The evidence-based practice movement rests on the premise that the scientific evidence regarding treatment should be used judiciously to inform treatment decisions. This article focuses on the most fundamental question regarding evidence-based practice: What is evidence? To address this question, the authors first review several of the definitions, criteria, and strategies that have been used to define scientific evidence. Second, a number of critical issues that have been raised regarding the nature of treatment evidence are discussed. Finally, suggestions for further consideration in the process of synthesizing evidence for clinicians are offered.
Despite the widespread recognition that social deficits are core features of autism spectrum disorders, few treatment programs for improving social adaptation have been developed. Curricula designed to practice social skills in a group setting are vital, but few are yet commercially available. This article outlines several elements the authors believe are important to successful group social skills intervention, provides specific examples translating these principles into actual practice, and includes illustrations from social skills groups conducted at the University of Utah.
Spirituality is a powerful force in the lives of children. Although spirituality has only recently begun to be a focus for psychiatric research, initial qualitative data suggest that children experience themselves as spiritual beings and that understanding and connecting with them around their spiritual lives can be an important adjunct to treatment. Clinicians should feel free to ask about a child's spiritual life and to work with the family using their spiritual resources if they are perceived to be beneficial in helping the child and family cope with their current situation. Because the work with children's spirituality is in its preliminary stages, qualitative methodology is still the recommended research method for investigating questions in this research area.
This article is a review of specific psychotherapies that have been supported in clinical trials. Treatments that showed significant effects in studies published over a period of 4 decades were identified, with the goal of complementing the overall picture of treatment benefit provided in narrative reviews and meta-analyses with a detailing of the specific interventions that have shown significant effects. The article focuses on treatments for four broad clusters of problems and disorders that account for a very large proportion of youth mental health referrals: anxiety, depression, attention-deficit/hyperactivity, and conduct.
The concept of bipolar disorder in children has its roots in ancient medicine. This article reviews the history of bipolar disorder, beginning from its early history in ancient Greece through 1980, when diagnostic criteria for children were being considered. The acceptance of bipolar disorder in children was highly controversial after the first criteria were developed by Anthony and Scott in 1960. The concept was rejuvenated when Robert DeLong investigated the use of lithium in children with symptoms of mania. In the late 1970s and early 1980s, diagnostic criteria began to define the major criteria for bipolar disorder in children.
Epidemiologic studies show that by late adolescence OCD has a lifetime prevalence of 2% to 3%. The age of onset is earlier in boys than in girls, and has a first peak around puberty and another in early adulthood. The natural course of the disorder is fairly stable, with a complete remission rate of 10% to 15%, although fluctuations in symptom level may make short-term apparent outcome unreliable. Comorbid conditions include depression, movement disorders, and anxiety disorders. Although the prevalence of OC symptoms and of OCD are not different for boys and girls, there may be gender differences in the symptom types. The boundary of the diagnosis of OCD is not always easy to determine, and individuals may meet threshold and subthreshold criteria at different times.
Attention-Deficit/Hyperactivity Disorder is a relatively common condition of childhood onset and is of significant public health concern. Over the past two decades there have been 19 community-based studies offering estimates of prevalence ranging from 2% to 17%. The dramatic differences in these estimates are due to the choice of informant, methods of sampling and data collection, and the diagnostic definition. This article provides a critical review of the community-based studies on the prevalence of ADHD in children and adolescents. Based on the 19 studies reviewed, the best estimate of prevalence is 5% to 10% in school-aged children. The review also examines age and gender effects on the frequency of ADHD. The article closes with a discussion of psychosocial correlates and patterns of comorbidity in ADHD.
This article examines the general principles of psychopharmacologic treatment of obsessive-compulsive disorder (OCD) in children and adolescents. It includes a description of the currently approved medications for the treatment of children and adolescents with OCD, their side effect profiles, approaches to refractory OCD, and a discussion of drug interactions. Future directions for research are also considered.
This article reviews controlled, prospective follow-up studies of children with attention-deficit disorders (ADHD) into young adulthood and adulthood. In their late teens, those with ADHD as children, compared with non-ADHD comparisions, show relative deficits in academic and social functioning. In addition, about two-fifths of these children continue to experience ADHD symptoms, and a significant minority demonstrate pervasive antisocial behaviors, including drug abuse. Many of these same difficulties persist into adulthood. Compared with the comparisons, former ADHD probands complete less formal schooling, hold lower ranking occupational positions, and continue to exhibit poor social skills, antisocial personality, and symptoms of the childhood syndrome. On the other hand, as adults, nearly all former cases are gainfully employed, some in higher level positions, and a full two-thirds show no evidence of any mental disorder. Although relative deficits are seen in early to middle adolescence, young adulthood, and adulthood, childhood ADHD does not preclude achieving one's educational and vocational goals, and the majority of these children do not experience emotional or behavioral problems by their mid-twenties.
