Faculty Bibliography

As pressure increases for the demonstration of effective treatment for children with mental disorders, it is essential that the field has an understanding of the evidence base. To address this aim, the authors searched the published literature for effective interventions for children and adolescents and organized this review as follows: (1) prevention; (2) traditional forms of treatment, namely outpatient therapy, partial hospitalization, inpatient treatment, and psychopharmacology; (3) intensive comprehensive community-based interventions including case management, home-based treatment, therapeutic foster care, and therapeutic group homes; (4) crisis and support services; and (5) treatment for two prevalent disorders, major depressive disorder and attention-deficit hyperactivity disorder. Strong evidence was found for the treatment of attention-deficit hyperactivity disorder, depression, anxiety, and disruptive behavior disorders. Guidance from the field relevant to moving the evidence-based interventions into real-world clinical practice and further strengthening the research base will also need to address change in policy and clinical training.

Research to elucidate the biological bases of psychopathology in children and adolescents is needed to understand pathogenesis and to develop effective and safe treatment and preventive interventions. Because of the effect of development, data collected in adults are not always applicable to youth, and direct participation of children in research is necessary. Many medications are currently used in the community to treat children and adolescents with neuropsychiatric disorders without adequate data about their safety and efficacy. Conducting research in children requires attention to specific ethical and regulatory factors. In deciding whether minors can participate in a study with potential direct benefit to the research subjects, the most important variable to consider is the balance between risks and potential benefit, in the context of the severity of the child's condition and the available alternatives. Research with no potential benefit to the participants is guided by the concepts of minimal risk (which may apply more to normal children) and minor increase over minimal risk (perhaps more relevant to children affected by psychopathology). Recently conducted studies relevant to this issue are reviewed. Of paramount importance is the ratio of risk/scientific value of the proposed experiment. In fact, no research is justifiable, no matter how low the risk may be, unless the potential yield of the study is important and may help advance our understanding of normal functioning and mental illness.

OBJECTIVE: To determine national pediatric prescribing practices for psychotropic agents and to examine these practices in view of the available evidence concerning their safety and efficacy in this age group. METHOD: Prescribing data from 2 national databases based on surveys of office-based medical practices were determined and reviewed vis-a-vis available safety and efficacy evidence. RESULTS: Data indicate that levels of psychotropic prescribing in children and adolescents are greatest for stimulants, resulting in nearly 2 million office visits and 6 million drug "mentions" in 1995. Selective serotonin reuptake inhibitors were the second most prescribed psychotropic agents, while anticonvulsant mood stabilizers (prescribed for a psychiatric reason), tricyclic antidepressants, central adrenergic agonists, antipsychotics, benzodiazepines, and lithium were also prescribed for a substantial number of office visits. Comparison of prescribing frequencies with available safety and efficacy data indicates significant gaps in knowledge for commonly used agents. CONCLUSIONS: Most psychotropic agents require further sustained study to ensure appropriate health care expenditures and vouchsafe children's safety. Recommendations for researchers, parents, federal agencies, and industry are offered as a means to accelerate the pace of research progress.

Explores the challenges entailed in moving away from optimal, university-based, research conditions to more real-world community settings that are palatable, feasible, durable, affordable, and sustainable for children and adolescents at risk or in need of mental health services. The authors discuss principles for effective and meaningful collaborations between university investigators and community partners, including (1) an enhanced focus on external validity, (2) the incorporation of the values and needs of community collaborators within research activities, (3) full conceptualization and assessment of outcomes, (4) flexibility to fit local needs and circumstances, (5) modifications of research methods, and (6) the embracing of long-term perspectives.

The authors review the constraints of current mental disorder classification systems that rely upon descriptive symptom-based approaches, and weigh the benefits and hazards of these classification and diagnostic strategies. By focusing principally on superficial descriptions of symptoms, current systems fail to address the complex nature of persons' transactions within and adaptations to difficult environments. While attempting to be atheoretical, current systems exclude types of information that may elucidate individuals' functioning across various contexts, often because it is difficult to obtain such data reliably. With current approaches, misdiagnosis is likely, particularly when diagnostic criteria are applied to persons in nonclinical settings. Alternative approaches that take fuller advantage of clinicians' expertise and other forms of clinical data are reviewed, and recommendations are made for the next generation of classification systems. Application of evolutionary theory to psychiatry and psychology, as well as development of a theory and nosology of context in terms of persons' adaptations, are needed to expand our knowledge of normal and abnormal human development and psychopathology.