colorado journal of psychiatry & psychology · dr. marissa schiel. a more detailed call for...

5 Obsessive Compulsive Disorder and Anxiety Disorders in Children and Adolescents

13 The Evidence Base for the Assessment and TreatmentofAttention-Deficit/Hyperactivityand OppositionalDefiantDisorder 23 SchizophreniaSpectrumandOtherPsychotic Disorders in Children and Adolescents 32 AssessmentandManagementofAutism Spectrum Disorder and Intellectual Disability in Children and Adolescents 42 AdolescentSubstanceUseDisorderPrevention and Treatment

50 EatingDisordersinChildrenandAdolescents 69 Perinatal, Infancy, and Early Childhood Mental Health 84 PediatricEmergencyBehavioralHealth,Suicidal Behavior,andNon-SuicidalSelf-Injury

90 Addressing Cultural Diversity in Children’s Mental HealthServices

99 BehavioralHealthandChildrenwithChronic MedicalConditionsorPhysicalIllnesses

106 Integrated and Embedded BehavioralHealthCareinPediatrics

ColoradoJournalof Psychiatry&PsychologyChild and Adolescent Mental Health

Volume 1 Number 1 May 2015

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School of MedicineDepartment of PsychiatryUniversity of Colorado Anschutz Medical Campus

ThefirstissueoftheColoradoJournalofPsychiatryandPsy-chologyisinmanywaystheapplicationofBacon’sprin-ciplesforpersonalgrowthanderuditionasappliedtoagreat,21st-centurydepartmentofpsychiatry. First,westudy.Westudytobebetterclinicians,tobebetterscientists,andtobebettereducators.Andasweaspire,as all in academic healthcare do, to produce meaningful newscholarship,itisthroughanintimateawarenessoftheworkthathascomebeforethatwefindtheplaceswherenewcontributionsareneeded.Second,wetalk.Academicmedicineisateamsport–weneverreallyworkalone–andthe richness of our collabora-tionsoftendefinethesuccessof our clinical, teaching, re-search, and scholarly endeav-ors.

Third,wewrite.Wewritetorecordourwork,toclarifyourideas,andtosharethemwithour colleagues. It is through thecrucibleofwell-informed,collaborative,andpeer-re-viewedwritingthatwemakeourselves the best professors wecanpossiblybe.TheColoradoJournalofPsy-chiatry and Psychology is a newavenuetosupportpursuitofexcellence.TheJournalisfor all of us—our department, theRockyMountainRegion,ourcolleaguesnationally,andespecially,ourpatientsandtheir families.

EditorialStaffDouglas K. NovinsEditor-in-Chief

Elise M. SannarAssociate Editor

Alyssa OlandAssociate Editor

Robert FreedmanDepartment Chair

Melissa MillerEditor/Designer

The Colorado Journal of Psychiatry and Psychology is accepting papers with a focus on child and adoles-cent mental health for an issue to be published in 2016. Editors for the issue will be Dr. Emily Edlynn and Dr. Marissa Schiel. A more detailed call for papers will be available in May 2015. Please direct any inquiries about potential submissions to Drs. Edlynn and Schiel by emailing Ms. Giomara Macias at Giomara.Macias@ childrenscolorado.org.

Call for Papers on Children’sMentalHealth

- Douglas Novins

Reading maketh a full man, conference a ready man, and writing an exact man.—Francis Bacon

CopyrightinColoradoJournalofPsychiatryandPsychologyisownedbyRegentsoftheUniversityofColorado,abodycorporate,2015. ThisisanOpenAccessjournalwhichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Copyrightineacharticleisretainedbyeachindividualauthor.

mailto:[email protected]

mailto:[email protected]

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ChildandAdolescentMentalHealthTAblE of CoNTENTS

84 PediatricEmergencyBehavioralHealth,SuicidalBehavior,and Non-SuicidalSelf-Injury Amy Becker, MD; John Peterson, MD; Elise M. Sannar, MD

13 The Evidence Base for the Assessment and Treatment of Attention-Deficit/HyperactivityandOppositionalDefiantDisorder Mary N. Cook, MD; Gautam Rajendran, MD; Jason Williams, PsyD, MS Ed

99 BehavioralHealthandChildrenwithChronicMedicalConditions or Physical Illnesses Cindy L. Buchanan, PhD; Jennifer Lindwall, PhD; Emily Edlynn, PhD; Emily Muther, PhD

90 AddressingCulturalDiversityinChildren’sMentalHealthServices JenniferLindwall,PhD;CindyBuchanan,PhD

23 SchizophreniaSpectrumandOtherPsychoticDisordersin Children and Adolescents SusanLurie,MD;GautamRajendran,MD;ScotMcKay,MD;EliseM.Sannar,MD

106 IntegratedandEmbeddedBehavioralHealthCareinPediatrics EmilyF.Muther,PhD;HeatherAdams,DO;BethanyAshby,PsyD;SallyTarbell,PhD

5 Obsessive Compulsive Disorder and Anxiety Disorders in Children and Adolescents BenjaminC.Mullin,PhD;ChristineMcDunn,PhD;ScotMcKay,MD;AlyssaOland,PhD

32 AssessmentandManagementofAutismSpectrumDisorderandIntellectualDisability in Children and Adolescents EliseM.Sannar,MD;PhilipO’Donnell,PhD;CarolBeresford,MD

69 Perinatal,Infancy,andEarlyChildhoodMentalHealth CelesteSt.John-Larkin,MD;JenniferJ.Paul,PhD;BethanyAshby,PsyD

42 AdolescentSubstanceUseDisorderPreventionandTreatment KellyCaywood,PhD;PaulaRiggs,MD;DouglasNovins,MD

50 EatingDisordersinChildrenandAdolescents GuidoK.W.Frank,MD;JenniferO.Hagman,MD;MindySolomon,PhD

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Forward

From the ChairRobert freedman, MD

OpeningtheTableofContentsofthefirstvolumeoftheColoradoJournalofPsychiatryandPsy-chology,Iwasimmediatelystruckbythescope

ofclinicalservicesandillnesses,andtheexpertiseofthefacultywhodailytreatpatientsatTheColoradoChildren’sHospital.Evenwithafacultyascollegialasours,inourdailyworkwetakeforgrantedthemanydifferentclinicalexpertswhoareamongus,treatingthewidediversityof illnesses that childrensuffer. Iam proud that they have chosen to develop their ex-pertiseatColorado,initsrenownedDivisionofChildand Adolescent Psychiatry.

Thewritingofpapersisatime-testedmethodtocon-solidate clinical expertise and make it available tostudents. This opportunity, once readily available to all good clinicians, has been increasingly reserved for

researcherswho are developing knowledge for thefuture.Whilesomeofthemareindeedrepresentedin this volume,most of the articles are written byclinician-teachers,whopracticeandteachevidence-based medicine today. The volume has had its in-tended role of including these clinical experts in the fellowshipofwritingandpeer-reviewing,whichmyownchief,DanielX.Freedman,termedthegreatestcollegewithoutwalls.

Asaneditormyself,myspecialkudostoDrs.OlandandSannar.Onlyanothereditorcanappreciatehowincredibletheireffortsandskillaretopullthisvolumetogether. Dr. Novins himself is a highly experienced editor. Itwashisdedication to thedevelopmentofhisfacultythatisnowintangibleforminthisvolume.

FromtheEditorialStaffAlyssa oland, PhD; Elise M. Sannar, MD; Douglas Novins, MD

ThedevelopmentofthefirsteditionoftheColo-rado Journal of Psychiatry and Psychology hasbeen an exciting journey! The idea to create

such a journal began as our Division of Child andAdolescent Psychiatry, headquartered at Children’s HospitalColorado,developeditsstrategicplan.Thisstrategywas guided by our division’s long-standingcommitment to provide high-quality behavioralhealth services to children and adolescents. At pres-ent, there are considerable unmet behavioral health needs for children and adolescents in Colorado. Our strategicplanidentifiedareasforenhancementandexpansion to bettermeet these needs. In planningfor these areas of enhancement and expansion, our divisionandhospitalwanted tobe sureoureffortsforgrowthanddevelopmentwereinformedbybest-practicestandards in thefield.As such, facultyvol-unteeredtoresearchinformationregardingetiology,assessment,andtreatmentinspecificareasrelevanttoidentifiedareasforgrowth.Thesearticleshelpedguideourstrategicplanningefforts,andwererevisedforpublicationinthisfirstvolumeofthejournal.

We identified the following as areas for enhance-ment or expansion in our strategic plan: (1) behav-ioralhealthservicesinprimarycaresettings,(2)ser-vicesforyoungchildren,(3)servicesforyouthwithsubstance use problems, (4) services for children with comorbid medical and psychiatric concerns,

(5) behavioral health services for childrenwith au-tismspectrumdisordersandintellectualdisabilities,and (6) tertiary psychiatric treatment services forpatientspresentingwithanacutepsychiatriccrises.Wealsohaveanoverarchingappreciationoftheim-portanceofprovidingculturally-sensitiveservicesasthe children and adolescents we serve come fromdiversebackgrounds.Thearticles in this journal fo-cus on these targeted areas. As editors of this inau-gural volumeof the Colorado Journal of PsychiatryandPsychology,wehavelearnedalotfromguidingthepreparationofthesearticlesforpublication.Weareexcitedtomakethisinformation,whichhasbeenso important to guiding our program development efforts,available toothers in the largercommunitywhoareequallypassionateaboutprovidingthehigh-estqualityservicestochildrenandadolescentswithmental health problems and their families.

AsstatedbyBenjaminFranklin, “Withoutcontinualgrowth and progress, suchwords as improvement,achievement, and success have no meaning.” Westrivetocontinuallygrowandimproveuponthewaysweservethebehavioralhealthneedsofchildrenandadolescents.Aseditors,wehavecertainlypersonallyandprofessionallygrownthroughreadingandlearn-ingfromthesearticles.Wehopethatyouwillenjoythemandlearnfromthemasmuchaswedid.

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Benjamin C. Mullin, PhD; Christine McDunn, PhD; Scot McKay, MD; Alyssa Oland, PhD

Obsessive Compulsive Disorder and Anxiety Disorders in Children and Adolescents

Anxiety disorders are the most common form of psychopathology found in children and adoles-

cents,1andtheyimpartsignificantfunctionalimpair-ment.Inrecentdecades,substantialprogresshasbeenmadedevelopingeffectivemethodstoassessandintervenewithanxiousyouths,yetmanyafflict-edindividualsareneveridentified,orreceivesub-optimalformsoftreatment.2Inthisbriefreview,weaim to summarize the current clinical understanding ofpediatricanxietydisorders,includinganoverviewofepidemiologicalfindings,factorsinvolvedinriskandresilience,prognosticguidelines,andcurrentfindingsregardingtheassessmentandtreatmentoftheseconditions.Givenspacelimitations,wewillfocus on the most common anxiety disorders includ-edinthefiftheditionoftheDiagnosticandStatisti-calManual(DSM-5),3 including generalized anxiety disorder (GAD), social anxiety disorder (SAD), sepa-rationanxietydisorder,specificphobia,panicdis-order,agoraphobia,andposttraumaticstressdisor-der(PTSD).Wealsoincludeobsessive-compulsivedisorder(OCD)inthisreview,thoughinDSM-5itisnolongergroupedwiththetraditionalanxietydis-orders(itisnowincludedinthechapter“ObsessiveCompulsiveandRelatedDisorders”).Wemadethisinclusion given that, phenomenologically, OCD is a disordercharacterizedbysignificantanxiety,andtheempirically-supportedtreatmentsforOCDoverlapconsiderablywithtraditionalanxietydisorders.

PrevalenceDetermining the prevalence of anxiety disorders among young children is challenging, given that anxietyisoftenstudiedmorebroadlyasacompo-nent of inhibited temperament in this age group

withoutconsiderationofdiagnosticthresholds.Nonetheless,thefewstudiesofchildrenbetweenages2-8suggestaprevalenceofroughly10%forallanxietydisorders,excludingOCDandPTSD,withanincreasetoaround12%inelementaryschool-agedchildren.4Specificphobiasarethemostcommondiagnosisinthisagegroup(6.7%),followedbysepa-rationanxietydisorder(3.9%),SAD(2.2%),andGAD(1.7%).5Inschool-agedyouths,theprevalenceofOCDisbelievedtobearound2%-3%,with2peaksofincidence:thefirstinpre-adolescentchildren,andthesecondinyoungadults(ie,earlytwenties).6 In adolescence, the overall rates of anxiety disorders remainsimilar(roughly11%),withanincreaseinratesofpanicdisorder,whichrarelyoccursbeforemid-adolescence.7 Rates of PTSD among adolescents havebeenestimatedat3.7%formales,and6.3%for females,8thoughasignificantadditionalportionofyouthexperiencetrauma-relatedimpairmentwithoutmeetingcriteriaforPTSD.9 Overall, anxiety disorders appear to have an earlier onset than other forms of mental illness. Several reports have suggested that females are at higherriskfordevelopinganxietydisorders,withsignificantsexdifferencesinoverallratesofanxietydisorders emerging by age 6.10Yetfollow-upstud-iesseemtoindicatethatsexdifferencesinratesofindividualdiagnosestendtoberelativelysmall.Onereportindicatedhigherratesofseparationanxietydisorderamongfemalesduringchildhood,withhigher rates of SAD and GAD among females during adolescence.11Interestingly,inpediatricOCD,thereis a male preponderance (3:2).5

Benjamin C Mullin, PhD; Christine McDunn, PhD; Scot McKay, MD; Alyssa Oland, PhD

Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Colorado School of Medicine

National Jewish Medical and Research Center, Denver Health Behavioral Health Services,

Pediatric Mental Health Institute, Children’s Hospital Colorado

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Risk FactorsRiskfordevelopingachildhoodoradolescent-onsetanxiety disorder seems to be largely determined by interactionsbetweenbiologyandenvironment.Initialstudies indicated higher rates of anxiety disorders amongthechildrenofparentswithanxietydisor-ders.12,13 Numerous family factors appear to increase theriskfordevelopinganxietydisorders,includinginsecureattachment14andoverprotectiveorhighlycriticalparentingstyles.11Acombinationoftwin,adoption,andmoleculargeneticstudieshashigh-lightedrolesforparticulargeneticpolymorphisms(eg,5-HTT)andnegativelifeevents(eg,lowfamilialsupport). One study reported that the heritability estimate(ie,theproportionofriskforaparticularconditionthatcanbeaccountedforbygeneticfactorsalone)forseparationanxietydisorderwas73%,whileforSADitwas60%.15OCDhasastronggeneticbasisaswell,withfirst-degreerelativesofpediatricOCDpatientshavinga24%-26%morbidrisk.16 Another studyexploringgene-environmentinteractionsfoundthatgenesappearedtosensitizeteenstotheanxiety-producingeffectsofnegativelifeevents.17 Among youths,anumberoffactorsappeartoincreaseriskfordevelopingPTSDfollowingatrauma,includingprevioustrauma,preexistingpsychiatricdisorder,femalegender,parentalpsychopathology,andlackofsocial support.11

PreventionGiventheprevalenceandlastingimpactofchildhoodanxiety disorders,18–20preventionandearlyinterven-tioneffortsarewarranted.Preventionprogramsarecategorized as universal, selected, or indicated.21 Universalprogramsaretargetedatanentirepopula-tion,regardlessofriskstatus;selectiveinterventionprogramsaretargetedatthosewhohavebeenidenti-fiedasbeingatrisk,butdonotyethaveanysignsofadisorder;andindicatedinterventionprogramsaretargetedatthosewhoarealreadypresentingwithsubclinical symptoms, yet do not meet criteria for adisorder.Inameta-analyticreview,indicatedandselectiveanxietypreventionprogramshadstrongereffectsizesthanuniversalprograms.22 Therefore, communityscreeningeffortsmaybeworthwhiletoidentifythoseatriskusingreliableanxietyscreen-ing instruments (described subsequently) or teacher nomination.23

Empirically-supportedandmodifiableriskfactorsfor the development of anxiety disorders (inhibited temperament,parentalanxiety,negativecognitivecontent, stressful life events, and response to stress) haveguidedthedevelopmentofpromisingpreventiveprograms.Recentmeta-analysessupporttheefficacyofsuchprograms(witheffectsizesrangingfromsmalltolarge),whichprimarilyutilizecomponentsofCogni-tiveBehavioralTherapy(CBT),thetreatmentofchoicefor child and adolescent anxiety disorders.24 Groupinterventionsatschoolorothercommunitysettingsimproveaccesstocareandmaydecreasestigmatization.TheFRIENDS program, a universal programdeliveredintheschoolsetting,hasshownpromising results,25andiscurrentlyusedinmultiplecountrieswithmaterialstranslatedinmultiplelan-guages(http://www.pathwaystoresilience.org/our-pa-tron/).Aselectiveprogramdesignedfortheparentsofpreschool-agedchildrenwithinhibitedtempera-ment(measuredbyinhibitedandwithdrawnbehav-iors)alsoshowedlastingbenefitsintoadolescence.26 Thisprogramincludedpsychoeducationaboutinter-nalizing disorders, a focus on reducing parental over-protectionandfosteringgreaterchildindependence,systematictechniquestoencourageinvivoexposureforthechild,andencouragementtocontinuethesetechniques,especiallyduringhighrisktimesinthefuture, such as the start of each school year.Anotherselectivepreventionprogram,TheChildAnxi-etyPreventionStudy,enrolledchildrenandtheirpar-entswithadiagnosedanxietydisorderinan8-weekCBTinterventionandcomparedthemtoawaitlist.Thisprogramincludedparent-onlyandparent/childsessionsfocusedonanxietymanagement/socialengagement,cognitiverestructuring,problem-solvingskills,contingencymanagement,andcommunicationskills.Atthe1-yearfollowup,30%ofthosechildreninthewaitlistgrouphaddevelopedananxietydisor-dercomparedto0%intheactivetreatmentgroup.27 Programs that include or consist primarily of teaching parentshowtomanageanxietyinthemselvesandtheirchildrenalsoappeartoreducefutureriskforyouths.24

Inaddition,evidencethatattentionbiastowardthreateningstimulimaybecausallyrelatedtoanxi-ety symptoms28supportspossiblepreventioneffortsusingcomputerizedattentionretraining/dot-probetasks.Otherautomatedandcomputerizedinterven-

http://www.pathwaystoresilience.org/our-patron/

http://www.pathwaystoresilience.org/our-patron/

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tionsshowedpromise,with60%ofanxietyprogramsyielding successful outcomes.29

WithregardstoPTSD,community-basedscreeningshouldbeconductedwithchildrenaftereventswiththepotentialtotraumatizewitnesses.Thisscreen-ingshouldbedonenosoonerthan4weeksaftertheeventbasedonpriorfindingsthatroughlyonly30%ofthosewithsymptomsimmediatelyfollowingatrau-maticeventwillcontinuetohavesymptoms1monthpost-event.30Groupinterventionshavebeenshowntobeeffective,suchasTrauma-FocusedCBTandtheUCLATraumaandGriefComponentTherapy.31 Uni-versal programs that foster general resiliency in youth arebeingtestedinternationallytoprovideprotec-tionforchildrenfromadverseaffectsoftraumaticevents.32

ComorbidityAnxietydisordersshowhighratesofconcurrentandlongitudinal comorbidity33witheachother.Inaddi-tion,youthswithanxietydisordersweremorethan27timesmorelikelytohaveaconcurrentdepressivedisorder,andmorethan3timesmorelikelytohaveattention-deficithyperactivitydisorder(ADHD)thanthosewithoutananxietydisorderdiagnosis.34 Early onsetOCDisassociatedwithriskforADHD,separa-tionanxietydisorder,specificphobias,andagorapho-bia.6

Prognosis Thelimitednumberoflong-termlongitudinalstud-ies that have assessed anxiety suggest that these are persistentdisordersthatfollowanintermittentcourse(ie,waxingandwaning).35,36 Indeed, studies of inhib-itedtemperamentindicatethatreactivitytonoveltyininfancy predicts later development of SAD in adoles-cence.37Earlyanxietydisordersserveasriskfactorsforthedevelopmentofotherillnesses,particularlydepression38 and substance use disorders.39 Other longitudinalstudieshaveshownthatadolescentanxiety disorders also predict subsequent suicidal behavior,educationalunderachievement,andearlyparenthood.39Overtime,childhood-onsetOCDoftenbecomes subthreshold or remits altogether, though worseoutcomesarepredictedbyearlierageofonset,increaseddurationofOCD,inpatienttreatment,andthepresenceofspecificsymptomsubtypes(eg,reli-

gious obsessions).40LongitudinalstudiesofPTSDshowthatmanychildrenshowagradualdecreaseinsymp-tomsovertime,withouttreatment.Howeverasignifi-cantnumberofyouthsshowchronicPTSDsymptomsover many years.41

Assessment Whenassessingforanxietyinchildhood,itneedsto be considered that having some anxiety can be a normal part of life and a youth’s progression through developmental stages. To determine if anxiety in a youth meets criteria for an anxiety disorder, providers shouldconsidertheintensity,duration,andassociat-edfunctionalimpairmentofthesymptoms.Providersalsoneedtoconsiderthesocio-emotionaldevelop-mentalstageofthechild,andwhattypeandintensityofanxietywouldbenormativeforthatdevelopmentalstage. They should also screen for other psychiatric conditions,medicalconditions,stressors,ortraumasthat might account for the anxiety symptoms.42 It is importanttoconsiderthatyouthcanpresentwithseveral comorbid anxiety disorders, and that youth mightalsopresentwithanxietydisorderscomorbidwithotherpsychiatricdisorders,suchasdepressionorADHD.42

Briefanxietyscreensprovideausefultoolforidentify-ingyouthwhorequireamorethoroughevaluationandpossibleanxiety-focusedtreatment.Therearenu-merous,briefself-reportmeasurestoassesspediatricanxiety;however,theMultidimensionalAnxietyScalefor Children (MASC) and the Screen for Child Anxiety andRelatedEmotionalDisorders(SCARED)appeartohavethestrongestpsychometricproperties,andarethemostwidelyused.43,44 The SCARED also has a parallelparent-reportformthatmaybeuseful.(Note:A more thorough discussion of the many screening instrumentsisbeyondthescopeofthisarticle,butforanauthoritativereview,seeSilverman&Ollen-dick,2005.)Generallyspeaking,itisimportanttouseinformationfromarangeofinformants(self-report,caregiver-report,andteacher-report),andtobesurethatmeasuresusedwithchildrenaredevelopmen-tallyappropriateintheirwording.Researchsuggeststhat,withveryyoungchildren,play,drawings,andobservationcanbeusefulforassessment,particularlywhencombinedwithparent-reportandteacher-reportmeasures.Itisbelievedthatchildrenarewellable to report about their internal state in regards to

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anxiety, and caregivers and teachers may not be as awareofthechild’sinternalstate,butareabletore-portfunctionalimpairmentthatmightbepresentandnot reported by the youth.45 AvarietyofstructureddiagnosticinterviewsthatcanbeusedincludetheAnxietyDisordersInterviewScheduleforDSM-IV:ChildandParentVersions(ADIS), Child and Adolescent Psychiatric Assessment, DiagnosticInterviewforChildrenandAdolescents,theNIMHDiagnosticInterviewScheduleforChildrenVersionIV,andtheScheduleforAffectiveDisordersandSchizophreniaforSchool-AgeChildren.Ofthese,the ADIS is most recommended because it has been themostwidelyused,andhasbeenshowntobevalidand reliable in diagnosing anxiety disorders.44

Psychotherapy ApproachesCognitivebehavioraltherapy(CBT)haslongbeenconsideredaneffectivetreatmentforpediatricanxi-etydisorders.CBTforanxietytargetsthecultivationofspecificcopingskills,includingrelaxation,cognitiverestructuring,andreducingavoidanceofanxiety-provokingsituationsthroughgraduatedexposureswithresponseprevention(ERP).Severaltreatmentmanualshavebeenconstructedincorporatingthesetechniques,andhavedemonstratedeffectivenessacross the range of anxiety disorders.46,47 In manual-ized treatments for pediatric OCD, ERP represents the primaryfocuswithlessemphasisoncognitiverestruc-turing.48Trauma-focusedCBT(TF-CBT)supplementselementsoftraditionalCBTforanxietywithnarrativeexposureworkandcognitiveprocessingofthetrau-ma,typicallyinconjointparent-childsessions.31 ThedefinitivestudyexaminingtheeffectivenessofCBTforpediatricanxietydisordersistheChild-Ado-lescentAnxietyMultimodalStudy(CAMS),amulti-siterandomizedcontrolledtrialcomparing12weeksofin-dividual CBT, sertraline, CBT + sertraline, and placebo inthetreatmentofSAD,GAD,andseparationanxietydisorderforyouthsbetween7-17yearsofage.Over-all,59.7%ofparticipantsintheCBTgroupqualifiedasremitted,versus54.9%inthesertralinegroup,80.7%inthecombinedtreatmentgroup,and23.7%intheplacebo group.49Asimilarmulti-siterandomizedcon-trolledstudywasperformedforpediatricOCD,calledthe Pediatric OCD Treatment Study (POTS), compar-ing12weeksofCBT,sertraline,CBT+sertraline,andplacebo.Ratesofclinicalremissionwere39.3%for

CBT,21.4%forsertraline,59.7%forcombinedtreat-ment,and3.6%forplacebo.AuthorsrecommendedCBTaloneorCBT+sertralineasfront-lineapproachesfor pediatric OCD.50 The largest randomized trial of TF-CBTfoundthatinasampleofsexually-traumatizedyouth,12weeksofTF-CBTwassuperiortosupportivepsychotherapy,producingsignificantimprovementinPTSD symptoms, depression, behavior problems, and shame-relatedattributions.31 These improvements werelargelypreservedat1-yearfollowup.51 Thereisnowrobustevidencesuggestingthattheef-fectivenessofCBTislong-lasting.Onefollow-upstudyassessedparticipantsbetween16-26yearsofage,8to13yearsaftertheyhadbeentreatedforanxietydisordersusingCBT.Over95%remainedinremissionfrom their original target disorder, and the authors alsoreportedlowratesofnewanxietydisorders.52 Otherfollow-upstudies(5to8yearsposttreatment)havefoundsimilarpreservationofgainsfromCBTtreatment of anxiety in children.48,50,53 Importantly, althoughtightly-controlled(oftenuniversity-based)efficacytrialshaverepeatedlyshownstrongeffectsofCBTforpediatricanxiety,severalcommunityeffec-tivenesstrialshaveoftenproducedequivocalresultsbetweenCBTandtreatmentasusual.54–56Thesefind-ingsaredifficulttointerpret,giventhatthereisoften“bleeding”ofCBT-styleinterventionsintostandardcommunity treatments, and they suggest the need foradditionaldismantlingstudiestoidentifycriticalmediators and moderators of successful treatment. ItshouldbenotedthatCBTinterventionsforpediat-ricanxietyhavebeenimplementedinawiderangeof formats, from individual to group therapy, and withandwithoutparentsandotherfamilymembers.Whilestrongargumentshavebeenmadeaboutthesuperiorityofoneformatversusanother,findingshave not consistently found any advantages.57 More recently,theCopingCatmanualizedCBTinterventionforpediatricanxietywastranslatedintoacomputer-ized format. In a randomized clinical trial, it proved equallyeffectivetothetraditionalin-personindividualtherapy format.58Duetopotentialcostefficiencyanddisseminationadvantages,computerizedinterven-tionsforpediatricanxietyarebeingstudiedclosely.

Pharmacotherapy ApproachesMostdatasuggestthatthefirstlineforthetreatmentofthemajorityofanxietydisordersinchildrenand

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adolescentsispsychotherapy.However,formoderatetoseverecasesofanxiety,medicationsareindicatedas a part of treatment.42 Studies demonstrate that medicationsindicatedforanxiety,includingselectiveserotoninreuptakeinhibitors(SSRIs),tricyclicantide-pressants (TCAs), buspirone, and benzodiazepines, are safe,tolerated,andefficaciousinthechildandado-lescentpopulation.Currentlyfluoxetine,sertraline,fluvoxamine,andclomipraminearetheonlyFDA-approvedmedicationsfortreatinganxietydisorders(allhavinganindicationforOCDonly)inchildrenaged6yearsandolder.Additionally,theSSRIshaveablackboxwarningforpotentialdevelopmentofsuicidalideationinthepediatricpopulation.However,thesedatacomefromthestudyofmedicationsinrelationtodepression,notanxiety,whichhascalledintoques-tiontheriskofdevelopingsuicidalideationonthesemedicationswhentreatinganxiety.42

TheaforementionedCAMSstudyshednewinsightinto the use of psychotherapy and SSRIs in the treat-mentofanxietyinthepediatricpopulation.Thisstudyemployedflexibledosingofsertralinestartingat25mgthatcouldbeadjustedupto200mg,withameandoseof133.7mg(range25-200mg)inthecombinationgroupand146mg(range25-200mg)inthesertralinealonegroup.Therewereminimaltonoadverseeffectsofsertralinenotedduringthestudy.Overall,CAMSshowednotonlythatcombinationtherapy is superior to CBT or SSRI alone, but also that CBTorSSRIalonecanbeeffectiveandtoleratedaswellforthetreatmentofSAD,GAD,andseparationanxiety disorder.49TheaforementionedPOTSstudyproducedsimilarresultswithrespecttoSSRItreat-ment of pediatric OCD.50 POTSalsousedaflexibledos-ingscheduleforsertraline,startingat25mg,whichcouldbeadjustedupto200mg.Themediandosesofsertralinewere150mginthecombinationgroup,and200 mg in the sertraline alone group. Again, this study foundthecombinationtherapysuperiortoCBTalone,whichwassuperiortosertralinealone.AsinCAMS,sertralinewashighlytoleratedwithnoswitchesintomania or increased suicidality in the study groups, andonly2participantswithdrewfromthestudyduetoadverseeffects.POTSfoundthatcombinationCBTandSSRItreatmentledtobetterremissioninOCDthaneithermodalityalone,withCBTaloneoutper-formingmedicationalone.

Other randomized controlled trials of SSRIs for anxiety inthepediatricpopulationhavegenerallyreportedpositiveresults.Ameta-analysisofpediatricanxietypsychopharmacologytrialsshowedthat59%respond-edonSSRItreatmentcomparedto31%onplacebo,withnoindicationofdifferencesinefficacyamongtheSSRIs(yetauthorsnotedthelackofhead-to-headtrials).59 Most of the evidence for SSRIs is strongest in regards to the treatment of OCD.59Thesamemeta-analysisshowedevidencethatfluoxetineandparox-etinecouldimprovefunctioningwithshort-termuse,butnoevidencethatfluoxetinecouldpreventrelapsewithlong-termuse.ThereviewalsonotedalargeportionofstudyparticipantsleavingSSRIstudiesforreportedadverseeffects,especiallyathigherdosesof the SSRIs, leading the authors to recommend using lowerdosesofthesemedicationsandtitratingupastolerated. Evidence for SSRIs in the treatment of pedi-atric PTSD is more limited, and 2 randomized trials in thispopulationfoundlimitedsupportfortheireffi-cacy.49,59 The American Academy of Child and Adoles-centPsychiatry’s(AACAP)PracticeParameteronthetreatment of pediatric anxiety recommends choosing anSSRIbasedonthesideeffectprofile,durationofaction,andpositiveresponsetoaparticularSSRIinafirst-degreerelative.42

Industry-sponsoredplacebo-controlledtrialsprovidesomeinitialevidencefortheeffectivenessoftheserotoninnorepinephrinereuptakeinhibitor(SNRI)venlafaxineintreatingbothSAD60 and GAD61 among children and adolescents. For pediatric anxiety, the Cochranereviewnotednodifferencesinthetolerabil-ity of venlafaxine compared to the SSRIs.59However,onetrialdidreportadifferenceinsubjectheightsaftertreatmentofthoseinthevenlafaxinearmversusthe placebo arm.61 TCAs are less used in clinical prac-ticesincetheadventoftheSSRIs,yetthereissomeevidence behind them in the treatment of pediatric anxietydisorders.TCAsarenolongerroutinelyusedduetotheneedforcardiacmonitoring,multiplesideeffects,andmedicalriskwithoverdose.Imipraminehasequivocaldatainregardstoseparationanxietyand school phobia.42 Clomipramine, on the other hand, has strong data in regards to the treatment of pediatric OCD.62 Despite some good evidence, TCAs arestillconsideredsecond-lineforpediatricOCDdueto similar response rates to the SSRIs that have more favorablesideeffectprofiles.

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Buspironeisaserotonin5-HT1ApartialagonistFDA-approved for anxiety in adults, yet it has minimal data to support its use in pediatric anxiety. Similarly, mul-tiplestudiesindicatethatbenzodiazepinesareequiva-lenttoplacebointhepediatricpopulation.42,59 Due toalackofefficacyevidenceandseveresideeffects,it is recommended that benzodiazepines not be used withchildrenandadolescents,oratbestreservedforsevere cases and used as acute treatment.

Recommendations for PracticeEvidence suggests that pediatric anxiety disorders are impairing,andoftenpersistandpotentiallycontributeto the development of other psychiatric problems throughoutdevelopment.Systematicscreeningforpediatric anxiety disorders using one or more of the aforementionedvalidatedscreeninginstrumentsiscritical,andshouldbeintegratedintotheintakeprocedures in all pediatric and child psychiatric clinics.

It is recommended that clinicians assess anxiety using amulti-informantapproach,asthisislikelytoprovidea more complete picture of overall symptomatology and impairment. A large body of research suggests thatbothCBTandSSRIsareeffective,particularlywhencombined,inthetreatmentofpediatricanxietydisorders, and in the case of CBT, treatment gains are oftenpreserved5ormoreyearsout.TF-CBTisthefirst-linetreatmentforyouthswithPTSDsymptoms,withmedicationsplayingamoresupplementaryrole,possiblytotreatsymptomsofcomorbidconditions.Preventiveinterventions,particularlythoseincorpo-ratingaspectsofCBTanddirectedtowardyouths(andtheirfamilies)whoareexperiencingsubthresholdanxietysymptoms,maybeeffectiveinpreventingtheeventual onset of anxiety disorders.

References

1. Kessler RC, Ruscio AM, Shear K, et al. Epidemiology of anxiety disorders. Curr Top Behav Neurosci.2010;2:21-35.2. Chavira D, Stein M, Bailey K, et al. Child anxiety in primary care: Prevalent but untreated. Depress Anxiety.2004;20(4):155-164.3. Diagnostic and Statistical Manual of Mental Disorders,5thEdition:DSM-5.5thedition.AmericanPsychiatricPublishing;2013.4. CostelloEJ,EggerHL,AngoldA.Thedevelopmentalepidemiologyofanxietydisorders:phenomenology,prevalence,andcomorbidity.Child

Adolesc Psychiatr Clin N Am.2005;14(4):631-648.5. CostelloEJ,EggerHL,CopelandW,etal.Thedevelopmentalepidemiologyofanxietydisorders:phenomenology,prevalence,andcomorbid-

ity. Anxiety Disorders in Children and Adolescents.2nded.Cambridge:CambridgeUniversityPress;2011:56-75.6. GellerDA,MarchJ.Practiceparameterfortheassessmentandtreatmentofchildrenandadolescentswithobsessive-compulsivedisorder.J

Am Acad Child Adolesc Psychiatry.2012;51(1):98-113.7. Phobic and Anxiety Disorders in Children and Adolescents: A Clinician’s Guide to Effective Psychosocial and Pharmacological Interventions.

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resultsfromtheNationalSurveyofAdolescents.J Consult Clin Psychol.2003;71(4):692-700.9. CarrionVG,WeemsCF,RayR,etal.TowardanempiricaldefinitionofpediatricPTSD:ThephenomenologyofPTSDsymptomsinyouth.J Am

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withoutcomorbidmajordepression.Psychiatry Res.1991;37(3):333-348.13. TurnerSM,BeidelDC,CostelloA.Psychopathologyintheoffspringofanxietydisorderspatients.J Consult Clin Psychol.1987;55(2):229-235.14. ManassisK,BradleyS,GoldbergS,etal.Attachmentinmotherswithanxietydisordersandtheirchildren.J Am Acad Child Adolesc Psychia-

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2001;179(2):116-121.18. EssauCA,ConradtJ,SasagawaS,etal.Preventionofanxietysymptomsinchildren:Resultsfromauniversalschool-basedtrial.Behav Ther.

2012;43(2):450-464.19. KellerM,LavoriP,WunderJ,etal.Chroniccourseofanxietydisordersinchildrenandadolescents.J Am Acad Child Adolesc Psychiatry.

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1992;31(4):595-599.20. OllendickTH,KingNJ.Diagnosis,assessment,andtreatmentofinternalizingproblemsinchildren:Theroleoflongitudinaldata.J Consult

Clin Psychol.1994;62(5):918-927.21. MrazekPB,HaggertyRJ.Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research.NationalAcademiesPress;

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25(8):1046-1059.23. LayneAE,BernsteinGA,MarchJS.Teacherawarenessofanxietysymptomsinchildren.Child Psychiatry Hum Dev.2006;36(4):383-392.24. Hirshfeld-BeckerDR,BiedermanJ.Rationaleandprinciplesforearlyinterventionwithyoungchildrenatriskforanxietydisorders.Clin Child

Fam Psychol Rev.2002;5(3):161-172.25. BarrettPM,FarrellLJ,OllendickTH,etal.Long-termoutcomesofanAustralianuniversalpreventiontrialofanxietyanddepressionsymp-

tomsinchildrenandyouth:Anevaluationofthefriendsprogram.J Clin Child Adolesc Psychol.2006;35(3):403-411.26. RapeeRM.Thepreventativeeffectsofabrief,earlyinterventionforpreschool-agedchildrenatriskforinternalising:follow-upintomiddle

adolescence. J Child Psychol Psychiatry.2013;54(7):780-788.27. GinsburgGS.Thechildanxietypreventionstudy:Interventionmodelandprimaryoutcomes.J Consult Clin Psychol.2009;77(3):580-587.28. MacLeodC,RutherfordE,CampbellL,etal.Selectiveattentionandemotionalvulnerability:assessingthecausalbasisoftheirassociation

throughtheexperimentalmanipulationofattentionalbias. J Abnorm Psychol.2002;111(1):107-123.29. ChristensenH,PallisterE,SmaleS,etal.Community-basedpreventionprogramsforanxietyanddepressioninyouth:Asystematicreview. J

Prim Prev.2010;31(3):139-170.30. KesslerRC,SonnegaA,BrometE,etal.Posttraumaticstressdisorderinthenationalcomorbiditysurvey.Arch Gen Psychiatry.

1995;52(12):1048-1060.31. CohenJA,DeblingerE,MannarinoAP,etal.Amultisite,randomizedcontrolledtrialforchildrenwithsexualabuse–relatedPTSDsymptoms.

J Am Acad Child Adolesc Psychiatry.2004;43(4):393-402.32. Macy R, Macy D, Gross S, et al. Save the Children Basic Training for the 9-Session CBI: A Psychosocial Trauma Informed Structured Interven-

tion for Youth Facing Life Threat and Other Extreme Traumatic Stress Exposures.Boston,MA:CenterforTraumaPsychology;1999.33. GregoryAM,EleyTC.Geneticinfluencesonanxietyinchildren:Whatwe’velearnedandwherewe’reheading.Clin Child Fam Psychol Rev.

2007;10(3):199-212.34. CostelloEJ,MustilloS,ErkanliA,etal.Prevalenceanddevelopmentofpsychiatricdisordersinchildhoodandadolescence.Arch Gen Psy-

chiatry.2003;60(8):837-844.35. BruceSE,YonkersKA,OttoMW,etal.Influenceofpsychiatriccomorbidityonrecoveryandrecurrenceingeneralizedanxietydisorder,social

phobia,andpanicdisorder:a12-yearprospectivestudy.Am J Psychiatry.2005;162(6):1179-1187.36. WittchenHU,LiebR,PfisterH,etal.Thewaxingandwaningofmentaldisorders:evaluatingthestabilityofsyndromesofmentaldisorders

inthepopulation. Compr Psychiatry.2000;41(2Suppl1):122-132.37. SchwartzCE,SnidmanN,KaganJ.Adolescentsocialanxietyasanoutcomeofinhibitedtemperamentinchildhood.J Am Acad Child Adolesc

Psychiatry.1999;38(8):1008-1015.38. BeesdoK,BittnerA,PineDS,etal.Incidenceofsocialanxietydisorderandtheconsistentriskforsecondarydepressioninthefirstthree

decades of life. Arch Gen Psychiatry.2007;64(8):903-912.39. WoodwardLJ,FergussonDM.Lifecourseoutcomesofyoungpeoplewithanxietydisordersinadolescence.J Am Acad Child Adolesc Psychia-

try.2001;40(9):1086-1093.40. GellerDA,BiedermanJ,JonesJ,etal.Isjuvenileobsessive-compulsivedisorderadevelopmentalsubtypeofthedisorder?Areviewofthe

pediatric literature. J Am Acad Child Adolesc Psychiatry.1998;37(4):420-427.41. PerkoniggA,PfisterH,SteinMB,etal.Longitudinalcourseofposttraumaticstressdisorderandposttraumaticstressdisordersymptomsina

community sample of adolescents and young adults. Am J Psychiatry.2005;162(7):1320-1327.42. Practiceparameterfortheassessmentandtreatmentofchildrenandadolescentswithanxietydisorders.J Am Acad Child Adolesc Psychia-

try.2007;46(2):267-283.doi:10.1097/01.chi.0000246070.23695.06.43. BirmaherB,BrentDA,ChiappettaL,etal.PsychometricpropertiesoftheScreenforChildAnxietyRelatedEmotionalDisorders(SCARED):a

replicationstudy.J Am Acad Child Adolesc Psychiatry.1999;38(10):1230-1236.44. SilvermanWK,OllendickTH.Evidence-basedassessmentofanxietyanditsdisordersinchildrenandadolescents.J Clin Child Adolesc Psy-

chol.2005;34(3):380-411.45. ChoudhuryM,PimentelS,KendallPC.Childhoodanxietydisorders:Parent–child(dis)agreementusingastructuredinterviewfortheDSM-

IV.J Am Acad Child Adolesc Psychiatry.2003;42(8):957-964.46. KendallPC.Treatinganxietydisordersinchildren:Resultsofarandomizedclinicaltrial.J Consult Clin Psychol.1994;62(1):100-110.

doi:10.1037/0022-006X.62.1.100.47. KendallPC,Flannery-SchroederE,Panichelli-MindelSM,etal.Therapyforyouthswithanxietydisorders:Asecondrandomizedclincaltrial. J

Consult Clin Psychol.1997;65(3):366-380.48. MarchJS,MulleK.OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual.NewYork:GuilfordPress;1998.49. WalkupJT,AlbanoAM,PiacentiniJ,etal.Cognitivebehavioraltherapy,sertraline,oracombinationinchildhoodanxiety.N Engl J Med.

2008;359(26):2753-2766.doi:10.1056/NEJMoa0804633.50. ThePediatricOCDTreatmentStudy(POTS)Team.Cognitive-behaviortherapy,sertraline,andtheircombinationforchildrenandadolescents

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withobsessive-compulsivedisorder:Thepediatricocdtreatmentstudy(POTS)randomizedcontrolledtrial.JAMA.2004;292(16):1969-1976.doi:10.1001/jama.292.16.1969.

51. DeblingerE,MannarinoAP,CohenJA,SteerRA.Afollow-upstudyofamultisite,randomized,controlledtrialforchildrenwithsexualabuse-related PTSD symptoms. J Am Acad Child Adolesc Psychiatry.2006;45(12):1474-1484.doi:10.1097/01.chi.0000240839.56114.bb.

52. SaavedraLM,SilvermanWK,Morgan-LopezAA,KurtinesWM.Cognitivebehavioraltreatmentforchildhoodanxietydisorders:long-termeffectsonanxietyandsecondarydisordersinyoungadulthood.J Child Psychol Psychiatry.2010;51(8):924-934.doi:10.1111/j.1469-7610.2010.02242.x.

53. PiacentiniJ,LangleyA,RoblekT.Cognitive-Behavioral Treatment of Childhood OCD: It’s Only a False Alarm: Therapist Guide.Oxford;To-ronto:OxfordUniversityPress;2007.

54. Southam-GerowMA,WeiszJR,ChuBC,etal.Doescognitivebehavioraltherapyforyouthanxietyoutperformusualcareincommunityclin-ics?Aninitialeffectivenesstest.J Am Acad Child Adolesc Psychiatry.2010;49(10):1043-1052.doi:10.1016/j.jaac.2010.06.009.

55. GinsburgGS,BeckerKD,DrazdowskiTK,TeinJ-Y.Treatinganxietydisordersininnercityschools:resultsfromapilotrandomizedcontrolledtrial comparing CBT and usual care. Child Youth Care Forum.2012;41(1):1-19.doi:10.1007/s10566-011-9156-4.

56. BarringtonJ,PriorM,RichardsonM,AllenK.EffectivenessofCBTversusstandardtreatmentforchildhoodanxietydisordersinacommunityclinicsetting.Behav Change.2005;22(01):29-43.doi:10.1375/bech.22.1.29.66786.

57. SilvermanWK,FieldA.Anxiety Disorders in Children and Adolescents.Cambridge,UK:CambridgeUniversityPress;2011.58. KhannaMS,KendallPC.Computer-assistedcognitivebehavioraltherapyforchildanxiety:Resultsofarandomizedclinicaltrial.J Consult Clin

Psychol.2010;78(5):737-745.doi:10.1037/a0019739.59. IpserJC,SteinDJ,HawkridgeS,HoppeL.Pharmacotherapyforanxietydisordersinchildrenandadolescents.In:Cochrane Database of Sys-

tematic Reviews.JohnWiley&Sons,Ltd;2009.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005170.pub2/abstract. Accessed December 13, 2013.

60. MarchJS,EntusahAR,RynnM,etal.ArandomizedcontrolledtrialofvenlafaxineERversusplaceboinpediatricsocialanxietydisorder.Biol Psychiatry.2007;62(10):1149-1154.doi:10.1016/j.biopsych.2007.02.025.

61. RynnM.Efficacyandsafetyofextended-releasevenlafaxineinthetreatmentofgeneralizedanxietydisorderinchildrenandadolescents:twoplacebo-controlledtrials.Am J Psychiatry.2007;164(2):290.doi:10.1176/appi.ajp.164.2.290.

62. DeVeaugh-GeissJ,MorozG,BiedermanJ,etal.Clomipraminehydrochlorideinchildhoodandadolescentobsessive-compulsivedisorder—amulticentertrial.J Am Acad Child Adolesc Psychiatry.1992;31(1):45-49.doi:10.1097/00004583-199201000-00008.

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005170.pub2/abstract

13

Mary N. Cook, MD; Gautam Rajendran, MD; Jason Williams, PsyDMaryN.Cook,MD;GautamRajendran,MD;JasonWilliams,PsyD

The Evidence Base for the Assessment and Treatment ofAttention-Deficit/HyperactivityandOppositional

DefiantDisorder

Introduction

Attention-Deficit/Hyperactivity Disorder (ADHD)ADHDisacommon,oftenchronic,treatablechild-hoodpsychiatricillness,characterizedbyapatternofdevelopmentallyinappropriateinattention,motorrestlessness,andimpulsivitythataffectsfrom5%to9%ofschool-agedchildren.1TheincidenceofADHDhasbeenestimatedashighas12%inchildbehavioralhealthoutpatientpopulations,and20%ofinpatientpopulations.Thepredominantlyinattentivetypeisrelativelymorecommoninfemales.ADHDoftengoesunrecognizedanduntreatedasdemonstratedbyarecentstudy,whichfoundthatamong a community sample of 3,082 youngsters, only52.1%ofpatientsfoundtomeetcriteriaforADHDhadbeenpreviouslyidentified,and68%ofthoseidentifiedhadnotreceivedtreatment.2ADHDhasbeenassociatedwithhighlevelsofcomorbidity,impairment, and persistence into adolescence and young adulthood.1Takentogether,thesecharacter-isticsmakeearlyrecognitionandtreatmentofADHDofparamountimportance.Treatmentoptionsincludebehaviormanagement,medicationalone,oracombi-nationofthetwo.

Oppositional Defiant Disorder (ODD)ODDisconsideredthelesssevereofthe2majordis-ruptivebehavioralsyndromesofchildhood,theotherbeingConductDisorder.ODDhasbeenestimatedtooccurinabout3%-15%ofchildren,withboyshavingonly a marginally higher prevalence rate than girls.3

WhilesomeofthecharacteristicsofODDmightbetypically observed during toddlerhood or adoles-cence, the DSM criteria that specify both clinically sig-nificantsymptomatologyforaminimumof6monthstypicallyexcludesthesedevelopmentally-appropriatebehaviors. ChildrenwithODDdemonstrateargumentative,disobedient,anddefiantbehavior,mostcommonlywithauthorityfiguressuchasparentsorteachers,al-thoughsuchinteractionscanalsobenotedinrelationtotheirownpeers.Theyaresometimesportrayedasbeingstubbornandunnecessarilynegativistic,oftenadoptingaself-defeatingstancewithauthorityfig-ures.Forexample,childrenwithODDareoftenwillingtoloseaprivilegeortoy,oracceptadifficultconse-quence, rather than lose an argument or concede a previouslyadoptedpositionofdefiance.ChildrenwithODDareexperiencedasbeingprovocative,astheywilloftendelay,procrastinate,orresorttosneakyordevious behavior to undermine an established rule or routineathome.

Etiology and Pathophysiology

ADHDGeneticfactorsareimplicatedinADHD,buttheirmechanismsofactionarenotcompletelyunderstood.ADHDverylikelyresultsfromamixtureofdominantandrecessivemajorgenesthatactwithcomplexpolygenictransmissionpatterns.4Twin,family,andadoptionstudiesofADHDhavesupportedastronggeneticcontributiontothedisorder,withheritabilityestimatesrangingfrom60%-90%.4,5Geneticstudies

Mary N. Cook, MD; Gautam Rajendran, MD; Jason Williams, PsyD



14

Attention-Deficit/Hyperactivity and Oppositional Defiant Disorders

havedemonstratedthatADHDsymptomsareoftenassociatedwithalterationsingenesinvolvedwithcat-echolamine transmission.6 More recent research high-lightedgenesinvolvedwithdopamine(DA)transmis-sion,andfoundassociationswiththeDAD1,D4,andD5 receptors, and the DA transporter.7-9 Also reported areassociationsofADHDwithnorepinephrine(NE)genes,includingthesyntheticenzymeforNE,dopa-mine-beta-hydroxylase,theNEtransporteraswellastheAlpha-2Adrenergic(α2A)receptor,whichisthesiteofNE’sbeneficialactionsinthePrefrontalCortex(PFC).10-12SuchsuboptimalcatecholamineregulationinthePFCmaycontributetotheimpairedattention,impulsiveness,andhyperactivebehaviorobservedinpatientswithADHD.13 There is increasing evidence that the frontostriatal networkisalikelycontributortothepathophysiologyofADHD.ThisnetworkinvolvesthelateralPFCanditsconnectionstothedorsalanteriorcingulatecor-tex,caudatenucleus,andputamen.InsubjectswithADHD,reductionsintotalcerebralandgraymattervolumehavebeenobserved,particularlyinthePFC,basal ganglia (striatum), dorsal anterior cingulate cor-tex, corpus callosum, and cerebellum.14 ThePFCisimportantforsustainingattentionoveradelay,inhibitingdistraction,anddividingatten-tion.ThePFCintherighthemisphereisespeciallyimportantforbehavioralinhibition.LesionstothePFCproduceaprofileofdistractibility,forgetfulness,impulsivity, poor planning, and locomotor hyperac-tivity.ThePFCisverysensitivetoitsneurochemicalenvironment,andeithertoolittle(drowsiness)ortoomuch(stress)catecholaminereleaseinthePFCweak-enscognitivecontrolofbehaviorandattention.15,16 Othernotablefindingsincludeevidencethatnorepi-nephrine enhances signalsthroughpostsynapticα2AreceptorsinthePFC,whiledopaminedecreasesnoise (ordistraction)throughmodestlevelsofD1receptorstimulation.Environmentalinfluenceshavealsobeendemonstrat-edtoplayinroleintheetiologyofADHD;childrenex-posedprenatallytoalcoholcanbecomehyperactive,disruptive,impulsive,andareatanincreasedriskfora range of psychiatric disorders.17Maternalsmokingproducesa2.7-foldincreasedriskforADHD,18 and a dose-responserelationshipbetweenmaternalsmok-ingduringpregnancyandchildhyperactivityhasbeenreported.19Thisishypothesizedtobeduetoaneffect

onnicotinicreceptors,whichmodulatedopaminergicactivity.20Additionalperinatalfactorshavealsobeenimplicated,witha2-foldincreaseinADHDinverylow-birthweightchildren,andanincreasedrateofpreg-nancyandbirthcomplicationsinmothersofchildrenlaterdiagnosedwithADHD.21 Among postnatal fac-tors,aroleformalnutritionanddietarydeficiencyinADHDhasbeenproposed.22

ODDSeveral psychosocial factors have been proposed in thegenesisandperpetuationofODD,inadditionto neurobiological and temperamental character-istics.Parentswithinsufficienttimeandemotionalenergymaypredisposethechildtoseektheiratten-tioninmaladaptiveways.Inconsistentmethodsoflimitsetting,disciplining,andsettingstructurecouldcontributetodeficientinternalworkingmodelsofsocialinteraction.23Achildidentifyingwithaparentwhoisalsostubborn,unpredictable,andnegativisticinfamilyandsocialinteractionsasarolemodelcouldbeexpectedtodemonstratedisobedientanddefiantbehavior.24

Langbehnetal25 suggested that symptoms of ODD inhighrisk,adoptedmalesmaybelinkedtogenetictraitsleadingtoadultantisocialpersonality.Inasam-pleofclinic-referredboyswithODD,44%developedCDovera3-yearperiod.26Riskfactorsforprogressionto Conduct Disorder include poverty, young maternal ageatfirstchildbirth,andparentalsubstanceabuse.26 Physicalfighting,lowsocioeconomicstatusoftheparent, ODD, and parental substance abuse have also beenshowntopredicttheonsetofCD.Attention-def-icithyperactivitydisorder(ADHD)predictedanearlyonset, but not later onset, of CD.27

Differential Diagnosis and Comorbidity

ADHDADHDcommonlyco-occurswithothermedicalandpsychiatricconditions.28 Studies suggest that as many as67%ofchildrenwithADHDhaveacoexistingconditionsuchasanadditionalpsychiatricproblem,learning disability, or developmental delay.29 The psychiatricconditionsmostlikelytobefoundcomor-bidalongsideADHDinclude:ODD(prevalenceof35%inADHD),conductdisorder(prevalenceof30%inADHD),anxietydisorder(prevalenceof25%inADHD),

15


andmooddisorder(prevalenceof18%inADHD).28 Additionally,othergeneticconditionsoftenmas-queradeasADHDandviceversa.30 Acute and chronic psychosocialstressorsmayinfluencechildbehaviorandfunctioningthroughmediationofhypothalamo-pituitaryaxisfunctioning,soallenvironmentalsystemsconnected to a child, including family and school, should be assessed.31

Dependentonboththespecificdefinitionsusedandtheresearchsetting,12%to60%ofchildrenwhohaveADHDmayhaveacoexistinglearningorlanguagede-lay.32ADisorderofWrittenLanguageisthemostcom-mondisabilityfoundtogetherwithADHD.33 Because mostchildrenwhohaveADHDexperienceacademicunderachievement,itisimportanttodistinguishwhetheralearningdisabilityalsoispresent.34

ODDCommoncomorbiditieswithODDincludeADHD,learningdisabilities,mooddisorders(depression,orbipolar disorder), and anxiety disorders. The recogni-tionandprompttreatmentofsuchconditionsises-sential,asitmaybedifficulttoimprovethesymptomsofODDwithouttreatingthecoexistingdisorder;suchdelaymayleadtorapiddeteriorationintheparentchildrelationshipandpreventabledisciplinaryissuesintheclassroom.AproportionofchildrenwithODDmay go on to develop conduct disorder.

