Effective treatment for mental disorders in children and adolescents

Psychoeducational treatment for school-aged children with bipolar disorder

Bipolar disorder (BPD) has received increasing attention from public and professional sources. Although pharmacologic treatments are considered the sine qua non in the treatment of youth with BPD, psychosocial interventions are critical to assist the child and family cope with symptoms that carry with them significant morbidity and mortality. Treatments developed to date are few in number; all are psychoeducationally based, using cognitive-behavioral and family systems interventions within a biopsychosocial framework. This paper reviews possible mediators of outcome, including caregiver concordance, children's social skills, hopelessness, and family stress. The author has developed two family-based psychoeducational interventions for the treatment of youth with BPD: multifamily psychoeducation groups (MFPG) and individual family psychoeducation (IFP). These treatments are both described and the results from a previously published randomized clinical trial (RCT) of MFPG are summarized. Then, new findings from an RCT of IFP are presented, along with preliminary pilot data from an expanded version of IFP. The paper concludes with recommendations for future research.

Increase in involuntary psychiatric treatment and child welfare placements in Finland 1996-2003. A nationwide register study

BACKGROUND

Emotional and behavioural problems are common in young people and mental health problems are frequently intertwined with social problems. Both involuntary psychiatric treatment and taking into care may be used in order to manage youth behavioural problems. Compulsory interventions always endanger violating basic civil rights and therefore careful monitoring of them is warranted.

AIM

The aim of this study was to evaluate trends in Finland in involuntary psychiatric inpatient treatment and taking into care 12- to 17-year-old adolescents from the mid-1990s to the early 2000s.

METHOD

A nationally representative retrospective register study of the period 1996-2003 using the hospital discharge register and child welfare register in Finland.

RESULTS

Both types of compulsory interventions increased vastly during the study period. The numbers of involuntary psychiatric treatment periods and child welfare placements of adolescents varied considerably in relation to each other, and across different regions of the country.

CONCLUSIONS

As there is no evidence of a vast increase in mental disorders or serious behavioural problems in young people, there is an obvious need for further research on reasons of the significant increase in the use of coercion and for the wide regional variation. Possible explanations discussed are different service structures and treatment cultures.

Theoretical, developmental & cultural orientations of school-based prevention programs for preschoolers

Schools are the primary environment in which to conduct prevention programs for school-age children. Educators, policy makers, and psychologist argue that prevention efforts should begin as early as possible to maximize their effectiveness. Surprisingly, there are relatively few school-based prevention programs targeted for preschoolers. Given the evidence supporting earlier rather than later prevention efforts and the fact that many children in the United States attend preschool programs, more research on the feasibility and effectiveness of prevention programs administered in preschool environments is warranted. In this article, we review the existing literature on school-based prevention programs targeted for preschool children. We examine whether school-based prevention programs are theory driven, developmentally appropriate, culturally sensitive, and aimed specifically at symptom reduction or behavior promotion. Based on the findings of this review, our aim is to identify gaps in the prevention research literature regarding programs for preschoolers and propose research to address such gaps to create more effective school-based prevention programs for young children.

Adopting a population-level approach to parenting and family support interventions

Evidence-based treatments and preventive interventions in the child and family area have not met with widespread adoption by practitioners. Despite the high prevalence of child behavioral and emotional problems, many parents and families in need are not receiving or participating in services, and when they do, the most efficacious interventions are not what is usually provided. Simultaneously addressing the issues of low penetration and insufficient dissemination of evidence-based programming requires a population approach to parenting and family support and intervention. Process issues are important, particularly in relation to engagement of stakeholders, recruitment of practitioners, consideration of organizational factors, and use of media and communication strategies. This article discusses why there is a need for a population-based approach, provides a framework of how to conceptualize such an approach, and describes an example from our own work of a recently initiated prevention trial that illustrates a population-based approach in action. The rationale, structure, and goals of the Triple P System Population Trial are described in the context of the aforementioned population framework.

Administrative barriers to the adoption of high-quality mental health services for children in foster care: a national study

While the need to provide appropriate mental health services to children in foster care is well recognized, there is little information on administrative barriers to assuring that such services are provided. This article presents results from a national survey of mental health agencies to profile their awareness of currently available practice standards, the roles these standards play in guiding practice of mental health agencies, common reimbursement strategies in use for mental health services, and collaborations between mental health and child welfare agencies that enhance children's access to appropriate mental health care. Implications and recommendations for mental health policymakers are discussed.

Is there an epidemic of child or adolescent depression?

BACKGROUND

Both the professional and the general media have recently published concerns about an 'epidemic' of child and adolescent depression. Reasons for this concern include (1) increases in antidepressant prescriptions, (2) retrospective recall by successive birth cohorts of adults, (3) rising adolescent suicide rates until 1990, and (4) evidence of an increase in emotional problems across three cohorts of British adolescents.

METHODS

Epidemiologic studies of children born between 1965 and 1996 were reviewed and a meta-analysis conducted of all studies that used structured diagnostic interviews to make formal diagnoses of depression on representative population samples of participants up to age 18. The effect of year of birth on prevalence was estimated, controlling for age, sex, sample size, taxonomy (e.g., DSM vs. ICD), measurement instrument, and time-frame of the interview (current, 3 months, 6 months, 12 months).

