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Editorial                                                                                                                                              Open Access

## Evidence-Based Treatment in the Field of Child and Adolescent Psychiatry

Ole Jakob Storebø

The requirement to base one's practice on evidence is growing  rapidly  worldwide.  This  requirement makes sense if you look quite soberly at the issue. Who  would  not  want  his  or  her  treatment  to  be based on the best possible evidence regarding safety and efficacy? Unfortunately, there is a relative lack of good safety and efficacy data in the field of child and adolescent psychiatry.

evidence from high-quality trials has improved cancer  survival  rates:  the  annual  reduction  from 1978  to  2005  in  the  risk  of  death  from  childhood cancer ranged from 2.7% to 12% (2).

There is longstanding agreement that a randomized controlled trial (RCT) is the best research  design  when  it  comes  to  examining  the efficacy of a specific treatment. Systematic reviews, which consider data from multiple RCTs, are at the top of the evidence hierarchy. However, we lack a focus on assessing the quality of RCTs and systematic reviews, because there are many parameters that can downgrade the quality of these methods. In some cases, this means that the evidence is very uncertain, even when it is based on RCTs and systematic reviews.

Evidence-based  practice  is  a  thorough,  explicit, rational,  and  thoughtful  use  of  the  best  evidence available when  making  decisions  related  to  the assessment  and  treatment  of  an  individual  patient. In this context, it is essential to integrate individual clinical  expertise  and  the  patient's  preferences-as well as the patient's parent's or guardian's preferences, if appropriate-with the best available external evidence (1).

In many medical specialties, medical practitioners have used the approach of evidence-based treatment for a long time. However, in the field of child and adolescent psychiatry, there is still a long way to go.

The childhood cancer specialties have been based on  evidence  for  many  years.  For  example,  for  the treatment of children with leukemia, there are now clear, step-by-step protocols that are followed. Evidence  from  RCTs  has  helped  oncologists  to learn  more  about  which  treatments  are  best,  and When  one  looks  at  the  Cochrane  Systematic Reviews published in the field of child and adolescent psychiatry, there is a lack of reviews and RCTs  of  good  quality  and  therefore  a  lack  of evidence. There is one new review from 2015 that investigated cognitive behavioral therapy for anxiety disorders in children and adolescents (3). This review included 41 studies and suggested that cognitive behavioral therapy is an effective treatment for child and adolescent anxiety disorders as  compared  with  wait-list  controls;  however,  the evidence  that  suggests  that cognitive behavioral therapy is more effective than active control interventions,  treatment  as  usual,  or  medication  is limited and inconclusive. Another review published in 2009  investigated the  efficacy  of  pharmacotherapy for anxiety disorders in children and adolescents and suggested that medications improve core symptoms (4). However, all of the trials had a high  risk  of  systematic  errors,  which  contributes uncertainty  to  the  meta-analytic  estimates.  When one looks at the Cochrane Systematic Reviews that have investigated the efficacy of treatment for attention-deficit/ hyperactivity disorder, the picture is  the  same:  there  is  a  lack  of  high-quality  RCTs, which  makes  the  evaluation  of  treatment  efficacy uncertain (5-7). Another review that investigated the efficacy of antidepressant and psychological treatments alone and in combination for depression in children and adolescents concluded that there is very limited evidence upon which to base conclusions about the relative efficacy of psychological  interventions,  antidepressant  medications,  or  a  combination  of  these  (8).  A  Cochrane Systematic Review that investigated the benefits of antipsychotic medication for childhood-onset schizophrenia concluded that there was little conclusive evidence regarding the effects of antipsychotic medication for those individuals with early-onset schizophrenia (9).

This leaves the clinicians who work in the field of child and adolescent psychiatry with a poor foundation for evidence-based therapy, and they are often forced to rely solely upon  their clinical experience. Why are there fewer high-quality treatment studies in this field than in the in the field of  childhood  cancer?  One  reason  may  be  that, unlike  most  other  medical  disorders,  psychiatric disorders may not be considered 'real diseases' in the  minds  of  many  people;  this  may  contribute  to the  poor  availability  of  research  funding  for  child and adolescent mental health problems. The Danish Council for Independent  Research  has recently given  153.8  million  DKK  to  fund  projects  in  the field  of  health  and  illness,  but  none  of  this  money was  given  to  projects  in  the  area  of  Child  and Adolescent  Psychiatry.  This  is  a  serious  problem, because  the  mortality  rate  among  individuals  with certain  mental  illnesses  (e.g.,  depression)  is  higher than that of the general population, and the burden of such diseases in the long run is higher than the disease burden of many cancers (10). Still, there is a lack of evidence for effective treatments, and there are also problems with getting children with depression into clinics that can provide appropriate assessment  and  diagnosis.  There  is  wide  regional variation  with  regard  to  the  availability  of  mental health assessment, and treatment is often based on the local standard of practice without the consideration  of  external  evidence  (2).  In  addition, the adverse effects of treatment are sometimes not adequately assessed in the existing treatment studies, which is another huge problem (11).

