There is no convincing evidence that interventions for the most common childhood mental disorders are beneficial in the long term

 Editorial Perspective: Are treatments for childhood mental disorders helpful in the long run? An overview of systematic reviews. Annelieke M. Roest, Ymkje Anna de Vries, Albert W. Wienen, Peter de Jonge. Journal of Child Psychology and Psychiatry, August 29 2022. https://doi.org/10.1111/jcpp.13677

Abstract: Mental disorders may have severe consequences for individuals across their entire lifespan, especially when they start in childhood. Effective treatments (both psychosocial and pharmacological) exist for the short-term treatment of common mental disorders in young people. These could, at least theoretically, prevent future problems, including recurrence of the disorder, development of comorbidity, or problems in functioning. However, little is known about the actual effects of these treatments in the long run. In the current editorial perspective, we consider the available evidence for the long-term (i.e., ≥2 years) effectiveness and safety of treatments for attention deficit hyperactivity disorder, behavior disorders, and anxiety and depressive disorders for children between 6 and 12 years old. After providing an overview of the literature, we reflect on two key issues, namely, methodological difficulties in establishing long-term treatment effects, and the risk–benefit ratio of treatments for common childhood mental disorders. In addition, we discuss future research possibilities, clinical implications, and other approaches, specifically whole-of-society-actions that could potentially reduce the burden of common childhood mental disorders.
 

---
Long-term treatment of behavior disorders

Psychosocial treatments of behavior disorders include child-level interventions such as social skills training, parent-level interventions such as parent management training, and multicomponent interventions, which target both the child and its parents and/or teachers. Concerning pharmacological treatments, while second-generation antipsychotics are prescribed most often, a wide range of drug classes have been studied, including antipsychotics, anticonvulsants, stimulants, and nonstimulants (Epstein et al., 2015). No drugs have received FDA or EMA approval for the treatment of behavior disorders, with the exception of risperidone for persistent aggression in conduct disorder in Europe.

Epstein et al. (2015) conducted a systematic review and meta-analysis on the effects of pharmacological and psychosocial interventions for disruptive behavior (e.g., as part of CD or ODD) in children and adolescents. This systematic review included studies with different designs, such as RCTs, extension trials, and cohort studies. A systematic review by Pillay et al. (2018) focused on the harms of first- and second-generation antipsychotics in the treatment of psychiatric and behavioral conditions in children, adolescents, and young adults and also included a variety of study designs, for example, RCTs, extension trials, cohort studies, and individual patient data meta-analyses.

Epstein et al. (2015) included a few small studies of antipsychotics and stimulants, which reported positive effects on disruptive behaviors in the short term. However, no studies with a follow-up long enough were available to conclude anything about the long-term effectiveness of treatment. Among psychosocial treatments, parent-level and multicomponent programs showed positive long-term effects, yet the number of studies was low and outcomes were not consistently positive (Epstein et al., 2015). In addition, studies uniformly failed to note whether the harms of psychosocial interventions were investigated (Epstein et al., 2015).

Antipsychotics prescribed for behavior disorders are associated with side effects such as extrapyramidal symptoms (particularly with first-generation antipsychotics), weight gain, sleepiness, sedation, and high triglyceride levels. Unfortunately, there are few studies with a long-term follow-up. However, second-generation antipsychotics have been found to also increase the risk for weight gain, high cholesterol, and type-2 diabetes in the long term (Pillay et al., 2018). Therefore, clinicians should weigh the benefits and harms when prescribing antipsychotics, especially when alternatives exist (Pillay et al., 2018).

[...]

Overview of (a lack of) systematic reviews

The impression that emerges from this overview is that there is no convincing evidence that interventions for the most common childhood disorders are beneficial in the long term. In addition, high withdrawal rates and exclusion of patients with a history of adverse events potentially distort findings of long-term studies on adverse effects of pharmacological treatments (Charach et al., 2011; Pillay et al., 2018), while reporting of potential negative effects of psychological treatments in primary studies is absent (Epstein et al., 2015). Virtually all reviews we discussed also concluded that there were few studies with a long-term follow-up available, often too few to allow firm conclusions. A potential reason for the lack of long-term studies is that many systematic reviews on treatment effects exclusively focused on RCTs, and RCTs with long-term follow-up periods are very scarce.

In conclusion, the scientific literature cannot answer the important policy and health care question regarding the long-term effectiveness and safety of treatment of childhood mental disorders with any confidence. We discuss potential methodological reasons in the next part of this editorial.