RESULTS

Twenty-six studies were identified, generating close to 60,000 observations on children born between 1965 and 1996 who had received at least one structured psychiatric interview capable of making a formal diagnosis of depression. Rates of depression showed no effect of year of birth. There was little effect of taxonomy, measurement instrument, or time-frame of interview. The overall prevalence estimates were: under 13, 2.8% (standard error (SE) .5%); 13-18 5.6% (SE .3%); 13-18 girls: 5.9% (SE .3%); 13-18 boys: 4.6% (SE .3%).

CONCLUSIONS

When concurrent assessment rather than retrospective recall is used, there is no evidence for an increased prevalence of child or adolescent depression over the past 30 years. Public perception of an 'epidemic' may arise from heightened awareness of a disorder that was long under-diagnosed by clinicians.

Predictors and moderators of acute outcome in the Treatment for Adolescents with Depression Study (TADS)

OBJECTIVE

To identify predictors and moderators of response to acute treatments among depressed adolescents (N = 439) randomly assigned to fluoxetine, cognitive-behavioral therapy (CBT), both fluoxetine and CBT, or clinical management with pill placebo in the Treatment for Adolescents With Depression Study (TADS).

METHOD

Potential baseline predictors and moderators were identified by a literature review. The outcome measure was a week 12 predicted score derived from the Children's Depression Rating Scale-Revised (CDRS-R). For each candidate moderator or predictor, a general linear model was conducted to examine main and interactive effects of treatment and the candidate variable on the CDRS-R predicted scores.

RESULTS

Adolescents who were younger, less chronically depressed, higher functioning, and less hopeless with less suicidal ideation, fewer melancholic features or comorbid diagnoses, and greater expectations for improvement were more likely to benefit acutely than their counterparts. Combined treatment, under no condition less effective than monotherapy, was more effective than fluoxetine for mild to moderate depression and for depression with high levels of cognitive distortion, but not for severe depression or depression with low levels of cognitive distortion. Adolescents from high-income families were as likely to benefit from CBT alone as from combined treatment.

CONCLUSIONS

Younger and less severely impaired adolescents are likely to respond better to acute treatment than older, more impaired, or multiply comorbid adolescents. Family income level, cognitive distortions, and severity of depression may help clinicians to choose among acute interventions, but combined treatment proved robust in the presence of moderators.

The kids oneida project: what happened to services when the payment rules changed

Community-based systems of care may provide high quality, cost-effective alternatives to institutional care for children and adolescents. This report examines Kids Oneida (KO), a not-for-profit managed care entity established in upstate New York in 1998 to serve such children and their families. Changes in payment rules that established the program allowed KO to contract with a wide array of providers to provide and be reimbursed for non-traditional and formerly unreimbursable services, such as mentoring and supervision. By design, emphasis was on highly individualized plans of care in which traditional office-based services played only a small part. During the first 30 months of KO's operation, 228 children, whose severity of emotional disturbances was comparable to those of children placed in residential treatment centers, had average monthly expenditures for first admissions of 2,734 dollars for services and 228 dollars for administrative fees. Median length of stay in the program was 13.5 months, yielding an estimate of 39,987 dollars for typical length of stay. Length of stay and treatment costs were not related to children's gender or race. Length of stay was significantly longer for children with diagnoses indicating attention deficit hyperactivity disorder and behavior disorders. Treatment costs were significantly higher for children with behavior disorders and/or substance use and children who had had prior contact with the juvenile justice system.

Short Term Involuntary Psychiatric Examination of Children in Florida

This study describes the use of emergency mental health services by children over a 4-year period. Analysis of a statewide database revealed 51,861 or 15% of all involuntary examinations were conducted on children. These youth were on average a little over 14 years of age and law enforcement officials initiated the majority of examinations. The majority of examinations were initiated due to the children demonstrating harmful behaviors to themselves or others. One-fifth of the children (21%) experienced more than one examination over the 4-year period. Areas of future research on this topic are discussed. The implications of the nature of examinations and patterns of repeated examinations are discussed.

Treatment and postrelease rehabilitative programs for juvenile offenders

The juvenile justice system has become notably aware of the increasing use of postrelease rehabilitative treatment interventions for offenders. In many instances, juvenile justice systems are required to ensure that core treatment needs of youth are met. As a result of the heightened awareness of the need for postrelease rehabilitation treatment programs, many researchers and providers are calling for more systematic approaches to offender treatment. This article summarizes a body of literature on juvenile offenders who have specialized postrelease rehabilitative treatment needs. It reviews cognitive-behavioral theoretical models and core postrelease treatment strategies. It presents a review of youth who have specialized needs in light of postrelease practices, describes several model postrelease rehabilitation programs, and reviews outcomes of these programs.

Mental health service provision in juvenile justice facilities: pre- and postrelease psychiatric care

High prevalence rates of mental illness among adolescents in juvenile justice facilities require multifaceted interventions. Children entering justice systems are frequently underserved and having their first contact with psychiatric services. Programming must be multidisciplinary and multifaceted, combining treatment within the facility with postrelease planning. It examines the role of the psychiatrist and the structure of mental health services within juvenile justice facilities.

