-line clinicians is the

identification of problems related to a child’s

functioning. Unfortunately, the measures that are

currently available for assessing functional

impairments or competencies are quite limited

and reflect outdated notions of functioning. The

most widely used measures are either global, thus

inadequately reflecting cultural variations, or

confound functioning with diagnosis (Canino,

Costello, & Angold, 1999). Conceptual problems

also plague the area of measurement of

functioning. The basic concept originated from

Vineland’s notion of "social usefulness," a concept

that was pertinent to adults with mental

retardation in the 1930’s, but that is hardly

sufficient for understanding children’s mental

health needs. Further, the theoretical notions of

"functioning" are conceptualized, measured, and

used in different ways across the major service

systems in which children are seen. As used in

health settings, functioning refers to events and

consequences such as losing a limb and requiring

prosthetic devices. In education, it refers to skills

such as social or communication abilities, as well

as handwriting. In mental health settings, it may

refer to a clinician’s global rating of whether the

child completes tasks in school or at home. So

measurement approaches that will not confound

functioning with clinical syndromes, that will

reflect culturally specific attitudes (rather than

global ratings), and that can flexibly assess core

elements of functioning are needed to cross

health, education, and mental health settings.

OBSTACLES AND GAPS

These new research directions will help to connect

the research base to clinical practice. However, it

should be acknowledged that one impediment to

the efficiency and usefulness of the research base
74

has been the scientific model that has driven the

development of a usable science. As previously

noted, one reason efficacy studies have not been

readily deployed into service settings may be that

the research model used to drive the development,

refinement, and testing of those treatments does

not mesh well with the exigencies of clinic or

community-based care (Weisz, 2000). In the face of

the mounting evidence base, different task forces

and separate reviews have applied different criteria

and guidelines. Despite the increased attention to

evidence-based treatments, there is as yet no

consensus on what constitutes this evidence base,

how these interventions should be disseminated, or

how outcomes for such efforts should be evaluated. 

Furthermore, the financing of mental health

services is currently not aligned with evidencebased practices. The relationship between financing

policy and dissemination of evidence-based care is

a close one. The current status quo (i.e., extensive

fiscal investment in clinical interventions without

an evidence base) is likely to continue unless policy

mandates reimbursement for evidence-based care.

Policymakers determine which interventions are

paid for as well as whether support is available to

train providers in evidence-based care. Professional

sanctions manifested in training, licensing, and

continuing education requirements are also

approaches to facilitate change in practice.

Providing the efficacy and effectiveness research

findings, along with the likely benefits and costs of

change, to policymakers and professional

organizations is a necessary first step. The next

challenge is to create assurances that widespread

implementation of innovative interventions is

feasible and that benefits obtained under controlled

conditions will be sustained in real-world clinical

settings. 

As the field of mental health services research

expands, it will be important to take advantage of

opportunities to study new services as they arise,

and to do so in a timely manner. Judging by past

performance, when treatments are developed and

tested via the traditional model, 10 to 20 years

may be required to advance to the point at which

the treatment can be understood with respect to

its effects in a practice setting. This timeframe is

impractical and inefficient if the goal of public

health science via-a-vis children’s services is to

improve practice. Instead, new models are needed,

such as the one proposed in this report, to

encourage studies of the real-world effectiveness

of new treatments or services within the context

of the practice setting where the service is

ultimately to be placed. Improved dissemination

and deployment of research should be a main goal

of system reform so that the investment in

research is truly extended to children in the

United States who need effective treatment and to

their families.

RECOMMENDATIONS FOR

DISSEMINATION/DEPLOYMENT RESEARCH 

A number of recommendations to improve

research in the dissemination/deployment area are

provided below. 

1. We recommend that investigators be strongly

encouraged to conduct dissemination studies in

public sector mental health sites, collaborating

with other child-serving sectors. Because of the

major activities of CMHS in promoting systems of

care through its Comprehensive Community

Mental Health Services for Children and Their

Families Program, we strongly endorse the NIMH

Program Announcement (PA-00-135),

“Effectiveness, Practice, and Implementation in

CMHS’ Children’s Service Sites.” This program

announcement is sensitive to the need to

disseminate evidence-based clinical practice to

very high-risk youth receiving services in public

sector programs. However, to facilitate

meaningful research in these public sector sites, a
75

major technical assistance effort will be necessary

to bring together investigators and service sites.

2. We recommend that priority be given to

research on the factors that facilitate or impede

the processes, transportability, or sustainability of

evidence-based treatments. Factors identified may

include extra-organizational factors (e.g.,

stakeholder involvement, triage system),

organizational factors, provider behavior factors

(e.g., attitudes and readiness to change), and

family and child characteristics (e.g., attitudes,

preferences, or co-occurring disorders) as they are

related to dissemination and uptake of effective

clinical services. Such factors may guide the

development of incentives to optimize the use and

sustainability of evidence-based treatments. Such

research is especially needed in communities or

populations where disparities in access to mental 

health care are prevalent, including minority

communities and the uninsured.

3. We recommend that NIMH consider the use

of Small Business Innovation Research program

funds for deployment, method/analysis

development, or dissemination research to

develop new commercial products and potentially

expand the range, function, and effectiveness of

therapeutic services.

4. We support continued partnerships with

other Federal agencies in order to capitalize on

their dissemination arms. These agencies include

those of HHS—CMHS/SAMSHA, AHRQ/HRSA,

MCHB/HRSA, the Administration for Children and

Families, and other NIH Institutes—the Office of

Special Education and Rehabilitative Services,

Department of Education; and the Office of

Juvenile Justice and Delinquency Prevention,

Department of Justice, to carry forward research

advances in both policy and practice arenas.

5. A highly visible, national dissemination

effort is needed. We recommend the creation of a

Dissemination Center. The research focus of this

center would include dissemination and

sustainability studies, with a special focus on

understanding the validity of evidence-based

treatments for minority populations. In order to

conduct these studies, theoretical and empirical

literature on organizational and practice change

will need to be critically and creatively addressed,

and different approaches to diffusion will need to

be tested. Initial work by the center would be to

identify experts in the change process from other

fields and to utilize them in adopting or adapting

the complex provision of mental health care

services for targeted children and families. 
77

III. Infrastructure and Training 

Problems and Progress

Mental health research is a broad and complex

field in which solutions to problems will likely

require the synthesis of knowledge across various

disciplines. Because an integrated knowledge base

is critical to advancing the etiologic

understanding of behavioral and emotional

disorders in children and adolescents—and hence

developing, implementing, and studying

interventions with children within their diverse

environments—interdisciplinary training must

become the norm. As delineated in the Institute of

Medicine (IOM) “Report on Bridging Disciplines in

the Brain, Behavioral, and Clinical Sciences”

(2000), many barriers to interdisciplinary research

exist. In the child mental health arena, salient

issues relate to the acute shortage of

developmentally oriented clinical investigators

with the interdisciplinary training to leverage

rapidly emerging knowledge in developmental

neuroscience, developmental psychology,

cognitive and behavioral neuroscience, genetics,

and other areas of basic science. One specific

challenge is to reduce the fragmentation of

knowledge across areas of child and adolescent

psychiatry, pediatrics, adolescent medicine,

developmental and behavioral pediatrics, pediatric

neurology, developmental and clinical psychology,

and developmental neuroscience. Most academic

settings are organized into discipline-specific

programs and provide little training in this

interdisciplinary perspective. 

The insularity of academic disciplines has resulted

in a dearth of research training programs and

mentors that bridge the traditional boundaries of

the various scientific disciplines. Further, funding

for interdisciplinary research is hampered by the

conservative nature of grant review or study

sections. Investigators who attempt to test

innovative models or alternative paradigms are

frequently penalized. For example, study sections

are often unreceptive to investigations that seek

to combine electrophysiological, molecular, and

biochemical approaches with studies of

environmental or activity-dependent determinants

of brain and behavioral development.

The shortage of well-trained mental health

investigators focused on children and adolescents

has been recognized repeatedly (IOM, 1989;

NAMHC, 1990; UNOCCAP Oversight Board, 1998).

A major obstacle to expanding the pool of junior

scientists is the lack of sufficient financial support

for training. Traditional research training

mechanisms are underused, in part, because

training grants typically provide little or no

overhead support in the form of indirect costs for

faculty salaries. Also, in recent years, clinical

revenue for many academic health sciences

centers nationwide has declined. This decline,

combined with the rise of financial requirements

for faculty, further constrains resources to offset

faculty time devoted to training and mentoring. 

These issues are especially challenging for those

interested in child mental health research because

(1) child research is more expensive owing to the
78

need for additional ethical precautions, the

necessary involvement of families, the use of proxy

informants, and sample size issues; (2) child

psychiatric training requires longer training periods

than traditional programs because trainees in many

disciplines must complete regular programs and

then complete additional pediatric training; and (3)

free-standing children’s hospitals and general

hospitals and their child training programs, in

general, are not reimbursed by Medicare for

graduate training similar to other clinical programs,

and thus bear a higher portion of all training costs. 

Funding Trends at NIMH—

Research and Training Grants

Funding trends at NIMH highlight some of these

issues. Overall, there has been an increase in the

number of grants on research related to children

and adolescents over the decade since the first

NIMH National Plan for Research on Child and

Adolescent Mental Disorders. From 1989 to 2000,

the number of child-related grants funded by NIMH

increased from 460 to 775 (see Figure A), and the

amount of funding increased from $95 million to

$262 million (see Figure B). The increase in

research in the child area is proportionate to the

increase in the overall NIMH research portfolio. In

other words, despite the increase in numbers, the

percentage of grants related to children and

adolescents has actually remained steady as a

proportion of the overall NIMH portfolio, both in

terms of number of grants (approximately onequarter; see Figure A) and amount of funding

(approximately one-third; see Figure B). 

Training funds include career awards (K grants),

individual fellowships (F’s), and institutional

training grants (T’s). Over the past decade, the

distribution of training funds has shifted. Of the

research funds related to children and adolescents

(see Figure C), institutional training grants have

not kept pace over the last 10 years. The proportion

of institutional training grants has decreased in

comparison to the total child portfolio, while career

awards (K’s) targeted at bringing in new researchers

have increased proportionately. Training

fellowships aimed at supporting pre- and

postdoctoral trainees have remained quite constant

(at or below 0.5 percent). When viewed in context

of how training grants are funded across the whole

Institute (Figure D), it appears that the trend of

decreased institutional training grants and

increased K awards over the past 10 years is

reflected Institute-wide. However, individual child

training fellowships have not kept pace with the

fellowship-funding pattern of the overall Institute.

The percentage of funds allocated for fellowship

training across the Institute is consistently double

the percentage for child research. A second trend is

the shift in funding from institutional training

awards to career awards. Because institutional

training grants are important in preprofessional

training, the implication of this shift is that less

money for training is available early on in the

careers of potential child mental health

investigators, a time when critical career choices

are being made. At the same time, K awards are

critically important to research career development.

Currently, no formal mechanism is available to

support interdisciplinary research training.

Training Issues From the

Perspective of Professional

Associations

The workgroup considered a wide range of trainingrelated problems and issues central to research in

child mental health. In its deliberations, the

workgroup solicited input from approximately 10

major professional associations involved in training
79

mental health scientists. Organizations surveyed

included the National Association of Social

Workers, the American Academy of Child and

Adolescent Psychiatry, the American Psychological

Association, and the Society for Developmental and

Behavioral Pediatrics (see appendix C for a list of

organizations who responded). 

Respondents were asked about (1) major barriers

to training future mental health scientists in child

and adolescent issues, (2) problems in training

capacity, (3) timing of training in mental health

research, (4) availability of training in evidencebased treatments or services or in children’s

service systems, (5) features of the child mental

health infrastructure that either encourage or

discourage research training, and (6) new training

models that integrate training across disciplines,

fields of science, or systems. In synthesizing the 

responses—responses from social work, child

psychiatry, and child psychology—a striking

similarity in issues emerges: 

 Barriers A major burden is the financial

debt for people going into research training

careers; more incentives must be offered. Another

barrier is a lack of infrastructure and established

programs.

 Capacity to train mental health

scientists Inadequate stipends are provided for

the trainees, and the number of role models

available for training is insufficient.

 Timing Current opportunities for training

are often introduced too late in the process,

usually when the trainees have finished their

post-doctorate or internship or when they are at

the end of their residency, at the point of having

to pay off their debt. Students need to be enticed

early on in their career, including at the

undergraduate level. 

 Training about evidence-based

treatments All respondents felt the current

training programs do talk a lot about evidencebased research and treatment within their clinical

training, but evidence-based data are limited.

 Mental health structure helping or

hindering research Service issues and clinical

training are a hindrance; the pressure is high on

trainees and faculty who do not have as much

time to spend with training when they have the

pressure of clinical demands. In pediatrics, there

used to be research that clinicians could do in

departments with free, protected time, considered

“limited studies.” That has disappeared because

of declining reimbursements.

 Transdisciplinary and interdisciplinary

training All programs said some

interdisciplinary training occurs.

 The Balanced Budget Act Academic

medical centers hit hard by the Balanced Budget

Act, particularly those that focus on the health,

well-being, and care of young people, need to be

supported.

 Research Units in Pediatric Practice

(RUPPs) Many want to consider expanding

RUPPs. A potential problem is that RUPPs are

designed in pediatric psychopharmacology and

follow a different model.

 Minority training Minority supplements or

some sort of supplements to R-01s should be

considered; NIH has a minority training grant

program. 

 Timing for graduate students Much of

what is said about academic medical centers does

not apply to graduate schools. For graduate

students, specifically those in clinical psychology,

the issue of timing is critical. When the funds are
80

available, it is too late for clinical graduate

students, because they have already decided on

their career track.

 R-25, child practice research

Institutional groups need to come together to

represent a critical mass, assuring review

committees that there are enough investigators to

carry out this research. 

Recommendations

The recommendations below reflect the consensus

of the workgroup discussions and the professional

association responses. Recommendations are

provided to facilitate and support the development

of interdisciplinary centers that focus on

conducting translational research for children and

to expand the pool of well-trained investigators in

child mental health. 

A. CAPACITY BUILDING

1. We recommend that NIMH develop a

payback program whereby individuals who pursue

careers in child and adolescent research may

apply for loan forgiveness. 

2. We recommend that NIMH develop

additional mechanisms to support mentoring for

new research scientists in child and adolescent

mental health. This program may include funding

for sabbatical leaves or teaching/mentoring time

provided in the form of supplements to grants.

Funding for teaching/mentoring time is critical

because there are so few clinical investigators, all

with multiple demands on their time.

3. To build the research capacity needed to take

advantage of the promise of interdisciplinary

research, we recommend that NIMH issue a new

initiative for the creation of Child and Adolescent

Interdisciplinary Training Institutes (CITI’s). Basic

requirements would include training or exposure

in at least the following scientific areas: basic

behavioral and neuroscience, epidemiology,

prevention, intervention development, services 

research, and health economics. Training

seminars, summer institutes, and intensive

coursework on methodology, statistics, and the

range of service settings where mental health

services are typically delivered (e.g., schools,

primary care, community clinics) would be

required. To initiate CITI’s, we recommend that

NIMH establish one or two pilot educational

research experiences in inter-disciplinary and

developmental research with the explicit focus of

encouraging child and adolescent studies. The

overall purpose would be to work out pragmatic

and feasibility issues in detail in at least one or

two universities on how to effectively integrate

basic and clinical training for clinically oriented

investigators. Successful pilot programs would

serve as a model for further interdisciplinary

training programs. We also recommend that the

directors of the CITI’s meet annually to discuss

training initiatives and new programs and to

modify educational objectives as needed. 

4. We recommend that a special announcement

be issued for child and adolescent research

supplements. Modeled along the lines of minority

supplements, they would be used to encourage

investigators in other fields (e.g., adult mental

health, primary care, education, neurology) to

receive training in child and adolescent mental

health and thus increase the numbers of investigators with expertise in child mental health

research.

5. We recommend that NIMH develop a

national mentorship program to increase the

number of racial/ethnic minorities among NIMHfunded trainees who can address the unique
81

needs of minority children. This mentorship

program could include the NIMH Intramural

Research faculty. Such an effort is critical in light

of changing demographics; minority children are

increasingly represented among those with

significant mental health needs.

B. PARTNERSHIPS TO FACILITATE

RESEARCH TRAINING

1. To enhance child and adolescent research

training activities, NIMH should explore

opportunities to partner with other Federal

agencies. Potential partners include MCHB and

AHRQ/HRSA; CMHS/SAMHSA and CSAP/SAMHSA. 

For example, NIMH should consider MCHB’s

Leadership in Education in Neurodevelopmental

Disabilities (LEND) programs as an avenue for

including more of a mental health perspective. 
83

IV. Future Directions for Child

and Adolescent Mental Health

Research

Children and adolescents with undiagnosed mental

illnesses may spend years depressed, perhaps

anxious or withdrawn, unable to learn or unable to

make meaningful connections with the people

around them. The clinical case example in

appendix B highlights the way significant scientific

advances in understanding the course and causes

of depression, its treatment, and service delivery

can be brought explicitly to bear on clinical practice.

From a public health standpoint, scientific

advances that do not ultimately lead directly to

improvements in clinical care are meaningless. The

endpoint of scientific progress in child and

adolescent mental health is improvement in care.

The case example shows us the opportunities for,

and limitations of, scientific knowledge in our

efforts to reach this goal. Reaching this goal will

require partnerships among scientists, families, and

other stakeholders to ensure that scientific

advances make their way into the clinics, schools,

and other settings where children and adolescents

receive mental health services. Such partnerships

and how they may work are explicated in the

conceptual models provided in chapter I, Figures 1

and 2. 

This report was written to serve as a strategic

guide for transforming the form, function, and 

purpose of research on child and adolescent mental

health. Three key issues have been identified as

essential to this transformation: (1) the recognition

of the lack of connection between basic science

(developmental neurobiology and developmental

behavioral science) and clinical intervention

development, (2) a commitment to accelerating the

pace of intervention development by contextual

repositioning of such work within real-world

settings, and (3) realignment of the evidence base

with clinical and service practice. To accomplish

these goals, linkages must first be made among the

various scientific disciplines in order to expand and

strengthen intervention development. Doing so will

entail not only support for interdisciplinary

research activities but also encouragement of new

training models. Second, the development of new

interventions should take into account those

contextual and system factors (often considered to

be “noise” in traditional studies) that may in fact

influence the outcomes of the intervention and

their sustainability within diverse communities.

Essentially, interventions must be developed that

are usable and that attend to social, cultural, or

community variations. Third, to improve the

dissemination of scientifically proven

interventions, those that have been shown to be

effective must be used. To ignore such knowledge is

to court disaster. But this requires strengthening
84

the knowledge base so that social, cultural, or

community factors that affect the value of

interventions are better understood. 

Priority Area 1: Basic Science and

the Development of New

Interventions 

The linkages among neuroscience, genetics,

epidemiology, behavioral science, and social

sciences provide opportunities for increasing our

understanding of etiology, attributable risk, and

protective processes (their relative potency,

sequencing, timing, and mechanisms). Such

knowledge is critical for the creation of

developmentally sensitive diagnostic

approaches and theoretically grounded

interventions. One critical piece of knowledge

needed is an understanding of the etiology of

mental illnesses, which can lead to better

identification of “high-risk” groups as the target

for these early interventions, as well as “highrisk” or vulnerable intervals in development.

Despite our appreciation of developmental

perspectives, many evidence-based interventions

for children and adolescents continue to represent

downward extensions of adult models, with

limited consideration of basic knowledge about

how causal mechanisms or processes may vary

across development or sociocultural context.

Conceptual approaches and developmental

theories are needed to guide intervention and

dissemination efforts. Information from

developmental neuroscience, behavioral science,

and epidemiology should be used to formulate

competing and testable hypotheses about those

developmental processes that lead to mental

disorders. At the same time, knowledge gleaned

from intervention testing and dissemination

research must inform basic research theory and

development.