Clinical Assessment

ADHDThe American Academy of Child and Adolescent Psy-chiatry’sPracticeParameterfortheAssessmentandTreatmentofChildrenandAdolescentswithAttentionDeficit/HyperactivityDisorder1 provides a detailed approachtoassessment,whichisbrieflysummarizedhere.PreliminaryassessmentforADHDoccursviaaclinicalinterview,whichshouldinvolvethechildandcaregivers. Further screening for the number, sever-ity,andsettingsofADHDsymptomsiscommonlyachievedthroughthecollectionofsymptomchecklistorratingscalesthatmaybecompletedbythepa-tients,caregivers,andteachers,dependingonthein-strumentchosen.Informationmustbegatheredfromcollateralsourcestoassesswhethersymptomsareev-ident,acrossratersandsettings,asADHD,which,bydefinition,presentspervasively.BecausetheDSM-5

symptomsforADHDwerenotformulatedviaascien-tificallyrigorousprocess,andbecausethereisagooddealofcriterionoverlapwithotherconditions,itischallengingtoestablisharatingscaleorscoringsymp-tomthatcandefinitivelyascertainwhetherornotaspecificchildhasADHD.Therefore,ADHD-specificratingscalesarenotdiagnostic.However,theymaybeusedtogatherinformationaboutthechild’sbehaviorsfromtheparent,and/orteacher.TheseratingscalesassessthecoresymptomsofADHD,asspecifiedintheDSM5,andtheyarerelativelyeasytoadminister.28

Theutilityoftheratingscalesrestsinthefactthatthey are comprised of DSM 5 symptoms.35Ratingscalesprobablyaremostusefulindocumentingwhethertheraterseesthecoresymptomsasbeingpresentforaspecificchildcomparedwithhisorhersame-agepeers.TheclinicianalsoshouldrecognizethatADHD-specificratingscalesdifferintheirnor-mativedata.35Forexample,normativedatafortheConnorsScalesandtheAttentionDeficitDisorderEvaluationScale(ADDES-3)wereformulatedbasedondiscrete age ranges (eg, comparing ages 3 to 5, and 6 to8);whereasotherscales,suchastheADHD-Symp-tomsRatingScale(ADHD-SRS),establishednormativedata based on broader age ranges (eg, 5 to 12 years, and 13 to 18 years).32 Only the Connors Scales have normativedataforpreschool-agechildren.Norma-tivedataalsomaydifferbyrace,sex,andgeographicarea.Therefore,whenusingaratingscale,itmaybedifficulttointerprettheresultsiftheclinician’spar-ticularpatientsampleisnotrepresentedinthescale’snormativedata.36,37

Ratingscalesalsomaybeusedtomeasurebehavioralchangesthatoccurovertimeorinresponsetotreat-ment.However,fewstudieshavebeenpublishedde-scribingtheirdiagnosticutilityinthiscontext.ManyoftheADHDratingscalesalsoprovidescreeningques-tionsforcomorbidconditions.38

Evidence-Based Interventions for ADHD and ODD

Psychosocial TreatmentsThereareseveralmajorfactorstoconsiderwhenmakingachoiceaboutwhatinterventionstrategiestousewithchildrenwhodisplaydisruptivebehavior,includingADHDandODD.Thesefactorsincludethequality of the research base (including documented

16


treatmentoutcomes),theeaseandpracticalityofimplementationforthepopulationtobeserved,andthe type of training and infrastructure needed.36,37 Dozens of psychosocial treatment protocols have beenestablishedasefficaciousfordisruptivebehav-iordisorders.ThefollowingcontentfocusesontheTripleP(PositiveParentingProgram),ParentManage-mentTraining,andParentChildInteractionTherapy,whichareamongthemostwidelydeployedandwellestablished.39The2013SAMA’spublicationprovidesathorough,evidence-basedoverviewofavailablepsychosocialtreatmentswhenworkingwithchildrenwithimpulsivebehaviors.Triple P (Positive Parenting Program). Triple P is a multi-levelsystemofparentingandfamilysupportprogramsthatapplytoprevention,earlyintervention,and treatment.39ThedevelopersareMathewSand-ers and his colleagues from University of Queensland in Australia. The program is used in a number of countries, including 9 states in the U.S. The intent of TriplePistopreventorreducebehavioral,emotional,and developmental problems in children. This reduc-tioninsymptomsisaccomplishedbyenhancingtheskills,knowledge,andconfidenceofthekeypeoplein children’s lives: their parents. It is designed to be usedwithchildrenfrombirthto16years,andcanbe delivered by a range of professionals in primary care (nurses and physicians), mental health, and educationalsettings(family/parentliaisons,daycarepersonnel, and school counselors). It is available in 10 differentlanguages,andculturaladaptationscanbemadedependingonthetargetedpopulation.40

Theinterventionoffers5differentlevelsofservicethat increase in intensity as a child and family’s need increases.Level1isapreventionapproach,andismoreinformationalinnature.Level2beginsusingabriefelectiveinterventionaimedatparentswithspecificconcernsabouttheirchild’sbehaviorand/ordevelopment.Level3beginstonarrowtheinterven-tiontoaveryspecificconcernfromtheparents.Thesessions become longer and more frequent at this level.ByLevel4,thereisabroadenedparenttrain-inginterventionforthosewhowanttoincreasetheirpositiveparentingskills.Level5isthe“EnhancedTripleP.”Theinterventionatthislevelisintensiveandtailoredforfamilieswithincreasedproblemsandad-ditionalstressors(eg,parentdepressionordivorce).

Triple P has been studied extensively since 1977, and has a strong research base. There are 29 randomized clinicaltrials,11controlledsingle-subjectstudies,9effectivenesstrials,and6disseminationtrials.Anin-terestingandinnovativeRCTwasdonelookingattheculturally and ethnically diverse children in China.39 Thesettingsofimplementationhavealsobeendi-verse, spanning both mental health and community settings.Parent Management Training-Oregon (PMTO). The PMTOmodel,basedonsocialinteractiontherapy,wasoriginallydevelopedinthe1970’sbyGeraldPatterson,MarionForgatch,andtheircolleaguesattheOregonSocialLearningCenter.39 PMTO is both a behavioralpreventionandclinicalinterventionmodel.Itfocusesonenhancingeffectiveparenting,whilereducingcoerciveparentingpractices.TheprogramiswidelydisseminatedinNorway,theNetherlands,andin 13 sites in the U.S. PMTO is designed for children aged 4 to 12 years old whodisplayseriousdisruptivebehaviors.Thetypicalsettingofimplementationistheclinic,butitcanalsobedeliveredinthehome.Theinterventionisdeliv-eredbytrainedproviders(typicallymaster’slevel-preparedprofessionals)over20sessions.However,thenumberofsessionscanbemodifiedtomeettheneedsofanindividualfamily.Theinterventionre-quiresparticipationofchildrenandparents.PMTOisamanual-basedinterventionwiththefollow-ing5essentialcomponents:(1)skillencouragement,whichteachespro-socialdevelopmentbybreakingbehaviorsdownintosmallstepsandcontingentposi-tivereinforcement;(2)discipline,whichdecreasesnegativebehaviorusingcontingentandappropriatemildsanctions;(3)monitoringorsupervisionofactivi-ties,peers,andlocationofchildrenandyouth,whichhelps the parents ensure a safe environment for their children;(4)problemsolvingskills,whichhelpthefamilytonegotiateagreementsandsetrules;and(5)positiveinvolvement,whichassistsparentswithoffer-ingloving,positiveattention.Theinfrastructureandstaffingrequirementsarerelativelymodest,andtrain-ing materials are readily available. The materials have beentranslatedinto4differentlanguages,includingSpanish.AllmaterialscanbefoundatImplementationSciencesInternational,Inc.(http://www.isii.net). PMTO has been evaluated extensively in community settings.Therearealsoanumberofcomparison

http://www.isii.net

17


studies done using random assignment. Other studies using control groups have yielded promising results. Researchto-datesupportstheclaimthattreatmenteffectsmaybegeneralizedacrosssettings,andeffectsare maintained for up to 2 years. There is also some evidencetosuggestthatthetreatmenteffectsextendto other deviant behaviors beyond those that are the primary focus of the treatment. Parent-Child Interaction Therapy (PCIT). PCIT is a par-enttraining/coachingprogramforfamilieswithchil-dren2to7yearsofagewhoaredisplayingdisruptivebehaviors.Theprogramwasoriginallydevelopedin1982 by Shelia Eyberg at the University of Florida, and wasinfluencedbytheearlierworkofConstanceHanfand Diane Baumrind.39Theinterventionhasbeenimplemented in both the United States and in 3 other countries,inlaboratoryclinicalsettings,communitymentalhealthsystems,HeadStartprograms,schools,andfostercaresettings.PCITisbrokendowninto2phases,anditscompo-nentsarebasedonattachmentandsociallearningtheories.Inthefirstphase—ChildDirectedInterac-tion—theparentslearnhowtostrengthentheirattachmentthroughdemonstrationsofwarmth,responsiveness,andsensitivity,inresponsetotheirchild’s behavior. The second phase—Parent Directed Interaction—involvestheparentslearninghowtobeeffectiveauthorityfiguresbygivingdirectionsinage-appropriate,positiveways,whilesettingconsistentlimitsandlearninghowtoappropriatelyimplementconsequences(ie,timeout).Theinterventionisstructuredthrough10to16weekly,60-minutesessionswitheithertheparentalone or the parent and child dyad. Trained masters or doctoral-leveltherapistsdelivertheintervention.Thetreatmentbeginswithanassessmentofthefamilyfunctioning,movestoteachinginthe2phasesmen-tionedabove,andthentogeneralization,homework,andpost-treatmentassessment.Thetherapistmoni-tors the client’s progress through the treatment. In re-searchsettingsthemonitoringisdoneviaaone-waymirrorwitha“bug”intheearoftheparent(ie,anearphonethroughwhichthetherapistcanassisttheparentintheinteractionwiththechild).Incommu-nitysettings,someadaptationshavebeenmade,suchasaliveobservationinthefamilies’homeorinthechild’sschoolsetting;itisnotyetclearwhatimpactthosechangeshadonthefidelityoftheintervention.

PCIThasbeentestedinanumberofreplicationandfollow-upstudiesandhasbeenfoundtobeeffectiveinimprovingtheinteractionstyleofparents,andinimproving behavior problems of children at home and in school.41Thisisincomparisontowaitlistcontrolgroups,classroomcontrolgroups,andmodifiedtreat-ment groups.41 There is also promising support for the culturallysensitiveadaptationsofPCIT.42 Therearesomenoteworthyimplementationchal-lengestoconsiderwhencontemplatingtheuseofPCITasaprimaryintervention.First,itisrecommend-edthattheclinicalsettingbestructuredsimilarlytotheconditionsusedintheresearchsetting(eg,aone-waymirrorandabugintheear).43 There is also aconsiderabletimeandfinancialcommitmentfromclinicalstaff.Theestimatedcostpercliniciantraineeis$3000,plusthereisadditionalcostfortheequipmentneededtodelivertheintervention.Trainingmaterials,workshops,on-goingconsultationaswellassupervi-sor training is also available (http://pcit.phhp.ufl.edu/General_Workshop.htm).

http://pcit.phhp.ufl.edu/General_Workshop.htm

http://pcit.phhp.ufl.edu/General_Workshop.htm

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TripleP-Positive Parenting

Parent Management Training-Oregon

ParentChildInteraction Therapy

Type of EBP Prevention/Multilevel Intervention InterventionSettings Clinic,Home,School Clinic,Home Clinic

Ages 0-16 4-14 2-17Training materials available

Yes Yes Yes

Outcomes Increaseinparentalconfidence,improvementsindysfunctionalparentingstyle,reductioninchild behavior problems

Significantreductioninchild’sbehav-iorproblems,reductionsincoerciveparenting,increasesineffectiveparenting

Improvementinparent-childinter-actionstyle,improvementinchildbehavior problems

Psychosocial Treatment Summary Tables

Psychopharmacologic Treatments of ADHDRationale.Amongthepsychiatricconditionsoccur-ringinchildhood,ADHDstandsoutasonewitharelativelyrobustevidencebaseforpharmacologicinterventions.44Stimulantshavelongbeendefinitivelyestablishedasfirst-linepharmacologicinterventionsforADHD,witheffectsizesaveragingbetween.9-1.1.45 Alpha adrenergic agents and the noradrenergic re-uptakeinhibiter,atomoxetine,areregardedassecond-linetreatmentsforADHD,witheffectsizesrangingbetween.5-.7.DatafromtheMulti-ModalTreatmentofADHDStudy(MTACooperativeGroup,1999),46functionalandstructural brain imaging,47andgeneticandfamilialstudies,48 have increasingly demonstrated that this conditionhassignificantheritability,alongwithclearneurophysiological or biological underpinnings. These findings,factoredtogetherwithothervariables,suchasinsufficientaccesstopediatricmentalhealthspe-cialtycareandevidence-basedbehavioraltreatments,haveincreasinglyspurredashifttomedicationstrate-gies,astheprimaryandsometimessolotreatmentforADHD.44 Over20long-actingformulationsofstimulantmedi-cationhaveevolvedoverthepastfewdecades,notonlyleavingpractitionersamultitudeofoptions,butalsonecessitatingabroadeningofknowledgebaseandsophisticationrelatedtoprescribingforADHD.49 Themyriadandever-expandingpoolofvariedformu-lationsofstimulantsandnon-stimulantshasledto

increased confusion and errors in the prescribing and dispensingofthesedrugs.Knowingandunderstand-ingtheadvantagesanddisadvantagesofthedifferentformulationscanfacilitateoptimalandcustomizedtreatment.FormulationslikeConcerta(OROS-meth-ylphenidate),Adderall-XR(mixedamphetaminesaltsextendedrelease),andVyvanse(lisdexamfetamine)providetheconvenienceofonce-dailydosing.Eachoftheseformulationsdeliversavariedamountofstimulantatpredictabletimeintervalsthroughouttheday.Vyvansehasauniquedeliverysystemthatmaylowertheriskforpatientsabusingordivertingtheirmedication.Daytrana(methylphenidatepatch)canbegiventopatientswhoareunabletoswallowpillsandadditionallyconfersflexibilityovereffectduration,viathechoiceoftimewhenthepatchisremoved.Forpatientswhocannotswallowtabletsorcapsules,thecapsulesofFocalin-XR(dexmethylphenidateextendedrelease),Adderall-XR,Metadate-CD(methylphenidateextendedrelease),andRitalin-LA(methylphenidateLA)canbeopenedandsprinkledinapplesauceoryogurt. Stimulants.Thestimulantscanbedividedinto2broadcategories:methylphenidateandamphetamine-de-rivedproducts.Therearecurrentlyover20long-act-ingstimulantformulationsonthemarket,employingamyriadoftechnologiesformedicationadminis-tration,delivery,absorption,andmetabolism.Theproductsintroducedduringthepast1-2decadeshavebeenspecificallydesignedtoovercomeaphenome-nonknownastachyphylaxis,whichreferstoanimme-

Table 1. Psychosocial Treatment Summary Tables.

19


diatetolerancetostimulantsthatdevelopsandmustbe overcome throughout the course of a given day, inorderthatthemedicationretainitsefficacyforanextended period.49Thefirstgenerationofsustainedreleasestimulantproducts,whichincludedRitalinSR(methylphenidate sustained release) and Dexedrine Spansules (dextroamphetamine sustained release), predated the discovery of the tachyphylaxis phenom-enon,andthereforewerenotinclusiveofadeliverymechanism designed to overcome this impediment to prolongeddurationofeffect.One strategy for overcoming tachyphylaxis involves theuseofrepeateddosesofshorter-actingproductsdeliveredatdistincttimes,suchasatthezeroand

4-hourmarks,usingeitherregular,short-actingstimu-lants,orbeadedformulations,whichcontainbeadscoatedwithshort-actingandlong-actingmembranes.Examplesofmedicationsusingthisbeaded,bimodalstrategyincludeRitalinLA,FocalinXR,MetadateCD,andAdderallXR.Anothermethodologyforovercom-ing tachyphylaxis is the use of a capsule containing multiplelayersofmembranesandanosmoticpres-sure delivery system that generates an ascending dose curve, or increasing blood levels as the day transpires,anexampleofwhichincludesConcerta.VyvanseandDaytranaalsoproducepharmacokineticprofilesassociatedwithanascendingdosecurveastheir mechanism for addressing tachyphylaxis.

OnsetofAction PeakClinicalEffectPharmacokineticProfile

DurationofAction Typical #Daily Doses

Short-Acting Preparations

Regular MPH 20-60minutes ~2hours;range0.3-4hours 2-4hours 2-3

AMPH 20-60minutes 1-2hours 3-6hours 2

Regular MAS 30-60minutes 1-2hours 3-6hours 2

First-Generation, Sustained-Release Preparations (Older Delivery Systems)

MPH-SR

Metadate ER

Methylin ER

60-90minutes ~5hours;range1.3-8.2hours 4-6hours 2

AMPHSpanulesSpansules 60-90minutes NA 4-6hours 2

Second-Generation, Extended-Release Preparations (Newer Delivery Systems)

MPHCD

Ritalin-LA

30minutes-2hours Bimodalpattern† 6-8hours 1

OROS MPH 30minutes-2hours Ascendingpattern† 10-12hours 1

MASXR 1-2hours Bimodalpattern† 10-12hours 1

LAMPH 1-2hours Ascendingpattern† 10-12hours 1

MPH Patch 1-2hours Ascendingpattern† 10-12hours 1

DMPH XR 1-2hours Bimodalpattern† 6-8hours 1

Table 2.StimulantMedicationsAvailablefortheTreatmentofADHD(adaptedfromSpencer45 and Chavez49).

Legend: MPH=Methylphenidate,AMPH=Dextroamphetamine,MAS=MixedAmphetamineSalts,DMPH=Dexmethylphenidate,LAMPH=Lisdexamfetamine,XR=ExtendedRelease,SR=SustainedRelease,CD=ContinuousDelivery

20


Althoughthereareavarietyoflong-actingstimulantproducts designed to be dosed once daily, there is substantialvariationinthedrugdeliverymechanisms,alongwiththeexpecteddurationofeffectandad-verseeventprofiles.Thebulkoftheseproductsarerepresentedinthetablebelow,withtypicalrangesfortheirexpectedonset,peaklevels,duration,andnumber of daily doses.Stimulantdosingisestimatedbasedonthechildoradolescent’sweightinkilograms.Regardlessofthedurationofeffect,mechanismofdelivery,ornumberof daily doses, the total amount of methylphenidate administered can be calculated using an expected rangeof0.5-2.0mg/kg/day.45ExceptionsincludeFocalinproductsandDaytrana,withFocalin’spotencyestimatedtoberoughlydoublethatofregularmeth-ylphenidate products. Daytrana has a higher potency aswell,roughly1.5timesthatofimmediatereleasemethylphenidate,withthefollowingestimatedequivalencies:10mgDaytrana=15mgRegularRitalin(methylphenidate),15mgDaytrana=22.5mgRegularRitalin,20mgDaytrana=30mgRegularRitalin,and30mgDaytrana=45mgRegularRitalin.49 Generally, the optimal total daily amount of methylphenidate givenwillrangebetween0.6-1.0mg/kg/day.Withinthisrange,maximumbenefitisgenerallyachievedwithconcurrentexcellenttolerability.Rarelywoulda child or adolescent require dosing of typical meth-ylphenidateproductsinexcessofatotalof1.0mg/kg/day.Aggressivemethylphenidatedosingabovethatbenchmarkhasbeenassociatedwithclinicallysignificantadverseeffects,includinggrowthretarda-tion,emotionallability,sleepdisturbances,andevenauditoryhallucinations.50,51

Regardlessofthedurationofeffect,mechanismofdelivery, or number of daily doses, the total amount of amphetamine administered can be calculated using anexpectedrangeof0.3-1.5mg/kg/day.45 An excep-tionincludesVyvanse,whosepotencyislessthanthatofotheramphetamineproducts.Theestimatedequivalencesincludethefollowing:30mgVyvanse=10mgAdderall(mixedamphetaminesalts),50mgVyvanse=20mgAdderall,and70mgVyvanse=30mgAdderall.AsidefromVyvanse,amphetamineproductsareroughly1.5timesaspotentasmethyl-phenidateproducts,sotheirdosingwillberoughlytwo-thirdsofwhatmightbeusedwithtypicalRitalinproducts.Generally,theoptimaltotaldailyamount

ofamphetaminegiventoachievesignificantbenefitwhileminimizingsideeffectsshouldrangebetween0.3-0.7mg/kg/day.Rarelywouldachildoradolescentever require dosing of typical amphetamine products inexcessofatotalof0.8mg/kg/day.Aggressivedos-ingabovethatbenchmarkhasbeenassociatedwithclinicallysignificantadverseeffects,includinggrowthretardation,emotionallability,sleepdisturbances,andevenauditoryhallucinations.50,51

Alpha Adrenergic AgentsAlpha Adrenergic Agents. The 2 alpha adrenergic agentscommonlyusedassecond-linemonotherapyoradjunctivetherapy,combinedwithstimulantsforADHD,includeguanfacineandclonidine.These2medicationshavebeenwidelyusedformanyde-cades, based primarily on clinical lore. A dearth of datafromcontrolledtrialswasavailabletoestablishtheirsafetyandefficacyfortheindicationofADHD.However,inrecentyears,bothagentsweredevelopedintoextendedreleaseproducts,whichhavebeenwellstudiedincontrolledtrials,andeachnewformulationreceivedFederalDrugAdministration(FDA)approvalfortheindicationofADHD.Intuniv (guanfacine extended release) is available in the strengths of 1, 2, 3, and 4 milligrams (mg). Its safetyandefficacyhavebeendocumentedviaatleast2randomized,controlledtrials,rangingfrom8-9weeksinduration,withsubjectpoolsof345and324,aged6-17years.Intunivwassignificantlyeffectiveforschool-agedyouth,butnotforadolescents.However,thefixed-dosemethodology,usedin25%ofsubjects,didnotaccountforvariabilityinsubjectsize,age,andweight,whichwasconjecturedastheprobableexplanationforfaileddemonstrationofefficacyintheolder cohort.Kapvay (clonidine extended release) has been ap-provedbytheFDAasmonotherapyforADHD,aswellasadjunctivetherapy,withastimulant.Itssafetyandefficacyweredemonstratedviaatleast2random-ized,controlledtrials,withasubjectpoolof236,aged6-17years.Twofixeddoses,0.2mgand0.4mg,werefoundtobesignificantlyimpactfulonADHDsymptoms,withroughlycomparabletolerabilityandefficacy,andaneffectsizeof0.7.45 Atomoxetine.Atomoxetine’ssafetyandefficacyarewellestablishedviaover20randomizedcontrolledtrialsinvolvingseveralhundredsubjectsaged6-17

21


years.52Ithasbeenstudiedasanadjunctivetreat-ment,incombinationwithstimulants,andisrecom-mendedforpatientswhoeithercannottolerateafulltherapeuticdoseofstimulants,orasmonotherapyforchildreninwhomstimulantsmightbecontraindi-cated.Aonce-dailydosingregimenperformedequiva-

lentlytoatwice-dailydosingregimen,andtheeffectsizerangedbetween.5-.7.Themostcommonadverseeffectissedation,sopreferredtimeofadministrationis before bed.

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668.51. FaraoneSP,BiedermanJ,MorleyCP,etal.(2008).Effectofstimulantsonheightandweight:areviewoftheliterature. J Am Acad Child Ado-

lesc Psychiatry.47:994-1009.52. Garnock-JonesKP,KeatingGM.(2010).Spotlightonatomoxetineinattention-deficithyperactivitydisorderinchildrenandadolescents

[Review].CNS Drugs.24(1):85-88.

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Susan Lurie, MD; Gautam Rajendran, MD; Scot McKay, MD; Elise M. Sannar, MDSusanLurie,MD;GautamRajendran,MD;ScotMcKay,MD;EliseM.Sannar,MD

SchizophreniaSpectrumandOtherPsychoticDisordersin Children and Adolescents

Introduction

Therearemultiplecausesofpsychosis,includingboth psychiatric and medical. Schizophrenia, the

mainfocusofthisarticle,isoneofthemostno-table. Schizophrenia is believed to have occurred in mankindthroughouthistory,andisgenerallyassoci-atedwithsignificantmorbidity.TheWorldHealthOrganizationranksitamongthemostdisablingandeconomically catastrophic medical disorders, and oneofthetop10illnessescontributingtotheglobalburden of disease.1 Schizophrenia occurs in approxi-mately1%ofthepopulationworldwide.Itaffectsmenandwomenequally,butmentendtomanifestsymptomsonaverage5yearsearlierthanwomen.2 The concept of schizophrenia and psychosis has evolvedforwelloveracentury.Thereisgeneralcon-sensus that schizophrenia is a neurodevelopmental disorder;thefinalpresentationoftheillnessistheend state of a complex pathological neural develop-mental process that started years before the onset of the illness.3Studiessupportamultidimensionalmodel,withtheinteractionofenvironmentalandgeneticinfluencesleadingtoacomplexsyndromeofinsidiousonsetandvariedpresentation.3

SchizophreniawasfirstidentifiedasadiscretementalillnessbyDr.EmileKraepelinin1887,whotermed it dementia praecox.4TheSwisspsychiatrist,EugeneBleuler,coinedtheterm,“schizophrenia” in1911;itisderivedfromtheGreekroots,schizo (split) and phrene (mind), to describe the fragment-edthinkingofpeoplewiththedisorder.Bleulerwasalsothefirsttodescribethesymptomsoftheillnessas“positive”or“negative.”5

Approximatelyone-thirdoffirstepisodesofschizo-phrenia occur before age 19,6 hence child and

adolescentpsychiatristsarelikelytoencounteranumberofpatientswithadolescentorevenyoungeronsetillness.Early-onsetschizophrenia(EOS)referstoindividualswhohavedevelopedthefullillnessbefore age 18, and childhood onset schizophre-nia(COS;onsetbeforeage12)isasubsetofEOS.Thediagnosticvalidityofschizophreniainchildrenyounger than 6 has not been established, though a fewcaseshavebeenreported.7

Diagnostic ConsiderationsDSMII,publishedin1968,wasthefirstmanualto include disorders of childhood. The concept of schizophreniaatthattimewasbroad,andincludedchildrenwithdevelopmentaldisabilitiesinaddi-tiontothosewithpsychoticsymptoms.SinceDSMIII, published in 1980, the criteria for diagnosis of schizophreniainyouthhavebeenessentiallythesame as those for the diagnosis in adults.TheDSM-5chapteron“SchizophreniaSpectrumandOtherPsychoticDisorders”includesschizophrenia,delusionaldisorder,briefpsychoticdisorder,schizo-phreniformdisorder,schizoaffectivedisorder,sub-stance/medication-inducedpsychoticdisorder,psy-choticdisorderduetoanothermedicalcondition,and schizotypal personality disorder. These disorders arealldefinedbysymptomsin1ormoreofthefol-lowing5domains:delusions,hallucinations,disor-ganizedthinkingorspeech,grosslydisorganizedorabnormal motor behavior (including catatonia), and negativesymptoms.8 Catatonia is conceptualized differentlyinDSM-5.Itisnotaclassinitself,butcanoccurinassociationwithanumberofpsychiatricandmedicalconditions,includingschizophrenia.Thecluster A personality disorders—schizotypal, para-

Susan Lurie, MD; Gautam Rajendran, MD; Scot McKay, MD; Elise M. Sannar, MD


Denver Health Behavioral Health Services, Pediatric Mental Health Institute, Children’s Hospital Colorado

24

Schizophrenia Spectrum and Other Psychotic Disorders in Children and Adolescents

noid, and schizoid—are considered to be related to psychoticdisorders.Thecurrentdiagnosticcriteriaforschizophrenia(DSM-5)requiresthepresenceof2ormorecharac-teristicsymptoms(hallucinations,delusions,disorga-nizedspeech,disorganizedorcatatonicbehavior,and/ornegativesymptoms),adeclineinsocialoroccupa-tionalfunctioning,andevidenceofthedisorderforatleast 6 months. The subtypes (paranoid, disorganized, catatonic,residual,andundifferentiated)havebeeneliminated. Attenuatedpsychosissyndrome(APS)hasbeenincludedintheappendixofDSM-5asaconditionforfurtherstudy.Symptomsarepsychosis-like,butbelowthethresholdforafullpsychoticdisorder.Preventivestrategies,includingpsychotherapyandantipsychoticmedication,typicallytargetthisearlyphase.Thoughthere is general agreement among researchers about the existence and importance of this syndrome, there isdebateaboutwhetheritshouldbeinthemainbodyofDSM-5.Concernsincludethefactthatitcan-notbereliablydiagnosedincommunitysettings,andthatthemajorityofindividualsdiagnosedwithAPSdonotgoontodevelopschizophreniaorfull-blownpsychosis.9Thereistheriskthattheymaybeexposedtounnecessaryandpotentiallyharmfulinterven-tions.10

In the EOS research literature, the terms clinical high risk(CHR)andat risk mental state are both used to refertowhatwasformerlyknownastheprodrome. Their criteria are overlapping, but not synonymous. These terms are preferred over prodrome as not all individualsatriskwilleventuallydevelopthefullill-ness.APSwasacompromisesetofcriteriabetweenbothsetsofresearchcriteria,andinputfromless-biasedindividualsoutsidethefield.

Course of IllnessSchizophrenia is unique among psychiatric disorders inthatdistinctphasesarerecognized.Notallindividu-alswithschizophreniapassthroughallofthephases.Intheclinicalhigh-riskphase,thereisusuallysomedegreeofsocialorcognitivedeteriorationbeforetheonsetofpsychoticsymptoms.Thesechangesmaybeassociatedwithdepression,anxiety,andotherbehav-ioralproblems,aswellassubstanceuse,makingthediagnosisofschizophreniaintheearlyphasedifficult.The onset of symptoms may be acute or insidious. Of-

tentimes,thisphaseisnotappreciateduntilreflect-ingbackaftertheemergenceofpsychoticsymptoms.Theacutephaseismarkedbytheonsetofprominentpositivesymptomsandasignificantdeteriorationinfunctioning.Itmaylastseveralmonths,dependingonthe onset of treatment and the response. The recu-perative/recoveryphaseoccursaftertheremissionofacutepsychosis,andisusuallyaseveral-monthperiodwherethepatientstillexperiencessignificantimpair-ment.Negativesymptomspredominate,thoughsomepositivesymptomsmaypersist.Anumberofpatientshavesignificantdepression.Intheresidualphase,mostpatientscontinuetobesomewhatimpairedduetothenegativesymptoms.Thoughtheymayimprovesignificantly,theymayneverreturntotheirpremor-bidlevelofcognitivefunctioning.11 Some individuals remainchronicallysymptomatic,despitetreatment,and never really enter the residual phase.

Differential DiagnosisWhenanindividualpresentstoamedicalsettingwithacutepsychosis,etiologiesotherthanpsychiatriccauses need to be considered. These include medi-calconditionssuchasCNSinfections,delirium,neo-plasms,endocrinedisorders,andgeneticsyndromes,including22q11.2deletionsyndrome.Inaddition,multipledrugsofabuse(cannabis,LSD,mushrooms,anddextromethorphan)andprescriptionsmedica-tions(steroids,anticholinergics,antihistamines,andstimulants)cancausepsychoticsymptoms.Acutepsy-chosis due to toxic exposure usually resolves in days toweeks,aftertheoffendingagentisremoved.Whendrug use occurs before the onset of schizophrenia, it canbedifficulttodeterminewhetherthepsychosisisanindependentdrugeffect,orduetotheunmaskingof the underlying illness in a vulnerable individual.12 Therearealsomultiplepsychiatricconditions,otherthanschizophrenia,thatcancausepsychoticsymp-toms.Bothbipolarmooddisorderandmajorde-pressivedisordercanpresentwithfloridpsychosis,includinghallucinationsanddelusions.13,14Youthwithcertainpsychiatricdisorders,includingpost-traumaticstressdisorder(PTSD),conductdisorder,and/ordepression,tendtoreporthighratesofpsychoticsymptoms.15Childrenwhohavebeenabusedareparticularlylikelytoreportpsychoticsymptoms,anditisfrequentlydifficulttodifferentiatetrauma-relatedsymptoms from other causes of psychosis.16 Individu-

25


alswithsevereobsessivecompulsivedisorderandpoorinsightcanalsoappearpsychotic.Themajorityofchildrenandadolescentswhoreportpsychoticsymptomswillnotgoontobediagnosedwithschizo-phrenia.

Etiology/Pathophysiology

Neuroimaging StudiesVolumetricstudiesofgraymatterinyouthatriskfor schizophrenia have demonstrated smaller gray matter(GM)volumesintheprefrontalcortex(PFC),superior temporal gyrus (STG), and limbic structures such as hippocampus, anterior cingulate cortex (ACC), and insula.17Thesevolumereductionscorrelatetoan increase in symptomatology. PFC change corre-latestogreatersymptomseverityandpoorexecutivefunction.STGchangecorrelatestolanguagedeficits,andACCandinsulachangescorrelatewithnegativesymptoms.TheGMlossinschizophreniawithonsetinchildhood becomes localized to prefrontal and tempo-ralcorticesbyage20.Similarpatternsofchangehavebeenseeninmostadultstudies,supportingbiologicalcontinuitybetweenchildhood-onsetandadultformsof the illness.18Recentlongitudinalstudiesofwhitematter(WM)showintegritychangesthroughoutthecourse of illness, most prominently in the PFC.19Diffu-sion tensor imaging studies in adolescents and adults withschizophreniaconsistentlyindicatewidespreadWMabnormalities.20

Genetic StudiesMultiplegenesandcopynumbervariants(CNVs)havebeenimplicatedintheetiopathogenesisofearly-onsetschizophrenia.22q11deletionsyndromeiscurrentlythemostcommonidentifiableriskfac-tor for schizophrenia.21One-thirdofindividualswiththisgeneticprofiledevelopschizophrenia-likesymp-toms.22Theothersupportedlociassociatedwithschizophreniaaredeletionsat1q21,2p53,3q29,15p11.2,15q11.3,17q12,andNeurexin1(NRXN1),23-26andduplicationsat7q36.3,25q11–13,16p11.2and16p13.1.27,28Epistaticandepigeneticinfluencesareviewedaskeyeventsintheeventualseverity/pheno-typic expression of the illness. In the two-hit model, otherfactorscouldincludeanotherCNV,adisruptivesingle-basepairmutation,oranenvironmentaleventinfluencingthephenotype.29

Risk and Protective FactorsGeneticvulnerabilitiesandenvironmentalriskfactorslikelyinteracttotriggerpsychosisinadolescenceandyoungadulthood.Environmentalriskfactorsassociat-edwithschizophreniaincludelivinginanurbanarea,immigration,famine,prenatalandperinatalfactors,and advanced paternal age.30Highfamilyexpressedemotionandcannabisusehavealsobeenimplicat-ed.31Preventingortreatingperinatalcomplications(suchashypoxia,infection,andmalnutrition),protect-ingyouthfromeverydaystressortrauma(ortreatingitwiththerapy),decreasingexpressedemotioninthefamilyenvironment,andminimizingorpreventingcannabisuseareallpotentiallyprotective.31 Interven-ingintheperinatalperiodwithsupplementssuchascholinemayaffectlaterexpressionofschizophreniainvulnerable individuals.32

PrognosisAtthepresenttime,theprognosisforEOSisdiscour-aging.Inarecentreview,only15.4%ofindividualswithEOSexperiencedagoodoutcome,24.5%expe-riencedamoderateoutcome,and61%experiencedapoor outcome.33PatientswithEOSalsoshowaworseprognosisthanpatientswithotherpsychoticdisordersasagroup(schizoaffective,schizophreniform,orbipo-lardisorderwithpsychoticfeatures).34Poorlong-termoutcomeispredictedbylowpre-morbidfunctioning,insidiousonset,higherratesofnegativesymptoms,childhoodonset,andlowerintellectualfunction-ing.34 Suicideisprevalentinyouthwithschizophreniaspectrum disorders,35 and they may also be at higher riskforviolence.36Individualswithschizophreniahaveincreased medical morbidity in adulthood, including obesity, diabetes, and heart disease.37

AssessmentThediagnosticassessmentofanindividualpresentingwithpsychoticsymptomsshouldincludeaninterviewwiththepatientandfamily,reviewofpastmedicalrecords,andancillaryinformation(teacherreports,reviewofsubstanceuse,cognitiveassessments,andcomplete developmental and family history).12 Diag-nosticinstrumentstoassesstheCHRphaseincludetheStructuralInterviewforProdromalSyndromes(SIPS) and a severity measurement, the Scale of Prodromal Symptoms (SOPS).38-40 These instruments areprimarilyusedinresearchsettings.Astructured

26


diagnosticinterview,suchastheKiddie-ScheduleforAffectiveDisordersandSchizophrenia(KSADS),mayincreasediagnosticaccuracy.41 An accurate diagnosis is vital, as the treatment for schizophrenia can be dif-ferentfromthatofotherDSM-5psychoticdisorders.Once a diagnosis of schizophrenia is established, the PositiveandNegativeSyndromeScale(PANSS)canbeused to assess illness severity. Symptoms should be assessedperiodicallyastheymaychangeovertime.12 Comorbidissueslikesubstanceabuseand/orcogni-tivedelaysshouldalsobeassessed,astheymayaffecttheclinicalpictureandcomplicatethediagnosticevaluation.12Aspsychoticsymptomsarestronglyas-sociatedwithincreasedriskforsuicidalbehavior,42 as-sessment should also include a screen for suicidality. Certain laboratory assessments may be indicated, in-cludingacompletebloodcount(CBC),thyroidstimu-latinghormonelevel(TSH),acompletemetabolicpanel (CMP), and a urine toxicology screen. In some cases, amino acid levels, ceruloplasmin level, or por-phobilinogencanalsobechecked.Thesetestsarein-dicatedifnon-psychiatriccausesofpsychosis,suchasWilson’sdiseaseoracuteporphyriaarebeingconsid-ered.Ifthepatienthasfacialdysmorphism,cognitiveimpairment,andadditionalmedicalcomorbidities,areferraltogeneticsandachromosomalmicroarrayisindicated. An MRI is only needed if the individual has other neurological symptoms.

Treatment

Clinical High Risk PhaseInitialtreatmentforindividualsdesignatedclinicallyhighrisk(CHR)forschizophreniaispsychotherapeutic,withsupportforvarioustherapymodalities.ThereislimitedevidencethatCBTcanreducetransitiontopsychosis,whencomparedtosupportivecounselingand monitoring.43InarecentstudyofFamily-FocusedTreatment(FFT)forCHRadolescentsandyoungadults,therewasgreaterreductioninpositivesymp-toms in the FFT group versus the Enhanced Care (EC) over6months.However,onlythoseparticipantsover20showedimprovedpsychosocialfunctioningwithFFT versus EC.44PsychotherapeutictreatmentsduringtheCHRphaseareconsideredclinicalguidelines,rath-er than standard of care, due to the small number of studiessupportingtheiruseandthelackofconsistentpositivefindings.Onestudysuggestedomega3fatty

acidsmayreducetheriskofprogressiontopsychosisinCHRindividuals.45Atypicalantipsychoticsarealsosometimesusedduringthisperiod.Becauseoftherisksofsideeffects,carefulobservation,monitoring,and psychosocial treatments are preferred.

Acute Phase

Medication ManagementAntipsychoticsareconsideredthemainchoicefortreatingacutepsychoticsymptomsandschizophre-nia in adult, adolescents, and children. Studies such asCATIE(ClinicalAntipsychoticTrialsofInterventionEffectiveness),CutLASS(CostUtilityoftheLatestAntipsychoticDrugsinSchizophrenia),andEUFEST(EuropeanFirst-EpisodeSchizophreniaTrial)questionthesuperiorityofatypicalantipsychoticsovertypicalantipsychotics,andraiseconcernsaboutsideeffects,lackoflong-termefficacy,andnoncompliance.ThelandmarkTreatmentofEarly-OnsetSchizophre-nia Spectrum Disorders Study (TOESS) is the largest publicmulti-centertrialinvestigatingpsychophar-macologyforEOStodate.Inthisstudy,participantswererandomizedinto1of3groupswithflexibledoseranges:molindone10-140mg/day(n=40),olanzapine2.5-20.0mg/day(n=35),orrisperidone0.5-6mg/day(n=41).Therewerenosignificantdifferencesinre-sponseratesbetweenthe3groups–molindone50%,olanzapine34%,andrisperidone46%.46Only12%ofenrolleescompleted52weeksontheiroriginally-ran-domized treatment, and response tended to plateau aftertheacute8-weekphaseofthetrial.47 Of the 15subjectswhodiscontinuedtheirmedications,11stoppedduetoweightgain.Therewasanincreaseinweightinallarmsafter8weeks,butthosereceivingolanzapinehadthehighestweightgain,withanaver-ageof6.1kggainedcomparedto0.3kginthemolin-donegroup,and3.6kgintherisperidonegroup.46 Therewerealsochangesinbaselinecholesterol,lipid,glucose,andprolactinprofiles.Olanzapinecausedthemostsignificantmetabolicchanges,andrisperidonecausedastatisticallysignificantincreaseinprolactin.Therewerenosignificantdifferencesinextrapyrami-dalsymptoms.Allpatientsinthemolindonegroupreceivedprophylacticbenztropine,whereasthoseintheolanzapineandrisperidonegroupsdidnot.Ulti-mately,TEOSSshowedthatnoagenthadhighefficacyintreatingearly-onsetschizophrenia,andeachagent

27


hadsomeadverseeffects.Clozapinehasshownefficacyaboveotherantipsy-choticsintreatingschizophrenia.48 Its use is reserved forrefractorycases(patientswhohavefailed2ormoreantipsychotictrials)duetoitsproblematicsideeffects,includingagranulocytosis,seizures,andweightgain.49 There have been several randomized, controlledtrialscomparingclozapinetobothfirst-generationandsecond-generationantipsychoticsinthepediatricpopulation.Clozapinewasfoundtobemoreeffectivethanhaloperidolfortreatingbothpositiveandnegativesymptoms.50 In 2 comparison, double-blindtrials,clozapinewasmoreeffectiveforbothnegativeandpositivesymptoms.51,52 A naturalis-ticfollow-upstudyofpatientsonmedicationsfor3-11yearsdemonstratedthatclozapinehasbetterclinicalimprovement,long-termfunctioning,andtolerabilitycompared to haloperidol, risperidone, and olanzap-ine.53Clozapineinitiationrequiresaslowincreaseofthemedicationovertime.Monitoringforagranulo-cytosisrequireswhitebloodcell(WBC)andabsoluteneutrophil(ANC)countsatbaseline,andthenweeklyforatleastthefirst6months.54,55 Earlystudiesshowedefficacyoftypicalantipsychot-icsinyouth,butwerelimitedbyresearchdesignandsamplesizes.Newer,industry-sponsoredrandomizedcontrolledtrialsforyouthwithschizophreniahavebeenconductedwithatypicalantipsychotics.Risperi-doneshowedefficacywithameandoseof4.0mg/day,56aripiprazoleshowedefficacyat10mg./dayand30mg/day,57andquetiapinewaseffectiveatthe400mgand800mg/daydose.58Additionally,astudyofflexibledoseolanzapine(range2.5-20.0mg/day)ver-susplaceboshowedimprovedsymptomratings,butnostatisticalsignificanceinresponserate.59 Overall, thesestudiesillustratetheeffectivenessofatypicalantipsychoticsoverplaceboinEOS.60Industry-fundedstudiesareunderwayforasenapineandlurasidone.61

Risperidone,aripiprazole,quetiapine,paliperidone,olanzapine, haloperidol, and molindone have FDA approval for the treatment of schizophrenia in youth aged 13 years and older. Molindone is no longer being manufactured.Depotantipsychoticpreparationshavenot been thoroughly studied in the pediatric popula-tion.Allantipsychoticshavepotentialadverseeffects.First-generationantipsychoticscarryahigherriskofneuro-logicsideeffects,andsecond-generationantipsychot-

icscarryahigherriskofweightgainandmetabolicsideeffects.Inonestudy,272antipsychotictreatmentnaïvepatients(aged4-19)withdiagnosesofpsycho-sis,mooddisorder,and/ordisruptivebehaviordisor-derwerefollowedfor12weeks.Weightgainwasacommonsideeffect,withsubjectsgaininganaverageof4.4kgonaripiprazole,5.3kgonrisperidone,6.1kgonquetiapine,and8.5kgonolanzapine,comparedtosimilarlydiagnosedpatientsnotreceivingantipsychot-ictreatment(average0.2kgweightgain).62 This same studyshowedincreasedcholesterolandlipidlevelinthosetakingolanzapine,quetiapine,andrisperidone.Theriskofweightgain,increasedbodymassindex(BMI),andabnormallipidlevelsisgreatestwitholanzapine,followedbyclozapineandquetiapine.62 Theriskofneurologicalsideeffectsisgreatestwithrisperidone, olanzapine, and aripirazole. Neurological sideeffectsareuncommoninchildrentreatedwithquetiapineandclozapine.Thereisnotenoughpediat-ricdataonziprasidonetodrawanyconclusions.63

Someopen-labelandsmallstudiesindicatemetfor-minaseffectiveinloweringmetabolicriskinindividu-alstreatedwithantipsychotics.64,65 Extrapyramidal sideeffects(EPS)canbemanagedwithanticholinergicagentslikebenztropineordiphenhydramine.66Anti-psychoticsshouldalwaysbediscontinuedwiththede-velopmentofneurolepticmalignantsyndrome(NMS),anddiscontinuedifpossiblewithtardivedyskinesia(TD).67,68IfapatientwithTDistakingafirst-generationantipsychotic,theyshouldbeswitchedtoasecond-generationantipsychotic.68 There is no standard treatment for TD once it has developed, though there arereportsofbenefitfromtetrabenazineandclon-azepam.69Adolescentsareathigherriskofdevelop-ingEPS,withminoritymaleshavingthehighestrisk,followedbyCaucasianmales.Otheradverseeffectsofsecond-generationantipsychoticsincludesedation,orthostatichypotension,sexualdysfunction,hyperp-rolactinemia(especiallywithrisperidone),prolongedQT interval, and elevated liver transaminases.Insummary,theuseofsecond-generationantipsy-choticsinschizophreniaisconsideredstandardofcare.Risperidone,aripiprazole,andquetiapineareconsideredfirst-lineagents.Choiceofmedicationshouldbeguidedbytheknownside-effectprofile.Clozapineshouldbeconsideredafter2failedtrialsofadequatedoseanddurationwithsecond-generationantipsychotics.Ifclozapineisnothelpful,orpoorly

28


tolerated,afirst-generationantipsychoticsuchashaloperidol is the next logical treatment choice. Side effectsshouldbetreatedasnecessary.Ingeneral,conservativemeasures,suchasloweringthedoseordiscontinuingthemedication,arepreferred.Becauseofthemetabolicsideeffects,closemedi-calmonitoringisneededduringtreatmentwithsecond-generationantipsychotics.Detailedmonitor-ingrecommendationsareoutlinedinAACAP’sPrac-ticeParameterfortheAssessmentandTreatmentofChildrenandAdolescentswithSchizophrenia,12 and in guidelines published by the Canadian Alliance for MonitoringEffectivenessandSafetyofAntipsychoticsin Children (CAMESA).63 A neurological exam for EPS, dyskinesia,andotherneurologicalsideeffectsshouldalso be done periodically. Assessment scales include the Abnormal Involuntary Movement Scale (AIMS), the Simpson Angus Scale, the Extrapyramidal Symp-tomRatingScale,andtheBarnesAkathisiaRatingScale.Recommendationsforthetreatmentofneu-rologicalsideeffectscanbeaccessedintheCAMESAguidelines.68

Psychosocial TreatmentsGeneralinterventionsthatareuniversallybeneficialfortreatingchronicmentalillnessinchildrenin-cludepsychoeducationforthefamily.Ifappropriate,educationshouldincludesubstanceusecounseling.Educationshouldbedeliveredinadevelopmentally-appropriatemanner,withagoalofpreventingre-lapse/re-hospitalization,andachievingpartnershipand treatment compliance. Standard of care also includesmilieutherapyduringhospitalization,socialskillstraining,andtrainingtoimproveproblemsolvingskills.Effortsshouldalsobemadetoenrollpatientsinspecializededucationalprogramsorvocationaltrain-ing, if indicated.70

Recentstudieshavefocusedonspecificcognitivetherapies.Specifically,cognitiveremediationtherapyhasbeenshownasaneffectiveinterventioninmul-tiplestudiesofschizophreniaandpsychosis.71-73 Young adultswithschizophrenia/schizoaffectivedisordermayalsobenefitfromcognitiveenhancementther-apy,ascomparedtoenhancedsupportivetherapy,forimprovingsocialcognitionandneurocognition.Improvementsinsocialfunctioningwerealsoseeninthecognitiveenhancementtherapygroupafterayearoffollowup.74

Recovery/Residual PhasesFor individuals in either the recovery or residual phases of illness, treatment should include ongo-ingmonitoringandsupport.Participationintherapy,monitoringofmedicationadherence,andevaluationofmedicationsideeffectsareallimportantcompo-nents of the treatment plan.

Recommendations For Children’s Hospital Colorado (CHCO)Mostclinicallyhigh-risk(CHR)patientsandthosewithEOSfirstpresenttochildandadolescentpsychiatrists.Thereisincreasedinterestinidentifyingandinterven-ingwithindividualsintheearlystagesofillness.Adedicated clinic for schizophrenia spectrum and other psychoticdisorderswouldallowfortheevaluationandtreatmentoftheseindividualsbyclinicianswhohaveexperiencewithpsychoticillness,andhavetheabilitytofollowcasesovertime.Longitudinalfollowupiscrucialforanumberofreasons:(1)thereisoftendiagnosticconfusionintheearlystages,(2)optimizingmedicationtreatmentandstabilizingindividualswithpsychosis can be a lengthy process, and (3) these indi-vidualsareatriskforconsiderablemorbidity.Familiesandpatientsbenefitfromconsistentsupportduringthe treatment of these challenging illnesses. Protocols shouldbeinplaceforevidence-basedassessment,treatment,andformonitoringandtreatingadverseeffectsofmedications.Suchaclinicwouldfunctionasareferralsourceforpatientsbothwithinthedepartmentandfromthecommunity,andcouldprovideconsultationtocom-munityprovidersmanagingpatientswithapsychoticdisorder. Research could also be imbedded in this setting.Ideally,therewouldbecollaborationwiththeCHCOMaternalFetalProgramandthe22q11.2Dele-tionSyndromeMulti-Disciplinaryclinic,bothofwhichservepatientswhomaybeatriskforschizophrenia.ContinuitywiththeUniversityofColorado’sAdultSchizophreniaClinicwouldensurethatpatientsarenotlosttofollowup.Thechildrenofadultsfollowedin such clinics could also be referred for screening. Cooperationwithcommunitygroupsthatfocusonrehabilitationandthedevelopmentofmulti-familysupportgroupswouldalsobehelpful.There are a number of clinics in the United States, andmanymoreworldwide,thatserveasmodelsfor

29


the development of a dedicated schizophrenia spec-trumandotherpsychoticdisordersclinicatCHCO.Themajorityevaluateindividualsage12andup,butcertainprograms,likeCANDI(ChildandAdolescentNeurodevelopmentalInitiative)atUMassevaluateyoungerchildren,includingthosewithbipolardisor-derandautismspectrumdisorder.Locally,theADAPT(AdolescentDevelopmentandPreventiveTreatment)Program at CU Boulder researches individuals be-tweentheagesof12and21whomightbeatriskfordevelopingathoughtdisorder.Theinvestigatorshope

todevelopaknowledgebaseforthepredictionofthought disorders, and an understanding of changes inbrainfunctionovertimeinthispopulation.Con-nectingwithoneormoreoftheseprogramswouldcreateopportunitiestolearnaboutthechallengesandpayoffsofsuchendeavors.

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24. LevinsonDF,DuanJ,OhS,etal.Copynumbervariantsinschizophrenia:confirmationoffivepreviousfindingsandnewevidencefor3q29microdeletionsandVIPR2duplications.Am J Psychiatry.2011;168(3):302-316.

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matched controls. Schizophr Res.2005;80(1):45-53.38. McGlashanTH,MillerTJ,WoodsSW.Ascalefortheassessmentofprodromalsymptomsandstates.In:MillerT,MednickSA,McGlashanTH,

eds. Early Intervention in Psychotic Disorders.TheNetherlands:KluwerAcademicPublishers.39. YungAR,YuenHP,McGorryPD,etal.Mappingtheonsetofpsychosis:theComprehensiveAssessmentofAt-RiskMentalStates.Aust N Z J

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Schizophr Bull.1996;22(2):283-303.41. CarlisleL,McClellanJ.DiagnosticInterviews.In:DulcanM,ed.Textbook of Child and Adolescent Psychiatry.WashingtonDC;AmericanPsy-

chiatricPublishing;2009:79-99.42. KelleherI,LynchF,HarleyM,etal.Psychoticsymptomsinadolescenceindexriskforsuicidalbehavior:findingsfrom2population-based

case-controlclinicalinterviewstudies.Arch Gen Psychiatry.2012;69(12):1277-1283.43. StaffordMR,JacksonH,Mayo-WilsonE,MorrisonAP,KendallT.Earlyinterventionstopreventpsychosis:systematicreviewandmeta-analy-

sis. BMJ.2013;346:f185.44. MiklowitzDJ,O’BrienMP,SchlosserDA,etal.Family-focusedtreatmentforadolescentsandyoungadultsathighriskforpsychosis:results

of a randomized trial. J Am Acad Child Adolesc Psychiatry.2014;53(8):848-858.45. AmmingerGP,SchaferMR,PapageorgiouK,etal.Long-chainomega-3fattyacidsforindicatedpreventionofpsychoticdisorders:arandom-

ized,placebo-controlledtrial.Arch Gen Psychiatry.2010;67(2):146-154.46. SikichL,FrazierJA,McClellanJ,etal.Double-blindcomparisonoffirstandsecond-generationantipsychoticsinearly-onsetschizophrenia

andschizo-affectivedisorder:findingsfromthetreatmentofearly-onsetschizophreniaspectrumdisorders(TEOSS)study.Am J Psychiatry. 2008;165(11):1420-1431.

47. FindlingRL,JohnsonJL,McClellanJ,etal.Double-blindmaintenancesafetyandeffectivenessfindingsfromtheTreatmentofEarly-OnsetSchizophrenia Spectrum (TEOSS) study. J Am Acad Child Adolesc Psychiatry.2010;49(6):583-594;quiz632.

48. KaneJM.Clinicalefficacyofclozapineintreatment-refractoryschizophrenia:anoverview.Br J Psychiatry Suppl.1992(17):41-45.49. SchneiderC,CorrigallR,HayesD,KyriakopoulosM,FrangouS.Systematicreviewoftheefficacyandtolerabilityofclozapineinthetreat-

mentofyouthwithearlyonsetschizophrenia.Eur Psychiatry.2014;29(1):1-10.50. KumraS,FrazierJA,JacobsenLK,etal.Childhood-onsetschizophrenia.Adouble-blindclozapine-haloperidolcomparison.Arch Gen Psychia-

try.1996;53(12):1090-1097.51. KumraS,KranzlerH,Gerbino-RosenG,etal.Clozapineandhigh-doseolanzapineinrefractoryearly-onsetschizophrenia:a12-weekran-

domizedanddouble-blindcomparison.Biol Psychiatry.2008;63(5):524-529.52. ShawP,SpornA,GogtayN,etal.Childhood-onsetschizophrenia:Adouble-blind,randomizedclozapine-olanzapinecomparison.Arch Gen

Psychiatry.2006;63(7):721-730.53. CianchettiC,LeddaMG.Effectivenessandsafetyofantipsychoticsinearlyonsetpsychoses:along-termcomparison.Psychiatry Res.

2011;189(3):349-356.

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54. MidbariY,EbertT,KosovI,KotlerM,WeizmanA,RamA.Hematologicalandcardiometabolicsafetyofclozapineinthetreatmentofveryearlyonsetschizophrenia:aretrospectivechartreview.J Child Adolesc Psychopharmacol.2013;23(8):516-521.

55. FindlingRL,FrazierJA,Gerbino-RosenG,KranzlerHN,KumraS,KratochvilCJ.Istherearoleforclozapineinthetreatmentofchildrenandadolescents? J Am Acad Child Adolesc Psychiatry.2007;46(3):423-428.

56. HaasM,EerdekensM,KushnerS,etal.Efficacy,safetyandtolerabilityoftwodosingregimensinadolescentschizophrenia:double-blindstudy. Br J Psychiatry.2009;194(2):158-164.

57. FindlingRL,RobbA,NyilasM,etal.Amultiple-center,randomized,double-blind,placebo-controlledstudyoforalaripiprazolefortreatmentofadolescentswithschizophrenia.Am J Psychiatry.2008;165(11):1432-1441.

58. FindlingRL,McKennaK,EarleyWR,StankowskiJ,PathakS.Efficacyandsafetyofquetiapineinadolescentswithschizophreniainvestigatedina6-week,double-blind,placebo-controlledtrial.J Child Adolesc Psychopharmacol.2012;22(5):327-342.

59. KryzhanovskayaL,SchulzSC,McDougleC,etal.Olanzapineversusplaceboinadolescentswithschizophrenia:a6-week,randomized,double-blind,placebo-controlledtrial.J Am Acad Child Adolesc Psychiatry.2009;48(1):60-70.

60. SarkarS,GroverS.Antipsychoticsinchildrenandadolescentswithschizophrenia:asystematicreviewandmeta-analysis.Indian J Pharma-col.2013;45(5):439-446.

61. Klein C, Bespalov A. Development of novel therapy of schizophrenia in children and adolescents. Expert Opin Investig Drugs. 2014;23(11):1531-1540.

62. CorrellCU,ManuP,OlshanskiyV,NapolitanoB,KaneJM,MalhotraAK.Cardiometabolicriskofsecond-generationantipsychoticmedicationsduringfirst-timeuseinchildrenandadolescents.JAMA.2009;302(16):1765-1773.

63. PringsheimT,PanagiotopoulosC,DavidsonJ,HoJ,CanadianAllianceforMonitoringE,SafetyofAntipsychoticsinChildrenguidelineg.Evidence-basedrecommendationsformonitoringsafetyofsecond-generationantipsychoticsinchildrenandyouth.Pediatr Child Health. 2011;16(9):581-589.

64. ShinL,BregmanH,BreezeJL,NoyesN,FrazierJA.Metforminforweightcontrolinpediatricpatientsonatypicalantipsychoticmedication.J Child Adolesc Psychopharmacol.2009;19(3):275-279.

65. MorrisonJA,CottinghamEM,BartonBA.Metforminforweightlossinpediatricpatientstakingpsychotropicdrugs.Am J Psychiatry. 2002;159(4):655-657.

66. KranzlerHN,CohenSD.Psychopharmacologictreatmentofpsychosisinchildrenandadolescents:efficacyandmanagement.Child Adolesc Psychiatr Clin N Am.2013;22(4):727-744.

67. NeuhutR,LindenmayerJP,SilvaR.Neurolepticmalignantsyndromeinchildrenandadolescentsonatypicalantipsychoticmedication:areview.J Child Adolesc Psychopharmacol.2009;19(4):415-422.

68. PringsheimT,DojaA,BelangerS,PattenS,CanadianAllianceforMonitoringE,SafetyofAntipsychoticsinChildrenguidelineg.Treatmentrecommendationsforextrapyramidalsideeffectsassociatedwithsecond-generationantipsychoticuseinchildrenandyouth.Pediatr Child Health.2011;16(9):590-598.

69. AiaPG,RevueltaGJ,CloudLJ,FactorSA.Tardivedyskinesia.Curr Treat Options Neurol.2011;13(3):231-241.70. RinaldiM,KillackeyE,SmithJ,ShepherdG,SinghSP,CraigT.Firstepisodepsychosisandemployment:areview.Int Rev Psychiatry.