The ARC organizational and community intervention strategy for implementing evidence-based children's mental health treatments

This paper reviews the implications of organizational and community intervention research for the implementation of effective mental health treatments in usual community practice settings. The paper describes an organizational and community intervention model named ARC for Availability, Responsiveness and Continuity, that was designed to support the improvement of social and mental health services for children. The ARC model incorporates intervention components from organizational development, interorganizational domain development, the diffusion of innovation, and technology transfer that target social, strategic, and technological factors in effective children's services. This paper also describes a current NIMH-funded study that is using the ARC intervention model to support the implementation of an evidence-based treatment, Multisystemic Therapy (MST), for delinquent youth in extremely rural, impoverished communities in the Appalachian Mountains of East Tennessee.

Evidence-based Treatments in the Field: A Brief Report on Provider Knowledge, Implementation, and Practice

This study examined familiarity, perceived effectiveness, and implementation of evidence-based treatments for children in community settings. A sample of service providers in agencies affiliated with federal programs to improve children's mental health services was identified using a snowball sampling procedure. Forty-four percent of the sample (n = 616) responded to a Web-based survey designed to collect data on evidence-based treatments. High familiarity with, relatively high-perceived effectiveness, and generally high use of evidence-based treatments were reported. Partial implementation of treatment protocols within the context of few agency mandates and widely ranging supports for the implementation of evidence-based treatments was found. Results support the inclusion of more complex models of diffusion, dissemination and implementation in research, and development efforts for evidence-based treatments.

Ecological influences on the sequelae of child maltreatment: a review of the literature

Numerous studies indicate that child maltreatment increases the risk for the development of internalizing and externalizing behavior problems. Great variations in outcome, however, have been noted among victims of maltreatment. From an ecological perspective, this review examines how the effects of maltreatment may be influenced by the contexts in which children develop, including their families, peer groups, schools, and communities. The literature reviewed suggests that contextual factors not only influence the incidence of maltreatment but also may moderate its developmental effects, thereby accounting for some of the heterogeneity in the outcomes associated with abuse and neglect. Closer examination of the influence contextual factors exert on the psychosocial sequelae of maltreatment will better inform the interventions, treatments, and public policies directed toward the maltreated population. Methodological considerations for conducting research in this area are also discussed.

Transforming mental health care for children and their families

In April 2002, the President's New Freedom Commission on Mental Health was created by executive order to study the mental health care delivery system in our nation and to make recommendations for improvements so that individuals with serious mental disorders can live, work, learn, and fully participate in their homes and communities. In its report, "Achieving the Promise: Transforming Mental Health Care in America," the commission provided strategies to address critical infrastructure, practice, and research issues. This article focuses on the work of the commission's Subcommittee on Children and Families, describing its vision for mental health service delivery for children and providing suggestions for strengthening community-based care for youths with or at risk of behavioral health disorders. Training, research, practice, and policy implications for psychologists are discussed.

The premature demise of public child and adolescent inpatient psychiatric beds : part I: overview and current conditions

Current trends on the national landscape of available treatment and delivery systems for children and adolescents with serious emotional disturbance indicate a sharp decline in the availability of inpatient psychiatric services. These trends are troubling as six to nine million children and adolescents in the United States suffer from some serious emotional disturbance, and the majority in need of treatment do not receive behavioral health services. The consequences of untreated mental illness in children are grave, and the cost to society of children's mental health problems is high in both human and fiscal terms. This paper will describe national trends in behavioral health in general and specifically children's mental health, and will detail the experiences of many states to identify possible problems and pitfalls to downsizing and closing child and adolescent inpatient psychiatric beds.

10-year research update review: the epidemiology of child and adolescent psychiatric disorders: I. Methods and public health burden

OBJECTIVE

To review recent progress in child and adolescent psychiatric epidemiology in the area of prevalence and burden.

METHOD

The literature published in the past decade was reviewed under two headings: methods and findings.

RESULTS

Methods for assessing the prevalence and community burden of child and adolescent psychiatric disorders have improved dramatically in the past decade. There are now available a broad range of interviews that generate DSM and ICD diagnoses with good reliability and validity. Clinicians and researchers can choose among interview styles (respondent based, interviewer based, best estimate) and methods of data collection (paper and pencil, computer assisted, interviewer or self-completion) that best meet their needs. Work is also in progress to develop brief screens to identify children in need of more detailed assessment, for use by teachers, pediatricians, and other professionals. The median prevalence estimate of functionally impairing child and adolescent psychiatric disorders is 12%, although the range of estimates is wide. Disorders that often appear first in childhood or adolescence are among those ranked highest in the World Health Organization's estimates of the global burden of disease.

CONCLUSIONS

There is mounting evidence that many, if not most, lifetime psychiatric disorders will first appear in childhood or adolescence. Methods are now available to monitor youths and to make early intervention feasible.

A theoretical model of common process factors in youth and family therapy

Recently there has been an increasing emphasis in the youth and family mental health treatment literature on the use of empirically supported treatments (ESTs). In contrast there has been scant attention paid to more universal aspects of the therapy process that may have even greater impact upon therapy outcomes. It is likely that the success of the techniques proposed by ESTs may depend on the presence of common process factors. In this article, the authors explore the status of common process factors research in the youth and family therapy literature, and propose a theoretical model linking specific therapeutic relationship variables and treatment outcomes for children and adolescents. This model is intended to guide synthesis of the empirical evidence for common process factors in youth and family treatment and to stimulate future research on common process factors.

