Faculty Bibliography

OBJECTIVE: : Clinical research depends on the participation of representative samples. At the 2001 Annual Meeting of the American Academy of Child and Adolescent Psychiatry, the Workgroup on Research conducted a research forum with the purpose of improving recruitment and retention of children and adolescents in research protocols. METHOD: : An interdisciplinary group of participants focused on (1) consumers and families, (2) communities, (3) professionals and health care delivery systems, (4) regulatory bodies, and (5) alternative research designs. Obstacles and challenges were identified and solutions were discussed. RESULTS: : Key recommendations include the following: Investigators must become involved with community stakeholders and more explicitly communicate with families about research procedures, risks, and benefits; budgets should include explicit items for case management and referrals to families who do not meet entry criteria; the culture of clinical settings must incorporate research conducted by clinicians; regulatory bodies must streamline and coordinate protocols and procedures; designs emphasizing flexible treatment strategies and adaptive treatments should be encouraged; and health care systems should consider changing incentives for research participation, including the radical notion that reimbursement be made in terms of improvement rather than service units. CONCLUSIONS: : An integrated approach is recommended, requiring direct involvement of investigators in communities where research is to be conducted

OBJECTIVE: The use of placebo in the pediatric age group has come under increasing scrutiny. At the 2002 Annual Meeting of the American Academy of Child and Adolescent Psychiatry, the Academy's Workgroup on Research conducted a research forum. The purpose was to identify challenges and their solutions regarding the use of placebo in randomized controlled trials in pediatric psychopharmacology. METHOD: Workgroups focused on problems and solutions in five areas: ethics and human subjects, research design and statistics, partnering with consumers, U.S. Food and Drug Administration and pharmaceutical industry perspectives, and psychosocial treatments. RESULTS: In many but not all circumstances, inclusion of a placebo control is essential to meet the scientific goals of treatment outcome research. Innovative research designs; involvement of consumers in planning and implementing research; flexibility by industry, academia, the National Institutes of Health, and regulatory agencies acting in partnership; and concomitant use of evidence-based psychosocial services can and should assist in making placebo-controlled trials acceptable. CONCLUSIONS: Properly designed placebo-controlled trials remain necessary, ethical, and feasible.

OBJECTIVES: (1) To examine U.S. national trends in the use of concomitant pharmacotherapy with the stimulant class of psychotropic drugs in youth; and (2) to present these trends in the context of (a) extant safety and efficacy data, and (b) overall trends in concomitant pharmacotherapy with psychotropic drugs for youth. METHODS: Prescribing data for youths under age 18 years from National Ambulatory Medical Surveys from 1993 to 1998 were analyzed. The visits were categorized into monotherapy (only one psychotropic prescribed) and concomitant pharmacotherapy (>1 psychotropic prescribed). The proportions of these groups were computed as a percentage of all visits during which a psychotropic medication was prescribed. Differences in proportions between surveys were analyzed to determine trends. RESULTS: Between 1993--94 and 1997--98, the proportions of visits for concomitant pharmacotherapy in association with the stimulant class increased nearly five-fold. This increase paralleled an overall increase in the proportion of visits involving prescription of more than one psychotropic medication among youth. CONCLUSIONS: The growth in concomitant pharmacotherapy with the stimulants class has out-paced the increase in safety/efficacy data to inform the use of this practice, resulting in a mismatch between trends in prescribing and growth in knowledge. A simultaneous trend of note is the overall increase in the use of concomitant pharmacotherapy with all psychotropic drugs in youth. Controlled trials are particularly needed to support commonly used combinations of stimulants with antidepressants in youth. In the absence of definitive data, clinical guidelines based on expert consensus and limited data are available and are useful.

This article focuses on an attempt to integrate evidence-based engagement interventions into "real world" outpatient child mental health settings in order to increase access to care for urban youth and their families. More specifically, empirical support for introducing engagement interventions into child clinical settings will be reviewed. Then, specific engagement interventions that are delivered during the initial telephone contact with a child's adult caregiver or during the first face-to-face contact with a child and family are described with attention paid to the training necessary to assist service providers in adopting this change in practice. Factors that serve to facilitate or impede adoption of evidence-based engagement interventions are also reviewed. Finally, preliminary evidence for the effectiveness of integrating such evidence-supported approaches is presented.

Herschell, McNeil, and McNeil's (see record 2004-15972-007) documentation of the lag in the dissemination of child empirically supported treatments (ESTs) relative to adult ESTs highlights an important issue that needs to be addressed if progress is to be made in helping children who suffer from debilitating behavioral and emotional disorders. The Herschell et al. article brings to the foreground a myriad of other issues, however, that need to be addressed in order that the profession may achieve the long-term goal of widespread deployment of ESTs. In this commentary, we use Herschell et al. as a point of departure for highlighting one issue that we believe is particularly critical. Namely, we highlight the importance of balancing Herschell et al.'s current call for more basic research on dissemination with a call for more basic theory on effectiveness, transportability, and dissemination, and, more significantly, the integration of theory and research.

One issue of "Child and Adolescent Psychiatric Clinics of North America" was planned to examine two questions: (1) What is the current state of the evidence?; and (2) What is the potential to move evidence into practice? Papers were invited around these two major themes. Authors responded enthusiastically, such that two issues were required to accomodate their contributions. The content divided naturally into "Part One: Evidence Update" and "Part Two: Effecting Change." Part Two will be released in the Spring of 2005. Part One provides an update on the status of recent studies examining the impact of specific treatment approaches (medication, psychosocial, and community- based services) on child and family outcomes. In Part Two, the voices and views of stakeholders about evidence-based practice, most critically those of family members and clinical practitioners, are echoed in several papers, along with theoretical and empirical data about attitudinal factors related to changing practitioner practice. In conclusion, the critical question seems to be whether or not the field has the confidence, forbearance, and strategic capability to effectively move the current evidence, albeit incomplete and steadily emerging, into practice.

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

OBJECTIVE: To identify the obstacles and special challenges-ethical, practical, scientific, and regulatory-faced by investigators who attempt to conduct psychopharmacological studies in preschoolers. METHOD: In a workshop held at the 47th Annual Meeting of the American Academy of Child and Adolescent Psychiatry, featuring interactive sessions designed to elicit discussion of the theory and feasibility of research in this young population, several key domains were identified: diagnosis and assessment, ethics, research design, special considerations for preschoolers, regulatory/industry issues, and education/training. RESULTS: A Pediatric Psychopharmacology Initiative is needed to consolidate recommendations from this and other workshops and current federal, research, and regulatory committees. A scholarly review and a guide for institutional review boards and investigators should be prepared on issues related to preschoolers. Developmental specialists provide valuable expertise that can strengthen studies of pediatric psychopharmacology. 'N of 1' case studies can provide valuable information to clinicians. Only preschoolers with severe symptoms that occur in several interpersonal contexts should be entered into trials. Indications for the study of symptom complexes (e.g., aggression) rather than specific diagnoses should be examined and considered for regulatory activities. Psychopharmacology practice parameters for preschoolers are needed. CONCLUSIONS: With preschoolers being increasingly treated with psychopharmacological agents, the need for investigations to address the safety and efficacy of these medications is becoming a central issue for researchers from many disciplines

Describes current perspectives on evidence-based practices in psychology, medicine, and education. The paper also discusses challenges in the implementation and dissemination of research-based findings into schools and in particular understanding the fit between empirically validated interventions and organizational structures. Following that discussion, differences between current models of organizational behavior as studied in children's mental health services and in education are described and finally, the kinds of programmatic research models within school psychology that can move evidence-based practices towards system-wide policies are described. Implications for practice and policy are noted.