2010;22(2):148-162.71. UelandT,RundBR.Cognitiveremediationforadolescentswithearlyonsetpsychosis:a1-yearfollow-upstudy.Acta Psychiatr Scand.

2005;111(3):193-201.72. UelandT,RundBR.Acontrolledrandomizedtreatmentstudy:theeffectsofacognitiveremediationprogramonadolescentswithearly

onset psychosis. Acta Psychiatr Scand.2004;109(1):70-74.73. WykesT,NewtonE,LandauS,RiceC,ThompsonN,FrangouS.Cognitiveremediationtherapy(CRT)foryoungearlyonsetpatientswith

schizophrenia: an exploratory randomized controlled trial. Schizophr Res.2007;94(1-3):221-230.74. EackSM,GreenwaldDP,HogartySS,KeshavanMS.One-yeardurabilityoftheeffectsofcognitiveenhancementtherapyonfunctionalout-

come in early schizophrenia. Schizophr Res.2010;120(1-3):210-216.

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Autism Spectrum Disorder and Intellectual Disability in Children and Adolescents

AssessmentandManagementofAutismSpectrum Disorder and Intellectual Disability in

Children and Adolescents

Introduction

AutismSpectrumDisorder(ASD)isacomplexneurodevelopmental disorder characterized by

impairmentsinsocialcommunicationandinterac-tion,andthepresenceofrestrictedandrepetitiveinterests. Intellectual Disability (ID) is a heteroge-neousconditiondefinedbysignificantlysub-averageintellectualandadaptivefunctioningwithonsetprior to the age of 18.1NotallindividualswithASDhaveID(approximately85%ofindividualswithASDhavesometypeofcognitiveimpairment).2 The syndromeofautismwasfirstdescribedbychildpsychiatristLeoKannerin1943,whenhedetailedagroupof11childrenwithlimitationsintheirabilitytoconnectwithothers,butincreasedsensitivitytonon-socialaspectsoftheenvironment.3 Over the years,diagnosticcriteriaforASDhavebeenrefinedand the biological underpinnings of the syndrome arebetterunderstood.AccordingtotheCentersforDisease Control (CDC), the prevalence of an ASD diagnosis based on parent report in individuals aged 6-17is1/50.4Thisisa72%increasefrom2010rateof1/88.5However,themajorityofnewcasesidenti-fiedhadmildersymptomsandwerediagnosedlaterin life. There has been a great deal of controversy abouttheexponentialriseinASDoverthepast20years.TheCDCattributessomeoftherisetoimproveddiagnosticunderstanding,bettertestingmethods,andincreasedawareness.ThereisalsoanappreciationthatASDmaybethefinalmanifesta-tionofdifferentatypicaldevelopmentalprocesses,manyofwhicharepoorlyunderstood.5 Individuals withASDand/orIDcanrequirehighlevelsofmedi-cal,behavioral,andacademicinterventions,often

atagreatcosttofamiliesandstateandfederally-funded programs.6 Yearly health care expenditures forachildwithASDareestimatedtobe8-9timesthatofachildwithoutASD.Medicationexpensesmakeupapproximately27%ofthiscost.7 Because of the enormity of the issue, a basic understanding of ASDanditstreatmentiscrucialtopracticingmentalhealth professionals.

DefinitionsPriortothereleaseofDSM-5in2013,PervasiveDevelopmentalDisorderswastheumbrellacategoryfor5distinctdiagnoses:AutisticDisorder,Asperger’sDisorder, Pervasive Developmental Disorder Not OtherwiseSpecified(PDDNOS),ChildhoodDisin-tegrativeDisorder,andRett’sDisorder.8 Individuals whofellwithintheautism spectrum manifested variablesymptomswithin3categories:qualitativeimpairmentinsocialinteraction,qualitativeimpair-mentincommunication,andrestrictedrepetitiveandstereotypedpatternsofbehavior,interests,andactivities.ThosewithAsperger’sDisorderdidnothavegenerallanguagedelays,andthosewithPDD NOS had severe and pervasive impairments as describedabove,butdidnotmeetfulldiagnosticcriteriaforAutisticDisorderorAsperger’sDisor-der.InDSM-5,thereisnolongeracategorycalledPervasiveDevelopmentalDisorders,andAutisticDisorder, Asperger’s Disorder, and PDD NOS have beencollapsedintothegeneraldiagnosisofAutismSpectrum Disorder (ASD). For a diagnosis of ASD, the individualmanifestssymptomswithin2categories:(1)persistentdeficitsinsocialcommunicationandsocialinteraction,and(2)restricted,repetitivepat-

Elise M. Sannar, MD; Philip O’Donnell, PhD; Carol Beresford, MD



33


ternsofbehavior,interests,oractivities.Thediagnosisisfurtherspecifiedasoccurringwithorwithoutac-companyingintellectualimpairment,withorwithoutaccompanyinglanguageimpairment,associatedwithaknownmedicalorgeneticconditionorenvironmen-talfactor,associatedwithanotherneurodevelopmen-tal,mental,orbehavioraldisorder,and/orwithcata-tonia. The severity level of the disorder is described bythelevelofsupportneededtofunction.Symptomsmustbepresentwithintheearlydevelopmentalpe-riod,butmaynotbecomeapparentuntillaterinlife.1 ThisdiffersfromthequalifierinDSM-IV-TR:“Delaysorabnormalfunctioningmustbepresentwithonsetpriortoagethreeyears.”ChildhoodDisintegrativeDisorderandRett’sDisorderarenolongerlistedasdistinctdiagnosesinDSM-5.AccordingtoDSM-5,“IntellectualDisability(ID)isadisorderwithonsetduringtheearlydevelopmentalperiodthatincludesbothintellectualandadaptivefunctioningdeficitsinconceptual,social,andpracti-cal domains.”1Theseverityofthedisorderisspecifiedas mild, moderate, severe, or profound, based on the individual’sadaptivefunctioning.InDSM-IV-TR,IDwasreferredtoasMentalRetardation(MR),withthesamespecifiers,basedontheindividual’sIQscore.8 TheshiftfromusingIQscoretoadaptivefunction-ingtodescribeseveritywasmadebecauseadaptivefunctioningbetterpredictsthelevelofsupportstheindividualwillrequire.IDisusuallydescribedasaneurodevelopmental disorder, but it can be acquired, asinthecaseoftraumaticbraininjury.

EpidemiologyBothASDandIDhaveaprevalencerateofabout1%ofthepopulation,withapproximately85%ofindi-vidualswithASDhavingsomesortofcognitiveim-pairment,and10%ofindividualswithIDhavingASD.Generally,andinassociationwithASD,mildIDisthemost common type of impairment. Males are more likelythanfemalestobediagnosedwithASDinara-tioofabout4:1.SomestudiessuggestthatmalesaremorelikelytobediagnosedwithID,butothersareinconclusive.9 ID is more prevalent in studies based on children/adolescents,comparedtoadults.Individualsfromlowandmiddleincomecountriesareoverrepre-sented.9GirlswithIDaremorelikelytobediagnosedwithASDthanthosewithoutID,whereasthisisnotthecaseforboys,suggestingthatsocialimpairments

ingirlsmaybehardertorecognizewhenthereisnoco-occurringID,duetobetterfaceandaffectrecogni-tion,emotionalexpression,andperspectivetaking.10

Risk and Protective FactorsTheetiologyofASDisknowninonlyaportionofcases. The syndrome is considered to be neurobiologi-cal,asmultiplegeneshavebeenidentifiedasincreas-inganindividual’sriskforASD.Themajorityofthesegenes encode proteins that regulate synapse devel-opmentandactivity-dependentneuralresponses.11 Thereisalsoevidencethatcertainneurotransmitterlevels, including serotonin and GABA, are altered in ASD.12Approximately30%ofindividualswithASDhaveEEGabnormalitiesand/orahistoryofseizures.13 Therearesomewell-definedgeneticsyndromesthatareassociatedwithASD,includingTuberousSclerosis,FragileXSyndrome,andPraderWilliSyn-drome.14Somewouldarguethatchildrenwiththesesyndromes do not have ASD, but rather, they have behavioral phenotypes similar to ASD.14DSM-5makesnosuchdistinction;anyknownassociatedmedicalorgeneticconditionshouldberecordedwiththediagnosis.1Definedgeneticmutationsorsyndromesaccountforabout10%-20%ofASD.15

ASDisheritable,withaconcordancerateof60%-90%inmonozygotictwins,approximately10timeshigherthantherateindizygotictwinsandsiblings.Thereisa50foldincreasedriskforASDinfirst-degreerelativescomparedtothegeneralpopulationprevalence.11

PerinatalandneonatalriskfactorsassociatedwithASDincludeabnormalpresentation,umbilical-cordcomplications,fetaldistress,birthinjuryortrauma,multiplebirth,maternalhemorrhage,summerbirth,lowbirthweight,smallforgestationalage,congenitalmalformation,low5-minuteApgarscore,feedingdif-ficulties,meconiumaspiration,neonatalanemia,ABOorRhincompatibility,andhyperbilirubinemia.16 These riskfactorscanalsobeassociatedwithID.17 Overall fetal health is more important than any one neonatal orperinatalriskfactorforthedevelopmentofASDorID.17

PrognosisThe presence or absence of ID, language impairment, and/orcomorbidpsychiatricdisordersarethebestidentifiedprognosticfactorsinASD.18 ID is generally

34


consideredalifelongandnon-progressivedisorder.19 Therearesomeassociatedgeneticdisorders,suchasRett’sDisorder,whichhaveaprogressivecourse.Earlyintensivebehavioralinterventions(EIBI)havebeenshowntoimproveachild’sprognosisinASD.20 ThereareafewstudiesthathavefollowedthecourseofindividualswithASDoveraperiodofmorethan10years.Thesestudiessuggestthatabout10%ofchil-drenwillimprovedramaticallyintheirmid-teens,butthatover80%ofchildrenhavesymptomsthatremainconsistent into adulthood.21ThemajorityofadultswithASDcontinuetodependonfamilyorothersup-port services.22

Differential DiagnosisThedifferentialdiagnosisofASDincludesotherge-neticsyndromes,IDwithoutASD,languagedisorders,learningdisorders(diagnosedbydemonstratingagapbetweenanindividual’scurrentperformanceandpotential),sensorydisorders,ChildhoodOnsetSchizo-phrenia,andReactiveAttachmentDisorder.1

Screening and AssessmentPediatricians and other community health provid-ersaretypicallythefirstprofessionalstobealertedto developmental concerns through parent report or directobservationofachild.TheAmericanAcademyof Pediatrics recommends that all children undergo screeningforASDaspartoftheir18-and24-monthwell-childvisits.23 Screening instruments typically usedinageneralmedicalpracticearedesignedtoidentifychildrenatriskwithinanunselectedorlowriskpopulation(level1screeners).Onceidentifiedasat-risk,morespecificscreeningtools(level2screen-ers) can be administered. Most of these tools are baseduponparentreportandarequicktoadminister,score,andinterpret.Screeninginstrumentsofferausefulstartingpointforexploringdevelopmentalcon-cernswithfurtherevaluationneededtodistinguishbetweenASDandotherdevelopmentaldisordersorID.24 Standardized screening instruments are impor-tanttoidentifychildrenwithdevelopmentaldisorderswhoarenotcapturedthroughclinicalobservationorparent report. Parents’ experiences and cultural dif-ferencesinchildrearingpracticesanddevelopmentalexpectationscontributetodifferentialpatternsofreportingbehavioralconcerns.25 Moreover, children mayshowsubtlesymptomsofASD,orseemingly

normativedevelopmentmayplateau,decelerate,oreven regress.24

The Modified Checklist for Autism in Toddlers(M-CHAT)26 is a level 1 screening tool designed for use withchildrenage16to30months.Ithasbeenex-aminedinseveralempiricalstudiesandshownhighsensitivity(reportedratesrangefrom0.75to0.98dependinguponthesample)inidentifyingchildrenwhoarelaterdiagnosedwithASD,andthosewhoalready carry the diagnosis.25Atwo-stepapproachincludingabriefstandardizedfollow-upinterviewhelpstoreducefalsepositives.27Intheirreview,Nor-risandLeCavalier28 found the Social Communication Questionnaire (SCQ)tobethemostwidelyresearchedlevel2screeninginstrumentwithmultiplestudiessupportingitsdiagnosticaccuracy.TheSCQappearstobemostaccurateinidentifyingASDamongchildrenages7andolder,withprogressivelylowersensitiv-ity rates for younger children. Other instruments, including the Social Responsiveness Scale (SRS) and the Autism Spectrum Screening Questionnaire (ASSQ) showpromise,buthavenotbeenwidelysubjectedtoindependent research. AfterchildrenhavebeenidentifiedaspossiblyhavingASD, it is important that they undergo a comprehen-sivediagnosticevaluationasearlyinlifeaspossible.Anaccurateclinicaldiagnosisisoftenessentialtochildrenobtainingnecessaryinterventionsfromavariety of systems (schools, mental health agencies, and developmental disability boards). Diagnosing ASD iscomplicatedbytheheterogeneouspresentationofthedisorder,andrequirestheevaluatingcliniciantohaveexpertiseintypicalchilddevelopmentandau-tism-specificassessmenttools.Aswithanydiagnosticassessmentofchildren,autismassessmentsshouldincludedatafrommultipleinformantsandmethods.Theminimumbestpracticestandardforacompre-hensivediagnosticassessmentofASDincludesanobservationalassessmentandaparentinterview.29 TheAutismDiagnosticObservationSchedule,Sec-ondEdition(ADOS-2),iswidelyconsideredthegoldstandard tool for diagnosing ASD.30TheADOS-2usessemi-structuredplayactivitiesandsocialinteractionstocreatesituationalpressesforsocialinitiationsandresponses.30 Children’s behaviors are coded and ap-pliedtoadiagnosticalgorithm,yieldingaclassifica-tionofnon-ASD,ASD,orautism,aswellascompari-sonscoresforthelevelofautism-relatedsymptoms.

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TheAutismDiagnosticInterview,Revised(ADI-R),allowsforadetailedexplorationofdevelopmentalconcernsandhistoryofspecificsymptomsofASD.31 ItsupplementstheADOS-2observationalassessmentbyprovidingimportantinformationaboutthechild’spresentationovertimeandacrossmultiplecontexts.Thecombinationofbothtoolshasbeenshowntobesuperior to a single measure in correctly classifying childrenwithASD.32

Other tools may be necessary to clarify the diag-nosticpicture,especiallywhenobservationaldataand parent report are discrepant. Comprehensive measuresofcognitiveabilityareimportanttoruleoutcomorbidIDandidentifyspecificimpairmentsthat may relate to observed delays. Several standard-ized,norm-referencedmeasuresareavailableforusewithverbalchildren(WechslerIntelligenceScaleforChildren,FourthEdition;Stanford-Binet,FifthEdi-tion;MullenScalesofEarlyLearning)andnon-verbalchildren(Leiter-R;ComprehensiveTestofNonverbalIntelligence).33Standardizedmeasuresofadaptivefunctioning(Vineland-II;ScalesofAdaptiveBehavior,SecondEdition),speechandlanguage,motorskills,andsensory-relatedissuesalsohelptounderstandan ASD child’s unique needs and tailor appropriate interventions.33

Availablediagnostictoolsforautismhavenotbeenwellvalidatedwithculturallyandlinguisticallydiversesamples. As a result, it is possible that children in thesegroupsaremisidentifiedorunder-identifiedcompared to Caucasian samples.34Itiscriticalforclinicianstotakeintoaccountculturalandlanguagefactorsthatmayaffectchildren’spresentationsandparents’reportswithinthediagnosticevaluationprocess. Similar concerns exist regarding gender dif-ferences.MalesaredisproportionatelyrepresentedinASD research, including samples used to develop and validate common screening and assessment tools. Asaresult,genderdifferencesintheexpressionofASDmaynotbewell-capturedbycurrentdiagnos-ticschemes,andidentifiedfemalesmayrepresentamoresevereendofthespectrum,oftenwithco-morbidintellectualdifficultiesorothercomplicatingorganicconditions.35

Childrenpresentingwithdevelopmentaldisabili-tiesalsoneedathoroughmedicalexaminationandwork-up.ThismayincludeconsultationwithGenet-icsand/orNeurology.Dependingonthepresenceof

significantbehavioralsymptoms,individualswithIDmaybemorelikelytopresenttoapediatricpracticethanapsychiatrypractice.EtiologiesofID,includinggeneticsyndromesandin-bornerrorsofmetabolism,haveoftenalreadybeenscreenedforbythetimeanindividual presents for a mental health assessment.23 Ideally,individualsdiagnosedwithASDintheab-sence of ID should also be screened for the presence ofchromosomalabnormalitieswithamicroarray(toidentifysinglenucleotidepolymorphismsandcopynumbervariantswhichmaybeassociatedwithASD).However,checkingachromosomalmicroarrayisnotyetconsideredstandardofcareandisnotalwayscov-ered by insurance companies.36

Comorbid ConditionsGiventhewiderangeofdevelopmentalimpairment,including the frequent presence of ID,37 the treatment ofpediatricpatientsdiagnosedwithASDrequirestheparticipationofmultipledisciplines,includingspeechandlanguage,occupationaltherapy,psychol-ogy,behavioraltherapy,andsocialwork.Commoncomorbiditiesincludepsychiatricdiagnoses,38 medi-caldiagnosesthatmayinitiallypresentwithbehav-ioralescalations(dentalproblems,constipation),andgeneticconditions.Ideally,psychiatricandpediatricpractitionersshouldworktogetherinthecareofchildrenandadolescentswithASD.Involvingmultipledisciplinesmakesitpossibletolookbeyondthe“tipoftheiceberg”presentingsymptoms(usuallyexter-nalizing behavioral symptoms), to the many possible underlyingcontributingfactors.37Withthehelpofthediscerning eye of each discipline, the most prominent underlyingfactorscanbeidentified,leadingeventu-allytospecificdiagnosesthatcanbeaddressed.Individualswithdevelopmentaldisability,whetherASD,ID,oracombinationofboth,areatgreaterriskthanthegeneralpopulationofhavingacomorbidpsychiatricdiagnosis.SeventypercentofchildrenwithASDhaveatleast1psychiatriccomorbidity,and40%ofchildrenwithASDhave2ormorecomorbiddiag-noses.39Oneofthemajorconcernsinpsychiatricanddevelopmentaldisabilitiesliteratureisthatofdiag-nostic overshadowing.Thetermdiagnosticovershad-owingwasfirstusedin1982torefertothetendencyforclinicianstoattributesymptomsorbehaviorofapersonwithIDtotheirunderlyingcognitivedeficitsand hence to under diagnose the presence of comor-

36


bid psychopathology.40Despitetherecognitionofdiagnosticovershadowingwithinthemedicallitera-ture,thereisstillsomedisagreementastowhethercommonpresentingbehavioraldifficultiesinindividu-alswithdevelopmentaldisability(DD)shouldqualifyaspartoftheDDitself,orasadisorderinadditiontoDD.37However,thefrequentpresenceofbehavioral,mood,andanxietydifficultiesinpatientswithDDisclear. All categories of psychiatric illness can present inanindividualwithASDorID,withmoodandanxi-ety disorders being the most common, and substance abuse disorders being the least common.38DSM-5nowallowsforthediagnosisofAttentionDeficitHy-peractivityDisorder(ADHD)inanindividualwithASD,butadiagnosisofReactiveAttachmentDisorder(RAD)stillprecludesadiagnosisofASD.Presentingpsychiat-ric symptoms can be similar to those in the neurotypi-calpopulation,buttherearesomedifferences.Forexample,anindividualwithMajorDepressiveDisor-derandModerateIDisunlikelytoreportfeelingguilt,asheorshemaynotevenbeawareoftheconceptofguilt.41TheDiagnosticManual-IntellectualDisability(DM-ID)wasdevelopedbytheNationalAllianceofthe Dually Diagnosed (NADD) to help mental health practitionersworkingwiththedevelopmentallydis-abledbemoreattunedtorecognizingthemanifesta-tionsofcommonpsychiatricconditions.41 Diagnosing apsychiatricdisorderinachildwithadevelopmentaldisability also requires an understanding of the child’s baselineleveloffunctioning.Changesinappetite,sleep,mood,behavioralissues,self-injury,andabilitytoperformactivitiesofdailylivingcanallsignalthepossibility of a comorbid psychiatric disorder.ComorbidmedicalconditionsinASDmustalsobeconsidered.BecausemanyindividualswithASDandIDhavecommunicationimpairments,makingdiagno-sescanbedifficult.Gastrointestinalissuesandsleepproblemsare2commonlyassociatedconditions.42 In anefforttofurtherinternationalcollaboration,theAutismTreatmentNetwork(ATN)wasdeveloped.TheATNisanetworkofhospitals,physicians,researchers,and families across 17 sites in the United States and Canada. The goal of the ATN is for treatment provid-erstoshareinformationinordertodevelopasetofclinical guidelines for the management of various con-cernsinASD.Guidelinesandinformationarealsoputtogetherinaseriesof“toolkits”accessibletoparentsandfamiliesontheAutismSpeakswebsite.Children’sHospitalColoradoisamemberoftheAutismTreat-

mentNetworkwithprovidersinDevelopmentalPedi-atrics,Psychiatry&BehavioralSciences,OccupationalTherapy,andSpeechLanguagePathology.42

Medical InterventionsPsychopharmacological treatment of ASD and ID is basedonthepresentingsymptomsandcomorbidpsychiatricdiagnosis.Medicationtreatmentshouldalwaysbeapartofacomprehensivetreatmentplanthatincludesbehavioralandeducationalinterven-tions,andshouldbefocusedonspecifictargets.43 Ap-proximately45%ofchildrenwithASDareprescribedpsychotropicmedication.44 Even if a formal psychiatric diagnosis is not made, the range of serious symptoms includingagitation,aggression,andself-injurywillnecessitatepsychiatricevaluationandmanagement.The child and adolescent psychiatrist is called upon to(1)searchformedicalcausationofthebehavioralandmoodsymptoms,referthepatienttopediatricsas appropriate, and help coordinate needed medical treatments;and(2)toperformpsychiatricmedicationevaluations,prescription,andmanagementinrelationtothepresentingsymptoms.Thepsychiatristisjustonememberofamultidisciplinaryteam,anditistheresponsibilityofthepsychiatristtoworkcloselywithotherdisciplines,aswellasthefamily,inthecareofthe child.Despitethegrowingnumberofrandomizedcon-trolled trials over recent decades, there are several factorsthatstandinthewayofadvancingtherapeuticpracticesforchildrenwithASDandID.45 These fac-torsincludethelackofanaccepteddiagnosticsystemfor comorbid psychiatric illness, controversy as to whethertostudycomorbidpsychiatricdiagnosesorto study symptom clusters (for example, aggression andself-injury),controversyastowhetherbehavioralclustersfoundinpatientswithASDcorrelatewithbehaviorsandsymptomsinaneurotypicalpopulation,thelackofwidelyusedandagreeduponoutcomemeasuresforpatientswithASD,andarelativefocusonpatentedprescriptionmedicationstotheexclu-sionofotheragents.ThereisnomedicationthathasshownefficacyfortreatingthecoresymptomsofASD(socialandcommunicationimpairment,andrestrictedandrepetitiveinterests).Risperidoneandaripiprazoleare the only drugs that have Food and Drug Adminis-trationapprovalforthetreatmentofsevereirritabilityandaggressionassociatedwithASD.46

37


Risperidone has been the most extensively inves-tigateddrugfortreatmentofsevereirritabilityinASD,includingan8-week,multi-site,double-blind,placebo-controlledstudyofmeandailydosage1.8mg.Risperidonetreatmentledtoa57%decreaseontheAberrantBehaviorChecklist(ABC)Irritabilitysubscalescoreversusa14%decreasewithplacebo.47 Aprolongedextensionphaseofthestudycontinuedtoshowefficacyofrisperidoneascomparedtopla-cebo,thoughsignificantweightgainwasasideeffect.Overall,69%hadapositiveresponseonrisperidoneversus12%positiveresponseonplacebo.Therewerealsosignificantpositivefindingsforhyperactivityandstereotypy.46

Aripiprazole,targetingirritabilityasmeasuredbytheABC,resultedina56%positiveresponse(TDD5mgaripiprazole)versus35%withplacebo.Therewassig-nificantimprovementinirritability,hyperactivity,andstereotypysubscales.Sideeffects,asforrisperidone,includedweightgain,fatigue,and/ordrooling.48

Otherclassesofmedication,includingSSRIs,stimu-lants, alpha agonists, and mood stabilizers are fre-quently used for treatment of behavioral problems in childrenwithDD;however,therehavebeenfewran-domizedplacebo-controlleddrugstudiessupportingtheir use.49 Anxiety disorders are the most common psychiatriccomorbidityinchildrenwithASD,yettherehave been no controlled trials of pharmacologic treat-mentofanxietyinthepopulation.Thestudiesthatdoexist are small and uncontrolled. In 2009, a random-izedplacebo-controlledtrialofcitalopramtargetingrepetitivebehaviorin145childrenwithASD(ages5-17)showednosignificantimprovement.Comparedtoindividualstreatedwithplacebo,individualstreat-edwithcitalopramhadincreasedenergy,impulsivity,decreasedconcentration,increasedhyperactivity,andincreased stereotypy.50 There is some evidence that treatmentofADHDsymptomswithmethylphenidateisbeneficial.However,treatmenteffectsarelessrobust than those seen in neurotypical children, and childrenwithASDaremorelikelytoexperiencesideeffects.51

SleepdisturbanceiscommoninindividualswithASD,and melatonin is frequently the treatment of choice. Thereissomeevidencesupportingitsuse,butsimilartoothermedications,therearefewrandomizedcon-trolledtrialsorlong-termfollowupdata.52

Behavioral InterventionsFocusedinterventionpractices(FIPs)targetspecificskillsorsymptoms.ManyFIPsarecomponentsofthemorecomprehensivetreatmentmodels;however,theyarealsodeliveredasstand-aloneinterventionsandhavebeenstudiedfortheireffectivenessintreat-ingcoreASDsymptoms(socialorcommunicationimpairments,andrestrictedandrepetitiveinterests).SeveralinterventionscommonlyusedtobuildsocialskillsandcommunicationamongchildrenwithASDhave empirical support. Applied behavior analysis (ABA)strategies,suchasprompting,reinforcement,and discrete trial training, have demonstrated ef-fectivenessinteachingspecificskills(forexample,eyecontact,greeting,andcommunication)throughstructuredsequencesofstimulus-behavior-reward.53 Theseinterventionsareoftendeliveredinahighly-controlledclinicalsetting,potentiallyleadingtoproblemswithgeneralizingskillstomorenaturalisticornovelsettings.53 Naturalisticbehavioralinterventions(incidentalteach-ing, milieu teaching, and pivotal response training) incorporatemotivationalcomponentstoimproveachild’sresponsivenessacrosssettingsandwithinmorenaturalinteractions.Componentsofnaturalisticin-terventionswithdemonstratedeffectivenessincludetaskvariability,maintenancetasks,immediateandnaturalconsequences,andprovidingchoiceofstimu-lus materials and topics.54 Training peers and parents toprovideteachingopportunitiesandreinforcetargetbehaviorshasalsoshownpromiseinbuildingsocialandcommunicationskills.55Forchildrenwithlimitedexpressivecommunicationskills,AugmentativeandAlternativeCommunication(AAC)systemsusetech-nology (voice output devices) and other materials (symbols, pictures, and visual schedules) to enhance receptiveandexpressivevocabulary.Forexample,childrenwithASDandcommunicationimpairmentshaveshownsuccessinusingthePictureExchangeCommunicationSystem(PECS)asacommunicationtool,althoughresearchonthegeneralizationofskillsoutside of the training environment is limited.56

Functionalbehavioranalysis(FBA)isacommontechniqueforevaluating,andthenreducing,problembehaviorsinchildrenwithASD.Thisprocessinvolvestheobservationandmanipulationoftheantecedentsandconsequencesofbehaviorstoidentifywhichfac-torsarecausal.Onceidentified,antecedent-behavior-

38


consequence chains can be altered to reduce problem behaviors.57 Problem behaviors may also be due to a lackofunderstandingofacomplexordifficultsitua-tion.Socialstoriesusewordsandpicturestoexplainappropriatebehaviorsinparticularsituations.58 These storiesareoftenhighlypersonalizedinordertoin-creaseachild’smotivationandinterestinthemate-rial.Withfrequentrepetition,socialstoriesmayhelpreplacenegativebehaviorswithmoreappropriateal-ternatives.59Researchoninterventionsspecificallyforrestrictedrepetitivebehaviors(RRBs)islimited.Again,behavioralstrategiesthatinvolvedisruptingthere-lationshipbetweenthebehaviorandreinforcement,modifyingtheenvironmenttoreducepotentialtrig-gersofthebehavior,andteachingadaptiveskillsthatmayreplaceorresultincollateralreductionsinRRBsarethemostcommonlyinvestigatedapproaches.60

Comprehensive treatment models (CTMs) for ASD targetawiderangeofdevelopmentaloutcomesandskillswithinaconceptuallyorganizedtreatmentpackage.61EarlyIntensiveBehavioralInterventions(EIBI),basedontheprinciplesofoperantcondition-ing and ABA62,areamongthefirstandmostwidely-researchedtreatmentsforchildrenwithASD.EIBItypicallyinvolvesfrequent(over40hoursperweek),long-term(2ormoreyears),andhome-basedbehav-ioral therapy. Parents receive extensive training in the applicationofbehavioralstrategiestoprovidecon-sistentandcontinuousinterventionthroughoutthechild’sday.TheexistingresearchonEIBIhasshownpositivegainsinIQscores,language,adaptivebehav-iors,andeducationalattainment62,63withmoreposi-tiveoutcomespredictedbyearlierinitiationofinter-ventionsandhighlevelsoftrainingandcredentialsofclinical supervisors.64

The Early Start Denver Model (ESDM)65 is a behav-iorally-basedinterventionforchildrenbetweentheagesof12and48-months-old.Itcanbedeliveredinaclinicorhomesetting,utilizingindividualandgroupmodalities,withahighdegreeofparentinvolve-ment.InterventionsfollowadevelopmentalsequenceanduseABAprinciplescombinedwithinterpersonalinteractions,jointactivity,andpositiveaffect.Aran-domizedcontrolledtrialofEDSMfoundsignificantgainsinIQ,language,andadaptivebehaviorsamongchildrenwhoreceived15to20hoursperweekoftheinterventionovera2-yearperiodcomparedtoothercommunity-basedtreatmentsforASD.66 Con-

sistentwiththeresearchonEIBI,treatmentgainsweregreateramongchildrenwhowereenrolledatan earlier age and received more intensive services.66 Whenparent-deliveredESDM,consistingofupto12weeklyhour-longsessions,wascomparedwithcommunitytreatmentasusual,nodifferenceswerefound on the primary outcome measures of devel-opment,cognition,andbehavior.67 Comprehensive, behaviorally-basedinterventionsforyoungchildren,suchasLovaas-basedEIBIandESDM,showpromiseinimprovingoutcomesforchildrenwithASD;however,therehavebeenveryfewrandomizedcontrolledtri-als,andexistingstudiesarelimitedbysmallsamplesizesandalackofrandomassignment,fidelitydata,and standardized comparison or control groups.68,63

AnotherCTMusedwithindividualswithASDacrossthelifespanistheTreatmentandEducationofAu-tisticandCommunicationHandicappedChildren(TEACCH)program.Thismodelusesstructuredteach-ingmethodsthataresensitivetotheuniquevisuallearningstylesassociatedwithASD,especiallyrela-tivestrengthsinvisualprocessingandattentiontovisual details.69 These methods include structuring the physical environment (furniture arrangement and visuallabeling)toprovidemeaningfulinformationtotheindividual;usingascheduletocommunicateasequenceofevents;andvisuallyorganizingtaskstoshowwhatistobedone,thelengthofthetask,prog-ress,whenitisfinished,andwhatwillhappennext.TEACCHmethodshavebeenshowntobeeffectiveinimprovingparentalskillsandbehaviorsofchildrenwithASD.70Visualstructures,suchasindependentworksystems,havebeenshowntoincreasetaskac-curacy and reduce the need for adult support among studentsinspecialandgeneraleducationsettings.71

Conclusion and Future DirectionsChildren’sHospitalColoradocurrentlyoffersfrag-mentedservicesforchildrenwithdevelopmentaldisabilities.ManyofthesechildrenarefirstevaluatedthroughtheChildDevelopmentUnitorJFKPartners,and some of them receive their primary care services throughtheSpecialCareClinic(withintheDivisionofDevelopmentalPediatrics).However,thereislimitedhelpforroutinepsychiatricmedicationmanage-ment and therapy. The Neuropsychiatric Special Care unithasdemonstratedremarkableachievementinpositivelychangingthelivesofmanypatients,72 and

39


offersvitalcomprehensiveinpatientanddaytreat-ment levels of care for those individuals in psychiatric crisis.However,oncechildrenarereadytodischargebackintothecommunity,familieshaveadifficulttimefindingoutpatientproviderswillingandcapableof managing their child’s needs. Appropriate care forachildwithadevelopmentaldisabilityrequiresamultidisciplinaryapproach.Psychiatry,Developmental

Pediatrics,Psychology,SocialWork,PhysicalTherapy,SpeechLanguagePathology,andOccupationalThera-pyallhavevaluableinsightstooffertoachild’streat-ment.ThecreationofanoutpatientcliniccapableofcoordinatingservicesunderoneroofwouldbeahugeassetforthetreatmentofchildrenwithASDandIDinthe state of Colorado.

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68. ReichowB.(2012).Overviewofmeta-analysesonearlyintensivebehavioralinterventionsforyoungchildrenwithautismspectrumdisor-ders. Journal of Autism and Developmental Disorders. (42):512-520.

69. MesibovGB,SheaV,SchoplerE.The TEACCH Approach To Autism Spectrum Disorders.NewYork:Springer,2005.70. WelterlinA,Turner-BrownLM,HarrisS,MesibovG,DelmolinoL.(2012).ThehomeTEACCHingprogramfortoddlers.Journal of Autism and

Developmental Disorders. 42:1827-1835.71. HumeK,PlavnickJ,OdomSL.(2012).Promotingtaskaccuracyandindependenceinstudentswithautismacrosseducationsettingthrough

theuseofindividualworksystems.Journal of Autism and Developmental Disorders. 42:2084-2099.72. GabrielsR,AgnewJA,BeresfordC,MorrowMA,MesibovG,WamboldtM.(2012).Improvingpsychiatrichospitalcareforpediatricpatients

withautismspectrumdisordersandintellectualdisabilities.Autism Research and Treatment.doi:10.1155/2012/685053.

42

Adolescent Substance Use Disorder Prevention and Treatment

Adolescent Substance Use Disorder PreventionandTreatment

Introduction

Substanceabuseproblemsrepresentasignificantpublic mental health issue for adolescents in the

UnitedStates,with23%ofyouthhavingdevelopeda substance use disorder by the age of 18.1 Child-hood mental health problems increase the overall riskfordevelopingadolescent-onsetsubstanceusedisorders. Conversely, adolescent substance misuse increasestheriskofdevelopingco-occurringmen-talhealthproblems,andtheco-occurrencementalhealth and substance use problems complicates clin-ical management and treatment. Fortunately, there areanumberofpracticalandeffectiveapproachestothepreventionandtreatmentofadolescentsub-stanceabuseproblemsandtheirco-occurrencewithmental health problems that could—and should—be included in the deployment of comprehensive child and adolescent behavioral health services.

EpidemiologyThere is rich literature regarding the epidemiology of substance use problems among adolescents. One ofthemostrecentrigorouseffortsistheNational Comorbidity Replication–Adolescent Supplement (NCS-A),whichexaminedtheprevalenceofbehav-ioralhealthproblemsandrelatedserviceutilizationamonganationallyrepresentativesampleofado-lescentsages13-18years.1,2-4Consistentwithotherstudiesinthisarea,thevastmajorityofadolescentsreport that they had consumed alcohol by age 18 (78.2%),withaboutaquarterhavinguseddrugsbyage18(24.4%).Alcoholanddrugusewasrarelyinitiatedpriortoage13,butacceleratedrapidlythroughout adolescence. Substance use disorders showedasimilar,butslightlylaggedpatternwith

accelerationindiagnosticratesstartingafterage14.Thelifetimeprevalenceofalcoholuseanddrugusedisordersbyage18was6.4%and8.9%,respectively.Alcoholanddrugusedisordersweresomewhatmorecommoninmalesthanfemales(7.0%vs.5.8%and9.8%vs.8.0%,respectively).Equallystrikingarethehighratesofcomorbidityamongsubstanceusedisorderswithotherpsychi-atricdiagnoses.IntheNCS-A,60%ofyouthwithan alcohol use disorder had a comorbid drug use disorder,and44%ofthosewithadrugusedisor-derhadanalcoholusedisorder.Thirty-twopercentofadolescentswithasubstanceusedisordermetcriteriaforanon-substanceusepsychiatricdisorder.Particularlyconcerningistherelationshipofsub-stanceusedisorderswithsuicidalbehaviors,with24%and35%ofadolescentswhoattemptedsuicidemeetingcriteriaforanalcoholoradrugusedisor-der,respectively.ArmstrongandCostello5 examined theratesofcomorbiditybetweensubstanceusedisorders and other mental disorders reported in 15 epidemiological studies. Compared to adolescents withoutsubstanceuseproblems,only2classesofdisorderswereclearlymorecommonamongadolescentswithsubstanceuseproblems:Disrup-tiveBehaviorDisorders(mainlyConductDisorderwithratesof25.0%to50.0%)followedbyMajorDepressiveDisorder(withratesof20.0%to30.0%).RatesofothermentaldisordersthatwereprevalentamongadolescentswithsubstanceusedisordersincludedAnxietyDisorders(7%to44%),AttentionDeficitHyperactivityDisorder(12%),Post-traumaticStressDisorder(11%),andEatingDisorders(5%).The rates of comorbidity are higher in treatment set-tings.Forexample,Aaronsetal.6foundthat40.8%

Kelly Caywood, PhD; Paula Riggs, MD; Douglas Novins, MD

Divisions of Child and Adolescent Psychiatry and Substance Dependence

Department of Psychiatry, University of Colorado School of Medicine


43

KellyCaywoodPhD;PaulaRiggs,MD;DouglasNovins,MD

of youth receiving treatment in public mental health settingsmetcriteriaforasubstanceusedisorder.6

Thereisrichliteratureontheriskandprotectivefac-torsforsubstanceusedisorders.Geneticfactorsareestimatedtoaccountfor40%-70%ofriskfordevelop-ing substance use problems (the magnitude of this associationvariesacrosssubstances).7 Key psychologi-calandsocialriskfactorsincludesensationseeking,antisocialbehavior,peerandparentalsubstanceuse(andattitudestowardssubstanceuse),aswellascommunity norms regarding substance use (eg, rates ofadultalcoholuseandadultdrunkdrivingareasso-ciatedwithadolescentsubstanceuse).8 Mental disor-ders,particularlyConductDisorder,increasedtheriskof substance use disorders.5Protectivefactorsincludesocialskills,engagementinrecreationalactivities,havinganon-parentaladultrolemodel,andreligiousinvolvement.8 It is also notable that substance use dis-orders, especially during adolescence, are associated withagreaterriskofdevelopingmentalhealthprob-lems.9,10 For example, cannabis use increases odds of psychosisby1.41;frequentcannabisuseby2.09.10

Disparitiesintheratesofsubstanceusedisordersarealsowelldocumented.IntheNCS-A,non-HispanicblackshadlowerratesofsubstanceusedisordersthanwhitesandHispanics.1 Studies of American In-dian adolescents suggest that they have higher rates ofsubstanceuseproblemsthannon-nativeyouth.11

InColorado,thegrowthofthemedicalmarijuanaindustryandthelegalizationofrecreationalmarijuanafor adults over 21 is already having impacts on ado-lescent substance use. There is strong evidence for thediversionofmedicalmarijuanatoadolescents.12,13 Therearealsoconcernsthattheshiftinattitudestowardsmarijuanauseindicativeofitsmedicaliza-tionandlegalizationwillresultingreateradolescentmisuse and related problems, though a recent survey suggeststhatwhileamajorityofparentsofadoles-centsinColoradoaresupportiveofthedecriminaliza-tionofmarijuanauseforadults,theywantstrictcon-trolsofitsdistributionandusebecauseofconcernsregarding its health impacts on youth.14

Finally,despitethelong-standingrecognitionofado-lescentsubstanceuseasasignificantpublichealthproblem, access to care remains severely limited. In theNCS-A,only15.4%ofadolescentswithsubstanceuse disorders received substance abuse services.2

PreventionThereare3typesofpreventionprogramscitedintheliterature related to substance misuse among ado-lescents. Universal preventionreferstointerventionaimedattargetingtheentirepopulation,selective preventiontargetssubgroupswithinthepopulationwhoareconsideredhighrisk(eg,individualswithageneticpredisposition),andindicated prevention describesinterventionsthataregearedtowardthosewhoarealreadyexhibitingearlysignsofsubstanceuse problems, engaging in substance misuse, or other highriskbehaviors.15

Cochranereviewsofvarioustypesofpreventionpro-gramshavedescribedtheevidenceasbeingrelativelyweakwithheterogeneousandmodestinitialeffectsizesthatdiminishovertime.Universalpreventionprogramsthataredesignedtotargetyouthwhohavenotyetinitiatedsubstanceusetypicallyhavelimitedeffectiveness.16,17

Themosteffectivedrugpreventionapproachesfocusonreducingriskfactorsandincreasingprotectivefac-tors.15,18Additionally,multi-modaluniversalpreven-tionprogramsthatutilizedevelopmentallytailoredboostersessionstendtoshowmorerobust,longer-termeffects.19Forschool-basedinterventions,thereissomeevidencethatpreventionprogramsusingnon-teacherfacilitators(eg,mentalhealthcounselors,peer leaders, and health professionals) or a combina-tionofteachersandotherfacilitatorsaremoreeffec-tivethanteacher-ledinterventionsalone,althoughtheseresultsaresomewhatinconsistent.19 ArecentCochranereviewofuniversalschool-basedinterventionprograms,publishedin2011,identified3programsdeemedtobemosteffective:(1)theLifeSkillsTrainingProgram,(2)theUnpluggedProgram,and (3) the Good Behavior Game.20 TheLifeSkillsTrainingprogramutilizesacognitivebe-havioralskillsframeworkwithgoalsofimprovingself-esteem,assertiveness,drugresistance,problemsolv-ing,communication,emotionregulation,andsocialskills.Theprogramprovideseducationaboutnegativeconsequences of drugs and alcohol. This program isintendedtobedeliveredstartingintheseventhgrade,withboostersessionsinsubsequentyears(10sessions in eighth grade, and 5 in ninth grade). Find-ingsrelatedtotheLifeSkillsTrainingprogramshowedlowerratesofsubstanceusethancontrols.21,15

44


TheUnpluggedProgramisbasedonasocialinflu-encemodelandfocusesonteachinglifeskills,suchasassertiveness,problemssolving,coping,effectivecommunication,andself-control.Italsoincorporateseducationregardingriskandprotectivefactors.Itisdelivered using 12 sessions.17,22

The Good Behavior Game focuses on behavioral managementwiththeintentionofpromotinganunderstandingofthechild’srolewithintheclassroomcommunity.Itisdeliveredtofirstandsecondgradechildren.23Astudyexaminingthelong-termeffectsofthisinterventionfoundthatthosewhoreceivedtheGoodBehaviorGameinterventionhadlowerratesofproblematicbehaviorssuchassubstanceusedisor-ders,antisocialbehaviors,andsuicidalideationinyoung adulthood.23

Arecent,comprehensive,systematicreviewofselec-tivepreventionprogramsindicatesthatwhiletherearesomeprogramsthatshowpromisingresults,duetothelimitednumberofstudies,currentfindingsareconsidered preliminary.24

Indicatedpreventionprogramsthathaveshownpromisingefficacyareschool-based,andfocusonservingyouthwhohavealreadyinitiatedamildtomoderatelevelofsubstanceuse.Winters25andWalk-er26describeverybriefinterventionsconsistingof2to3individualsessionsofMotivationalEnhancementTherapy(MET)/MotivationalInterviewingcomparedtoanEducationalFeedbackControl(EFC).Theseverybriefinterventionsshowmodestshort-termreductionsinself-reportedcannabisuse,primarilyinadolescentswhoelectedtoparticipateinasmanyas4additional(andoptional)CognitiveBehavioralTherapy(CBT)sessionsaftercompletingthebriefMETintervention.Thissuggeststhatlongerschool-basedMET/CBTinterventionsareneededforthegrowingnumberofhighschoolstudentswhoregularlyuse(approximately25%),ortheestimated10%-15%whomeetdiagnosticcriteriaforSubstanceUseDisorders(SUD). Results from a recently completed pilot study provideempiricalsupportforthisconjecture.27 The studyadaptedanexisting16-weekevidence-basedMET/CBT+CMintervention(Encompass) as a briefer (8-week)school-basedintervention.Fifteenstudentswhocommitteddrug/alcoholrelatedschooloffenceswereconsecutivelyreferredforclinicalevaluation.AllmetDSM-5diagnosticcriteriaforcannabisusedisor-der,and13/15enrolledinthe8-sessionintervention

afteradolescent/parentconsent.Nine(69%)com-pletedtreatmentwith95%compliance(CBTsessionattendance),andmorethanhalf(56%)achievedatleast1monthofsustainedabstinenceduringtreat-mentbasedonweeklyurinedrugscreens.27

Screening And AssessmentThere are 2 types of assessments for substance use andabuseinadolescentsthatarewidelyused:briefscreening,andcomprehensiveevaluation.Briefscreeningisusedwiththeintentionofidentifyingwhetherthereisacauseforconcern,anddeterminesifthereisaneedforfurtherevaluation.Briefscreen-ingcanbecompletedinaveryshortperiodoftime(typicallywithinminutes),andshouldbeapartofanyclinicalintakeprocess.Comprehensiveevalua-tiontoolsareutilizedwhenapotentialsubstanceuseproblemhasalreadybeenidentified.Thesetypesofevaluationscantakeupto2to3hours,depend-ingonthestructureoftheparticularevaluation.Thegoal of these more comprehensive assessments is to gain a clearer understanding of the nature and sever-ity of the substance problem. They may also gather relevantbiopsychosocialinformation,establishinganappropriate diagnosis, determining the presence of comorbidities,andprovidingaframeworkfortreat-ment planning.18,28,29Thereareseveralcommonly-usedinstrumentstoaccomplishtheabovetasks,30,31,28 whicharesummarizedinTable1.Reviewarticlesre-gardingscreeningandassessmentshouldbereviewedformoredetaileddescriptionsandevaluationsoftheinstruments,aswellasadiscussionregardingtheirutility,reliability,andvalidityinformation.30-32

45


Evidence-Based Interventions For Adolescents With Substance Use Disorders (SUD)

Evidence-Based Psychosocial/Behavioral Treatments for Substance Abusing AdolescentsAccordingtorecentpublishedreviews,thefollowingpsychosocialinterventionsareconsideredtohave“well-establishedefficacy:”(1)IndividualCognitiveBehavioralTherapy(CBT)withorwithoutacompo-nentofMotivationalEnhancementTherapy(MET),(2)MultidimensionalFamilytherapy(MDFT),(3)FunctionalFamilyTherapy(FFT),and(4)CognitiveBehavioralTherapy-Group(CBT-G).33,34Interventionsdeemedtobe“probablyefficacious”include:(1)BriefStrategic Family Therapy (BSFT), (2) Behavioral Fam-ilyTherapy(BFT),and(3)Multi-SystemicTherapy(MST).34Takentogether,theseinterventionshavecomparableandmoderateacutetreatmenteffectsizesonreductionsinsubstance,andmoremodesteffectsonsustainedabstinence.33-35 Of those listed above,interventionsthatutilizeindividualMET/CBThaveconsistentlyshowngreatersustainedoremerg-ingpost-treatmenteffectsizecomparedtofamily-basedinterventions.33-35Otherstudieshaveshownthatcontingencymanagement(CM)usingmotivation-alincentives(ie,voucherpaymentsorprizedrawings)

significantlyincreaseratesofsustainedabstinence,whenaddedtoindividualMET/CBTcomparedtoMET/CBT alone.36,37 In a randomized controlled trial of CM in69adolescents(ages14-18)withcannabisusedis-orders,50%oftheparticipantswhoreceiveCM+MET/CBTachievedatleast10weeksofabstinencecom-paredto18%whoreceivedMET/CBTalone.Inthisstudy,betweengroupdifferencesweremaintainedat6months,butnotthe9-monthpost-treatmentfollowup.38

Medication-Assisted Treatment for Adolescents with SUD Numerousstudiesinadultshaveshownthatmedica-tionscanbeusefulwhenusedinconjunctionwithpsychosocialorbehavioralinterventionsforaddictiontoalleviatesymptomsofwithdrawal,reducecravinganduse,preventrelapse,ortotreatcommonco-occurringpsychiatricconditionssuchasdepressionor anxiety disorders.39Unfortunately,relativelyfewrandomizedcontrolledmedicationtrialshavebeenconducted in adolescents or young adults compared toadultswithsubstanceusedisorders.Medicationsthatareefficaciousorprobablyefficacious,andwhichhaverelativelygoodsafetyprofilesinadolescentswithSUDareshowninTable2.

Screening&BriefAssessment ComprehensiveEvaluation• CRAFFT–Thisisabrief6-itemscreeningtool

• SubstanceAbuseScreeningInventory-AdolescentVersion

• PersonalExperienceScreeningQuestionnaire:PESQ:

• DrugUseScreeningInventory(DUSI-A)

• AdolescentDrinkingIndex(ADI)

• Adolescent Drug Involvement Scale (ADIS)

• DrugAbuseScreeningTest-10(SBIRT)–Thisisa10-itemin-strumentthatshouldtakelessthan8minutestocomplete.Itcanbeusedwithadultsorolderyouth.

• AdolescentDiagnosticInterview(ADI)

• Adolescent Drug Abuse Diagnosis (ADAD)

• Adolescent Drug Involvement Scale (ADIS)

• Adolescent Alcohol and Drug Involvement Scale (AADIS)

• Personal Experience Inventory (PEI)

• KiddieScheduleforAffectiveDisordersandSchizophrenia(KSADS)-comprehensivesemi-structureddiagnosticinterview

Table 1.Commonly-UsedMeasuresforScreeningandComprehensiveAssessmentofSubstanceUseProblems.

46


Medications for Cannabis Use Disorders.N-acetylcys-teine(NAC)iswidelyavailableasanover-the-counterantioxidantsupplementorneutriceutical.An8-week,randomized,double-blinded,placebo-controlledtrialevaluatedtheimpactofN-acetylcysteine(NAC)(1200mgtwicedaily)comparedtomatchingplacebooncannabisuseandcravingin116cannabis-dependentadolescents/youngadults(ages15-21)inthecontextofbriefweeklycessationcounselingandcontingencymanagement.ParticipantswhoreceivedNACwere2.4timesmorelikelytohaveanegativeurinecan-nabinoidtest(THC)atpost-treatmentfollow-upvisit,andhadsignificantlymorenegativeurinedrugtestsduringtreatmentcomparedtothosewhoreceivedplacebo(19%vs10%,respectively).40

Medications for Opiate Use Disorders.Inopiate-de-pendentadolescents(ages15-21),longerterm(12-week)treatmentwithbuprenorphine-naloxonehasbeenshowntobemoreeffectivethanbrief14-daybuprenorphine-naloxonetaper(detoxification)withregardto:(1)treatmentcompliance,(2)feweropiatepositiveurinedrugscreens,(3)lessself-reportedopi-ate use.41

Medications for Smoking Cessation.Althoughfindingsaresomewhatmixed,andeffectsizesandcessationratestendtobesomewhatlowerthanthatreportedinadultstudies,bothNicotineReplacementTherapy(NRT)andBupropion-SRhavebeenshowntoberelativelysafeandmoreeffectivethansmokingcessa-

tioncounselingaloneinnicotine-dependentadoles-cents.42,43-45

Medications for Co-occurring Psychiatric Disorders

Major Depressive Disorder.Fluoxetinehasbeenshowntobemoreeffectivethanplaceboforco-occurringde-pressioninadolescentsconcurrentlyparticipatinginoutpatientsubstancetreatmentwithindividualMET/CBT.39Despitenon-abstinenceinmostparticipants,fluoxetinewasalsowell-tolerated,anddemonstratedagoodsafetyprofile.Attention-Deficit Hyperactivity Disorder

BothOsmotic-ReleaseMethylphenidate46 and atom-oxetine47havebeenshowntoberelativelysafeandprobablyefficaciousforco-occurringADHDinado-lescentsconcurrentlyreceivingoutpatientsubstancetreatmentwithindividualMET/CBT.

Summary And Recommendations For Clinical PracticeResearch in the past decade has increased our under-standing of biological and developmental processes, aswellasenvironmentalriskfactorsthatcontributetoadolescent-onsetsubstanceusedisorders(SUD).Therehasalsobeensignificantprogressinthedevel-opment,implementation,anddisseminationofpsy-chosocialinterventionsthathavebeendeemedtobeefficaciousorprobablyefficaciousforadolescentSUD.

Medication Targeted SUD or Psychiatric Comorbidity

Reduce Craving

Agonist Replacement Therapy

Psychiatric Comorbidity

N-Acetylcysteine(NAC) Cannabis Use Disorder XBuprenorphine Opiate Dependence XNicotineReplacementTherapy

NicotineDependence X X

Bupropion NicotineDependence X X*

*(ADHD,MDD)Fluoxetine MajorDepressiveDisorder

(MDD) X

Osmotic-Release Methylphenidate(OROS-MPH)

ADHD X

Atomoxetine ADHD X

Table 2.MedicationsforAdolescentswithSubstanceUseDisorders.

47


Ahandfulofmedicationshavealsobeenshowntobeusefulforreducingwithdrawalsymptoms,drugcrav-ing,andco-occurringpsychiatricdisorders.Despitesignificantprogress,existingbehavioralinterventionsforadolescentSUDshowrelativelymodestreductionsindrugusethatattenuateovertime,lowratesofab-stinence,andhighrelapserates.Althoughadditionalresearchisneededtoimproveexistinginterventionsordevelopmoreeffectiveinterventions,manytreat-mentprogramscouldcurrentlyimproveabstinenceratesbyincorporatingCM/motivationalincentivesintoexistingtreatment.Unfortunatelyfewcommu-nity-basedtreatmentprogramscurrentlyutilizeCM/incentives.Treatmentcouldalsobeimprovedbyimplementingstandardizedclinicalassessmentsandrepeated measures to enable treatment programs to more rigorously evaluate clinical outcomes and inform practiceimprovement.De-identifieddatafromclinicalassessmentscouldalsobeusedtodevelopcompeti-tivegrantproposalstofurtheradvanceresearchandclinicalpractice.Themostsignificantlimitationofthetreatmentsystem are the considerable barriers to treatment access,includingthelimitedavailabilityofadolescent-focusedsubstanceabuseservices.Toourknowledge,thereisnootherareaofmedicineforwhichthegapbetweentreatmentneedandavailabilityisasgreatasitisforadolescentswithsubstanceusedisorders(SUD).Existingcommunity-basedadolescentsub-stance treatment programs predominantly serve youthwhoarereferredbythejuvenilejusticesystem,inpart,becausethejuvenilejusticesystemisthelarg-estthird-partypayerforadolescentdrugtreatment,nationwide.Suchyouthrepresentlessthan10%ofthosewhocouldbenefitfromsubstancetreatment.Veryfewtreatmentoptionsexistfortheestimated11%ofadolescentsintheU.S.,themajorityofwhomarehighschoolstudents,whomeetcriteriaforsub-stanceusedisorders,butwhoarenot(yet)involvedwiththejuvenilejusticesystem.Thevastmajorityofexistingschool-baseddrugpreventionprogramsaredesignedforyouthwhohavenotyetinitiatedsub-stanceuse.School-basedinterventionsforyouthwhohaveprogressedtoproblematicuse,abuse,and/ordependenceareverybrief,utilizing1-3sessionmoti-vationalenhancementinterventionsthathaveshownmodesttoweakshort-termreductionsinsubstanceusethatattenuateovertime.

Itispossiblethattheeffectivenessofevidence-basedsubstancepsychosocialtreatmentinterventionslocatedincommunity-basedtreatmentsettingscouldbeimprovedifadaptedasschool-basedinterven-tionsfornon-juvenile-justice-involvedhighschoolstudentswhomayhavesomewhatlessserioussub-stanceinvolvement.ThiswouldbealignedwithTheAmerican Academy of Pediatrics and the President’s NewFreedomCommissiononMentalHealth(NFC)recommendationsthatmentalhealthandsubstancetreatmentservicesbeextendedtonon-traditionaltreatmentsettings,especiallyschools,toaddresscriticalgapsinaccessandavailabilityofhighqualitybehavioral health treatment for youth and families. Thiswouldalsohelpaddressexistingdisparitiesinac-cessforsocioeconomicallydisadvantagedandracial/ethnicminorities,andfacilitategreatercontinuityandcoordinationwithprimarymedicalcareinmanyexist-ingschool-basedhealthclinics.Effortstosignificantlyincreaseaccessandtheavail-ability of substance or integrated behavioral health treatmentwillalsorequiresignificantexpansionoftheworkforce.Clinicaltrainingprogramswillneedtobesignificantlyenhancedandtransformedtoaddressthecriticalshortageofclinicianswithdualtrain-inginmentalhealthandaddictionpreventionandtreatment,asidentifiedbytheInstituteofMedicine.University-basedresearchandclinicaltrainingpro-gramsmaybeinthebestpositiontotaketheleadindeveloping enhanced clinical training programs, and establishingclinicalcompetencyandcredentialingcri-teria. Mental health clinician training should include (1)traininginsystematicassessmentofbiological/developmentalprocesses,environmentalrisk,andprotectivefactorsassociatedwithadolescent-onsetsubstanceabuse;(2)traininginevidence-basedpreventionandtreatmentinterventionsthathavebeenshowntoreduceriskandenhanceresilienceorprotectivefactors(eg,ParentManagementTrainingforchildrenwithODD/CD);(3)traininginevidence-based approaches to integrated or coordinated treat-ment(eg,co-locatedmentalhealth/addictiontreat-mentservices);and(4)trainingincontinuingcare(eg,relapseprevention,recoverysupportservices)andcoordinatedcaremodelsforyouthwithco-occurringsubstance abuse and mental health problems.