Youths living away from families in the US mental health system

This study examines the clinical characteristics of youths who lived away from families at the time of admission to specialty mental health services, and investigates the association between type of nonfamily living situation and admission to residential versus outpatient programs. Of 3995 youths sampled from 1598 mental health programs in the United States, 14% lived away from their own families, either in foster care, group care settings, or correctional settings, or were emancipated. As a group, youths living away from families were more seriously emotionally disturbed and more likely to receive treatment in residential care programs. Youths who lived in foster care were more likely to be admitted to outpatient programs, while youths who lived in group care settings or correctional settings were more likely to be admitted to residential care programs, controlling on demographic and clinical characteristics. Targeting resources to enhance the availability and therapeutic capacity of foster care may facilitate community living, and decrease time spent in institutional settings.

Youth versus parent working alliance in usual clinical care: distinctive associations with retention, satisfaction, and treatment outcome

We investigated associations between both youth-therapist and parent-therapist alliances and retention, satisfaction, and symptom improvement among 65 youth and their parents receiving usual community-based outpatient mental health services. Parent (but not youth) alliance was significantly related to more frequent family participation, less frequent cancellations and no-shows, and greater therapist concurrence with termination decision. In contrast, youth (but not parent) alliance was significantly related to both youth and parent reports of symptom improvement. Youth and parent alliance were each significantly related to their satisfaction with services. Findings suggest that youth and parent alliance may play important but distinctive roles in the processes and outcomes of usual clinical care.

Psychosocial treatment of children in foster care: a review

A substantial number of children in foster care exhibit psychiatric difficulties. Recent epidemiological and historical trends in foster care, clinical findings about the adjustment of children in foster care and adult outcomes are reviewed, followed by a description of current approaches to treatment and extant empirical support. Available interventions for these children can be categorized as either symptom-focused or systemic, with empirical support for specific methods ranging from scant to substantial. Even with treatment, behavioral and emotional problems often persist into adulthood resulting in poor functional outcomes. We suggest that self-regulation may be an important mediating factor in the appearance of emotional and behavioral disturbance in these children.

A public health strategy to improve the mental health of Canadian children

Mental health problems are the leading health problems that Canadian children currently face after infancy. At any given time, 14% of children aged 4 to 17 years (over 800,000 in Canada) experience mental disorders that cause significant distress and impairment at home, at school, and in the community. Fewer than 25% of these children receive specialized treatment services. Without effective prevention or treatment, childhood problems often lead to distress and impairment throughout adulthood, with significant costs for society. Children's mental health has not received the public policy attention that is warranted by recent epidemiologic data. To address the neglect of children's mental health, a new national strategy is urgently needed. Here, we review the research evidence and suggest the following 4 public policy goals: promote healthy development for all children, prevent mental disorders to reduce the number of children affected, treat mental disorders more effectively to reduce distress and impairment, and monitor outcomes to ensure the effective and efficient use of public resources. Taken together, these goals constitute a public health strategy to improve the mental health of Canadian children.

The Treatment for Adolescents With Depression Study (TADS): demographic and clinical characteristics

OBJECTIVE

The Treatment for Adolescents With Depression Study is a multicenter, randomized clinical trial sponsored by the NIMH. This study is designed to evaluate the short- and long-term effectiveness of four treatments for adolescents with major depressive disorder: fluoxetine, cognitive-behavioral therapy, their combination, and, acutely, pill placebo. This report describes the demographic and clinical characteristics of the sample and addresses external validity.

METHOD

Participants are 439 adolescents, aged 12-17 years inclusively, with a primary DSM-IV diagnosis of current major depressive disorder. Baseline data are summarized and compared with those from national samples and previous trials.

RESULTS

The sample composition is 54.4% girls, 73.8% white, 12.5% African American, and 8.9% Hispanic. The mean Child Depression Rating Scale-Revised total score is 60.1 (SD = 10.4, range 45-98) with 86.0% experiencing their first major depressive episode. The most common concurrent diagnoses are generalized anxiety disorder (15.3%), attention-deficit/hyperactivity disorder (13.7%), oppositional defiant disorder (13.2%), social phobia (10.7%), and dysthymia (10.5%). Demographic results are consistent with data from national samples and large psychopharmacology trials involving depressed adolescents.

CONCLUSIONS

The Treatment for Adolescents With Depression Study provides a large, diverse, and representative sample of depressed adolescents that highlights the complexity of major depressive disorder in adolescents and provides a rich source for explicating the effects of moderator and mediator variables on baseline psychopathology and treatment outcome.

Acute service delivery in a police-mental health program for children exposed to violence and trauma

The Child Development Community Policing Program represents a national model of community-based collaboration between police and mental health professionals for violence-exposed and traumatized children. Administrative data from clinical records of a 24-hour consultation service were examined through stepwise multivariate logistic regression to identify child and event characteristics associated with a direct, in-person response at the time of police contact. Of 2361 children, 809 (34.3%) received a direct, in-person response. Relative to Caucasian children, Hispanic youth were more likely to receive this form of response (OR = 1.36). An acute clinical response was more likely for incidents of gang involvement (OR = 8.12), accidents (OR = 5.21), felony assaults (OR = 2.97), property crimes (OR = 2.30), family violence (OR = 1.53) and psychiatric crises (OR = 1.29). Acute response was less likely when juvenile conduct problems (OR = 0.61), fires (OR = 0.59), child maltreatment (OR = 0.57), and domestic violence (OR = 0.44) were involved. Incidents that were more severe or involved a primary mental health component were related to utilization of intensive CDCP resources.