Priority Area 2: Intervention

Development, Moving From Efficacy

to Effectiveness

The current model of treatment development

(typically followed in biomedical science studies)

stipulates that such development begin in

laboratory settings; that highly specific sample

selection criteria be used; that refinement,

manualization or algorithm development, and

delivery be carried out by research staff (as

opposed to practicing clinicians); and that aspects

of the service setting where it is ultimately

destined to land be ignored. This model creates an

illusion that science-based treatments are not

meant to be used or usable. This report suggests

that a different model of intervention development

be followed. This new model requires two strands

of research activity: The first strand necessitates a

closer linkage between basic science and clinical

realities (as described in Priority Area 1); the

second strand requires that a focus on the

endpoint and its context—the final resting place

for treatment or service delivery—be folded into

the design, development, refinement, and

implementation of the intervention from the

beginning. Furthermore, such interventions

should also be developmentally sensitive and take

into account family and cultural contexts. Finally,

in order to explain why treatments work, it will be

important to identify core ingredients of

intervention, including the mechanisms that led

to therapeutic change and the processes that

influenced outcomes.

Priority Area 3: Intervention

Deployment, Moving From

Effectiveness to Dissemination

For evidence-based interventions to be used in
85

clinical practice, knowledge about effective

dissemination strategies is needed. The application

of the traditional biomedical model of intervention

development does not always lead to interventions

that are adaptable, applicable, or relevant to realworld clinical practices. To ensure that the current

evidence base is used appropriately, a new genre of

scientific effort is needed to better understand

factors that influence the transportability,

sustainability, and usability of interventions for

real-world conditions. Many promising preventive

and treatment interventions have not paid enough

attention to factors that influence family

engagement in services, for example, nor to the

broader socioecological contexts and systemic

issues that influence access to and use of such

services. Such research is critical if the current

evidence base on effective interventions is to be

brought to scale, sustained in service settings, and

made accessible to the children and families in

need.

Meeting These Priorities

BARRIERS TO CHANGE 

Current research practice and incentives are not

well-aligned to promote interdisciplinary research

or the development of interventions that are

transportable to or sustainable in real-world

settings. Further, the research training

infrastructure to support a cadre of investigators

who can conduct the kind of research necessary to

bridge the gaps among mental health researchers

from various disciplines or among the research

community, practice community, and policymakers

is lacking. Such barriers occur at every level,

including within the Institute (e.g., NIMH review

practices/policies), within child and adolescent

psychiatry (philosophical bias toward disease

orientation rather than functional adaptation), and

within academia, where the insularity of academic

disciplines and the academic promotion structure

do not support such efforts. Researchers need

training so that they can step outside their

prescribed area to consider the wider implications

of their work on the larger system that affects

children’s mental health care and their needs.

Incentives must be provided to conduct research

regarding the public health significance of their

work.

FACILITATING CHANGE

In order to facilitate change, NIMH must make

concerted efforts from within its own organization,

as well as in partnership with other stakeholders in

the field of child and adolescent mental health.

NIMH needs to carefully consider the significant

resources allocated for child research and identify

ways to realign the incentives to encourage the

linkages that will result in a true interdisciplinary

research effort. Clearly, the viability of these

linkages depends in part on the scientific advances

within each area (e.g., neuroscience, behavioral

science, prevention and treatment, and services

research). Priorities for advancing research in each

area are described in the corresponding sections of

this report, and NIMH should pay close attention to

guiding this research and research training. 

In addition to increasing the interdisciplinary

nature of child and adolescent mental health

research, NIMH should continue to develop publicprivate partnerships with advocacy groups,

professional organizations, service agencies, the

health care industry, and legislators. Such

partnerships are critical to ensure that the public

has access to the most current, state-of-the-art

knowledge on interventions, that limited resources

are efficiently used, and that all children and their

families have access to appropriate and timely care

for their mental health needs. Partnerships with

other stakeholders, including academic institutions
86

and advocacy and professional organizations, could

be forged to develop incentives for interdisciplinary

research training and to create a usable science

base that can ultimately address the mental health

needs of children and their families.

Closing the Gaps and Meeting the

Needs of Children and Adolescents

A public health effort to improve child and

adolescent mental health, supported by taxpayer

dollars, is warranted only insofar as it leads to

improvements in the quality of care that children

and adolescents receive and, thus, improvements

in the quality of the lives they lead. The toll that

preventable, untreated, or poorly treated mental

illness takes on children, adolescents, and their

families and society is profound and

unacceptable. Over the past 10 years a vast

amount of knowledge has been garnered about

prevention, identification, treatment, and services

for mental illness in children and adolescents.

This knowledge can and should be used to

improve care. But in the next decade, we must be

more exacting. The next generation of child and

adolescent mental health science will require a

transformation of form, function, and purpose if a

true public health model is to be realized and

sustained.
87 

NIMH Research & Training Grants

Fiscal Years 1989 - 2000

By Number of Grants

1778

1908

2085 2176 2173 2263 2300 2353

2466 2565

2782

3011

460 499 520 544 544 591 575 620 621 630 662

775

89 90 91 92 93 94 95 96 97 98 99 00

Fiscal Year

0

500

3,5003,0002,5002,0001,5001,000

Number of Grants

All Research Child-Related Research

Contracts and grants transferred to CMHS in1992 not included. 

Child as % of total: 25.9 26.2 24.9 25.0 25.0 26.1 25.0 26.3 25.2 24.6 23.8 25.7 

V. Figures Figure A 
88 

Figure B 

NIMH Research & Training Grants

Fiscal Years 1989 - 2000

By Awarded Amount

$283

$338

$397 $430 $431 $462 $482 $507 $508

$578

$660

$760

$95 $117 $134 $144 $147 $165 $168 $183 $187 $191 $211

$262

89 90 91 92 93 94 95 96 97 98 99 00

Fiscal Year

$0

 $900 $800 $700 $600 $500 $400 $300 $200 $100

 $1,000

Awarded $ (Millions)

All Research Child-Related Research

 Contracts and grants transferred to CMHS in 1992 not included.

 Child as % of total: 33.5 34.7 33.8 33.4 34.1 35.8 34.9 36.0 34.2 32.9 32.0 34.5 
89 

 NIMH Child Training Grants 

 Fiscal Years 1989 − 2000 

Contracts and grants transferred to CMHS in 1992 not included. 

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

8.0% 6.0% 4.0% 2.0% 0.0% 

12.0% 10.0% 

As a Percent of Total Awarded $ 

K GRANTS 3.2 % 4.0 % 4.2 % 4.8 % 4.9 % 4.8 % 5.0 % 6.0 % 5.9 % 6.8 % 6.4 % 6.0 %FELLOWSHIPS

0.4 % 0.3 % 0.2 % 0.2 % 0.2 % 0.3 % 0.3 % 0.3 % 0.4 % 0.5 % 0.5 % 0.6 %

INSTITUTIONAL 11.2 % 10.5 % 9.0 % 8.2 % 8.3 % 7.7 % 7.7 % 6.9 % 7.2 % 7.5 % 8.6 % 7.6 %

Figure C 
90 

NIMH Training Grants 

Fiscal Years 1989 - 2000

Contracts and grants transferred to CMHS in 1992 not included. 

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

8.0 % 6.0 % 4.0 % 2.0 % 0.0 % 

12.0 % 10.0 % 

As a Percent of Total Awarded $ 

K GRANTS

4.7 % 5.6 % 5.4 % 5.5 % 6.0 % 6.1 % 6.5 % 6.7 % 6.5 % 6.7 % 6.4 % 6.2 %

FELLOWSHIP

0.8 % 0.8 % 0.8 % 0.8 % 0.9 % 1.0 % 1.0 % 0.9 % 1.0 % 1.1 % 1.3 % 1.3 %

INSTITUTIONAL

7.0 % 6.8 % 6.0 % 5.6 % 5.6 % 5.4 % 5.3 % 5.2 % 5.2 % 5.1 % 5.0 % 4.7 %

Figure D 
91 

 

 

 

VI. Appendices 

 Research Center on Managed Care 

 for Psychiatric Disorders 

 A JOINT PROGRAM OF THE UCLA NEUROPSYCHIATRIC INSTITUTE AND RAND

 NATIONAL ESTIMATES OF MENTAL HEALTH UTILIZATION AND EXPENDITURES 

FOR CHILDREN IN 1998 

Roland Sturm, Jeanne Ringel, Catherine Bao, Bradley Stein, Kanika Kapur, Winnie Zhang, Feng Zeng 

 November 2000 

 Working Paper No. 205 

FUNDED BY THE NATIONAL INSTITUTE OF MENTAL HEALTH 
93

Appendix A

NATIONAL ESTIMATES OF MENTAL HEALTH

UTILIZATION AND EXPENDITURES FOR

CHILDREN IN 1998

EXECUTIVE SUMMARY

This report provides updated utilization and

expenditure estimates for mental health treatment

provided to children and adolescents. It addresses

the following questions:

1. How many children and adolescents are using

services?

2. How does utilization differ by insurance

status? 

3. How much was spent in 1998 on mental

health treatment for children and adolescents?

4. How were mental health expenditures

distributed by type of service and child insurance

status?

The report focuses on service utilization and

associated expenditures and does not include any

estimates of indirect costs, such as burden on

family members or society.

KEY FINDINGS

 Based on three national surveys fielded

between 1996 and 1998, between 5 percent and 7

percent of all children use any mental health

specialty services in a year. This average rate is

similar to the rate among adults, but it obscures

major differences across age groups. Only 1 percent

to 2 percent of preschoolers use any services, but 6

percent to 8 percent of the 6-to-11 age group and 8

percent to 9 percent of the 12-to-17 age group do.

 There is substantial variation in mental health

service utilization by type of insurance, ranging

from 8.4 percent for Medicaid enrollees to 4.0

percent for the uninsured. The intensity of

outpatient care (number of visits) differs similarly.

Children on Medicaid are estimated to have more

than 1,300 specialty visits per 1,000 children per

year, compared with 462 specialty visits per 1,000

children with private insurance, 391 visits per

1,000 children with other types of insurance, and

366 visits per 1,000 children with no insurance.

 Mental health utilization varies across

racial/ethnic groups. Latinos are the least likely of

all groups to access specialty care (5.0%), even

though they and Black children have the highest

rates of need (10.5%) based on measures in the

National Health Interview Survey (NHIS).

Approximately 7 percent of families with a child

with need (based on NHIS measures) claimed

financial barriers as the reason for not getting any

mental health care.

 More than half of all outpatient specialty

mental health services provided to children with

private insurance are out-of-plan. The education

sector likely provides a substantial portion of these

services. 

 Regarding inpatient mental health care,

between 0.2 percent and 0.3 percent of children

aged 1 to 17 use inpatient mental health services in

community hospitals. This rate is much lower than

the rate for adults (0.6%). Across all insurance

types, adults and adolescents have greater

inpatient days per 1,000 population than young

children. Among the privately insured and the

uninsured, adolescents have higher inpatient

service use than adults. In contrast, among the

publicly insured, inpatient days per 1,000

population are significantly higher for adults than

for adolescents. 

 Approximately 4.3 percent of children received

psychotropic medication, and utilization is

concentrated among older children: 5.0 percent of

6- to 11-year-olds and 5.6 percent of adolescents

are on psychotropic medication, while only 0.7
94

percent of children ages 1 to 5 used such

medication.

 Total treatment expenditures for children in

1998 are estimated to be approximately $11.75

billion, or about $173 per child. Adolescents (12

to 17) account for 59 percent of the total and also

have the highest expenditures per child at $291;

children 6 to 11 account for 34 percent of the total

at $165 per child; children 1 to 5 for 7 percent at

$39 per child.

 Across service types, outpatient services

account for 57 percent of the total ($6.7 billion),

inpatient for 33 percent ($3.9 billion), psychotropic

medications for 9 percent ($1.1 billion), and other

services for 1 percent ($0.07 billion).

 Across children’s insurance status, children

with private insurance account for 47 percent 

($5.5 billion), Medicaid enrollees for 24 percent

($2.8 billion), children with other public insurance

for 3 percent ($0.4 billion), and the uninsured for

5 percent ($0.6 billion). We could not allocate

State/local expenditures (21%, or $2.5 billion) by

child insurance status. The majority of these

services were provided to children with private

insurance coverage or Medicaid, but they were not

paid by insurance. 

 Total expenditures on psychotropic

medications for children in 1998 are estimated to

be $1.1 billion. The largest proportion of

expenditures was for stimulants, which accounted

for slightly over 40 percent of the total.

Antidepressant costs were the second largest

category, accounting for 33 percent of the total.

INTRODUCTION 

Over the course of a year, approximately 20

percent of children and adolescents meet criteria

for a mental disorder diagnosis, and half of these

youth also have significant functional impairment

(U.S. Department of Health and Human Services,

1999). Thus, mental health services for children

and adolescents should be a significant

component of health care. Expenditures for the

full population have been estimated repeatedly

(Coffey et al., 2000; Mark et al. 2000; Mark et al.,

1998; Rice et al., 1990; Frank & Kamlet, 1985),

but no recent national data about utilization of

services or about financing and expenditures for

mental health care for children are available

(Hoagwood and Rupp, 1994). The most recent

available expenditure estimates were for 1986,

and they were in the range of $3.5 billion (OTA,

1991; Burns, 1991). 

This report provides an update of previous work

in an effort to answer the following questions: 

1. How many children and adolescents are using

services?

2. How does utilization differ by insurance

status? 

3. How much was spent in 1998 on mental

health treatment for children and adolescents?

4. How were mental health expenditures

distributed by type of child insurance status?

Several factors help to explain the absence of

national estimates of child/adolescent mental

health care utilization and expenditures. First, the

low prevalence rates of child mental health use

requires very large data sets to obtain the necessary

number of patients (or visits or days) for precise

estimates. Second, national cost data that use a

top-down approach by collecting data from more

aggregate units (hospitals, providers, pharmacies)

rather than at the individual patient level do not

have the age-specific information to subset overall

estimates for children (Institute of Medicine, 1989).

Finally, the continuing fragmentation in the way

child mental health services are delivered, as well

as definitional and diagnostic inconsistencies,
95

make comprehensive estimates difficult to obtain

(Hoagwood and Rupp, 1994). In addition to private

insurance and public treatment settings, some

mental health services are delivered and paid for by

the education, child welfare, and juvenile justice

sectors. Social services are major sources of services

for children but are not part of the National Health

Accounts (NHA), the best known summary of

annual health care costs

(http://www.hcfa.gov/stats/NHE-Proj/; Levit et al.,

2000). 

The 1986 Office of Technology Assessment (OTA)

report on Children’s Mental Health Problems and

Services conjectured that “federal and private

sources currently bear less of a burden” but

warned that there are no data to support a firm

conclusion: “In the case of Medicaid, for example,

the only mental health expenditure known is that

of mental hospitals. Private third-party payers

prefer not to disclose what they pay for mental

health services and the amount actually spent by

clients themselves is not known. The proportion

of costs specifically for children’s mental health

treatment is even more difficult to determine”

(p. 132). 

A later OTA report on adolescents (1991) provided

utilization estimates for specific services based on

several different databases (National Ambulatory

Care Survey, National Health Interview Survey,

Inventory of Mental Health Organization, some

secondary sources) but cautioned that “these

estimates from varying sources do not allow an

overall estimate of mental health services

utilization by adolescents” (p.457). An

unpublished background paper by Burns, Taube,

and Taube cited in the report gave total estimates

for U.S. adolescents in 1986 at $3.5 billion (see

also Burns, 1991). Of this, 46 percent was

attributed to hospital inpatient care, 28 percent to 

residential treatment centers, and 26 percent to

outpatient care. 

BACKGROUND ON HEALTH SPENDING AND

UTILIZATION ESTIMATES 

Since 1964, the U.S. Department of Health and

Human Services has published an annual series of

statistics presenting total national health

expenditures during each year. The aim of these

National Health Accounts (NHAs) is to identify all

goods and services that can be characterized as

relating to health care in the nation and

determine the amount of money used for the

purchase of these goods and services. The NHA

framework is a matrix of operational categories

classifying sources of health care dollars and

services purchased with these funds (HCFA,

various years). The NHA recognize several types

of spending, including "personal health care,"

"government public health activity," "program

administration," and "research and construction."

In 1997, national health expenditures were

estimated at $1,092.4 billion (13.5% of GDP and

$3927 per capita) and expected to grow to

$1,316.2 billion (14.3% of GDP and 4,611 per

capita) by 2000. Most of the expenditures are for

personal health care, broken down by type of

expenditure and payer. For the purposes of this

project, we are concerned only with personal

health care, not the other categories, even if they

relate to child mental health, such as NIMH

funded research. The NHA collects information

primarily from larger reporting units (e.g.,

hospitals) instead of trying to aggregate

individual service or patient information. The

NHA contains no information about health care

utilization (e.g., number of physician visits or

hospital days) for specific patient groups. 

An ongoing project funded by the Substance Abuse

and Mental Health Services Administration

(SAMHSA) provides national estimates for mental

health and substance abuse expenditures (Mark et

al., 1998; Coffey et al., 2000). The project builds on

earlier work by Frank and Kamlet (1985), Rice et al.
96

(1990), and others but refines the methodology.

The SAMHSA project uses an indirect approach that

starts with aggregate NHA estimates as the basis

for the general health care sector and carves out of

the NHA estimates the share of mental health

expenditures. The authors then add expenditures

for specialty facilities from the Inventory of Mental

Health Organizations (IMHO) and the Uniform

Facility Data Set (UFDS). The IMHO and UFDS

surveys are answered by facility administrators and

report statistics at the aggregate facility level. No

patient-level or service-level data are available from

these surveys. Including specialty providers that

were not captured in the NHA, the 1997

expenditure estimate was $85.3 billion, of which

$73.4 billion (86%) was for treatment of mental

health (MH) disorders and $11.9 billion (14%) for

treatment of substance abuse (SA) (Coffey et al.,

2000). NHA-equivalent MH/SA expenditures were

about $3 billion less ($82.2 billion) in 1997.

According to this approach, MH/SA expenditures

represented about 7.8 percent of all U.S. health care

expenditures in 1997, or 8.5 percent of personal

health expenditures. 

Most closely related to the current project in terms

of goal and scope are two OTA reports: the 1986

report on Children’s Mental Health Problems and

Services and the 1991 report on adolescents. The

basis of utilization and expenditure estimates in

the latter report was an unpublished background

paper by Burns, Taube, and Taube, which gave

total estimates for U.S. adolescents in 1986 at

$3.5 billion. Of this, 46 percent was attributed to

hospital inpatient care, 28 percent to residential

treatment centers, and 26 percent to outpatient

care. The estimates were based on several

different databases (National Ambulatory Care

Survey, National Health Interview Survey,

Inventory of Mental Health Organization, some

secondary sources), and the report cautioned that

“these estimates from varying sources do not

allow an overall estimate of mental health

services utilization by adolescents” (p.457). A

major difficulty in calculating national estimates

of mental health service utilization and cost for

children is determining which mental health

services are provided in non-mental-health

contexts, such as the educational, child welfare,

and the juvenile justice systems. A top-down or

indirect approach is difficult to implement because

mental health services account for only a very

small part of the resources in those sectors, and

no national (and sometimes not even

regional/local) data have measured individual

services that would allow one to break out mental

health expenditures. For example, even though

education statistics provide expenditures on

special education for children with serious

emotional disturbances (SED) separately, one

cannot include those numbers as mental health

expenditures. The costs are made up of at least

three components. First, there are the basic

education costs that would be incurred if the child

were not SED. Second, there are the higher

educational costs per SED student not related to

mental health treatment (such as increased costs

incurred by having higher teacher-to-student

ratios in special education classes). These costs

could be considered part of the social costs of

mental illness but not direct mental health care

expenditures. Finally, there are the direct costs of

providing mental health treatment services

through the school. The sum of the latter two

could be roughly estimated as the excess

expenditures for special education over regular

education, and we provide an estimate of this, but

it is not possible to estimate the share of direct

mental health services from such aggregate data.

Similar considerations apply to the other sectors,

primarily juvenile justice and child welfare. We

are not aware of any study of national scope for

those sectors. However, the National Survey of

Child and Adolescent Well-Being, which is currently

in the field, may provide such estimates for child

welfare in the future.
97

For adults, several national or large multisite

studies have been conducted that provide

information on utilization of mental health

services, including the Epidemiologic Catchment

Area Program (ECA), the National Comorbidity

Study (NCS), the Medical Outcomes Study (MOS),

and HealthCare for Communities (HCC). The first

wave of the HCC study, fielded in 1997–1998, is

the most recent national data set currently

available for public use (Sturm et al., 1999); a

second wave is being fielded in 2000. Results

from that survey found that the probability of a

psychiatric disorder (measured by the Composite

International Diagnostic Instrument (CIDI)

screening items) was highest among Medicaid

eligibles (nearly 41%), followed by the uninsured

(22%), those with private insurance (12 to 13%),

and elderly Medicare recipients (7.8%) (Wells et

al., 2000). The probability of specialty mental

health or substance abuse care in 1998 exhibited

a similar pattern and ranged from 14 percent in

Medicaid to about 5 percent among the privately

insured and uninsured and 1 percent among

Medicare recipients. However, the percentage that

had contact with a primary care physician and

discussed mental health issues or received

treatment in that sector was much larger. 

