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What Works for Whom?Review - What Works for Whom?
A Critical Review of Treatments for Children and Adolescents
by Peter Fonagy, Mary Target, David Cottrell, Jeannette Phillips, Zarrina Kurtz
Guilford, 2002
Review by Roy Sugarman, Ph.D.
Jun 17th 2008 (Volume 12, Issue 25)

This book could be anything, so here is a quick overview of the chapters.  Outcome  measurement is introduced, then an interesting foray into epidemiology, then the meaty bits begin, with anxiety disorders, depressive disorders, disturbance of conduct, ADHD, Tourette's, psychotic disorders, pervasive developmental disorders, self-harming disorders, physical symptoms, specific developmental disorders, and then a long analysis of issues pertinent to the treatment of children and adolescents.

A handy little glossary is there to inform on psychopharmacological treatments, and a separate index of search terms.

The books substantial obstacles are not trivial.  The authors note that seldom do groups of individuals involved with an identified youthful patient agree on the exact nature of the problem formulation, a kind of Rashomon effect.  Of course, seldom is the child's own view of their illness taken into consideration. Even if children do have a view, this is seldom a serious consideration.  Given the causal chain in a developmental view of mental health is complex, basing assessment measures of outcome on signs and symptoms is not a valuable approach.  After all, as Russell Barkley is keen to repeatedly note, many of these conditions do not disappear, they simply change the nature of their presentation as the youth ages.  Evidence is thus not absolute, and so this volume and others have their science mitigated by the cultural contexts that give these conditions their meaning. This book and its comments thus have to be reviewed in that relativist framework.

Related to this is the silo effect, where experts argue in turn that their particular measure of outcome is the best one to use.  Embarking recently on one of the largest depression studies in history, my group asked the world's premier experts to define the best toolsets in the industry and in depression, and then looked for overlap: there was virtually none, and we have had to embark on a study to mine the value of each and make that determination ourselves.  Defining the multiple levels of assessment possible, and what constitutes significant change, are thus not trivial issues.  These fluctuations are of course often limited value measures owing to measurement error, and that damn confounder of all mainstream and alternative medicine, the Placebo Effect.  Return to normative ranges on the DSM IV and other measures does not equate with remission or psychosocial recovery.  As with any tests, the ecological value of each test does not specify exactly how parents and children experience their lives. Statistical significance is of course in itself not enough, as noted in the book, God loves .06 as much as .05, the 95th percentile as much as the 98th.  There are multiple arguments and levels of argument here, and the authors devote much time to each of them.  This chapter would serve as a good primer for students of the subject.

The Epidemiology chapter sets out the scale of the problem, which varies from each geographical area and culture to another.  I do not share the authors' belief that the DSM and ICD have added clarity and validity to classification of children and adolescent's disorders, and cannot understand how the authors could have missed this, even in 2002.  If the categorical nosology of these volumes was anywhere near adequate, we would have had a plethora of drugs and treatments that work.  Unfortunately, since this book was scoped and written, Black Box warnings and other controversies have rocked the world, and changed the prescribing patterns of the western world.  Not that this has prevented children from toxic pharmacology, and the panel on the recent NIMH consensus meeting on ADHD failed to produce a reasonable response to a simple question on the definition of this condition when asked directly. I am informed by experts in managed health care in the USA, that toxic polypharmacology is not unheard of, with young children on multiple medications with scant consideration for receptor occupancy in the brain.  Worse, the majority of three year olds showing problems still showed problems years and years later.  This being so, then each generation of children has a greater proportion diagnosed as ill than the last.

Each chapter now follows the same format, with a definition, prevalence figures, clinical presentation, comorbidity, natural history, and then treatment.  Studies with SSRI's are difficult as some are not controlled, and one that was, had its numbers of active treatment patients dwindle from 15 down to 6, hardly reasonable numbers, and in itself it tells you what the effectiveness turned out to be.  The chapter also looks at other treatments, hence the title of the book, reviewing various talk therapies.  The chapter concludes that only half the OCD patients get better on medication, and special training is need in CBT and BT to augment the treatment.