Effectiveness Research: Transporting Interpersonal Psychotherapy for Depressed Adolescents (IPT-A) From the Lab to School-Based Health Clinics

This paper describes the process of modifying and transporting an evidence-based treatment, Interpersonal Psychotherapy for Depressed Adolescents (IPT-A), from a university setting to school-based health clinics. It addresses conceptual issues involved in the shift from efficacy to effectiveness research as well as operational issues specific to the transport of IPT-A into school-based health clinics. Consideration is given to the rationale for an IPT-A effectiveness study, methodological concerns, and the timing of the move from the "lab" to the community. The authors identify challenges and barriers to initiating effectiveness and transportability research and provide suggestions for overcoming these barriers. Recommendations for conducting research in school-based practice settings are provided.

Evidence-based treatments: challenges and priorities for practice and research

This article discusses key issues in identifying evidence-based treatments for children and adolescents. Among the issues discussed are obstacles in transporting treatments from research to clinical services, the weak criteria for delineating whether a treatment is evidence based, and barriers to training therapists. Recommendations for research are made to accord much greater attention to mechanisms of change in therapy so we understand why and how treatments work and can use this information to optimize treatment effects in clinical work. Other recommendations focus on the need for an expanded portfolio of therapies that consider disseminability, cost, and scale of applicability of treatment, and the importance of including systematic evaluation of patient progress over the course of therapy.

Intensive home and community interventions

This article reviews the evidence base for community-based interventions from a systems of care perspective. The article summarizes previous reviews and provides updates and current directions for recent and ongoing studies. As expected, the evidence base is strongest for multisystemic therapy and treatment foster care. A relatively well-developed evidence base is also revealed for case management. The article concludes with recommendations for future directions within each of the designated types of interventions.

Mental health provider attitudes toward adoption of evidence-based practice: the Evidence-Based Practice Attitude Scale (EBPAS)

Mental health provider attitudes toward organizational change have not been well studied. Dissemination and implementation of evidence-based practices (EBPs) into real-world settings represent organizational change that may be limited or facilitated by provider attitudes toward adoption of new treatments, interventions, and practices. A brief measure of mental health provider attitudes toward adoption of EBPs was developed and attitudes were examined in relation to a set of provider individual difference and organizational characteristics.

METHODS

Participants were 322 public sector clinical service workers from 51 programs providing mental health services to children and adolescents and their families.

RESULTS

Four dimensions of attitudes toward adoption of EBPs were identified: (1) intuitive Appeal of EBP, (2) likelihood of adopting EBP given Requirements to do so, (3) Openness to new practices, and (4) perceived Divergence of usual practice with research-based/academically developed interventions. Provider attitudes varied by education level, level of experience, and organizational context.

CONCLUSIONS

Attitudes toward adoption of EBPs can be reliably measured and vary in relation to individual differences and service context. EBP implementation plans should include consideration of mental health service provider attitudes as a potential aid to improve the process and effectiveness of dissemination efforts.

Multisystemic treatment: a meta-analysis of outcome studies

Multisystemic treatment (MST) is a family- and home-based therapeutic approach that has been found to be effective in treating antisocial youths and that has recently been applied to youths with serious emotional disturbances. In light of the increasing dissemination of MST, this review examines the effectiveness of MST by quantifying and summarizing the magnitude of effects (treatment outcomes) across all eligible MST outcome studies. Included in a meta-analysis were 7 primary outcome studies and 4 secondary studies involving a total of 708 participants. Results indicated that across different presenting problems and samples, the average effect of MST was d = .55; following treatment, youths and their families treated with MST were functioning better than 70% of youths and families treated alternatively. Results also showed that the average effect of MST was larger in studies involving graduate student therapists (i.e., efficacy studies; d = .81) than in studies with therapists from the community (i.e., effectiveness studies; d = .26). In addition, MST demonstrated larger effects on measures of family relations than on measures of individual adjustment or peer relations.

Mental health need and access to mental health services by youths involved with child welfare: a national survey

OBJECTIVE

This study assessed the relationship between the need for and use of mental health services among a nationally representative sample of children who were investigated by child welfare agencies after reported maltreatment.

METHOD

Data were collected at study entry into the National Survey of Child and Adolescent Well-Being and were weighted to provide population estimates.

RESULTS

Nearly half (47.9%) of the youths aged 2 to 14 years (N = 3,803) with completed child welfare investigations had clinically significant emotional or behavioral problems. Youths with mental health need (defined by a clinical range score on the Child Behavior Checklist) were much more likely to receive mental health services than lower scoring youth; still, only one fourth of such youths received any specialty mental health care during the previous 12 months. Clinical need was related to receipt of mental health care across all age groups (odds ratio = 2.7-3.5). In addition, for young children (2-5 years), sexual abuse (versus neglect) increased access to mental health services. For latency-age youths, African-American race and living at home significantly reduced the likelihood of care. Adolescents living at home were also less likely to receive services, whereas having a parent with severe mental illness increased (odds ratio = 2.4) the likelihood of service use.

