The relevance of current clinical practice in child psychotherapy to child psychiatry

SUMMARY

The role of child psychiatrists is evolving. Economic and psychosocial factors such as marital breakdown, inner city decline, unemployment, plus increased awareness of conditions such as Substance Abuse and all forms of Child Abuse have led to stress for children and their caretakers. There is also increasing recognition that with help many troubled children and their families can emerge better able to function. Child psychiatrists occupy a pivotal position in the child mental health team and need to be familiar with all the treatment options available to ensure their effective use. This paper presents examples of current work being undertaken by child psychotherapists and discusses the implications of this for the training of child psychiatrists as well as for clinical work.     

Connections between experience, beliefs, scientific knowledge, and self-evaluated expertise among investigators of child sexual abuse in Finland

The purpose of this study was to investigate whether clinicians investigating child sexual abuse (CSA) rely more on scientific knowledge or on clinical experience when evaluating their own expertise. Another goal was to check what kind of pre-trial beliefs the clinicians had. The connections between these different factors were investigated. A questionnaire covering items concerning demographic data, experience, knowledge about CSA, self-evaluated expertise and beliefs about CSA was given to 126 social workers, 60 child psychiatrists and 134 psychologists. The results showed that the clinicians relied more on their clinical experience than on scientific knowledge when evaluating their expertise as investigators of CSA. Furthermore, social workers possessed stronger attitudes in favor of children than the other groups, while child psychiatrists had more negative attitudes towards the criminal justice system. Male participants had less strong beliefs than did the female participants. The findings indicate that the education of CSA investigators should focus more on theoretical knowledge and decision-making processes as well as the role of pre-trial beliefs.     

Psychopharmacologic strategies for the treatment of aggression in juveniles

Maladaptive aggression in youth is one of the most common and troublesome reasons for referrals to child psychiatrists. It has a complex relationship with psychopathology. There are several syndromes, which are primary disturbances of clustered maladaptive aggression, most notably oppositional defiant disorder and conduct disorder. However, problems with aggression also appear in a wide range of other disturbances, such as bipolar disorder, posttraumatic stress disorder, and mood disorders. Additionally, aggression is normative, serves an adaptive purpose and can be situationally induced. These complexities need to be carefully addressed before targeting maladaptive aggression psychopharmacologically. We summarize the literature on the psychopharmacology of maladaptive aggression in youth, focusing on disorders without cognitive impairment. We delineate the subtypes of aggression which are most likely to respond to medication (reactive-affective-defensive-impulsive in their acute and chronic form) and conclude with a discussion of specific medication strategies which are supported by controlled clinical trials and clinical experience.     

Child Maltreatment in DSM‐5 and ICD‐11

Child maltreatment is widespread and has a tremendous impact on child victims and their families. Over the past decade, definitions of child maltreatment have been developed that are operationalized, face valid, and can be reliably applied in clinical settings. These definitions have informed the revised Diagnostic and Statistical Manual (American Psychiatric Association, 2013) and are being considered for the International Classification of Disease–11 (World Health Organization). Now that these definitions are available in major diagnostic systems, primary healthcare providers and clinicians who see children and families are poised to help screen for, identify, prevent, and treat child maltreatment. This article reviews the definitions of maltreatment in these diagnostic systems, along with assessment and screening tools, and empirically supported prevention and intervention approaches.     

Measuring Parental Treatment Adherence in a Multimodal Treatment Program for Children with ADHD: A Preliminary Investigation

This study evaluated the clinical significance of measuring between session parental adherence on child and parent outcomes for 51 children (age 4 to 8.5 years) with attention deficit/hyperactivity disorder (ADHD) in a multimodal group training program. Three group treatment conditions: (a) child-only treatment (C1), (c) child and parent training (C2), and (c) C2 + Parent Adherence Measure [PAM (C3)] were compared to assess the clinical significance of measuring parental adherence on child behavioral problems, socialization skills, and parental efficacy. Parents administered the PAM (C3) displayed, in general, better outcomes on child and parent measures than the other two conditions. Results suggest that a multimodal group training program for young children with ADHD is favorable to child group training only. This study offers preliminary support for the clinical utility of measuring parental adherence in a child ADHD multimodal group training program.     