There have been no equivalent results to date on

child mental health utilization. The NIMH

Methods for the Epidemiology of Child and

Adolescent Mental Disorders (MECA) study is the

only multisite community study that has assessed

mental health status and utilization among

youths. It studied children and adolescents ages 9

through 17 years at four sites in 1992 (Leaf et al.,

1996; Glied et al., 1997). The sites were not

randomly selected or chosen for national

representativeness (comparable to the ECA, but in

contrast to the NCS and HCC, which were designed

for national estimates), and the sample size was

too small to assess detailed utilization patterns.

The MECA study had fewer than 1,500

respondents at four sites, whereas the NCS and

HCC had around 10,000 geographically dispersed

respondents. The Great Smoky Mountains Study

of Youth (GSMS) is another population-based

community survey with around 1,000 children,

but it is a regional sample (Burns et al., 1995,

1997; Farmer et al., 1999). These two studies

(GSMS and MECA), however, appear to be the

most representative estimates for child/adolescent

mental health utilization that are currently

available. The main results of these studies are

summarized in table 1. 

A further complication in the estimation of mental

health utilization and costs for children is that a

small number of individuals tend to account for a

large proportion of costs. Children with

particularly high needs and costs are in out-ofhome placements, in foster care, or on probation.

No national or multisite cost and utilization data

are available, although results from two State

case studies suggest that the higher costs of

treatment for children in foster care are driven by

higher rates of any use rather than by higher costs

per user. The latest data, for 1995–1996 in

California, indicate that 31 percent of children in

foster care use mental health services, and the

average expenditure is $1,864 per user (Libby,

Rosenblatt, & Snowden 1999). Halfon et al.

(1992a, 1992b) analyzed California Medicaid data

from 1988 and found that although foster

children accounted for less than 4 percent of

enrollment, they accounted for over 40 percent of

mental health service users and over 50 percent of

all mental health outpatient visits or mental

health hospital stays. The study reports that

nearly 90 percent of adolescents in foster care

used mental health services in 1988. Takayama et

al. (1994) studied the use of mental health

services by children in foster care in Washington

State. The study focused on a younger population

(children under age 8), and thus the utilization

rate was somewhat lower than the estimates from
98 

Table 1:

Utilization of Mental Health Services, Results from Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) 

and The Great Smoky Mountains Study of Youth (GSMS) 

Study Population Sample 

Size 

Any MH specialty care 

Inpatient Use Outpatient Use Intermediate 

Services 

School-based Social Service Notes 

Burns et al., 1997 Journal of Child and Family Studies 6(1): 89-111. 

Public school youths in the GSMS ages 9, 11, and 13 followed over a 2-year period. 

N=1,015 Varies from 6.7% 

to 44.4% by insurance status and level of need. Including both inpatient and outpatient. 

Varies from .3% to 18.9% by insurance status and level of need. Including hospitals, residential treatment centers, detox units, group homes, and TFCs. 

Varies from 6.7% to 43.9% by insurance status and level of need. Including day hospitals, SA clinics, MH centers, and private MH professionals. 

N/A Varies from 22% 

to 63% by insurance status and level of need. 

N/A Both MH and SA care 

during a 2-year period. Aggregate 

use data not available. 

Burns et al., 1995 Health Affairs 14(3): 147-159. 

Public school youths in the GSMS ages 9, 11, and 13 in 1992. 

N=1,015 4.0% 

Inpatient + outpatient, same definition as in the study above. 

N/A N/A N/A 

Services received in the general medical sector: 16%* 12%=1.92% 

16% received some MH care, among which 70% to 80% seen by providers in the education sector: 16%*75%=12% 

Child welfare: 1.2% to 16.4%; Juvenile justice: 0.5% to 4.3% by diagnostic groups. 

First-wave data (1992–1993) and refers to the preceding 3 months. 

Farmer et al., 1999 Community Mental Health Journal 35(1): 31-46. 

Public school youths in the GSMS ages 9, 11, and 13 in 1992. 

N=1,007 Nearly 8% 0.8% received outof-home 

placement. 

N/A N/A 12%, among 

which 95% received services from a school counselor. 

Juvenile justice: 0.7% Child welfare: 1.4% Informal or nonprofessional sources: 4% 

Any use during the first year of the study. 21.1% received some type of service; general medical sector provided services to 4%. 

Glied et al., 1997 Health Affairs16(1): 167-174. 

MECA: Youths ages 9–17 in three U.S. communities in 1992 (the Puerto Rico sample was not included in this study). 

N=973 Private ins: 0.6% 

Public ins: 1.5% No ins: 1.1% 

Offices of MH professionals and psychiatric OP departments: Private ins: 6.0% Public ins: 9.0% No ins: 6.5% Offices of general medical providers: Private ins: 3.2% Public ins: 3.0% No ins: 4.3% 

N/A Private ins: 8.7% 

Public ins: 17.9% No ins: 12.9% 

 Rate of any use: 

Private ins: 16.1% Public ins: 28.4% No ins: 20.4% Rate of any use during 1 year. Aggregate rate not available. 

Leaf et al., 1996 Journal of the American Academy of Child and Adolescent Psychiatry 35(7): 889-897. 

MECA: Youths ages 9–17 in four U.S. communities in 1992. 

N=1,285 8.1% Not identified Not identified Not identified 8.1% Clergy: 

1.2% Social services: 1.6% 

Unweighted rate of any use in 1 year, parent report; Rate of any MH use: 14.9% 

Note: MH = mental health; OP = outpatient; SA = substance abuse; TFC = treatment foster care; N/A = not available. 
99 

Table 2:

Results on Medication Use Among Children in the Literature

Study Population Sample size Stimulant Other medication Schoolbased care Psychosocial treatments Angold et al., 2000 Journal of the American Academy of Child and Adolescent Psychiatry, 39(8): 975-984. 

Children at 9, 11, and 13 years, from public schools in 11 counties in western North Carolina (the Great Smoky Mountains). 

N=1,422; 4,964 annual observations over 4 waves. 

7.3%, at some point during the 4 years (average duration of treatment greater than 3 years; 7.3%*3/4=5.5%) 

N/A N/A N/A 

Buck, 1997 Psychiatric Services, 48(1): 65-70.

Nondisabled children and adolescents under 19, 

continuously enrolled in Medicaid of Michigan and Tennessee in 1990 and with MH services, including SA treatment. 

N=16,544 in Michigan N=10,992 in Tennessee 

Michigan: 5%*1/3*64.0%=1.1% Tennessee:7%*1/4*36.1%=0.6% First number in the formula: percentage of the population using MH care; Second number: among those using MH 

care, proportion using prescription drug; Third number: distribution of prescription drug claims to stimulant 

Michigan: 5%*1/3*36.0%=0.6% Tennessee: 7%*1/4*63.9%=1.1% 

N/A N/A 

Jensen et al., 1999 Journal of the American Academy of Child and Adolescent Psychiatry, 3(7): 797-804. 

Youths ages 9–17 in four 

U.S. communities; 12-month recall. 

N=1,285 1.4% [0.9-2.3] 1.1% [0.6-1.9] 8.0% [6.6-

9.7] 

9.9% [8.4-11.7] 

LeFever et al., 1999 American Journal of Public Health, 89(9): 1359-1364. 

Students in grades 2 through 5, enrolled in public schools in southeastern Virginia. 

N=29,734 (N=5,767 in city A; N=23,967 in city B) 

City A: 8%*90%=7.2% City B: 10%*90%=9% Overall % weighted by sample size: 8.65% 

10% received another medication alone; 5% received with stimulant 

N/A N/A 

Rappley et al., 1999 Archives of Pediatric and Adolescent Medicine, 153: 1039-1045. 

Very young children (3 years old or younger) continuously enrolled in Michigan Medicaid for 15 months and with ADHD. 

N=223 Methylphenidate: 

73/223=32.7% 

Clonidine: 48/223=21.5% 82.5% of the population received medication other than Methylphenidate. 

N/A N/A 

Safer et al., 2000 Pediatrics, 106(3): 533-539. 

Maryland public school students (grades K-12); medication at the time of the survey. 

N=816,465 2.46%+73%*0.46%=2.8% 

(Constituted 84% of all ADHD medication) K–5: 3.11% 6–8: 2.91% 

9–12: 0.87% 

(1-73%)*0.46%=0.12% K–5: 0.55% 

6–8: 0.57% 

9–12: 0.19% 

N/A N/A 

Zito et al., 2000 Journal of the American Medical Association, 283(8): 1035-1050. 

Preschoolers (ages 2-4 years) in two State Medicaid programs and a group-model HMO 

Midwestern State Medicaid: 158,060; Mid-Atlantic State Medicaid: 54,237; Northwest HMO: 19,322 

1995 data: 1.2% Children 2–4 treated at 1/10 the rate of their 5-14-year-old 

counterparts; largest gain in use seen in 15-19-year-old group. 

1995 data: Antidepressants: 0.32% Clonidine: 0.23% Neuroleptics: 0.09% For HMO: clonidine (0.19%) vs. antidepressants (0.07%) 

N/A N /A 

Zito et al., 1999 Archives of Pediatrics and AdolescentMedicine, 153: 1257-1263. 

Children 5 to 14 years with office visits for ADHD 

# of total youth visits from 1989 to 1996: N=20,013 N=3,315 in 1991 N=2,081 in 1996. Among the ADHD visits, 77% include a psychotherapy agent. 

Among the ADHD visits, visits with stimulant therapy onlyaccount for 77%*82.8%=63.8% 

Among the ADHD visits, visits with one or more psychotherapies other than stimulant account for 77%*7.6%=5.9% visits with both stimulant and otheraccount for 77%*9.6%=7.4% 

N/A N/A 

Note: ADHD = attention deficit hyperactivity disorder; HMO = health maintenance organization; MH = mental health; SA = substance abuse; N/A = Not applicable.
100

Halfon et al. (1992a, 1992b). Utilization in this

group, however, is still far higher than among

other children on Medicaid (25% of children in

foster care used mental health services in 1990,

compared with 3% of other children in Medicaid).

Adjusting for age group differences, the foster care

utilization results from Washington State are

similar to those of California (about 23% based on

Halfon et al.’s numbers).

While the growth of managed care has changed

utilization patterns for all types of services in the

past two decades, nowhere have changes been

more dramatic than in the use of psychotropic

medication. This is likely due to the development

of new, safer medications and to an increased

willingness on the part of many physicians and

parents to use psychotropic medications in

children. For example, the proportion of

outpatient psychiatric visits in which an

antidepressant was prescribed more than doubled

between 1985 and 1993 (Olfson et al., 1998).

Table 2 summarizes results from the latest

published studies on psychotropic drug use in

children (some of the entries in the table are based

on calculations by the authors of this report).

Some studies are more recent than the MECA

study and have larger sample sizes (such as

Medicaid data). Unfortunately, the most recent

studies are local or regional in scope and the wide

variation across studies suggests very large

regional variations that limit the generalizability

of single-site data. The exception is the study by

Zito et al. (1999) based on the National

Ambulatory Medical Care Survey (NAMCS), but the

design of the NAMCS (a sample of visits to

physicians) is so different that it is difficult to

compare results with those from other community

studies. Besides, the populations studied vary in

age, type of school attended, or type of health

insurance plan.

METHODS

The two goals of this study are 

1. To provide more recent estimates of mental

health utilization patterns for children and

adolescents and the relationship to insurance

status and ethnicity.

2. To obtain an overall estimate of all the

resources available for child mental health by

aggregating all expenditures by all types of

services/providers and payers. Payment sources

include out-of-pocket payments, private

insurance, Medicaid, other State/local resources,

and other Federal payments (primary block

grants), as well as resources that are not usually

included as part of the health system, such as

counselors in schools. 

Whenever possible, we provide estimates for

preschoolers (ages 1 to 5), children (6 to 11), and

adolescents (12 to 17). We do not consider

children under the age of 1, because the diagnosis

and treatment of mental health disorders in

infants remains ill-defined and controversial.

DATA SOURCES 

Table 3 summarizes the sources of data we used.

We tried to obtain 1998 data where possible. When

only earlier data sets were available, we adjusted

dollar numbers for inflation and corrected for

changes in the population but made no adjustment

for possible changes in utilization patterns. To

obtain overall estimates of users and for details on

differences in access among the

noninstitutionalized household population and

insurance status, we used the 1997 National

Survey of American Families (NSAF), the

1996/1997 Community Tracking Study (CTS), and

the 1998 National Health Interview Survey (NHIS).

The NSAF also has items on intensity of care

(number of contacts with a provider) and provides a 
101 

Table 3: 

Primary Data Sources Used to Estimate Mental Health Utilization and to Derive MH/SA Expenditure 

Estimates for Children and Adolescents 

Data Source Description of Data Source Most Recent Year of 

Data Source

National Survey of American Families 

(NSAF) 

Household survey with 34,390 children and adolescents. 

Question on mental health use and intensity. 

1997 

Community Tracking Study (CTS) Household survey with 10,646 children and adolescents. 1996/1997 

National Health Interview Survey 

(NHIS) 

Sampling frame for other surveys (MEPS). 14,390 

children and adolescents. Contains screening version of 

the Child Behavior Check List. 

1998 (without 

insurance 

information) 

Medical Expenditure Panel Survey 

(MEPS) 

Nationally representative survey of health care use, 

expenditures, sources of payment, and insurance 

coverage for the U.S. civilian noninstitutionalized 

population. 

1996 

Ingenix A proprietary database compiled by Ingenix, this is one 

of the largest single sources of private health insurance 

claims available for analysis. We use claims for about 

1.5 million employees and dependents with private 

insurance, including mental health, pharmacy, and 

medical claims. 

1998 

United Behavioral Health Survey 

(UBH) 

Proprietary data, largest claims database, but only 

managed mental health specialty care. 

1998 

Health Care Financing Administration 

(HCFA) Medicaid Statistics 

HCFA statistics on health care utilization, most detailed 

summaries available for 10 States in 1993 (CMHS 

reports, Buck et al., 2000). Additional tables for 

Michigan and California for 1992 (Wright et al., 1995). 

1993 

National Hospital 

Discharge Survey 

(NHDS) 

A nationally representative sample of hospitals and 

discharges, collected by the National Center for Health 

Statistics (NCHS). Data are for non-Federal, shortstay, and general hospitals in the U.S. and include about 

300,000 of the 30,000,000 U.S. discharges per year. 

1997 

Healthcare Cost and Utilization Project, 

Nationwide Inpatient Sample (HCUPNIS) 

Hospital discharge data from 900 hospitals in 20 States. 1997 

National Ambulatory 

Medical Care Survey 

(NAMCS) 

NCHS national probability survey of visits to office-based 

physicians in the U.S. Drugs prescribed during the visit 

are included. 

1997 

National Hospital 

Ambulatory Medical 

Care Survey 

(NHAMCS) 

NCHS national probability survey of visits to hospital 

emergency and outpatient departments in U.S. nonFederal, short-stay, and general hospitals. 

1992-1997 

Inventory of Mental Health 

Organizations (IMHO) 

Substance Abuse and Mental Health Services 

Administration (SAMHSA) survey of mental health 

facilities. 

1994 

Education Department of Education statistics (special education), 

Los Angeles Unified School District (mental health 

expenditures by type of provider and payment source). 

1998 
102

sample of 1,700 child/adolescent users, which is

more than twice the size of the NHIS and three

times the size of the CTS. The NSAF, however, was

fielded primarily in 13 States. In contrast, the CTS

has national coverage, although it is concentrated

at 60 sites. The NHIS is the most recent survey (by

1 year), but insurance information has not yet been

released. Although 1996 Medical Expenditure

Panel Survey (MEPS) provides more detailed cost

data, it also is the smallest and oldest of those

surveys. In fact, it is smaller than the NHIS by

design as the MEPS surveys a subset of NHIS

participants (from earlier NHIS rounds). None of

these studies are large enough to estimate

residential or inpatient costs precisely and do not

assess them.

The NSAF, CTS, and NHIS differ slightly in the

questions asked (table 4). The CTS and NHIS use the

same mental health utilization question, except that

the CTS refers to the child talking to an MH

specialist and the NHIS refers to the parent talking to

an MH specialist about the child. Since some

settings, especially counseling at schools, do not

always involve the parent, we expect the NHIS

estimates to be lower than the CTS estimates, except

for the smallest children. The methods effect of the

NSAF versus CTS question is less clear. The NSAF

includes a broader range of providers, and “doctor”

could be understood to include primary care

providers, not just psychiatrists. This would suggest

a higher estimate of any use in the NSAF. On the

other hand, the NSAF wording about “receiving

services” may suggest more active treatment to

respondents than “seeing or talking” and, therefore,

may lead to lower estimates. Another difference is

that the NSAF asked for a specific number, not just

yes or no. We also tested whether regional

variations could account for differences in the

estimates, but the CTS estimates remained

unchanged when subset to the States in the NSAF. 

It is important to note that relying on survey data

for outpatient utilization is not without problems.

In all three surveys, parents provide all the

information about the child. Recent studies have

found reporting errors and recall biases, such as

telescoping and heaping when parents reported

their children’s utilization (Bruijnzeels et al.,

1998). Mathiowetz and Dipko (2000) examine

differences in reporting biases between adults and

adolescents and find that parents tend to

underestimate their children’s utilization while

adolescents tend to overreport use. Given these

findings, the utilization rates from the NSAF, CTS,

and NHIS may underestimate total mental health

service use among children.

 Table 4:

 Mental Health Utilization Questions in

 Household Surveys

Survey

NSAF During the past 12 months, how many

times has [child] received mental

health services, including mental

health services received from a doctor,

mental health counselor, or therapist

(do not include treatment for

substance abuse or smoking

cessation). Valid range: 0 to 500

CTS During the past 12 months, has [child]

seen or talked to a mental health

professional, such as a psychiatrist,

psychologist, psychiatric nurse, or

clinical social worker?

NHIS During the past 12 months, have you

seen or talked to any of the following

health care providers about [child's]

health? A mental health professional

such as a psychiatrist, psychologist,

psychiatric nurse, or clinical social

worker?
103

The 1997 NAMCS/NHAMCS provide two other data

sets for outpatient care. Unfortunately, the

NAMCS/NHAMCS data are quite small. The most

recent NAMCS only includes about 4,000 physician

visits for children/adolescents, and only about 3

percent of those had a mental health diagnosis. The

unit of observation in the NAMCS is a visit, and it is

not possible to estimate number of users or visits

per user, which makes the NAMCS somewhat less

useful than other survey data to assess utilization

patterns. Although the earlier releases have been

used in previous studies of mental health use (Zito

et al. 1998; Olfson et al., 1998, 1999), we note that

estimates relying on the NAMCS/NHAMCS result in

a substantially lower number of mental health

visits than estimates based on any other data set. A

main reason is that the NAMCS only includes

nonfederally employed office-based physicians

primarily engaged in direct patient care. However,

non-MD mental health specialists account for most

psychotherapy and counseling. A recent study of

managed behavioral health plans found that Ph.D.

psychologists (33.4%) accounted for most mental

health claims in 1996, followed by psychiatrists

(30.5%), social workers (19.8%) and other master’slevel therapists (13.8%) (Sturm & Klap, 1999). 

The Healthcare Cost and Utilization Project (HCUP)

and the National Hospital Discharge Survey (NHDS)

are the main data sources for national information

on inpatient utilization. One important limitation is

that NHDS excludes hospitals with an average

length of stay of more than 30 days, Federal

hospitals, and hospital units of institutions (such

as prison hospitals). These settings are not included

in the HCUP-NIS either but are included in some of

the HCUP State data. 

The Ingenix database provides a cross-section of

private insurance plans, similar to the MedStat

data used in the SAMHSA studies by Coffey et al.

(2000) and Mark et al. (1998). Neither one is

designed as a nationally representative sample;

they primarily reflect the clients of Ingenix or

MedStat. Nevertheless, these two databases are

the only available data sources for research that

provide comprehensive data on utilization and

costs for large privately insured populations under

a cross-section of insurance plans. We also use

the Ingenix database to estimate expenditures per

service unit, and it is the source for studying the

use of medications among children and

adolescents. 