The extent of actual external evidence in the field of child and adolescent psychiatry can practically be read as 'No evidence for anything.' It is important to  remember  that  the  absence  of  evidence  is  not evidence  of  the  absence  of  effect.  The  lack  of external evidence underlines first the need for more high-quality research in the area. Increased research funding for the field of child and adolescent psychiatry  is  of  crucial  importance,  and  this  is  the take-home  message  for  health  care  policy  makers. This does not mean that the interventions that are currently used in this field are worthless or that they should  not  be  used  by  clinicians.  Rather,  it  means that there is a lack of external evidence to support the available treatments. It is always the patient who is  the  main  focus  of  evidence-based  treatment,  as stated by the late David Sackett, who was one of the founders of evidence-based practice (1). He emphasized that the experiences of clinicians should be looked at as internal evidence and that this type of  evidence  is  equally  as  important  as  external evidence. He stated that 'the practice of evidencebased medicine means integrating individual clinical expertise  with  the  best  available  external  clinical evidence  from  systematic  research.'  When  Sackett used  the  term individual clinical expertise, he  was referring to the proficiency and judgment  that individuals  acquire  through  clinical  experience  and clinical  practice  (12).  This  means  that  clinicians must continue to use their 'best practice' approaches, because there is also no evidence that these approaches do not represent good treatment. It  is  important to understand this assertion. At the same  time,  it  must  also  be  understood  that  there really  is  a  pressing  need  for  additional  high-quality intervention studies in the field of child and adolescent psychiatry.

## References

1. Sackett  DL,  Rosenberg  WM,  Gray  JA,  Haynes  RB,  Richardson WS.  Evidence  based  medicine:  what  is  it  and  what  it  isn't.  BMJ 1996;212(7023):71-2.
2. Stringaris  A.  Editorial:  Trials  and  tribulations  in  child  psychology and psychiatry: what is needed for evidence-based practice. J Child Psychol Psychiatry 2014; 55(11):1185-6.
3. James  AC,  James  G,  Cowdrey  FA,  Soler  A,  Choke  A.  Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev 2015;2:CD004690.
4. Ipser JC, Stein DJ, Hawkridge S, Hoppe L. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev 2009;3:CD005170.
5. Storebø  OJ,  Skoog  M,  Damm  D,  Thomsen  PH,  Simonsen  E, Gluud C. Social skills training for Attention Deficit Hyperactivity Disorder  (ADHD)  in  children  aged  5  to  18  years.  Cochrane Database Syst Rev 2011;12:CD008223.
6. Zwi M, Jones H, Thorgaard C, York A, Dennis JA. Parent training interventions for Attention Deficit Hyperactivity Disorder (ADHD) in children aged 5 to 18 years. Cochrane Database Syst Rev 2011;12:CD003018.
7. Bjornstad GJ, Montgomery P. Family therapy for attention-deficit disorder or attention-deficit/hyperactivity disorder in children and adolescents. Cochrane Database Syst Rev 2005;2:CD005042.
8. Cox  GR,  Callahan  P,  Churchill  R,  et  al.  Psychological  therapies versus  antidepressant  medication,  alone  and  in  combination  for depression  in  children  and  adolescents.  Cochrane  Database  Syst Rev 2014;11:CD008324.
9. Kennedy  E,  Kumar  A,  Datta  SS.  Antipsychotic  medication  for childhood-onset schizophrenia. Cochrane Database Syst Rev 2007;3:CD004027.
10. Collins  PY,  Patel  V,  Joestl  SS,  et  al.  Grand  challenges  in  global mental health. Nature 2011;475(7354):27-30.
11. Storebø  O,  Ramstad  E,  Krogh  H,  et  al.  Methylphenidate  for attention  deficit  hyperactivity  disorder  (ADHD)  in  children  and adolescents. Cochrane Database Syst Rev 2015;(in press).
12. Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidencebased medicine:  How  to  practice  and  teach  EBM.  London: Churchill Livingstone; 1997.