Depression gets the same 'treatment' by the authors.  As with everyone else, response to medication was only partial, in about 40% of patients, with two thirds who did improve, not moving to recovery, with a high rate of placebo effect, and the need for psychosocial intervention.  The authors conclude dismally that 40-50% of children, no matter what the treatment, do not improve, a dismal finding after millions spent on trials of medication.  The question about why is not answered.

For anyone who believes that much of this field is about social control, the next chapter should encourage that view somewhat.  The chapter is 87 pages and covers so-called Disturbances of Conduct.  And understandably, given the heterogeneity of the groups here covered by conduct disorder and oppositional defiant disorder, there is here the use of significant polypharmacy, and of course much active placebo effect.  The drugs that are put forward as putative treatments, all are plagued with side effects and failures of efficacy, with long term stimulants put forward as the most useful with limited side effects.

ADHD predictably is next, covering only thirty pages in contrast.  Behavioral therapy and medication in combination appears to have the best evidence, but who gets put where, has no markers.  My own team is beginning to demonstrate markers for medication, so there is some movement in the science since the authors wrote their chapter, more than six years ago, but not much would change their view today. As they note, this is another heterogenous condition with dubious treatment guidelines and long term outcomes.

Tourette's gives us a short chapter indeed, just a few pages, and the treatment regime offered is just depressing.

If that were depressing, the short chapter on the psychotic disorders should actually result in severe depression in the reader, especially so in the face of the millions spent on drugging children from many categories in the DSM, and the virtual total absence of evidence for how, why, how much, for how long. Dismal. Even the following chapter on pervasive developmental disorders is more upbeat about Autism, but less so in Asperger's, Retts, or disintegrative disorder.

Self harming disorders includes eating disorders , substance abuse, and suicide. The evidence for what works is a little less pessimistic here, but again, the outcomes do not look encouraging.

The book continues by discussing various aspects of physical illness and the interventions that might help, and the specific development disorders, with the caveat for the latter that interventions in 2-3 year olds should be delayed.

The conclusions are meager as one would imagine, with the authors identifying the gaps in the evidence for both pharmacological and behavioral interventions in kids and adolescents.  One has to smile though, as reading through this book is the antidote to the gross arrogance of the medical profession in putting forward the idea that people should rush for treatment, as these exist.  As with adults, the current state of the world in psychiatric terms is quite horrid. Storming the gates of medicine, seeking answers in behavioral conditions, is likely to prove fruitless.  Luminaries such as the past head of the NIMH are asking if neuroscience can now inform on the next versions of the definitive works which the authors began by applauding.

Nowhere in their work do they perhaps reason that the failure of the literature to identify robust and convincing treatments in the illnesses as classified, has something to do with the classification system. If the DSM is not entirely lauded in adults, why should it be regarded as any better in a rapidly developing and heterogeneous group as children and adolescents, where rapid brain changing is the norm?  Since the drug companies have been scrupulous in their inclusions and exclusions of subjects according to the classification systems such as these, there is surely no surprise in the news that they have failed to reliably beat placebo by any really valuable way, in all cases. The possible exception is in severe depression where the placebo effect is easier to beat.

The book carefully serves its purpose in this way, as a humbling lesson to those who declare pompously that mental illness is a medical condition subject to the laws of medicine. It isn't, and most HMO's in the USA and elsewhere are close to conceding defeat, and moving on to different pathways, such as supporting Wellness programs and dealing with presenteeism. 

Alternative medicine practitioners are the fastest growing industry in health care, in many cases accepting the label of charlatans, ignoring the value of creating an evidence base, as the queues from their doors don't shorten, and the demand in the face of no evidence, remains high.  Alternatively though, some treatments do fail miserably, as the very recent collapse of the Australian and UK Dore group has demonstrated, with their failure to secure their position in the ADHD treatment market. Others, like EEG Spectrum in the USA, claim good outcomes in ADHD in about 50% of cases for some practitioners, where the need for medication is eliminated, and in other cases, reduced.  Many other brain-based treatments are emerging, none of them medical in nature.

The book needs updating, but sadly, I don't think much has changed, except perhaps the scope of the problem.  What works and for whom? Not much, and not many.

© 2008 Roy Sugarman

Roy Sugarman, PhD, Brain Resource Limited

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