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http://drugfree.org

http://drugfree.org

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27. RiggsP,etal.Encompass:AnIntegratedTreatmentInterventionforAdolescentswithCo-OccurringPsychiatricandSubstanceUseDisorders.Abstract,INScientificProceedingsoftheAmericanAcademyofChildandAdolescentPsychiatry61stAnnualMeeting(AACAP),October2014.

28. http://www.ImprovingHealthColorado.org,2013.Screening,BriefIntervention,andReferraltoTreatment(SBIRT)Connectingsubstanceuseandhealth.SBIRTColoradoLiteratureReviewSummary:February2013.PreparedbyOMNIInstituteSBIRTandmarijuanause.

29. CarneyT,MyersBJ,LouwJ.Briefschool-basedinterventionsandbehaviouraloutcomesforsubstance-usingadolescents(Protocol).Co-chrane Database of Systematic Reviews.2011,Issue2.Art.No.:CD008969.DOI:10.1002/14651858.CD008969.

30. WintersKC,KaminerY.Screeningandassessingadolescentsubstanceusedisordersinclinicalpopulations.J Am Acad Child Adolesc Psychia-try.2008;47(7):740–744.

31. FarrowJA,SmithWR,HurstMD.Adolescent Drug and Alcohol Assessment Instruments In Current Use: A Critical Comparison.WashingtonOlympia,WA:WashingtonState,DivisionofAlcoholandSubstanceAbuse,1993.

32. WintersKC,StinchfieldRD,etal.Validityofadolescentself-reportofalcoholandotherdruginvolvement.The International Journal of the Addictions.1990;25(11A):1379-1395.

33. TripodiSJ,BenderK,LitshgeC,VaughnMG.Interventionsforreducingadolescentalcoholabuse:Ameta-analyticreview.Arch Pediatr Ado-lesc Med.2011;164(1):85-91.

34. WaldronH,TurnerC.Evidence-basedpsychosocialtreatmentsforadolescentsubstanceabuse.Journal of Clinical Child Adolescent Psychol-ogy.2008;37:238-261.

35. MinozziS,AmatoL,VecchiS,Davoli.Pswychoasocialtreatmentsfordrugsandalcoholabusingadolescents(Protocol)TheCochraneCollabo-ration.The Cochrane Library.2011,Issue3.JohnWileyandSons,Ltd.

36. StangerC,BudneyAJ,etal.ARandomizedTrialofcontingencymanagementforadolescentmarijuanaabuseanddependence.Drug and Alcohol Dependence.2009;105(3):240-247.

37. BudneyAJ,RoffmanR,StephensRS,WalkerD.MarijuanaDependenceandItsTreatment. Addiction Science and Clinical Practice. 2007, 4(1), 4-16.

38. StangerC,BudneyAJ.Contingencymanagementapproachesforadolescentsubstanceusedisorders.Child Adolesc Psychiatr Clin N Am. 2010Jul;19(3):547-62.

39. RiggsP,LevinF,GreenAI,VocciF.ComorbidPsychiatricandSubstanceAbuseDisorders:Recent Treatment Research Substance Abuse. 2008;29(3):51-63.

40. GrayKM,etal.Adouble-blindrandomizedcontrolledtrialofN-AcetylcysteineinCannabis-DependentAdolescents.Am J Psychiatry.2012;169:805-812.

41. WoodyG,PooleS,SubramaniamGA,etal.Extendedmedication-assistedtherapyproducesbetteroutcomesthandetoxificationamongopioid-addictedyouth.JAMA.2008;300:2003–2011.

42. GrayKM,CarpenterMJ,BakerNL,HartwellKJ,LewisAL,HiottDW,DeasD,UpadhyayaHP:BupropionSRandcontingencymanagementforadolescentsmokingcessation.J Subst Abuse Treat.2011;40:77–86.

43. Muramoto,ML,LeischowSJ,SherrillD,MatthewsE,StrayerL.J.(2007).Randomized,double-blind,placebo-controlledtrialof2dosagesofsustained-releasebupropionforadolescentsmokingcessation.Archives of Pediatrics and Adolescent Medicine.161(11),1068-1074.

44. MoolchanE.T,RobinsonML,ErnstM,CadetJL,PickworthWB,HeishmanSJ,SchroederJR.(2005).Safetyandefficacyofthenicotinepatchandgumforthetreatmentofadolescenttobaccoaddiction.Pediatrics.115(4),e407-414.

45. KillenJD,RobinsonTN,AmmermanS,HaywardC,RogersJ,StoneC,SchatzbergAF.(2004).Randomizedclinicaltrialoftheefficacyofbupro-pioncombinedwithnicotinepatchinthetreatmentofadolescentsmokers. Journal of Consulting and Clinical Psychology.72(4),729-735.

46. RiggsPD,etal.RandomizedControlledTrialofOsmotic-ReleaseMethylphenidatewithCBTinAdolescentswithADHDandSubstanceUseDisorders. J Am Acad Child Adolesc Psychiatry. 2011;50(9):903-914.

47. ThurstoneC,RiggsPD,Salomonsen-SautelS,Mikulich-GilbertsonSK.Randomized,controlledtrialofatomoxetineforattention-deficit/hy-peractivitydisorderinadolescentswithsubstanceusedisorder.J Am Acad Child Adolesc Psychiatry.2010;49(6):573–582.

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Eating Disorders in Children and Adolescents

EatingDisordersinChildrenandAdolescents

Introduction

Feedingandeatingdisordersarecharacterizedbyapersistentdisturbanceofeatingoreating-

related behaviors that result in altered consump-tionorabsorptionoffoodsignificantlyimpairingphysicalorpsychosocialfunctioning.1 The typical eatingdisorders(EDs)havebeenanorexianervosa(AN) and bulimia nervosa (BN). In the most recent DiagnosticandStatisticalManualofMentalDisor-ders(DSM-51)anewdisorder,bingeeatingdisorder(BED),hasbeenincluded.IndividualswithEDsthatdonotmeetfullcriteriaforAN,BN,orBEDarenowdescribed in the Other Specified Feeding or Eating Disorder and Unspecified Feeding and Eating Dis-order categories. EDs are severe psychiatric disor-derswithabout1.5timesthemortalityratesforallcauses,andbetween4and6timesthestandardizedmortality rates for suicide. EDs are highly associ-atedwithanxietyandmooddisorders;theyoftentakeachroniccourseandcausesignificantnega-tiveeconomicimpact.3-5Ourknowledgeabouttheunderlying neurobiology is limited, as are treatment optionsforAN,BN,andBED.Yet,specificevidence-based guidelines for assessment and treatment of EDshavebeendeveloped.ThefeedingandeatingdisorderscategoryinDSM-5nowalsoincludespica,rumination,andavoidant/restrictivefoodintakedisorder(ARFID),whichwerepreviouslypartoftheDisorders Usually First Diagnosed in Infancy, Child-hood, or Adolescence.Thosedisorderswillnotbediscussedinthisarticle.

Anorexia NervosaAnorexia Nervosa (AN) is characterized by severe emaciationfromself-drivenfoodrefusal,motivation

forweight-loss,andaperceptionofbeingover-weightinspiteofaverylowbodyweight.6 A restrict-ingsubtypehasbeendifferentiatedfromabinge-purgesubtype,wheretheformeraimstocontrolweightthroughrestrainingdietaryintakeandthelatterengagesinepisodesofbingeeatingorpurgingbehaviororboth(eg,self-inducedvomiting,laxativeabuse,diuretics).7 AN typically develops during ado-lescence and is the third most common chronic ill-ness among female teens.8Lifetimeprevalencerateshavebeenestimatedupto1%infemalesand0.3%in males.4 Psychological comorbidity is present in over half of cases, and anxiety and depressive disor-dersareparticularlycommon.4Inaddition,mortalityinANisstrikinglyhigh,withsomeestimatessuggest-ingthatitis12timeshigherthanthedeathrateas-sociatedwithallcausesofdeathforfemales15-24years old.9,10Theinterplaybetweenneurobiological,psychological, and environmental factors in AN are difficulttodisentangleandtreat.11 As a result, treat-menteffectivenessforANislimited,12whichmaybea reason for the disorder’s chronic course, frequent relapse, high treatment cost, and disease burden.13 ThereisnomedicationthathasbeenapprovedforthetreatmentofAN,anditremainsuncertainwhatpsychotherapeuticapproachmightworkbest.14 Importantly,atypicalantipsychoticmedicationhasoftenbeenused,buttheireffectivenesshasbeencontroversial.Thelargestdouble-blind,controlledstudy that tested in adolescent AN and the use of atypicalantipsychoticsresearchedwhetherrisperi-done is helpful in treatment, but the study did not showbenefits.15Weightrestoration16isstillthemost“likelytobebeneficial”treatment17 and is reinforced by meal support.18

Guido K.W. Frank, MD; Jennifer O. Hagman, MD; Mindy Solomon, PhD



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GuidoK.W.Frank,MD;JenniferHagman,MD;MindySolomon,PhD

Bulimia NervosaBulimia Nervosa (BN), a disorder characterized by repeatedepisodesofbingeeatingandpurginginthepresenceofshapeandweightconcerns,ismoreprevalent than AN,19affecting1.5%offemalesand

0.5%ofmales.4BNcanbedifficulttoidentifygiventhatpatientsaretypicallyofnormalweightandtendtobesecretiveaboutengaginginEDbehavior.20 LikeAN,BNetiologyiscomplexandthoughttobeaconsequence of biological, psychological, and cultural factors.21BNisassociatedwithsignificantpsychologi-cal and medical comorbidity including mood, anxiety, and substance use disorders,4aswellaselectrolyteimbalances and arrhythmias.22 Increased mortality in BN(fromallcauses)iscomparabletoestimatesinANatabout1.5timestherateinthegeneralpopulation;however,deathbysuicideis6-7timesgreaterinBNthaninthegeneralpopulation,whichissignificantlyhighercomparedtoANwitha4-5timesincreasedrisk.3LikeinAN,therecoveryratesforBNarerathermodestandthereissignificantoverlapandfluctua-tioninsymptomsacrossthesedisordersduringboththe course of illness and recovery process, as illus-tratedinTable1-TreatmentPrognosis.23,24 Although slightlybetterthanwhatisobservedinAN,BNisalsoassociatedwithchronicityandfrequentrelapse.Psy-chologicalandpharmacologicalinterventions,suchasCognitiveBehavioralTherapy(CBT),InterpersonalPsychotherapy(IPT),andantidepressantmedicationtreatment,haveshowntobeefficaciousinthetreat-

ment of BN,25,26butstillapproximatelyhalfofindivid-ualswillcontinuetosufferfrompartialorfullformsofthe illness or experience relapse.20

Other Eating Disorders Including Binge Eating Disorder (BED)Eatingdisordernototherwisespecified(EDNOS)intheDSM-IV-TR,6whichhasbeenreplacedwithOther Specified Feeding or Eating DisorderaswellasUn-specified Feeding and Eating DisorderinthenewDSM-5,27 is a residual category meant to classify indi-vidualswithclinically-significantEDsymptomswhofailtomeetthespecificdiagnosticcriteriaofAN,BN,BED,orARFID,andhasbeenassociatedwithlevelsof symptomatology, psychosocial impairment, and mortalityriskcomparabletotheseillnesses.3,28-30 In previous research, EDNOS has been cited as the most commonEDdiagnosisinclinicalsettings,29-31whereapproximately60%ofoutpatientEDclinicpatientsmet criteria for this disorder.32BingeEatingDisorder(BED),formallypartofEDNOSandnowitsownformaldiagnosisinDSM-5,27 is characterized by the presence ofrepeatedbingeeatingepisodesintheabsenceofcompensatorybehaviorsalongwithassociatedfeatures(eg,eatingrapidly,feelingguiltyaftereat-ing,andeatingwhennotphysicallyhungry).BEDhasreceivedincreasingattentionintheliteratureandisconsideredthemostprevalentformalED,affectingupto3.5%offemalesand2.0%ofmales.4AmajorityofindividualswithBEDhavepsychiatriccomorbidity(eg,depression,anxiety,and/orsubstanceusedisorders)andmorethan60%ofthosesufferingfromBEDarealso obese.4,33LikeBN,someefficaciouspsychologi-cal and pharmacological treatments are available for BED;however,fewwiththedisordereverseektreat-ment34andmanycontinuetosufferfromprolongedEDandassociatedmedicalsymptomsovertime.35

WithBEDnowbeingaformaldiagnosis,insurancecompanieswillbemorelikelytoreimbursetreatment,andtreatmentprogramsforthisdisorderwillbecomemoreavailable.ThiswillalsostimulateresearchforbettertreatmentoptionsforBED.InordertohavemoredefinedtypesofEDsandreducethenumberofpatientsthatareincludedintheEDNOSgroup,anewcategoryhasbeenincludedinDSM-5:Other Specified Feeding or Eating Disor-ders (OSFED). That group further includes Atypical AnorexiaNervosa,wheretheindividual’sweightis

Anorexia Nervosa27% Good Outcome25% Partiallyrecovered39% Chronic course8% Deceasedatfollowup(12years)

Flchter, Quadflleg, & Hedlund, 2006

Bulimia Nervosa50% Full recovery27% Partiallyrecovered23% Chronic,non-remitting

Stelnhausen & Weber, 2009

Table 1. Treatmentprognosisineatingdisorders.

~ 35% with AN will develop BN

~ 25% with BN will develop AN

Tozzi et al., 2005

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withinorabovenormal;BingeEatingDisorderoflowfrequencyorlimitedduration;BulimiaNervosaoflowfrequencyorlimitedduration;PurgingDisorder:Recurrentpurgingintheabsenceofbingeeating;andNightEatingSyndrome:Recurrentnighteatingthatisnotbetterexplainedbyenvironmentalinfluencesorsocial norm or by another mental health disorder (eg BED).Researchoverthenextyearswillhavetoshowthevalidityorclinicalutilityofthosecategories.

AssessmentTheassessmentofindividualswithEDsusuallyin-volvesamultidisciplinaryassessmentthatincludespsychiatry,psychology/psychotherapy,medicalmoni-toring,andnutritionevaluation.Generalpsychiatricassessmentandmanagementiscritical,andincludesmanagementofcomorbidconditions,coordinatingcareandcollaboratingwithotherclinicians,andas-sessingandobservingeatingdisordersymptomsand

behaviors. A psychotherapist typically provides indi-vidualandfamilypsychotherapy,aswellasongoingassessment,andmonitoringthepatient’ssafetyandmental health status. A primary care provider should evaluateandmonitorthepatient’sgeneralmedicalcondition.Adieticianmaybeinvolvedtoevaluateeatingpatternsandrecommendanoptimalnutritionplan,takingintoaccountweightrestorationneedsandeatingdisordersymptomsimpactingnutritionandhealth.Adetaileddescriptionoftheseaspectsoftreatment and assessment can be found in the Ameri-canPsychiatricAssociation’spracticeguidelinesforeatingdisorders.2

Laboratory Assessments for Patients with Eating Disorders Specialattentionmustbepaidtolaboratorystudiestoassessandmonitormedicalstabilityandeatingdisorderseverity,asindicatedinTable2-Laboratory

Laboratory AssessmentsBasic Analyses—All patients with eating disordersBlood chemistry studiesSerum electrolytesBlood urea nitrogenSerumcreatinine(interpretationsmustincorporateassessmentsofweight)Thyroid-stimulatinghormonetest;ifindicated,freeT4,T3CompletebloodcountincludingdifferentialErythrocytesedimentationrateAspartateaminotransferase,alanineaminotransferase,alkalinephosphataseUrinalysisAdditional Analyses—Malnourished and severely symptomatic patientsComplement component 3a

Blood chemistry studies

Serum calciumSerum magnesiumSerum phosphorusSerumferritinElectrocardiogram24-hoururineforcreatinineclearanceOsteopenia and Osteoporosis Assessments—Patients amenorrheic for >6 monthsDual-energyX-rayabsorptiometrySerumestradiolinfemalepatientsSerumtestosteroneinmalepatients

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Assessments.Some experts recommend assessment of complement component3asamarkerfornutritionaldeficienciesevenwhenotherlaboratorytestresultsareinthenormal range.36,37Duringhospitalre-feeding,serumpotassium, magnesium, and phosphorus levels should beassesseddailyfor5daysuntiladequatecalorieshavebeenreachedtosustainweightgain.Somesug-gestfurtherlabtestingthereafter3timesperweekfor3weeks,buttheclinicalutilityofthoseongoinglabtestsmaynotbesignificant.38,39

Treatment–Levels of Care There are typically 6 levels of care available for EDs16: (1)outpatienttreatment(OTP),(2)intensiveoutpa-tienttreatment(IOP),(3)partialhospitalization(PHP,mosteffectiveifadministeredforatleast8hours/day,5days/week;lessintensivecareisdemonstrablylesseffective40),(4)residentialtreatmentcentertreatment(RTC),(5)specializedeatingdisorderfocusedpsychi-atricinpatienthospitalizationtreatment(IP)designedforbothmedicalstabilizationandacutestabilizationofbehavioralconsiderations;and(6)inpatientmedi-cal care (IMC) focused primarily on medical stabiliza-tion.Levelofcarecanbedeterminedbyavarietyof factors, including medical status, suicidality, body weight,motivationtorecover,co-occurringdisorders,structureneededforeatingandgainingweight,abilityofthefamilytomanageeatingdisorderbehaviors,the ability to control compulsive exercising or urging behavior(laxativesanddiuretics),andwhattreatmentisavailableinaspecificgeographicalregion.Thede-scribedlevelsorcareareadaptedandmodifiedfromLaViaetal.41 The APA last published guidelines for

careofpatientswithEDsin2006.Theguidelineswereprimarily based on care of adults, and not adapted specificallyforchildrenandadolescents.Researchoverthepastdecade,alongwithimprovementsinac-cesstocare,earlieridentificationofeatingdisorders,andafocusonevidence-basedcarespecificallyforchildren and adolescents, have led to an emphasis on providingcareinlowerlevelsofcarewheneverpos-sible.Inpatientmedical,psychiatric,andresidentialcareforEDsareveryhighcostwhencomparedtoPHPandoutpatientinterventions,withoutclearevidenceof improved outcomes. For instance, one study com-paredPHPwithIPcareforadolescentAN,andfound1yearaftertreatmentnobenefitofprolongedIPtreatmentoverPHPafteraninitial3-weekhospital-izationformedicalstabilization.42 Another study that assessedadolescentswithAN1,2,and5yearsaftertreatmentalsodidnotfindbenefitsformprolongedIPtreatments,suggestingthatIPisnotacost-effectivelevel of care.43 Formedicalreasons,IMCisindicatedforpatientswithheartrate<40bpm;blood,pressure<90/60mmHg;glucose<60mg/dl;potassium<3mEq/L;electro-lyteimbalance;temperature<97.0°F;dehydration;hepatic,renal,orcardiovascularorgancompromiserequiringacutetreatment;orpoorlycontrolleddiabe-tes. For children and adolescents, criteria have been slightlymodifiedtowhenheartrateiscloseto40,orthostatiocbloodpressurechangeswith>20bpmincreaseinheartrateor>10mmHgto20mmHgdrop,abloodpressure<80/50mmHg,hypokalemia,hypo-phosphatemia, or hypomagnesaemia. IP(medicalorspecializedeatingdisorderpsychiatricunits)isalsoindicatedwhenbodyweight,aspercent-

Nonroutine assessments

Toxicologyscreen–PatientswithsuspectedsubstanceuseSerumamylase–Patientswithsuspectedsurreptitiousvomiting(fractionatedforsalivaryglandisoenzymeifavailabletoruleoutpancreaticinvolvement)GonadalHormones–Patientswithpersistentamenorrheabutwhoarenormalweight

(Serumluteinizinghormone,follicle-stimulatinghormone,-humanchorionicgonadotropin,prolactin)Brainimaging–Patientswithsignificantcognitivedeficits,otherneurologicalsoftsigns(Magneticresonanceimaging,computedtomography)Stoolforguaiac–PatientswithsuspectedGIbleedingStoolorurineforlaxatives–Patientswithsuspectedlaxativeabused(Bisacodyl,emodin,aloe-emodin,rhein)

Table 2. LaboratoryAssessments.

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ageofhealthybodyweight,is<85%,orwhenthereisacuteweightdeclinewithfoodrefusalevenifnot<85%ofhealthybodyweight.RTCcanbeindicatedwhenbodyweightaspercentageofhealthybodyweightis<85%,PHPandIOPareindicatedwhenbodyis>80%ofhealthybodyweight,andOTPwhenbodyweight>85%ofhealthybodyweight.DSM-5islessstrictwithweightcriteriacomparedtopreviousguidelines.Forinstance,apatientwhohasbeenatahigherthannormalweightpremorbidlymayqualifyafterweightlossforANevenifataweight>85%ofnormal.Rateofweightlossmustalsobetakenintoaccount,andveryfastweightlossmayputsomeoneatriskforre-feedingsyndrome,andrequireIPtreat-ment.Admission is indicated if there is acute suicidality, in-cludingaspecificplanwithhighlethalityorintent;ad-missionmayalsobeindicatedinpatientswithsuicidalideasorafterasuicideattemptorabortedattempt,depending on the presence or absence of other fac-torsmodulatingsuiciderisk.Suicideriskassessmentisacomplexproblemandspecificguidelinesshouldbeadhered to for this assessment.16 A general psychiatric inpatientunitmaybeneededforpatientswithsig-nificantsuicidalideation,orsuicidalorself-injuriousbehavior, in case it cannot be handled on the ED inpatientunit.Motivationtorecover,alsodescribedas“readinessforchange”(RFC),includescooperative-ness, insight, and ability to control obsessive thoughts and respond to supervision and support, and has beenlinkedtopositivetreatmentoutcomes.Thedeterminationoflevelofmotivation,orRFC,mustbeassessedcarefully,takingeachpatient’sspecificback-groundintoconsideration.44OTPisoftenadequateforpatientswithfair-to-goodmotivationandIOPisoftenadequateforpatientswithfairmotivation.Forpatientswithpartialmotivation(definedbypatientswhoarecooperative,butpreoccupiedwithintrusive,repetitivethoughts>3hours/day,andhavingdiffi-cultyinterruptingeatingdisorderbehaviors),PHPismorelikelytobethemosteffectiveandleastrestric-tivelevelofcarenecessary.RTCmaybeindicatedforpatientswithlowmotivation,andRTCforpatientswhohavenotbeensuccessfulinotherlevelsofcare,includingbriefinpatientstabilizations.Patientswithlow/poormotivationarepreoccupiedwithintrusive,repetitivethoughts,whichimpacttheirbehavior,andrequire the external structure and constant supervi-sionofahighly-structuredtreatmentenvironment.

However,therearealsoquestionsthathavebeenraised about RTC treatment. First, those centers are expensive, and their quality of care is variable, and largely unregulated.45Second,therearepositivere-ports published on outcome from RTCs, but there are nocomparativestudieswithothertreatmentmodali-ties.Thishasbeenespeciallybroughttotheforefrontinthecontextoffamily-basedtreatments,asRTCsare typically far from home, and the families may be less involved than maybe necessary. In general, RTC treatmentmaybeparticularlysuitableforpatientswithseverecomorbidconditions,chronicself-harm,and personality disorders.46IPisindicatedforpatientswhosemedicalconditionorintensityofbehaviorsrequire24-hourcarebeforetransitiontoPHPorOTP.Patientwithhigherlevelsofawareness,insight,andmotivationarelikelytoimprovemorequickly,andac-ceptinterventionsandsupportwithlessdistress.Comorbidconditions,includingsubstanceuse,havetobeassessedindividuallyforeachpatient,andtakenintoconsiderationfordeterminationoflevelofcare.Forpatientswithseverefood-avoidancebehaviors,nasogastricfeedingmaybenecessary,whichisusuallyinitiatedduringaninpatientstayonamedical,psychi-atric,orspecializedeatingdisorderunit.OTPandIOPareoftenadequateforpatientswhoareabletoeatwithfamilysupport.PHPisusefulbothforstabilizingeatingdisorderbehaviorswhenthefamilyisabletoprovide support and supervision in the evenings, and forsupportingthetransitiontohomeandschool.RTCareindicatedforpatientswhoneedahigherlevelofsupervision,andhavenotbeenabletomakeprog-ress in the home environment due to severity of their symptoms, or challenges in their primary support system.Itiscriticaltocarefullyevaluatetheabilityofparentstosupport—andactivelyparticipatein—treatmentforchildrenandadolescents.Familieswhoarenotwillingorabletoparticipateincarearemorelikelytorequiremoreextendedinterventionsandhigherlevelsofcarethanfamilieswhoaremotivatedandengagedintreatmentofthechildwithaneatingdisorder.Patientswithseverepurgingbehaviorswhoneedsu-pervisionduringandafterallmealsandinbathrooms,andareunabletocontrolmultipledailyepisodesofpurging that are severe, persistent, and disabling, despiteappropriatetrialsofoutpatientcare,needIPlevelofcare,evenifroutinelaboratorytestresults

55


revealnoobviousmetabolicabnormalities.Iftherearenosignificantmedicalcomplicationsfrompurgingbehavior, such as electrocardiographic or other ab-normalitiesthatsuggesttheneedforhospitalization,thenpatientsmaybemanagedonOTP,IOP,orPHPlevels of care. Severeenvironmentalstressorfamilyconflictscanmakehigherlevelsofcarenecessary.Anotherreasonforhigherlevelofcarecanbewhenapatienthastotravel out of state for a specialized ED treatment pro-gram,andRTCorIParetheonlyviablealternatives.ForBN,ingeneral,outpatienttreatmentisrecom-mended,exceptwhentherearecomplicatingfactors(eg, serious general medical problems, suicidal behav-

ior, or psychosis), or severe disabling symptoms that donotrespondtooutpatienttreatment.Astudycom-pared2optionsforsuchpatients:IPandPHPtreat-ment.Inthatstudy,55patientswithsevereBNwererandomlyassignedtoeitheroneofthosesettings.At3monthspost-treatment,bothtreatmentswereassociatedwithreducedgeneralandspecificpathol-ogy.47WhilemoredeteriorationinbulimicsymptomsoccurredfollowingIPthandayclinictreatment,theresultsoverallwerefoundtobecomparable.

Treatment–Specific Interventions

Controlled Treatment Studies

Anorexia Nervosa Bulimia NervosaLikely to be Beneficial–Anorexia Nervosa Likely to be Beneficial–Bulimia NervosaRe-feeding Rigaud et al, 2007 CognitiveBehavioralTherapy(CBT)

SSRIs(FLXT,Citalopram,Sertraline)Monoamine Oxidase InhibitorsTricyclicantidepressants(desipramine/imipramine)

Hayetal,2007Shapiro et al, 2007Bacalchuc, 2002Shapiro et al, 2007

Clinical Evidence FitzpatrickandLock,2011

Unknown Effectiveness Unknown Effectiveness

AtypicalAntipsychotics Benzodiazepines Cyproheptadine SSRIs Pyschotherapy InpatientvsOutpatientTx Estrogen for osteoporisis

Mehler-Wexetal,2008 Nosyst.review,RCTs Halmietal,1986Claudino et al, 2010Hayetal,2010Buliketal,2007Klibanskietal,1995

CBT+Exposure,Resp.PreventionInterpersonal PsychotherapyGuidedSelfHelpCBTDialecticalBehavioralTherapyHypnotherapyMotivationalEnhancementPharmacotherapy + CBTMirtazpineReboxetineVenlafaxineTopiramate

Hayetal,2007NICE, 2004Bailer et al, 2004Hayetal,2007Griffithsetal,1994Treasure et al, 1999Shapiro et al, 2007nosyst.Review,RTCnosyst.Review,RTCnosyst.Review,RTCArbaizar et al, 2008

Likely to be Ineffective or HarmfulOlderGenerationAntipsychoticsTricyclicAntidepressants

Relly et al, 2000Claudino et al, 2010

Table 3. Summary of Anorexia Nervosa and Bulimia Nervosa.

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Table3illustratesthesummarybyFitzpatrickandLock(2011),andHayandClaudino(2012)ofthestud-iesthatwereavailableatthetime.12,17,48-63

Inaddition,avarietyofotherstudieshavebeenre-portedonsincethattime,assummarizedinGuidelineWatch(August2012).64Afewstudiesassessedtheeffectsofnasogastricfeedingsinopentrials.Inonetrial49ANpatientswererandomlyassignedtoatube-feedinggroup(n=41)oracontrolgroup(n=40).After2months,weightgainwas39%higherinthetube-fedgroup,andbinge-eatingepisodeswerelower.Thetube-fedgroupalsohadalongerrelapse-freeperiodafterdischarge(34.3±8.2weeksvs26.8±7.5weeks).Inanother study,65 adultoutpatientswithANorBNwererandomlyassignedto2monthsofcognitivebehavior-altherapy(CBT)alone(n=51)orCBTplustubefeeding(n=52).CBTplustubefeedingledtomorerapidandfrequentabstinencefrombingeeatingandpurging,more improvement on depression and anxiety, and patientsreportedbetterqualityoflife.A1-yearfollowupfurthersupportedthoseresults.BMIforpatientsinthetubefeedingplusCBTarmwas18.2±3.3,andtheanalysisdidnotseparatenormal-weightpatientswithBNfrompatientswithAN,binge-eatingpurgingtype. In general, nasogastric tube feeding is not rec-ommendedfornormalweightpatients.16,64Arecently-developed treatment modality, enhancedCBT,whichincludesaspectsofinterpersonaltherapy(IPT),wasappliedto125patientsatapublicoutpatientclinic.66 Reportedlytwo-thirdsofthosewhocompletedtreat-ment(and40%ofthetotal)achievedpartialremis-sion.However,only53%completedthetreatment.MedicationuseinANgenerallyhasnotbeeneffec-tiveforweightgain,butareviewof4randomizedcontrolledtrialsand5open-labeltrialssuggestedthatolanzapine,quetiapine,andrisperidonemayimprovedepressionandanxiety,andmaybecoreeatingcogni-tions.67Inanotherstudythatassigned23outpatientswithANto8weeksofolanzapine(2.5mg/day,upto10mg/dayastolerated)ortoplacebo,68patientsreceivingolanzapineshowedasmall(1point)butsig-nificantgaininBMI.However,othersfoundnodiffer-encesinpercentagechangeinmedianbodyweight,ratesofweightgain,orimprovementinpsychologi-calmeasures5or10weeksafterasmallsingle-site,randomized, controlled trial of olanzapine versus placeboin15outof20adolescentfemaleswhocompleted the study.69Anotheratypicalantipsychotic,

risperidone,studiedinadouble-blind,randomized,controlledtrialof40hospitalizedadolescentswithAN,15 did not provide an advantage (average dose 2.5 mg/day,prescribedupto4weeks)overplaceboforweightrestoration.

New treatment interventions and comparative effectivenessArelativelynewinterventionthathasbeentestedinyouthwithANisFamily-BasedTreatment(FBT),amanualizedandwidely-studiedfamilyinterventionfor adolescent AN. FBT stresses behavioral change by encouraging increased parental control over adoles-centmaladaptiveeatingpatterns.Thisinterventionhasshownhigherratesoffullremission,andgreaterimprovements8to12monthsfollowingtreatmentwithregardstoweightandEDpathologycomparedto family counseling and adolescent focused therapy, anindividualoutpatientinterventionthatisgearedtoimproveeatingsymptomsandemotionaltoler-ance.70,71However,longer-termstudiesoftheef-fectivenessofthisinterventionandotherfamilytreatmentsarelimited.One5-yearfollow-upstudyproducedevidencesuggestingthatwhenahighlevelofparental(specificallymaternal)criticismispresent,theuseofseparatedfamilytherapy,atleastinitiallyintreatment,issuperiortousingconjointfamilytherapy(asistraditionalFBT).72However,longer-termstud-iesoftheeffectivenessofthisinterventionandotherfamilytreatmentsareotherwiselimited.Importantly,newresearchnowshowsthatinthegeneralOTPset-ting,FBTismoresuitableforlessseverecaseswithAN.73

Long Term Outcome StudiesTherearedifferentwaystoassesslong-termoutcome.Oneistofollowpatientsanddeterminethenatural-isticcourseofillness.Anothermethodistostudytheeffectsofspecifictreatmentinterventions.Table4describesnaturalisticfollow-upstudies,andthereisaverywiderageofpossibleoutcomesacrossstudies.

57


Study Population Sample (N)

Follow-upduration*

Outcome Measures Findings

AN Fichter et al. (2006)74

Adult and late adoles-centwomen,restrictingand binge purging type

103 12 EDI-2,Morgan-Russell Scales†, ED diagnosis(SIAB-EX)

EDcognitionsimprovedbutremainedsignificantlyelevatedcompared to controls. Overall, 43%hadpooroutcome,27%had intermediate outcome, 30%hadgoodoutcome,basedonbodyweightandresump-tionofmenses.Diagnosisdatashowed30%obtainedlong-term, sustained recovery and wereED-free,43%experiencedresurgence of symptoms, and 27%hadchronicED.

Ratnasuriya et al. (1991)75

Adultwomenandmen 38 20 Morgan-RussellScales†

30%hadgoodoutcome,33%had intermediate outcome, and 37%hadpooroutcome.

Eckertetal.(1995)76

Severely ill adolescent and adult females§

76 10 ModifiedMorganRussell Scale assess-ingweight,menses,eatingdisorderbe-haviorandattitudes,and body image disturbance.

24%hadahealthybodyweight,resumed menses and had no eatingorbodyimageconcerns;26%hadgoodmedicaloutcome,butmaintainedEDattitudes/concerns;51%hadintermediatetopooroutcomes,withbothmedical and psychological ED symptoms.

Herzogetal.(1999)

Adolescent and adult women,restrictingandbinge purging type

136 7.5 PSR (ED symptoms): recoverydefinedasfull symptom remis-sionfor≥8weeks.

Aminority(34%)recovered,and84%experiencedreductionofsymptoms (subthreshold AN) duringfollow-upperiod.Shorterdurationofillnesspredictedquickerrecovery.40%relapsedafterrecovery.

Loweetal.(2001)

Adolescent and adult women,restrictingandbinge purging type

84 21 PSRwithrecov-erydefinedasfullsymptom remission (PSR=1)overprevi-ous 3 months.

51%recoveredandhadim-provements in psychosocial adjustment;21%werepartiallyrecovered;26%hadpoorout-come,including14%mortalityrate due to AN.

Steinhausen et al. (2000)77

Adolescent males and females

60 11.5 11 domains of eatingdisordersymptoms, sexual-ity, and psychosocial functioning.

80%ofsurvivingadolescentshadrecovered,buttherewashighutilizationoftreatmentthroughoutfollow-upperiod.

Strober et al. (1997)78

Adolescent male and femaleinpatients§

95 10-15 Recovery (free from all AN criterion items≥8weeks),remission, and relapse.

76%metfullrecoverycriteria,with30%reportingrelapsesinsymptomsduringfollow-upperiod. Time to recovery in ado-lescentsisprotracted,takinganaverageof5-7years.

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Follow-upduration*

Outcome Measures Findings

BN Zeecketal.(2011)

Adult day and inpa-tients

36 3 SCIDIandSIAB;EDremission(nob/p)and rare ED preoc-cupationinthelast3 months

1/3showedcompleteremission,1/3showedpartialremission,and1/3continuedtohaveBN.

Herzogetal.(1999)

Adolescent and adult women

110 7.5 PSR (ED symptoms) anddurationofsymptoms. Recov-erydefinedasfullsymptom remission for≥8weeks.

Amajority(74%)recovered,99%experiencedreductionofsymp-tomsconsistentwithsubthresh-oldBNduringfollow-upperiod,and35%relapsedafterrecovery.

Fichter&Quadflieg(2004)

Adult female medical inpatientswithpurgingtype-BN

196 12 SIAB-EX,EDI-2,PSR BNsymptomsimproved.70%nolongermetDSM-IVcriteriaforaneatingdisorder,13%hadEDNOS,10%maintainedBN-Pdiagnosis,and2%werede-ceased. Psychiatric comorbidity predicted outcome.

BED Agras et al. (2009)

Adult females, treat-ment,andnon-treat-mentseekingsample

104 4 EDE: Remission definedasabsenceofanyeatingdisor-der diagnosis for 6 months.

82%hadremittedatfollowup.

Fairburn et al. (2000)

Lateadolescentandadult females from non-treatment-seekingsample

48 5 EDE:DSM-IVdiag-noses

85%nolongermetcriteriaforanEDafter5years;9%main-tained BED status.

Other EDs

Fichter et al. (2008)79

Adultfemaleinpatients 68 12 SIAB-EX:DSM-IVdiagnoses

31%metcriteriaforanEDatfollowup(67%withoutanyED),wherepsychiatriccomorbiditypredicted poor outcome.

Agras et al. (2009)

EDNOS (excluding BED) 149 4 EDE: Remission definedasabsenceofanyeatingdisor-der diagnosis for 6 months.

78%hadremittedatfollowup,whichoccurredmorequicklythanforthosewithAN,BN,orBED.

Table 4.Long-termnaturalisticstudiesofrecovery,remission,andrelapseineatingdisorders. Diagnoses:ED=EatingDisorder,AN=AnorexiaNervosa,BN=BulimiaNervosa,BED=BingeEatingDisorder;Measures:EDE=EatingDisordersExamination,EDI-2=EatingDisorderInventory-2,SIAB-EX=StructuredInventoryforAnorexicandBulimicSyndromes,PSR=Psychiatric;RatingScale,DIS=DiagnosticInterviewSchedule,VersionIII,SCIDI=StructuredClinicalInterviewforDSM-IVDisordersI;*durationinyears;§perDSM-III-Rcriteria;†Morgan-RussellScales:good,intermediate,pooroutcomebasedonBMIandmen-strual status.

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There are no uniform treatments used in EDs. Table 5 summarizes studies on outcomes across ED types andtreatmentmodalitiesused,basedonavarietyof

outcome measures. The primary goal though in AN is weightrestoration,BNandBEDreduction,orcessa-tionofbingeeatingand/orpurgingepisodes.


Follow-upduration*

Intervention Outcome Measures Findings

AN Eisler et al.

(1997)80

Adults, subtyped by age of onset, durationofillness, and binge/purgesymptoms

77 5 Family Therapy, Individual Sup-portivePsycho-therapy

1)Bodyweight

2)Morgan-RussellScale†

Early onset, short durationANhadbetteroutcomeswithfamilytherapy.LateonsetANhadbetteroutcomeswithindividualsupport-ive psychotherapy. Poor outcomes in early onset ANwithlongdurationandinbinge/purgesymptoms.

Carter et al. (2011)14

Adultwom-en, broad AN (BMI≤19.0)

43 6.7 IPT, CBT, SSCM Global outcome

(1,asymptomaticto4, full AN)

SSCMassociatedwithdeterioratingsymptomsovertime;IPTassoci-atedwithimprovedsymptomsovertime.Overall,nosignificantdifferencesbetweentreatmentsatlong-termfollowup,wherehalfachieved good out-comes.

Whitneyetal.(2012)81

Adult inpa-tientsandfamilies

44 AN

82 family members

3 3-dayfamilyskillsworkshop,individual fam-ily therapy

1) Caregiver dis-tress, appraisal, expressedemotion

2)PatientBMI,SEEDs, IIP

Nosignificantdiffer-encesinpatientorcare-giveroutcomebetweeneducationalworkshopor individual family therapy.

Eisler et al. (2007)72

Adolescent outpatientsand families

38 5 Family Therapy, conjointorseparated

Morgan-RussellScale†

76%ofpatientsinbothtreatmentswithgoodoutcome.

Nodifferencesbe-tweenthe2familyinterventions;however,inpatienttreatmentandmaternalcriti-cism predicted poor outcome.Patientswithparentsendorsinghigh-expressedemotionhadbetterweightgaininseparate family therapy.

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Follow-upduration*


BN Carter et al. (2003)82

Older ado-lescents and adult females (17-45years)

113 3 CBTplusB-ERP,CBTplusP-ERP,relaxationtraining

Frequency of bing-ing and compen-satory behaviors, dietaryrestriction,bodydissatisfaction(EDI), depression (HDRS)

69%EDfreeatfollowup,withnodiffer-ences in outcome in thosereceivingadjunctbehavioralorrelaxationtherapy.

McIntosh et al.(2011)-continuationof Carter et al. (2003)82,83

Older ado-lescents and adult females (17-45years)

109 5 CBTplusB-ERP,CBTplusP-ERP,relaxationtraining

Frequency of bing-ing and compen-satory behaviors, dietaryrestriction,bodydissatisfaction(EDI), depression (HDRS)

65%withoutEDdiag-nosis.Abstinenceratesfrombingingweresig-nificantlyhigherfortheexposure treatments (thanforrelaxation).Frequency of purg-ingwaslowerfortheexposure treatments thanrelaxationtraining.Nodifferencesinothermeasures observed betweentreatments.

Fairburn et al. (1995)84

Adults 89 5.8 CBT, behavioral therapy, FIT

ED symptoms and diagnoses (EDE), general psychopa-thology (SCID), BSI, APFAI,socialadjust-ment

CBTandFITwereas-sociatedwithgreaterremission status than behavior therapy. CBT associatedwithlowerED symptoms overall compared to other treatments.

Keel et al. (2002)85

Adult fe-males

101 10 CBT,anti-depressant medication(imipramine), placebo

Depression(HDRS),bodydissatisfaction(EDI),BSQ,EDE-Q,SAS

Nolong-termdiffer-ences in depression, bodydissatisfaction,or bulimic symptoms. Activetreatments(CBTand/orimipramine)wassignificantlyassociatedwithimprovementinsocialadjustment.

Nevonen and Broberg (2006)86

Adult fe-males(18-24years)

69 2.5 CBT plus IPT, group and indi-vidual format

Frequency of binge eating&compensa-tory behaviors, ED symptoms, general psychopathology (RAB,EDI-2,IIP,SCL,BDI, BMI)

Greater improvements in binging and com-pensatory behavior in individuals receiving individual therapy. No otherdifferencesbe-tweentreatments.

Thiels et al. (2003)87

Adults 28 4 GSHplus4CBTsessions, 16 CBT sessions

EDE:overeating,vomiting,dietaryrestraint, shape and weightconcerns,BITE,BDI,Self-Con-ceptQuestionnaire

Significantimprove-ments in both groups in terms of outcome measureswithnodiffer-encesbetweentreat-ments.

BED Wilsonetal.(2010)88

Overweight/Obese Adults

205 2 IPT,BWL,CBT-GSH

BingeEatingFre-quency (EDE)

IPT and CBT resulted ingreaterbingeeatingremissionthanBWLatfollowup.

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Follow-upduration*


Ricca et al. (2010)89

Full and subthreshold adult BED

144 3 Individual and group CBT

EDE,EDE-Q,BES,EES, BMI

Significantreductionsinbingeeatingfrequencyandmildweightreduc-tioninbothtreatments.Loweremotionaleatingandbingeeatingsever-ity at baseline predicted fullrecovery;lowemo-tionaleatingpredictedweightreduction.

Munsch, Mey-er, and Biedert (2012)90

Overweight/Obese Adults

52 6 CBT,BWL Bingeeatingfrequency,eatingdisorder pathology (EDE-Q),BDI,BMI

CBTassociatedwithlowerbingefrequency.In both treatments, bingeeatingandgeneral ED pathology improvedduringactivetreatment. Compared to baseline, symptoms im-provedat6-yearfollowup.Only8%individu-alscontinuedtomeetcriteriaforBEDwith19%abstinentfrombingeeatinginpreviousmonth.

Table 5.Long-termtreatmentoutcomestudiesinAN,BN,andBED. Diagnoses:AN=AnorexiaNervosa,BN=BulimiaNervosa,BED=BingeEatingDisorder;Treatments:IPT=InterpersonalPsychothera-py,CBT=CognitiveBehavioralTherapy,SSCM=SpecialistSupportiveClinicalManagement,FIT=FocalInterpersonalTherapy,B-ERP=BingingExposureandResponsePrevention,P=ERP=PurgingExposureandResponsePrevention,GSH=GuidedSelf-Help,BWL=BehavioralWeightLoss;Measures:BMI=BodyMassIndex,EDE=EatingDisordersExamination,EDE-Q=EatingDisorderExamina-tionQuestionnaire,EDI-2,EatingDisordersInventory2,GAF=GlobalAssessmentofFunctioning,HDRS=HamiltonDepressionRatingScale,SEEDs=ShortEvaluationofEatingDisorders,IIP=InventoryofInterpersonalProblems,BSI=BriefSymptomInventory,APFAI=AdultPersonalityFunctioningAssessmentInterview,BSQ=BodyShapeQuestionnaire,SAS=SocialAdjustmentScale,RAB=RatingofAnorexiaandBulimiaInterview,SCL=SymptomsChecklist,BITE=BulimicInvestigatoryTestEdinburgh,BES=BingeEatingScale,EES=EmotionalEatingScale;*durationinyears;†Morgan-RussellScales:good,intermediate,pooroutcomebasedon1)nutrition,2)menstruation,3)mentalstate,4)psychosexualfunction,5)socialfunctioning

The Treatment in the Eating Disorder Program at Children’s Hospital ColoradoOurmodelisbasedonexistingevidenceemphasiz-ing the important role of the family in child and adolescentonsetEDs.Theprogramisinnovativeanduniquewithfamiliesengageddailyintreatment,planning meals for their child in all levels of care, andparticipatingindailymealsandprogramthera-pies.Weprovideconsultationandsupporttootheracademiccentersandprivatefor-profitprogramsineffortstoimprovetheirownapproachestocareandprogram development. The emphasis of treatment is

onhelpingfamiliesbuildtheskillstheyneedtohelptheirchildrecoverathome.Family-BasedTherapy(FBT)principlesofempoweringparentstoeffectivelymanageeatingdisordersymptomsareintegraltoourParent-SupportedNutrition(PSN)modelofcare.92-94This approach in the treatment of child and adoles-centonsetANhasfacilitatedshiftingtolowerlevelsofcaremorequickly(PHP,IOP,OP).Theemphasisintreatmentisonparenttrainingandskillsformanag-ingsymptomsathome,whichdecreasestheneedfortimeawayfromthefamilyandschool.Modelsofcareforchildren,adolescents,andadultswithEDsvarywidelyacrosstheUnitedStatesandhavetypicallyem-

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phasizedresidentialtreatmentwhenapatientdidnotimprovewithoutpatientcare.RTCcaretypicallylasts60-120days,andthechildrenareseparatedfromtheirparentsforthemajorityoftheepisodeofcare,creatingchallengesinthetransitiontohome.Whiletherearestillmanyresidentialprograms(RTC)intheU.S.,therehasbeenasignificantshifttospecializedoutpatientcareanddaytreatment,withinpatientcareprimarilyusedformedicalstabilization.Lowerlevelsofcarearelessdisruptivetofamilyandschoolfunctioning,aremorecosteffective,andresearchshowssimilarorevenimprovedoutcomes.ThespecializedEatingDisorderProgramintheDe-partment of Psychiatry, Division of Child and Adoles-cent Psychiatry at the University of Colorado Anschutz MedicalCampus,isembeddedwithintheChildren’sHospitalColoradoandprovidesspecializedmedicalfloorcare,InpatientEatingDisorderUnit(IP-EDU),PHP,IOP,aswellasOTPlevelsofcare.TheIP-EDUal-lowspatientswhostillneednursesupervision,cardiacmonitoring,andlowactivitytobemovedfromthemedicalfloortotheEatingDisorderProgramquickly,forintensivefamily-basedtherapyandparentinvolve-mentincare,whilestillmedicallystabilizing(improv-ingheartrateandweight)toapointthatthepatientcansafelysleepathome.Thisalsoallowsthehospitalto improve access to medical beds, decreases cost of care, and improves the ability of the parent and child toworktogetherduringthedayinourtherapeuticmilieu.Ourparent-supportedrecoverymodel,whichincludesparentskillstrainingandparent-supportednutrition(PSN),hasdecreasedthenumberofadmis-sionstotheinpatientlevelofcare,anddecreasedthelengthofstayinbothinpatientandPDTlevelsofcare.Morepatientsaretriagedtooutpatientfamily-basedtherapy.Patientsadmittedtohigherlevelsofcare(daytreatmentorinpatient)averageabout24daysinprogramover5weeksinwhichtimetheemphasisisonteachingparentsmealplanningandmeal-supportskills,aswellashelpingthemlearnandpracticeskillsformoreeffectivecommunicationandimprov-ingthefamilystructure.Patientscanadmittoanyofthelevelsofcaredescribedinthefollowingsection,andlevelofcareisdeterminedthroughevaluationofmedical,behavioral,andemotionalsymptoms,andthefamilies’capabilitytoparticipateincare.Theemphasisforpatientsisonskill-buildingfortoleratingtheexternalstructureandcontainment,whichservestointerrupteatingdisorderbehaviorsanddrives.

Children’sHospitaldoesnothavearesidentiallevelofcare,astheprogramemphasizeskeepingchildrenandadolescentswiththeirfamiliesandintheirhomecommunities.

Intake and Treatment Process, and Levels of CareInitialintakeconsultationandtriage:Atherapistfromtheeatingdisorderteamandanadolescentmedicinephysicianevaluatethechild,gatheringinformationabout the current concerns, symptoms, and contrib-utingfactors,anddetermineifaneatingdisorderislikely.Theparentsarealsointerviewed,andateamrecommendationisdiscussedwiththefamilyfortreatmentinterventions.Decision-makingaboutthemostappropriate,leastrestrictivelevelofcareisbasedonthefollowingpoints.• Outpatient level of care:Medicallystable(HR>50,

weight>80%IBW,electrolytesstable).Guardianableandwillingtoprovideadditionalsupportandsupervisionandtobeactiveintreatment.Abletoweightrestoreoverthefirstmonthofoutpatientcare.

• Inpatient Medical Unit admission: Medically un-stable,restingHR<45(HR<35atnight),rapidweightloss,weight<75%IBW,lowkcalintake(<1000/kcal/day),riskofrefeedingsyndrome,needforbedresttointerruptweightloss.Transi-tiontoinpatientEDUwhenHRis>35atnight.

• Inpatient Eating Disorder Unit admission:HRrest-ingHR45-50(HR>35)atnight,rapidweightlossorlowkcalintake(1000–1500kcals),weight<80%IBW,significantresistancefromchildtoparents’effortstoprovidesupportandsupervi-sion. May also have safety issues such as suicidal ideationorself-injuriousbehaviors.

• Extended Day Treatment Program (10-12 hours): Morelikelytoberecommendediffamilyhasnotbeensuccessfulwithoutpatientcare.Medicallystable,butunabletointerrupteatingdisorderbehaviorsathome.Familyandpatientneedmoresupport and coaching to be successful at home.

• Regular Day Treatment program (7 hours):PartialsuccesswithPSN/FBTprinciplesinoutpatientlevelofcare,medicallystable,familyandpatientneed more support and coaching to be successful at home.

• Intensive Outpatient Program: Monday, Tuesday,

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Thursday,2:30–5PM.Multifamilymodelofcare,emphasisoncontinuedrecovery,relapsepreven-tionandadaptingPSN/FBT-basedprinciplestohomeandschool,aswellassupportinggradualtransitionstonormalizedeatingandactivities.Families can enroll in IOP if they need more sup-portthanweeklyoutpatienttherapy,oraspartofthetransitionfromhigherlevelsofcare.

Conceptual Description of Treatment PhasesCHCO Eating Disorder Program–Parent Supported Nutrition: Five Phases of CareThese5phasesaretypicallyaccomplishedover5-6weeksandabout24daysinprogram.The treatment program in higher levels of care in-cludesastep-downmodel,whichallowsfamiliestopracticemealsathomeandtransitionmoresmoothlyto caring for their child at home. Outpatientcarefollowsasimilarmodel,withweeklyvisitsover2-3months.Childrenusuallycontinuetoattendschooliftheyareinoutpatientcare.

Each family entering a higher level of care is adminis-tered a clinical assessment comprised of a variety of measures including assessment of comorbid anxiety anddepression,eatingdisorderseverity,personal-ityfeatures,familysatisfactionandcommunication,perceivedexpressedemotion,andparent-perceivedempowerment.Theresultsofthiscomprehensiveassessment informs the families’ individualized treat-mentplanandroadmaptohowtheycanmosteffec-tivelyuseourprogramresources,andhelpthetreat-mentteamdefinepersonalizedfamilytreatmentgoalswithineachofthe5phasesofcare.Themeasuresarere-administeredafter3weeksinprogramtodelin-eateareasofgrowthandidentifycontinuedareasforgrowthinanefforttohelpsupportthefamiliesastheybegintotransitionhome.The phases are not dependent on level of care.

Neurobiological Research in Eating Disorders and Brain Research at the Children’s Hospital Colorado (CHCO) Eating Disorders Program

CHCO Parent-Supported Recovery 5 Phases of Care

Phase 1 Family:InitiatingParent-supportedNutrition(PSN/)

Patientlearningexpec-tationsandrulesofPSN

Phase 2 Family: Improving PSN skills

PatientbeginningtotrustfamilywithPSN

Phase 3 AdaptingPSNtohome

Learningabouttriggersandmakingadaptations

Phase 4 PracticingPSNoutsidethe program

Phase 5 Transition

Stabilizeeatingdisorderbehaviors

Medicalstabilization

Able to complete meals withparentsupport

Medically stable, ED behaviors improving

Able to begin to in-creaseactivity,increas-ing food tolerance and variety

Transitiontoshorterdaytreatment and days out of program

Followingmealplanathome

Begintransitionbacktoschool

Parents learn meal plan-ning and meal support skills

Parents begin to learn meal planning for home

Completingbreakfastout of program

Parentabletoadjustplanandactivitybasedon needs

Parent managing nutri-tionneedsflexiblyathome

Evaluatingmotivation,factors maintaining the eatingdisorder,chal-lenges to providing structure and support

Parents and child gain understanding of eatingdisorderandap-proachestotoleratingdistresswhilemanagingsymptoms and decreas-ing behaviors

Parentsandchildwork-ing together on inter-ruptingeatingdisorderdrives and behaviors and reducing symptoms, identifyingvaluesandmotivationfor recovery

Managing challenges at home, parent in strong supportiverole.Child’smotivationimprov-ingthroughpracticingvalue-drivenbehavior

Familyabletoadjustlife and school to need for supervision of meals andactivity.Workingtogetherwelltomanagechallenges.

Table 6.Parent-SupportedRecovery5PhasesofCare.

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Over the past decade, brain imaging has helped bet-terdefineeatingdisorder-relatedbraincircuitry.95 Brainresearchongrayandwhitemattervolumeshadbeeninconsistent,possiblyduetotheeffectsofacutestarvation,exercise,medication,andcomorbidity,butnewerstudiesarecontrolledforsucheffects.Thosestudiessuggestlargerleftmedialorbitofrontalgyrusrectus volume in ill adult and adolescent anorexia nervosaafterrecoveryfromanorexianervosa,andin adult bulimia nervosa. The orbitofrontal cortex is importantinterminatingfoodintake,andalteredfunctioncouldcontributetoself-starvation.Therightinsula,whichprocessestastebutalsointeroception,wasenlargedinilladultandadolescentanorexianervosa,aswellasadultsrecoveredfromtheillness.Thefixedperceptionofbeingfatinanorexianervosacouldberelatedtoalteredinsulafunction.Afewstudiesinvestigatedwhitematterintegrity,withthemostconsistentfindingofreducedfornixintegrityinanorexiaandbulimianervosa,alimbicpathwayimportantinemotion,butalsofoodintakeregula-tion.Functionalbrainimagingusingbasicsweettastestimuliineatingdisordersduringtheillstateorafterrecoveryimplicatedrepeatedlyrewardpathways,in-cluding insula and striatum. Brain imaging that target-eddopamine-relatedbrainactivityusingtaste-rewardconditioningtaskssuggestedthatthiscircuitryishy-persensitiveinanorexianervosa,buthypo-responsivein bulimia nervosa and obesity. Those results are in linewithbasicresearch,andsuggestadaptiverewardsystem changes in the human brain in response to extremesoffoodintake—changesthatcouldinterferewithnormalizationofeatingbehavior.Inadditiontoprovidingevidence-basedhighqualityofcare,theCHCOEatingDisorderprogramandteamare focused on improving care and disease outcomes throughactiveresearchprotocols.TheDevelopmen-talBrainResearchProgramfocusesonbrain-imagingofrewardmechanismsinthebrain,howunderlyingtraitsmaypredisposetodevelopmentofaneatingdisorder,andwhatbiologicalmechanismmayhinderrecovery. These studies contribute to our approaches tocarebyimpactinghowweunderstandthecogni-tiveprocessesofindividualswithAN,suchasintoler-anceofuncertainty,harmavoidance,motivation,andreward-seekingbehaviors.Allpatientsandfamiliesintheprogramalsohavetheopportunitytopartici-pateintheOutcomeStudy,whichisembeddedinthe

clinicalprogram,andallowsinformationfromtheirclinicalcaretobeusedforstudiesoffactorsthatinflu-ence onset, maintenance, and outcome of treatment. Throughthiswork,wehopetodevelopmoreeffec-tiveandefficientinterventionstoshortendurationoftreatment,decreaseseverityanddurationofillness,andimproveoveralllifefunctioning.Mostimportantly,weusethisnewknowledgetobuildmodelsforEDbrainpathology,consideringhowitmayaffecttreatmentandoutcome.Wepresentthisinformationinaregularparentseminar,whichistypi-callyverywellreceived.