Incorporating a developmental perspective in doctoral training: survey of clinical child psychology training programs and introduction to the special section

Examined the degree to which clinical child programs incorporate and integrate developmental theory into their training, and introduced the contributions of 6 leaders in the field to this special section. Fifty-one clinical child doctoral programs responded to the survey. Results indicate that 3 types of training programs are operating: (a) child emphasis (n = 7), which do not have a formal clinical child training program but do have a faculty member who has child research interests; (b) clinical child (n = 37), which have a group of faculty members with specific child research and clinical interests and a formalized program of study; and (c) developmental-clinical programs (n = 7), which are similar to clinical child programs but require a substantive amount of developmental psychology course work and endorse a developmental psychopathology perspective. Findings reveal that clinical child programs have become increasingly differentiated and specialized over the past 20 years, but, with the exception of developmental-clinical programs, most programs are still neglecting to incorporate developmental theory into training. This issue, as well as concerns about the future direction of clinical child doctoral training is addressed in this special section on the Importance of Incorporating Developmental Theory Into Clinical Child Training.     

An evaluation of a partial training program in psychiatric residency on the later practice of marital and family therapy

Abstract

This paper reports on the results of a survey of psychiatrists and residents who received marital and family therapy training during their second year of residency. The data indicate that such training has an immediate positive effect on practice and is carried forward into later practice. Practicing psychiatrists trained in marital and family therapy during residency report spending 25% of their caseloads in marital and family therapy which was seen as producing positive change in patients. In line with previous training, practicing psychiatrists define the unit of treatment as more than an identified patient and treat marital and family therapy cases themselves or refer to others for such therapy. Variations in practice and techniques raise questions regarding the structure and content of marital and family therapy training in psychiatry residency programs and point out the importance of such training in the later practice of psychiatry.     

Behavioral Health Integration in Health Care Settings: Lessons Learned from a Pediatric Hospital Primary Care System

Behavioral health integration within primary care has been evolving, but literature traditionally focuses on smaller scale efforts. We detail how behavioral health has been integrated across a large, urban pediatric hospital system’s six primary care clinics (serving over 35,000 children annually and insured predominately through Medicaid) and discuss strategies for success in sustaining and expanding efforts to achieve effective integration of behavioral health into primary care. In a time span of 3 years, the clinics have implemented routine, universal behavioral health screening at well child visits, participated in a 15-month behavioral health screening quality improvement learning collaborative, and integrated the work of psychologists and psychiatrists. Additional work remains to be done in improving family engagement, further expanding services, and ensuring sustainability.     

United we stand, divided we fall: the education and training needs of clinical child psychologists

Reviews efforts to delineate training needs for psychologists who are providing clinical services to children, adolescents, and families. In particular, this article (a) describes efforts of clinical child and other psychologists who work with children, adolescents, and families to develop education and training guidelines; (b) discusses the overlap among various child and adolescent providers within psychology; and (c) highlights several key competencies that have been identified as important for all psychologists in practice roles with children and adolescents. In particular, we emphasize the need for greater collaboration and integration among various psychological specialties that focus on children, adolescents, and families and for greater system-wide discussion of training needs and priorities.     

Mental stress on children exposed to war and natural catastrophes

This paper calls attention to the plight of children exposed to various traumas associated with wars and other natural disasters around the world. Little systematic attention has been paid to the mental health needs of child survivors of armed conflict. Our observations and experiences around the world would suggest that there are significant differences in the degree to which children have been prepared in anticipation of exposure to violence and in interventions applied after their exposure. It is the authors' impression that prevention and intervention can be quite powerful when employed in these situations.     

RECENT TRENDS IN RESPONSE TO CHILD VICTIMIZATION

Abstract

This chapter serves as an introduction to the many roles of health care professionalsin the assessment, care, and treatment of child victimization. It concentrates on those professionals caring for the physical health of victims of child abuse and neglect, although there are many similarities between child maltreatment and other family violence victims. In reviewing the health impact of maltreatment and the historical contributions of health care professionals, it discusses the roles that health care disciplines play in clinical care, training, research, and advocacy and their interaction with the community's child welfare, legal, and criminal justice systems.     