CONCLUSIONS

Routine screening for mental health need and increasing access to mental health professionals for further evaluation and treatment should be a priority for children early in their contact with the child welfare system.

A review of clinical characteristics and residential treatments for adolescent delinquents with mental health disorders: a promising residential program

As treatment systems throughout the country have deinstitutionalized, under-use of community-based residential treatment systems has escalated. Reliance on juvenile justice systems for the care of the mentally ill adolescent has increased. There is considerable overlap between the mentally ill adolescent population within the community-based mental health systems and the offender population within the juvenile justice systems. With the inconsistent epidemiological prevalence and longitudinal treatment data, mental health treatment providers have also begun addressing this problem. This is currently being done by designing and implementing community-based residential mental health programs for delinquent adolescents of the juvenile justice system as well as nondelinquent adolescents within the mental health treatment systems. Providers have relied on both systems' literature in establishing theoretical treatment programs. The authors review critical treatment components currently used by both the treatment and juvenile justice systems. A promising integrative program is described.

Child mental health in Latin America: present and future epidemiologic research

OBJECTIVE

This report reviews population studies of child and adolescent mental health carried out in Latin America over the past 15 years. Also considered is the issue of how to meet the needs of children and adolescents who may present mental health problems in Latin America, given that most of them live in poverty in economies that are underdeveloped, providing limited resources.

METHOD

Ten studies from six different countries were identified that employed some form of randomized sampling method and used standardized instruments for assessment. The authors present a summary of the main characteristics of these studies, highlighting methodological features that may account for differences in the rates obtained.

RESULTS

Overall, a similar pattern of prevalence and risk factors for mental health problems in children and adolescents in Latin American countries emerged. Moreover, rates of disorders in these children are similar to the 15 to 20% found in other countries. These findings are similar to those observed when adult mental health problems are considered. Prevention and treatment strategies are discussed and the peculiarities of the delivery of mental health services for children and adolescents are explored.

CONCLUSIONS

Future research needs to focus on understanding of resilience and formal and informal mental health delivery systems of care available in different Latin American countries. Such research has high potential for ameliorating the prevention and treatment of child and adolescent mental health problems in this region of the world.

Behavioral and mental health problems in low-income children with special health care needs

This study examined caregiver perceptions of mental health problems and counseling needs in low-income children with special health care needs (CSHCN). Interviewers collected data from 257 caregivers of CSHCN (61% males; 60% African American; Mean age = 8.4 years) attending six Midwestern inner-city health clinics. Measures included the Child Behavior Checklist (CBCL) and an investigator-designed questionnaire. CBCL T-scores indicated that 38% of CSHCN had a behavioral or mental health problem, but only 26% of caregivers perceived the need for treatment or counseling. CSHCN should be assessed and referred appropriately for behavioral and mental health problems during routine health care visits.

Unmet need for counseling services by children in New York City after the September 11th attacks on the World Trade Center: implications for pediatricians

OBJECTIVE

The objectives of this study were to describe the prevalence of counseling services, contrasted with the need after the terrorist attacks of September 11, 2001, the types of counseling received, and the predictors of receipt of counseling services.

METHODS

A cross-sectional, random-digit-dial survey was conducted in New York City (NYC) of parents (N = 434) of children who were 4 to 17 years of age 4 months after the September 11th terrorist attacks on the World Trade Center.

RESULTS

Overall, 10% of NYC children received some type of counseling after the September 11th attacks, according to parental report. Among these, 44% received counseling in schools, 36% received counseling from medical or professional providers, and 20% received counseling from other sources. However, only 27% of the children who had severe/very severe posttraumatic stress reactions (PTSR) after the attacks received counseling services. In a multivariate model, receipt of counseling before the September 11th attacks (odds ratio: 4.44) and having severe/very severe PTSR (odds ratio: 3.59) were the most important predictors of use of counseling services after the September 11th attacks. Minority status and having a parent who experienced the loss of a friend or a relative were also associated with receipt of services.

CONCLUSIONS

There was substantial disparity between apparent need (as indicated by severe/very severe PTSR) for and receipt of mental health services for children after the September 11th attacks. There is need for intensified efforts to identify, refer, and treat children in need, especially for children who are not already in a therapeutic relationship. An enhanced role for pediatricians is indicated.

The policy context for child and adolescent mental health services: implications for systems reform and basic science development

Significant state and national policy initiatives are focusing on strategies for financing and structuring the delivery of evidence-based services for children. These initiatives reflect, in part, an increased awareness of and respect for scientific standards about effective treatments and services. At the same time, major studies of system reform and organizational behavior are calling into question the effectiveness of current practices and identifying the complexities of taking science-based services to scale. Four major policy initiatives are described and the implications of scientific developments within the basic neurosciences for improving policy, practice, and service in children's mental health is discussed.