Future Research DirectionsTreatmentinterventionsforchildrenandadolescentswithEDsshouldbefocusedonstabilizingdisorderedeatingbehaviorandrestoringoptimalhealthfornormalgrowthanddevelopment.Levelofcareshouldbe determined by symptom severity, medical stabil-ity,andabilitytomakeprogressinlowerlevelsofcare(outpatient,anddaytreatment)withhigherlevelsof care, primarily recommended for medical instabil-ityorconcernforself-injuriousbehaviorsorseverelydysregulatedeatingbehaviorthathasnotrespondedtolowerlevelsofcare.Diagnosisofco-morbidcondi-tionsandspecificsymptom-basedtreatmentplanning(includingconsiderationofmedications)toencom-passboththeeatingdisorderandco-morbiddiagno-ses is recommended. Further research is needed on components of care that improve outcomes and can improvecosteffectivenessoftreatmentinterventions.Further research is needed to understand factors that contribute to onset and maintenance of AN, BN, and otherEDs,aswellasfactorscontributingtosuccessfultreatment and recovery. There are many symptoms, suchasfoodrestriction,episodicbingeeating,purg-ing, or excessive exercise that are either overlapping or lie on opposite ends of a scale or spectrum across thosedisorders.IdentifyinghowspecificEDbehav-iorsarelinkedtoparticularneurobiologicalmecha-nismscouldhelpbettercategorizeEDsubgroupsanddevelopspecifictreatments.Thereissupportfromrecent brain imaging research that brain structure and functionmeasurescanbelinkedtodisorder-specificbiologicalorbehavioralvariables,andcanhelpdistin-guish,orfindcommonalitiesbetweenEDsubgroups.Thissuggeststhatbrainstructureandfunctionmaybe suitable as research targets to further study the re-

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lationshipbetweendimensionsofbehaviorandbrainfunctionrelevanttoEDsandbeyondthecategoricalAN,BN,andBEDdistinctions.

ResourcesThereareavarietyoforganizationsthatprovideinformationbothforpatientsafflictedwitheatingdisorders,andforprofessionalsintheeatingdisordertreatmentfield,includingtherapists,medicaldoctors,andnutritionists.Academy for Eating Disorders, AED: www.aedweb.orgTheAcademyforEatingDisordersisaglobalprofes-sionalassociationcommittedtoleadershipineatingdisorderresearch,education,treatment,andpreven-tion.Alliance for Eating Disorders: http://www.alliance-foreatingdisorders.comNational Association of Anorexia Nervosa & Associ-ated Disorders (ANAD): www.anad.orgANAD advocates for the development of healthy at-titudes,bodies,andbehaviors.ANADpromoteseatingdisorderawareness,prevention,andrecoverythroughsupporting,educating,andconnectingindividuals,families, and professionals.Binge Eating Disorder Association (BEDA): www.bedaonline.comBEDAisthenationalorganizationfocusedonincreas-ingprevention,diagnosis,andtreatmentofBEDandassociatedweightstigma.Throughoutreach,educa-tion,andresources,BEDAiscommittedtofacilitatingawareness,excellenceincare,andrecoveryforthosewholivewithandthosewhotreatbingeeatingdisor-deranditsassociatedconditions.Eating Disorders Coalition: www.eatingdisorderscoali-tion.org

TheEatingDisordersCoalitionforResearch,Policy,andActionisworkinginWashington,D.C.toincreaseawareness,educatepolicymakers,andpromoteun-derstandingaboutthedisablingandlife-threateningeffectsofeatingdisorders.Itsmissionistoadvancethefederalrecognitionofeatingdisordersasapublichealth priority.International Association of Eating Disorders Profes-sionals (iaedp): http://www.iaedp.comTheInternationalAssociationofEatingDisordersProfessionalsFoundation’s(iaedp)goalistoprovideexcellenceinprovidingfirst-qualityeducationandhigh-leveltrainingstandardstoaninternationalmul-tidisciplinarygroupofvarioushealthcaretreatmentproviders, and helping professions that treat the full spectrumofeatingdisorderproblems.National Eating Disorders Association, NEDA: www.nationaleatingdisorders.orgNEDAsupportsindividualsandfamiliesaffectedbyeatingdisorders,andservesasacatalystforpreven-tion,cures,andaccesstoqualitycare.National Institutes of Mental Health (NIMH): http://www.nimh.nih.gov/health/publications/eating-disor-ders-new-trifold/index.shtmlThisfederalinstitutionprovidesinformationaboutmentalhealthproblemsincludingeatingdisorders.Thesiteanswersthefollowingquestions:(1)Whatareeatingdisorders,(2)Whatarethedifferenttypesofeatingdisorders,(3)Howareeatingdisorderstreated,and(4)Whatisbeingdonetobetterunderstandandtreateatingdisorders?

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http://www.nimh.nih.gov/health/publications/eating-disorders-new-trifold/index.shtml



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ricMeasures.4ed.WashingtonDC:American Psychiatric Association. 2000.7. APA.Diagnostic&StatisticalManualofMentalDisorders:DSM-IV-TR.4theditioned:American Psychiatric Association. 2000.8. GoldenNH.Eatingdisordersinadolescenceandtheirsequelae.Best Practice & Research in Clinical Obstetrics & Gynecology.2003;17(1):57-

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Behav Res Ther.Jun2005;43(6):691-701.33. Striegel-MooreRH,CachelinFM,DohmFA,PikeKM,WilfleyDE,FairburnCG.Comparisonofbingeeatingdisorderandbulimianervosaina

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Arch Gen Psychiatry.2000;57:659-665.35. CachelinFM,Striegel-MooreRH,ElderKA,PikeKM,WilfleyDE,FairburnCG.Naturalcourseofacommunitysampleofwomenwithbinge

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trolled trials. Int J Eat Disord. Mar 16 2007.58. BacaltchukJ,HayP.Antidepressantsversusplaceboforpeoplewithbulimianervosa.Cochrane Database Syst Rev. 2003(4):CD003391.59. ExcellenceNIfHaC.Eating Disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Re-

lated Eating Disorders.Leicester(UK)2004.60. BailerU,deZwaanM,LeischF,etal.Guidedself-helpversuscognitive-behavioralgrouptherapyinthetreatmentofbulimianervosa.Int J

Eat Disord.May2004;35(4):522-537.61. GriffithsRA,TouyzSW,MitchellPB,BaconW.Thetreatmentofbulimianervosa.Aust N Z J Psychiatry.Mar1987;21(1):5-15.62. TreasureJL,KatzmanM,SchmidtU,TroopN,ToddG,deSilvaP.Engagementandoutcomeinthetreatmentofbulimianervosa:first

phaseofasequentialdesigncomparingmotivationenhancementtherapyandcognitivebehaviouraltherapy.Behav Res Ther. May 1999;37(5):405-418.

63. ArbaizarB,Gomez-AceboI,LlorcaJ.Efficacyoftopiramateinbulimianervosaandbinge-eatingdisorder:asystematicreview.Gen Hosp Psychiatry.Sep-Oct2008;30(5):471-475.

64. YagerJ,DevlinM,HalmiK,etal.Practice Guideline for the Treatment of Patients With Eating Disorders, 3rd Edition. Guideline Watch. 2012. 65. RigaudDJ,BrayerV,RoblotA,BrindisiMC,VergesB.Efficacyoftubefeedinginbinge-eating/vomitingpatients:a2-monthrandomizedtrial

with1-yearfollow-up.JPEN. Journal of parenteral and enteral nutrition.May2011;35(3):356-364.66. ByrneSM,FurslandA,AllenKL,WatsonH.Theeffectivenessofenhancedcognitivebehaviouraltherapyforeatingdisorders:anopentrial.

Behav Res Ther.Apr2011;49(4):219-226.67. McKnightRF,ParkRJ.Atypicalantipsychoticsandanorexianervosa:areview.European eating disorders review: the journal of the Eating

Disorders Association.Jan2010;18(1):10-21.68. AttiaE,KaplanAS,WalshBT,etal.Olanzapineversusplaceboforout-patientswithanorexianervosa.Psychol Med.Oct2011;41(10):2177-

2182.69. KafantarisV,LeighE,HertzS,etal.Aplacebo-controlledpilotstudyofadjunctiveolanzapineforadolescentswithanorexianervosa.J Child

Adolesc Psychopharmacol.Jun2011;21(3):207-212.70. LeGrangeD.Familytherapyforadolescentanorexianervosa.J Clin Psychol.1999;55:727-739.71. LockJ.TreatmentofAdolescentEatingDisorders:ProgressandChallenges.Minerva Psichiatr.Sep2010;51(3):207-216.72. EislerI,SimicM,RussellGF,DareC.Arandomisedcontrolledtreatmenttrialoftwoformsoffamilytherapyinadolescentanorexianervosa:

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100.75. RatnasuriyaRH,EislerI,SzmuklerGI,RussellGF.Anorexianervosa:outcomeandprognosticfactorsafter20years.Br J Psychiatry. Apr

1991;158:495-502.76. EckertED,HalmiKA,MarchiP,GroveW,CrosbyR.Ten-yearfollow-upofanorexianervosa:clinicalcourseandoutcome.Psychol Med.Jan1

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ders. Psychol Med.Sep2000;30(5):1089-1098.78. StroberM,FreemanR,MorrellW.Thelong-termcourseofsevereanorexianervosainadolescents:survivalanalysisofrecovery,relapse,

andoutcomepredictorsover10-15yearsinaprospectivestudy.Int J Eat Disord.Dec1997;22(4):339-360.79. FichterMM,QuadfliegN,HedlundS.Long-termcourseofbingeeatingdisorderandbulimianervosa:relevancefornosologyanddiagnostic

criteria. Int J Eat Disord.Nov2008;41(7):577-586.80. EislerI,DareC,RussellGF,SzmuklerG,LeGrangeD,DodgeE.Familyandindividualtherapyinanorexianervosa.A5-yearfollow-up.Arch

Gen Psychiatry.1997;54:1025-1030.81. WhitneyJ,MurphyT,LandauS,etal.Apracticalcomparisonoftwotypesoffamilyintervention:anexploratoryRCToffamilydayworkshops

andindividualfamilyworkasasupplementtoinpatientcareforadultswithanorexianervosa.Eur Eat Disord Rev.Mar2012;20(2):142-150.82. CarterFA,McIntoshVV,JoycePR,SullivanPF,BulikCM.Roleofexposurewithresponsepreventionincognitive-behavioraltherapyforbuli-

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termeffectsofthreepsychologicaltreatments.Arch Gen Psychiatry.Apr1995;52(4):304-312.85. KeelPK,MitchellJE,DavisTL,CrowSJ.Long-termimpactoftreatmentinwomendiagnosedwithbulimianervosa.Int J Eat Disord. Mar

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community physician. Pediatr Child Health.Jan2010;15(1):31-40.93. HildebrandtT,BacowT,MarkellaM,LoebKL.Anxietyinanorexianervosaanditsmanagementusingfamily-basedtreatment.European eat-

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cusedindividualtherapyforadolescentswithanorexianervosa.Arch Gen Psychiatry.Oct2010;67(10):1025-1032.95. FrankGK.RecentAdvancesinNeuroimagingtoModelEatingDisorderNeurobiology.Current Psychiatry Reports. in press.

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CelesteSt.John-Larkin,MD;JenniferJ.Paul,PhD;BethanyAshby,PsyD

Perinatal, Infancy, and EarlyChildhoodMentalHealth

Introduction

Thisarticleaddressesacriticaltimeduringbothinfantandchilddevelopment,aswellasduring

theadultlife-cycle:theperinatalperiod.Treatmentof mental health concerns during pregnancy and postpartum stages can be both challenging and rewarding,astherearelong-termimplicationsfortheparent,infant,andrelationshipbetweenparentand child. The special topic of adolescent pregnancy is also discussed, as it places both the pregnant teenandtheinfantathighriskforcomplications.The importance of addressing the needs of infants andyoungchildren,aswellaspotentialdisrup-tionsintheirrelationshipswithprimarycaregiverswithinacontinuumofcareformothers,cannotbeoveremphasized. Adverse life events in childhood, oftennowreferredtoastoxic stress,areknowntohavelong-termimplicationsformentalandphysicalhealth in adulthood.1Appropriatetherapeuticandmedicationinterventionsduringpregnancy,postpar-tum, and early childhood to decrease the impact of mental illness and stressful life events on mothers andtheirchildrenwillhavelastingresultsforfami-lies.

Pregnancy Related Depression and Other Psychiatric Disorders in the Perinatal PeriodMaternal depression and anxiety is increasingly recognizedasanimportantpublichealthissue,withimplicationsnotonlyforthemother,butalsothelong-termoutcomesininfantsandchildren.De-pression, anxiety, and bipolar disorder commonly begininwomenduringchildbearingages.Nationally10%-23%ofwomenwilldevelopdepressionduring

pregnancy and the postpartum period.2-4Thismakesdepressiononeofthemostcommoncomplicationsofpregnancy.SpecificallyinColorado,1outof9womenwhogivebirthwillexperiencedepressivesymptoms.5

Between50%-85%ofwomenmayexperiencethebaby bluesinthefirst2weekspostpartum.Thisincludestearfulness,moodreactivity,andirritability,butnotsuicidalideationorsignificantimpairmentinfunctioning.Halfofpostpartumdepressionepisodesbeginduringpregnancy.DiagnosisismadewiththeusualMajorDepressiveEpisodecriteria,plusaspecifierofwithperipartumonset.Womenwithpe-ripartum depression commonly experience intense anxiety,suchaspanicattacksandobsessive-compul-sivethinkingandbehaviors.Womenwithpostpar-tum mood episodes (depressive, manic, or mixed) areatriskforpsychoticfeatures,whichoccurin1in500 to 1 in 1,000 deliveries. These symptoms may range from mild to life threatening for the mother and the infant.6 The recurrence rate for peripartum depressionis50%.Therelapserateforwomenwithbipolarmooddisorderis30%-50%intheperipartumperiod.Womenwithahistoryofperipartumpsycho-sishavea70%chanceofrecurrence.7

Riskfactorsforperinataldepressionincludeprevi-ous depression, especially postpartum depression, and depressive symptoms during pregnancy, includ-inganxiety,lifestress,lackofsocialsupport,beingasingleparent,youngerage,experienceofdomesticviolence,unintendedpregnancy,andlowersocio-economic status.8-10 Depression and anxiety during pregnancy and the postpartum period predisposes motherstothefollowingcomplications:lowma-ternalweightgainanddecreasedfetalgrowth,

Celeste St. John-Larkin, MD; Jennifer J. Paul, PhD; Bethany Ashby, PsyD



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Perinatal, Infancy, and Early Childhood Mental Health

increased incidence of preterm delivery, preeclamp-sia,postnatalcomplications,anddecreaseinvaginaldeliveries.Thereisanincreasedriskofsuicide,sub-stance abuse, recurrent or longer depressive epi-sodes, and increased healthcare costs.11,12,4

Infantsandchildrenborntomotherswithperinataldepressionfaceincreasedlikelihoodofcomplicationssuchaslowbirthweightandpoorweightgain,sleepdysfunction,decreasedbreastfeeding,poorattach-ment,andinfanticide.Longertermoutcomesincludedelaysinlanguageandsocialdevelopmentandworselong-termmentalhealthoutcomes.13-15

AssessmentScreeningwomenforperinatalmoodandanxietysymptomsacrossavarietyofsettingsiscriticalforin-creasingidentificationandtreatment.TheEdinburghPostnatal Depression Scale is the most commonly usedandevidence-basedtoolusedtoscreenfordepression.DevelopedbyCox,Holden&Sagovsky,16 theEPDSwasdesignedtoallowscreeningofpostna-taldepressionintheprimarycaresetting.Itisrecom-mendedthatroutineadministrationoftheEPDStakeplaceatleastbetween6-8weekspostpartumandagainbetween3-6monthspostpartum,17andwithongoing screening through 12 months postpartum be-inguseful.AlthoughtheEPDSwasoriginallyintendedto screen for depression in the postpartum period, it has more recently been validated for use in screen-ingforantenataldepressionaswell.18Whenusedtoscreen for antenatal depression, it is recommended thatahighercut-off(15ormoreascomparedto13ormoreforpostpartumdepression)beutilized.Itissuggestedthatthetotalscoreprovidesadistinctlyaccurateindicationofthelikelihoodofclinicalde-pression across numerous cultures and countries. Asthismeasurebecamewidelyused(andmisused),the original authors of the scale more recently pub-lishedabooktoensureproperimplementationofthescreening tool.19

Inadditiontoidentifyingdepressionandanxietyintheperinatalperiod,itisalsocriticaltoscreenforbipolardisorder.Mostwomenwithbipolardisorderwillexperienceamoodepisodeduringpregnancyandthepostpartumperiod(ashighas60%-70%inrecentstudies).20,21Womenwithbipolardisorderarealsoatriskfordevelopingpostpartummaniaandpsychosis,withestimatesrangingfrom25%-50%.Onsetisusu-

allywithin3weeksofdelivery.22-24Recommendationsincludescreeningforbipolardisorderinwomenwhopresentwithdepressivesymptomsduringtheprena-tal period and postpartum. This is especially impor-tantwhenconsideringprescribinganantidepressant,giventheriskofinducingmaniaorhypomaniaifanunderlyingbipolardisorderisnotidentified.Womenwithapreviouspostpartumepisodeareatgreaterriskfordevelopingbipolardisorder.TheMoodDisor-derQuestionnaire(MDQ),abriefmeasurethathasbeenstudiedacrossprimarycaresettings,hasbeenrecommendedinarecentreviewofscreeninginstru-ments for bipolar disorder in the perinatal period. It issuggestedtoscreenatthefirstprenatalvisit,withinthefirstfewdayspostpartum,at4-6weekspostpar-tum,andatanypointthatawomanpresentswithdepressive symptoms during the perinatal period.25

My Mood Monitor (M3) is a screening tool for depres-sion, anxiety (including OCD and PSTD), and bipolar disorder that has also been used in the primary care population.26Additionalquestionsspecificallyad-dressing postpartum depression and anxiety have beenadded.Validationstudiesareunderwayinado-lescent pregnancy, also.Giventhelongtermimplicationsofdepressiononthemother-infantrelationship,evidence-basedmeasureshavealsobeendevelopedtoassessthisarea.TwoexamplesincludetheWorkingModeloftheChildIn-terview(WMCI),andtheEarlyRelationalAssessment(ERA)videotapedparent-childinteractionevalua-tion.27,28

Treatment Options: TherapySimilar to depression outside of the perinatal period, avarietyoftherapeuticmodalitiesmaybehelpful.A2008meta-analysisconcludedthatpsychotherapeuticinterventionsprovidedmoderatesymptomimprove-mentforwomenexperiencingpostpartumdepres-sion.29

CognitiveBehavioralTherapy(CBT)hasbeenwellestablishedintheliteratureasaneffectivetreat-mentfordepression(seeButler,Chapman,Forman,&Beck30forareview).Evidencehasbeenmixedregard-ingtheusefulnessofCBTintheperinatalperiodwithsomestudiessuggestingimprovementindepressivesymptomsoverwait-listorstandardcarecontrols31-33 andotherssuggestingminimalornoadvantageforCBToverotherpsychotherapeuticinterventions.34

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However,inthemeta-analysisnotedabove,29 CBT withwomenexperiencingpostpartumdepressionwasnotnearlyaseffectiveinreducingsymptomsasCBT for those experiencing general depression. More recently, O’Mahen and colleagues35 have suggested thatgeneralCBTmayneedtobemodifiedtoprovemosteffectiveforwomenexperiencingperinataldepression. They suggest the importance of focus on negativethoughts,behavioralimpactandresiliency,efficacy,andcopingspecificallywithinthecontextsofthe domain of motherhood, the interpersonal do-main,andthedomainofthewoman’sselfforutiliz-ingCBTtoeffectivelytreatwomeninthepostpartumperiod.Individual Interpersonal Therapy (IPT) is currently the mostwell-validatedinterventioninthetreatmentofwomenexperiencingpostpartumdepressionacrossthe spectrum from mild to severe depression.36,37 DevelopedintheUnitedStatesbyWeissmanandcolleagues,38 Interpersonal Therapy focuses on areas relevant to pregnancy and the birth of a child such as grief,transition,andinterpersonalconflict.39 A recent meta-analysisofavarietyoftreatmentinterventionsfor postpartum depression suggested that interven-tionsincorporatinganinterpersonalcomponenttobemosteffective.40IPThasbeenshowntobeeffectivenot only in the postpartum period, but also during the antepartumperiodduetoitsfocusontreating“life-event-basedillnesses,”bothoftheseperiodsbeingmajorlifetransitionsforwomen.41

Manywomenfeelisolatedduringthepostpartumperiod, especially if symptoms of anxiety and depres-sioninterferewithnormalsocialandoccupationalfunctioning.Grouptherapycanhelpaddresstheneedforpeersupport,whileprovidingevidence-basedtreatment for mental health disorders. Group Inter-personalPsychotherapy(IPT-G)isabrief,focused,andmanualized approach that places emphasis on the roleofattachmentstyleinone’sabilitytonavigatethetransitiontoparenthood;ithasbeenshowntobeaneffectiveinterventionforwomenpostnatally,resultinginbothrapidandsustainedreductionindepressivesymptoms,aswellasgainsininterpersonalfunction-ing.42IPTinagroupsettinghasalsobeendemon-stratedasefficaciousinthepreventionofpostpartumdepressionwhenprovidedtowomenproactivelywithinthefirst3monthspostpartum.43

TheMother-InfantTherapyGroup(MITG)isamanual-

ized group therapy treatment developed for moth-ersexperiencingpostpartumdepressionthatutilizesexercisesandstrategiesbasedinbothcognitive-be-havioral and interpersonal therapies to treat mother, infant,andtherelationshipbetweenthetwo.44 Re-searchhascontinuedtosupporttheuseofacombi-nationofCBTandIPTingroupstoreducesymptomsacross all group members.45

Treatment Options: Medications during PregnancyMedicationuseduringpregnancypresentsspecialconcerns for the mother and prescribing physician. All psychotropicmedicationspassthroughtheplacenta.Therisksoftreatmentduringpregnancycontinuetobe evaluated and are not fully clear. Most studies of antidepressantuseduringpregnancyhavedifficultycontrollingforpossibleeffectsofdepressionandotherconfoundingvariables.Treatmentrisksmustbebalancedwiththeriskofuntreateddepressionorothermentalillnessduringpregnancy,includingrisksto the fetus, the infant, and the mother.

Depression and AnxietyIn2009,theAmericanPsychiatricAssociation(APA)and the American Congress of Obstetricians and Gy-necologists(ACOG)issuedajointreportontheman-agement of depression during pregnancy.4 Treatment algorithmsareincludedformanagementofmajordepression(MDD)inpreconceptionplanning,andforwomenwithMDDwhoarepregnantandeitheronoroffmedication.ArecentarticlebyLindaChaudron,MD,MS,suggestsstrategiesandconsiderationstotakeintoaccountwhentreatingdepressionbeforeand during pregnancy.46Statisticsinthefollowing2paragraphsaresummarizedfromthisreviewarticleand the above referenced report by the APA and ACOG.Pleaseseethesearticlesforadditionalrefer-ences. Aquantitativereviewfoundanassociationforin-creasedriskofspontaneousabortioninearlypreg-nancywithantidepressantuse(relativerisk1.45).The studies evaluated did not control for psychiatric illness state and confounding variables such as health habits,nicotineanddruguse,andage.Bothdepres-sionandantidepressantusemayhavesomeassocia-tionwithfetalgrowthchangesandshortergestations.Nospecificpatternoffetalmalformationshasbeenassociatedwithdepressionorantidepressantuse.

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Somedatabasereportsshowedincreasedriskofcardiacmalformationswithparoxetine,whileotherstudiesdidnotfindthisassociation.CongenitalheartdefectsmaybeincreasedwithconcurrentuseofanSSRI and benzodiazepine.Short-termneonatalirritabilityandneurobehavioralchangesarealsolinkedwithdepressionandanti-depressant use. Poor neonatal adaptation occurs in infantsofabout15%-30%ofwomenwhotakeSSRIsinlate pregnancy. This may include transient symptoms of tachypnea, hypoglycemia, temperature instability, irritability,weakorabsentcry,andseizures.UseofSS-RIs in the third trimester has been found to increase theabsoluteriskofpersistentpulmonaryhyperten-sionfrom0.5-2/1000to3-6/1000,thoughsubsequentstudiesdidnotshowanincreasedrisk.Acontrolledprospectivestudyof238womenwitheither exposure to depression, SSRIs, or no depres-sion or SSRI treatment during pregnancy found no differencesbetweenthegroupsinminorphysicalanomalies,maternalweightgain,birthweight,andneonataloutcomes(exceptforasmalldifferencein5-minuteApgarscores).ContinuousexposuretoSSRIsoruntreateddepressionduringpregnancywereeachassociatedwithhigherpretermbirthrates.47

Psychotherapyaloneisrecommendedwhenappropri-ate,butmaynotbeavailabletoallwomen,andsomewomenmaypreferorneedpharmacotherapytoadequately treat depressive symptoms. ECT has been regardedassafeandeffectiveduringpregnancyforsevere depression.4

Discontinuingantidepressantsduringpregnancymustbe considered carefully. In one study, relapse rates amongeuthymicwomenwithahistoryofdepressionwhodiscontinuedantidepressantsduringpregnancyweresignificantlyhigherthanthosewhocontinuedantidepressantmedication(68%vs26%relapserate).48

Bipolar Disorder and Psychosis Treatment of bipolar disorder presents challenges, asmanymoodstabilizersarealsoknownteratogens.Althoughpregnancywashistoricallythoughttohaveaprotectiveeffectformoodepisodes,aprospectivestudyofpregnantwomenwithbipolardisorderwhodiscontinuedmoodstabilizershadarecurrencerateof85%vs37%inthosewhocontinuedmoodstabiliz-

ers.Overallriskofrecurrencewas71%,usuallyearlyin the pregnancy.21Preconceptionplanningisidealforhelpingwomenwithbipolardisorderdecideonthebest course of treatment during pregnancy.Lithiumwaspreviouslybelievedtocausesignificantcardiacmalformations(ie,Ebstein’sAnomaly).Morerecentstudieshavesuggestedtheriskislowerthanpreviousestimates(1/2000vs1/1000previouslyes-timated).Lithiumlevelsshouldbemonitoredclosely,as higher doses are needed during pregnancy due to increasedclearancewithincreasedbloodvolume,GlomerularFiltrationRate(GFR),andotherchangesduringpregnancy.Thedosemaybeheldfor24-48hoursbeforedelivery,ordecreasedtopre-pregnancydoses in the immediate postpartum period.7,49

Lamotrigineisagoodoptionformaintenanceandbipolar depression treatment during pregnancy due toitsrelativesafetycomparedwithotheranticonvul-sants.Thereisasmallriskofcleftlip/palatewithfirsttrimesterexposure,withaprevalenceof9per1000.Due to increases in the clearance of lamotrigine dur-ing pregnancy, higher doses are needed to maintain therapeuticeffect.Closemonitoringinthepostpar-tum is also necessary, as the dose must be decreased rapidly to avoid toxicity.50

Valproicacid,whentakenduringpregnancy,increasestheriskofcardiac,oralclefts,urologic,skeletal,neuraltube,andbehavioraldefects(lowerIQ),andshouldnotbethedrugofchoiceinwomenofchildbearingage.Carbamazepinehassimilarrisksforneuraltubedefects.7Otheranticonvulsants,includinggabapentin,oxcarbazepine, and topirimate, raise concerns for use duringpregnancy,thoughareconsideredlessriskythan valproate.Haloperidol,orotherfirst-generationantipsychotics,havebeenhistoricallytheconventionaltreatmentofchoiceforpregnantwomenwithbipolardisorderorpsychosis.Withtheincreaseintheuseofatypicalan-tipsychoticsforbipolardisorderandpsychoticillness-es,naturallymorepregnantwomenhavebeentakingthesemedicationsatconceptionorduringpregnancy.Therearenoknownmajorcongenitalmalformationsassociatedwithfirstorsecondgeneration(atypical)antipsychotics,thoughsafetydataislimited.51,7

Withdrawaldyskinesiashavebeennotedinnew-borns.TheFDAissuedawarningaboutabnormalmusclemovementsandwithdrawalsymptomsin

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newbornsassociatedwithatypicalantipsychotics.49,52 However,thecasesusedasthebasisforthewarningincluded use of confounding drugs (benzodiazepines, non-benzodiazepinehypnotics,opioids,antidepres-sants),whichmayalsocausesimilarwithdrawalsymp-tomsandothercomplications.Pregnantwomentakingatypicalantipsychoticsaremorelikelytodevelopgestationaldiabetesanddeliver larger babies.53,54 Another study found that womentakingsecondgenerationantipsychoticshadahigherincidenceoflargeforgestationalageinfantsthanthereferencegroup,notonantipsychoticmedi-cation.Womentakingfirst-generationantipsychoticshadahigherincidenceofsmallforgestationalageinfants than the reference group.55Long-termrisksforproblemswithglucosemetabolisminbabiesexposedinuteroisunknown.Giventheseresults,considerationshouldbegiventousingfirst-generationantipsychoticsinpregnancy.However,whenawomanbecomespregnantwhoistakinganeffectiveantipsychotic,continuationofthecurrentmedicationispreferred.53 Similar to other psychotropicmedicationsduringpregnancy,abruptdiscontinuationofantipsychoticmedicationisnotrecommended,asthiscancauseseverewithdrawalsymptoms,andworseningofpsychosisormoodsymptoms.56

Drug registries have been established to help sys-tematicallycollectdataonmaternalandfetalout-comesformedicationclassesusedinthetreatmentofbipolardisorder.TheNationalPregnancyRegistryforAtypicalAntipsychotics(http://www.womensmen-talhealth.org/pregnancyregistry) collects data on atypicalantipsychotics,andtheNorthAmericanAntiepilepticDrugPregnancyRegistry(http://www.aedpregnancyregistry.org)collectsdataonantiepilep-tics.

Treatment Options: Medications During Postpartum and Breastfeeding Although postpartum depression is common, there havenotbeenmanystudiessystematicallyassess-ingtheefficacyofpharmacologictreatments.7 There has been one randomized controlled trial of 1 or 6 sessionsofCBT,plusfluoxetineorplacebo.57Short-term(6session)CBTorfluoxetinewereshowntobeequallyeffectiveover3months.Antidepressants,suchassertraline,fluoxetine,andvenlafaxine,have

beenshowntobeeffectiveandwelltoleratedinpostpartum depression at standard doses. Choice of antidepressantisbasedonpastresponseandsideeffectprofile.SSRIsaregenerallyfirstline,butbu-propion, SNRIs, and TCAs are also frequently used.7 Benzodiazepines, such as clonazepam and lorazepam, arecommonlyusedtotreattheanxietythatisoftenpresentwithpostpartumdepression.Although hormonal therapies have been considered in postpartum depression, there is no clear evidence to support the use of progesterone or estrogen for treatment of depression in the perinatal period, es-peciallygivenriskssuchasdecreasedmilkproductionandthromboembolicevents.Antidepressantsremainthe treatment of choice.7

Treatment of Depression and Anxiety during BreastfeedingMothers and treatment providers commonly face decisionsabouttakingmedicationswhilebreastfeed-ing.Evidencesupportscontinuationofaneffectiveantidepressantthatthemotherhastakenduringpregnancy,orresumingaspecificantidepressantthathas been helpful in the past.58 The use of the rela-tiveinfantdosecalculationisageneralguidelineforsafetyofmedicationsduringbreastfeeding.Arela-tiveinfantdoseviabreastmilkoflessthan10%ofthematernalweightadjusteddoseisgenerallycon-sideredsafe.Mostantidepressants,includingSSRIs,SNRIs,andtricyclicantidepressants,areexcretedatlowdosesintobreastmilkandaregenerallybelowthe10%thresholdforrelativeinfantdose.59 Sertraline andparoxetinehavethelowestrelativeinfantdosesamong the SSRIs. One pooled analysis of 57 studies showedthatsertraline,paroxetine,andnortryptylinewereundetectableinover200infantstested.Otherantidepressantsweredetectedatlowlevelsinsomeinfants.60 There have been case series and reports of possiblesideeffectsintheinfantsofmotherstakingantidepressants,includingsleepproblems,irritability,poorfeeding,anddrowsiness(whichcanbesubtle,andnotspecificallycausedbythemedication).Thesearemostoftenreportedwithfluoxetine,inpartduetothelargenumberofwomenwhohavetakenthismedication,andalsocitalopram.However,discontinu-ingthesemedicationsisnotrecommendediftheyareeffective.Infantscanbemonitoredbythemotherand health care provider for any subtle changes or

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sideeffects.Prematureinfants,orthosewithim-pairedmetabolism,mayneedadditionalmonitoring.Benzodiazepines are generally considered safe during breastfeeding.61

Seriousadverseeventswhiletakingantidepressantshavegenerallynotbeenreported.Lessisknownaboutlong-termeffectsofexposuretoantidepres-santsthroughbreastfeeding.However,theloworundetectablelevelsofantidepressantsinasymptom-aticinfants,aswellasantenatalstudiesthatsuggestlittleornoadverseeffectsfromantidepressantexpo-sure,canbesomewhatreassuring.Mothersshouldbeinformedthatourunderstandingoflong-termeffectsisstillevolving,butbasedoncurrentevidence,anti-depressants are a reasonable choice, especially given therisksofuntreatedpostpartumdepression.62,60

Treatment of Bipolar Disorder and Psychosis during BreastfeedingDivergentfromtherecommendationsduringpreg-nancy,anticonvulsants,suchasvalproicacidandcarbamazepine, are generally considered safe during breastfeeding.Thereislessdataonoxcarbazepineandtopirimatewhilebreastfeeding.63

Lamictalhasbeenevaluatedby6studiesandcasereportsduringbreastfeeding,withnoadverseeventsreportedintheinfants.Druglevelsintheinfantswerebetween25%-30%ofthematernaldose,however,noadverseeventswerereported.54 Monitoring for sideeffects,especiallySteven’sJohnsonSyndrome,is important, though no cases have been reported in infantsexposedthroughbreastmilk.Lithiumisexcretedintobreastmilkatupto40%ofmaternallevels,andpreviouslywasconsideredcontraindicatedwithbreastfeeding.However,infantsmaybebreastfedwhiletheirlithiumlevelsaremoni-tored—andkeptmuchlowerthantherapeuticlev-els—andtheinfantisnotshowinganysignsoftoxic-ity.64

Basedonlimiteddataonantipsychoticmedications,itisdifficulttodrawconclusionsaboutsafetyforbreastfeedinginfants.Oftheatypicalantipsychot-ics,somedataexistsforrisperidoneandquetiapinethatdoesnotsuggestlikelihoodofadverseevents.Adverseeventshaveoccurredwitholanzapine(ex-trapyramidal symptoms) and clozapine (hematologic complications),thereforebreastfeedingisnotrecom-

mendedonthese2medications.65 There is no data for aripiprazole, ziprasidone, lurasidone, or paliperidone. Amorerecentreviewsuggestedthatolanzapineandquetiapinewereacceptableforbreastfeeding,whereasothers,suchasrisperidone,chlorpromazine,andhaloperidolcouldbeconsideredforbreastfeedingwithmedicalsupervision.66Theseconflictingrecom-mendationshighlightthedifficultyinstudyingefficacyandsafetyinthispopulation,aswellastheneedforindividualizedrisk-benefitdiscussionswithpatientsduring the peripartum period.

Resources for Pregnancy Related Depression and Medication UseResourceshavebeencreatedtoprovideinformationtowomenaboutpregnancy-relateddepression,useofantidepressantsduringtheperinatalperiod,andevidence-basedrecommendationsregardinguseofmedicationsduringbreastfeeding.Specifically,theMotherRiskwebsitehasevidence-basedrecom-mendationsandresourcesregardingmedicationsduringbreastfeeding(http://www.motherisk.org/women/breastfeeding.jsp),theWisconsinAssocia-tionforPerinatalCarewebsiteprovidesaconcisesummaryofantidepressantmedicationuseintheperinatal period (http://store.perinatalweb.org/index.php?route=product/product&product_id=56), and HeathTeamWorksinaffiliationwiththeColoradoDepartmentofPublicHealthandEnvironmenthasdevelopedaClinicalGuidelineandpatienthandoutaboutpregnancy-relateddepression(http://www.healthteamworks.org/guidelines/prd.html).

Adolescent MothersThe rate of teen pregnancy in the United States far outdistancestheratesinotherWestern,industrial-izednations.Despitethesimilarprevalenceofsexualintercourse, the increased pregnancy rate in the U.S. islikelyduetothesignificantlylowerrateofcontra-ceptiveuseamongAmericanadolescents.Over7%ofadolescent girls become pregnant each year and over 4%goontodeliverbabies.Therearesignificantdif-ferences in ethnicity and poverty level among adoles-centmothers,withpoor,ethnicminorityadolescentgirlsbeingoverrepresentedwithintheadolescentmotherpopulation.67

Therearemultiplepredictorsforadolescentmoth-erhood that also have important psychological and

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psychiatricimplications.68-70These include aggression, substanceabuse,conductdisorder,lackofacademicgoals, childhood sexual abuse,71 anxiety, and mood disorders.72 Adolescent motherhood itself is associat-edwithitsowndifficulties,whichincludepoverty,73,74 loweducationalachievement,75,76andrapid-repeatpregnancy.77 Children of adolescent mothers are at greaterriskforavarietyofnegativeoutcomes,includ-ing academic delays and school problems, behavior problems, and becoming adolescent parents.78,79,73 In additiontotheaboveriskfactorsandpsychosocialissues,postpartumdepressionhasbeenspecificallyrecognized as having a deleterious impact on both mother and baby.80-83Multiplestudiessuggestthatadolescentmothershavealmosttwicetherateofdepression as adult mothers and that their depres-sivesymptomslastsignificantlylonger.84-86 Depression during the postpartum period impacts infant care, createsmorenegativeinteractionsbetweenmotherandbaby,andmakesitmoredifficultformotherstoengagewiththeirbabieswhenbabieshavenegativeresponses such as crying.87,88Additionally,depressioninthepostpartumperiodputbabiesathigherriskforabuse.89

AssessmentThe Edinburgh PostNatal Depression Scale (EPDS) and Center for Epidemiologic Studies Depression Scale (CES-D)arethe2measureswiththemostevidencefor assessing postpartum depression in adolescent mothers.90 There are no clinical assessment mea-suresspecificallyrecommendedforgeneralissuesinworkingwithadolescentmothers.Therefore,clinicalinterviewswiththepatientandfamilymembers,ifpossible,inadditiontostandardadolescentmeasuresforanxiety(State-TraitAnxietyInventory),trauma(TraumaSymptomChecklist),andbipolarmooddisor-der(MoodDisorderQuestionnaire)areadvised.Addi-tionally,therearemeasuresusedtoassessthequalityoftherelationshipbetweenmotherandbaby,suchastheWorkingModeloftheChildInterviewandCrowellProcedures.However,thesehavenotbeenvalidatedwithadolescentmothers.

Evidenced-Based/Informed TreatmentsMultiplestudiesdemonstratetheeffectivenessofcognitivebehavioraltherapy,interpersonaltherapy,andpsychopharmacologyintreatingpostpartumde-

pression in adult mothers.90However,thereisapau-cityofliteratureontreatmentofpregnancy-relateddepression in adolescents. Using interpersonal thera-py,Millerandcolleaguesconducteda12-weekgroupwithdepressedpregnantadolescents.91 Symptoms improved,andthisimprovementwasmaintainedinthepostpartumperiod.Thisistheonlyevidence-basedinterventionforthispopulationfoundintheliterature.

Infancy and Early ChildhoodCriticalperiodsindevelopmentcontinuepasttheprenatal and infancy periods into early childhood. Factorscontributingtothedevelopmentoflifelongmental and physical health problems include the con-cept of toxic stress.AsdefinedbytheNationalScien-tificCouncilontheDevelopingChild,toxicstressisa“strong,frequent,and/orprolongedactivationofthebody’sstress-responsesystemsintheabsenceofthebufferingprotectionofadultsupport.”92 That adult supportisespeciallycriticalduringthefirstseveralyears of life. There is evidence that elevated maternal cortisolandpsychosocialstressduringpregnancycon-tributes to an increase infant physiological and behav-ioral responses to stress.93Responsetoseparation-re-unionstress(usingAinsworth’sStrangeSituation)waselevatedin17-montholdswhosemothershadelevat-edcortisolinamnioticfluidduringpregnancy.94 These effectscanextendbeyondinfancy,asdemonstratedinastudythatshowedincreasedratesofanxietyanddepressioninchildrenages6-8yearswhenmothershadincreasedlevelsofcortisolprenatally.95

A study of Adverse Childhood Events (ACE), includ-ingchildhoodemotional,physical,orsexualabuse,domesticviolence,parentalmentalillness,andsub-stanceabuseinnearly10,000patientspresentingforroutinemedicalcare,demonstratedastronggradedrelationshipbetweenthenumberofeventsthatapersonwasexposedtoandadulthealthriskbehaviorsandchronicdiseases,severalofwhicharetheleadingcauses of death in adults.1Forthosewithgreaterthan4exposures,therewasa4to12-foldincreasedriskof alcoholism, drug abuse, depression, and suicide attemptsoverthosewhohadnoexposurestochild-hood adverse events. As summarized in a report for theAmericanAcademyofPediatrics,Shonkoffandcolleaguesstate,“Advancesinneuroscience,mo-lecular biology, and genomics have converged on 3

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compelling conclusions: (1) early experiences are built intoourbodies,(2)significantadversitycanproducephysiologicdisruptionsorbiologicalmemoriesthatundermine the development of the body’s stress responsesystemsandaffectthedevelopingbrain,cardiovascular system, immune system, and meta-bolic regulatory controls, and (3) these physiologic disruptionscanpersistfarintoadulthoodandleadto lifelong impairments in both physical and mental health.”96Onemediatoroftheseeffectsmaybetheparent-childattachmentrelationship,whichcanbeimpairedinmanyofthesituationsclassifiedasACEsabove.Aprospectivelongitudinalstudywasrecentlypublishedexaminingtherelationshipbetweenat-tachmentclassificationininfancyandphysicalhealthoutcomes30yearslater.Resultsshowedthatinsecureattachmentatbothages12and18monthspredicteda4-foldincreaseinreportingofinflammation-relatedand general physical illnesses at age 32 years.97

Inadditiontomaternalmentalillnessandprenatalstress, there is also evidence that the father’s men-talhealthandstresslevelshavesignificantimpacton infant and child outcomes. Paternal depression prenatally is a predictor of infant crying behavior.98 Additionally,menandteenboysaremoredangeroustobabiesinregardstofrequencyofshakenbabysyn-drome.99 The importance of paternal involvement and well-beingarecriticaltoaddressduringthisperiod.Families bring infants, toddlers, and young children inforevaluationsforproblemsinavarietyofareasincludingemotional,behavioral,relational,orde-velopmentaldifficulties.100Infants(0-12monthsofage)aremostoftenseenforproblemsrelatedtothedysregulationofphysiologicalfunctioning,includingfussyorcolickybehavior,feeding,sleeping,andfailuretothrive.Toddlers(12-36monthsofage)andyoungchildren(ages3-5years),areoftenreferredforbe-havioraldisturbances,includingaggression,defiance,impulsivity,over-activity.Otherreasonsforreferralstomentalhealthprovidersmayincludeconstitutionalissues, such as developmental delays, subtle physi-ologic,sensory,andsensory-motorprocessingprob-lems.Discrepanciesbetweenthechild’stemperamentandparentsexpectationscanleadtorelationshipdifficulties(eg,“goodnessoffit”),whichmayalsoprecipitate a referral. Concerns about neglect, physi-cal,orsexualabuseofthechildoftenalsonecessitateinvolvement of mental health professionals.

AssessmentAssessment of the child and family should have an ori-entationtowardpreventionofpsychopathologyanddevelopingwiththefamiliesasharedunderstandingofthecoreconcernsthatledtothepresentation.Because infants and toddlers are dependent upon their parents and other caregivers, these caregivers are an integral part of the assessment process and the treatmentplan.Multidimensionalperspectivesshouldbe included during the assessment including develop-mental,relationshipandattachment,andborrowingfrompediatrics,developmentalpsychology,speech/languagetherapy,occupationaltherapy,andphysicaltherapy.Multipleassessmentsareneededovertime,giventherapid pace of development and change in response to internal and external stressors of children in this agegroup.Observationinmultiplesettingsandwithdifferentcaregiversisideal.Inadditiontoessentialinformationfromparentsandprimarycaregivers,currentandpastfunctioningshouldbeassessedfromothersourcesfamiliarwiththechild,suchaschildcareproviders,fosterparents,caseworkers,andmedical providers.100TheInfant-ToddlerMentalStatusExam(ITMSE)maybeusedasaguidefortranslatingcategoriesofthetraditionalexaminationofadultsandolderchildrentobeapplicabletotheobservationofinfantsandyoungchildren.Thisisawaytoassessthedevelopmental,social,andemotionalfunctioningofthechild,includinginteractionswithcaregiversandan unfamiliar adult.100

Inadditiontoafamilyinterviewandobservationdur-ingfreeplayandastructuredactivity,standardizedassessments are available for this age group. These includetheITSEA(Infant-ToddlerSocialandEmotionalAssessment),Brief-ITSEA,101,102andtheASQ-SE(AgesandStatesQuestionnaire:SocialandEmotional).103 Full references and further details of each instrument areavailableintheAACAPPracticeParameter100 Bay-ley Scales of Infant Development III, Child Behavior Checklist(CBCL),VinelandAdaptiveBehaviorScales,HomeObservationforMeasurementofEnvironment,Parent-ChildEarlyRelationalAssessment,andParent-ing Stress Index.TheDiagnosticClassificationofMentalHealthandDevelopmental Disorders of Infancy and Early Child-hood(DC:0-3R)wasdevelopedbyZerotoThreeandinfant mental health experts in 1994, and revised in

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2005.DC:0-3Risthestandardformakingdiagnosesinyoungchildreninadevelopmentallysensitivewaythattakesintoaccounttheimpactofearlyrelation-ships and the caregiving environment.104

Evidenced-Based/Informed Treatments: Individual and Group TherapyThereareseveraltherapymodalitiesthathaveevi-dencetosupportefficacyforavarietyofbehavioralandemotionalproblemsinearlychildhood.Inaddi-tiontothosedescribedbelow,arecentreviewarticlehighlightsothertherapieswithevidenceforuseininfants and young children, including CBT, Trauma Focused-CBT,andCirclesofSecurity.105

ChildParentPsychotherapy(CPP)isarelationship-based,manualizedtherapythatwasdevelopedtotarget the sequelae of trauma in young children and their caregivers. CPP integrates theories and mo-dalitiesfrompsychodynamic,attachment,trauma,cognitive–behavioral,andsociallearningtheories.Sixtherapeuticmodalitiesareimplementedwithafocuson“legitimizingtheaffectiveexperienceandpromotingasenseofcompetenceinboththeparentand the child.”106These6interventionstrategiesare:(1)promotingdevelopmentalprogressthroughplay,physicalcontact,andlanguage;(2)offeringunstruc-turedreflectivedevelopmentalguidance;(3)model-ingappropriateprotectivebehavior;(4)interpretingfeelingsandactions;(5)providingemotionalsupportandempathiccommunication;and(6)offeringcrisisintervention,casemanagement,andconcreteassis-tancewithproblemsofliving.Theparent/caregiverandchildarepresentforweeklysessions,withaddi-tionalindividualparentsessionsasneeded.Thereisafocusonstrengtheningthedyadicrelationshipwhilehelpingthechildandparentdevelopajointnarrativeofthetraumaticevents.Thedurationisgenerally1year,thoughcanbeflexiblebasedonthecircum-stances and needs of the family.Initialandfollow-upstudieshaveshownstrongevi-denceforCPPintreatingthesymptomsandbehav-ioral issues related to PTSD. A randomized, controlled trialwith75participantsassignedtoCPPormonthlycasemanagementshowedsignificantdecreasesintotalbehavioralproblemsontheCBCLandDC0-3TraumaticStressDisordersymptoms.Therewasalsoasignificantdecreaseinmaternalsymptomsofavoidance.106A6-monthfollowupstudyofthesame

participantsdemonstratedlastingeffectsforCPPinsignificantlydecreasingtheCBCLTotalBehaviorProblem score, and maternal symptoms, as measured by the Global Severity Index.107Inaddition,asubse-quentanalysisshowedthatchildrenwithmultipletraumaexposureshadverysignificantreductionsinPTSDanddepressionsymptoms,withCPPvscasemanagement, as did the mothers.108 A randomized preventativestudyofmaltreatedinfantsat13monthsolddemonstratedthatthosewhosefamilieswhoreceivedCPPorapsychoeducationalparentingin-tervention,hadsimilarlevelsofmorningcortisolasthoseinanon-maltreatedinfantcontrolgroup.Thedivergenceincortisollevelsofthoseintreatmentvsthosewithstandardcommunityservicesaroseatmid-intervention,andwassustainedthrough38monthsofage(1yearpost-interventionfollowup).Theseresultsdemonstratetheimportanceandefficacythatearlyinterventioninchildhoodmaltreatmentcannormalizea biological mediator of adverse child events and toxic stress.109

Parent-ChildInteractionTherapy(PCIT)isamanu-alizeddyadicbehavioralinterventionintendedforchildrenbetweentheagesof2and7yearswithdisruptivebehaviorsalongwiththeircaregivers.Treatment focused on decreasing externalizing behav-iorproblemsandincreasingsocialskillsinthechildthroughcoachingparentstoutilizechild-directedplayasasocialreinforcerforpositivechildbehavioraswellasbehaviormanagementtechniquesinresponsetonegativechildbehavior.110 PCIT is implemented through 2 successive components of treatment: (1)Child-DirectedInteraction(CDI),and(2)Parent-DirectedInteraction(PDI).InCDI,theparentistaughthowtofollowthechild’sleadinplayviabug-in-the-earcoachingbyatherapistobservingtheparent-childinteractionthroughaone-waymirror.Thepurposeofthisfirstcomponentoftreatmentistosupporttheparentindevelopingpositivecommunicationwiththeirchildbygivingthechildattentionfollowingposi-tivebehaviorandignoringnegativebehavior.Daily5-minutechild-directedparent-childplayinteractionisalsoassignedashomeworkduringthiscomponentofthetreatment.AftertheparenthasmasteredCDIskills,theparent-childdyadtransitionsintothesec-ond component of PCIT (ie, PDI) together. In PDI, the parentistaughthowtoeffectivelymanagethechild’sbehavior(againviabug-in-the-earcoachingbyather-apistobservingtheparent-childinteractionthrough

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aone-waymirror)throughgivingclearcommandsorinstructions,followedbypraisewhenthechildobeys,andatime-outprocedurewhenthechilddisobeys.PCIT can be delivered individually or in a group for-mat,istime-unlimited,andmaterialsareavailableinboth English and Spanish.PCITisanEvidence-BasedTreatmentwithresearchin-dicatingmoreeffectiveparentingskills(ie,higherlev-elsofpraise,lowerlevelsofcriticism,increasedabilitytomanagechallengingbehaviors)andsignificantlyim-proved child behavior (eg, increased compliance and decreasedexternalizing)overtime.110-112 Even those dyadswhoparticipatedinanabbreviatedversionofPCITseemedtobenefitfromanincreaseinparentalskillsanddecreaseinoppositionalbehavior.113 PCIT hasalsobeenshowntobeusefulwithfamilieswhoaremostatrisk.ArecentstudybyChaffinandcol-leagues114demonstratedPCITasaneffectiveinterven-tionforchildwelfare-involvedfamilies,manywithahistory of having had their children removed prior to treatment.The Incredible Years (IY) is a series of manualized, developmentally-informed,groupcurriculaintendedforchildrenages0-13yearsoldwhoaredisplay-ingbehaviorproblemsalongwiththeirparentsandteachers. It consists of 3 separate, but coordinated curricula: (1) for the parent, (2) for the teacher, and (3)forthechild.Theparent-focusedcurriculumcon-sists of the BASIC parent training program, aimed at increasingparentingskillsofthosewhosechildrenaredisplayingoppositionalordisruptivebehaviorprob-lems,andtheADVANCEparenttrainingprogram,ad-dressinginterpersonalskillsofparents.115 The Teacher TrainingInterventionisintendedtoincreaseteachercompetencies as related to classroom conduct issues andpromotethestrengtheningofhome-schoolcon-nections.116TheIYChildTrainingIntervention(Dino-saur School)isagroup-basedinterventionintendedtoteachchildrenages3-8yearsoldproblem-solvingandsocialskills.117

The IY Parent Training program is the core of the intervention.TheADVANCEparenttrainingprogramisrecommendedasasupplementalinterventionfordy-adsinwhichparentalpersonalandinterpersonal(eg,parental mental illness, environmental stressors, etc) impactparentingbehaviorandparent-childinterac-tions.TheBASICtrainingprogramfocusesonpromot-ingpositiveparent-childrelationships,helpingparents

learnhowtosetuppredictableandconsistentrulesandroutines,teachingspecificnonviolentdisciplinetechniques,andsupportingparentsinteachingtheirchildrenproblem-solvingskills.118Homeworkactivi-tiesareassignedtoreinforceskillslearnedingroup.The BASIC program has recently been divided into age-basedcategories:infant(0-1year),toddler(1-3years),preschool(3-6years),andschoolage(6-13years). A strong evidence base exists for IY interven-tionwithchildrenages4through8yearsold,andaresearchbaseisstillbeingdevelopedfortheyoungerand older ends of the age spectrum.119 Studies indi-catedthatIYParentTrainingisnotonlyeffectiveintheshort-term,butalsogainsinparentingskillsandreductioninconduct-relatedchildbehaviorseemtobe sustainable at least into adolescence.118

Evidenced-Based/Informed Treatments: MedicationsThe American Academy of Child and Adolescent Psychiatry published guidelines on the Psychophar-macologicalTreatmentofVeryYoungChildrenin2007.120 This includes algorithms for assessment and treatment of disorders seen in preschoolers, including ADHD,disruptivebehaviordisorders,majordepres-sion, bipolar disorder, anxiety, OCD, pervasive devel-opmental disorders, and primary sleep disorders. A trialofpsychotherapyisalwaysrecommendedpriortoinitiatingpsychopharmacology,asevidenceforusingmedicationsinpreschoolchildrenislimitedinmostcases.ThePreschoolADHDTreatmentStudy(PATS)wasanNIMH-funded,6-center,randomizedcontrolledtrialwhichdemonstratedsafety,toler-ability,andefficacyfortheuseofmethylphenidateinpreschoolchildrenwithADHD.121,122EffectsizeswerelowerthaninolderchildrentakingmethylphenidateforADHD.AmphetamineformulationshaveanFDAindicationforchildrenages3-5yearsforADHD,how-ever this is not supported by a randomized controlled trial.Risperidonehasshownefficacyinpreschoolpopulationswithautismspectrumdisorderin2ran-domizedcontrolledtrialswith24childrenages2.5-6,and39childrenages2-6.123,124 Other recommenda-tionsdiscussedintheguidelinearesupportedbyopen-labelstudies,retrospectivechartreviews,casereports,andextrapolationofevidencefromstudiesinolder children. It is important for clinicians to balance therisksandbenefitsofmedicationswiththerisksofnottreatingindifficultcasesthatarenotrespondingtopsychotherapeuticinterventions,placingyoung

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childrenatincreasedriskforimpairedfamilyandpeerrelationships,highriskbehaviors,andfuturementalhealth problems.100

ConclusionAlthoughsignificantchallengesanduncertaintiesexistintheevaluationandtreatmentofpatientsduringthe perinatal and early childhood period, evidence supportsscreeningandtimelytreatmentforperinataland early childhood mood, anxiety, and other psychi-atric disorders. As a result, further development of innovativeprogramsacrossdisciplineswillenhanceidentificationandtreatmentforteenandadultmoth-ersat-riskforperinatalmentalhealthproblems.Giventhepotentialforsignificantlong-termimpactsofpostpartumdepressionontheparent-childrelation-ship,itiscriticaltoprovidemultipleopportunitiesforearlyintervention.Forexample,therecognitionofthelastingeffectsoftoxicstressininfancyandearly

childhoodallowsforinterventionstohavehighreturnontheinvestmentoftime,effort,andfundingfortreatment. The impact of perinatal depression on the familyshouldbeaddressedwithacontinuumofcarefor mothers, fathers, infants, and young children. As wediscussed,severalevidence-basedtherapytreat-ments exist that can address perinatal mental health symptoms,andamelioratetheeffectsoftrauma,parent-childrelationshipproblems,andpsychiatricdiagnosesinyoungchildren.Whenmedicationisindi-cated,providersandpatientsshouldhaveathoroughdiscussionoftherisksandbenefitsforthemother,thefetus,infant,andchild,includingtheseriousrisksof untreated illness.

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trialwithshorttermmaintenance.Journal of Clinical Child Psychology. 27(1),34-45.

http://edissertations.nottingham.ac.uk/2502/1/Rebecca_J_Feetham_dissertation.pdf

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111. EybergSM,FunderburkB.W,Hembree-KiginT,McNeilCB,QueridoJ,HoodKK.(2001).Parent-childinteractiontherapywithbehaviorprob-lemchildren:One-andtwo-yearmaintenanceoftreatmenteffectsinthefamily.Child & Family Behavior Therapy. 23,1-20.

112. HoodKK,EybergSM.(2003).Outcomesofparent-childinteractiontherapy:Mothers’reportsonmaintenancethreetosixyearsaftertreat-ment. Journal of Clinical Child and Adolescent Psychology. 32,419-429.

113. NixonRDV,SweeneyL,EricksonDB,TouyzSW.(2003).Parent-ChildInteractionTherapy:Acomparisonofstandardandabbreviatedtreat-mentsforoppositionaldefiantpreschoolers.Journal of Community and Clinical Psychology. 71(2),251-260.

114. ChaffinM,FunderburkB,BardD,ValleL.A,GurwitchR.(2011).AcombinedmotivationandParent-ChildInteractionTherapypackagere-duceschildwelfarerecidivisminarandomizeddismantlingfieldtrial.Journal of Consulting and Clinical Psychology. 79,84-95.

115. ReidMJ,Webster-StrattonC.(2001).TheIncredibleYearsparent,teacher,andchildintervention:Targetingmultipleareasofriskforayoungchildwithpervasiveconductproblemsusingaflexible,manualized,treatmentprogram.Journal of Cognitive and Behavior Practice. 8, 377-386.