For Medicaid, CMHS has compiled detailed tables

on mental health utilization for 10 States (Buck et

al., 2000). Those data are already somewhat older

(1993), and the States were not necessarily

representative because they had a larger share of

traditional indemnity insurance than other States

(Buck, personal communication). Wright et al.

provide similar numbers for California and

Michigan for 1992. Other than 1998 data on

mental health service utilization in Medicaid

managed care programs for counties in the State

of Washington, we could not obtain more recent

data. Relying on those older utilization estimates

for Medicaid is a limitation of this study, but new

data analysis on those complex data sets was

outside the scope of this project. 

Important other sectors that provide mental

health services to children include education,

child welfare, and juvenile justice. There are no

national data sets available to estimate mental

health services delivered in these sectors, and we

therefore have to combine estimates from the

literature or use specific regional data sets. For

the educational system, we obtained data from

the Los Angeles County Office of Education. While

regional data are not likely to be nationally

representative, they will provide some insight into

the extent of mental health services provided for

children in schools.
104

CALCULATION OF MENTAL HEALTH

EXPENDITURES

In this project, we consider only services provided

by health and mental health professionals to treat

mental illness, not other social expenditures.

Broader types of services in the general

population—such as testing and supportive

services to patients or their families (special

education)—that are related to mental health are

excluded. We also exclude indirect costs

associated with mental health disorders (such as

future lost wages as a consequence of worse

educational outcomes) or comorbid health costs

(for example, injuries related to suicide attempts

or other trauma). Such potential costs would be

part of the social cost of illness. 

Two general approaches can be used to estimate

the costs of children’s mental health service use.

The first approach is direct and associates

expenditures with estimated utilization patterns,

aggregating to national expenditures from the

bottom up. The advantage of this approach is its

consistency with the reported utilization data.

This is our preferred approach in this project. A

second approach is indirect; it starts with

aggregated data and uses micro-information to

carve out individual pieces. This indirect, topdown approach, which calibrates estimates

against NHA, is particularly useful for

comparisons with other reports that use a similar

approach, such as Coffey et al. (2000). As a

sensitivity analysis, we try to replicate the

SAMHSA approach by comparing utilization

patterns for mental health care for children versus

adults to derive weights and applying them to the

numbers reported by Coffey et al. (2000). 

It is important to keep in mind that all approaches

are conventions that have different advantages and

shortcomings. The direct approach may omit

services for which no data are collected and is

therefore more likely to be biased downward; the

indirect approach, which tries to separate a larger

conceptual piece into specific categories, may

misattribute expenditures and can be biased

upward if the separation does not account for all

the components that went into the aggregate. The

direct approach becomes more advantageous with

narrowly defined target estimates (e.g., insurance

payments to psychiatrists for child mental health

services). All methods approximate a theoretical

concept of health spending differently, but none

can capture it unambiguously, even if there is

agreement on what to include under “mental

health” expenditures. 

THE DIRECT, BOTTOM-UP APPROACH

Expenditures on mental health services are

calculated for each category of insurance coverage

that children have: private, Medicaid, other public,

and none. Total mental health expenditures

(including insurance and patient copayment) are

calculated for the different categories of services,

such as outpatient care, inpatient care, and

psychotropic medications. Totals from each

category are summed to get total mental health

expenditures. To estimate the number of children in

the United States with each category of health

insurance, we use a weighted average of estimates

from the Community Tracking Study (CTS) and the

National Survey of American Families (NSAF). Both

surveys are nationally representative and go to

great lengths to determine the health insurance

status of survey respondents and provide mutually

exclusive point-in-time categories. However, they

include only children in the community, so we

must adjust for institutionalized children using

other data sources, primarily from payers (Medicaid

and State mental health agencies). 

For privately insured children, we use the average

cost per mental health visit estimated from the

Ingenix data, combined with estimates of the
105

number of visits per user from the NSAF, to

estimate outpatient expenditures. For

expenditures on inpatient services, we use a

combination of data from the IMHO and the

HCUP. The IMHO captures inpatient stays in

psychiatric hospitals, while the HCUP is used to

estimate the costs of inpatient stays in community

hospitals. In our calculations from the HCUP, we

use cost/charge ratios from the Agency for

Healthcare Research and Quality (AHRQ) to

deflate charges reported on the hospital discharge

records. Expenditures on psychotropic

medications and other mental health services are

calculated using estimates from the Ingenix data

on costs per member per year for each category. 

No public agency or insurance company maintains

a large database on the use of health care services

by the uninsured. Thus, some assumptions about

the patterns of mental health services use for the

uninsured must be made. We assume that cost per

service unit is the same for the uninsured and the

privately insured and that the two groups differ in

the percentage of any use and the number of visits

per user. Estimates of expenditures on inpatient

mental health service are taken from HCUP. For

psychotropic medication, we assume the same costs

per user for the uninsured and the privately insured

but adjust for the lower probability of any use

among the uninsured. 

A recent CMHS publication, Mental Health and

Substance Abuse Services in Medicaid, 1993

(Buck et al., 2000), has information on Medicaid

mental health service utilization in 10 States:

Delaware, Georgia, Kentucky, Maine, Missouri,

Tennessee, Utah, Vermont, Washington, and

Wisconsin. We use the results from those 10

States as representative of all children enrolled in

Medicaid in the United States and assume that

utilization patterns remain constant between

1993 and 1998. Additionally, we have been

unable to develop an adjustment for differences in

utilization across managed care and fee-forservice programs and assume that utilization

across the two types of programs is comparable.

Thus, the only adjustments to the tables published

in Buck et al. (2000) are for changes in Medicaid

enrollment by age group and for inflation between

1993 and 1998. The Medicaid spending estimates

must be interpreted with the limitations of the

available data in mind. 

A relatively small group of children

(approximately 3%) have insurance through public

programs other than Medicaid. These “other

public” programs vary widely across cities and

States. To estimate the costs of mental health

services obtained by children in these other public

programs, we assume that the utilization patterns

are the same as among children in Medicaid. 

Expenditures by State mental health agencies and

other State and local payers on children’s mental

health service utilization are largely outside the

categories mentioned so far. This includes all noncommunity hospitals (excluded from HCUP) and

residential treatment centers for children.

Unfortunately, no patient/encounter-level data are

available and we therefore need to deviate from

our general approach to capture this sector. We

use data from the IMHO to estimate the

expenditures made by State and local

governments (excluding Medicaid). As a

comparison, we obtained State-level expenditure

data for children obtained from the National

Association of State Mental Health Program

Directors (NASMHPD). The NASMHPD numbers

are fairly consistent with our estimates based on

IMHO (within 10%). This approach may lead to a

small amount of double counting if services used

by some of the privately insured children and the

uninsured children are paid for by State agencies.

This would be primarily for outpatient services

that we have calculated based on NSAF/CTS,

which we expect to be very small. 
106

MENTAL HEALTH EXPENDITURES IN THE

EDUCATION SECTOR

While there is wide agreement that the education

sector is an important provider of mental health

services for children, there are no comprehensive

national data on the amount of money spent

providing such services. Given the paucity of

national data, we have looked to other sources.

We have obtained data from the Los Angeles

County Office of Education regarding expenditures

on services provided by mental health

professionals working in the schools, but we

caution that Los Angeles County is unlikely to be

representative. To provide additional information

on the extent of expenditures for mental health

services in the education sector we use estimates

taken from the literature on the excess cost of

educating children designated as having a serious

emotional disturbance (SED).

THE TOP-DOWN APPROACH

Coffey et al. (2000) estimated that $73.4 billion

was spent on mental health services in 1997 (see

also Mark et al., 2000). The top-down approach to

estimating total expenditures on mental health for

children uses micro-level information to allocate

the total expenditures between children and

adults. We estimate children’s (versus adults')

share of expenditures for each major category of

mental health services: outpatient, inpatient, and

prescription drugs. For outpatient visits, we use

the children’s share of total mental health

outpatient visits estimated from NSAF and CTS;

inpatient expenditures are allocated according to

HCUP estimates; psychotropic expenditures are

based on Ingenix. The expenditures on residential

treatment centers for children from Coffey et al.

are fully attributed to children. 

LIMITATIONS

Estimating how much is spent on child/adolescent

mental health care is a very complex project and

requires aggregating across data sources that are

not necessarily comparable. Several important

pieces of data rely on regional or State

information that is not necessarily nationally

representative, and other crucial data sources are

older than desirable, in particular IMHO and the

Medicaid data summary published by SAMHSA

(Buck et al., 2000). Unfortunately, running new

analyses even on only a few selected Medicaid

databases was not possible in the scope of this

project. Other limitations are well known and not

unique to this study. For example, underreporting

of MH diagnoses in health care claims may be due

to differential coverage for mental health or to

concern about stigma. Claims data may

underestimate out-of-pocket spending when there

are no claims because of limits in insurance

coverage. 

One of the biggest problems is the fragmentation

of mental health delivery. Individual survey data

are more likely than administrative claims data to

capture the full range of services. Our attribution

by a child’s health insurance status, however, will

misclassify such services if they are paid for by

nonhealth sectors (for example, publicly paid

services received by children with private

insurance are allocated to private insurance). 

To see the complexity of trying to build up

expenditures using individual payment sources—

and the holes in these estimates—consider the

following table, which shows the type of nonFederal funding sources in sites that participated

in the Comprehensive Community Mental Health

Services for Children and Their Families Program.

That program was established by Congress in

1992 as a demonstration program that

reorganizes child mental health services into true

“systems” of care. Of course, these programs

include more than just the direct mental health
107

services that are the scope of this report, and most

of the funding sources are very minor.

Nevertheless, the table highlights the impossibility

of collecting data from all potential sources and

suggests that relying on survey data will remain

essential for future work that assesses mental

health services more broadly. The existing

national survey data are limited in their scope and

are used in this study only for direct mental

health services. Assessing broader social services

would require different survey instruments.

 Table 5:

 Sources of Non-Federal Resources Used at Participating Sites of the Comprehensive

 Community Mental Health Services for Children and Their Families Program

Source System Description

State Mental health General fund; Medicaid; Federal

mental health block grant

Child welfare Title IV-B (family preservation); Title IV-B

(foster care services); Title IV-E

(adoption assistance, training,

administration) 

Juvenile justice Federal funds for juvenile justice prevention;

State appropriations

Education Special education; general education;

training and technical assistance;

in-kind staff resources

Governor’s office/cabinet Special children’s initiatives, often including

interagency blended funding

Social services Title XX funds and realigned welfare funds

Temporary Assistance for Needy Families

(TANF)

Bureau of children with special needs Title V Federal funds and State resources

Health department State funds

Public universities In-kind support

Department of children In States where child mental health services

are responsibility of child agency

Vocational rehabilitation Federal and State-supported employment

funds

Housing Various sources

Local County, city, or local township General fund

Social services/child welfare Locally controlled funds

Juvenile justice Courts; probation department and community

corrections

Education Local schools (including in-kind donations of

staff time); school district

County Tax for specific purposes 

Food programs In-kind donations

Health Local health-authority-controlled resources

Substance abuse In-kind support

Private Third-party reimbursement Private insurance and family fees

Local businesses Donations and in-kind support

Foundations Grants

Charities Faith organizations, homeless programs, and

food 

Family organization In-kind support

Source: Koyanagi C, Feres-Merchant D. (2000). For the long haul: Maintaining systems of care beyond the federal

investment. Systems of Care: Promising Practices in Children’s Mental Health, 2000 Series, Volume III. Washington,

DC: Center for Effective Collaboration and Practice, American Institutes for Research.
108

NEW ESTIMATES OF SERVICE UTILIZATION

FROM MICRO-LEVEL DATA

This section provides new results from databases

that have only recently become available. These

utilization results are the foundation of the direct

cost estimates. Only our new analysis results are

shown here, not components for which we relied on

earlier studies or secondary sources (Medicaid,

other State/local expenditures, education, welfare).

USE OF ANY SERVICES

Based on three national surveys fielded between

1996 and 1998, between 5 percent and 7 percent of

all children use any mental health specialty

services in a year. This average rate is similar to the

rate among adults, but it obscures the major

differences across age groups. Only 1 percent to 2

percent of preschoolers use any services, but the

rate is 6 percent to 8 percent for the 6–11 age

group, and 8 percent to 9 percent for the 12–17 age

group (see Figure 1). Survey information differs

from claims data in that it captures out-of-plan use,

which is particularly important because it is widely

believed that school-based services are a major

component of child mental health care (Burns et

al., 1995).

Figure 1:

Access to Specialty Mental Health Services

As expected, there is a substantial variation in

rates of any mental health service use by type of

insurance. Children in Medicaid are most likely to

receive mental health services, and children

without insurance are least likely. The utilization

rates are roughly 1 percentage point higher than

the mental health specialty rates for comparable

age/insurance groups based on the 1992 MECA

sample (Glied et al., 1997). While this could

indicate an increase in the percentage of children

accessing mental health services, it is not strong

evidence of such an increase. The MECA study is

based on a small sample size at a limited number

of sites; thus, the results are not necessarily

generalizable to the national level. Unfortunately,

none of the surveys collects information about the

source of care.

 

Also noticeable is the variation across ethnic

groups. Black and Latino children have lower

rates of any service use, and those differences

increase when adjusting for insurance status.

Figure 2:

Insurance Differences in Access to

Specialty Mental Health Services
109

Figure 3:

Ethnic Disparities in Access to

Specialty Mental Health Services

R

Results from the NHIS and NSAF indicate that the

majority of children who are likely to benefit from

mental health care do not receive any. The index

of mental health need in the NHIS ranges from 0

to 8 and is based on four questions from the Child

Behavior Check List (CBCL). Based on NHIS, 9.2

percent of the children had a need for mental

health care, ranging from 4.4 percent among

preschoolers to 11.0 percent among adolescents.

Black and Hispanic children display higher need

(10.5%) compared with White (8.7%) and other

minority (6.6%) children. Among those with a

need, only 23.5 percent received some care.

Hispanics and other minorities show the highest

rates of unmet need, 86.4 percent and 86.6

percent, respectively, compared with 78.3 percent

for Blacks and 69.3 percent for Whites.

Approximately 7 percent of the families with a

child in need claimed financial barriers as the

reason for not getting any mental health care.

The intensity of care is as important a factor as

the percentage of users when considering

utilization patterns. The bar graph in Figure 5

shows the number of contacts per 1,000

population by age group. Among the privately

insured and the uninsured, adolescents tend to

have more contacts with mental health specialists

than adults, while the younger children (ages 1 to

11) have the fewest. In Medicaid and other public

insurance programs, adults (ages 18 to 64) tend

to have more contacts per 1,000 population than

children. The high contact levels for publicly

insured adults reflects the fact that the adults who

are eligible for public insurance programs tend to

have more serious mental illnesses than the

general population.

Figure 4:

Unmet Need for Mental Health Services

Figure 5:

Outpatient Visits per 1,000 Population
110

Figure 6:

Inpatient Days per 1,000 Population

We compared the survey results regarding contacts

per 1,000 population with 1998 claims/encounter

data from United Behavioral Health, the thirdlargest managed behavioral health organization,

with around 18 million covered lives in all 50

States (Cuffel et al., 1999), and traditional plans of

large employers that are customers of Ingenix. The

rates of any mental health specialty use among the

privately insured members were somewhat lower

than the survey rates (roughly 1 percent, although

with a substantial variation across employers and

States), but the number of visits per user was

substantially lower. As a consequence, the number

of outpatient visits per 1,000 was under 220 in the

privately insured 6–11 age group and under 360

for the 12–17 age group. These numbers account

for only about 50 percent of the outpatient visits

per 1,000 estimated from the NSAF, which suggests

that a large proportion of services is provided

outside mental health specialty settings covered by

insurance. The education sector likely accounts for

a large portion of the difference. Our estimates of

out-of-plan specialty care use may even be an

underestimate, because parent reports of child

utilization, as in the NSAF, are likely to be biased

downward. It is important to note that not all

outpatient mental health services are obtained

through specialty providers. Data from Ingenix

provide evidence that a substantial amount of

mental health care is provided in primary care

settings (304 primary care mental health

outpatient visits per 1,000 population).

INPATIENT UTILIZATION IN COMMUNITY

HOSPITALS 

Data from the HCUP and NHDS indicate that

between 0.2 percent and 0.3 percent of children

ages 1 to 17 use inpatient mental health services.

This rate is substantially lower than the rate for

adults (0.6%). While the two data sources lead to

similar estimates of population inpatient use, the

percentage of hospital inpatient stays with a

primary diagnosis of a mental health disorder is

higher in the NHDS. The patterns of use across

age and insurance groups, however, are quite

similar. The youngest group has the lowest

utilization of inpatient mental health services and

adolescents have the highest. There is no major

difference in the average length of mental health

inpatient stays, although the mean stay for

children ages 6 to 11 was slightly longer than for

the other age groups. Interesting differences in

inpatient mental health care utilization are found

across insurance types. Medicaid and other public

insurance programs have the longest stays. The

privately insured and the uninsured look very

similar in their patterns of inpatient mental health

service use. 

The HCUP data highlight interesting differences in

the patterns of inpatient mental health service use

between adults (ages 18 to 99) and children.

Across all insurance types, adults and adolescents

have greater inpatient days per 1,000 population

than young children. Among the privately insured

and the uninsured, adolescents have higher

inpatient service use than adults. In contrast,
111

among the publicly insured, inpatient days per

1,000 population are significantly higher for

adults than for adolescents. The adults who are

eligible for Medicaid and other public insurance

programs tend to have higher levels of mental

health service need than the general population. 

MEDICATIONS

The fast-growing use of psychotropic medications

for children has received attention in both the

professional and popular press. The Ingenix data

provide estimates of medication use among

privately insured children in 1998. Approximately

4.3 percent of children received psychotropic

medication. Utilization is concentrated among

older children, with 5.0 percent of 6–11-year-olds

and 5.6 percent of adolescents on psychotropic

medication, while only 0.7 percent of children

ages 1 to 5 had any use. 

 

Stimulants were the most common medication

prescribed in all age groups; they were used

substantially more often than all other

medications combined in 1–5-year-olds and 6–11-

year-olds. In adolescents, the rate of

antidepressant use approached that of stimulants,

which is not surprising given the increased

prevalence of mood disorders in teens. 

Figure 7:

Utilization of Psychotropic Medications

NATIONAL EXPENDITURE ESTIMATES 

Total treatment expenditures for children in 1998

were estimated to be around $11.75 billion, or

about $173 per child. Adolescents (12–17)

account for 59 percent of the total and also have

the highest expenditure per child at $291;

children 6 to 11 account for 34 percent of the total

and $165 per child; children 1 to 5 for 7 percent

and $39 per child.

Figure 8:

Total Mental Health Costs, by Age Group

In contrast to the previous estimates for

adolescents, which attributed about two-thirds of

all expenditures to inpatient (hospital and

residential) care (OTA, 1991; Burns, 1991),

estimates for 1998 show that outpatient care

accounts for the largest share (see Figure 9). This

finding for children replicates the differences

between recent managed care data and earlier

actuarial databases for privately insured

populations (Sturm, 1997). Over the past decade,

there has been a dramatic shift away from

inpatient toward outpatient care, a trend that is

not unique to mental health. Some of the shift has

been driven by economic factors and managed

care, and some has been the result of therapeutic

advances. 
112

In the calculation of the cost shares by service

type, the State and local expenditures estimated

from the IMHO are allocated between outpatient

and inpatient services. This process may lead to

some overcounting, as some of the outpatient visits

paid for by State and local payers may be included

in the NSAF-based estimates of specialty outpatient

expenditures for the privately insured. We expect,

however, that this double counting is minimal.

There is some variation across age groups in the

cost share of outpatient services. The share of

outpatient costs for the 1–5 age group is greater

than that for the other groups, while the share of

inpatient costs is lower. The share of medication

costs remains relatively constant across age groups.

For targeting policy interventions, it is important to

see which children account for what proportion of

expenditures. One difficulty in separating costs by

payer is that a child’s insurance status is not a

reliable indicator of who actually pays for services.

State and local mental health agencies (including

Federal block grants) account for about 25 percent

of all expenditures but serve children with private

insurance, no insurance, or Medicaid or other

public insurance programs, and we cannot assign

the relative proportions. Nevertheless, Figure 11

shows that children with private insurance account

for at least 47 percent of all expenditures and

possibly over 55 percent, depending on the share of

the resources from State mental health agencies

that they receive. The role of private insurance also

differs by age groups and is largest for adolescents.