The American Academy of Child and Adolescent Psychiatry (AACAP) is preparing a publication, Practice Parameter on Gay, Lesbian or Bisexual Sexual Orientation, Gender-Nonconformity, and Gender Discordance in Children and Adolescents. This article discusses the development of the part of the parameter related to gender nonconformity and gender discordance and describes the practice parameter preparation process,rationale, key scientific evidence, and methodology. Also discussed are terminology considerations, related clinical issues and practice skills, and overall organization of information including influences on gender development, gender role behavior, gender nonconformity and gender discordance, and their relationship to the development of sexual orientation.
Affective neuroscience allows investigators to study the biologic basis of psychologic phenomena such as emotion and mood. Understanding the components of emotion, valence, and arousal and their physiologic correlates is the starting point for studies that quantify emotional and physiologic reactions. This information could provide insight into the biologic foundations of numerous psychiatric conditions. Understanding the normal development of emotions and regulation of emotion will provide new avenues of research into the complex problem of severe mood disorders.
A number of child psychiatric disorders have recently been associated with specific structural brain abnormalities. This article discusses the advantages of neuroimaging for genetic studies, such as clarifying etiologic heterogeneity and establishing pathophysiology. The advantages of twin or family designs for neuroimaging investigations are also discussed.
There is growing interest in the neurologic, behavioral, and cognitive effects of child abuse and neglect. This article explores the literature on the short and long term sequelae of physically and sexually abused and neglected children, along with controversies generated by the studies themselves. Recommendations are made for swift and ongoing intervention in cases of child abuse to protect young victims from potentially devastating effects.
Previous research has documented a strong linkage between substance abuse and criminal activity among young offenders. Consequently, the provision of effective substance-abuse interventions for this population is of paramount importance to the criminal justice system. This article explores the literature on the treatment of substance abuse in offender and nonoffender populations. It reviews three major areas: pretreatment variables (eg, gender and psychopathology), in-treatment variables (eg, program targets, program setting, client-treatment matching), and posttreatment variables (eg, aftercare). The article concludes with a list of empirically derived guidelines for the effective development and implementation of substance-abuse treatment programs for adolescents.
Adolescents use a wide variety of drugs and supplements, including anabolic steroids, to improve their sports performance and physical appearance. Prevalence rates for steroid use generally range between 4% and 12% among male adolescents and between 0.5% and 2% for female adolescents. Although the short-term health effects of anabolic steroids such as effects on the liver, serum lipids, reproductive and cardiovascular systems, and moods and behavior have been increasingly studied, the long-term health effects are not well known. Steroid users are more likely to be boys, participate in strength-related sports, and use other illicit drugs. The effects of many other potential risk factors have not been fully elucidated, however. Assessment of anabolic steroid abuse includes physical and mental status and laboratory examinations. Steroid cessation, supportive therapy, and adjunctive pharmacotherapies are all employed in treating steroid abuse and dependence.
This article reviews the literature for the most pressing diagnostic and treatment challenges faced in working with adolescents. Diagnosing the treatment interventions required for this population involve psychoeducation, engagement of the patient and family in the treatment process, and use of antipsychotic medications. Cannabis may be a causal risk factor in psychotic illness, and data support recommendations to reduce or cease cannabis use in this population. Treatment strategies are discussed that are effective in adult patients and that may be efficacious for youth to abstain from substances after the resolution of psychotic symptoms.
Alcohol exposure in utero affects growth and morphology, and produces FAS, adverse cognitive outcomes, and poorer linguistic abilities and deficits in attention and memory. Maternal smoking, which is widespread in pregnancy, has been associated with physical, cognitive, and behavioral effects in offspring. The effects of fetal exposure to cocaine are more controversial, but increasing evidence identifies a pattern of decreased neonatal head circumference, decreased adaptability to stress, including a disruption in the habituation response in infants, and impaired attention. The literature on the effects of in utero exposure to marijuana is thus far inconclusive, but there is compelling evidence for its producing decreased birth weight and length and deleterious cognitive and attentional effects in some preschool and early school-age samples. Of the widely prescribed medications used in psychiatric practice, evidence for the deleterious effects of lithium and the anticonvulsants carbamazepine and depakote is well-established and compelling. More prospective studies are required before the safety of the atypical antipsychotics and the newer antidepressants is established. Difficulties of standardizing amount, timing, and patterns of use, as well as the confounding effect of the risk factors, must be carefully considered when interpreting the results of outcome studies, especially those regarding substances of abuse.
During the past decade there has been rapid progress in the understanding of the effects of exposure to traumatic life experiences on subsequent psychopathology in children. Trauma exposure affects what children anticipate and focus on and how they organize the way they appraise and process information. Trauma-induced alterations in threat perception are expressed in how they think, feel, behave, and regulate their biologic systems. The task of therapy is to help these children develop a sense of physical mastery and awareness of who they are and what has happened to them to learn to observe what is happening in present time and physically respond to current demands instead of recreating the traumatic past behaviorally, emotionally, and biologically.