116. Webster-StrattonC,ReidMJ.(2004).Strengtheningsocialandemotionalcompetenceinyoungchildren—ThefoundationforearlyschoolreadinessandsuccessIncredibleYearsclassroomsocialskillsandproblem-solvingcurriculum.Infants and Young Children. 17(2),96-113.

117. Webster-StrattonC,ReidMJ.(2003).Treatingconductproblemsandstrengtheningsocialandemotionalcompetenceinyoungchildren:TheDina Dinosaur treatment program. Journal of Emotional and Behavioral Disorders. 1(3),130-143.

118. Webster-StrattonC,RinaldiJ,ReidJM.(2011).Long-termoutcomesofIncredibleYearsparentingprogram:Predictorsofadolescentadjust-ment. Child and Adolescent Mental Health. 16(1),38-46.

119. MentingaATA.,OrobiodeCastroB,MathysW.(2013).EffectivenessoftheIncredibleYearsParentTrainingtomodifydisruptiveandproso-cialchildbehavior:Ameta-analyticreview.Clinical Psychology Review.38(8),901-913.

120. GleasonMM,EggerHL,EmslieGJ,GreenhillLL.,KowatchRA,etal.(2007).PsychopharmacologicalTreatmentforVeryYoungChildren:Con-texts and Guidelines. Journal of the American Academy of Child & Adolescent Psychiatry. 46(12),1532-1572.

121. GreenhillL.KollinsS,AbikoffH,MccrackenJ,RiddleM,SwansonJ,VitielloB.(2006).EfficacyandSafetyofImmediate-ReleaseMethylpheni-dateTreatmentforPreschoolerswithADHD.Journal of the American Academy of Child & Adolescent Psychiatry. 45(11),1284-1293.

122. WigalT,GreenhillL,ChuangS,McGoughJ,VitielloB,SkrobalaA,KollinsS.(2006).SafetyandTolerabilityofMethylphenidateinPreschoolChildrenwithADHD.Journal of the American Academy of Child & Adolescent Psychiatry. 45(11),1294-1303.

123. LubyJ,MrakotskyC,StaletsMM,BeldenA,HeffelfingerA,WilliamsM,SpitznagelE.(2006).RisperidoneinPreschoolChildrenwithAutisticSpectrumDisorders:AnInvestigationofSafetyandEfficacy.Journal of Child and Adolescent Psychopharmacology. 16(5),575-587.

124. NagarajR,SinghiP,MalhiP.(2006).RisperidoneinChildrenWithAutism:Randomized,Placebo-Controlled,Double-BlindStudy.Journal of Child Neurology. 21(6),450-455.

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Pediatric Emergency Behavioral Health, Suicidal Behavior, and Non-Suicidal Self-Injury

PediatricEmergencyBehavioralHealth,SuicidalBehavior,andNon-SuicidalSelf-Injury

Emergency Behavioral Health

Over the past decade, emergency departments (EDs) across the country have experienced a

dramaticinfluxofpsychiatricpatients.Studieshaveshownthatbehavioralhealthemergenciesrepre-sentnearly2%ofallEDpresentations,andtodatein 2013, behavioral health emergencies at Children’s HospitalColorado(CHCO)constituteanaverageof4.9%ofallEDvisits,morethantwicethenationalaverage.1-3 The reasons for this discrepancy are not entirelyclear,aspopulationstudiesdemonstratehigher rates of emergency department pediatric be-havioral health visits in the Northeast and Southern partsoftheUnitedStates;howeveritisofinterestthatColoradoranks32ndinoverallpublicbehavioralhealth spending and 50th in the number of available inpatientbeds,seeminglysupportingtheconjecturethatEDsarebecomingthe“safetynet”forafrag-mented,underfunded,andunder-resourcedbehav-ioral health system in crisis.4

The ED behavioral health crisis, as it is experienced fromwithinsystemsofcare,isnotonlyafunctionoftheever-expandingvolume,butalsotheinfluxofthishighacuitypatientpopulationfurthertaxesEDsbytheirdisproportionateconsumptionofresources.ThelengthofstayofbehavioralhealthpatientsintheEDfarexceedstheaveragelengthofstayofnon-psychiatricpatients;intheCHCOED,thisdifferenceisalmost3hours.Assessmentsaretime-consuming,asinformationfrommultiplecollateralsourcesisoftenrequiredtocompleteacomprehensiveriskassessment, and the need to admit or transfer a patienttoapsychiatricfacility(thedispositioninnearly46%ofpsychiatricpatientsfromtheCHCOED) further prolongs the process. Behavioral health

patientspresentingtotheEDarealsoatriskfordan-gerousbehaviors,includingaggressionandattempt-edelopement,whichhavebeendemonstratedtooccurinover20%ofEDencounters.5Thesehigh-riskbehaviorsoftennecessitatetheuseofseclusion,restraint,emergencymedications,andintensivemonitoringtomaintainthesafetyofthepatient,staff,andtheenvironment.Thereisagreementacrossnationalprofessionalor-ganizations,includingtheInstituteofMedicine,theAmerican Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry (AA-CAP), that models and standards of care are needed to address this burgeoning clinical need.6-8However,arecentreviewofpsychiatricemergencycareforchildren and adolescents demonstrates that there is no clear consensus or recommended care for this population.9 In 2002, the American Psychiatric As-sociation(APA)convenedataskforceonPsychiatricEmergency Services that conducted a similar re-viewoftheadultpsychiatricliterature.Thefindingsresulted in a comprehensive summary of proposed categorizationsandmodelprogramdescriptions,whichincludedminimumstandardsofpracticeforthe structure and process of psychiatric emergency services.Thetaskforcereportincludedprogramdescriptionsthatcouldbeimplementedinthehos-pitalsetting,anexpandeddescriptionofambulatoryurgent care services, and a comment about tele-medicine.10Importantcommonalitiesthatappearto emerge, from both the pediatric and adult psychi-atricliterature,aretheneedtoclarifydefinitionsofemergency, urgency, and crisis, and that approaches topatientcareshouldstartwithbasicprocesscom-ponentsofregistration,stabilization,evaluationandassessment,disposition,treatment,referral,andfol-

Amy Becker, MD; John Peterson, MD; Elise M. Sannar, MD



85


lowup.Additionally,ofpossibleusetothepediatriccommunityisthecreationofamodelcurriculumforresidencytrainingbytheAmericanAssociationforEmergency Psychiatry (AAEP).11TheimportantworkoftheAPAandAAEPhasthepotentialtoinformpediatricprovidersandadministratorsaswestrivetocreateandimplementevidence-basedmodelsofcare, and train future providers in the management of pediatric behavioral health emergencies. Patientsandfamiliespresentforemergencyroomevaluationswithavarietyofpsychiatriccrises.Stud-iesthatexaminedemographicanddiagnosticchar-acteristicsofchildrenandyouthreportthatsuicideattemptandnon-suicidalself-injuryareamongthemostcommonpresentingproblems.2,5 It is thus im-portanttoexpandourknowledgeaboutthescopeoftheproblem,factorswhichplaceourpatientsatrisk,andavailablestandardsforassessment,treat-ment,andprevention.

Suicidal Behavior in Children and AdolescentsSuicide is the second leading cause of death in the 15-24yearagegroup,withColoradorankingsev-enthinthenationatarateof16.7per100,000population.Adolescentmalesmostcommonlycompletesuicide,whileadolescentfemalesmorecommonlyattempt.Themostcommonmethodofsuicidecompletionisbygunshot,followedbysuffo-cation,andpoisoning.12Itisestimatedthatover30%ofhouseholdsinColoradocontainfirearms,andteenagers that complete suicide by gunshot most oftenuseafirearmthatisownedbyafamilymem-ber. Colorado is 1 of only 4 states in the union that hasaseparateOfficeofSuicidePrevention,whichwascreatedthroughHouseBill00-1432inJune2000,withthechargetoleadthestatewidesuicidepreventionandinterventionefforts.Withtheemergenceofadolescentsuicideasasignificantpublichealthconcernandtheknowledgethat15%to30%ofadolescentsuicideattemptersre-attemptwithinayear,itisessentialtoidentifyandintervenewithadolescentswhoarehighsuiciderisk.13,14 Numerous trait and state factors have been identifiedthatelevatetheriskforsuicide.Inaddi-tiontothemalegender,adolescentsaremorelikelyto complete suicide than children. Compared to the

statisticsfor15-24yearoldsinthestatecitedprevi-ously in the under 15 year age group, suicide is the fourth leading cause of death at a rate of 0.7 per 100,000population.15Adolescentswithsymptomsofpsychiatricillnessarealsoatriskforsuicide—including depression, impulsive aggression, and hopelessness—withdepressionbeingamongthemostpotentriskfactorsforsuicide.Familyhistoryofsuicideattemptsorsuicidecompletion,ahistoryof abuse—especially sexual abuse—or stress in the familysystemareadditionalriskfactorsforsuicide.Gay, lesbian, bisexual, and transgender youth are alsothoughttobeathigherrisk,asarepediatricpatientswithahistoryofsubstanceabuse,suicideattempt,ornonsuicidalself-injury.16-18

Nonsuicidal Self-Injury (NSSI) in Chil-dren and AdolescentsChildrenandadolescentswithself-harmingbe-havior(bothsuicidalandnonsuicidalself-injury)arefrequentlyencounteredintheEDsetting.Theprevalenceratesfornonsuicidalself-injuryarequitevariable,butcommunitystudiesindicatebetween13%and45%ofadolescentsreportengaginginself-injuryatsomepointintheirlifetime.13,14,19,20 In clinicalsettingsitisevenhigher,atapproximately40%-60%.21,22Studiesofself-harmingbehaviorarecomplicated by the variety of terms used to de-scribethebehavior(eg,self-harm,self-mutilation,parasuicidal,self-injury,suicidegesture),andrecentattemptshavebeenmadetocategorizeandclarifytheses terms.23 The term deliberate self-harm en-compassesbothsuicideattempts(havingtheintenttodie)andnonsuicidalself-injury(NSSI),whichisself-injurywithouttheintenttodie.WhileitmaybedifficulttodistinguishadolescentsuicideattemptsfromNSSI,teenagerswhoharmthemselveswithoutsuicideintentarestillathighriskforsuicideandsuicideattempts.24 Adolescents whoengageinNSSIaremorelikelytohavesuicidalbehavior and vice versa.25Inonelargestudy,70%oftheadolescentswhoengagedinNSSIhadmadeatleast1suicideattempt,and55%mademultipleat-tempts.26Aprevioussuicideattemptisasignificantpredictor of future suicidal behavior in teenagers, but more recent studies indicate that NSSI is the strongestpredictoroffuturesuicideattemptsin

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depressed adolescents.26-29 Nonsuicidal and suicidal behaviorsmayservedistinctlydifferentpurposes,withamajorfunctionofNSSIbeingthemanagementofdistressingthoughtsandemotions,andmanyteen-agersreportingthatNSSIhelpsthemtostopsuicidalthoughtsandavoidsuicideattempts.30-32 As a result, NSSI has been conceptualized as a morbid form of self-help.33 CharacteristicsofNSSIincludeanageofonsetbe-tween12to14years.Cuttingoneselfwitharazororsharpobjectisthemostcommonmethod,andforearms, legs, and stomach are the most common locations.33 In community studies, most adolescents reportengaginginNSSIonlyafewtimes(<10life-timeepisodes),whereasinpatientpopulationsreportmorefrequentepisodesofself-injury(averaging>50episodes in the previous year).34,35

Theriskofself-injuryisincreasedbyanynumberofgeneralfactorsthatcreategreaterdifficultyregulatingaffective,cognitive,andsocialexperiences.Distalfac-torsmightincludechildhoodabuse,whereasproximalfactors might include physiological hyperarousal in response to stress.36

Screening and Assessment of Suicidal Behavior and NSSIThe frequency of suicidal behavior and nonsuicidal self-injury,andtheassociatedmorbidityandmortal-ity,makeitincumbentuponpsychiatricproviderstoidentifythoseindividualsatrisk,andtoprovidethenecessaryintervention.Inaddition,theJointCom-missiononAccreditationofHealthcareOrganizations(JCAHO)hasincludedinitsNationalPatientSafetyGoalstherequirementto“identifypatientsatriskforsuicide.”37CHCOrespondedtotheJCAHOmandatebyreviewingavailableresearchandcreatinga4-questionscreeningtool,whichwasinclusiveofquestionsfoundtobemostpredictiveofsuiciderisk.38 As of 2013, screeninghasbeencompletedintheCHCOemer-gencyroomwithallpatientsovertheageof12years,regardlessofpresentingproblem.Oncepatientsareidentifiedasmoderateorhighriskforsuicide,theyarereferredtotheCHCOPsychiatricEmergencySer-vice(PES)formorecomprehensiveassessment.Whilethere are a number of suicide assessment tools that areutilizedandvalidatedthroughresearch,admin-istratorsintheCHCODepartmentofPsychiatryandBehavioral Sciences selected the Columbia Suicide

SeverityRatingScale(C-SSRS)foruseinthePES,tofurtherstratifyriskforsuicideinouradolescentpa-tients.TheC-SSRSwasdevelopedin2003byagroupofresearchersfromColumbiaUniversity,andwasdesignedtodistinguishthedomainsofsuicidalide-ationandsuicidalbehaviorsbymeasuring4research-supportedconstructsincludingseverityofideation,intensityofideation,suicidalbehavior,andlethalityofactualattempts.39,40TheC-SSRSincludesquestionsabout NSSI, and in a 2011 study of depressed adoles-centsandadults,hasdemonstratedgoodsensitivity,specificity,andconvergentanddivergentvaliditywithothermulti-informantsuicidalideationandbehaviorsscales.41

Treatment and Prevention of Suicidal Behavior and NSSIInarecentanalysisoftreatmentinterventionsforself-harmingandsuicidaladolescents,itwasnotedthattherearestillnoevidence-basedpsychologicalor pharmacological treatments for adolescent suicidal behavior or NSSI.42Despitethelackofempirically-validated treatments, some treatment approaches, such as managing underlying psychiatric disorders withpsychotherapyandconsiderationofmedicationinterventions,identifyingtriggersforself-injuriousacts,improvingfamilyrelationships,anddevelop-ingimprovedcommunicationandcopingskills,arestronglyrecommended.Giventhatthehighestriskforrecurrentsuicidaleventsinadolescentsiswithin1to4weeksafterdischargefromthepsychiatrichospitaloremergencydepartment,coordinatingbetteraccessandintensityofcareattherighttimeisalsostronglyrecommended.Factorsthathavebeenidentifiedastargetsforevaluationandinterventioninadolescentswithself-harmbehaviorsincludethefollowingfac-tors:motivationtochange,substanceabuseissues,familysupport,facilitatingpositiveaffect,improvingpeerandsocialrelationships,andhealthysleep.Withasignificantproportion(30%-50%)ofadolescentsuicideattemptersbeingnon-adherenttotreatment,motivationalinterviewingmaybehelpful.42Thiswasthecaseinonestudyofadolescentsuicideattempt-ers,wheremotivationalinterviewingwashelpfulinreducingalcoholandsubstanceabuseaswellasrecurrent suicidal behavior.43Familyconflictisoneofthe stronger predictors of suicidal events in teenag-ers,consistentwiththefindingthatfamilysupport

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andcohesionareprotectiveagainstrecurrentsuicidalbehavior.28Studiesthathaveshownsomefocusonimprovingthequalityoftheparent-childrelationshiphaveshownpositiveeffectsondecreasingself-harmand suicidality.42 Insomnia is one of the strongest predictors of imminent suicide in adults, and sleep problemspredictsuicidalideationandself-harminadolescents,45buttherearenostudiesevaluatingwhetherimprovedsleepwilldecreasesuicidalide-ationandself-harm.Despitethelackofevidence-basedtreatmentinter-ventionsforsuicideandNSSI,approachestosuicidepreventionhaverecognizedimportance.TheAACAPPracticeParameterfortheAssessmentandTreatmentofChildrenandAdolescentsWithSuicidalBehaviorwaspublishedin2001,andwhilemuchofthecontentrequiresupdating,theexecutivesummaryreviewstheimportanceofmediacounselingandpostventionfollowingyouthsuicide,whichiscurrentlybelievedtobeimportantinassessmentfortraumaticresponseinsurvivors,andpreventingthedevelopmentofsui-cide contagion.46,47MeansRestrictionCounseling,anapproachtosuicidepreventionthatinvolveseducat-ingparentsontheimportanceofrestrictingaccessof their adolescents to lethal means for suicide, has alsoincreasinglyreceivedattention,andhasbeenfoundtoeffectivelyalterthestoragepracticesofhouseholdfirearms.48TheCHCOPESpilotedaqualityimprovementprojectinJanuary2014thatincorpo-ratedstandardizedMeansRestrictionEducationinto

thedischargeprocessforalladolescentpatientsthatpresentwithachiefcomplaintofsuicidality.Parentsnotonlyreceivededucationabouttheimportanceofsafefirearmstoragepractices,butwerealsogiventheoptiontotakealockboxhomeforsecuringhouseholdmedications.

ConclusionThe management of pediatric behavioral health emergenciescontinuestobearapidly-growingclini-cal need. EDs have become the safety net to a mental healthsystemincrisis,andpatientsandtheirfamiliesarepresentingtoEDswithever-increasingfrequency.Improvedsystemsofcare,includingalternativestore-liance on general ED services for psychiatric crisis and relatedclinicalexpertiseareneededtosupportthisburgeoningclinicalneed.Whilemodelcurriculaandprocesses have been proposed, none have been rigor-ouslystudiedinthepediatricpopulation.Themostcommonpresentingproblemsaresuicideattemptandnonsuicidalself-injury.Evidence-basedscreeningand assessment tools have been developed, as have strategiesforsuicideprevention,whicharecurrentlybeingutilizedintheCHCOEDandthroughouttheDe-partment of Psychiatry. Approaches to the treatment ofsuicidalityandNSSIareunfortunatelylacking.Gapsinknowledgecreateopportunitiesforinnovationandresearch,andtheCHCOsystemofcareandtheUni-versityofColoradoarewell-positionedtocontributetotheexpansionofthisknowledgebase.

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8. HoyleJD,WhiteLJ.PediatricMentalHealthEmergencies:SummaryofaMultidisciplinaryPanel.Prehospital Emergency Care. 2003.7:60-65.9. JanssensA,HayenS,WalravenV,etal.EmergencyPsychiatricCareforChildrenandAdolescents:ALiteratureReview. Pediatric Emergency

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Addressing Cultural Diversity in Children’s Mental Health Services

Addressing Cultural Diversity in Children’sMentalHealthServices

Introduction and Overview

As the United States becomes increasingly more diverse,itiscriticalforourhealthcaresystem

torespondtotheneedsofourculturally-diversesociety.Thisresponseincludesintegratingculturally-relevantpracticesintoourhealthcaresystem,1,2 including health care provided by mental health practitioners.3-5Fortunately,thefieldsofpsychologyandpsychiatryhaveattemptedtomorethoroughlyaddressthisissueoverthepastfewdecades.6,7,3 Theseeffortshavesparkedsignificantdiscussionamongmentalhealthpractitioners.Manysupporttheseefforts,8-10 but others have raised disagree-ments.11,12 These discussions have also highlighted thewaysinwhichourdefinitionsofmentalhealthissues,includingdiagnosticclassificationsintheDi-agnosticandStatisticalManual(DSM),havefailedtoadequately incorporate issues of cultural diversity.13

Effectivelyattendingtoculturaldiversityinmen-talhealthcareisparticularlyimportantgiventheculturaldisparitiesthatpersistinourhealthcaresystem.14-17Itiswellknownthatmentalhealthser-vicesarelessavailableandmoredifficulttoaccessforculturalminorities,makingitlesslikelyfortheseindividuals to obtain necessary mental health treat-ment. Furthermore, individuals from cultural minor-itypopulationswhoareabletoaccessmentalhealthservicesaremorelikelytoreceivelowerqualitycareand have poorer outcomes,17suggestingthatcurrentmentalhealthservicesforculturalminoritiesarenoteffective.Also of concern is the fact that cultural minority youthareunder-treatedwithpsychotropicmedica-tionwhenitisindicated.However,overall,psycho-tropicmedicationisbeingincreasinglyprescribed

toyouthwithinourcountry,suggestingthatculturalminorityyouthremaindisproportionatelyunder-treatedwhenmedicationisindicated.Researchindicatesthatthereisnotasignificantvariationinpharmacological responses to psychiatric medica-tionsamongyouthofvariousculturalbackgroundswhich,again,suggeststhatdifferentialaccesstoap-propriate psychiatric care is the underlying cause for thesedisparities.15 Multiplefactorsmayperpetuatethedisparitieswithinthehealthcaresystemingeneral,andinmentalhealthcareinparticular.Forexample,cultur-albarriers,suchaslanguage,cannegativelyimpactcommunicationbetweenahealthcareproviderandthepatient,satisfactionwithhealthcareservices,andanindividual’sutilizationofneededhealthcareservices.18 Diverse cultural beliefs and values regard-ingmentalhealthissuesarenotalwaysreflectedinWesternhealthcaresettings,creatingevenmorebarriersforsomeculturalgroupswhoattempttoobtain treatment.15Inaddition,certainculturalgroups,suchasAfricanAmericans,Latinos,Ameri-canIndians,andcertainAsianAmericanpopulations(ie,Cambodian,and/orSamoan)aresignificantlyunderrepresented among health care profession-als.19Thismaycreateagapbetweenmentalhealthprofessionals and diverse children and families in need of treatment.Giventhesedisparities,itisimperativethatmentalhealthpractitioners,includingpsychologists,psy-chiatrists, and other behavioral health clinicians, activelyintegrateculturally-informedconceptualframeworksandpracticesintoourclinicalservices,our research, and the infrastructure of our mental healthsettingsandservices.Sucheffortswillhelpto

Jennifer Lindwall, PhD; Cindy Buchanan, PhD



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JenniferLindwall,PhD;CindyBuchanan,PhD

promotethepositivewell-beingofdiverseindividu-als, including children and families. The purpose of thisarticleisto:(1)reviewtheexistingliteratureon culture and cultural competence as it relates to healthcare,andtomentalhealthcareinparticular;(2)highlightwaysinwhichculturaldiversitycanbeintegratedintoclinicalpracticeforchildrenandfam-ilies;(3)reviewchallengesassociatedwithculturaldiversityinresearch,includingevidence-basedprac-tices;and(4)offerrecommendationsforincreasingculturally-relevantpracticesintotheprofessionalactivitiesofmentalhealthprofessionals.

Culture and Cultural CompetenceA number of terms and models are present in the scholarship of culture and diversity. Although these variousdefinitionshavesomecommonalities,therearealsodifferences,whichcancreateconfusion.Therefore,establishingashareddefinitionofcultureforaparticularprofessionalcommunityisafirststeptodesignculturally-relevantservicesforpsycholo-gists and psychiatrists.5Kreuteretalwrite:

“Althoughnosingledefinitionofcultureisuniversallyacceptedbysocialscientists,there is general agreement that culture is learned,shared,andtransmittedfromonegenerationtothenext,anditcanbeseeninagroup’svalues,norms,practices,systemsofmeaning,waysoflife,andothersocialregularities.”2

Formentalhealthpractitioners,itisimperativetoemphasizethatthedefinitionofculturemusten-compassmultipleculturalvariables,includingrace,ethnicity, socioeconomic status, gender, immigra-tionstatus,language,sexualorientation,andability.WassermanandFlannery20 also highlight the impor-tanceofattendingtothesocialandhistoricalcon-textofculturalgroupswhendefiningculture.Whilesome progress for social equity has been made, a historyofoppression,racism,and/ordiscriminationremainsforsomeculturalgroups;therefore,ithasthepotentialtocontinueaffectingtheexperiencesof these diverse children and families—including theirexperienceswithinthementalhealthcaresystem.Variousconceptualizationshavealsobeenusedtodescribetheeffortsthatattendtoculturalissues,

including“culturalsensitivity,”“culturalresponsive-ness,”“multiculturalcompetence,”“culturaltar-geting,”and“culturaltailoring.”Whileallofthesetermsattempttodescribeasimilareffort,cultural competencehasbeenadvocatedasaparticularlymeaningfulconceptualizationformentalhealthpractitionerstoembrace.4 Cultural competence, as aconcept,highlightstheneedforpractitionerstodevelopskillsforeffectivelyworkingwithdiverseindividuals,notsimplytakinganalreadyestablishedareaofcompetence(eg,aparticularevidence-basedpsychotherapy treatment) and applying it from one cultural group to another. Cultural competence hasalsobeendefinedinmultipleways,andthesedefinitionshavesimilaritiesaswellasdifferences.4,5 WhaleyandDavisofferadefinitionofculturalcom-petencethatattemptstoincludemajorcommonali-tiesthatareofferedfromvariousscholars:

“…weviewculturalcompetenceasasetofproblem-solvingskillsthatinclude(a)theability to recognize and understand the dynamicinterplaybetweentheheritageandadaptationdimensionsofcultureinshapinghumanbehavior;(b)theabilitytouseknowl-edge acquired about an individual’s heritage andadaptationalchallengestomaximizetheeffectivenessofassessment,diagnosis,andtreatment;and(c)internalization(ie,incor-porationintoone’sclinicalproblem-solvingrepertoire)ofthisprocessofrecognition,acquisition,anduseofculturaldynamicssothatitcanberoutinelyappliedtodiversegroups.”.5

Culturally-mindedmentalhealthprofessionalsshould strive to gain cultural competence to more effectivelyworkwithculturally-diversechildrenand families. In order to do so, these professionals shouldascribetoaconceptualframeworkofculturalcompetencytoguidetheirpractice.Thisisparticu-larlyimportantgiventhevariouswaysinwhichtheconstructhasbeendefined.Themodeloftenrefer-enced includes 3 components that every therapist should possess3,4:1. Cultural awareness and beliefs: understanding

that one’s personal values, biases, and overall worldviewmayimpactthetherapeuticrelation-ship.

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2. Cultural knowledge: understanding about an indi-vidual’sculture,worldview,andbeliefsystem.

3. Cultural skills:abilitytoworkwithanindividualinamannerthatisattentivetoandrespectfulofcultural issues.

Psychologists, psychiatrists, and other mental health cliniciansshouldreceiveon-goingtrainingtodevelopstrategies for increasing cultural competency in each of these 3 areas. Training in these areas has been proposedasastrategyforimprovingoverallpatientcare,reducingerrorswhenprovidingcare,andulti-matelyreducingtheculturaldisparitiesthatexistinour health care system.21

Integrating Cultural Diversity into Clinical Practice Whiletheimplementationofculturally-competentpracticeshasbeenpromotedasawaytoreducehealthdisparitiesthatexistamongculturally-diversepopulations,22determiningexactlywhatculturally-competentpracticesshouldbeimplementedandhowtodosoinaneffectivemannerremainschallenging.These challenges are impacted by the limited amount of empirical data available regarding cultural compe-tenceandculturalissuesinmentalhealthpractice.4 Asaresult,itisdifficulttodeterminewhatculturally-competentpracticelookslike,andhowtosystemati-callyassesstheimpactofsuchpracticesonclinicalcare for diverse children and families.22 Fortunately, scholarshipaddressingthesechallengesisgrow-ing, and a number of topics in the literature serve as a guide for developing mental health services for childrenandfamiliesthatattendtoissuesofculturaldiversity.

Using a Bioecological Framework for Approaching Mental Health Treatment Whileitislargelyunderstoodthatculturemustbetakenintoconsiderationwhenprovidingclinicalcare,cultureisoftenassumedandnotfullyassessedtoinform mental health treatment.2Furthermore,whileitisimportanttohaveknowledgeaboutdifferentculturalgroups,itisimperativenottoover-generalizethisknowledgeinamannerthatdisregardsindividualvariationwithinculturalgroups.Rather,itisimpor-tanttouseamiddle-groundapproachthatrecognizescharacteristicsoftentypicalofculturalgroups,whilealsoexploringindividualdifferences.2 In order to con-

siderculturalcharacteristicswhilealsoattendingtothe uniqueness of each individual, it is recommended thatmentalhealthpractitionersuseaculturally-appropriateconceptualframeworkasastartingpoint—onethatallowsforeffectiveassessmentofculturalissues,conceptualizationofpatientconcerns,and guidance of treatment planning for children andfamilies.Usingsuchaframeworkisparticularlyimportantbecausepractitionershavetraditionallyconceptualized mental health issues as being a result ofindividualcharacteristics,suchasbehavioraland/orpsychologicalfactors.Asaresult,traditionalmen-tal health treatments and theories of psychotherapy oftenassumethecultureofmiddle-class,EuropeanAmericanindividuals,thusutilizingaEurocentricworldview.23,24TheseapproachesareoftenrootedinEuropeanAmericanvalues,suchas“optimism,individualism,egalitarianism,glorificationofsocialmobility, and encouragement of personal change.”24

Thesevaluesmaynotbecongruentwiththevaluesthatcomprisetheworldviewofeachchildandhisorherfamily.Sometraditionalmentalhealthtreatmentsalso place a great deal of emphasis on internal fac-tors, and assume that the individual has a high degree ofcontroloverchange.Furthermore,thereisoftenanassumptionthatindividualshaveaccesstoresourcesandarewillingandabletojointhemainstreamcul-ture.25Thesenotions,however,arenotnecessarilytrue for all individuals.Aconceptualframeworkthatcanbehelpfulformen-talhealthpractitionersstrivingtoprovideculturally-competent care is the bioecological model, such as that proposed by Bronfenbrenner.26,27 This model allowsfortheintegrationofculturalandcontextualfactors (eg, ethnicity, social class, race, gender, sexual orientation,language,ability,andimmigrationsta-tus)whenassessingtheworldviewofachildandhisorherfamily,andwhendevelopinginterventionsthatattendtotheseculturalfactors.Abioecologicalframeworkpositsthatanindividual’sbehaviorandpsychologicalwell-beingresultsfromthedynamicinteractionsbetweentheindividualandmultipleculturalfactors,includinglargersocial,institutional,andhistoricalcontexts.Thisframeworkdepartsfromadeficitmodelbecauseitconceptualizesthatchangeprocesseswithinmentalhealthtreatmentdonotliesolelywithintheindividual,butalsowithinhisorher context. Importantly, the bioecological model integratesmulticulturalpracticesandrecognizeshow

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one’spsychologicalwell-beingishighlyimpactedbyone’srace,ethnicity,andculturalvalues,aswellas experiences of oppression, privilege, racism, and discrimination.9,25,28 By applying a bioecological per-spectivetothedeliveryofmentalhealthservices,wecanstrivetoimplementculturally-relevanttreatmentsinordertomeetthespecificneedsofdiversechildrenand families. Mentalhealthprofessionalsmayalsowanttocon-sider developing a more formalized tool to guide assessmentsthatareconsistentwiththebioecologi-calframework,suchastheSocioculturalAssessmentProtocol(SCAP)proposedbyYamada&Brekke.29 The SCAP assesses for a number of factors that may be im-pacted by a child or family’s culture (eg, social stress-orsandsocialsupportnetwork,lifecontrol,changeofenvironment,and/orlanguage/communication).AnotherusefultoolistheCulturalFormulationInter-view(CFI)includedintheDSM-5.TheCFIisasetof16questionsthatmentalhealthproviderscanusetoguideadiagnosticassessmentthatincludesattentionto important cultural factors. The CFI includes ques-tionsthatassessthefollowingareas:one’sculturalidentity,culturalconceptualizationofdistress,psycho-social stressors and cultural features of vulnerability andresilience,culturalfeaturesoftherelationshipbetweentheindividualandtheclinician,andoverallculturalassessment.Suchtoolsallowforassessmentofculturally-diversechildrenandfamiliesbyhelpingto understand their goals for mental health treatment and their unique cultural experiences that can inform treatment planning.

Cultural TailoringAnotherconceptthatcanbeusedinconjunctionwithabioecologicalmodelofpracticeis“culturaltailor-ing.”2 This involves recognizing that cultural variables may be salient to an individual, and therefore are importanttoaddresswhenprovidingculturally-appropriatementalhealthcare.However,individualassessmentmustalsotakeplacetodeterminehowrelevantthesecharacteristicsaretoeachindividual,whichcanideallybecompletedusingthebioecologi-calframework.Forexample,ifanindividual’sculturalbackgroundincludesahighvalueplacedonreligion,specificindividualassessmentshouldtakeplacetoexamineifandhowreligionisrelevanttotheparticu-larindividual.Resultsfromthisassessmentwillhelp

toinformcaseconceptualizationandtreatmentplan-ning.Culturaltailoringallowsmentalhealthpractitio-nerstopayparticularattentiontosalientculturalfac-tors that are most important to children and families, andinturnhelptodevelopeffectiveinterventions.

Cultural AdaptationWhileasignificantamountofliteratureexistsaboutthetheoreticalunderpinningsofculturally-appropri-atementalhealthservices,themosteffectivewaytodeliver culturally-adaptedmentalhealthinterventionsis less clear.30 Furthermore, although studies support theeffectivenessofsomementalhealthtreatmentingeneral, such as psychotherapy, this research does not adequatelyaddresshowvariousculturalfactorsplayaroleintheeffectivenessofthepsychotherapeuticprocess.25,28,31,32Scholarssuggestthatexistingmentalhealthinterventionsshouldbeadaptedforculturally-diverse individuals. For example, Griner and Smith30 reviewedtheliteratureandidentified4commonthemesabouthowtodelivermentalhealthinterven-tionsusingculturaladaptations:(1)activelyidentify-ingandintegratingtheculturalvaluesoftheindi-vidualintothetherapeuticprocess;(2)whenpossible,matchingindividualswithmentalhealthcliniciansthathavesimilarculturalcharacteristics(eg,race,ethnicity,orlanguage);(3)providingmentalhealthin-terventionsinamannerthatisaccessibleandreadilyavailableforculturally-diverseindividuals(eg,offeringcommunitymentalhealthservicesdirectlywithintheneighborhoodofaparticularculturalgroup);and(4)includingsupportiveindividualsandresourcesthatareimportanttotheindividualandhis/herculturalbackground(eg,extendedfamilymembers,orreli-gious/spiritualleaders).Followingtheirreviewoftheliterature,GrinerandSmithconductedameta-analysisof76culturally-adaptedmentalhealthinterventionstodeterminetheeffectivenessofthesetreatments.Empiricalstudieswereincludedinthemeta-analysisunderthefollow-ingguideline:“Themanuscripthadtoexplicitlystatethattheadaptationswerebasedonculture,ethnicity,or race.”30Resultsfromthismeta-analysisidentifiedanaverageeffectsizeof.45acrossstudies(d=.45,SE=.04,p<.0001),suggestingamoderatelystrongbenefitforthesetypesofinterventions.Furthermore,mentalhealthinterventionsdeliveredtospecificcul-turalgroupswere4timesmoreeffectivethanthose

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interventionsprovidedtogroupsofindividualsfromdifferingculturalbackgrounds.GrinerandSmith30 alsoreportedthatwheninterventionsweredeliv-eredtonon-nativeEnglishspeakersinanindividual’snativelanguage,theywere2timesaseffectiveasinterventionsdeliveredinEnglish.Otherresearchhasdemonstratedthatlanguage-basedinterventions(eg,oralinterpretation)arerelatedtobetterpatientexperiences,improvedpatientcomprehension,andmore appropriate use of health care services.18 These findingsprovidesomeinsightintothewaysinwhichmentalhealthinterventionscanbeeffectivelyadapt-edforculturally-diverseindividuals.Inanefforttolookmorecloselyatevidence-basedtreatmentsforculturally-diverseyouthinparticular(individualsages18andyounger),HueyandPolore-viewed25availableresearchstudiesrelevanttomen-talhealthcare.Theyappliedthedefinitionoftreat-mentasdefinedbyWeiszandWeiss(1995):“‘anyinterventiontoalleviatepsychologicaldistress,reducemaladaptivebehavior,orenhanceadaptivebehav-ior through counseling, structured or unstructured interaction,atrainingprogram,orapredeterminedtreatment plan,’”33ResultsfromHueyandPolo’smeta-analysissuggestamoderatebenefitoftheseinterventions(d=.44,SE=.06,p<.01). They concluded thattherewerenowell-establishedtreatmentsintheirreview,buttheydididentifyprobably efficacious and possibly efficacious treatments for ethnic minor-ityyouthwithanxietyproblems,attention-deficit/hyperactivitydisorder,depression,conductproblems,substance use problems, trauma, and other clinical problems.Baseduponthisreview,cognitive-behavior-altreatmentsdemonstratedthemostpositiveout-comeswithethnicminorityyouthingeneral.Further-more,certaintherapeutictreatmentswereidentifiedasmoreeffectiveforparticularculturalgroups.Forexample,usingcognitivebehavioraltherapyorin-terpersonalprocesstherapymaybemoreeffectivefordepressedLatinoyouththanothertypesoftreat-ment. Family systems treatments, including Brief StrategicFamilyTherapy,MultidimensionalFamilyTherapy,andMultisystemicTherapyappeareffectiveforculturally-diverseyouthwithconductanddrug-related problems. Whilemanypsychotherapyinterventionsattempttoincludeculturaladaptations,thereislimitedempiri-calevidencetodatethatdemonstratesifandhow

theseadaptationsactuallyimprovepsychotherapyoutcomes.33 Despite this, evidence from the broader literaturemaintainsthatculturally-competenttreat-mentinterventionsarevaluableandneeded.4 As a general guideline, it appears that certain psychologi-cal theories are broadly applicable to human behav-iorandemotionalfunctioning.However,weneedtoconsidertheseuniversaltheoriesusingaculturally-specificlens,andeffectivelyadaptinterventionstoprovideculturally-diverseindividualswithqualitymental health treatment.34Additionalresearchisneededtobetterunderstandtheimpactofculturalmodifications.

Cultural LeverageAnotherusefulconceptualizationfortranslatingmul-ticulturalprinciplesintoactioniscultural leverage. Thisconceptisparticularlyusefulformentalhealthprofessionalsinthehealthcaresetting,andhasbeendescribed as:

“…afocusedstrategyforimprovingthehealthofracialandethniccommunitiesbyusingtheirculturalpractices,products,philosophies,orenvironments as vehicles that facilitate behavior changeofpatientsandpractitioners.Buildingonpriorstrategies,culturalleverageproactivelyidentifiestheareasinwhichaculturalinterven-tioncanimprovebehaviorsandthenactivelyimplementsthesolution.Culturalleverageisaprocesswherebytheprinciplesofculturalcompetencearedeliberatelyinvokedtodevelopinterventions;ithasthepotentialtooperateatmultiplelevelsthroughoutthehealthcaredeliveryprocess.Asweconsiderindividuals,theircommunitiesandthemeansbywhichtheyaccess the health care environment, culture becomes central: factors such as language, fam-ilynorms,andsexualityshapetheframeworkthroughwhichhealthcareisaccessed.”14

Fischer and colleagues14 applied their conceptualiza-tionofculturalleveragetodetermineitsimpactondecreasinghealthdisparities.Multiplehealthcareproviders, including nurses, counselors, and commu-nityhealthcareworkersdeliveredhealthinformationinculturally-relevantways.Theinterventionsutilizedin these studies integrated cultural factors into the followingtypesofinterventions:(1)changinghealthbehaviorsofindividualswithincommunities,(2)

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increasingaccesstomentalhealthservices/systems,and(3)makingchangeswithinhealthcaresystemstoimproveservicesprovidedforracial/ethnicminoritypatients.Resultsfromthisreviewsuggestthattheseinterventionsshowpromiseforreducingculturaldisparitiesthatexistinourhealthcaresystembyincreasingpatients’knowledgeforself-care,reducingbarriers to receiving health care services, and increas-ing the cultural competence of health care providers.Giventhepromisingresultsregardingthepotentialbenefitofstrategiesbasedontheconceptofculturalleverage,itisimportanttoconsiderhowthesestrate-gies might be translated to mental health interven-tionsforchildrenandfamiliesinparticular.Whendoingso,itisimportanttoconsiderhowstrategiesgrounded in cultural leverage can be used in combina-tionwith“generic”healthcarestrategiestooptimizeefforts.14 It is not necessarily the case that one set of strategies should be used over the other, but rather theyshouldbeusedincombination.Forexample,whenworkingwithaparticularchildandfamilyinneedofmentalhealthservices,thefollowingstrate-giesmaybeused:communityoutreachtoidentifyculturally-relevantmentalhealthresources(culturalleveragestrategy),providinginformationregardingmentalhealthcareusinglanguagethatfitswithintheculturalworldviewofthechildandthefamily(culturalleveragestrategy),advocatingforthechildandfamilytoobtainservices—particularlywhenculturalbarriersmayinterferewithaccessingtheseservices(culturalleveragestrategy),andtrackingthechildandfamily’sutilizationofrecommendedmentalhealthservices(generic strategy).Fisher et al14proposeseveralrecommendationstocontinuemakingchangesandtopromoteculturally-relevant care using cultural leverage as a guiding framework:1. Healthcarecommunitiesneedtocontinueinvolv-

ingculturally-diversecommunitiesineffortstoreducehealthcaredisparities.Thistypeofcol-laborationwillhelptoidentifymoreeffectiveandculturally-relevantstrategies,andwillgivevoicetotherepresentativecommunity,bridgingthegapbetweenhealthcareandthesurroundingcommu-nity members.

2. Itisimperativeformultidisciplinarycollaborationtotakeplacebetweenphysicians,mentalhealthprofessionals, nurses, and community members

whendesigningandimplementingculturally-rele-vant health care strategies.

Attending to Cultural Diversity in Mental Health ResearchWhenconsideringthemethodologyofmentalhealthresearch,ofparticularconcernisthelackofattentionpaidtorecruitingindividualswhoareculturally-di-verse.17,5Furthermore,whenexaminingtheliteratureregardingevidence-basedtreatment,itisunfortunateandconcerningthatmostevidence-basedtreatmentsare supported by research that has not adequately takenculturalcharacteristicsintoconsideration.35 Giventhelackofculturally-diverseindividualsrep-resentedinexistingmentalhealthresearch,thesefindingsmaynotbeapplicabletocertainculturalgroups.36,5 It has been suggested that cultural minori-tiesarelesswillingtoparticipateinresearch—ano-tionthatmaycreatefurtherdividebetweenscholarsandculturally-diversechildrenandfamilies.However,datahasrefutedthisclaim,suggestingthatwilling-nesstoparticipateinresearchinvestigationsisnotsignificantlydifferentamongdifferentculturalgroups.Therefore, the responsibility lies upon researchers to activelyincreaseaccessibilityforculturalminoritiestoparticipateinresearch,ratherthanchangingtheattitudesorbeliefsthatdiverseindividualshaveaboutresearch.37 Furthermore, a call has been made to involveculturally-diversecommunitiesinthedevelop-mentofinvestigationsthatexaminementalhealthtopicstoencouragecollaboration,andtobetterunderstand the experiences of diverse children and families.5

Other methodological challenges also complicate re-searchinthisfield.First,becauseculturalcompetencyhasbeendefinedinmultipleways,itisachallengingconstructtostudyduetoalackofappropriatemea-surement and research designs.4 Second, it is im-perativeformorerigorousresearchinvestigationstoexaminetheeffectivenessofculturally-adaptedmen-talhealthinterventions.30 Finally, it is important for healthcaresystemstodevelopsystematiceffortsforgathering data about cultural variables, and examine thisdatatoinformthedevelopmentofeffectivemen-talhealthinterventionsforchildrenandfamilies.18 Improvingmethodsofgatheringdatawilllikelyleadtobetteropportunitiesforassessingcurrentpracticesandidentifyingareasforgrowth.

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RecommendationsAs previously discussed, a number of strategies should be implemented by mental health profession-alstomoreeffectivelyaddressissuesofculturaldiver-sity in the delivery of mental health services. These strategiesaresummarizedasfollows:1. Strive to Enhance Understanding of Culture and

Cultural Competence It is important to ensure that mental health practitionersunderstandtheirprofessionalcom-munity’sdefinitionofculture.Thiswillserveasafoundationforenhancingeffortstoattendtoculturaldiversity.Furthermore,itiscriticalthatmentalhealthprovidersengageinon-goingtrain-ingandprofessionaldevelopmentopportunitiesto strengthen cultural competence (eg, training, workshops,andfeedbackduringannualprofes-sionalreviews).Finally,itisimperativethatmentalhealthprovidershaveadequateeducationregard-ing the resources that are available in their orga-nizationthatcanassistthemwithattendingtoimportantissuesofculturaldiversitywhenwork-ingwithpatientsandtheirfamilies(eg,interpreterservices or community resources), and each men-talhealthprovidershouldstrivetoutilizetheseresources as needed.

2. Utilize a Bioecological Framework to Guide Practice Mental health providers should be cognizant ofutilizingaculturally-appropriateframework,such as the bioecological model,26,27 for providing culturally-sensitivecareandadequatelyassessingfor cultural factors that can inform development ofinterventions.Cliniciansshouldreceiveon-go-ing training and professional development in using suchaculturally-informedframeworkfordeliver-ing mental health treatment.

3. Maintain a Commitment to Using Culturally-Com-petent Practices when Delivering Mental Health Interventions Mentalhealthprovidersshouldcontinuetouseevidence-basedtreatments(eg,CBT)fortreatingculturally-diverseyouth,whilebeingmindfuloftailoring these treatments to the cultural needs ofindividualchildren/families.Whenappropri-ate, clinicians should consider matching children

andfamilieswithmentalhealthproviderswhohave similar cultural factors (eg, race, ethnicity, or language)whenthishasthepotentialtoincreasetheeffectivenessofinterventions.Furthermore,mentalhealthinterventionsshouldbeofferedinawaythatmakestheseservicesasaccessibleandreadilyavailabletochildren/familiesaspossible(eg,offeringcommunitymentalhealthservices/outreachdirectlywithintheneighborhoodofaculturalgroup).Finally,whenworkingwithpa-tientsandfamilies,mentalhealthcliniciansshouldconsider using assessment tools (eg, SCAP, CFI) to assistwithgatheringculturally-relevantinforma-tionaboutpatientsandfamiliesthatcaninformtreatmentgoalsandinterventions.

4. Utilize Cultural Leverage Strategies14 Mental health providers should strive to engage culturally-diversecommunitiesincreatingstrat-egiesforreducinghealthcaredisparities.Thistypeofcollaborationwillhelptoidentifymoreeffectiveandculturally-relevantstrategiesforchildrenandfamilies,andwillhelpgivevoicetotherepresentativecommunity.Suchstrategieswillhelptobridgethegapbetweenhealthcareandthesurroundingcommunitymembers.Whenpossible,mentalhealthprovidersshouldactivelyparticipateinadvocacyandoutreacheffortstoreachculturally-diversechildrenandfamiliesinthecommunity,andcreatepartnershipswiththecommunity to obtain direct input about devel-opmentofculturally-appropriatementalhealthservices for children and families.

5. Develop Strategies for Gathering Data about Cultural Issues18 Mentalhealthprovidersshouldworktodevelopacomprehensivedatacollectionmechanismforcapturing cultural variables (race, ethnicity, lan-guage, etc) about children, adolescents, and fami-lies in the community. This data can be used to understandtheculturalmake-upofthesurround-ingcommunityandwhatmentalhealthservicesareneeded,andtodevelopeffectiveprogramsforaddressinghealthcaredisparitiesthatarepresentin the community.

6. Increase Access and Availability of Culturally-

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Appropriate Mental Health Services18 Mental health providers can implement a number of strategies to help increase access to mental healthservicestoculturally-diverseindividuals.Forexample,itisimportanttoofferwrittenandspokenlanguageservices,andensurethatchil-drenandfamiliesareawareoftheopportunityto access these services. Mental health provid-ersshouldalsoconsiderdevelopingculturally-appropriatewrittenmaterialsaboutmentalhealthservices for children and families.

7. Conduct Culturally-Relevant Mental Health Research Mentalhealthprovidersshouldmakeeffortsto

engage in research relevant to providing cultural-ly-appropriateservices.Forexample,itwouldbeimportanttoroutinelyexaminedifferencesamongcultural variables and mental health outcomes in childrenandfamilieswhoreceivementalhealthservices.18 Mental health scholars should also makeanefforttorecruitculturally-diverseyouthand families into research studies to ensure that culturally-diverseindividualsarerepresentedinresearch studies. Finally, there is a need for addi-tionalresearchthatexamineswhatmentalhealthinterventionsareparticularlyeffectiveforvariousculturalgroups,andtakesimportantculturalchar-acteristicsintoconsiderationwhenunderstandingpsychological health in children and adolescents.

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19. GrumbachK,MendozaR.(2008).Disparitiesinhumanresources:Addressingthelackofdiversityinthehealthprofessions.Health Affairs. 27(2),413-422.

20. WassermanJ,FlanneryMA,ClairJM.(2007).Raisingtheivorytower:TheproductionofknowledgeanddistrustofmedicineamongAfricanAmericans. Journal of Medical Ethics.33(3),177-180.

21. BrachC,FraserirectorI.(2000).Canculturalcompetencyreduceracialandethnichealthdisparities?Areviewandconceptualmodel.Medi-

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cal Care Research and Review.57(1),181-217.22. WeechMaldonadoR,ElliottM,PradhanR,SchillerC,HallA,HaysR.(2012).Canhospitalculturalcompetencyreducedisparitiesinpatient

experiencesincare?Medical Care.50(11,Suppl3),S48-S59.23. PedersenPB,DragunsJG,LonnerWJ,TrimbleJE.(1996).Counseling across cultures(4thed).ThousandOaks,CA:Sage.24. SueDW,IveyAE,PedersenPB.(1996).A theory of multicultural counseling and therapy.PacificGrove,CA:Brooks/ColePublishing.25. ColemanHLK,WampoldBE.(2003).Challengestothedevelopmentofculturallyrelevant,empiricallysupportedtreatments.In:DBPope-

Davis,HLKColeman,WMLiu,RLToporek(Eds),Handbook of multicultural competencies in counseling and psychology.(227-246).ThousandOaks,CA:SagePublications.

26. Bronfenbrenner U. (1979). The ecology of human development: Experiments by nature and design.HarvardUniversityPress:Cambridge,MA.

27. Bronfenbrenner U. (2005). Making human beings human: Bioecological perspectives on human development.SagePublications:ThousandOaks,CA.

28. WampoldBE.(2001).Great psychotherapy debate: Models, methods, and findings.Mahwah,NJ:Erlbaum.29. YamadaA,BrekkeJ.(2008).Addressingmentalhealthdisparitiesthroughclinicalcompetencenotjustculturalcompetence:Theneedfor

assessmentofsocioculturalissuesinthedeliveryofevidence-basedpsychosocialrehabilitationservices.Clinical Psychology Review. 28(8), 1386-1399.

30. GrinerD,SmithTB.(2006).Culturallyadaptedmentalhealthintervention:Ameta-analyticreview. Psychotherapy: Theory, Research, Prac-tice, & Training. 43(4),531-548.

31. NorcrossJC.(2002).Psychotherapy relationships that work.NewYork:OxfordUniversityPress.32. ZaneN,HallGC,SueS,YoungK,NunezJ.(2004).Researchonpsychotherapywithculturallydiversepopulations.InM.J.Lambert(Ed.),Ber-

gin and Garfield’s Handbook of psychotherapy and behavior change.(767-804).NewYork:Wiley.33. HueySJJr.,PoloAJ.(2008).Evidence-basedpsychosocialtreatmentsforethnicminorityyouth:Areviewandmeta-analysis.Journal of Clini-

cal Child and Adolescent Psychology. 37(1),262-301.34. MunozRF,MendelsonT.(2005).Towardevidence-basedinterventionsfordiversepopulations:TheSanFranciscoGeneralHospitalpreven-

tionandtreatmentmanuals.Journal of Consulting and Clinical Psychology.73,790-799.35. ClayDL.(2009).Culturalanddiversityissuesinresearchandpractice.InM.C.Roberts&R.G.Steele(Eds.),Handbook of Pediatric Psychology

(4thed).89-98.NewYork:GuilfordPress.36. UnitedStatesDepartmentofHealthandHumanServices&ServicesAdministrationBureauofHealthProfessions.(2006).The rationale for

diversity in the health professions: A review of the evidence.Retrieved11/30/2013from:http://bhpr.hrsa.gov/healthworkforce/reports/diversityreviewevidence.pdf.

37. WendlerD,KingtonR,MadansJ,etal.(2006).Areracialandethnicminoritieslesswillingtoparticipateinhealthresearch?PLOS (Public Library of Science) Medicine. 3(2),e19,0201-0210.

http://bhpr.hrsa.gov/healthworkforce/reports/diversityreviewevidence.pdf

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Cindy L. Buchanan, PhD; Jennifer Lindwall, PhD; Emily Edlynn, PhD; Emily Muther, PhDCindyL.Buchanan,PhD;JenniferLindwall,PhD;EmilyEdlynn,PhD;EmilyMutherPhD

BehavioralHealthandChildrenwithChronicMedicalConditionsorPhysicalIllnesses

Psychosocial and behavioral factors such as cop-ing,adjustment,medicaladherence,qualityof

life,andfamilyfunctioning,impacthowchildrenand families navigate the stressful course of living withchronicmedicalconditions.Thesecrosscuttingissuesallpotentiallyaffecttheoutcomeofmedicalinterventionsandmedicaltreatmentforchildren.Psychosocialandbehavioralhealthproblemsoftenpresentsomeofthemostsignificantobstaclestoeffectivemedicalcare.Thus,awidevarietyofpsy-chologicalinterventionsandtreatmentapproachescansubstantiallyhelpfamiliesmoresuccessfullymanage the experience of a child’s medical illness. Thisarticlefocusesontheissuesfacedbychildrenwithmedicalillnessandtheirfamilies;reviewstheliteraturerelatedtoprevention,intervention,andtreatmentforthesechildren;andoffersrecommen-dationsforprovidingbehavioralhealthandpsycho-socialservicestothispopulation.

Crosscutting Issues Facing Children with Chronic Illnesses

Quality of LifeTheconceptofHealth-RelatedQualityofLife(HRQL)encompasses the impact of childhood illness on a child’sphysicalandemotionalwell-being.1HRQLincludes physical symptoms or health status, psy-chologicaladjustment,andallaspectsofsocialfunctioning(eg,peerandfamilyrelationships,andacademicfunctioning).1 All of these are crucial and complementaryfactors—inadditiontotreatingmedical problems—that can and should help inform medicaldecision-making.Inthisrespect,standard-izedqualityoflifemeasures(eg,PedsQL)arerou-tinelyutilizedinpediatricpopulationsbybehavioral

health providers.2,3 These standardized tools can help inform both medical and mental health treat-ment.Theycanalsoprovideinformationonotherareas of a child’s life that can be improved through targetedinterventionsbybehavioralhealthprovid-ers.4 Behavioral health providers in a variety of set-tingshavesuccessfullyimplementedinterventionstoincreaseHRQL,demonstratingimprovedqualityoflifeacrossawidespectrumofpediatricchronicillnesses(eg,asthma,cysticfibrosis,cancer,and/ortransplant).5-7

Coping and AdjustmentTwoofthemostsalientissuesfacingchildrenwithchronicmedicalconditionsarecopingandadjust-ment. Children and families are required to man-agetheshockofnewmedicaldiagnoses,dealwithongoinginvasivemedicalprocedures,andadjusttochangesinfunctioningforboththechildwiththemedicalillnessandtheentirefamily.Behavioralhealthandemotionalsupportareoftenvitaltohelping families navigate these stressors. Research has supported that individual, group, and familyinterventionsnotonlyimprovecopingandadjustmentoverall,butcanalsopreventincreasedhospitalizationandriskformentalhealthdiagnosesforchildrenwithchronicmedicalconditions.8 An areathatexemplifiesthebenefitofpsychotherapeu-ticinterventionistheevidenceshowingthatCogni-tiveBehavioralTherapy(CBT)techniquesreducepain and anxiety related to medical procedures in thepediatricpopulation.9EffectivecomponentsofCBTincludebreathingexercisesandotherrelaxationanddistractionstrategiessuchasguidedimagery,cognitivecopingskills,filmedmodeling,behavioralrehearsal,andactivecoaching.Theoverarching

Cindy L. Buchanan, PhD; Jennifer Lindwall, PhD; Emily Edlynn, PhD; Emily Muther, PhD



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Behavioral Health and Children with Chronic Medical Conditions or Physical Illnesses

goalofCBT,whichoverlapswithothertherapeuticapproaches, is to improve quality of life and help childrenfunctionmoreadaptivelywithfewerpsy-chiatricsymptomsduringtimesofstressthatarerelated to medical illnesses.

Emotional Well-BeingAlthoughmostchildrenwithchronicillnessesdem-onstratefunctioningsimilartohealthychildrenorcontrols,asubsetofchildrenwithchronicmedicalconditionsareatanincreasedriskfordepressionascompared to community samples of children and healthy peers.10-12Evenwithoutclinically-significantimpairmentinfunctioning,childrenwithchronicmedicalproblemsoftenhaveotherproblemsthatimpacttheiroverallfunctioningandemotionalwell-being. Increased depressive symptoms interfere withachild’sabilitytocopewithmedical-relatedstressorsandleadtoadecreasedmotivationtoen-gageinself-carebehaviors.13,14 Of note, depressive andanxietysymptomsareoftenexacerbateddur-ingtimesofextrememedicalstressors.13,15 Although symptomsvarywidelyamongchildrenwiththesamemedicalconditions,somedisorderslikeasth-ma,recurrentabdominalpain,andsicklecellane-miapresentahigherriskofdepressiveandanxietysymptomsthanotherdisorders(eg,cancer,cysticfibrosis,and/ordiabetesmellitus).10Withregardstomedically-illchildrenwithpsychiatricdiagnoses,evidence supports that the same psychiatric treat-mentsusedwithchildrenwithoutmedicalillnessareeffective.(See“Evidence-basedpracticeresources”16 and“Effectivechildtherapy”17 for further details on treatment.)Whenconsideringpsychotropicmedica-tion,itisimportanttoknowthatchildrenareoftenalreadytakingmedicationfortheirchronicillness,and can have unique baseline physiology. Before startingamedicationforachildwithachronicill-ness,thefollowingshouldbeconsidered:(1)thepsychologicalimpactfortheindividualof“yetan-otherapilltotake,”(2)medicationinteractionswiththeirothermedications(egSSRIandlinezolid),and(3)thepotentialofthemedication’ssideeffectpro-filetoworsentheperson’soverallhealth(egstimu-lantspotentialtoincreasebloodpressure,whichcouldseverelyimpactapersonwhohaspulmonaryhypertension).Theseissuesmustbebalancedwiththeimportanceoftreatingtheindividual’smental

healthsymptomsandthepotentialimpactonthechild’soverallhealth,whichcanbeaddressedbycollaborationbetweenpsychiatryandtheprimarymedicalteamforthechildwiththemedicalillness.

