Interventions for Childhood Mental and Developmental Disorders

Neurodevelopmental disorders (ND) as grouped by DSM-5 include autism, ADHD, learning, communication and motor disorders, and intellectual development disorders (intellectual disability). Neurodevelopmental disorders (ND) are defined as having an onset in the early developmental period, typically in early childhood. Neurodevelopmental disorders (ND) tend to have a steady rather than remitting and relapsing course and their core features show marked maturational changes from childhood to adult life. It is now recognized that these disorders, or at least some symptoms and impairment, persist well into adult life for many.^[1] It is therefore imperative that as much prevention work and early treatment be done to mitigate these symptoms and help children grow into functioning adults with a higher quality of life.

The needs of children with ND are typically multivariate (i.e., they may need pharmacological, educational, and psychotherapeutic as well as social/economical support). Alas, health and community services for people with ND are often experienced as poorly integrated.^[2] Schools have a profound influence on children, families, and communities. School-based mental health services also have the potential to bridge the gap between need and utilization by reaching children who would otherwise not have access to these services. These settings could provide an ideal environment in which programs for child mental health can be integrated in a cost-effective, culturally acceptable, and non-stigmatizing manner. Agencies in the voluntary sector (those that are nongovernment and not-for-profit) have traditionally played an important role in raising awareness of the issues faced by children with mental health difficulties and their families, as well as in reducing the associated stigma.^[3]

Figure 1. Helping parents develop skills and strategies to support their children with mental disorders improves the emotional and behavioral outcomes for the children.

Providing early interventions to children with developmental disorders may optimize their developmental outcomes, and screening is necessary to identify children in need of these resource-intensive interventions. Parenting skills training aims to enhance or support the parental role through education and training, thereby improving emotional and behavioral outcomes for children. A meta-analysis identified four components of parenting skills training that were particularly effective. Increasing positive parent-child interactions, teaching parents how to communicate emotionally with their children, teaching parents the use of time out as a means of discipline, and supporting parents to consistently respond to their children’s behaviors had the largest effects on reducing externalizing behaviors in children. Additionally, several systematic reviews have demonstrated the effectiveness of parenting skills training in reducing internalizing and externalizing problems in children, as well as in reducing the risk of unintentional childhood injuries and improving the mental health of parents. Childhood disruptive and externalizing behaviors may persist into adolescence, affecting peers, schools, and communities. Therefore, parenting skills interventions can reduce or prevent the onset of childhood mental disorders and subsequent adverse health and social outcomes.^[4]

Autism

Early behavioral interventions or speech therapy can help children with autism gain self-care, social, and communication skills. Although there is no known cure, some autistic adults are able to live independently whereas others are not. An autistic culture has developed, with some individuals seeking a cure and others believing autism should be accepted as a difference to be accommodated instead of cured. This was also discussed in the “Neurodiversity” section on the page that reviewed ASD. 

The main goals when treating children with autism are to lessen associated deficits and family distress and to increase the quality of life and functional independence. In general, higher IQs are correlated with greater responsiveness to treatment and improved treatment outcomes. As with most treatment for childhood disorders, no single treatment is best and treatment typically should be tailored to the child’s needs. Families and the educational system are the main resources for treatment. Services should be carried out by behavior analysts, special education teachers, speech pathologists, and licensed psychologists. Studies of interventions have methodological problems that prevent definitive conclusions about efficacy, however, the development of evidence-based interventions has advanced in recent years. Intensive, sustained special education programs and behavior therapy early in life can help children acquire self-care, communication, and job skills and can often improve functioning and decrease symptom severity and maladaptive behaviors; claims that intervention by around age three years is crucial are not substantiated. While medications have not been found to help with core symptoms, they may be used for associated symptoms, such as irritability, inattention, or repetitive behavior patterns. Early, intensive, applied behavior analysis (ABA) therapy has demonstrated effectiveness in enhancing communication and adaptive functioning in preschool children; it is also well-established for improving the intellectual performance of that age group. Similarly, a teacher-implemented intervention that utilizes a more naturalistic form of ABA combined with a developmental social pragmatic approach has been found to be beneficial in improving social-communication skills in young children, although there is less evidence in its treatment of global symptoms.

ADHD

The most common method of treating ADHD is to prescribe stimulant medications such as Adderall. These medications treat many of the core symptoms of ADHD—treated children will show improved impulse control, time-on-task, and compliance with adults, and decreased hyperactivity and disruptive behavior. However, there are also negative side effects to stimulant medication, such as growth and appetite suppression, increased blood pressure, insomnia, and changes in mood (Barkley, 2006). Although these side effects can be unpleasant for children, they can often be avoided with careful monitoring and dosage adjustments.