To stress a point made earlier, whether backyard or Little League, the tone of the youth sports experience is greatly influenced by the player and team selection process. All possible steps should therefore be taken to ensure that the draft is held on high moral ground, and that the adult participants, even on the Major Little League level, behave cooperatively rather than competitively. If it is the community's hope that Little League will "build character, and not characters," it must embrace Shields and Bredemeier's work and flood the Draft Room with the four virtues of compassion, fairness, sportspersonship, and integrity. In one attempt to achieve fairness and balance, some leagues enter player evaluations into a data base and allow a properly programmed computer to project equal teams. It might be best, however, to borrow a page from backyard baseball, and make team selection a more cooperative venture. Wolff has proposed such a draft model. He recommends that each child's name be placed on a big blackboard at the beginning of the draft. All assembled give their assessment of each child's baseball ability, and a consensus skill-level number (one through five) is entered next to each player's name. If there are 72 names, and the league wishes to form six teams of 12 players each, dividing up the rated players so that the skill levels balance would assure everyone (coaches, parents, the league, and by extension, the community) that the teams were of relatively equal strength. No coach at this point would know to which team he or she was being assigned, so there would be no motive for "stacking" a given team. Each team would be designated by a letter of the alphabet, and the six letters would be thrown into a hat. The six coaches would then blindly pick a team from the hat. If a coach desired that his or her child play on his or her team, fair adjustments (trades) could be made subject to majority agreement. The three draft models can be summarized as follows: Draft Model 1 Public tryouts Previous year rating Coach makes selections Can be very competitive, lacking in "character" Can result in very unequal teams Draft Model 2 Player evaluations placed into a data base Properly programmed computer projects equal teams Draft Model 3 All names placed on a blackboard Relative merits of players discussed Equal team drawn up and placed into a hat Adjustments can be made for coach's child If practical, this author suggests that coaches not pick a name for the team until the first team meeting or practice, when that task can be given to the children. In a symbolic way, this returns some of the sport to them while encouraging social interaction among new teammates, and helping the coach detect who the leaders are. Names of professional teams in the major sports, especially baseball, are to be avoided, as they fuel longstanding unconscious associations and fantasies, and may subtly tilt all participants toward the professional "win at all costs" mentality. No one draft model is perfect for every town, and even the most ethical attempt to achieve balance among teams can be severely tested by parents who request that their athlete be placed on the same team as another child for social or car pool reasons. Such requests are not inviolate, however. For example, they do not usually dictate placement in school classes, and car pools are frequently disrupted when children, in individual sports such as Tae Kwan Do, reach different ability levels, and so attend practices at different times. Baseball is no longer the national pasttime and, as we approach the millennium, American children have too many other attractive, competing interests and time demands to spontaneously organize a pick-up game. One coach shared with the author that his saddest moment in CAP League came when he arrived at 6 PM at a field that had been "reserved" for his team, and found a group of boys who were playing a pick-up game. The coach's impulse was to set his boys fre
During the Outreau case in France, 13 individuals were falsely accused of child sexual abuse and incarcerated. The author of this article testified as a psychiatric expert when the convictions were appealed. He explains how purposeful false statements by adults, inept expert witnesses, and the judicial assumption that children do not lie converged to create a tragic legal outcome. This article explains how psychiatric experts should conduct evaluations in cases of alleged child sexual abuse.
Adolescent substance abuse rarely occurs without other psychiatric and developmental problems, but it is often treated and researched as if it can be isolated from comorbid conditions. Few comprehensive interventions are available that effectively address the range of co-occurring problems associated with adolescent substance abuse. This article reviews the clinical interventions and research evidence supporting the use of Multidimensional Family Therapy (MDFT) for adolescents with substance abuse and co-occurring problems. MDFT is uniquely suited to address adolescent substance abuse and related disorders given its comprehensive interventions that systematically target the multiple interacting risk factors underlying many developmental disruptions of adolescence.
This review of the psychiatric, neuropsychological, and familial contributions to aggressive behavior makes clear that conduct disorder is not a single diagnostic entity. It is, rather, the final common pathway of the interaction among a variety of different kinds of intrinsic vulnerabilities and environmental stressors. In every aggressive child all of these vulnerabilities (none of which necessarily meets full criteria for a specific DSM-IV diagnosis) and stressors must be considered and, if present, addressed systematically. We know that psychotic symptomatology, especially paranoia, combined with neuropsychological vulnerabilities and a history of severe abuse become a recipe for violence, and the more impaired the child, if abused, the more violent the child will become as an adolescent and adult. The clinician must, therefore, think of himself or herself as the only knowledgeable adult who will ever take the time to discover these ingredients and deal with the violent child positively and therapeutically.
This article begins by defining sexual abuse, and reviews the literature on the epidemiology of child sexual abuse (CSA). Clinical outcomes of CSA are described, including health and mental health. An outline is given of all the services often involved after an incident of CSA, and the need for coordination among them. Treatment strategies and evidence-based recommendations are reviewed. Challenges around dissemination and implementation, cultural considerations, and familial dynamics are described. Possible future directions are discussed.
Substance use disorders and sleep disorders are among the most common psychiatric problems in children and adolescents. They often co-occur and have a significant negative effect upon normal development. This article provides a review of the most recent literature on the relationship between these disorders, along with recommendations on how to recognize and clinically address these disorders in children and adolescents.