Family Functioning, Peer Relationships, and Educational FunctioningCorrelatesoflivingwithamedicalillness(schoolabsenteeismanddecreasedsocializationwithpeers due to medical care and illness) can interfere withnormativedevelopmentacrosschildhoodandadolescence.Arecentmeta-analysisof954stud-ies found that, in general, children and adolescents withchronicphysicalillnesshavelowerlevelsofacademicandsocialfunctioningthantheirhealthypeers.18 Some children require formal Individualized EducationPlans(IEP),or504Plans,tohelpdevelopaccommodationstofostersuccessinschool.Home-boundinstructionortherapeuticschoolsarealsooptionsforchildrenwithchronicmedicalconditions,althoughhomeboundserviceslimitsocializationop-portunities.Positivefamilyfunctioningcanbeanadditionalcontributortothesuccessfulnavigationofachild’sillness.Significantdistressaroundthetimeofanewdiagnosis is certainly a common occurrence for par-ents;however,literaturesupportsthatadjustmentandadaptationgenerallyimprovesovertimeformost parents.19,20 Unfortunately, caregiver depres-siveandanxietysymptomsareriskfactorsforin-creased emergency department use and hospitaliza-tionsinmanypediatricmedicalconditions;withoutpsychiatrictreatmentforcaregivers,childrenshowworseoutcomes.21-23Parentaldistressisalsolinkedwithdistressofchildrenwithmedicalproblems,whichhighlightstheimportanceofusingamodeltoconceptualizechildwell-beingwithinacontextthatacknowledgestheinfluenceoftheirfamily.24,25 Siblingsareoftenafrequently-overlookedcom-ponentwithinpediatricillness,andclearlyimpactthefunctioningofthechildwiththeillnessandtheentirefamilyunit.26

Severaltheoreticalmodelsfocusonunderstand-ingfamilyfunctioning,siblingrelationships,schoolfunctioning,andpsychologicalproblemswithinthecontextofchronicmedicalconditions.Behavioralfamily systems theory, and social ecology and family

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systems theories have helped to inform treatment development,testingofinterventions,andpracticeguidelinesfortreatmentforchildrenwithchronicill-nesses and their families.27-30

Giventheimpactonsocialfunctioningforchildrenwithchronicillnesses,interventionprogramsintend-edtoimprovetheirsocialskillscanbeveryhelpful.These programs are usually delivered in small groups, andoftenteachsocialskillswithrole-playing.31 Groupsfocusedonimprovingsocialfunctioningcanhelptoreducethesignificantimpactofrepeatedschool absences, and improve ability to reconnect withpeerswhentheirmedicalstatusallows.Inadditiontoskill-basedgroupsforchildrenwiththechronic illness, family therapy, psychotherapy groups for parents, and psychotherapy groups for siblings areoftenfoundtobehelpfulinimprovingfamilyfunctioning,increasingadherence,andimprovingadaptation.32-34Additionally,interventionsthatcanbeintegratedwiththeongoingmedicalcareofchildrenwithchronicillnessesaddvaluetocomprehensivecare,andimproverelationshipsbetweencaregiversand children. This integrated approach provides an-otheravenueofsupportingfamiliesastheydealwiththe pediatric illness of a child.35

AdherenceNonadherence,anothercrosscuttingissueinpedi-atricchronicillness,isafrequentreferralquestionfor pediatric psychologists and psychiatrists.36,37 One recentstudyfoundthat77%ofthereferralquestionsto pediatric psychologists related to nonadherence.37 Nonadherencecanbeeitherintentionaloruninten-tionalandcantakeonmanyforms,includingskippingmedicationdosesand/ornotfillingprescriptions.Thoroughmeta-analysesindicatethattheaverageadherence rates to medical regimens in pediatric populationshoveraround75%.38 Child psychosocial functioningisalsoclearlyrelatedtononadherencetomedical regimens.38-40Depression, anxiety, behavioral problems,familystressors,adjustmentproblems,medicaltrauma,lackofunderstandingofmedicaltreatment,andchallengeswithcommunicationbe-tweenfamiliesandmedicalprovidersallcontributetochallengeswithadheringtoamedicalregimen.Asnotedabove,notallchildrenwithmedicalcondi-tionsmeetcriteriafordiagnosablepsychiatricdis-orders;however,theimpactofsomelevelofinter-

nalizingorexternalizingsymptomscanstillimpactadherence.36 Depending on the disease severity and type,nonadherencecanleadtodevastatingconse-quencesincludingadeclineinfunctioningorevendeath.Additionally,nonadherenceleadstoanin-creasedutilizationofmedicalservicesandagreaternumberofhospitalizations.Nonadherencealsoresults in preventable morbidity and mortality, and a massivelossofhealthcaredollarsandproductivity.41

Despitethenumerousdifficultiesandrisksassoci-atedwithnonadherenceinpediatricpopulations,thereisstillreasontobehopeful.Consistently,be-havioralandpsychologicalinterventionshavehelpedincrease medical adherence in children and youth.42,43 Primarytheoreticalmodelsusedwithinthetreat-mentofadherenceincludetheHealthBeliefModel,44 TheoryofPlannedAction/PlannedBehavior,45 Social CognitiveTheory(Self-Efficacy),46 Applied Behavior AnalyticTheory,47andtheTranstheoreticalModel.48 Allofthesemodelsfocusonexplaining,predicting,and improving adherence from their various perspec-tives.49,50Atthecoreofeachmodel,thefollowingelements exist: (1) the health care provider’s com-municationwiththepatient,(2)anoutlineofthepatient’scognitiveandsocialprocesses,and(3)anaccountingofpatientresources,suchaspsychologicalwell-beingandsocialsupport.Interventionsfocusedontreatingtheunderlyingpsychologicalproblem,and developing behavioral strategies and supports to increaseadherencecontinuetobehighlightedintheadherence literature.37Arecentmeta-analysisof71studiesfoundthatinterventionsincludingeducationandbehavioralstrategiesshowedgreaterimprove-mentspost-interventionforchildrenandadolescentswithadherencedifficultiesthanthosewithoutthesestrategies.51Family,individual,group,andtechnology-basedinterventionshavebeenusedacrossavarietyof chronic illnesses to promote adherence. Current clinicaleffortsrelatedtopediatricadherenceincludecontinueddevelopment,dissemination,andimple-mentationofadherencetoolsandinterventions.

Palliative CarePalliativecareisamedicalsubspecialtyfocusedonaholisticapproachtothereliefofsufferingforchildrenandadultslivingwithalife-limitingorlife-threateningillness.Althoughwell-establishedinadultmedicine,pediatricpalliativecarehasonlyexpandedinthelast

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decade.52TheWorldHealthOrganization,InstituteofMedicine,andtheAmericanAssociationofPediatricshave all publicly recognized the importance of devel-opingpediatricpalliativecareasafield.53,54 A survey ofhospitalswith50ormorebedsindicateda126%increaseingeneralpalliativecareprogramsbetweentheyears2000through2008;however,pediatricprogramsarenotspecified.55Inpediatricpopulationsparticularly,thenatureofbarrierstointegratingpal-liativecarerangesfromculturaltoinstitutional(eg,accuratelydefiningpalliativecareassimultaneouswithcurativetreatment,distinguishingfromhospice,andlackingknowledgeaboutthedocumentedben-efitsofpalliativecare).56 Researchhasbeguntodocumentthepositiveout-comesassociatedwithpediatricpatientswhoreceivepalliativecare.Theseoutcomesincludefewerproce-dures,lessinvasiveinterventions,fewerdaysininten-sivecare,agreaterlikelihoodofthefamilyreceivingsupportiveservices,andhigherfamilysatisfaction.57,58 Althoughthepremiseofpalliativecarerestsonaholisticapproachtothepatientandfamily,psycholo-gists and psychiatrists are rarely team members on palliativecareservices.59,56Teamsoftenincludeasocialworkerandchaplaintoaddressemotionalandspiritualaspectsofsufferingandqualityoflife.Thereisevidence,however,thattheinclusionofpsychol-ogy and psychiatry may add important competencies tothepalliativecarepatient’sassessment,symptommanagement, and quality of life.59,60,54 Apsychologicalassessmentcandistinguishnormativeversuspathologicalsymptomswithinthecomplexityofchildhooddevelopmentlayeredbylife-threateningillness,thusidentifyingchildrenatriskforapsychi-atricdiagnosisthatmayotherwisebemissed.56,54 Thegoalofpalliativecareispalliation, or relief of suffering.Mood,anxiety,andbehaviorsymptomsthatco-occurwithlife-threateningillnessesandtheirtreatmentssignificantlycontributetothisoverallex-perienceofsuffering.60 Psychopharmacological inter-ventionsareoftenakeypartofreducingacuteanxi-etyinthemedicalsetting,aswellassleepdisruptionsthatcontributetoheightenedanxietyandworsenedmood.Behavioralinterventionshelpdecreaseprob-lem behaviors, especially in young children, and can focusonmedicaladherenceissuesinterferingwithquality of life42,43;relaxationstrategiestargetingsleepdisruptions,anxiety,andpainsymptoms61;andcogni-

tivebehavioralinterventionsaddressingworriesandfearsthatareinherentincopingwithalife-threat-eningorterminalillness.Hypnosis,guidedimagery,biofeedback,andmindfulness-basedstressreductionhaveshowntobeefficacioustreatmentsofpainandstress,61 and therefore important components of ad-dressingsufferingandsymptomsinpediatricpallia-tivecarepatients.Interventionstargetinganticipatorygriefandbereavementgriefarealsoanessentialpartofprovidingthespectrumofpalliativecare.60

RecommendationsChildrenwithchronicmedicalconditionsandtheirfamilies face a number of challenges as they respond toandadjusttolifefollowingdiagnosis.Clearly,thenature of these challenges means that behavioral healthprovidersareespeciallywell-positionedtohelp.Accordingly,thefollowingstrategiesarerecom-mendationstoimprovetheaccesstoandsuccessesofbehavioralhealthservicesforchildrenwithchronicillnesswhoareseeninchildren’shospitalsettings.First,children’shospitalsettingsshouldensuresmooth referral processes for medical providers refer-ringpatientstopsychiatryproviders.Ideally,utiliza-tionofembeddedbehavioralhealthproviderswithinspecialty medical clinics can help to develop screen-ing methods and streamline the referral process. However,wherethisisnotavailable,astandardizedandsimplestrategytoreferpatientstoonecentral-ized place in the psychiatry department is vital. Short waitingperiodsforthesereferredpatientstobeconnected to a behavioral health provider increase thelikelihoodofpatientsfollowinguponthereferralsprovided by their specialty or primary medical provid-ers.Giventhatchildrenwithchronicmedicalcondi-tionsoftenhavetomakemanyvisitstothemedicalsetting,itisalsorecommendedthatallattemptsbemadetocoordinatepsychiatrydepartmentvisitswithmedical visits.Aspreviouslymentioned,manychildrenwithchronicmedicalconditionsdonotmeetthecriteriaforpsy-chiatricconditions;however,theywouldstillbenefitfrom referrals to receive behavioral health interven-tionsandservices.Strategiesshouldbedevelopedtoimprove reimbursement for such behavioral health servicesprovidedtochildrenwithchronicmedicalconditions.Thismayrequireincreasedfocusonau-thorizationforhealthandbehaviorbilling,andpro-

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vidingassociatedinsuranceauthorizationteamstheappropriateknowledgeandskillsrelatedtocontract-ing for health and behavior assessments and billing. Along these lines, psychiatry departments should engageinadvocacyatthestateandnationalleveltoimprove reimbursement rates for health and behavior codesforpatients.Psychiatry departments should also focus on preven-tion,whichcouldbedonebydevelopingstrategiestoscreenchildrenwithnewdiagnosesregardingtheirneedforsupportduringadjustmenttonewmedicalconditions.Thisrecommendationoftenstandsinstarkcontrast to the current, standard referral for consul-tationliaisonservicesoroutpatientpsychiatrywhenchildren are in crisis (eg, prolonged period of nonad-herence,and/orsuicideattempts).Specialized programming including support groups, socialskillsgroups,andparentingskillsshouldbeavailableforchildrenwithchronicmedicalconditionsandtheirfamilies.Commonalitiesoccuracrossmanychronicillnessdiseasetypescreatingthepotentialtodevelopmulti-illnessgroupstargetingthesameissues(eg, adherence or social acceptance). Groups could be hostedwithgreaterfrequency,andwithlessoverallresources,iftheyareembeddedwithinadepartmentof psychiatry rather than duplicated in each depart-ment.

Educationandtrainingonadherenceassessmentsandinterventionsshouldbeprovidedtotrainees,staff,andfacultyinthedepartmentofpsychiatrywithaspecificfocusonadherencetopsychotropicmedica-tions.Offeringeducationtomedicalprovidersonthewaystheycanfacilitateadherenceintheirpatientsinordertooptimizetreatmentadherencefromthestart,ratherthanafterproblemsemerge,isalsorec-ommended.Departmentscanalsoprovideeducationtomedicalcolleagues about the role of pediatric psychologists and psychiatrists to improve understanding about the following:(1)theroleoftheseproviders,(2)appropri-atereferrals,(3)thewayinwhichpediatricpsycholo-gistsandpsychiatristscontributetomultidisciplinarypatientcare,and(4)thestrategiesandinterventionsthattheseproviderscommonlyusewithpediatricpatients.Lastly,muchroomexistsforasignificantincreaseinthelevelofcollaborationbetweenpsychiatryandpsychologyservicesandpalliativecare.Expandingallcurrentpalliativecareprogramstoinvolvementalhealthservicesintheinpatientsettingwillcertainlybe an improvement.

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in adolescent transplant recipients. Pediatric Transplantation. 9(3),381-390.40. WuYP,AylwardBS,SteeleRG.(2010).Associationsbetweeninternalizingsymptomsandtrajectoriesofmedicationadherenceamongpedi-

atric renal and liver transplant recipients. Journal of Pediatric Psychology. 35(9),1016-1027.41. OldridgeNB.(2001).Futuredirections:Whatpathsdoresearchersneedtotake?Whatneedstobedonetoimprovemulti-levelcompli-

ance?In:LEBurke,ISOckene(Eds).Compliance in Healthcare and Research. (331-347).Armonk,NY:Futura.42. KahanaS,DrotarD,FrazierT.(2008).Meta-analysisofpsychologicalinterventionstopromoteadherencetotreatmentinpediatricchronic

healthconditions.Journal of Pediatric Psychology.33,590-611.43. SimoniJM,FrickPA,PantaloneDW,TurnerBJ.(2003).Antiretroviraladherenceinterventions:Areviewofcurrentliteratureandongoing

http://www.apadivisions.org/division-54/evidencebased/index.aspx

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http://effectivechildtherapy.com

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studies. Topics in HIV Medicine. 11(6),185-198.44. BeckerMH.(1974).Thehealthbeliefmodelandsickrolebehavior.Health Education Monograph. 2,409-419.45. MontanoDE,Kasprzyk.(2008).Theoryofreasonedaction,theoryofplannedbehavior,andtheintegratedbehavioralmodel.InK.Glanz,B.

K.,Rimer,&K.Viswanath(Eds.).Health Behavior and Health Education: Theory, Research, and Practice. (67-96).SanFrancisco:Jossey-Bass.46. BanduraA.(2004).Healthpromotionbysocialcognitivemeans.Health Education & Behavior. 31,143-164.

doi:10.1177/1090198104263660.47. CooperJO,HeronTE,HewardWL.(2007).Applied Behavior Analysis.SaddleRiver,NJ:PrenticeHall.48. ProchaskaJO,VelicerWF.(1997).Thetranstheoreticalmodelofhealthbehaviorchange.American Journal of Health Promotion. 12(1),38-

48.49. BowenDJ,HelmesA,LeaseE.(2001).Predictingcompliance:Howarewedoing?InL.E.Burke&I.S.Ockene(Eds.).Compliance in Health-

care and Research. (25-41).Armonk,NY:Futura.50. DiMatteoMR.(2004).Variationsinpatients’adherencetomedicalrecommendation:Aqualitativereviewof50yearsofresearch.Medical

Care. 42(3),200-209.51. GravesMM,RobertsMC,RapoffM,BoyerA.(2010).Theefficacyofadherenceinterventionsforchronicallyillchildren:Ameta-analytic

review.Journal of Pediatric Psychology. 35(4),368-382.doi:10.1093/jpepsy/jsp072.52. FeudtnerCF,WomerJ,AugustinR,RemkeS,WolfeJ,FriembertS,WeissmanD.(2013).Pediatricpalliativecareprogramsinchildren’shospi-

tals:Across-sectionalnationalsurvey.Pediatrics. 132,1063-1070.53. AmericanAcademyofPediatrics.(2000).PalliativeCareforChildren.Pediatrics.106,351-357.54. MoodyK,SiegelL,ScharbachK,CunninghamL,CantorM.(2011).Pediatricpalliativecare.Primary Care: Clinics in Office Practice. 38,327-

361.55. CentertoAdvancePalliativeCare.AnalysisofU.S.hospitalpalliativecareprograms2010snapshot.RetrievedonlineApril18,2012:http://

www.capc.org/news-and-events/releases/analysis-of-us-hospital-palliative-care-programs-2010-snapshot.pdf.56. SourkesB,FrankelL,BrownM,etal.(2005).Food,toys,andlove:Pediatricpalliativecare.Current Problems in Pediatric Adolescent Health

Care. 35,350-386.57. KeeleL,KeenanHT,SheetzJ,BrattonSL.(2013).Differencesincharacteristicsofdyingchildrenwhoreceiveanddonotreceivepalliative

care. Pediatrics. 132,72-78.58. PierucciRL,KirbyRS,LeuthnerSR.(2001).End-of-lifecareforneonatesandinfants:Theexperienceandeffectsofapalliativecareconsulta-

tionservice.Pediatrics.108,653-660.59. EdlynnES,DerringtonS,MorganH,etal.(2013).Developingapediatricpalliativecareserviceinalargeurbanhospital:Challenges,lessons,

and successes. Journal of Palliative Medicine. 16,342-8.60. InstituteofMedicine(2003).When Children Die: Improving Palliative and End-of-Life Care for Children and their Families.Washington,DC:

TheNationalAcademiesPress.61. Palermo T. (2012). Cognitive-Behavioral Therapy for Chronic Pain in Children and Adolescents.NewYork:OxfordUniversityPress.

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http://www.capc.org/news-and-events/releases/analysis-of-us-hospital-palliative-care-programs-2010-snapshot.pdf

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Integrated and Embedded Behavioral Health Care in Pediatrics

Integrated and Embedded Behavioral HealthCareinPediatrics

Introduction

Over the past 30 years there has been an increas-ing presence of behavioral health services inte-

grated into pediatric primary care and subspecialty clinics.Whiletherangeofpediatricconditions/clinicswherementalhealthprofessionalspracticeisbroad,thelargestevidencebasefortheintegrationof behavioral health is in the treatment of children withchronicpain,hematological-oncologicaldis-orders,anddiabetes.However,theresearchbaseisexpandingtoincludeconditionssuchasasthma,obesity,sleepdisorders,andinterventionsinpediat-ricprimarycare.Behavioralhealthinterventioncanbeorganizedaroundchildrenwithaspecificmedicaldiagnosis,symptommanagement,orcrosscuttingissuessuchasadherence.Whileinitialintegrationof mental health in pediatric care focused on spe-cialtypediatrics,withinthepast10yearstherehasbeenanincreasedrecognitionofthebenefitsofprovidingbehavioral/developmentalscreeningandmentalhealthcareintheprimarycaresetting.Onecommonthreadthroughallofthesesettingsistheparticipationofthebehavioralhealthclinicianinamultidisciplinaryteamthatincludesnotonlypediat-ricmedicalpractitioners,butalsoavarietyofalliedhealth professionals. It is beyond the scope of this articletoexhaustivelyreviewtheliteratureoninte-gratedmentalhealthcareinpediatricsasthefieldnowencompassesaverybroadrangeofpediatricconditions;instead,thearticlewillhighlightareasofintegrated care that represent the broader range of servicesprovided.Inparticular,behavioralhealthinpediatric primary care, pediatric chronic pain, Type I Diabetes,andobesitywillbereviewed.

Behavioral Health in Pediatric Primary CarePediatricprimarycare(PPC)providesanoptimalset-tingforthepracticeofintegratedbehavioralhealthservices.Pediatricprimarycaresettingsprovidecontinuousandcomprehensivemedicalservicesthatarereadilyaccessibletothevastmajorityofchildren in the United States and their families.1 Thesesettingsareideallysuitedtopromoteoptimaldevelopmentandwell-beingthroughtheprovisionof expanded services that address parental con-cerns,developmentaltasks,psychosocialfactors,and behavioral health issues in the context of trust-ingrelationshipswithfamiliarproviders.2 Behav-ioral health clinicians integrated into PPC are able topromotethehealthandwell-beingofchildrenandfamiliesinamannerdirectlyalignedwiththemandatesandguidelinesofthepracticeofprimarycare.3 According to the American Academy of Pedi-atrics (AAP)4 and the Centers for Disease Control,1 thereareapproximately34,000,000routineinfant/childwell-childchecksperyearinPPCintheUnitedStatesforpatientsfrombirthto22yearsofage,withapproximately121,000,000visitsforchildrenunder 15 years of age. Pediatric primary care is oftentheonlyavailableentrypointtoservicesforvulnerable children and their families.2

Although the American Academy of Pediatrics and BrightFuturesprovidesystematicguidelinesandoutline methods for comprehensive surveillance andscreeningduringwell-childchecks,mostpedi-atricpracticesandprovidersareoverwhelmedbythecomplexriskfactorspresentedduringroutinevisitslastinganaverageof18minutes,andmaybereluctanttosolicitinformationaboutbehavioralandpsychosocialmattersbecausetheyfeelunableto

Emily F. Muther, PhD; Heather Adams, DO; Bethany Ashby, PsyD; Sally Tarbell, PhD



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adequately address them.5,6,2 Therefore, children ex-periencingsignificantriskfactorsthatimpactdevel-opmentandfamilyfunctioningremainunidentified.Evenwhenriskorearlydisturbanceisidentified,familiesoftenhavedifficultyaccessingnecessarycommunity resources.2 Behavioralhealthdisordersandpatientsandfami-lieswithenvironmentalriskfactorsoftenpresentfirsttoPPCbeforeaccessingservicesthroughthemental health system.3 PPC clinicians play an im-portant role in screening for behavioral and devel-opmentalconditions,andprovidingearly and less intensiveinterventions.Withthehelpofintegratedbehavioral health clinicians, primary care providers havethecapacitytoidentifyandmanageemotionalconditionsearlyon,whenthereisagreaterlikeli-hood they can be prevented or ameliorated. Data haveclearlydemonstratedthatintegratingmentalhealthcareintoprimaryhealthcareleadstobetterhealthoutcomesandsubstantialcostsavings.7 Morethan20%ofchildrenandadolescentsintheU.S. have a diagnosable mental health problem, and onlyapproximately20%ofthosereceiveadequatetreatment.3Althoughthereareoftenaccessissuesanddifficultiesnavigatingcomplexmentalhealthsystems, most children do receive pediatric primary medical care. Therefore, screening, assessment, and interventionsembeddedwithinPPCareclearlyindi-cated,andhavebeendemonstratedtobeeffective.The American Academy of Child and Adolescent Psychiatry and the American Academy of Pediat-rics3havebothrecognizedthesignificantneedforearlierdetectionandpreventionofmentalillnessinchildren,aswellasimprovedabilityofprimarycarephysicianstoinitiatetreatment.Statisticsindicatethat15%-25%ofpediatricpatientshavesignificantpsychopathology,functionalimpairment,and/orpsychiatric comorbidity.8Additionally,18%ofpa-tientsmeetfullcriteriaand14%meetsubthresholdcriteria for mental health diagnoses.8 Approximately 75%ofchildrenwithpsychiatricdisturbancesareseen in PPC,9and50%ofallPPCvisitsinvolvecon-cernsaboutbehavioral,psychosocial,oremotionalconcerns.8

Assessment MethodsThe American Academy of Pediatrics Bright Fu-

tures program5 emphasizes frequent mental health screeningtobegintheprocessofidentifyingchil-drenwhomayneedmentalhealthresourcesandreferrals. Assessment in PPC can range from brief, informalassessmentsthatinvolverecord/casereviewwithaphysiciantomoreextended,formalassessment.Clinicalconsultation,behavioralob-servation,andclinicalassessmentperformedbyamentalhealthclinicianareoftenperformedinthecontextofPPC,whenanidentifiedconcernhasbeenreported.ResearchhasshownthattoolssuchasthePediatricSymptomChecklist(PSC)canbeusedforroutineuseinaPPCsettingaswellascombinedwithotherassessmentmethodstocreateaninte-gratedapproachtoassessingandtreatingbehavior-al and physical health in a pediatric system of care.10 Assessment in PPC can serve a number of purposes, includingscreening,diagnosticassessmentandclarification,treatmentplanning,determiningeffec-tivenessoftreatment(eg,medicationorbehavioralintervention),andidentifyingbarrierstotreatment.ScreeninginPPCisafundamentalinterventionthatfacilitatesprevention,increasesanticipatoryguidance,andcreatesanopportunitytoassessriskfactorsandpromotewell-beingandpositivefunc-tioning.Screeningisdefinedasabrief,formal,stan-dardizedevaluation,fortheearlyidentificationofpatientswithunsuspecteddeviationsfromnormal.11 ThereareseveraltypesofscreeninginterventionsindicatedforusewithinPPC.Developmental screening. To improve the early identificationandtreatmentofchildrenwithde-velopmental disability, the American Academy of Pediatrics (AAP) recommends that all infants and young children be screened for developmental delays in the context of PPC.12 Furthermore, the AAP recommends performing developmental surveil-lanceateverywell-childvisit,andifdevelopmentalconcerns are raised by the parent or provider dur-ing surveillance. Select screening measures that are brief, accurate, and easy to administer and score are available to assist primary care providers in the early detectionofdevelopmentalandbehavioraldisor-ders. There are several developmental screening teststhatuseinformationprovidedbyparentsordirectobservationofproviders.TheAgesandStagesQuestionnaires(ASQ,formerlytheInfantMonitor-ingSystem)isoneofthemostwidelyusedtoolsto

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screen development in children from 4 to 60 months13 on5domains:communication,grossmotor,finemo-tor,problemsolving,andpersonal-social.Pregnancy-related depression screening. There has beendebateaboutwhetherornotscreeningforpreg-nancy-relateddepressioninmothersbelongsinPPC.14 BrightFuturesforMentalHealthencouragespediatricprimary care providers to inquire about depressive symptoms and consider formal screening for preg-nancy-relateddepressionusingavalidatedscale.14,15 Researchindicatesthatpediatricprimarycareofficescanreadilyidentifypregnancy-relateddepressionandrelatedconcerns,andmakeappropriatereferralstolocal mental health providers.16Whensymptomsareidentified,recommendationsincludediscussingthesafety of mother and baby, referring the mother to a mental health provider, scheduling more frequent pe-diatricvisits,andusingphonecontactsbetweenvisitsfor ongoing monitoring.14

Interventions in PPCBehavioralhealthcliniciansinPPCengageinactivitiesthat“improvethehealth-relatedqualityoflifeofchil-dren and their families.”17Suchactivitieshavebeenshowntobeeffective,sustainable,anddirectlyrelat-edtoimprovinghealthandwell-being.18Theseactivi-tiesinclude:providinganticipatoryguidanceduringroutinewell-childvisits;screening;earlyidentificationand referral related to developmental and behavioral issues;providinginitialassessmentandtreatmentforissuesthatcouldleadtosignificantimpairmentifleftuntreated;andtriaging,referringto,andcoordinatingcarewithcommunityresourceswhenhigherlevelsofcare are necessary.2 Behavioral health clinicians in PPC help improve adherence, promote healthy behaviors andreducebehaviorsthatincreasehealthrisks,andimprovecommunicationbetweenhealthcareprovid-ersandthepatientsandfamiliestheyserve.17

Attemptstodeliverintegratedmentalhealthtreat-mentinPPChaveshownpromiseinrandomizedtrials.19-21Astudyofaninternet-basedpsychoeduca-tioninterventiontargetingpatientswithbehavioralproblemshasshowntobeeffectiveinaPPCsetting.22 Anotherstudyofanon-sitefamilyinterventionforchildrenwithbehaviorproblemshasalsobeensup-portedasaneffectiveinterventioninPPC.23Addition-ally, studies have found an increase in family compli-anceandsatisfactionwithservicesdeliveredbyan

on-sitenurseclinicianwithinacollaborativementalhealthteaminaPPCpractice.24,20 There have been 2 studiesshowingmodesteffectsatreducingdepres-sioninadolescentsthroughanon-siteInternet-basedinterventioninPPC.25,26 Anon-sitemodularinterventionwithinPPCaimedatimproving access to mental health services and out-comesforchildrenwithbehavioralproblemsdemon-stratedanincreasedlikelihoodthatpatientsreceivedmentalhealthservices,reportedfewerbarrierstoandmoresatisfactionwithservices,andshowedgreaterimprovements on outcomes related to behavioral disordersat1-yearfollowup,comparedtoenhancedusualcarewithinPPC.20Thisinterventionincludedap-proximately6sessionswithanursefortraininginCBTskills,andasneeded,2-4boostersessionstoaddressemergent issues or promote maintenance of the par-entingskillstaughttothesefamilies.Thisinterventionwascomparedto,andshowntobemoreefficaciousthan,enhancedusualcarewithinPPC,whichincludedareferraltoanoff-sitementalhealthprovider.20 TheServicesforKidsinPrimary-care(SKIP)treatmentresearchprogram(www.skipprogram.org)integratespersonalized behavioral health services in PPC set-tingsandhasproducedimpressiveresultsrelatedtotheefficacyofintegratedbehavioralhealthprogramsin PPC.20,27Thefeasibilityandclinicalbenefitsofdoc-torofficecollaborativecare(DOCC)hasbeenshowntobeeffectiveinaddressingbehavioralproblemsandsupportingtheintegrationofbehavioralandmentalhealth services in PPC.28Significantimprovementsinbehavioralandemotionalproblemswerefoundforpediatricpatientswhoreceivedpsychoeducation,briefmodulesofskillstraininginCBT,andcareco-ordinationbybehavioralhealthcliniciansortrainednursesembeddedwithinPPCascomparedtopediat-ricprovidersprovidingtheparentwithpsychoeduca-tionaboutthechild’ssymptoms,clinicalrecommen-dations,andupto3referraloptions.28

Recommendations Thewell-understoodbarrierstoaccessingspecialtymentalhealthservicesalongwiththegrowingsig-nificanceofuntreatedmentalhealthproblemsinchildren and adolescents have expanded the need for PPCtobetteridentifyandmanagebehavioralhealth.Whilesubstantialbarriersexistincreatingsustain-able behavioral health programs in PPC, the evidence

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clearly highlights the importance of integrated mental health programs for children and adolescents in their medicalhome.Betteradvocacyisneededtoaddressthesignificantchallengessurroundingreimburse-ment for behavioral health services in primary care, and to ensure that health and behavior codes are (1) routinelyusedbybehavioralhealthclinicianstodocu-menttheservicesprovidedinPPC,and(2)universally-coveredbenefitsinpediatrichealthinsuranceplans.2 Additionalexplorationanduseofinnovativefundingmechanismscouldbettersustainandsupportbehav-ioral health billing in PPC.2 Additionalresearcheffortsandfundingopportunitiesareneededtoassessthecostsandbenefitsofinte-gratedmodelsinPPCtodeterminethemosteffectiveandefficientapproachtoservices.Whileprogramssuch as SKIP20,27havedemonstratedefficacyinimple-mentingacollaborativecaremodelofinterventionforthe treatment of externalizing childhood behavioral healthdisorders,itisrecommendedthatadditionalevidence-basedprogramsbedevelopedtoaddressabroad range of behavioral health disorders to test the feasibilityandsustainabilityofPPC-specificinterven-tionstotreatpediatricmentalhealthdisordersinPPC.

Behavioral Health in the Management of Pediatric Chronic PainItisremarkablethatthereisnowanextensiveevi-dence base for the behavioral management of pedi-atric chronic pain, given that as recently as the mid 1980’stherewerestillquestionswithinthemedicalliteratureastowhetherinfantsandchildrencouldfeel pain, due to the immaturity of their central ner-voussystem.Afterpioneeringresearchinanesthesiol-ogy and pediatrics demonstrated unequivocally that infants and children do in fact feel pain, and that the practiceofnottreatingpaincouldleadtoincreasedmorbidity and even mortality in children, the stage wassetforthedevelopmentofthefieldofpediatricpain research and treatment. Today there is a strong evidencebaseforcognitivebehavioraltherapyinter-ventionsinthemanagementofchronicpediatricpain.The pediatric chronic pain literature has focused on childrenaged7-18years.Theprevalenceofchronicpain in children varies according to the medical condi-tion,withestimatesrangingfrom6%-18%forchildrenwithtensiontypeormigraineheadaches,13%forabdominalpaininchildrenand17%inadolescents,

and23%-45%formusculoskeletalpain,withahigherprevalence in adolescents and in females. Disease ortreatment-relatedpainhasasignificantlyhigherprevalence,rangingfrom29%withphantomlimbsto88%inirritablebowelsyndrome.29 The most com-monpediatricchronicpainconditionsareheadache,abdominalpain,musculoskeletalpain,andfibromy-algia.30Pain-relateddisabilityincreaseswithage,andthereisagenderdifferencethatemergesinadoles-cence;moregirlsthanboysreportingpain-relatedfunctionaldisability.31

Assessment Methods Assessmentofchronicpaininchildhoodstartswithabiopsychosocialperspectivetotakeintoaccountthemultiplefactorsthatcaninfluencethechild’spainexperienceandthepathwaysbywhichtheyexerttheseeffects.Severaldevelopmentallysensitive,validatedinstrumentsarenowavailabletomeasurethesensory,affective,behavioral,andinterpersonal/social aspects of children’s pain.32 Thorough baseline andongoingassessmentisessentialforguidinginter-ventionsforchronicpainandevaluatingthechild’sresponsetotreatment.Representativeassessmentmethodsaredetailedbelow.Clinical interviews and comprehensive pain assess-ment questionnaires. The Children’s Comprehensive PainQuestionnaire(CCPQ)33andtheVarni-ThompsonPediatricPainQuestionnaire34areinterviewsthatseparately assess the child’s and parents’ experience ofthechild’spainproblemswithopen-endedques-tions,checklists,andquantitativepain-ratingscales.Thewell-documentedcomorbiditybetweenpediatricchronicpainandpsychiatricdisorders,particularlyinternalizing disorders such as depression and anxiety, obligate the clinician to screen for these disorders alongwithpain-relatedfearsandavoidancebehav-iors.35-41InstrumentssuchasthePain-AnxietySymp-toms Scale (PASS) use a comprehensive approach to assessing pain.42,43

Coping.ThePainCopingQuestionnaire(PCQ),44 Pain Response Inventory (PRI),45 Pediatric Pain Coping Inventory(PedsQL),46 Pain Catastrophizing Scale for Children(PCS-C),47andResponsetoStressQuestion-naire (RSQ)48assesspain-specificcopingstrategies.Researchersareidentifyingsubgroupsofpediatricchronicpainpatientsbasedoncopingprofilestobet-tertargettreatmenttoindividualcharacteristics.49,50

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Functional Impairment. The Pediatric Migraine Dis-abilityScale(PedMIDAS)assessesfunctionalimpair-mentassociatedwithheadache.51TheChildActivityLimitationsInterview(CALI)52 assesses the impact of recurrentpainonchildren’sdailyactivitiesasawaytoidentifyappropriatetargetsfortreatment.Addition-ally,theFunctionalDisabilityInventory(FDI)53 and The PedsQLGenericCoreScales54 assess the impact of painonchildfunctioningandhealth-relatedqualityofliferespectively.TheQualityofLifePain-Youth(QLP-Y)55wasdevelopedtoaddressqualityoflifeissuesparticulartochronicpain.Behavioral observations and symptom diaries. Behav-ioralobservationscales56provideinvivoinformationonpain-specificbehaviors,whileelectronicdiarieshavebeenshowntobefeasibleandresultingreateradherence and accuracy in recording as compared totraditionalpaperdiariesinchildrenwithrecurrentpain.57,58

Evidenced Based/Informed TreatmentsBehavioralpaininterventionsaretypicallydeliveredwithinthecontextofamultidisciplinaryteamthatcaninclude physicians, nurses, and physical and occupa-tionaltherapists,alongwithpsychologistsormentalhealth providers. Importantly, chronic pain treatment programs typically require behavioral health assess-mentandtreatment,giventhesocialandemotionalimpact of chronic pain on the child and the family as a whole.Arehabilitativeapproachthatshiftsthefocusfromthenarrowgoalofpainreductiontodecreasingpain-relatedemotionalandbehavioraldisabilitytoimprovethechild’sfunctionalstatuscharacterizesthecourse of most chronic pain treatment programs for children. Research on the use of psychological therapies is lim-itedprimarilytoclinicaltrialsinchildrenwithhead-ache.59Inameta-analysisconductedtoevaluatetheefficacyofbehavioralinterventionforpediatricchron-icpain,Ecclestonandcolleaguesconcluded,“Thereisstrong evidence that psychological treatment, primar-ilyrelaxationandcognitivebehaviouraltherapy,arehighlyeffectiveinreducingtheseverityandfrequencyof chronic pain in children and adolescents.”59

Psychological treatments have been found to im-provepaininforchildrenwithsicklecelldisease,60-62 recurrent abdominal pain,63-66 complex regional pain syndrome, Type I,67musculoskeletalpain,68,69 and

juvenileprimaryfibromyalgiasyndrome.70,71 A recent meta-analysisfoundalargepositiveeffectforpsycho-logicalinterventiononpainreductionpost-treatmentanduponlonger-termfollow-upwithsmallandnon-significanteffectsfoundfordisabilityandemotionalfunctioning.72 Acceptance and Commitment therapy (ACT) has been found to be a promising treatment for adolescentswithchronicpain.73 Thereisgrowingacknowledgmentoftheparents’crucialroleinsuccessfulrehabilitationofyouthwithchronic pain, and thus treatments are increasingly involvingparentsasactivepartnersintheirchild’streatment.65,74-77

There is evidence to support the use of single behav-ioraltreatmentmodalitiesinthetreatmentofpediat-ricchronicpain,asintheuseofthermalbiofeedbackandrelaxationforrecurrentpediatricheadache.78 Most treatment programs include a diverse array of techniques that treat chronic pain by modifying children’scognitive,affective,andsensoryexperienceof pain, their behavior in response to pain, and envi-ronmentalandsocialfactorsthatinfluencethechild’spain experience. Techniques to alter the sensory aspectsofchronicpaincanincluderelaxationtraining,biofeedback,imagery,andhypnosis.Fewcomponentanalyseshavebeenconductedtodeterminewhichpsychologicaltherapiesmaybemostessentialinmanagementofpediatricchronicpain.Evaluationofspecificbehavioralcomponentscouldprovideakeyevidencebaseforwhatthemostactivecomponentsareinmulticomponentinterventions,andinformthetailoringofinterventionstotheindi-vidualpatient.Whiletheresearchtodatehasfocusedonimprovedpain control as a primary outcome of treatment, stud-iesareunderwaytoexaminetheimpactoftreatmentonpsychiatriccomorbidityandfunctionalstatus.Complementarytherapiessuchasoccupationalandphysical therapies, massage, yoga, and acupuncture are increasingly available to children seen in chronic pain clinics, but there is limited literature to docu-menttheefficacyofthesetreatmentsinpediatricpatients.79 Treatment Delivery. Several methods for the delivery ofpsychologicalinterventionsforrecurrentorchronicpaininchildrenhavebeenshowntobeeffective,includingthosethatinvolveintensiveinpatient74,80 or

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outpatienttreatment,66,73thosethatareself-adminis-tered,81school-based,82,83Internet-based,84CD-ROMbased,85 and those that involve minimal clinic contact withhome-basedpractice.86,87 The variety of methods forthedeliveryoftheseinterventionsofferoppor-tunitiestoreachabroadpopulationofchildrenwithchronicpain,thusincreasingthepotentialtoreachmany more children than can be treated in specialized pediatric pain treatment centers.

RecommendationsBehavioral health is integrated into the Integra-tiveHeadacheClinicinNeurologyattheChildren’sHospitalColorado(CHCO),wherechildrenreceiveamultidisciplinaryassessmentatbaseline.However,thereareinsufficientresourcesforongoingbehavioralhealthtreatmentaftertheinitialassessment,causinga disconnect in the biopsychosocial approach to treat-ingpatients.Theanesthesiachronicpainprogramhaspsychologists;however,behavioraltreatmentisco-locatedbutnotintegratedwithotherhealthcareproviders. Oneimportantrecommendationinvolvestheconsid-erationofprovidingformalizedtraininginpain-copingskillsforconditionsknowntobeassociatedwithrecurrent or chronic pain. These include headache, inflammatoryboweldisease,juvenileidiopathicarthritis/juvenilerheumatoidarthritis,andfunctionalGIdisorders.Additionalrecommendationsincludetheuse of standard assessments for psychiatric comorbid-itiesandthedevelopmentofinterdisciplinarytrans-diagnosticskillsgroupsforchildrenwithrecurrentorchronicpaininadditiontoE-healthoptions,includinginternetandapp-basedinterventions.

Behavioral Health in the Management of Pediatric Type 1 Diabetes MellitusOver 215,000 U.S. residents younger than 20 years old have type 1 (T1DM) or type 2 diabetes. This repre-sents0.26%ofallpeopleinthisagegroup.During2002–2005,15,600youthwerenewlydiagnosedwithT1DMannually,and3,600youthwerenewlydiag-nosedwithtype2diabetesannually.TheprevalenceofT1DMinAmericansunderage20roseby23%between2001and2009.88 OptimalglycemiccontrolofhemoglobinA1c(HgbA1c)between6%and8%foradolescentsisusedtoensure

currenthealthandreducetheriskoffuturemicrovas-cularandmacrovascularcomplicationssuchasheartdisease,nephropathy,retinopathy,andneuropathy.95 Multiplestudiesdemonstratethatyoungadulthoodistheperiodofpoorestglycemiccontrol,withmeanHg-bA1clevelpeakinginlateadolescence.AverageresultforHgA1cinonestudywas11.1%at18-19yearsofage.89Glycemiccontroloftendeterioratesduringado-lescence90 such that by 20 to 29 years old, mortality is increased3-foldindiabeticmenand6-foldindiabeticwomencomparedwiththegeneralpopulation.91 Acutecomplicationsarethemajorcauseformortalityinthisagegroup,with68%ofdiabetes-relateddeathsbeingcertifiedasduetohypoglycemiaandketoacido-sis.92 Even small changes in insulin control can have largebenefitstohealth.OnepercentagepointdropinHgbA1c(eg,9.0%–8.0%)isassociatedwitha40%riskreductionofdevelopingretinopathy.93 Coincidingwithpoorglycemiccontrolisaconcomi-tant rise in mental health issues. During the period of 17-25yearsofage,psychiatricdisordersinpatientswithdiabetesneedinginsulinmanagementincreasedfrom16%-29%andpredictedrecurrentadmissionwithdiabeticketoacidosis.94 This leads to concerns for howtomanagepatientswithbothhigh-riskmedica-tionsandhigh-riskmentalhealthdisorders.AdolescentslivingwithT1DMmustlearntocopewiththe demands of adhering to a lifelong medical regi-men,which,inturn,mayimpactpsychologicalwell-beingandreducethelikelihoodofoptimaltreatmentadherence.95Behavioralproblemsresultinginpoortreatment adherence include greater youth responsi-bilityforself-carethatinturnpredictspoorerself-carebehaviors, less frequent exercise, less frequent blood glucose monitoring, increasing behavioral problems, poorcommunicationandhighlevelsofconflictwithinthefamily,andpoorsocialskillsandcopingabili-ties.96-98Themostcommonreferralsforpsychological/behavioralinterventionincludeproblemswithtreat-mentadherence,socialconcerns,anddiabetes-relat-ed anxiety.95

AdolescentsdiagnosedwithT1DMhavea2to3-foldincreasedrisk(22.8%)fordepressioncomparedtohealthy peers.99 An increase in general anxiety and illness-specificfearsisalsocommon.100 Depressive symptomologyinadolescentswithT1DMispredic-tiveoflessfrequentbloodglucosemonitoringandincreasesinHgbA1cby0.5%(8.5%-9.0%)forevery5

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points increase on Children’s Depression Inventory.99 AnxioussymptomologyisalsoassociatedwithhigherHgbA1clevelsandlessfrequentbloodglucosemoni-toring.100Inadditiontothehighratesofcomorbidanxietyanddepression,eatingdisordersarecommonpsychologicalproblemsforadolescentswithT1DM.101 Eatingdisordersareassociatedwithpoorglycemiccontrol.Anestimated10%ofadolescentgirlswithT1DMmaymeetcriteriaforaneatingdisorder,twicetherateforgirlswithoutdiabetes.102

All of these impairments, plus the added burden of functioningwithachronicmedicalillness,resultsinoveralldecreasedqualityoflife(QOL),measuredbythePedsQL,aswellasimpairedpeer,school,andfam-ilyfunctioning.101Interventionsthatimprovepsycho-logicalfunctioninganddiabetes-relatedbehaviorsareassociatedwithoptimalglycemiccontrol.Towardthat end, an integrated care model of embedding psychologistswithinanurbanpediatricendocrinologyclinichasbeenshowntoimprovemedicaloutcomesofadolescentswithT1DM.103

Assessment MethodsMany studies have demonstrated improvements in glycemic control and treatment adherence for youth withdiabetes.104-107Adherencecanbemeasuredwith:(1)HgbA1C,whichdemonstratesa3-monthmeasure-mentofglycemiccontrol;and(2)DiabetesSelf-Man-agementProfile,a24-itemstructuredinterviewthatyieldsanestimateofoveralltreatmentadherenceover 3 months.107

Resultantchangesinqualityoflifeandaffiliatedmen-tal health issues are also a high burden in this popula-tion.Theseissuescanbeassessedusingahealth-re-lated quality of life scale such as the Pediatric Quality ofLifeInventory(PedsQL),amodularinstrumentdesignedtomeasurehealth-relatedqualityoflife(HRQOL)inchildrenandadolescentsaged2-18years;a depression scale such as the Children’s Depression Inventory(CDI),whichevaluatesthepresenceandseverityofspecificdepressivesymptomsinyouthandthe Revised Children’s Anxiety and Depression Scale (RCADS);andtheSpenceandSCAREDscalesforselfand parent report of anxiety symptoms. The RCADS, Spence,andSCAREDscalesarequicklyandeasilyadministered, and their availability for use at no cost facilitates the assessment of anxiety and depressive symptoms during medical visits.108

Accessandutilizationofpsychologicalservicesareanongoingdifficultyinvariouspopulationsofatriskyouth. Among adolescents referred to psychology ser-vicesfrommedicalpractices,66%initiatedtreatmentwhenserviceswereofferedinclinic,whereasonly2.6%followedthroughwiththereferralwhenitwaslocatedoff-site.109Thisstudyhighlightspotentialim-provement in care for medical and psychiatric symp-tomswhencarecanbeaccessedinthesameclinic.

Evidence-Based InterventionsInterventionshavetargetedtreatmentadherenceandself-management,familydynamics,socialfunctioning,copingskills,anddiabetes-specificanxietymanage-ment.103

Trialswitheducationdirectedatcopingskillstrain-ingreportedlowerimpactofdiabetes,bettercopingwithdiabetes,betterdiabetesself-efficacy,fewerdepressive symptoms, and less parental control.110 Psychologicalinterventionsofvarioustheoreticalorientationshaveimprovedaspectsofself-careinadolescentswithT1DM.Examplesincludecognitivebehavior therapy (CBT),111 behavioral family systems therapy (BFST),95,107 family systems theory,112multi-systemic therapy (MST),113andcopingskillsforyouthwithT1DM.114 Inafamilysystemsgroupintervention,perceptionsofdiabetes,estimatesofyoungsters’self-care,familyfunctioning,andmorepositiveperceptionsofbeingateenagerwithdiabeteswerefound.112 Adolescents demonstratedclinicallysignificantimprovementsinHgbAlcthatweremaintainedat6-monthfollowup.Parent reports suggested that adolescents in the in-terventiongroupsimprovedtheirdiabetescare.Find-ingssupporttheuseofmultifamilygroupsplusparentsimulationofdiabetesasaninterventionstrategyforadolescentswithdiabetes.112

StudiesusingMultiSystemicTherapy(MST)suggestithasthepotentialtodecreaseinpatientmedicaladmissionsamongadolescentswithpoorly-controlledT1DM.113 Revised Behavioral Family Systems Therapy (BFST)interventionsshowenhancedimpactondia-betes outcomes compared to previous BFST interven-tions.95,107Therevisionsincludedrequiredtargetingofdiabetes-specificbehavioralproblems,extensionof treatment from 3 to 6 months, training in behav-ioralcontractingtechniquesforallfamilies,a1-weekparentalsimulationoflivingwithT1DM,andoptional

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extensionoftherapeuticactivitiestootherextra-fa-milialsocialenvironmentsaffectingthechild’sdiabe-tesmanagement.Astatistically-significantreductionofupto1%inHgbA1Cwasseenwhencomparedtothecontrolgroupafter6-18monthsinBFST-D.107

Multi-componentinterventionsthataddresstheemo-tional,social,andfamilyprocessesassociatedwithbeinganadolescentwithT1DMcanhavemorerobusteffectsonHgbA1cthanasingle-pointinterventionlikeincreaseinbloodglucosemonitoringfrequency.115 Acopingskillstrainingprogramproducedstatisti-callysignificantimprovementinHgbA1c,medicalanddiabetesself-efficacy,andqualityoflife.Thisprogramof6smallgroupsessionsandmonthlyfollowuphelpyouthcopewiththeirlivesinthecontextofdiabetesmanagement.Skillsincludesocialproblemsolving,cognitivebehaviormodification,andconflictresolu-tion.114

Anat-riskpopulationofadolescentswithT1DMwhoengagedinpediatricpsychologytreatment,whichincludedincorporatingfamilyintocareofthepatient,behavioral aspects of their medical management, and improvingcognitiveprocessingforthepatientandfamily that may impact overall psychological health, experiencedsignificantreductionsinHgbA1covertimecomparedtonotreatmentandcontrolgroups.Theaveragenumberofsessionsanddurationoftreat-mentforadolescentsandfamilieswas8.28sessionsovera9-monthperiod.103Thesestudiesshowthatbe-havioralinterventionscanhaverealimpactonmedi-caloutcomesinchildrenandadolescentswithT1DM.

RecommendationsContinuedparentalsupervisionofadolescents,alongwithmonitoringdiabetesknowledgeandefficacy,mayhelpoptimizetransferofdiabetescarefrompar-entstoyouth.Behaviorproblemswarrantimmediateattentionbecauseoftheirdirectandadverserelationto metabolic control.96 Results suggest that depres-sivesymptomsareimportantpredictorsofHgbA1cchangebythemselves,aswellaswhenconsideredwithadherencetobloodglucosemonitoring.Screen-ing for depressive symptoms, and expanding and developingpreventionandinterventionstrategiesputadolescentswithT1DMinthebestpositionforopti-mal glycemic control.99

TheInternationalSocietyofPediatricandAdolescentDiabetesConsensusGuidelinesstates,“Psychologi-

calfactorsarethemostimportantinfluencesaffect-ing the care and management of diabetes.”116 Social workersandpsychologistsshouldbepartoftheinterdisciplinary health care team. Overt psychological problems in young persons or family members should receive support from the diabetes care team and expertattentionfrommentalhealthprofessionals.The diabetes care team should receive training in the recognition,identification,andprovisionofinforma-tionandcounselingonpsychosocialproblemsrelatedto diabetes.Psychologicalinterventionscanimproveglycemiccon-trolforadolescentswithT1DM.AlthoughindividualCBT therapies are more common, family therapies appearmoreeffectiveforadolescents.117 Across treat-mentmodalities,theinclusionofpsychologicalinter-ventionasacomponentofpediatricdiabetescarecanimproveindividualandfamilyadjustmentandmayincrease treatment adherence and glycemic control.103

Embeddingpsychologistswithinpediatricendocrinol-ogypractice,inlieuofreferringtoanoutsidementalhealth provider, is one strategy used to facilitate the provision of interdisciplinary care, increase access to andutilizationofservices,andimprovepatientcom-municationamongproviders.Thismodelappearstobethemosteffectiveatengagingadolescentsandfamilies.Psychologicalservicescanbeeffectivelyem-beddedinapediatricendocrinologyclinictoofferanaccessibleandwidely-utilizedservicethatresultsinmeaningfulreductionsinHgbA1candareductioninlong-termmicrovascularcomplicationrisk.103

Behavioral Health in the Management of Pediatric ObesityThe incidence and prevalence of childhood obesity hasincreasedsignificantlysincethe1980s,andtheaverageoverweightchildtodayismoreoverweightthan the average child of 20 years ago.118,119 Approxi-mately15%ofchildrenandadolescentsbetweenages6-9areobese,and10%ofchildrenbetween2-6yearsof age are obese.118Therearesignificantdifferencesin childhood obesity among racial and ethnic groups. Morethan23%ofAfricanAmericanandLatinochil-drenareobese,withAfricanAmericangirlshavingthehighest rates of obesity.118

Certain psychosocial factors put children at a higher riskofobesity.Thesefactorsincludeabuse,neglect,

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andhavinganonsupportivefamily.Childrenwhoex-perienceneglecthavea9timesgreaterriskofbecom-ing obese.120 Obese children and adolescents have higherratesoflowself-esteemandnegativebodyimage than their same age peers.121-127 In terms of psy-chiatriccomorbidity,obesechildrenwhopresentformental health treatment have higher rates of depres-sion,anxiety,somatoform,andeatingdisorders.128-131 Inadulthood,childhoodobesityisassociatedwithfeweryearsofeducationandincreasedpoverty.132,133 Thereisanarrayofhealthcomplicationsassociatedwithpediatricobesity.Inadolescents,obesityisas-sociatedwithhighbloodpressureandelevatedlipids,whichincreasesriskofdiseaseanddeath.134 Com-paredtoadultswhohadnormalweightaschildren,adultswhowereobeseaschildrenhavetwicetherates of heart disease and high blood pressure and 3 timestherateofdiabetes.135 Further, being obese as anadolescentisabetterpredictorofadultmortal-ity than being obese as an adult.136 The rate of type 2diabetesinchildrenincreased10timesfrom1982-1992,withover90%ofthosechildrenhavingaBMIgreaterthan90thpercentile.137Over90%ofobesechildrenhavesomekindofsleepdisorder,typicallysleep apnea.137

Assessment MethodsObesity is determined by body mass index (BMI), wherechildrenwithBMIsgreaterthanthe95thper-centileareconsideredobese,138andthosewithBMIsbetweenthe85thand95thpercentileconsideredoverweightandhighrisk.Becauseofwell-document-edhealthrisksassociatedwithobesity,acompletephysicaliswarrantedtoruleoutanyhealthcomplica-tionsorcontributingfactors.There are no psychological assessment measures specificallyrecommendedforpediatricobesity.There-fore,clinicalinterviewswithparentsandchild,aswellas standard measures for depression (Child Depres-sionInventory,andChildBehaviorChecklist),anxi-ety(State-TraitAnxietyInventory),andself-esteem(Perceived Competence Scale for Children) are recom-mended.137TheChildren’sEatingBehaviorInventoryandtheChildren’sEatingAttitudeTestcanalsobeused to determine readiness to change, or readiness forreferraltoaweightmanagementclinic/program.137

Evidenced-Based/Informed InterventionsUnlikethetreatmentofadultobesity,theprimarygoalfortreatingpediatricobesityisimprovingeat-inghabitsandincreasingphysicalactivity,notweightloss.134 Although the models are heterogeneous, be-havioralinterventionsareconsideredfirst-linetreat-ments for pediatric obesity. They have demonstrated thegreatestefficacy,withmediumtohighintensitylevelinterventionshavingthemostimpact.139 In addi-tiontochangesindietandactivitylevel,familiesaretypically included in treatment, especially for younger orschool-agedchildren.105,137Specificinterventionstrategiesincludeimprovingproblem-solvingskills,goalsetting,decreasingexposureandaccesstoun-healthyfoods,andrelapseprevention.139-141 Evidence supportstheuseofweight-lossmedicationcombinedwithbehavioraltreatmentinolderadolescentswhomeet criteria for class II obesity.140

RecommendationsTreatment for pediatric obesity typically occurs in specialtyobesityclinicswithmultidisciplinaryteamsthatoftenincludesocialworkersand/orpsychologistsinadditiontoavarietyofothermedicalproviders.140 Formalguidelinesandpoliciesshouldexistthatreflecttheimportanceofmultidisciplinarycareforpediat-ric obesity and mandate the presence of behavioral healthprovidersaspartofcareteams.Additionaleffortscouldfocusonimplementingroutinepsycho-socialscreenerstoidentifyriskfactorsandcomor-biditiesthatcanbetreatedtoimproveobesityandadherencetoobesity-relatedinterventions.Twobehavioraltreatmentsforpediatricobesityhighlightedinrecentreviewarticleshavebeenrecom-mendedforuseinprimarycaresettingsduetothebriefinterventiontimerequired(about4hourstotal),anduseofsupportstaffformailingsandphonecallcounseling.142,143,140Suchinterventionsshouldbeeval-uatedforefficacy,feasibility,sustainability,andimple-mentationintovarioustypesofpediatricprimarycareclinics(eg,community-based,academicmedicine,federallyqualifiedhealthcenters,etc).Collaborativeeffortsshouldfocusontrainingmedicalproviderstofeelmoreconfidentinknowingwhentoappropriatelyassessandtreatpediatricobesitywithinprimarycare,andwhentoreferouttosubspecialtyclinics.