Similar patterns of shares are seen across all age

groups. The expenditure share attributed to the

privately insured is smaller than the percentage of

children with private insurance. Likewise, the

Medicaid share of expenditures is greater than the

percentage of children with Medicaid coverage.

Figure 9:

Total Mental Health Costs, by Type of Service

Figure 10:

Total Mental Health Costs, by Type of

Service and Age Group
113

These estimates indicate that the mental health

costs per child enrolled are higher under Medicaid

than under private insurance.

Based on survey data, children with private

insurance have more mental health specialty visits

than can be accounted for by paid claims. A large

share of those additional visits are provided

through schools, and some services are self-paid,

out-of-plan use or services provided by public

mental health agencies. In addition, expenditures

for mental health services in primary care paid for

by insurance are greater than specialty mental

health services paid by insurance. Figure 13 shows

that primary care outpatient expenditures paid by

insurance are significantly larger than for specialty

care in the adolescent group. For the younger age

groups, the expenditures between the different

types of providers are closer in size. The primary

care expenditures shown in Figure 13 may include

some expenditures for specialty mental health

outpatient visits. There appears to be some

inconsistency in the reporting of specialty versus

primary care in our private sector data sets, and

some specialty visits may be categorized as primary

care.

 

For uninsured children, probably only a small share

of the expenditures will be paid out-of-pocket; most

are paid through a mixture of charity care, schoolbased services, and public agencies. 

MEDICATION COSTS

Total expenditures on psychotropic medications for

children in 1998 are estimated to be $1.1 billion.

The largest proportion of expenditures was for

stimulants, which accounted for slightly over 40

percent of the total. Antidepressant costs made the

second largest contribution, accounting for 33

percent of the total. The share of prescriptions

differs because the majority of stimulant

prescriptions written in 1998 were relatively

Figure 11:

Total Mental Health Costs, by Insurance Status

Figure 12:

Total Mental Health Costs, by nsurance

Status and A e Group
114

inexpensive generic methylphenidate, while the

majority of antidepressant and antipsychotic

prescriptions were for brand name medications for

which generic equivalents are not yet available.

However, the recent increase in prescribing of

nongeneric stimulants (new stimulant

formulations and extended-release

methylphenidate) may lead to an increase in the

overall cost of stimulants.

The shares of total drug costs vary across age

groups. The stimulant cost share is lower for

adolescents than for the other age groups. This is

due in part to the increased importance of

antidepressants in the total drug costs for the

12–17 age group. 

MENTAL HEALTH EXPENDITURES IN THE

EDUCATI0N SECTOR

The out-of-plan specialty outpatient visits that are

seen in the NSAF likely reflect in large part

services received through the school system. The

data however, do not allow us to test this

hypothesis. In an effort to estimate school-based

expenditures directly, we obtained data from the

Los Angeles County School District on salaries for

mental health professionals. These data show that

the district spends approximately $72 per enrolled

student on mental health professionals in the

school. If Los Angeles County were representative

of all school districts, this finding would indicate

that total school expenditures in the United States

on mental health professionals would be $4.1

billion. Los Angeles County, however, does not

appear to be typical in that its expenditures per

student are higher than we would expect to find

in most districts. Thus, these data likely provide a

high estimate of school-based expenditures on the

provision of mental health services in the

education sector.

An additional method of measuring the

expenditures on mental health treatment in the

school setting is to compare the expenditure per

pupil in regular and special education. The

difference between the two per-pupil measures

can be seen as the excess cost of educating a child

with a disability. Estimates in the literature of this

excess cost range from approximately $4,600 to

$10,100 per student (Lankford and Wyckoff,

1996; Lewit et al., 1995; Chaikind and Corman,

1991). The excess cost incorporates both direct

mental health treatment expenditures and

expenditures on ancillary services. Unfortunately,

we are unable to break the aggregate estimate

down into these two components. To obtain

national estimates of school mental health

expenditures, we used data from the U.S.

Department of Education report on the

implementation of the Individuals with

Disabilities Education Act (IDEA)(U.S. Department

of Education, 2000). These data indicate that

approximately 450,000 children with SED were

served under IDEA during the 1997-98 school

year. Consequently, the excess cost of educating

SED children in the United States is estimated to

be between $2.0 and 4.5 billion. 

THE TOP-DOWN APPROACH

As a basis of comparison for our estimates, we

started with the total mental health spending

estimates for all ages from Coffey et al. (2000) and

used micro-level data to carve out the portion that

could be attributed to children. This method

produces an estimate of child mental health

expenditures of $14.3 billion. Although the total

is somewhat higher, the share breakdown across

the type of service provided based on the topdown approach (shown in Figure 14) is quite

similar to that from our bottom-up approach.
115

Figure 13:

Outpatient Health Costs for the Privately Insured

Figure 14:

Expenditures on Psychotropic Medications, by

Drug Category

Figure 15:

Expenditures on Psychotropic Medications,

by Drug Category and Age Group

Figure 16:

Tot l M nt ealth Costs from the TopDown Approach, by pe of Service
116

ACKNOWLEDGMENTS

NIMH funded the research for this report. We thank

Barbara Burns, Agnes Rupp, and members of the

NIMH Child Council Workgroup for comments

during the preparation of the report. Cheri Dolezal,

John Landsverk, Noel Mazade, Abram Rosenblatt,

and Bonnie Zima helped us to gain access to

additional data. 

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Table A-1:

Breakdowns of Total Mental Health Expenditures for Children

1 to 17 1 to 5 6 to 11 12 to 17

GRAND TOTAL 11,750 774 4,047 6,930

Totals by Insurance Status

Private 5,456 411 1,725 3,320

Uninsured 621 41 202 378

Medicaid 2,762 207 1,267 1,288

Other public insurance 408 18 146 243

State and local payers 2,504 96 707 1,701

Totals by Service Type Outpatient 6,739 502 2,554 3,683

Inpatient 3,870 209 1,032 2,629

Medications 1,068 42 439 586

Other mental health services 74 20 22 32

Note: Expenditures are in millions of dollars.
120 

120 

Table A-2: 

Total Mental Health Expenditures for Children, by Insurance Status and Type of Service 

Totals by Insurance Status and Type of Service 1 to 17 1 to 5 6 to 11 12 to 17

Private 

Specialty outpatient 1,867 98 758 1,011

Primary care outpatient 1,669 137 484 1,048

Inpatient 1,190 138 195 856

Medication 670 20 270 380

Other mental health services 61 18 19 25

Private Total 5,456 411 1,725 3,320

 

Medicaid 

Outpatient 1,460 165 672 623

Inpatient 1,047 26 479 542

Medication 254 17 115 122

Other mental health services 0.9 0.0 0.2 0.7

Medicaid Total 2,762 207 1,267 1,288

 

Other Public Insurance 

Outpatient 264 15 96 153

Inpatient 83 1 27 54

Medication 57 2 22 32

Other mental health services 4 0.1 0.9 3

Other Public Insurance Total 408 18 146 243

 

Uninsured 

Specialty outpatient 214 12 81 121

Primary care outpatient 285 24 78 183

Inpatient 27 0 8 18

Medication 88 3 33 52

Other mental health services 8 2 2 3

Uninsured Total 621 41 202 378

Note: Expenditures are in millions of dollars. The $2,504 million in expenditures made by State and local payers cannot be 

allocated among children with different insurance types. 
121

Appendix B

CLINICAL CASE STUDY 

HOW RESEARCH INFORMS CLINICAL CASE

MANAGEMENT IN CHILDHOOD-ONSET

DEPRESSION

INTRODUCTION

The direct relevance of research findings to clinical

care is not always clear. This appendix presents a

clinical case example to illustrate how clinicians, in

treating children, can use specific research findings

from basic and applied studies. The clinical case

about Amy provides an illustration of how the

types of research discussed throughout this report

can guide clinical care and influence the

developmental trajectory of childhood-onset

depression. Depression is highlighted because of its

public health relevance. It is a common, chronic,

and recurrent condition that can disrupt and skew

normal development and result in significant longterm morbidity (e.g., academic problems,

delinquency, unemployment, marital difficulties,

and medical hospitalization) and mortality (e.g.,

suicide). In spite of the recognition of the serious

consequences of depression, it is frequently underdiagnosed and inadequately treated in children

(Beasley & Beardslee, 1998; Wolraich, Felice &

Drotar, 1996). This case illustrates how consistent

application of research findings to clinical practice

can allow for a more systematic, science-based and

developmentally informed approach to treatment

and prevention of depression in children.

The utility of the science base and its importance

for preventive efforts and clinical decision-making

will be highlighted in this appendix with

discussions addressing risk factors,

phenomenology of depression across development,

psychosocial and pharmacological treatments,

suicide and social connectedness, course and

outcome, and access to care and prevention.

CASE PRESENTATION

Amy is a 10-year-old girl with new onset depressive

symptoms over a 5-month period. These were first

noted in school, where her teachers described her as

irritable, with a low frustration tolerance, decreased

concentration, and decreased motivation in

completing her school assignments. She attended

the 4th grade in a public school, and over the past

several months, her grades began to drop from B’s

to D’s. Amy reported feeling increasingly guilty “for

being the cause of the fighting” between her parents

and for “having caused” her parents to divorce 2

years ago. Amy was offered supportive therapy by a

school counselor, with whom she met weekly for the

next 2 months. Not only did her symptoms not

improve, but also, her mother noted Amy’s

increased tearfulness, difficulty falling asleep, low

energy, and decreased appetite, with a 5-pound

weight loss, despite a 1⁄2” growth in height. In

addition, Amy complained to the school counselor

that nothing was fun anymore, and that she felt

worthless. She was becoming increasingly socially

isolated from a group of same-sex peers and

dropped out of her community basketball league.

Although Amy could be defiant at times, she did not

tend to break rules at home or school and her only

conduct problem was a new trend of telling lies to

her friends, “so they will like me better,” behavior

which was consistent with the low self-esteem noted

by her teachers. Amy tended to view the world in a

negative self-defeating manner, even when positive

things happened to her.

Amy’s parents became concerned with her change

in behavior and decreased functioning and took

Amy to her pediatrician for a medical evaluation.

Her mother felt very guilty for not recognizing her

daughter’s symptoms earlier because she was

distracted by her failing marriage. Amy’s parents

had each tried to talk her out of her sad and

irritable moods, but the discussions would usually
122

result in Amy’s increased crying and running out of

the room yelling, “Nobody understands me.” At the

conclusion of the pediatric interview, it was

apparent that her parents had been emotionally

unavailable to Amy over the past several years, had

not been involved with or aware of her school or

social functioning skills, were often critical of her

apparent lack of motivation, and were often

inconsistent with discipline.

 

In terms of her past history, Amy struggled with

reading in the first grade but was never tested for

learning disabilities. She was described as an

anxious, shy child who frequently had difficulty

separating from her mother. She was able to

overcome this anxiety to such an extent that she

could make friends and go to school without any

psychological or psychiatric intervention. In terms

of her past medical history, Amy had been

diagnosed with mild asthma at age 8; she used a

steroid inhaler for flare-ups of the disease. She had

reached precocious puberty with menarche at age

10. She was of average height and weight. 

Her parents divorced when Amy was 8 years old,

but marital conflict had been present for many

years prior to the divorce. Her parents now had

minimal contact with each other, and their contact

was often filled with conflict. Amy, her 16-year-old

brother, and her mother moved into a small house

in a substantially less-expensive part of town, while

her father moved away to a neighboring middleclass suburb where he continued to work as a

salesman. Amy missed her father, with whom she

had limited contact every other weekend. Her

mother, who worked as a secretary, had a history of

recurrent depression and Amy’s older brother,

although an average student and good athlete, used

marijuana and alcohol regularly. There was also a

history of depression in the maternal grandparents,

as well as a paternal uncle who suffered from

alcoholism. 

Amy’s parents married after high school, and while

her mother was continuing her education, she

unexpectedly became pregnant with Amy’s brother

at the age of 20. Amy was the result of a planned

pregnancy 6 years later. The pregnancy progressed

normally and there was no prenatal exposure to

medications, alcohol, or drugs, except for

intermittent tobacco use. Amy was delivered 2

weeks early by a caesarian section due to hypoxia,

but appeared normal at birth. Amy’s mother had

depressive symptoms throughout the pregnancy,

which evolved into a severe depression during the

first year of Amy’s life, making her emotionally

unavailable to her baby. Although Amy reached

normal developmental milestones in terms of

walking and talking, when compared with her

toddler peers she did not seem to explore her

environment with the same enthusiasm, had less

affective responsiveness to emotion-inducing

situations, and demonstrated an insecure

attachment to her mother.

The pediatrician ruled out medical causes for

depressive symptoms such as hypothyroidism,

anemia, or drug abuse. The family was referred to a

local mental health clinic. During her evaluation

with a licensed psychologist, Amy was cooperative

and superficially friendly. Her speech and cognitive

functioning appeared normal. She was

intermittently fidgety in her chair but otherwise had

no abnormal movements. She described her mood as

sad and her affect fluctuated between forced

cheerfulness and tearful lability. She denied any

current suicidal or psychotic thoughts, but she

endorsed guilt and worthlessness during the end of

the interview after initially denying these

symptoms. 

DISCUSSION

1. Risk Factors for Child and Adolescent

Depression

Known vulnerabilities for childhood depression
123

include familial, biological, psychosocial, and

cognitive factors. The case illustrates the presence

of multiple risk factors commonly seen among 

children at risk for depression. A discussion of each

of these risk factors follows. 

A. Familial Risk Factors

Many studies suggest that familial factors are the

best predictors of the development of depressive

disorders in youth (Garrison et al., 1997; Kaslow,

Deering & Ash, 1996; Kaslow, Deering & Racusin,

1994) and such factors may serve as an important

starting point in diagnostic and treatment

considerations. The case example illustrates

several types of family risk factors, including the

presence of parental psychopathology, high levels

of family conflict, and inconsistent parenting

(Birmaher et al., 1996; Reinherz, Giaconia, Hauf,

Wasserman & Paradis, 2000; Rutter, 1990).

Maternal depression can have an especially

profound effect on infant development, not only

by increasing the heritable risk for depression

(Beardslee, Versage & Gladstone, 1998), but also

psychosocially by sensitizing the child to later loss

experiences or threats and undermining

opportunities for social development due to

parental unresponsivity and neglect (RadkeYarrow, Cummings, Kuczynski & Chapman, 1985;

Rutter, 1995). The effects of a mother’s

depression on shaping her child’s brain circuitry

and subsequent behavioral performance can begin

in utero. Studies examining the neurobiology of

pregnant, depressed women found higher plasma

cortisol, beta-endorphins, and corticotropinreleasing hormone levels (Handley, Dunn,

Waldron & Baker, 1980; Smith et al., 1990). The

fetus, via placental blood flow, can experience

these maternal neuroendocrine abnormalities.

Further, fetuses may be at elevated risk due to

inadequate health care and health risk behaviors

(e.g., maternal smoking, poor nutrition) that have

been associated with depression (Stowe, Calhoun,

Ramsey, Sadek & Newport, 2001). Thus, even in

utero factors such as depressive symptoms and

intermittent tobacco use by her mother may have

shaped Amy’s neurobiological vulnerability. 

Family interactions of depressed parents with

depressed offspring are characterized by more

conflict, rejection, problems with communication,

and less expression of affect, attention, and

support when compared with families of normal

controls (Beardslee et al., 1996; Downey & Coyne,

1990; Goodman & Gottlib, 1999; Harrington et al.,

1997; Schwartz, Dorer, Beardslee, Lavori & Keller,

1990). Families of depressed children also showed

increased levels of criticism (Puig-Antich et al.,

1985) and rejection (Cole & McPherson, 1993),

attachment difficulties, and elevated

maternal/parental overprotection compared with

controls (Armsden, McCauley, Greenberg, Burke &

Mitchell, 1990; Burbach, Kashani & Rosenberg,

1989; Lovejoy, Graczyk, O’Hare & Neuman, 2000;

Martin & Waite, 1994; McFarlane, Bellissimo &

Norman, 1995). However, the stress caused by

associated marital or economic factors may have

more impact on parenting than direct aspects of

parental depression (Downey & Coyne, 1990;

Goodman & Brumley, 1990; Goodyer, Herbert,

Tamplin, Secher & Pearson, 1997; Stubbe, Zahner,

Goldstein & Leckman, 1993). 

 

Studies show that the emotional stress Amy

experienced as a result of her mother’s affective

illness may have been reduced if her parents had

learned how to respond in an accepting and

validating way to her emotional needs (FochtBirkerts & Beardslee, 2000). Collectively, studies

suggest that early detection and treatment of

maternal depression during pregnancy and in the

postpartum period may have had a positive impact

on Amy’s depressive trajectory, given the available

effective treatment of depression during pregnancy

(Szigethy & Wisner, 2000). 

In addition to neglect secondary to maternal

depression, this case also highlights another form

of parental nonavailability: family conflict and

divorce, and the need to focus more attention

clinically on the impact of these factors on children
124

like Amy. Recent studies investigating the impact

of divorce on children have found that many of

the psychological effects seen in children can be

accounted for by the negative effects of a troubled

marriage prior to divorce (Kelly, 2000). In fact,

marital conflict has been shown to be a more

important predictor of child adjustment than either

the divorce itself or any post-divorce conflict

(Hetherington, 1999; Hetherington & StanleyHagan, 1999; Kline et al., 1989). Direct

detrimental effects of marital conflict include

modeling of parents’ behavior, failure to learn

appropriate social interaction skills, and

physiological effects (Davies & Cummings, 1994).

More recent research points to disturbances in

affect regulation or emotional arousal mechanisms

in young children exposed to violent or repetitive

severe parental conflict (DeBellis, 1997; Lieberman

& Van Horn, 1998). Indirect effects of marital

conflict highlighted by the current case include poor

quality of parenting and less paternal involvement,

which can make children feel rejected or guilty,

particularly children in the pre-adolescent

developmental phase (Hetherington, 1999).

Children of divorce, when compared with children

in never-divorced families, have significantly more

adjustment problems. Hetherington (1999)

summarized the complexity of gender and age

issues with adjustment and achievement in boys

and girls after divorce varying with age, time since

divorce, type of parenting, and type and extent of

conflict. These findings may explain why Amy

manifested depressive symptoms while her brother

struggled with substance abuse issues. The

findings emphasize the need for the clinician to

focus on each child individually and in the

appropriate developmental context, particularly in

high-conflict divorce families.

These reciprocal interactions with parents not only

influence the child’s behavior but may also affect

the development of neural circuits of the infant’s

brain (Lyons-Ruth & Zeanah, 1993; Rogeness &

McClure, 1996). Recent findings in rats suggest that

the impact of early life events on the development

of behavioral and endocrine responses to stress are

mediated through changes in mother-offspring

interactions; these findings have identified brain

regions (e.g., locus ceruleus, amygdala, frontal

cortex) and hypothalamic-pituitary-adrenal (HPA)

glucocorticoid systems as critical targets for the

effects of variations in maternal care (Francis,

Caldji, Champagne, Plotsky & Meaney, 1999; Caldji

et al., 1998; Francis & Meaney, 1999; Meaney et

al., 1996; Meaney, 1999). In human infants,

neglect has been associated with lower reactivity of

the HPA axis, which has been hypothesized to

represent a self-protective feedback mechanism to

counter the potentially damaging effects of elevated

cortisol levels (Gunnar, 1998). Elevated cortisol

levels have been associated with damage to the

hippocampus, a region essential for memory

(Sapolsky, 1996). Finally, both monkey and human

infants exposed to maternal neglect have shown

changes in the development of norepinephrine

systems; norepinephrine is a neurotransmitter

implicated in many regulatory brain functions

(Fleming, O’Day & Kraemer, 1999; Rogeness &

McClure, 1996). Such fundamental work in

neuroscience has helped to connect what is known

about the effects of parental neglect on the

developing brain and has important implications

for the development of early interventions for any

form of parental neglect. 