The outcomes of psychotherapy with adolescents: a practitioner-friendly research review

This article summarizes the outcome findings of psychotherapy with adolescents through an examination of the research literature. In this problem-focused review of the research literature, we consider adolescent treatment of anxiety disorders, depression, eating disorders, disruptive behavior disorders, multiple problems of adolescence, and health risk behaviors. The evidence base for the effectiveness of various psychotherapies for adolescents is mixed. Psychotherapy in general has been a ripe field in which unsupported approaches have grown, and this is certainly true for psychotherapeutic interventions with adolescents. Nonetheless, there is a growing body of evidence to support various types of interventions as effective for different presenting problems. Researchers and clinicians need to recognize the complexity of the diverse characteristics of adolescents, including variations of culture, race, ethnicity, gender, class, physical disability, family definitions and constellation, and sexual orientation. These require sensitivity, responsiveness, and competence by the therapist, but clinical research has not fully examined these considerations.

Deconstructing the pipeline: using efficacy, effectiveness, and cost-benefit data to reduce minority youth incarceration

Investing in effective prevention and early intervention programs will reduce human costs of victimization and also save tax dollars in the short and long terms.

Psychological and/or educational interventions for the prevention of depression in children and adolescents

BACKGROUND

Depression is the fourth most important disease in the estimation of the burden of disease Murray 1996 and is a common problem with prevalence rates estimated to be as high as 8% in young people. Depression in young people is associated with poor academic performance, social dysfunction, substance abuse, suicide attempts, and completed suicide (NHMRC 1997). This has precipitated the development of programmes aimed at preventing the onset of depression. This review evaluates evidence for the effectiveness of these prevention programmes.

OBJECTIVES

To determine whether psychological and/or educational interventions (both universal and targeted) are effective in reducing risk of depressive disorder by reducing depressive symptoms immediately after intervention or by preventing the onset of depressive disorder in children and adolescents over the next one to three years.

SEARCH STRATEGY

The Cochrane Depression, Anxiety and Neurosis Group trials register (August 2002), MEDLINE (1966 to December Week 3 2002), EMBASE (1980 to January Week 2 2003), PsychInfo (1886 to January Week 2 2003) and ERIC (1985 to December 2002) were searched. In addition, conference abstracts, the reference lists of included studies, and other reviews were searched and experts in the field were contacted.

SELECTION CRITERIA

Each identified study was assessed for possible inclusion by two independent reviewers based on the methods sections. The determinants for inclusion were that the trial include a psychological and/or educational prevention programme for young people aged 5 to 19 years-old, who did not meet DSM or ICD criteria for depression and/or did not fall into the clinical range on standardised, validated, and reliable rating scales of depression.

DATA COLLECTION AND ANALYSIS

The methodological quality of the included trials was assessed by two independent reviewers according to a list of pre-determined criteria, which were based on quality ratings devised by Moncrieff and colleagues (Moncrieff 2001). Outcome data was extracted and entered into Revman 4.2. Means and standard deviations for continuous outcomes and number of events for dichotomous outcomes were extracted where available. For trials where the required data were not reported or could not be calculated, further details were requested from first authors. If no further details were provided, the trial was included in the review and described, but not included in the meta-analysis. Results were presented for each type of intervention: targeted or universal interventions; and educational or psychological interventions and if data were provided, by gender. Where possible data were combined in meta-analyses to give a treatment effect across all trials. Sensitivity analysis were conducted on studies rated as "adequate" or "high" quality, that is with a score over 22, based on the scale by Moncrieff et al (Moncrieff 2001). The presence of publication bias was assessed using funnel plots.

MAIN RESULTS

Studies were divided into those that compared intervention with an active comparison or placebo (i.e. a control condition that resembles the intervention being investigated but which lacks the elements thought to be active in preventing depression) and those that used a "wait-list" or no intervention comparison group. Only two studies fell into the former category and neither showed effectiveness although one study was inadequately powered to show a difference and in the other the "placebo" contained active therapeutic elements, reducing the ability to demonstrate a difference from intervention. Psychological interventions were effective compared with non-intervention immediately after the programmes were delivered with a significant reduction in scores on depression rating scales for targeted (standardised mean difference (SMD) of -0.26 and a 95% confidence interval (CI) of -0.40 to -0.13 ) but not universal interventions (SMD -0.21, 95% CI -0.48, 0.06), with a significant effect maintained on pooling data (SMD -0.26, 95% CI -0.36, -0.15). While small effect sizes were reported, these were associated with a significant reduction in depressive episodes. The overall risk difference after intervention translates to "numbers needed to treat" (NNT) of 10. The most effective study is the targeted programme by Clarke (Clarke 2001) where the initial effect size of -0.46 is associated with an initial risk difference of -0.22 and NNT 5. There was no evidence of effectiveness for educational interventions. Reports of effectiveness for boys and girls were contradictory. The quality of many studies was poor, and only two studies made allocation concealment explicit. Sensitivity analysis of only high quality studies did not alter the results significantly. The only analysis in which there was significant statistical heterogeneity was the sub-group analysis by gender where there was variability in the response to different programmes for both girls and boys. For the most part funnel plots indicate findings are robust for short term effects with no publication bias evident. There are too few studies to comment on whether there is publication bias for studies reporting long-term (12-36 month) follow-up.

