Good morning. Unfortunately for me I have to oscillate between two meetings in the same building, and since human cloning is not yet practicable, I will be a bit impolite and be going back and forth. But I think it is really important to focus on some critical issues facing us in our collaborative deliberations. I am very keen on this kind of collaboration with NIDA, which is absolutely critical if we expect to seriously address these problems.

Let me put my interests and concerns in context. On Thursday, I had the opportunity to testify before a Senate committee on parity for health insurance for mental disorders, and a number of people also raised the issue of insurance parity for substance abuse. One of the issues in discussing these matters before the Senate was exactly this: that there are, in the long run, enormous health benefits and cost offsets if we treat early mental disorders in an appropriate and effective fashion. An example that came up, because it is always in the public mind, is ADHD. But arrayed on the other side, of course, are people who have money to lose, in essence, by extending insurance coverage to children with a diversity of disorders, and they would say again and again, ALet me see your data.@ They have become increasingly sophisticated and, in fact, asked questions that are not beneath contempt, but are rather questions that we ought to be concerned about. That is to say, we really do need to understand the impact of early interventions in mental disorders on long-term outcomes. Despite some wonderful and helpful forays, we do not have the data that will convince them or convince us yet.

The reasons for that, however, are complex and difficult, and will require, I think, this group of people to take us to the next level. In particular, the issues have to do with understanding that we are faced with very long-term developmental issues. We are looking at risk factors operating very early in life. We are looking at the onset of mental disorders very early in life in many cases. Therefore, the children with the worst ADHD might be showing behavioral signs and symptoms as early as age 2 or 3; for mood disorders, as early as age 5 or 6; and for anxiety disorders probably also quite early in life. And we are thinking about outcomes perhaps almost a decade later. Despite the good research that has been done, we really cannot address, in a continuous way, the impact of interventions at different early stages on these very late outcomes.

If this were simply a matter of money, I am sure that we and NIDA, together, would have the will to do it. But of course, as you know, trying to understand these very long-term outcomes faces difficulties in organizing the investigation and also ethical difficulties. That is, the most ideal kinds of studies, which might involve randomization with long-term followup, rapidly move into the ethical gray zone as we think about how long a child can be part of an experiment, even if we do not know the right answers. The MTA trial, which was so important in addressing the treatment of ADHD, lasted for 14 months, 1 school year plus a summer, in essence. It is hard to see how we could ethically keep children randomized longer than that period of time. Also, one needs to think about retention, about power, and about the fact that the child is changing before our eyes as he or she moves from developmental stage to developmental stage. Despite these difficulties and obstacles, we are in a challenging world. We do need to know, ultimately, what interventions will make a difference. We need to know this information not only to encourage employers and insurers who in many ways were the skeptical audience listening to the Senate hearing, but also obviously to practice—not because it sounds right and good to intervene early, but because the interventions that we want to import into health care settings, schools, and other settings are the right ones. We need to determine how they should be administered and understand their impact.

I believe that we have an enormous amount of hard work ahead of us, and we will hear about very important data that have created a platform. Other important data will be arriving in the next 5 or 10 years on genetic risk factors that may indeed be shared between what we can now hypothesize to be primary substance use disorders and mental disorders. But we obviously cannot wait for these data. It is clear that as a community, as a shared community between drug abuse researchers and mental health researchers, we have our important work cut out for us. I wish you the best of luck in your discussions and deliberations today. Thank you.

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