Opinions differ on whether stimulants should be used to treat children with ADHD. Proponents argue that stimulants are relatively safe and effective, and that untreated ADHD poses a much greater risk to children (Barkley, 2006). Critics argue that because many stimulant medications are similar to illicit drugs, such as cocaine and methamphetamine, long-term use may cause cardiovascular problems or predispose children to abuse illicit drugs. However, longitudinal studies have shown that people taking these medications are not more likely to experience cardiovascular problems or to abuse drugs (Biederman, Wilens, Mick, Spencer, & Faraone, 1999; Cooper et al., 2011). On the other hand, it is not entirely clear how long-term stimulant treatment can affect the brain, particularly in adults who have been medicated for ADHD since childhood.

Finally, critics of psychostimulant medication have proposed that stimulants are increasingly being used to manage energetic but otherwise healthy children. It is true that the percentage of children prescribed stimulant medication has increased since the 1980s. This increase in use is not unique to stimulant medication, however. Prescription rates have similarly increased for most types of psychiatric medication (Olfson, Marcus, Weissman, & Jensen, 2002). As parents and teachers become more aware of ADHD, one would expect that more children with ADHD will be identified and treated with stimulant medication. Further, the percentage of children in the United States being treated with stimulant medication is lower than the estimated prevalence of children with ADHD in the general population (Nigg, 2006).

Figure 2. Parent training may improve a number of behavioral problems including oppositional and non-compliant behaviors.

Parent Management Training

Parenting children with ADHD can be challenging. Parents of these children are understandably frustrated by their children’s misbehavior. Standard discipline tactics, such as warnings and privilege removal, can feel ineffective for children with ADHD. This often leads to ineffective parenting, such as yelling at or ridiculing the child with ADHD. This cycle can leave parents feeling hopeless and children with ADHD feeling alienated from their family. Fortunately, parent management training can provide parents with a number of tools to cope with and effectively manage their child’s impulsive and oppositional behavior. Parent management training teaches parents to use immediate, consistent, and powerful consequences (i.e., rewards and punishment), because children with ADHD respond well to these types of behavioral contingencies (Luman, Oosterlaan, & Sergeant, 2005). Other, more intensive, psychosocial treatments use similar behavioral principles in summer camp–based settings (Pelham, Fabiano, Gnagy, Greiner, & Hoza, 2004), and school-based intervention programs are becoming more popular.

The Multimodal Treatment Study

A large-scale study, the Multimodal Treatment Study (MTA) of Children with ADHD, compared pharmacological and behavioral treatment of ADHD (MTA Cooperative Group, 1999). This study compared the outcomes of children with ADHD in four different treatment conditions, including standard community care, intensive behavioral treatment, stimulant medication management, and the combination of intensive behavioral treatment and stimulant medication. In terms of core symptom relief, stimulant medication was the most effective treatment, and combined treatment was no more effective than stimulant medication alone (MTA Cooperative Group, 1999). Behavioral treatment was advantageous in other ways, however. For example, children who received combined treatment were less disruptive at school than children receiving stimulant medication alone (Hinshaw et al., 2000). Other studies have found that children who receive behavioral treatment require lower doses of stimulant medication to achieve the desired outcomes (Pelham et al., 2005). This is important because children are better able to tolerate lower doses of stimulant medication. Further, parents report being more satisfied with treatment when behavioral management is included as a component in the program (Jensen et al., 2001). In sum, stimulant medication and behavioral treatment each have advantages and disadvantages that complement the other, and the best outcomes likely occur when both forms of treatment are used to improve children’s behavior.

Learning Disorders

Various interventions can improve outcomes for children with learning disabilities, and often these can resolve on their own as children age. These include the mastery model (learners work at their own level of mastery, they practice, and gain fundamental skills before moving forward), direct instruction (careful planned lessons for small learning increments, correcting mistakes immediately, achievement-based grouping and frequent progress assessments), classroom adjustments (special seating assignment, alternative/modified assignments, quieter environment), special equipment (word processeres and spell checkers, text-to-speech/speech-to-text programs, talking calculators, computer-based activities), classroom assistants (note-takers, readers, proofreaders, scribes), and special education (such as prescribed hours or placement in a resource room, individual education plan and educational therapy). 

Communication Disorders

Treatment for communication disorders is usually carried out by speech and language therapists/pathologists, and/or audiologist, who use a wide range of techniques to stimulate language learning. Treatment can also include: language therapy, special education classes for children at school, and a psychologist if accompanying behavioral problems are present. These disorders can improve with time, depending on severity and early treatment.

Another way contemporary remediation differs from the past is that parents are more likely to be directly involved, but this approach is largely used with preschool children, rather than those whose problems persist into school age. For school-aged children, teachers are increasingly involved in intervention, either in collaboration with speech and language therapists/pathologists, or as the main agents of delivery of the intervention. Evidence for the benefits of a collaborative approach is emerging, but the benefits of asking education staff to be the main deliverers of speech-language therapy (SLT) intervention (the “consultative” approach) are unclear. When speech-language therapy (SLT) intervention is delivered indirectly by trained speech-language therapy (SLT) assistants, however, there are indications that this can be effective.