REVIEWER'S CONCLUSIONS

Although there is insufficient evidence to warrant the introduction of depression prevention programmes currently, results to date indicate that further study would be worthwhile. There is a need to compare interventions with a placebo or some sort of active comparison so that study participants do not know whether they are in the intervention group or not, to investigate the impact of booster sessions to see if effectiveness immediately after intervention can be prolonged, ideally for a year or longer, and to consider practical implementation of prevention programmes when choosing target populations. Until now most studies have focussed on psychological interventions. The potential effectiveness of educational interventions has not been fully investigated. Given the gender differences in prevalence, and the change in these that occurs in adolescence with a disproportionate increase in prevalence rates for girls, it is likely that girls and boys will respond differently to interventions. Although differences have been reported in studies in this review the findings are contradictory and a more definitive delineation of gender specific responses to interventions would be helpful.

Children and evidence-based practice

Issues and challenges related to reducing the gap between child mental health research and practice are not minor. As the field continues to mature, energized by the challenges to develop treatment in more innovative ways and to disseminate EBP, the potential for improving child mental health is strong.

Childhood behavioral and emotional disorders

We reviewed the literature on family treatment for childhood behavioral and emotional disorders and found an increase in the number of studies since 1995; however there was significant variation by disorder and therapy model. There is substantially more research on externalizing disorders (i.e., conduct disorder, attention deficit hyperactivity disorder, oppositional defiant disorder) then internalizing disorders, depression and anxiety disorders. The data support the conclusion that family-based interventions produce results comparable to individually oriented interventions, and in some cases family-based interventions are superior to individual treatments. To date, cognitive behavioral family therapy and parent management have been the two models studied, almost exclusively. Implications for family therapy and future research are considered.

Mental health services utilization by maltreated children: research findings and recommendations

Many maltreated children have, or are at risk for, emotional and behavioral disorders. Some of these children need mental health services but do not receive them because of service delivery and use barriers. Knowledge about the factors related to service utilization is needed to increase access to and use of services. Studies on mental health services utilization by maltreated children in foster care or otherwise monitored by child protective services are reviewed to ascertain service use correlates. Children in foster care had higher use rates than comparison groups of Aid to Families With Dependent Children not in foster care. Need and nonneed variables predicted service use. Race was the most consistent nonneed predictor. Future research needs include the development of conceptual models to guide research on service access and use. More work is needed on the conceptualization and operationalization of mental health services, need for services, and service use.

Assessing the wraparound process during family planning meetings

Research and evaluation of the wraparound process has typically focused on outcomes, service providers, and costs. While many of these studies describe a process that is consistent with the wraparound approach, few studies have reported attempts to monitor or measure the treatment fidelity of the wraparound process. The purpose of this study was to assess the fidelity of the wraparound process in a community-based system of care using the Wraparound Observation Form-Second Version. Results from 112 family planning meetings indicated some strengths and weaknesses within the current system. Families and professionals were frequently involved in the planning and implementation of the wraparound process. However, informal supports and natural family supports were not present in a majority of the meetings. Given the significant number of youth served in wraparound programs, the benefits of using the Wraparound Observation Form-Second Version as an instrument to monitor the fidelity of the wraparound approach should not be ignored.

Family psychoeducation: an adjunctive intervention for children with bipolar disorder

Childhood onset bipolar disorder is associated with significant morbidity and mortality, yet effective treatment strategies have remained underdeveloped and understudied. While some headway is being made vis-a-vis pharmacologic treatments, empirical efforts have not focused on adjunctive psychosocial interventions for childhood bipolar disorder. In this review, we discuss psychoeducation, delivered via workshops, multifamily psychoeducation groups, or individual-family psychoeducation, as an adjunct to the ongoing pharmacotherapy, psychotherapy, and school-based interventions for children with bipolar disorder. We review the theoretical rationale for psychoeducation, including expressed emotion and caregiver concordance; summarize findings in the adult literature; and then describe our development and testing of psychoeducational interventions for mood-impaired children. Data from three pilot studies are reviewed, and progress on two studies currently underway is presented. We conclude with current limitations of psychoeducation and recommendations for future study to develop psychoeducation as an empirically supported adjunctive intervention for children with bipolar disorder.

One-year follow-up of multisystemic therapy as an alternative to the hospitalization of youths in psychiatric crisis

OBJECTIVE

This study presents findings from a 1-year follow-up to a randomized clinical trial comparing multisystemic therapy (MST), modified for use with youths presenting psychiatric emergencies, with inpatient psychiatric hospitalization.

METHOD

One hundred fifty-six children and adolescents approved for emergency psychiatric hospitalization were randomly assigned to home-based MST or inpatient hospitalization followed by usual services. Assessments examining mental health symptoms, out-of-home placement, school attendance, and family relations were conducted at five times: within 24 hours of recruitment, shortly after the hospitalized youth was released from the hospital (1-2 weeks after recruitment), at the completion of MST (average of 4 months postrecruitment), and 10 and 16 months postrecruitment.

RESULTS

Based on placement and youth-report measures, MST was initially more effective than emergency hospitalization and usual services at decreasing youths' symptoms and out-of-home placements and increasing school attendance and family structure, but these differences generally dissipated by 12 to 16 months postrecruitment. Hospitalization produced a rapid, but short-lived, decrease in externalizing symptoms based on caregiver reports.

CONCLUSION

Findings suggest that youths with serious emotional disturbance might benefit from continuous access to a continuum of evidence-based practices titrated to clinical need.