The interplay between genetic and environmental

factors in determining risk for psychopathology in

children at risk of depression is complex. Amy

showed vulnerability to depression in several

domains of functioning, including cognitive (low

self-esteem, helplessness), affective (poor emotional

regulation), and behavioral functioning (social

isolation, low mastery motivation). Goodman &

Gotlib (1999) proposed a developmental model,

based on empirical evidence from animal and

human studies, for understanding the mechanisms

of transmission of risk from depressed mothers to

their offspring. In this model, four mechanisms

through which risk might be transmitted are
125

evaluated: (1) heritability of depression; (2) innate

dysfunctional neuroregulatory mechanisms; (3)

exposure to negative maternal cognitions,

behaviors, and affect; and (4) the stressful context

of the children’s lives. Three factors were proposed

to moderate such risks, including the father’s

health and involvement with the child, the course

and timing of the mother’s depression, and

characteristics of the child. This model is consistent

with the literature on resiliency. Many children

appear to develop normally both in terms of brain

and behavior in the face of parental adversities

(Luthar & Cicchetti, 2000). Similar factors appear to

play a role in determining resilience: (1) attributes

of the children (e.g., temperament, cognitive and

social-emotional competence, self-confidence,

realistic assessment of parental limitations); (2)

aspects of their families (e.g., parental perspectives

about children and the developmental process,

maternal interactive behaviors); and (3)

characteristics of their wider social environments

(family social support, social status) (Cicchetti &

Rogosch, 1997; Luthar & Cicchetti, 2000; Masten,

Best & Garmezy, 1990; Sameroff, Seifer, Barocas,

Zax & Greenspan, 1987). Resilient youth with

affectively ill parents were found to be activists,

deeply involved in school and extracurricular

activities, deeply committed to interpersonal

relationships, and they valued self-understanding

in coping with parental affective illness (Beardslee

& Podorefsky, 1988). Similarly, protective buffers

for children in high-conflict marriages include a

good relationship with at least one parent, parental

warmth, supportive siblings, and, for adolescents,

good self-esteem and peer support (Emery, 1999).

Based on this research, multiple interventions can

be included in a treatment plan to reduce Amy’s

risks and increase her resiliency. These could

include working with her parents to increase

consistent parenting and more positive

engagement with Amy and decreasing parental

conflict given the detrimental effects of untreated

adversity on the child’s developing brain and

behavior (Downey & Coyne, 1990). Additional

strategies may include increasing paternal

involvement; identifying and treating maternal

depression; utilizing extended family or community

social support; encouraging Amy’s continued

involvement in extracurricular activities to increase

social competence and self-confidence; providing

psychoeducation about depression; and offering

age-appropriate explanations of the psychological

and legal aspects of the divorce process to support

children’s positive adjustment and mental health

(Beardslee et al., 1997; Pruett & Pruett, 1999). 

 

B. Biological Considerations/Risk Factors

Gender—Another important risk factor for Amy’s

expression of depression is her female gender.

Adolescent females are twice as likely to experience

depression than their male peers; this is a crosscultural phenomenon (Angold, Costello &

Worthman, 1998; Nolen-Hoeksema et al., 1994).

Explanations for the increase in adolescent

females’ vulnerability to depression include

differences in sex-role socialization, cognitive

styles, presence and timing of negative life events,

greater interpersonal sensitivity, and differential

hormonal changes associated with puberty (e.g.,

changes in circulating gonadal hormones exerting

direct or potentiating effects on the central nervous

system related to mood disturbances) (Brooks-Gunn

& Warren, 1989; Cyranowski, Frank, Young &

Shear, 2000; Petersen et al., 1993; Schraedley,

Gotlib & Hayward,1999; Silberg et al., 1999;

Warren & Brooks-Gunn, 1989). Physical changes

associated with puberty (e.g., breast development,

increased body fat) have been related to negative

perceptions of body image, particularly if females

experience these changes before those in their peer

group (Angold et al., 1998; Ge, Conger & Elder,

1996; Siegel, Yancey, Aneshensel & Schuler, 1999).

The precocious puberty exhibited by Amy is

consistent with studies that related early pubertal

maturation in female offspring to maternal

depression, an effect that appears to be mediated by

discordant family relationships and the absence of

the biological father (Ellis & Garber, 2000; Kim &

Smith, 1998). 
126

One integrative model exploring the etiology of

depression further suggests that the combination of

social and hormonal mechanisms present in

pubertal females stimulates heightened needs for

affiliation (e.g., preference for intimacy within

interpersonal relationships) (Cyranowski et al.,

2000). While most adolescent females undergo the

transition from parental to peer attachments with

relative ease, children like Amy, with insecure

parental attachments, poor interpersonal coping

skills, or anxious or inhibited temperaments, can

have increased difficulties with socially expected

role transitions and thus have a greater risk of

depression during puberty. These findings suggest

that these related realms of functioning deserve

particular attention by the treating clinician,

particularly for children at a higher risk for

depression.

Psychiatric Comorbidity—One promising area for

integrating basic behavioral and neuroscience

research into clinical practice is the comorbidity of

depressive and anxiety disorders. As noted above,

children with anxious temperaments, particularly

girls like Amy, have an increased risk for later

onset of social anxiety and depression and

differences in sympathetic reactivity (Kagan &

Snidman, 1999; Schwartz, Snidman & Kagan,

1999). In adults, generalized anxiety disorder has

been conceptualized as a prodrome or severity

marker of major depression (Birmaher et al., 1996;

Kessler, DuPont, Berglund & Wittchen, 1999;

Merikangas, Risch & Weissman, 1994; Pine, Cohen,

Gurley, Brook & Ma, 1998; Pine & Grun, 1999;); in

adolescents, the expression of depression has been

related to changes in processing fear, threat, and

anxiety (Pine et al., 1998; Pine & Grun, 1999).

Further, both depressive and anxiety disorders

share a common genetic diathesis, puberty-specific

expression in females, similar neuroanatomical

underpinnings (e.g., amygdala, cingulate cortex,

orbital cortex), and neurochemical substrates (e.g.,

serotonin, catecholamines) for pharmacological

interventions (Birmaher et al., 1996; Dahl, 2001;

DeBellis et al., 2000; Drevets, 2000; Kendler, 1996;

LeDoux, 1998). In fact, abnormal amygdaloid

function has been implicated in anxiety and

depression and its function normalized after

antidepressant treatment (Drevets, 1999; Drevets,

Gadde & Krishnan, 1999). Finally, cognitivebehavioral interventions have been shown to be

effective in the treatment of both anxiety disorders

and depression. It is possible that such

interventions targeted early in the course of some

anxiety disorders (and/or in some high risk

individuals at risk for anxiety/depression) may be

capable of altering the developmental path of these

disorders. A better understanding of the basic

changes in affect regulation and underlying

neurobehavioral systems and circuits may help to

better focus these interventions. 

Another area for integrating basic behavioral and

neuroscience research is in the area of learning

disabilities. It is not uncommon for children like

Amy to encounter learning problems in conjunction

with anxiety and depression (Lyon, 1996). A

comprehensive neuropsychological assessment will

be important to better understand the extent of her

learning problems. Such an assessment is

important for an understanding of the emotional

and neuropsychological contributions to Amy’s

learning difficulties. In other words, understanding

whether Amy’s learning problems are secondary to

her depression and anxiety or if they coexist with

her psychiatric conditions can aid in the

development of a more effective treatment plan.

Identifying the pattern of cognitive functioning

within different cognitive areas (e.g., executive

functioning, language functioning, sensoryperceptual functioning) can aid in the choice of

treatment(s) for her learning problems as well as

her psychiatric disorders. Developmental processes

(Durlak, Fuhrman & Lampman, 1991) can

influence whether particular types of therapy (e.g.,

CBT) will be useful. 

Physical Illness Comorbidity—Another important

yet often neglected area in the clinician’s office is

the overlap of depression and chronic physical
127

illness in children and adolescents. Children like

Amy, with comorbid depressive disorder and

chronic physical illness such as asthma, have

higher health care utilization, poor medical

outcome, more functional impairment, decreased

quality of life, and increased mortality (Strunk,

1987). Despite findings that children with certain

disorders (e.g., asthma, cancer, sickle cell anemia)

appear to have increased risk of depressive

symptoms compared with other disorders, physical

illness factors (e.g., type of disorder, severity or

duration of disorder) are generally poor predictors

of depressive symptoms (Bennett, 1994). This is

further complicated by difficulties defining and

measuring depression in this population due to

overlap of symptoms (e.g., insomnia, changes in

appetite and energy). Interestingly, certain

psychosocial interventions (e.g., writing about

stressful experiences, family therapy) have been

shown to improve physical disease status in adults

with asthma (Smyth, Stone, Hurewitz & Kaell,

1999) even in the absence of depression. This effect

is thought to be mediated by the improvement of

the immune response. Such studies could provide

the foundation for examining potential mediators

and moderators of treatment effect when co-morbid

depression is present, as was the case for Amy, and

suggests that psychosocial strategies to help her

cope with her asthma may have had preventive

effects on her depressive symptoms.

C. Psychosocial Factors

Cultural—Another often-neglected area in clinical

practice is the appreciation of the role of cultural

differences and similarities in the etiology,

expression, and phenomenology of depressive

disorders (Marsella, 1987). A number of risk factors

have been associated with depression in AfricanAmerican children, including higher levels of childreported daily stress, poverty, teenage pregnancy,

lack of maternal contact, low educational level of

mother and/or head of household, high levels of

family conflict, use of corporal punishment, and

domestic violence (Marsella, 1987). Research also

suggests that culture influences the manifestations

of depressive symptoms in youth. For example,

somatic complaints and interpersonal difficulties

are common in depressed American Indian

children, whereas cognitive and affective

complaints characterize depressed European

American children (Manson, Ackerson, Dick &

Baron, 1990). An understanding of the cultural

background of Amy’s family, the context within

which her symptoms developed, and the family’s

response to them are all important issues to

consider. 

Poverty—Although poverty has been shown to be a

risk factor for juvenile depression, data are mixed

regarding the link between social class and rates of

depression and depressive symptoms in youth.

There are virtually no data on the interaction of

socioeconomic status and ethnicity with depressive

symptoms/disorders and youth. Interestingly, the

effect of low socioeconomic status may be more a

function of being at the bottom of the social

hierarchy and less due to absolute income levels or

cultural differences (Goodman & Gottlib, 1999;

Keating & Hertzman, 1999). The divorce-related

change in the socioeconomic status of Amy’s

mother may have additionally contributed to

maternal unavailability (through work pressures)

and may have the potential to indirectly affect

Amy’s mental health outcome by limiting the

family’s access to mental health care. 

Cumulative Life Stressors—Life events are

positively correlated with symptoms of depression,

particularly when these events are severe,

numerous, and/or related to key interpersonal

relationships (Birmaher et al., 1996; Compas,

Grant, & Ely, 1994; Garber & Hilsman, 1992;

Williamson, Birmaher, Anderson, al-Shabbout &

Ryan, 1995). Negative life events most likely to

precipitate depression in adolescents relate to

structural changes in the family (e.g., divorce) and

rejection from peers (Bell-Dolan, Last & Strauss,

1990; Brent et al., 1993; Reinherz et al., 1993;

Weller, Weller, Fristad & Bowes, 1991). Although

most research suggests that depression is a familial
128

disorder with strong genetic influences,

environmental factors appear to account for the

variance in liability to major depression (Sullivan,

Neale & Kendler, 2000). The influence of

environmental factors is highlighted in this case by

the fact that while both Amy and her brother

shared a family vulnerability for major depression

and substance abuse, and may have shared a

genetic vulnerability, Amy manifested depressive

symptoms while her brother presented with

substance abuse issues. Studies to date support a

number of potential reasons for this differential

expression of psychopathology in the two siblings.

The cumulative presence, timing, and contextual

threat level of negative life events (e.g., changes in

family structure, social isolation from peers, or

coping with asthma) may have been more

etiologically relevant in inducing depression in Amy

than in her brother. Alternatively, her brother’s

less-inhibited temperament, increased cognitive

maturity, and good athletic abilities may have been

protective factors against depression.

 

D. Cognitive Style

Individuals with negative attributional styles,

cognitive distortions, and social skill deficits tend to

become hopeless and dysphoric, and they appear to

be at higher risk for developing depression

(Asarnow & Bates, 1988; Gladstone & Kaslow,

1995; Gotlib, Lewinsohn, Seeley, Rohde & Redner,

1993; Hammen & Zupan, 1984; Rudolph,

Hammen, & Burge, 1994; Wagner, Rouleau, &

Joiner, 2000). Children with maladaptive

attachments to parents may develop unhealthy

cognitive styles, including negative models of self

and others, and poorly developed social and coping

skills (Burge et al., 1997). Others have proposed

that negative attributional styles and negative

cognitions increase the risk of depression when

prepubertal children experience stressful life events

(Hammen, 1992; Hillsman & Garber, 1995). In the

case of Amy, an awareness of factors that could

induce or maintain her negative self-image (e.g., a

learning disability preventing academic competence

or social skill problems interfering with peer social

competence) may help guide the target of

psychosocial interventions.

SUMMARY OF RISK FACTORS

For Amy, factors such as an inhibited/anxious

temperament, the absence of maternal emotional

responsivity, prenatal exposure to tobacco, and

genetic predisposition for depression could have

primed her neurobiological reactivity to stress.

Exposure to adversity during sensitive periods of

brain development may have induced alterations in

her perceptions and responses to environmental

stressors, making her more vulnerable to react

negatively to future stress (e.g., family conflict),

particularly in the absence of effective coping

models at home and increased genetic susceptibility

for depression. It is important to note that any

single risk factor may lead to a variety of different

negative outcomes or may have no effect at all

(Rutter, 1990). For example, evaluation of the

effects of parental depression on offspring over a

10-year period revealed that offspring of depressed

parents had higher rates of suicide, major

depression, phobias, panic disorder and alcohol

dependence, and lower levels of functioning at

home, work, and within marriage and families than

children with non-ill parents (Weissman, Warner,

Wickremaratne, Moreau & Olfson, 1997). The

specificity of negative outcomes may be enhanced

when several risk factors are combined. Thus, in

cases like Amy’s, it may be more important to

address the multiplicity of risk factors in treatment

rather than any single risk variable (Hammen,

1992; Rutter, 1979). Beardslee et al. (1996)

developed an “adversity index” using a nonreferred

sample of adolescents with affectively ill parents.

They found that the combination of the duration of

parental affective disorders, the number of parental

non-affective diagnoses, and the total number of

prior child psychiatric diagnoses predicted the onset

of disorder in these adolescents over a 4-year

period. Similar findings regarding the cumulative

effects of risk factors in predicting outcomes in

young children have been reported by Sameroff et
129

al. (1987). Thus, the phenotypic expression of

depression appears to be related to the interaction

of genetic vulnerability, cognitive coping style, and

psychosocial stress factors. In diagnostic

considerations, it is important to identify malleable

risks such as family communication, parenting

style, adequate treatment of parental

psychopathology, and adequate consideration of

the presence of, or risk for, comorbid psychiatric,

substance abuse, and medical conditions. 

The science base clearly suggests several possible

interventions that can address the variety of risk

factors to better prevent and treat psychopathology

in the child and the family. Yet, the science base is

limited in terms of providing guidance as to the

relative potency of these risk factors at different

developmental periods, their specificity of effect,

strategies to target such risks (e.g., sequence, timing

and type of intervention), or determining how much

of an effect is possible in light of the resources and

sociocultural context of Amy’s family. 

 

2. Phenomenology of Depression Across

Development

If lasting solutions to these problems are to be

achieved, research into the environmental and

genetic interactions that bring about brain and

behavioral development must develop in parallel

with psychological and sociological solutions to the

problems faced by children in our society.

Knowledge pertaining to the neurobiological

underpinnings of behavior and their relation to the

etiology of mental disorders over the

developmental trajectory will be fundamentally

important in developing accurate diagnostic tools

and early interventions.

Infancy to Middle Childhood

The importance of linking genetic, environmental

and brain developmental factors during childhood

is well-illustrated in the particular case of maternal

depression, where negative effects on the child have

been documented during both infancy (e.g., more

fussy/difficult temperaments, delayed mental and

motor development, and less secure maternal

attachments) and toddlerhood (e.g., more negative

reactions to stress and delayed acquisition of

effective self-regulation strategies). Although early

brain development is predominantly genetically

determined, the determination of which synaptic

connections will persist in the brain is

environmentally regulated. Given that affectregulation processes require maturation of the

frontal lobes, a process that is not completed until

adolescence, early mother-infant interactions are

critical in helping the child acquire healthy selfregulation strategies. One aspect of maternal

depression is the absence of these sensitive

interactions between parent and young child. Some

depressed mothers are withdrawn and disengaged;

others are insensitive, intrusive, and sometimes

angry (Cohn & Tronick, 1989). In the absence of

experiences of external modulation of affect, the

infant brain is unable to learn self-regulation of

affect, part of the process of ontogenesis

(development of self through self-regulation)

(Glaser, 2000). The understanding of such brainenvironment interactions could lead to earlier

detection of maternal depression and to preventive

psychosocial interventions that are better at

targeting the mother-infant dyad. 

The diagnosis of depression in infants and toddlers

is compromised, as infants lack the cognitive and

language skills necessary to self-reflect and report

depressive thoughts and symptoms. Nevertheless,

depressive-like states in infants and toddlers have

been described in the literature. Distressed infants

exhibit symptoms commonly associated with

depression, including lethargy, feeding and sleep

problems, irritability, sad or expressionless faces,

and decreased affective responsivity, attentive

behavior and curiosity (Carlson & Kashani, 1988;

Field, 2000). Changes in these behaviors imply

changes in underlying neural development, such as

cell survival, neuron density, brain vascularization,

neural connectivity, and neurochemical expression.

It is interesting to speculate how identification of
130

many of these behaviors during Amy’s infant years

and consequent intervention with the motherinfant dyad may have altered the course of her

depressive illness. Several studies have examined

the outcome of such interventions for infants and

children at high risk for developing such problems

on the basis of the presence of depression in the

mothers (Cicchetti, Rogosch & Toth, 2000; Field,

1998; Lyons-Ruth, Connell, Grunebaum & Botein,

1990; Sexson, Glanville & Kaslow, in press).

Collectively, these studies found improved affective

regulation, lower levels of salivatory cortisol,

increased weight gain in treated infants, and

improved cognitive functioning both in the short

and long term (3 years) in treated toddlers. 

Middle Childhood to Adolescence

It is important that depressive phenomenology and

its treatment be considered in a developmentally

appropriate context for this age group. For example,

while there is a relatively stable pattern of

depressive symptoms in 6- to 8-year-olds that

includes prolonged unhappiness, decreased

socialization, sleep problems, irritability, lethargy,

poor school performance, accident-proneness,

phobias, separation anxiety, and attention-seeking

behaviors (Carlson & Kashani, 1988; Edelsohn,

Ialongo, Werthamer-Lars, Crockett & Kellam, 1992),

children at this age typically do not verbalize

hopelessness and self-deprecation. In contrast, 9- to

12-year-olds who are more self aware often

verbalize feelings of low self-esteem and

helplessness when depressed (Carlson & Kashani,

1988; Weiss et al., 1992). More severe symptoms

may also emerge at this time, such as suicidal

ideation (Poznanski, 1982). 

Other studies comparing the phenomenology of

depression in child and adolescent samples indicate

that the similarities in symptom expression exceed

the differences (Mitchell, McCauley, Burke & Moss,

1988; Ryan et al., 1987). Both groups evidence

somatic complaints, social withdrawal,

hopelessness, and irritability. However, as a result

of the cognitive developmental shift that

accompanies formal operations, when compared

with depressed elementary school children,

depressed adolescents report more concern about

the future and pessimism, worthlessness, and

apathy, as demonstrated by Amy (Weiss et al.,

1992). As adolescents mature, their self-reported

symptoms seem to be more accurately correlated

with a diagnosis of depression (Kazdin, French &

Unis, 1983; Shain, Naylor & Alessi, 1990). The case

illustrates the importance of using multiple

informants, including the child’s report, when

assessing internalizing symptoms. Although the

family situation may have contributed to the

parents’ lack of attunement to Amy’s depression, it

is not uncommon to miss early signs of depressive

symptoms due to young children’s limited ability to

verbalize their hopeless thoughts and feelings, nor

is it uncommon for their depressive symptoms to

manifest themselves as irritability rather than

sadness. In this case, Amy did not receive help until

teachers at school noted a decline in her school

functioning and her symptoms became more

severe. 