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ConclusionWhiletherangeofintegratedbehavioralhealthservices, from primary care to the most specialized tertiarycare,isincreasing,theneedforsuchservicesis endless. One of the biggest challenges to the devel-opmentofintegratedservicesisthedecisionmakingaboutwhichservicesprovidemeasurablebenefitstothepopulationsserved,andtheoptimalplatformsfordelivery.Rationaldecisionmakingwillrequireserviceproviders to gather data to inform service develop-ment and monitor the impact of such services on health outcomes and sustainability. There is prelimi-naryevidenceoftheacceptabilityandeffectivenessofproviding integrated mental health services in primary care,aswellasinsubspecialtyclinics.Theearlyiden-tificationandtreatmentofdevelopmentalandpsychi-atricdisorderswithinthecontextofthechild’smedi-cal care, family, and larger social environment provide

theopportunitytopreventandmanagethelong-termhealthconsequencesofcomplexconditionssuchasdiabetesandobesity.Thepotentialforimprovingthehealthofchildrenandtheirfamiliesisgreat;however,tofulfillthepromiseofintegratedservices,invest-mentinresearchandqualityimprovementeffortsareessentialtoensurethatthetreatmentsaimedtoimprovehealthforthechildandthefamilyasawholecanbesubstantiatedandsupportedbyhealthcaresystems and payers.

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Heather Adams, DO; Author

HeatherAdams,DOisanassistantprofessorofpsy-chiatryattheUniversityofColoradowithanappoint-mentatChildren’sHospitalColoradoontheIntensiveServicesunit.Herresponsibilitiesincludeclinicalcareforchildrenandadolescentswithmentalhealthissuesintheinpatientandpartialdaytreatmentsettings.Dr.Adamsalsohasanoutpatientclinicprovidingmedi-cationmanagementandpsychotherapyservicestorecentlydischargedpatientswhoarewaitingtofindother community providers. Dr. Adams teaches medi-cal students and residents during their clinical rota-tions,andalsoparticipatesinfelloweducationviatheBehavioral Medicine course. She is currently involved inongoingresearchtitled,“PatientandFamilyOut-comes on Intensive Services Treatment.”Dr.AdamsreceivedherbachelordegreeatWashing-ton State University in Molecular and Cell Biology and Genetics,andhermedicaldegreeatMidwesternUni-versity.Shefinisheda5-year,tripleboardresidencyatCincinnatiChildren’sHospital,whichincludedtrain-ing in pediatrics, adult psychiatry, and child psychiatry. SheisboardcertifiedinPediatrics.Hermainareasofinterestarechildanxietydisordersandworkingwithchildrenandteenswithweightandobesityissues.

Bethany Ashby, PsyD; Author Bethany Ashby, PsyD is an assistant professor of psy-chiatryandobstetrics/gynecologyattheUniversityofColorado School of Medicine, and serves as a psychol-ogist in the Colorado Adolescent Maternity Program (CAMP)atChildren’sHospitalColorado.CAMPisateen-totclinicthatprovidesobstetrics/gynecologyandpediatriccareforpregnantandparentingadoles-cent girls (up to age 22) and their children. Dr. Ashby istheClinicalProgramDirectorforMentalHealthServicesinCAMP,andalongwith2medicaldirectors,codirectstheHealthyExpectationsAdolescentRe-sponseTeam(HEART),amultidisciplinarytreatmentteamthatprovidespsychotherapyandmedicationmanagementtoperinataladolescents.Inaddition,she is responsible for providing individual psychother-apyandconsultationtoclinicmedicalproviders.

Dr.Ashbyprovidessupervisionandadministrativeoversightto2socialworkersandacasemanager.Shelecturesincommunitysettingsonissuesfacingadolescent families and perinatal mood disorders in adolescent mothers. Dr. Ashby’s research focuses on evaluatingmentalhealthservicesprovidedtoadoles-centmothers,andsheisparticularlyinterestedinthetreatment of trauma and comorbid mood disorders in thispopulation.Dr. Ashby received her bachelor degree in Psychol-ogy from Simpson College, and her doctoral degree in ClinicalPsychologywithanemphasisinFamilyPsy-chologyfromAzusaPacificUniversity.ShecompletedapostdoctoralfellowshipinPediatricPrimaryCareatChildren’sHospitalColorado. Amy Becker, MD; Author

AmyBecker,MDisanassistantprofessorofpsychiatryat the University of Colorado School of Medicine, and the Medical Director of the Psychiatric Emergency ServiceatChildren’sHospitalColorado.Dr.Becker’sclinical focus is on the assessment and management of pediatric behavioral health emergencies, and she worksinconsultationwithprovidersatChildren’sHospitalColoradoandwithinsystemsofcarethrough-outthestateofColorado.Dr.Beckerisinvolvedinteachingandclinicalsupervisionoffellows,residents,andmedicalstudents,withaparticularfocusonriskassessment and emergency psychiatry. She is also currently involved in the development and implemen-tationofapilotqualityimprovementprogramaboutMeansRestrictionEducation,anevidenced-basedapproachtoadolescentsuicideprevention.Dr.Beckeris the President of the Colorado Child and Adolescent PsychiatricSociety,andwastherecipientofthe2013ChildandAdolescentPsychiatryFellowshipTrainingProgramFacultyAwardforMentorship.Dr.BeckerreceivedherbachelordegreeinBiologyfrom Gustavus Adolphus College, and her medical degreefromtheUniversityofMinnesota.Dr.Beckercompleted an internship and Adult Psychiatry Resi-dencyTrainingattheUniversityofColoradoHealthSciences Center, and her Child and Adolescent Psy-chiatryFellowshipattheYaleChildStudyCenter.

Contributors

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Carol Beresford, MD; Author

Carol Beresford, MD is an associate professor of child and adolescent psychiatry at the University of Colorado School of Medicine on the Neuropsychiat-ricSpecialCareUnit,apsychiatricinpatientanddaytreatmentunitforpediatricpatientswithdiagnosesofautismspectrumdisorderandotherdevelopmentaldisabilitiesatChildren’sHospitalColorado.Dr.Beres-ford is responsible for providing psychiatric clinical servicestothepatientsontheunit,andalsoservesas the Medical Director for the unit. Dr. Beresford provides bedside teaching to child and adolescent psychiatryresidents,neurologyfellows,anddevelop-mentalpediatricsfellows.Shealsoprovidesdidacticteaching on psychopharmacology, as it relates to childrenandadolescentswithdevelopmentaldisabili-ties,tothechildandadolescentpsychiatryresidents.Dr. Beresford’s research interests are in the area of psychopharmacology,withthegoalofestablishingim-provedguidelinesforoptimalmedicationtreatment,inconcertwithbehavioraltreatments,inthespecialpopulationsnotedabove.Dr. Beresford received her bachelor degree in English from Stanford University, and her medical degree fromTuftsUniversitySchoolofMedicineinBoston,MA. She completed a pediatrics internship and resi-dencyatTufts,afellowshipinadolescentmedicineat the University of CA, San Francisco and at Stanford University,achildandadolescentpsychiatryfellow-ship at the University of Michigan, and an adult psy-chiatry residency both at the University of Michigan and at the University of Colorado. Cindy Buchanan, PhD; Author, Reviewer

Cindy Buchanan, PhD is an assistant professor in the Departments of Psychiatry and Pediatric Surgery at the University Of Colorado School Of Medicine. She serves as the Pediatric Psychologist for the Pediatric Transplant,PediatricUrology,andBowelManage-mentprogramsatChildren’sHospitalColorado.Dr.Buchanan serves as course instructor for the Pediatric Behavioral Medicine course for psychology interns andpsychiatryfellows.Shealsoregularlyteachesdi-dacticstosurgeryresidentsandfellowsonadherence,adjustment,qualityoflife,andrelationshipbuilding.Dr.Buchananiscurrentlyinvestigatinginterventionsthatworktoimproveadherencetomedicationregi-mensforpediatrictransplantpatients.Additionally,

sheisinvestigatingtherelationshipbetweencoping,familystressors,andthetreatmentofdysfunctionalvoiding syndrome. Related to her teaching endeavors, Dr.Buchananreceivedthe2012TeachingAwardforthe psychology internship program.Dr. Buchanan received her bachelor degree in Psy-chologyfromBakerUniversity,hermasterdegreeinCounseling Psychology from the University of Kansas, and her doctoral degree in Counseling Psychology from the University of Kansas. She completed her pre-doctoralinternshipatTempleUniversityHealthSciencesCenterwithafocusonhealthpsychology.Dr.Buchanancompletedapostdoctoralfellowshipinpe-diatricpsychologywithafocusonpediatrictransplantattheChildren’sHospitalofPhiladelphia. Kelly Caywood, PhD; Author

KellyCaywood,PhDisaseniorinstructorofpsychia-try at the University of Colorado School of Medicine, andservesasapsychologistatChildren’sHospitalColorado.Dr.CaywoodistheClinicalDirectorfortheMood and Thought Disorders Clinic. She is respon-sible for providing both individual and group clinical services.Dr.CaywoodfacilitatestheGeneralIntensiveOutpatientprogramforadolescents,aswellastheDialecticalBehaviorTherapymultifamilymoodgroupforadolescents.Dr.Caywoodsupervisespsychologyinterns and externs, child and adolescent psychiatry residents,andapostdoctoralfellow.Shealsoregular-lygivesdidacticlecturestotraineesofvariousdisci-plinesandlevelsoftraining.Dr.Caywood’scurrentresearchprojectaimstoevaluatetheefficacyofmodi-fiedDialecticalBehaviorTherapyinthetreatmentofmooddysregulationandinterpersonalconflictforadolescentsdiagnosedwithamooddisorder.Dr.CaywoodreceivedherbachelordegreefromtheUniversity of Colorado, Boulder, and her master and doctoral degrees in Clinical Psychology from Palo Alto University.

Mary Cook, MD; Author

MaryN.Cook,MDisanassociateprofessorofpsy-chiatry at the University of Colorado School of Medi-cine, currently serving as the Medical Director of OutpatientServicesintheDepartmentofPsychiatryattheChildren’sHospitalColorado.Sheisextensivelyinvolved in the training of medical students, psychol-

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ogyandsocialworkgraduatestudents,andpsychiatryresidents.Sherecentlywonaresident-nominatedawardforteachingexcellence,andhasalsobeenrecognized by the American Academy of Child and Adolescent Psychiatry (AACAP) as an Outstanding Mentor.Shespecializesinworkingwithfamiliespre-sentingwithchildrenwhohavebeendiagnosedwithdisruptivebehaviordisorders.Shespearheadedthedevelopmentofaseriesofmultidisciplinary,outpa-tientspecialtyclinics,alongwithintensiveoutpatientprogramsattheChildren’sHospitalColorado.Sheauthoredabookdetailingtheevidence-based,stan-dardized,skills-buildingtreatmentprotocolsusedinboththeroutineandintensiveoutpatientprograms,andapeerreviewedjournalarticle,demonstratingpositiveclinicaloutcomes.Shehasauthoredbooks,bookchapters,andreviewarticles,andhascontribut-edtoAACAPPracticeParametersonfamilyinterven-tions.Shefrequentlyperformspresentationsinthecommunity for school, primary care, and youth out-reachprograms.Inaddition,sheroutinelypresentsatregionalandnationalprofessionalconferences,oftenonaninvitedbasis.Herpassionsaredevelopingandapplyingstrengthsandfamily-basedapproaches,pur-suantofagoaltominimizemedicationwhileoptimiz-ingparentingandpsychosocialskills.Hermantrais“MoreSkills=LessPills!”Dr.CookreceivedherbachelordegreeinPsychology,withhonors,fromtheUniversityofMichigan,andhermedicaldegreefromWayneStateUniversity.Shecompleted her general psychiatry residency at the NavalMedicalCenter,SanDiego,andherchildfellow-ship training at the University of California, San Diego.

Anthony R. Cordaro, MD; Reviewer

AnthonyR.CordaroJr.,MDisanassistantprofessorof psychiatry at the University of Colorado School of Medicine,andservesasanattendingchildpsychia-trist for the psychiatric emergency service (PES) and outpatientmentalhealthclinic.WhileonthePES,heoverseesamultidisciplinaryteamcaringforfamiliesandchildreninacutecrisisandalongwithcrisisas-sessments,providestargetedbriefinterventions.Inhisoutpatientpractice,Dr.Cordarospecializesinthetreatment of children, adolescent, and young adults withchronichealthconditions.Assuch,heoftencol-laborateswithprovidersofvariousmedicalspecialtieson improving access to care for families struggling

withchronichealthissues.Hisclinicalapproachisfamily-focused,andhispastresearchhasleadtoimprovementsindefiningparent-childrelationalproblemsintheDSM-5.Hehasalsoco-foundedand/orservedontheboardofdirectorsfornon-profitor-ganizationsdedicatedtohelpingfamiliesdealingwithchronic illness. Dr. Cordaro received his bachelor degree in Psychol-ogy from the University of Texas, and his medical degreefromtheUniversityofTexas–SouthwesternMedicalSchool.Hecompletedhisgeneraladultresidencyandchildandadolescentpsychiatryfellow-shipattheUniversityofColorado/Children’sHospitalColorado,whereheservedasChiefChildPsychiatryFellow.Inaddition,hewasselectedasaDorisDukeClinicalResearchFellowduringmedicalschoolalongwithcompletingtheDevelopmentalPsychobiologyResearchGroup2-yearpostdoctoralresearchfellow-ship. Emily Edlynn, PhD; Author

Emily Edlynn, PhD is an assistant professor of psychia-try at the University of Colorado School of Medicine, and serves as the Clinical Program Director for the Medical Day Treatment (MDT) program at Children’s HospitalColorado.Dr.Edlynnoverseesprogramdevelopmentactivitiestomaximizeoverallservicedelivery in the MDT program, and provides individual, group, and family therapy for children and adoles-centsstrugglingwithchronicandlife-threateningmedicalillnesses.Dr.Edlynnhasabackgroundinpediatricpainandpalliativecare,helpingtodevelopthepalliativecareserviceatChildren’sHospitalLosAngeles(CHLA).Dr.Edlynnhastaughtmedicalresi-dentsandpsychologytraineesinpalliativecare,griefandbereavement,andnon-pharmacologicalpainmanagement. Dr. Edlynn’s research has focused on programdevelopmentandpalliativecare.Aspartofthepalliativecareteam,Dr.EdlynnreceivedtheHu-manismAwardatCHLA.Dr. Edlynn received her bachelor degree in English from Smith College, and her doctoral degree in Clini-calPsychologyfromtheLoyolaUniversityofChicago.ShecompletedapostdoctoralfellowshipinPediatricPsychologyatChildren’sHospitalOrangeCounty.

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Guido K.W. Frank, MD; Author

GuidoK.W.Frank,MDisanassistantprofessorofpsychiatry and neuroscience at the University of ColoradoSchoolofMedicine,andservesasAttend-ingPsychiatristandAssociateDirectorontheEatingDisordersProgramatChildren’sHospitalColorado.Dr.Frankprovidesdirectpatientcaretopatientsandtheirfamiliesadmittedtotheinpatient,partialhospi-tal,andoutpatientlevelsofcare.Dr.Frankalsopro-videssupervisiontoresidentsandotherstaffintheEatingDisordersProgram,andpsychotherapysupervi-sion to child and adolescent psychiatry residents. Dr.Frankteachesbothpsychiatryresidentsandpsychology interns in neurodevelopmental underpin-ningsofpsychiatricdisorders,whichincludesteachingmethodssuchasbrainimagingandgenetics.Dr.Frankis the Director of the Developmental Brain Research Program,wherehisresearchfocusesontheneuro-biologyofeatingdisordersandhowbrainfunctiontranslatesintotheclinicalpresentationofindividu-alswithdisorderedeating.Dr.Frankhasreceivedmultipleawards,includingvariousresidentawards,aNARSADaward,andanNIHMinorityAccesstoRe-searchCareerProgram(NIMH)MentorRecognitionaward.Inaddition,Dr.Frankhasreceivedgrantfund-ingfromtheNIMHforthepast6years.Aftercomplet-ingaK23mentoredaward,heisnowfundedthroughanRO1award.Dr.FrankcompletedmedicalschoolattheLudwigMaximiliansUniversity,Munich,Germany.Hetrainedfor3yearsinpsychosomaticsintheRoseneckCenterfor Behavioral Medicine, Prien, Germany. For the 3 yearsthatfollowed,hewasavisitinginstructorattheWesternPsychiatricInstituteandClinic,EatingDisordersProgram,attheUniversityofPittsburgh.HecompletedAdultPsychiatricResidencyattheWesternPsychiatricInstituteandClinic,andthentrainedinchild and adolescent psychiatry, and completed aT32 NIHresearchfellowshipattheUniversityofCalifornia,SanDiego.Dr.Frankisboardcertifiedinbothadultand child and adolescent psychiatry. Robin Gabriels, PsyD; Reviewer

Robin Gabriels, PsyD is a licensed clinical psychologist, associate professor of psychiatry and pediatrics at the University of Colorado School of Medicine, Pro-gram Director for the Neuropsychiatric Special Care

program,andpsychiatricinpatientanddaytreatmentunitforchildrenwithautismspectrumdisorders(ASD)and/orintellectualdisabilitiesatChildren’sHospitalColorado.Dr.Gabrielshasover28yearsofclinicalexperiencedevelopinginterventionprogramsandtreatingavarietyofpediatricandadultpopula-tions.Hercurrentclinical/administrativeresponsibili-tiesincludepediatricindividual,group,andfamilytherapiesandassessmentservicesalongwithclinicalprogram development and management. Dr. Gabriels mentors medical and psychiatry residents and super-visespsychologypostdoctoralfellowsandinterns.Sheisacertifiedautismdiagnosticobservationschedule-2trainer,providingtrainingtoacademicinstitutionsacrosstheU.S.Shehaspublished2editedbooks,andwrittenarticlesandbookchaptersinthefieldsofautism,asthma,andarttherapy.ShehaslecturedandconductedworkshopsonASD,bothnationallyandinternationally.Dr.Gabriels’researchfocusesonASD treatment outcomes and she is currently the PI ona4-yearproject(currentlyinitsthirdyear)study-ingtheEffectsofTherapeuticHorsebackRidingonChildrenandAdolescentswithAutism(ProjectNum-ber:1R01NR012736-01).SheisalsothesubcontractPIforamulti-siteprojectfundedbytheSimonsandLurieFoundations,aimingtophenotypeapopulationofASDpatientsadmittedtoASDspecialtypsychiatrichospitalunits.Dr.Gabrielswashonoredwiththe2013AlumniMasterScholarAwardbytheUniversityofDenver’s Graduate School of Professional Psychology.Dr. Gabriels received her bachelor degree in Psy-chology from University of Northern Colorado, her masterdegreeinArtTherapyfromVermontCollegeofNorwichUniversity,andherdoctoraldegreeinClinical Psychology from the University of Denver. She completedherpostdoctoraltraininginautismandneurodevelopmentaldisabilitiesattheUniversityofColorado-JFKPartners.

Jennifer Hagman, MD; Author, Reviewer

JenniferHagman,MDisanassociateprofessorofpsychiatry at the University of Colorado School of Medicine.Sheisboardcertifiedinbothchildandadolescent psychiatry and general psychiatry. She has beentheMedicalDirectoroftheEatingDisorderPro-gramatChildren’sHospitalColoradosince1993,andhasintegratedevidence-basedclinicalapproachesand a comprehensive research component into the

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Contributors

program,whichprovidesafamily-centeredapproachtoparent-supportednutritionandrecovery.SheisalsotheAdministrativeMedicalDirectorofmedi-cal–psychiatricclinicalservicesatChildren’sHospitalColorado. She is a past president of the Colorado Psychiatric Society, Colorado Child and Adolescent PsychiatricSociety,andEatingDisorderProfessionalsof Colorado. She supervises psychiatry residents and giveslecturesandpresentationsattheUniversity,inthecommunity,andatnationalandinternationalmeetings.Herresearchisfocusedonfactorsrelatedto the onset, course of illness, and recovery from anorexia nervosa. She has published many research articlesandchapters,andisanexpertinthediagnosisandtreatmentofeatingdisordersinchildhoodandadolescence.ShehasreceivedtheDanePrughawardforDistinguishedTeachinginChildPsychiatry,theOutstandingAchievementAwardfromtheColoradoPsychiatricSociety,theFacultyAwardforMentorshipfor the Child and Adolescent Psychiatry Residency Classof2013,wasrecognizedasaWoman of Distinc-tionbytheMileHighGirlScoutsorganization,andwasthekeynotespeakerforthe2008NorthAmericanLeadershipConference(NALC)ofChildren’sHospitals.Dr.HagmanreceivedherbachelordegreeinMolecu-lar, Cellular, and Developmental Biology (MCDB) and Psychology from the University of Colorado Boulder, and her medical degree from the University of Kan-sas. She completed her psychiatry residency training, andchildandadolescentpsychiatryfellowshipattheUniversityofCalifornia-Irvine. Jenny Lindwall, PhD; Author

JenniferLindwall,PhDisanassistantprofessorofpsychiatry at the University of Colorado School of Medicine.SheisapediatricpsychologistwiththeCysticFibrosisCenter,DepartmentofPulmonaryMedicine,andtheChildPsychiatryConsultation-LiaisonServiceattheChildren’sHospitalColorado.Dr.Lindwallprovidesconsultationandinterventiontopromotepositivepsychosocialfunctioninginchildrenwithsignificantmedicalillness,andhasworkedwithanumberofpediatricpopulationsincludingchildrendi-agnosedwithcysticfibrosis,multiplesclerosis,cancer,sicklecelldisease,andspinalcordinjury.Dr.Lindwall’sclinical, teaching, and research interests are focused onpsychosocialissuesaffectingchildrenwithchronicmedicalillness,includingsocial-emotionalhealth;

adjustment,stress,andcopingrelatedtomedicalillness;qualityoflife;familyfunctioning;andfactorscontributingtoresiliencywhilefacingthechallengesofchronicillness.AtChildren’sHospitalColorado,Dr.Lindwallisparticularlydedicatedtoworkingwithpediatricpatientswithcysticfibrosisandmultiplesclerosis,andcreatingintegratedpsychologyservicesforpatientsandtheirfamilies.Sheisalsointerestedineffectivelyintegratingculturaldiversityintoclini-calcare,andservesasCo-ChairfortheDiversityandInclusionCommitteeintheDepartmentofPsychiatry.Dr.LindwallreceivedherbachelordegreeinPsychol-ogy, master degree in Counseling, and PhD in Coun-selingPsychologyfromtheUniversityofWisconsin-Madison. She completed her predoctoral internship attheTempleUniversityHealthSciencesCenter/ShrinersHospitalsforChildreninPhiladelphia,P.A.,withafocusonpediatricandhealthpsychology.Dr.Lindwall’spostdoctoralfellowshiptrainingfocusedonclinicalinterventionandresearchwithpediatriconcology/hematologypatientsatSt.JudeChildren’sResearchHospitalinMemphis,TN. Susan Lurie, MD; Author

SusanLurie,MDisaclinicalassociateprofessorofpsychiatry at the University of Colorado School of Medicine, and is currently supervising and seeing patientsinthePsychiatricDayTreatmentProgram.Dr.Luriehasextensiveclinicalexperienceinalllevelsofpsychiatriccare,andisanexpertintheevaluationandtreatmentofyouthwithanxietydisorders,mooddisorders,andpsychosis.Shehasaprivatepracticeinthe community and also consults to Denver Children’s Home,aresidentialtreatmentcenterforyouthwithearlytraumaandsignificantbehavioralandemotionaldifficulties.Dr.Luriehasbeeninvolvedinresidencytrainingformanyyears,andinadditiontoprovidingindividualsupervision,sheistheCo-DirectorofthePsychopathology and Psychopharmacology course for thefirst-yearchildresidents.In2013,shereceivedtheDaneG.PrughAwardforOutstanding and Inspi-rational Teaching.Dr.LurieworkedformanyyearsinthePsychiatricResearchCenterasaprimaryandsub-investigatoronnumerousindustry-sponsoredclinicalmedicationtrials.Since2010,shehasservedastheColorado Delegate to the Assembly, American Acad-emy of Child and Adolescent Psychiatry (AACAP), and she is a past president (2010) of the Colorado Child

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and Adolescent Psychiatric Society (CCAPS). Dr.LuriereceivedhermedicaldegreefromtheUni-versityoftheWitwatersrand,Johannesburg,SouthAfrica. She completed her adult psychiatry residency trainingatStLukesRooseveltMedicalCenter,NewYork,andchildpsychiatrytrainingatColumbiaUniver-sity,CollegeofPhysiciansandSurgeons,NewYork.

Christine McDunn, PhD; Author

ChristineC.McDunn,PhDisaseniorinstructorofpsychiatry at the University of Colorado School of Medicine, and serves as both the Associate Director of Training for Psychology, and as a psychologist in theStress&AnxietyProgramatChildren’sHospitalColorado. Dr. McDunn is the primary supervisor and administratorofthePsychologyPracticumProgramatChildren’sHospitalColorado.Sheisresponsibleforproviding both individual and group therapy for indi-vidualswithanxietyandrelateddisorders,andover-sees the training component of the Anxiety Program. Dr.McDunnco-leadsaclassonsupervisionforthepsychology predoctoral interns, and leads a course for cognitivebehavioraltherapyforanxietyandrelateddisorders in a course for psychology interns and child and adolescent psychiatry residents. Dr. McDunn recentlywasrecognizedforExemplary Teaching by the psychology predoctoral interns. Dr. McDunn’s re-searchfocusesonevaluatingtreatmentoutcomesforanxiety disorders. Dr. McDunn received her bachelor degree in Psychol-ogy from The University of Texas at Dallas, and her doctoral degree in Clinical Psychology from the Uni-versity of Denver. She completed a postdoctoral fel-lowshipinanxietydisordersandpediatricpsychologyatChildren’sHospitalColorado. Scot McKay, MD; Author

Scot McKay, MD is an assistant professor at Denver HealthBehavioralHealthServices,andservesasanattendingpsychiatristintheSchool-BasedHealthClin-ics throughout Denver Public Schools, at the Family CrisisCenter(FCC),andintheOutpatientChildPsy-chiatricClinicatDenverHealth.Dr.McKayprovidespsychiatric care to students in the Denver Public Schools,residentsoftheFCC,andoutpatientsattheDenverHealthclinic,andcollaborateswiththesocialworkers,psychologists,nursepractitioners,physi-

cians,andothermedicalcareproviderswhoworkin these clinics. Dr. McKay facilitates the Basics Psy-chiatrycoursetosmallgroupoffirstandsecond-yearmedical students at the University of Colorado School of Medicine, teaching students about mental illness, andhoningtheirmedicalinterviewingskillsthroughdiscussionandinterviewingpatientswithpsychiatricdiagnoses.Dr.McKayisalsoinvolvedinpolicymak-ingandlegislativeaffairsasanexecutivecommitteemember of the Colorado Child and Adolescent Psychi-atricSociety.HeisafellowoftheAmericanPsychiatricAssociation.Dr. McKay is involved in research that examines the effectivenessofschool-basedmentalhealthcare,and the improvement of the screening and referral processforthosewithmentalhealthissuestoschool-based health care. Dr. McKay received his bachelor degree in Biology atWoffordCollege,andhismedicaldegreeattheMedicalUniversityofSouthCarolina.Hecompletedhisresidencyandfellowshiptraininginbothgeneraland child and adolescent psychiatry at the University ofColorado,andisboardcertifiedintheaforemen-tionedspecialtyandsubspecialty. Benjamin Mullin, PhD; Author, Reviewer

BenjaminMullin,PhDisanassistantprofessorofpsychiatry at the University of Colorado School of Medicine, and serves as a psychologist in the outpa-tientclinicatChildren’sHospitalColorado.Dr.MullinleadstheChildAnxietyIntensiveOutpatientProgram(AIOP),providingshort-term,evidence-basedgrouptherapytoyouthswithacuteanddisablinganxiety.Dr. Mullin also provides training for clinical psychology externsandinternsonevidence-basedtreatmentsforanxiety,tics,andsleepdisorders.Dr.Mullin’sresearchfocuses on the pathophysiology of anxiety disorders amongyouth,andinparticular,howsleepdisrup-tionmayprecipitateemotiondysregulationbyalter-ingactivityinkeyneuralcircuits.Heisalsopursuingresearchtodevelopandevaluatenovelinterventionsforchild-onsetanxietydisorders.Dr. Mullin received his bachelor degree in Psychology fromClarkUniversity,andhismasteranddoctoraldegrees in Clinical Psychology from the University of California,Berkeley.Hecompleteda2-yearresearchfellowshipinsleepmedicineandtranslationalneuro-

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scienceattheUniversityofPittsburghSchoolofMedi-cine.Hecompleteda1-yearfellowshipinpediatricanxietydisordersatChildren’sHospitalColorado. Emily Fazio Muther, PhD; Author

Emily Fazio Muther, PhD is an assistant professor of psychiatry and pediatrics at the University of Colorado School of Medicine, and serves as a licensed pediat-ricpsychologistattheChildren’sHospitalColorado(CHCO).Dr.MutherworksprimarilyonthePsychiatryConsultationandLiaisonServiceandinintegratedprimarycareintheChildHealthClinicatCHCO.Ad-ditionally,Dr.MutherservesasthepsychologistintheIntegrativeHeadacheClinicinthedepartmentofNeurologyatCHCO.Dr.Mutherisresponsibleforpro-vidingconsultativeservicestopediatricpatientsandtheirfamilieswhoareadmittedforinpatientmedi-calhospitalization,andworksprimarilywithpatientswithchronicmedicalillnesstoaddressissuesrelatedtoadherencetomedicalcare,copingwithillness,andimprovement of overall quality of life. She also pro-videsclinicalcaretopediatricpatientsseeninprimarycareatCHCO,andisasupervisingpsychologistwithinProjectCLIMB(ConsultationandLiaisoninMentalHealthandBehavior).Dr.Mutherprovidessupervi-sionandtrainingtoawidevarietyoftraineeswithinthe hospital, including psychology trainees, psychiatry fellows,pediatricresidents,andmedicalstudents,andregularlygivesdidacticinstructionaspartofthetrainingprogramswithinthedepartmentsofpsychia-try and pediatrics. Dr. Muther’s research currently focusesonutilizingclinicalinformaticstoevaluatetheservices provided in an integrated mental health pro-gramwithinprimarycare,andexamininghealthandbehavior-relatedoutcomesforpatientsandfamiliesseen as part of the integrated primary care program atCHCO.Additionally,Dr.Mutherhasresearchinter-estsandexperienceinimprovingandpredictingthefactorsrelatedtolong-termqualityoflifeinpediatricpatientslivingwithchronicmedicalillness.Dr.MutherreceivedherbachelordegreeinHonorsPsychologyfromtheUniversityofIowa.Shecom-pleted a terminal master degree in Clinical Psychol-ogy from the University of Denver, and a doctoral degree in Counseling Psychology from the University of Denver. She completed her predoctoral internship inpediatricpsychologyatHarvardMedicalSchoolandChildren’sHospitalBoston,andherpostdoctoralfel-

lowshipinintegratedpediatricprimarycareatChil-dren’sHospitalColorado. Douglas K. Novins, MD: Author, Reviewer, Editor-in-Chief

DouglasK.Novins,MDistheCannonY.&LydiaHar-vey Chair in Child and Adolescent Psychiatry, and ChairoftheDepartmentofPsychiatry&BehavioralSciencesatChildren’sHospitalColorado.HeisalsoProfessorofPsychiatryandCommunity&BehavioralHealthattheUniversityofColoradoAnschutzMedicalCampus. Dr. Novins serves as the leader of child and adolescentbehavioralhealthatChildren’sHospitalColorado and the University of Colorado Anschutz Medical Campus, leading the ongoing development of a diverse set of clinical, training, and research pro-gramswithover50facultyand250staff.Dr.Novins’expertiseisintheareasofadolescentsubstance-relat-edproblemsandtraumaticexperiences,particularlyamongAmericanIndianandAlaskaNativeyouth.Heis also Deputy Editor of the Journal of the American Academy of Child & Adolescent Psychiatry, the highest rankedpublicationinchildandadolescentpsychiatry.Dr.NovinsreceivedhisbachelordegreeinHistoryandPremedical Studies from Columbia College, and his medical degree from Columbia University’s College of PhysiciansandSurgeons.Hetrainedingeneralpsy-chiatryatNewYorkUniversity/BellevueHospital,andin Child and Adolescent Psychiatry at the University ofColorado.TheNationalInstituteofMentalHealthsupported Dr. Novins’ research training at the Uni-versity of Colorado through a postdoctoral research fellowshipindevelopmentalpsychobiology,andacareerdevelopmentawardinmentalhealthservicesresearch. Phil O’Donnell, PhD; Author

Philip C. O’Donnell, PhD is an assistant professor of psychiatry at the University of Colorado School of Medicine.HeistheClinicalDirectorfortheIntensivePsychiatric Services program in the Pediatric Mental HealthInstituteatChildren’sHospitalColorado.Hehas also served as a psychologist in the Neuropsychi-atricSpecialCareProgram,aninpatientandpartialhospitalizationprogramforchildrenandadolescentswithAutismSpectrumDisorders(ASD)andintellectu-aldisabilities(ID)whoareexperiencinganemotional

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or behavioral crisis. Dr. O’Donnell has specialized training in the forensic assessment of children and families.Heisactivelyinvolvedinthepsychology externship and internship training programs, super-visingtraineesduringtheirrotationintheintensiveservicesprograms.Heco-directsacourseonad-vanced topics in psychological assessment and regu-larlyprovideslecturesonriskassessmentandforensicevaluationswithcourt-involvedyouth.Hisresearchinterestsarerelatedtoriskassessmentandmanage-mentofyouthwithinpsychiatrictreatmentsettings,andviolenceriskassessmentofyouthwithdevelop-mentalandintellectualdisabilities.Dr. O’Donnell received his bachelor degree in Psychol-ogy from Creighton University, his master degree in Jurisprudence(childandfamilylaw)fromLoyolaUniv-eristyChicago’sSchoolofLaw,andhisdoctoraldegreeinClinicalPsychologyfromLoyolaUniversityChicago.Hecompletedapostdoctoralfellowshipinforensicpsychology at the University of Southern California’s InstituteofPsychiatry,Law,andBehavioralSciences. Alyssa Oland, PhD; Author, Reviewer, Editor

Alyssa Oland, PhD is an assistant professor at the University of Colorado Department of Psychiatry and BehavioralSciences,andatNationalJewishMedicalandResearchCenter.ShehasworkedontheIntensiveServicesTreatmentUnit(inpatientpsychiatricunitandpsychiatricdaytreatmentprogram),theConsult-LiaisonService,andintheoutpatientclinicatChil-dren’sHospitalColorado.Herareasofclinicalfocusareyouthwithco-occurringmedicalandpsychiatricdiagnoses, family issues, and serious mental illness in children and adolescents. Dr. Oland is responsible for providing individual, family, and group therapy. Shealsoactivelycollaborateswithschools,commu-nityproviders,andmulti-disciplinaryprofessionalsinprovidingcareforherpatients.Dr.Olandisprincipalinvestigatoronaresearchprojectaimedatlearningmore about serious mental illness in youth and inter-ventionstobesthelpthispopulation.Additionalre-searchinterestsincludeposttraumaticgrowth,qualityoflife,andfamilyfunctioninginyouthandfamiliesaf-fectedbyco-occurringmedicalandpsychiatricillness.Dr.Olandco-leadsadidacticforpredoctoralinternsontheprocessofsupervision,andalsoparticipatesasaco-facilitatorintheIPEDmultidisciplinaryethicscourseofferedthroughtheSchoolofMedicine.

Dr. Oland received her bachelor degree in Psychol-ogy from Emory University, and her doctoral degree in Clinical Psychology and Developmental Psychology fromtheUniversityofPittsburgh.Shecompletedapredoctoral internship in child clinical psychology at LucileSalterPackardChildren’sHospitalofStanfordandtheChildren’sHealthCouncil.ShecompletedapostdoctoralfellowshipinclinicalchildpsychologyatChildren’sHospitalLosAngeles. Jennifer J. Paul, PhD; Author

JenniferJ.Paul,PhDisanassistantprofessorofpsy-chiatryandtheTrainingDirectoroftheHarrisPro-graminChildDevelopmentandInfantMentalHealthat the University of Colorado School of Medicine. Dr. Paul is a licensed clinical psychologist, and the Clinical DirectoroftheHealthyExpectationsPerinatalMentalHealthProgramatChildren’sHospitalColorado,whichprovidespsychiatricevaluationandgrouptherapeuticsupportformothersexperiencingpregnancy-relateddepressionand/oranxietyandtheirbabies.Also,aftermanyyearsoffunctioningastheClinicalCoordinatorfortheKempeTherapeuticPreschool,sheisnowtheDirector of the Kempe CARES for Child Care program. KempeCARESprovidestraining,consultation,andre-flectivesupporttochildcareprovidersandcenterdi-rectorsinefforttopreventvariousformsofchildhoodabuseandneglect,includingShakenBabySyndrome.Dr. Paul leads classes on infant and early childhood developmentaswellasparent-childinteractionforchild and adolescent psychiatry residents. She also leads courses in infant and early childhood screening andassessmentaswellasdiversity-informedpracticein infant mental health for postdoctoral psychology fellowsintheHarrisprogram.Dr.Paulalsoprovidesoutpatienttherapeuticservicesasaninfantandearlychildhood mental health specialist through Children’s HospitalColoradotochildrenagesbirththrough5years old and their families. Dr. Paul received her bachelor degree in Psychology from theUniversityofWisconsin–Madison,andhermasterand doctoral degrees in Clinical Psychology from the UniversityofConnecticutatStorrs.ShecompletedherpredoctoralinternshipattheInstituteofLiving/HartfordHospital/ConnecticutChildren’sMedicalCenter,andapostdoctoralfellowshipininfantandearlychildhooddevelopmentandmentalhealthwiththeHarrisProgramat the University of Colorado School of Medicine.

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John Peterson, MD; Author

JohnPeterson,MDisanattendingpsychiatristintheEmergencyDepartmentatChildren’sHospitalColo-rado. As an associate professor of psychiatry at the University of Colorado School of Medicine, Dr. Pe-tersonwasalsotheDirectorofChildandAdolescentPsychiatricServicesatDenverHealth,retiringafter20yearsofclinicalservice,research,andteaching.Heiscurrentlyprovidingemergencypsychiatricevaluationsof children and adolescents in the emergency depart-ment, and he supervises psychiatric crisis assessments completedbymentalhealthcliniciansintheED.Healsoprovidespsychiatricconsultationtopediatricians,and clinical supervision and teaching for child and ad-olescentpsychiatryfellows.Dr.Petersonalsoteachesclassesforthechildpsychiatryfellowshipprogramand coordinates the child psychiatry grand rounds. Dr. Peterson received his bachelor degree in Biol-ogy and Psychology from the University of California, Santa Cruz, and his medical degree at the University ofCalifornia,SanFranciscoSchoolofMedicine.Hecompleted his residency training in psychiatry at the UniversityofColoradoSchoolofMedicine,wherehealso completed a child and adolescent psychiatry fel-lowship. Gautam Rajendran, MD; Author

GautamRajendran,MDisaseniorinstructorofpsy-chiatry at the University of Colorado School of Medi-cine,andservesasanattendingpsychiatristontheInpatientandDayTreatmentPsychiatricServicesforChildrenandAdolescentsatChildren’sHospitalColo-rado.Heprovidespsychiatricassessments,treatmentplanning,medicationmanagement,andpsychother-apyservices.Dr.Rajendranalsosupervisesgeneralpsychiatry residents, child and adolescent psychiatry fellows,andmedicalstudentsduringtheirinpatientpsychiatryrotations.Heregularlygiveslecturesforcross-disciplinetrainingatChildren’sHospital,andservesastheProgramCommitteeChairoftheColo-rado Child and Adolescent Psychiatric Society. Dr. Ra-jendran’sfieldsofinterestincludethoughtdisorders,psychosis,andattentiondeficitdisorderinchildrenandadolescents.Heconductslecturesonchildhoodonset psychosis and psychopharmacology, and directs the Systems of Care in Child Psychiatry course.Dr.RajendranreceivedhisbachelordegreeinMedi-

cineandSurgeryfromJawaharlalInstituteofPostGraduateMedicalEducationandResearch,Pondi-cherry,India.HecompletedhisgeneralpsychiatryresidencyatSouthernIllinoisUniversity,SpringfieldIL.,andhischildpsychiatryfellowshipatUniversityofColorado, Denver. Paula Riggs, MD; Author

Dr. Paula Riggs, MD is Professor and Director of the Division of Substance Dependence in the Department of Psychiatry at the University of Colorado School of Medicine,andboardcertifiedinchild,adolescent,andaddictionpsychiatry.Herresearchfocusesonim-provingtreatmentforadolescentswithco-occurringpsychiatric and substance use disorders, including amongthefirstrandomized,controlledmedicationtrials in such youth. Dr. Riggs and her research team have more recently developed an integrated mental healthandsubstancetreatmentinterventionknownasEncompass,basedonmorethan15yearsofNIDA-fundedresearch.Dr.Riggsalsohasacareer-longcommitmenttoteachingandmentoringjuniorinves-tigators.SheiscurrentlythePrincipalInvestigatoroftheNIDA-AACAPK12:PhysicianCareerDevelopmentAward,whichprovidesaddictionresearchtrainingand mentorship to child and adolescent psychiatrists whowishtobecomecareerinvestigatorsinthefieldofaddictionandmentalhealthresearch.Dr.Riggsreceivedanumberofhonorsandawardsforhercontributionstothefield,including2AmericanAcademy of Child and Adolescent Psychiatry Out-standing Mentorawards,5280Top Doctoraward,ScienceandManagementofAddiction(SAMA)Foun-dationResearchaward,KatherineAnnMullenMemo-rialAwardforOutstanding Contributions to the Field of Adolescent Health in the Rocky Mountain Region, andtheElaineSchlosserLewisAwardforBest ADHD Research and Paper Published in the Journal of the American Academy of Child/Adolescent Psychiatry. SheisfeaturedinHBO’sAddiction, and has appeared on the Dr. Oz showandothernationalmedia.Dr. Riggs received her bachelor and master degrees in Biology, and her medical degree from the University of Colorado, Denver. She subsequently completed a medicalinternship(1989-1990),generalpsychiatryresidency(1990-1992),andachildandadolescentpsychiatryfellowship(1992-1994)attheUniversityofColorado School of Medicine.

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Randal G. Ross, MD; Reviewer

RandalGRoss,MDistheL.McCartyFairchildChairinChildandAdolescentPsychiatry;Professor,Depart-mentsofPsychiatryandPediatrics;andDirectorofResearch and Research Training for the Department of Psychiatry at the University of Colorado School ofMedicine.HeisalsoDirectorofMedicalStudentResearch Training for the University of Colorado School of Medicine. Dr. Ross focuses his research on thedevelopmentalpathwaytomajorillnessfromconceptiontomid-adolescence.Hisworkincludesstudiesofchildrenwithandat-riskforschizophreniausing methodologies including electrophysiology, hor-mones,behavior,andnovelpreventiontrials.Dr. Ross received his bachelor degree in Physiological Psychology from the University of California, Santa Barbara, and his medical degree from Yale University. Hecompletedgeneralandchildandadolescentpsy-chiatryresidenciesattheUniversityofWashington,andapostdoctoralresearchfellowshipattheUniver-sity of Colorado School of Medicine. Elise M. Sannar, MD; Author, Reviewer, Editor

Elise M. Sannar, MD is a senior instructor of child and adolescent psychiatry at the University of Colorado SchoolofMedicine,practicingatChildren’sHospitalColorado.Dr.Sannarisoneof2attendingpsychia-trists on the Neuropsychiatric Special Care Unit (NSC), anintensiveinpatientanddaytreatmentprogramforchildrenandadolescentswithcomorbidpsychiatricanddevelopmentalissues.Sheisinvolvedinmultiplesubspecialty clinics in the hospital, including the Prad-erWilliMultidisciplinaryClinic,the22q11.2DeletionSyndromeClinic,andtheSieCenterforDownSyn-drome.ShehasalsoparticipatedinnationalresearchstudieslookingattheeffectsofnovelagentsonthecorebehavioralphenotypeofFragileXSyndrome.Inadditiontomanaginghersubspecialtyclinicpatients,Dr.Sannarseesotheroutpatientsforon-goingmedi-cationmanagement.Dr.Sannarbringsherpassionforservingspecialneedspatientstoherteachingoffel-lowsandresidents.SheprovidesdirectsupervisiontoresidentsrotatingthroughtheNSCunit,andlectures to general psychiatry residents, child and adolescent psychiatryfellows,anddevelopmentalpediatricsfel-lows.

Dr.SannarreceivedherbachelordegreeinWomen’sStudies and Chemistry from Pomona College, and her medicaldegreeattheUniversityofChicago.Herresi-dencyandfellowshiptrainingsoccurredthroughtheUniversity of Colorado School of Medicine. Mindy Solomon, PhD; Author

Mindy Solomon, PhD is an assistant professor of psy-chiatry at the University of Colorado School of Medi-cine, and serves as a psychologist and clinical program directorfortheEatingDisordersProgramatChildren’sHospitalColorado.Dr.Solomonisresponsibleforproviding direct clinical care by means of individual, family,andgrouptherapy,aswellasprogramdevel-opmentandmilieumentorshipforthetherapeuticmilieu program. Dr. Solomon is the primary supervisor ontheEatingDisorderProgramforpsychologyinternsandpostdoctoralfellows,andleadsseminarsforpost-doctoralfellowsonissuesrelatedtoeatingdisordertreatment, ethics, and professional development. She alsogivestalksincommunitysettings(eg,schools,andgiftedandtalentedorganizations)ontheidenti-ficationandtreatmentofeatingdisordersinchildrenand adolescents. Dr. Solomon’s research focuses on improvingoutcomesforfamiliesenteringtheEatingDisorderProgram,aswellasstudyingnoveltreat-mentstoenhancethetreatmentofeatingdisorders.Dr. Solomon received her bachelor degree in Psychol-ogy from the University of California, Santa Cruz, her masterdegreeinClinicalHealthPsychologyfromCalifornia State University, Northridge, and her doc-toral degree in Clinical Psychology from the California School of Professional Psychology at Alliant Interna-tionalUniversity.Shecompletedapostdoctoralfel-lowshipineatingdisorderstreatmentatWardenburgHealthCenter,UniversityofColoradoBoulder. Celest St. John-Larkin, MD; Author

CelesteSt.John-Larkin,MD,isTheAnschutzChairinHealthyExpectations,andassistantprofessorofPsychiatry at the University of Colorado School of Medicine.SheistheMedicalDirectorfortheHealthyExpectationsPerinatalMentalHealthProgramatChildren’sHospitalColorado.Dr.St.John-Larkinispassionateaboutcaringforwomenandinfantsdur-ing the perinatal period. The program provides group therapysupportforpregnantwomenandthosewithpostpartummoodandanxietydisorderswhilead-

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dressingtherelationshipbetweenmothersandtheirinfants.Dr.St.John-Larkinalsoprovidespsychiatricevaluationsandmediationmanagementtowomeninthisprogram,aswellaspreconceptionandpregnancyconsultationforwomentakingpsychotropicmedica-tionsfromacrossthestate.ShealsoprovidesservicestochildrenandadolescentsinoutpatientclinicatthePediatricMentalHealthInstitute.Withaninterestinworkingwithyoungchildrenandtheirfamilies,Dr.St.John-Larkinhasadditionaltraininginchild-parentpsychotherapy and infant mental health. She also worksinProjectCLIMBasaconsultantandprecep-torforpediatricresidentsintheChildHealthClinicatChildren’sHospitalColorado.Shehasgivenlecturesinthecommunityonadolescentandpregnancy-relateddepression, and supports community pediatric prac-ticesinaddressingthementalhealthneedsoftheirpatientsthroughtheCAPAproject.Previously,sheworkedontheinpatientanddaytreatmentservicesatChildren’sHospitalColorado.Dr.St.John-Larkinis a course coordinator in the child and adolescent psychiatryfellowship,andsupervisesresidentsdur-inginpatientandelectiverotations.SheservesontheexecutivecommitteeoftheColoradoChildandAdo-lescentPsychiatricSociety,andwasappointedtotheColoradoDepartmentofPublicHealthandEnviron-ment’sPregnancy-RelatedDepressionStateAdvisoryCommitteein2014.SheisalsoafoundingmemberoftheChildren’sHospitalColoradoMentalHealthFamilyAdvisory Council. Dr.St.John-LarkinreceivedabachelordegreeinHis-toryfromNorthwesternUniversity,andhermedicaldegreefromMichiganStateUniversity,CollegeofHu-man Medicine. She completed her internship and resi-dencyinadultpsychiatry,andfellowshipinchildandadolescent psychiatry at the University of Colorado SchoolofMedicineandChildren’sHospitalColorado. Sally Tarbell, PhD; Author, Reviewer

Sally Tarbell, PhD is an associate professor of psychia-try and pediatrics at the University of Colorado School of Medicine, and serves as the Chief of Pediatric PsychologyatChildren’sHospitalColorado.SheistheDirectorofthePsychologyPostdoctoralFellowshipProgram. Dr. Tarbell provides clinical care to pediatric patientsseenintheMotilityandInflammatoryBowelDiseaseprogramsintheDigestiveHealthInstituteatCHCO.Dr.Tarbellcontributeslecturestothepediat-

ric, psychology, and psychiatry training programs on pediatricpsychologytopics.SheservesasascientificadvisortotheInternationalCyclicVomitingSyndromeAssociation.Dr.Tarbell’sresearchfocusesonthedevelopmentofbehavioralmedicineinterventions,and the assessment and treatment of psychiatric co-morbidityinchildrenandadolescentswithfunctionalmedicaldisorders,includingcyclicvomitingsyndrome,nausea,posturalorthostatictachycardiasyndrome,migraine, and abdominal pain. Dr. Tarbell received her bachelor degree in Psychol-ogy from Trinity College, and her doctoral degree in ClinicalCounselingPsychologyfromYorkUniversity,Toronto, Ontario. She completed a postdoctoral re-searchfellowshipinthesocialandbehavioralsciencesatHarvardMedicalSchoolandChildren’sHospital,Boston.

Marianne Z. Wamboldt, MD; Reviewer

MarianneZ.Wamboldt,MDisaprofessorofpsychia-tryattheUniversityofColorado,theVollbrachtFam-ilyEndowedChairofStressandAnxietyDisorders,theMedical Director of the Psychosocial Research Center, and the Medical Director of the Anxiety Disorders Program,allatChildren’sHospitalColorado.ShehasbeenaboardcertifiedChildandAdolescentPsychia-tristforover25years.Inadditiontoseeingoutpa-tientsintheCHCOclinic,shesupervisesandteacheschild and adolescent psychiatry residents. She is the PresidentoftheFamilyProcessInstitute,aninterna-tionalgroupdedicatedtopromotingresearch,train-ing, and clinical care regarding families. Dr.Wamboldtreceivedhermedicaldegreeandcom-pleted her general psychiatry residency at the Univer-sityofWisconsinMadison;shecompletedaclinicalresearchfellowshipattheNIMH,followedbyseveralyearsofworkintheNIMHExtramuralProgram;shecompleted her child and adolescent psychiatry resi-dency at the University of Colorado.

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Jason Williams, PsyD, MS Ed; Author, Reviewer

JasonWilliams,PsyD,MSEdisanassistantprofessorof psychiatry at the University Of Colorado School of Medicine, and serves as Clinical Director and Direc-torofTraininginthePediatricMentalHealthInstituteattheChildren’sHospitalColorado.Dr.Williamshasaninterestinthedevelopmentofinnovativeteach-ingmethodologiesininter-professionalteams.Clini-cally, his interests lie in the use of technology both for clinical outcomes and in the development of trans-diagnosticservicedelivery.Heenjoysworkingwithchildrenandfamiliesclinicallywherehefocusesonpeoplewithimpulsecontroldisorders.Dr.WilliamsisthepastpresidentoftheColoradoPsychologicalAssociation,andtheChairoftheAs-sociationofPredoctoralandPostdoctoralInternshipCenters(APPIC).Dr.WilliamsreceivedhismasterdegreeinEducationfromtheUniversityofSouthernCalifornia, and his doctoral degree from the Califor-niaSchoolofProfessionalPsychologyinLosAngeles,California.Hecompletedaninternshipandpostdoc-toraltrainingprogramattheChildren’sHospitalinLosAngeles.Heworkedatthatinstitutionfor12yearsprior to returning home to Colorado.

Acknowledgements

Acknowledgements

Peerreviewisthemajormethodforassuringhigh-qualityscholarshipinacademicmedicine.Aknowledgeableandthoughtfulpeerreviewmakesthepapersshereviewsbetter.WeacknowledgetheimportantcontributionsofourcolleagueswhoservedaspeerreviewersforthisissueoftheColoradoJournalofPsychiatryand Psychology.

• Cindy Buchanan

• AnthonyCordaroJr.

• Robin Gabriels

• JenniferHagman

• BenjaminMullin

• Douglas Novins

• Alyssa Oland

• Randy Ross

• Elise M. Sannar

• Sally Tarbell

• MarianneWamboldt

• JasonWilliams

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Department of Psychiatry | School of Medicine | University of Colorado

About the University of Colorado School of Medicine Department of Psychiatry

TheUniversityofColoradoSchoolofMedicineisrankedinthetop10byU.S.News&WorldReport—inmultiplemedicalspecialties.LocatedontheAnschutzMedicalCampusinAurora,Colorado,theSchoolofMedicinesharesitscampuswithChil-dren’sHospitalColoradoandUniversityofColoradoHealth.

TheDepartmentofPsychiatryprovidesclinicalservicesthroughtheAddictionTreatmentServices,Children’sHospitalColorado,UniversityofColoradoHospital,andinconjunctionwithDenverHealthMedicalCenterandtheDenverVeteransAdministra-tionHospital.TheDepartmentofPsychiatrytrainingprogramsencompassafullspectrumofeducationallevels(frommedicalstudentandresidencyeducationthroughpostdoctoralfellowships)andmentalhealthdisciplines(eg,psychology,psychiatry,socialwork,andnursing),andarewidelyrecognizedfortheirconsistenthighquality.

With167full-timeand366volunteerfacultymembers,theDepartmentofPsychiatryisoneofthelargestintheUnitedStates.Itsresidencyprogramalsoranksamongthelargestprograms,with45residentsandoveradozenfellows.Manyofourfacultyhavepositionsofleadershipinnationalorganizations,includingtheAmericanPsychiatricAssociation,theAmericanPsychologi-calAssociation,andtheAmericanAcademyofChildandAdolescentPsychiatry.

Intermsofresearch,theDepartmentofPsychiatryregularlyranksasoneofthetop3ontheUniversityofColoradoAnschutzMedicalCampus,andwasrecentlyranked13thinthenationforresearchfunding.ItisalsooneofthestrongestcentersintheVeteran’sAdministrationforfundinginmentalhealthresearch.Thebreadthanddepthofscientificaccomplishmentsspantheneurosciences,developmentalneurobiology,addictions,infantdevelopment,childandadolescentpsychiatry,behavioralim-munology, schizophrenia, depression, transcultural, and public psychiatry.

Recentresearchawards,investmentsinclinicalservices,andteachingbybothouraffiliatedinstitutionsandthephilanthropiccommunityhavestrengthenedandenlargedourexistingprogramsaswecontinueourcommitmenttoabiopsychosocialmodel,medicalandpsychiatriceducation,aninterdisciplinaryresearchapproach,andtheprovisionofclinicalservices.

About the Division of Child and Adolescent Psychiatry Asoneoftheoldestandmost-respectedacademicprogramsinchildren’smentalhealthinthenation,theDivisionofChildandAdolescentPsychiatrysupportsawiderangeofclinical,teaching,andresearchprograms.TheDivisionisparticularlywell-knownforadvancingthescienceandpracticeofchildren’smentalhealthintheareasofaddictions,anxiety,autismspectrumdisorders,underservedpopulations,eatingdisorders,integratedcare,psychosisandearly-onsetschizophrenia,psychosomaticmedicine, stress and trauma, and telemental health. TheDivisionofChildandAdolescentPsychiatrycombinedeffortswithChildren’sHospitalColoradoin2002todevelopwhatisnowthePediatricMentalHealthInstitute.Children’sHospitalColoradosees,treats,andhealsmorechildrenthananyotherhospitalintheregion,providingintegratedpediatrichealthcareservicesattheAnschutzMedicalCampusaswellas16otherlocationsalongColorado’sFrontRange.Thehospitalisnationallyrankedasaleaderinpediatriccare,consistentlyrecognizedbyU.S.News&WorldReportasoneofthetop10children’shospitalsinthenation.

ThePediatricMentalHealthInstituteprovidesacompletecontinuumofpsychiatricservices,includingoutpatient,emergency,partialhospitalization,andinpatientserviceswithanemphasisondevelopingcoordinatedsystemswithinthehospitalaswellascollaboratingwithotheragenciesandproviders.Ourinterdisciplinaryfacultyandstaffincludespsychiatrists,psychologists,socialworkers,andnurses.Theinstituteisinthemidstofamajorexpansionthatistouchingalllevelsofclinicalcare,teaching,research,andscholarship,assuringitscontinuedplaceasoneofthenation’sleadingcentersforchildren’smentalhealth.

colorado journal of psychiatry & psychology · dr. marissa schiel. a more detailed call for...

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