Motor Disorders

There is no known cure for motor disorders, but knowledge, education, and understanding are uppermost in management plans for these disorders, and psychoeducation is the first step. A child’s parents are typically the first to notice the child’s tics; they may feel worried, imagine that they are somehow responsible, or feel burdened by misinformation about Tourette’s and other tic disorders. Parents may be overly concerned, and not realize that they, too, have tics while the child may not be bothered by the tics. In some cases, neither the parents nor their child know they have a tic; pointing out tics in this case will unnecessarily draw attention to them. In such a case, informing a parent who is unaware of their own tics can be disturbing, and they have a “right not to be informed.” When their child receives a diagnosis, such as Tourette syndrome or developmental coordination disorder, both parent and child usually feel relieved, although the diagnosis can also cause distress for the parents as they confront a chronic condition that can be difficult to treat. Effectively educating parents about the diagnosis and providing social support can ease anxiety. This support can also lower the chance that their child will be unnecessarily medicated or experience an exacerbation of tics due to their parents’ emotional state. Psychoeducation that encourages a matter-of-fact attitude and helps dispel misconceptions and stigma is most effective when provided to parents.

In some cases (specifically for DCD), physical or occupational therapy may be helpful. And in the case of tic disorders, behavioral therapies using habit reversal training (HRT) and exposure and response prevention (ERP) are first-line interventions, and have been shown to be effective. Because tics are somewhat suppressible, when people with Tourette’s are aware of the premonitory urge that precedes a tic, they can be trained to develop a response to the urge that competes with the tic. Comprehensive behavioral intervention for tics (CBIT) is based on habit reversal training (HRT), and the best researched behavioral therapy for tics. Comprehensive behavioral intervention for tics (CBIT) has been shown with a high level of confidence to be more likely to lead to a reduction in tics than other behavioral therapies or psychoeducation.

Intellectual Development Disorders (Intellectual Disabilities)

There are four broad areas of intervention that allow for active participation from caregivers, community members, clinicians, and of course, the individual(s) with an intellectual development disorder (intellectual disability). These areas include psychosocial treatments, behavioral treatments, cognitive-behavioral treatments, and family-oriented strategies. Psychosocial treatments are intended primarily for children before and during the preschool years as this is the optimum time for an intervention. This early intervention should include encouragement of exploration; mentoring in basic skills; celebration of developmental advances; guided rehearsal and extension of newly acquired skills; protection from harmful displays of disapproval, teasing, or punishment; and exposure to a rich and responsive language environment. A great example of a successful intervention is the Carolina Abecedarian Project that was conducted with over 100 children from low SES families beginning in infancy through preschool years. Results indicated that by age two, the children provided the intervention had higher test scores than control group children, and they remained approximately five points higher 10 years after the end of the program. By young adulthood, children from the intervention group had better educational attainment, employment opportunities, and fewer behavioral problems than their control-group counterparts. (You can read more about this project here: https://abc.fpg.unc.edu/abecedarian-project).

Core components of behavioral treatments include language and social skills acquisition. Typically, one-to-one training is offered in which a therapist uses a shaping procedure in combination with positive reinforcements to help the child pronounce syllables until words are completed. Sometimes involving pictures and visual aids, therapists aim at improving speech capacity so that short sentences about important daily tasks (e.g., bathroom use, eating, etc.) can be effectively communicated by the child. In a similar fashion, older children benefit from this type of training as they learn to sharpen their social skills such as sharing, taking turns, following instruction, and smiling. At the same time, a movement known as social inclusion attempts to increase valuable interactions between children with an intellectual development disorder (intellectual disability) and their unaffected peers. Cognitive-behavioral treatments, a combination of the previous two treatment types, involves a learning technique that teaches children math, language, and other basic skills pertaining to memory and learning. The first goal of the training is to teach the child to be a strategical thinker through making cognitive connections and plans. Then, the therapist teaches the child to be “metastrategical” by teaching them to discriminate among different tasks and determine which plan or strategy suits each task. Finally, family-oriented strategies delve into empowering the family with the skill set they need to support and encourage their child or children with an intellectual development disorder. In general, this includes teaching assertiveness skills or behavior management techniques as well as how to ask for help from neighbors, extended family, or day-care staff. As the child ages, parents are then taught how to approach topics such as housing/residential care, employment, and relationships. The ultimate goal for every intervention or technique is to give the child autonomy and a sense of independence using the acquired skills they have. In a 2019 Cochrane review (on beginning reading interventions for children and adolescents with intellectual development disorders small to moderate improvements in phonological awareness), word reading, decoding, expressive and receptive language skills and reading fluency were noted when these elements were part of the teaching intervention.

Although there is no specific medication for intellectual development disorders, many people with developmental disorders have further medical complications and may be prescribed several medications. Use of psychotropic medications such as benzodiazepines in people with intellectual development disorder requires monitoring and vigilance as side effects occur commonly and are often misdiagnosed as behavioral and psychiatric problems.