In conclusion, juvenile depression is a

heterogeneous condition resulting from

interactions between genetic, biological, and

environmental factors at any given developmental

period. Knowledge of underlying biological,

cognitive, and social processes in normal

development is critical in understanding the risks

for the development of psychopathology in

children. Understanding what leads to failures in

the development of competence can aid in

designing better preventive interventions and better

treatment of depressive symptoms. Current

treatment of juvenile depression generally neglects

the following areas: comorbid diagnoses, academic

and social functioning, and environmental

stressors (Hammen, Rudolph, Weisz, Rao & Burge,

1999). Treatments need to be informed by and

address the actual characteristics of depressed

youngsters and their environments, which are often

highly dysfunctional.
131

As Amy’s case illustrates, key developmental issues

for depressed youth are that they often find

themselves caught in environments that they

cannot control, they may lack the cognitive skills to

cope with such situations, and they may have longstanding additional problems contributing to

ongoing difficulties in achieving developmentally

important academic and interpersonal competence.

The plasticity of the young brain suggests that

appropriate early intervention may allow the child

to return to a healthy developmental trajectory. The

case raises questions about the importance of the

timing of interventions. Would the course of Amy’s

depression have been altered if the mother had

received treatment for postpartum depression with

subsequent improvement in her parenting capacity

and emotional availability? Would Toddler-Parent

psychotherapy, an intensive treatment to address

attachment difficulties, have been as helpful in

improving cognitive functioning as suggested in

other at-risk toddlers (Cichetti et al., 2000)? Would

family or marital therapy have been effective in

helping to deal with the marital conflicts? Such

interventions may have led to both behavioral

improvement and normalizing underlying brain

function. As the research evidence suggests, failure

to make appropriate diagnoses or provide

efficacious treatment regimens in a timely manner

can result in early onset mood disorders that may

derail development in very serious ways, with very

high costs not only to the child but also to her

family. 

After evaluation by the psychologist, Amy, who

was now almost 11 years old, was diagnosed with

a new-onset major depression of moderate severity,

a history of anxiety symptoms, and possibly a

learning disability. Individual cognitive behavioral

therapy (CBT) was initiated with a family

component to educate parents about depression

and help them parent Amy in a more unified, less

conflict-laden manner. Several meetings were

arranged with her school to develop an educational

plan to help Amy recapture her academic

functioning. At the end of this treatment, Amy felt

significantly better and was functioning back at her

baseline at school. She was also spending more

time socializing with her friends. Residual

symptoms of intermittent insomnia and a sense of

worthlessness persisted. CBT sessions were

continued on a monthly basis for 6 months, during

which time Amy remained in remission. The family

stopped coming to treatment after they had used up

their 20 allowable visits under their insurance plan.

3. Psychosocial Treatment of Juvenile

Depression

In contrast to the dearth of research on treatments

for depression in infants and toddlers, a larger body

of evidence exists regarding treatments of

depression in middle childhood. At present,

psychosocial treatments for depression in children

under age 13 have been investigated in10 studies.

Most of the studies have focused on cognitive

behavioral approaches, with most finding favorable

results, compared to a variety of comparison

conditions in both school-based (Rehm & Sharp,

1996; Stark et al., 1987) and clinic-based (Kahn,

Kehle, Jenson & Clark, 1990; Weisz, 1997)

programs. For adolescent depression, CBT has been

the most widely evaluated treatment and has been

found to demonstrate success across modalities, in

individual, group, and school-based treatment

(Clarke et al., 1995; Lewinsohn, Clarke, Hops &

Andrews, 1990; Reynolds & Coats, 1986).

Interpersonal therapy (IPT) has also been shown to

reduce depressive symptoms and improve social

functioning in adolescents (Mufson, Weissman,

Moreau & Garfinkel, 1999). IPT and CBT share

many common components; both forms of therapy

attempt to treat depressive symptoms in a problemfocused, time-limited manner with attention to

engagement in activities, problem solving, and

improvement of interpersonal relationships. Unlike

CBT, however, IPT focuses primarily on addressing

interpersonal conflicts, deficits, and themes rather

than on changing cognitive patterns and errors.

One recent study compared IPT, CBT, and wait-list
132

control conditions in a sample of Puerto Rican

adolescents. While both treatment groups showed

improvement in depressive symptoms and social

adaptation, the IPT group showed a greater

improvement in self-esteem and social adaptation

relative to the wait-list control group, suggesting

that IPT may be more useful for teens whose

depression either revolves around interpersonal

issues or has adversely affected their social

functioning (Rossello & Bernal, 1999). In clinical

practice, access to IPT appears to be limited, as few

clinicians are trained to use this modality.

Developmental factors in cognitive maturity and

style may play a role in determining optimal

clinical strategies for choosing a particular therapy

modality. During pre-puberty, cognitive strategies

include catastrophization, personalization,

egocentric thinking with perceived causal

responsibility for negative events, and absolutist

thinking which may decrease cognitive flexibility

(Weisz, Rudolph, Ranger & Sweeney, 1992).

However, more superficial and less global/stable

self-concepts may decrease vulnerability for

prolonged depression. Throughout adolescence,

cognitive processes undergo dramatic transformations that allow adolescents to handle and

process more complex information. With increased

ability for abstraction, recursive thinking, and an

ability for mutual perspective taking, adolescents

can understand the emotions of others, appreciate

mixed or contradictory emotions, separate behavior

and emotion, and understand the influence of

experiences outside of immediate relationships as

affecting emotions. In terms of cognitions and skill

deficits during depression, cognitive distortions,

negative self-concept, social skills deficits, passive

or avoidant coping strategies, and increased focus

on interpersonal schemas are more prevalent

(Gladstone & Kaslow, 1995; Hammen & Rudolph,

1996; Weisz, Rudolph, Ranger & Sweeney, 1992).

In the case described, Amy may have been more

susceptible than her older brother to certain

cognitive errors during her middle childhood (e.g.,

catastrophization, personalization), and to certain

aspects of depressive attributional style (e.g.,

attribution of negative events to internal, stable,

and global causes), thus making her more

vulnerable to developing depression. Although

chronological age is often used to decide treatment

modalities, the fact that a child uses cognitive

processing styles characteristic of a particular age

group may constitute more useful clinical data than

a child’s age alone.

Therapeutic interventions may be further informed

by knowledge about age-related changes in the

importance of particular domains of self-cognition.

For example, because acceptance and support from

peers becomes increasingly important in late

childhood and early adolescence, negative beliefs

about one’s social competence may be strongly

linked to depression at this stage, and interventions

targeting such cognitions may be particularly

beneficial. More broadly, Harter (1988) has

suggested that successful treatment depends not

only on knowledge of a child’s perceived

competencies across domains, but also on the

affective salience the child assigns to the various

domains. Treatment must be sensitive to age

differences in focus, meaning, and impact of selfdescriptive schemes across time in terms of

physical appearance, athletic ability, peer

acceptance, and academic ability. For example, in

adolescent depression, studies suggest depression

onset may be associated with social competence

deficits and with poor peer relationships. 

Evidence, however, is mixed with regard to three

issues: specificity (whether deficits are linked

specifically to depression or more generally to

psychopathology); state-dependence (whether

deficits are evident only during states of depression

or are characteristic of depression-prone kids even

when they are not depressed); and co-morbidity

(whether low levels of social competence in

depressed groups are accounted for by subgroups

who also meet criteria for other diagnoses,

especially conduct disorder and attention deficit
133

disorder). These three issues remain unresolved for

academic and behavioral competence as well, but

they still must be considered in comprehensive

treatment plans. In Amy’s case, a variety of factors

other than depression (e.g., parental criticism,

family conflict, anxious predisposition, poor social

skills, learning problems) likely contributed to the

maintenance of her sense of poor self-concept. 

 A few studies examining family involvement in

treatment also emphasize the importance of

adjusting interventions in developmentally

appropriate ways. In depressed elementary school

children, supplementation of individual CBT with

monthly family meetings was shown to enhance

outcome (Stark, Rouse & Livingston, 1991), but

this was not found to be the case for depressed

youth (Lewinsohn et al., 1990; Clarke, Rohde,

Lewinsohn, Hops & Seeley, 1999). Multi-Family

Psychoeducational Groups (MFPG) is a recently

developed family-based approach for treating

depressed adolescents, aimed at improving family

functioning by reducing the burden on family

caregivers in a manner more sensitive to normal

individuation-separation issues integral to

adolescence. Preliminary results suggest that MFPG

is associated with improved family climate,

increases parents’ understanding of the disorders,

and the ability to use appropriate resources

(Fristad, Gavazzi & Soldano, 1998). 

In one of the only studies that included a family

therapy condition for adolescents with depression,

individual CBT was found to be more effective than

individual nondirective supportive therapy (NST) or

systemic behavioral family therapy (SBFT) posttreatment (Brent et al., 1997). An exclusive focus

on recovery rates immediately after treatment,

however, may obscure the benefits of SBFT, which

is designed to bring about systemic rather than

simply individual change, and may have a slower

and subtler effect on depressive symptoms than

CBT. Thus, although treatment response was

significantly more rapid and remission rates were

significantly higher in the CBT group than in the

SBFT group (Brent et al., 1997), at 24 months posttreatment, recovery rates did not differ significantly

among CBT, SBFT and NST groups (Birmaher et al.,

2000). Participant characteristics were better

predictors of treatment outcome; individuals who

were less depressed at baseline and those who

reported lower levels of parent-child conflict,

hopelessness, and cognitive distortion were more

likely to recover over time following treatment. 

In summary, studies of CBT, IPT, and treatments

involving families in developmentally appropriate

ways indicate that these short-term therapies show

promise as efficacious treatments for depression.

Each, however, appears to confer a slightly

different set of benefits on recipients. Research that

matches treatment protocols with participant

characteristics may be an important next step in

evaluating treatment efficacy. IPT, for example,

may be the better treatment for teens whose

depression is associated with disrupted

relationships, as it has been shown to affect social

functioning as well as depressive symptomatology.

SBFT or MFPG, in contrast, may be preferable when

it is clear that family behavior patterns support the

development of depression or when multiple family

members are depressed. 

Research findings suggest that the impact of

comorbid diagnoses like anxiety merit additional

clinical attention. Brent and colleagues (1998)

found that comorbid anxiety was among the

primary predictors of poor outcome at the end of

treatment. Given that rates of comorbidity between

depression and other disorders are high (Brady &

Kendall, 1992), it is critical that researchers explore

strategies that effectively address problems

extending beyond depression. Kendall, Kortlander,

Chansky & Brandy (1992) outlined a framework for

designing treatment protocols targeting comorbid

depression and anxiety in children, which is largely

applicable to adolescents as well. In particular, they

recommended flexible use of manualized treatment

programs so that therapy can be geared to the

individual client and his or her unique
134

constellation of symptoms. Additionally, Kendall

and colleagues suggest adaptations of traditional

cognitive behavioral techniques (e.g., teaching

problem-solving skills) that address issues raised by

both anxiety and depression. 

It is also critical for clinicians to consider such

variables as gender and ethnicity in treatment

studies (Rosello & Bernal, 1999). Not surprisingly,

given the gender difference in depression

prevalence during adolescence, samples in most of

the treatment studies to date have been weighted

toward females. At least one gender-targeted

treatment study, evaluating a family treatment

protocol designed for depressed African-American

girls with a history of abuse, is currently under-way

(Kaslow et al., in press). In terms of culture,

clinicians must be aware that depression,

particularly suicidal depression, may manifest

differently in traditionally underserved populations

such as African American, Asian American, Latino,

and Native American adolescents than it does in

European American teens (e.g., Rotheram-Borus &

Trautman, 1988; Summerville, Abbate, Siegel,

Serravezza & Kaslow, 1992). Understanding gender

and cultural variations may be useful in helping

clinicians target treatments to address potential for

suicide or other functional impairments. 

Amy appeared to do well without mental health

intervention over the next year, but at age 13 she

began to experience depressive symptoms and

again showed a decline in her academic functioning

and social interactions. She was re-evaluated by her

initial treating psychologist, and the onset of her

current depression appeared to be related to a

break-up with her boyfriend of 3 months. On closer

examination of her peer relationships, Amy was

found to have a fear of intimacy and difficulty

keeping friends. She endorsed severe

neurovegetative symptoms and extreme

worthlessness, hopelessness, and suicidal ideation,

stating she wanted to kill herself “to escape” but

didn’t have a specific plan. She denied alcohol use

but had started smoking with peers, which resulted

in “increased energy” and feeling “jittery.” Weekly

group CBT sessions were initiated to work on

coping strategies with peers. However, given

worsening depressive symptoms over the next

month, the therapist initiated an evaluation by a

child psychiatrist to augment treatment with an

antidepressant. Fluoxetine (Prozac), a selective

serotonin uptake inhibitor (SSRI), was initiated,

after some reluctance on the part of Amy and her

mother. Eight weeks later, she reported feeling

significantly better and did not want to continue

further therapy because “it interfered too much with

her social life.” She did agree to come to the

psychiatric clinic every month for medication

checks, and admitted to her psychiatrist that she

felt somewhat embarrassed about receiving

psychiatric treatment and feared that her friends

would think she is “crazy.”

4. Pharmacological Treatment of Juvenile

Depression

Psychopharmacologic treatment studies using

tricyclic antidepressants in childhood depression

have generally been disappointing due to high

placebo response rates and/or the lack of

significant differences between active treatment

and placebo. Of the double-blind placebo controlled

studies in children (Connors & Petti, 1983; Geller,

Cooper, McCombs, Graham & Wells, 1989; Hughes,

Preskorn, Wrona, Hassanein & Tucker, 1990;

Kashani, Shekim & Reid, 1984; Petti & Law, 1982;

Preskorn, Weller, Hughes, Weller & Bolte, 1987;

Puig-Antich et al., 1987) using tricyclic

antidepressants, only one study, Preskorn et al.

(1987), found statistical significance evaluating

symptom reduction on an outcome variable. Factors

such as high placebo response rates and small

sample sizes may have contributed to the poor

response rates.

Recent focus has shifted to the use of selective

serotonin reuptake inhibitors (SSRI’s) in adolescent

depression, based mainly on reports of efficacy in

adults with major depression (Greenberg,
135

Bornstein, Zborowski, Fisher & Greenberg, 1994),

the benign side-effect profile, and low lethality in

overdose. While a double-blind, placebo-controlled

study of 40 adolescents with major depression did

not find any significant differences between placebo

and fluoxetine (Simeon, Dinicola, Ferguson &

Copping, 1990), more recent studies with much

larger samples and lower overall placebo responses

have suggested response rates comparable to those

reported in adults. Several open studies have

reported 70 to 90 percent response rates to

fluoxetine or sertraline for treatment of adolescents

with major depression (DeVane and Sallee, 1996).

An 8-week double blind study of treatment of

depression in a large sample of youth showed that

both children and adolescents responded

significantly better to fluoxetine than to placebo

(56% vs. 33%) (Emslie et al., 1997). In addition, a

multicenter, double-blind, placebo-controlled study

examined the efficacy of paroxetine and

imipramine in 275 adolescents with unipolar

depression (Keller, Ryan, Birmaher et al., 1998). 

Youth treated with paroxetine had a statistically

greater improvement over those treated with

placebo in global functioning and depression scores

at the end of study, and there was a remission of

depressive symptoms.

Better study paradigms, including augmentation

strategies, multiple medication strategies to

manage comorbid disorders, and the use of

algorithmic treatments, are needed to help guide

clinical practice. It is interesting that from 1996 to

1997, children between the ages of 6 and 18

received 792,000 prescriptions for SSRI’s to treat

depression (Hoar, 1998). This pattern is based on

relatively few studies, with relatively modest

effects, as noted above. For this reason, a multi-site

study was completed to develop an algorithm for

treating major depression, based on consensus

among academic clinicians, researchers, practicing

clinicians, administrators, consumers, and families.

The process initially addressed strategies of

treatment and tactics to implement the strategies,

including medication augmentation and medication

combinations (Hughes et al., 1999). 

In sum, most clinical trials of antidepressants

conducted to date have been based on open studies

and/or relatively small sample sizes, with

conclusions about their safety, efficacy, and

effectiveness based on group-means comparisons.

From a clinical utility perspective, separate and

distinct algorithms for management of the same

illness or disorder may be necessary for different

patient populations or different types of treatment

environments. In addition, unique developmental

characteristics, the presence of comorbid

symptoms, and the role for nonmedication

alternatives need to be considered. For example, a

study in adults found that treatment with

combined medication (nefazodone) and

psychotherapy (cognitive behavioral analysis

system) was more efficacious than treatment alone

for chronic major depression, suggesting that

combined treatments are superior (Keller et al.,

2000). 

The mechanisms by which antidepressants work to

address depressive symptoms are not well

understood. While both noradrenergic and

serotonergic neurotransmitter systems have been

implicated in the etiology of major depression, their

role must be understood in the developmental

context of how these systems mature during

childhood and adolescence. For example, lack of

response to tricyclic antidepressants in younger

cohorts could be secondary to later maturation of

noradrenergic brain substrates (Murrin, Gibbens &

Ferrer, 1985). Dopamine beta-hydroxylase, the

enzyme involved in the conversion of dopamine to

noradrenaline, increases in activity from birth to

about age 8 (Weinshilboum, 1983). Such

developmental differences are key in understanding

the molecular effects of antidepressants. Animal

studies have begun to characterize the subcellular

actions of antidepressant treatments such as

activation of the cyclic adenosine monophosphate

(cAMP), which in turn leads to regulation of specific

target genes (e.g., increased expression of brain-
136

derived neurotrophic factor in the hippocampus and

cerebral cortex) (Duman et al., 1997). Clinical

studies also provide evidence for atrophy and cell

death in the hippocampus as well as the prefrontal

cortex in response to stress and impaired function

of these neurons in depression (Bowen, Najlerahim,

Procter, Francis & Murphy, 1989; Sapolsky, Uno,

Rebert & Finch, 1990; Rajkowska et al., 1999).

Thus, it is possible that various antidepressant

treatments could limit these adverse cellular events

that might be best conceptualized as a loss of

neuronal plasticity in the developing nervous

system of children and adolescents. The clinical

utility of these research findings lies not only in

their potential for developing safer and more

effective treatments for children whose nervous

systems are still developing, but also, as in Amy’s

case, for educating her and her family about the

potential benefits of antidepressant treatment at

both the behavioral and the brain level.

Amy appeared to do better over the next year, but

then her progress appeared to come to a halt. 

During the summer of her sophomore high school

year when Amy was 16, her mother made a

decision to move from a house to a small apartment

in another neighborhood, due to significant

financial stress. Amy was extremely upset by the

move, became increasingly anxious about how her

friends might perceive her living situation, and

refused to socialize or engage in activities she used

to enjoy. She felt so dejected that she impulsively

attempted suicide by ingesting 30 Tylenol tablets.

She became scared of dying and told her mother,

who immediately took her to the emergency room.

Given the severity of her depression and the lethal

intent of her attempt, she was admitted to an

adolescent psychiatric inpatient unit for 4 days.

During this stay, she received intensive individual

therapy and family work and was switched from

fluoxetine to serzone (Nefazodone), a newer

generation of antidepressant with properties of both

an SSRI and a tricyclic antidepressant (TCA), to

target both depressive and anxiety symptoms. Amy

and her mother continued with outpatient

treatment over the next 6 months until her mother’s

work conflicts made it difficult for them to continue.

5. Suicide and Social Connectedness

Suicide is the third leading cause of death among

teenagers; nearly half of these suicides are

associated with depression. Several lines of

evidence indicate that suicidal behavior is linked to

a lack of social connectedness. Suicidal risk is

associated with interpersonal conflicts or losses

(e.g., romantic break-ups and parental divorce) in

adolescents (Brent et al., 1993; Gould, Fisher,

Parides, Flory & Shaffer, 1996). Another

phenomenon reported in the adolescent age group

is the clustering of teen suicides in close temporal

and geographic proximity to successful suicide

attempts, likely due to imitative behavior (Gould,

1990; Gould & Shaffer, 1986; Phillips &

Carstensen, 1986). In the case of Amy, these

findings argue for careful observation of social

behavior in teens predisposed to depression. Other

known risk factors for suicide that did not appear

to be present for Amy include substance abuse,

lifetime history of abuse, availability of a gun, and

past suicide attempts.

Primate studies suggest that the activity of the

serotonergic system helps regulate social

interactions and that social interactions can affect

serotonergic activity (Raleigh, McGuire, Brammer &

Yuwiler, 1984). For example, a dominant monkey

isolated from his social group can experience a

decrease in whole blood serotonin, while a

submissive monkey can be made dominant with

treatment using drugs such as fluoxetine and

tryptophan, which enhance serotonin function

(Rogeness & McClure, 1996). These findings offer

further indirect support for using serotonergic

antidepressants to treat adolescent depression and

improve social functioning in this developmentally

vulnerable period.

As adolescents transition to early adulthood, they
137

are faced with a number of major environmental

changes (e.g., leaving home, school changes,

employment) (Feehan, McGee, Williams & NadaRaja, 1995). Petersen and colleagues (1993)

reported that the accumulation of simultaneous

changes is associated with increased risk for

depression. The risk of depression and suicidality

was further increased when prepubertal children

with social skill deficits entered adolescence (Garber

& Hilsman, 1992; Marton & Kutcher, 1995;

Reinecke, 2000; Sadowski & Kelley, 1993). The

association between social problem-solving and

suicidality among adolescents appeared, however,

to be mediated by more directed effects of negative

mood and negative cognitions (Reinecke, 2000). It

is interesting to speculate whether more careful

attention to the social consequences of a major

move during high school for Amy, a teen with a

history of social difficulties, may have prevented

her suicide attempt. 

In terms of suicide prevention, pediatricians, in

collaboration with psychiatrists and other mental

health professionals, can make an important

contribution to the mental health of children and

adolescents through identification, referral, and

management of depressed and suicidal youth

(Brent et al., 1993). Clinical training must

emphasize diagnostic proficiency, assessment of

the entire family unit, and availability of firearms

in the home. With respect to changes in service

delivery, treatment is recommended for the entire

family unit, with a special focus on treatment of

psychiatric and substance abuse problems in the

same setting, and the need for a continuum of

intensity of care from inpatient to outpatient

(Rotheram-Borus et al., 1996). With respect to

policy changes, one suicide prevention study

recommended parity of mental and physical health

insurance coverage, screening for psychiatrically atrisk youngsters in schools and physician offices,

and gun control laws to restrict access to handguns

(Brent & Perper, 1995).

Over the next 3 years, Amy remained in remission.

Given her recurrent depression, history of comorbid

anxiety, and family history of depression, her

psychiatrist decided to continue her medication

even with her sustained remission. Although she

did well academically during her sophomore year at

a community college, she struggled to maintain

peer relationships for any sustained period.

6. Depression Course and Outcome

The continuity of depressive episodes from

childhood to adulthood has been studied

longitudinally in clinic (Harrington et al., 1990;

Kovacs, 1996; Weissman et al., 1999a; 1999b),

community (Lewinsohn et al., 2000; Pine et al.,

1998; Rueter et al., 1999), and high-risk

populations (Weissman et al., 1997). Data on

adolescent depression quite consistently point to

the continuity of depression into adulthood, with

varying degrees of association across studies. 

Stronger rates of recurrence are found in clinical

settings (70 to 80 percent, Kovacs, 1996) relative to

community-based settings (less than 50 percent,

Lewinsohn et al., 2000; Pine et al., 1998). By

contrast, data on pre-pubertal depression have not

been as consistent. Pre-pubertal depression shows

as strong or stronger associations with other

disorders as it does with major depression,

including bipolar disorder, conduct disorders and

substance use disorders (Harrington, 2001;

Weissman et al., 1999b).

The mean duration of an untreated depressive

episode is 7 to 9 months for clinically-referred

children, and 1 to 2 months for community

samples. While approximately 90 percent of major

depressive episodes remit within 2 years after

onset, up to 10 percent have a more protracted

course (Birmaher et al., 1996; Kovacs et al.,

1984a). Factors that appear to predict a protracted

course include depression severity, comorbid

psychiatric conditions, exposure to negative life

events, parental psychopathology and poor

psychosocial functioning (Birmaher et al., 1996,

Lewinsohn, Rohde, Seeley, Klein & Gotlib, 2000;
138

Sanford et al., 1995). Even those adolescents who

recover from an acute depressive episode continue

to manifest subclinical depressive symptoms,

negative attributions, pessimism, impaired

interpersonal relationships and increased physical

problems (Garber et al., 1988; Harrington et al.,

1990; Kovacs, Feinberg, Crouse-Novak, Paulauskas

& Finkelstein, 1984a). Depression in young

adolescent females has been strongly associated

with teenage pregnancy, higher rates of marriage

and subsequent marital dissatisfaction, increased

risk of tobacco use, and more medical problems. In

addition, longitudinal studies have shown that the

probability of recurrence is 6 percent by two years

after remission, and climbs to 70 percent after 5

years (Hammen, Burge, Burney & Adrian, 1990;

Kovacs et al., 1984b; Lewinsohn, et al., 1999,

2000; Rao et al., 1995). Predictors of recurrence of

depression include earlier age of onset, number of

previous episodes, severity of index episode,

psychosis, presence of psychosocial stressors and

presence of comorbid psychiatric disorders. In

addition to increased severity and duration of

depressive episodes, the presence of comorbid

disorders has been correlated with frequency of

suicidal behaviors, functional outcome, response to

treatment, and utilization of health services. In a

community sample of formerly depressed

adolescents, factors related to the recurrence of

major depressive disorder in young adulthood

included female gender, multiple depressive

episodes in adolescence and elevated borderline

personality symptoms (Lewinsohn et al., 2000). 

Conflict with parents in females independently

predicted recurrent major depressive disorder. 

Comorbid anxiety and substance abuse disorders in

adolescence and elevated antisocial personality

disorder symptoms independently distinguished

adolescents who developed recurrent major

depression comorbid with non-mood disorder from

those who developed pure major depressive

disorder.

Amy manifested many of the risk factors for a

protracted and recurrent course for her depression.

Over time, it is impossible to determine the extent

to which neurobiological vulnerability to stress,

poorly developed coping skills, psychosocial

deficits, and other contextual issues contributed to

her risk for recurrent depression. A better

understanding of the potency of such risks and

how they interact with one another to rekindle a

depressive episode have important implications for

clinicians in developing targeted interventions that

help individuals with chronic or intermittent

depression manage their disorder with minimal

interference of functioning. The limited current

research evidence suggests that continued

monitoring of individuals like Amy for depression

and associated problems as they transition into

adulthood and onward is warranted, including

identifying ways to prevent further

intergenerational transmission of depression.

7. Dissemination of Services and Access to

Care and Prevention

Research in the area of serious emotional problems

in children and adolescents supports the view that

effective mental health services should be familybased, individualized, and multifaceted. In the case

of juvenile depression, studies show consistent,

serious problems associated with characteristics of

the youth, their family, peer relations, and broader

ecological contexts (Birmaher et al., 1996). Yet

research focused on intervention development to

date often fails to take into account larger

contextual issues that influence treatment

outcomes. In particular, service context and factors

that influence family engagement in treatment

have received limited attention. The effectiveness of

services, no matter what they are, may hinge less

on the particular type of service, and more on

“how, when, and why families or caregivers are

engaged in the delivery of care” (Burns, Hoagwood

& Mrazek, 1999). Evidence-based services are not

routinely available. There are long waiting lists

even for existing services, and restrictions in

mental health coverage are common. Recent

evidence presented at the Surgeon General's
139

Conference on Children’s Mental Health (U.S. Public

Health Service, 2000) indicated substantial

disparities in access to specialty mental health care

(Wells, unpublished data). Racial, ethnic, and

cultural differences influence the expression and

identification of the need for services, quality of

care, referral bias or access to appropriate care, the

diagnostic process, and hence, subsequent care and

health outcomes. Insurance status also predicted

outcome, with the uninsured having the least

access. As seen in the case of Amy, parental

availability for treatment due to work

commitments, insurance limitations, financial

constraints, stigma, and the availability of

evidence-based care are common barriers in

accessing adequate treatments for their children. 

Mental health programs for children and

adolescents need to draw from the adult literature

on how to disseminate effective treatment and

collaborative care models. In adult patients, quality

improvement programs in managed care practices

for depressed primary care patients have been

found to improve quality of care, health outcomes,

and employment (Wells, 2000). While such

improvement was small, it could reflect substantial

societal impact when accumulated nationally. The

dissemination trial is similar to a social experiment

in that it replicates naturalistic practice conditions

including usual care providers and full choice of

treatments.

Evidence for the poorer prognosis of early-onset

depression suggests that more focus on preventive

programs targeting infants, children and

adolescents at risk for future depressive episodes

are needed. Studies designed to intervene with

depressed mothers at various points in their

children’s development are needed. Several NIMHfunded studies are currently underway: one

focusing on the perinatal period (Zayas,

MH57936); one on postpartum depression (O’Hara,

MH50524); one on infants of depressed mothers

(Field, MH46586); one on toddlers of depressed

mothers with demonstrated beneficial effects on

cognitive development (Cicchetti, MH45027;

Cicchetti et al., 2000); and three targeting older

children and adolescents (Diamond, MH57977;

Garber, MH57822; Riley, RO1MH58384). One

preventive intervention has demonstrated some

success in preventing depression among at-risk

adolescents (with subclinical symptoms) using

school-based cognitive behavioral programs (Clarke

et al., 1995). Interventions selectively targeting

adolescents with a family history of affective

disorder have also demonstrated some beneficial

effects (Beardslee et al., 1997). Ways to assess the

viability of such programs in service settings and

their cost-effectiveness once adapted for

widespread dissemination and implementation are

critical in light of the chronic and costly nature of

juvenile-onset depression. It is interesting to

speculate how the availability of such programs

may have altered the trajectory of Amy’s illness

course.

8. Summary 

Amy’s case emphasizes the critical interplay among

genetic or biological predisposition and child

characteristics, family factors, and the broader

social context in the development of mental

disorders. It further illustrates the importance of

understanding developmental processes in child

mental health treatment, prevention, and services.

Clearly, a scientific knowledge base is available to

guide clinical decision-making. It is equally clear

that this knowledge base is uneven. 

Amy’s case demonstrates how a more integrated

approach, which combines basic neuroscience

(pharmacological, genetic) and behavioral and

prevention research knowledge with developmental

processes and contextual issues, is critical in

understanding, preventing, and treating childhood

depression. A major barrier to developing more

effective early interventions (and, ultimately,

preventive efforts) for depression is the lack of

understanding of the etiology, pathophysiology,

and mechanisms underlying affect dysregulation
140

and negative cognitions. Cognitive and biological

theories of depression remain relatively isolated

(Weissenberger & Rush, 1983). In cognitive models,

adolescent depression is characterized by negative

cognitions (Laurent & Stark, 1993). Diathesisstress models of depression propose that depressive

etiology is found in the activation of latent

depressive schema by stressors, such as physical

illness (Burke & Elliott, 1999; Garber & Hilsman,

1992). The second type of model links clinical

depression to altered neurobiology (e.g., HPA axis

dysfunction, sleep changes, neurochemical

changes) (Armitage, Emslie, Hoffmann, Weinberg,

Kowatch, Rintelmann, & Rush, 2000; Dahl, 1992;

Rao et al., 1996; Williamson et al., 1995) and

implicates certain brain regions (e.g., the prefrontal

cortex) (Drevets, 2000). The interaction between the

neurobiology and negative cognitions is complex

and not understood. Clearly, a better

understanding of the pathophysiology, etiology,

and mechanisms of risks leading to depression may

help clinicians identify critical windows of

opportunity for targeting and adjusting the

intensity, type, and duration of treatment to

increase the likelihood of Amy’s optimal

functioning. Further, the recognition that so many

children with mood disorders, like Amy, have

additional diagnoses including anxiety disorder,

learning disability, and substance abuse disorders,

suggests that the current classification system may

have set boundaries between disorders in a way

that does not reflect what goes wrong in the brain.

The episodic and chronic nature of childhood onset

depression indicates that we need to better

understand the relative potency of risks and

protective factors and the timing of their effects. At

the same time, identifying the mechanisms by

which various factors at the individual, familial,

sociocultural, and organizational levels interact to

influence the etiology and course of illness over

time is a critical next step in child and adolescent

mental health. In Amy’s case, knowledge about

risks and protective factors was useful in

identifying her as a child at high risk. Such

knowledge must be augmented by research that

determines the mode of genetic-psychosocial

transmission of depression across the life span so

that clinical practice can be guided to effectively

prevent her illness, or the onset of comorbid

conditions and more severe impairments.

Longitudinal assessments of risks factors spanning

infancy, childhood and adolescence that examine

genetic, cognitive, interpersonal and other

contextual processes associated with depression

risk and course can help identify targeted

opportunities for intervention throughout the

developmental trajectory. 

To date, we are still excessively reliant on CBTs,

which have been shown to be efficacious mainly in

adults. The effectiveness of such therapies in older

children is equivocal and clearly inappropriate for

young children. Although cognitive behavioral

treatments make the assumption that altering

cognitions leads to reduced depression, most fail to

provide evidence on (a) whether cognitions were in

fact altered, (b) whether changes in depressive

symptomatology were mediated by changes in

cognition, or (c) any other processes that may have

operated as mediators of change. This suggests that

considerable work will be needed to bring research

designs into synchrony with our need to

understand causal mechanisms by which

psychotherapy for depression produces effects.

Although several researchers have included familybased interventions for treating childhood

depression, the effectiveness of such therapies has

yet to be rigorously examined. It is also critical that

we begin to apply what we know about the

developmental processes involved in functional

brain maturation and the regulation of cognitions,

emotions, and mood to design developmentally

sensitive psychotherapies for children and

adolescents. Researchers must find ways of directly

assessing the developmental dimensions of interest

rather than relying on assumptions about where

children fall on those dimensions, based on

children’s chronological age alone.
141

Given that childhood-onset depression is often

chronic, intermittent, and comorbid with other

disorders, intervention studies must go beyond the

typical short-term trials and address problems

beyond depressive symptoms. The frequent and

increasing use of psychotropics to treat childhood

depression in clinical practice, despite limited

evidence of its safety or efficacy, points to the need

to better understand the long-term impact

(beneficial or detrimental) of acute and chronic

exposure to pharmacological agents on brain

development. The reluctance of parents like Amy’s

to consent to medication treatment is

understandable, given the limited science base. To

this end, animal models are critical in advancing

our knowledge about the development of the

circuits that underlie emotion, brain-behavior

relationships, and the mechanisms of drug action. 

It is critical to note that the current research base is

largely developed using group-means comparisons

derived from studies on subpopulations, and in

settings that may not be readily generalized to

many real-world settings. Conceptual frameworks

and research paradigms that recognize individual

differences (e.g., vulnerabilities and protective

factors) and contextual variables (e.g., family

context, cultural factors, service settings) are

needed to increase the usability of the science base

by clinicians in practice. In Amy’s case, when the

use of evidence-based CBT treatments or

medications result in limited benefits,

understanding the individual factors that may

moderate or mediate their effectiveness will be

important in guiding clinical decisions to adjust or

augment treatment accordingly.

This case also illustrates commonly encountered

difficulties in access to mental health treatment.

Multiple opportunities for prevention and

intervention were missed from the time even before

Amy was born. The lack of availability or the

difficulty that pregnant women and their children

have in accessing mental health treatments needs

to be better understood in the larger organizational

and sociopolitical context. There is a clear need to

increase the science base on how to develop

treatments that are transportable into real-world

settings so that they can be disseminated and

implemented with fidelity in a variety of settings.

As a step forward in bridging the gaps among

research, practice, and policy, researchers must

work not only across disciplines to advance the

science base, but they must also ensure that their

research findings are ultimately usable in realworld settings. To do so, the clinical utility of

research must be considered at the very start of any

research endeavor, be it basic, intervention, or

services research. Further, public and private efforts

are needed to ensure that current resources are

utilized in ways that increase the likelihood that

science-based interventions and services are

positioned permanently within communities to

provide adequate care over time to children and

their families. 

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155

Appendix C

RESPONDENTS, TRAINING

RECOMMENDATIONS FROM MAJOR

PROFESSIONAL ASSOCIATIONS 

Cynthia Belar, Ph.D.

American Psychological Association

Pamela High, M.D.

Chair, Education Committee

Society for Developmental and Behavioral

Pediatrics

Peter Jensen, M.D.

American Academy of Child and Adolescent

Psychiatry

Center for the Advancement of Child and

Adolescent Mental Health

Columbia University

Ellen C. Perrin, M.D.

Chair, American Board of Pediatrics

Society for Developmental and Behavioral

Pediatrics

Enola K. Proctor, Ph.D.

National Association of Social Workers

Director, Center for Mental Health Services Research

Washington University
156

Appendix D

NATIONAL ADVISORY MENTAL HEALTH

COUNCIL 

CHAIRPERSON 

Steven E. Hyman, M.D. 

Director 

National Institute of Mental Health 

Bethesda, Maryland

EXECUTIVE SECRETARY

Jane A. Steinberg, Ph.D.

Director, Division of Extramural Activities

National Institute of Mental Health

Bethesda, Maryland

MEMBERS

Robert Boorstin

Vice President 

Greenberg Quinlan Research, Inc. 

Washington, DC

Mary L. Durham, Ph.D. 

Kaiser Foundation Hospitals 

Mary Jane England, M.D. 

President 

Washington Business Group on Health 

Washington, DC

Javier I. Escobar, M.D. 

Professor and Chairman, 

University of Medicine and Dentistry of New

Jersey, Robert Wood Johnson Medical School

675 Hoes Lane 

Piscataway, New Jersey

Susan Folkman, Ph.D. 

Professor and Co-Director 

Department of Medicine 

Center for AIDS Prevention Studies (CAPS) 

UCSF Prevention Sciences Group 

San Francisco, California

Ellen Frank, Ph.D. 

Professor of Psychiatry and Psychology 

Department of Psychiatry 

School of Medicine 

University of Pittsburgh

Pittsburgh, Pennsylvania

Henry Lester, Ph.D. 

California Institute of Technology 

Division of Biology 16-29 

Pasadena, California

Jeffrey A. Lieberman, M.D. 

Professor and Vice Chairman 

Department of Psychiatry 

School of Medicine 

University of North Carolina, Chapel Hill 

Chapel Hill, North Carolina

James L. McClelland, Ph.D. 

Co-Director 

Center for the Neural Basis of Cognition 

Carnegie Mellon University 

Pittsburgh, Pennsylvania 
157

James P. McNulty 

President 

Manic Depressive and Depressive Association of

Rhode Island 

Providence, Rhode Island

Charles B. Nemeroff, M.D., Ph.D. 

Reunette W. Harris Professor and Chair 

Department of Psychiatry and Behavioral Sciences 

Emory University School of Medicine 

Atlanta, Georgia

Anne C. Petersen, Ph.D. 

Senior Vice President for Programs 

W. K. Kellogg Foundation 

Battle Creek, Michigan

Elaine Sanders-Bush, Ph.D. 

Professor, Department of Pharmacology 

Vanderbilt University School of Medicine 

Nashville, Tennessee 

Edward Scolnick, M.D. 

President 

Merck Research Laboratories 

West Point, Pennsylvania

Larry R. Squire, Ph.D. 

Professor and Research Career Specialist 

Department of Psychiatry 

University of California School of Medicine 

Veterans Affairs Medical Center 

San Diego, California

James G. Townsel, Ph.D. 

Professor and Director 

Center for Molecular and Behavioral 

Neuroscience 

School of Medicine 

Meharry Medical College 

Nashville, Tennessee

Ming T. Tsuang, M.D., Ph.D. 

Professor and Director 

Department of Psychiatry 

Harvard Medical School 

Massachusetts Mental Health Center 

Boston, Massachusetts

Roy C. Wilson, M.D. 

Director 

Missouri Department of Mental Health 

Jefferson City, Missouri 

EX OFFICIO MEMBERS 

U.S. Department of Health and Human Services

(DHHS)

Tommy G. Thompson, J.D. 

Secretary, Department of Health and Human

Services 

Washington, DC

National Institutes of Health

Ruth Kirschstein, M.D. 

Acting Director 

National Institutes of Health 

Bethesda, Maryland

Department of Defense

Elspeth Cameron Ritchie, M.D. 

LTC, MC, USA 

Program Director, Mental Health Policy and

Women’s Issues, OSD/HA 

Falls Church, Virginia

Department of Veterans Affairs

Robert Freedman, M.D. 

Medical Director 

Center for Basic and Clinical Studies in

Schizophrenia 

Colorado Veterans Administration Hospital 

Professor of Psychiatry/Pharmacology 

University of California Health Sciences Center 

Denver, Colorado
158

LIAISON REPRESENTATIVE

Center for Mental Health Services

Michael J. English, J.D., Director 

Division of Knowledge Development and Systems

Change 

Center for Mental Health Services 

Substance Abuse and Mental Health Services

Administration 

Rockville, Maryland
159

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