Psychoanalytic Controversies: The relationship between psychoanalysis and schizophrenia

In this article, the author considers psychoanalysts' current attitudes towards schizophrenia. After early optimism of a psychoanalytic approach, interest has waned, other than in the field of first-onset psychosis. This was because of poor outcome figures and regarding schizophrenia as now having a biological, rather than psychological, base. The author argues that there is a paradox, because only psychoanalysis offers a framework for relating to psychotic patients in a way that helps them to make sense of their experiences. A framework is described, with clinical examples, to illustrate the application of analytic thinking to patients with schizophrenia. Psychoanalysis needs to revitalise its attitude to psychosis, as it has a significant contribution to make within general psychiatry, not least in the training of the next generation of psychiatrists.     

Examining Influences on Problem Recognition and Help-Seeking for Child Externalizing Behaviors Among African American Mothers

Childhood behavior problems are one of the most common clinical referrals. If left untreated, these behaviors can result in detrimental consequences to the child’s development (Wehmeier et al., 2010; Scholtens et al., 2012). Behavior parent training has been identified as first-line treatment for oppositional behavior; however, many racial minority families fail to enroll in behavior parent training. The current study examines maternal help-seeking for children displaying oppositional behavior in hopes to delineate variables that might influence parent training enrollment among African American families. Participants were 112 African American mothers who were provided child behavior vignettes and completed measures assessing factors related to problem recognition, parental attributions, child rearing values, mental health stigmatization, racial identity, and treatment utilization. Results found that when presented with a child displaying clinically significant externalizing child behaviors, slightly more than half of African American mothers recognized clinically significant child behavior problems. Mothers were more likely to engage in behavioral parent training if problematic behavior was recognized. Additionally, mothers’ attributions of child behavior, cultural values, and mental health stigmatization were influential to help seeking. This study supports the importance of considering cultural variables that impact problem recognition and subsequent treatment utilization among African American families.     

TWO-TO-ONE versus ONE-TO-ONE STUDENT-TEACHER RATIOS IN THE OPERANT VERBAL TRAINING OF RETARDED CHILDREN1

The operant training of two retarded children simultaneously on a picture-naming task was investigated as an alternative to the more commonly reported one-to-one student-teacher ratio. In Experiment I, two conditions were compared in which the children received primary reinforcement on a fixed-ratio schedule for responding correctly on prompt and probe trials in a standardized picture-naming procedure. During the “Group Condition”, the experimenter alternated from one child to the other after each primary reinforcement, after each incorrect response, after each response omission, and after each 10-sec period in which a child did not “attend” (by making a trial-initiating response) when it was his or her turn to be worked with. During the “Individual Condition”, the experimenter worked with only one child, and presented trials whenever the child made attending responses. Experiment I demonstrated that the Group Condition was more efficient than the Individual Condition in terms of total correct responses and total pictures learned per unit of training time. Incidental learning was also found in that the children learned some of each others' pictures as well as their own, thus indicating a further advantage of the larger student-teacher ratio. In Experiment II, an attempt was made to equate the two conditions, except for the presence of two children in the Group Condition, by ignoring the child in the Individual Condition for brief periods equal to those that occurred in the Group Condition when the experimenter presented training trials to the other child. The results demonstrated that the greater efficiency of the Group Condition was not due to the manner in which training time was allocated to the two members of a group. It also replicated the finding that the children learned some of each others' words in the Group Condition.     

Self-centeredness and the adult male perpetrator of child sexual abuse

Self-centeredness has been identified as a quality of the adult male perpetrator of child sexual abuse, but little or no effort has been expended toward defining the concept clearly. In this paper, the research literature on the perpetrator and psychoanalytic writings on narcissism are reviewed for the purpose of developing a comprehensive definition of self-centeredness. Literature related to the social and developmental context of child sexual abuse also is discussed. In the final section of the paper, implications for primary prevention and treatment are drawn.This is a revised version of a paper presented at the Groves Conference on Marriage and the Family, July, 1986, in London, England. Support for the paper was provided through the Minnesota Agricultural Experiment Station and the Faculty Summer Research Fellowship Program, Graduate School, University of Minnesota.     

成人注意缺陷多动障碍诊断与心理治疗的研究进展

注意缺陷多动障碍（ADHD）是指一种以注意缺陷、多动、冲动的行为表现为主要特征的精神病理障碍。对儿童注意缺陷多动障碍的研究有了长足的进步,但对成人注意缺陷多动障碍的研究相对较少。本文阐明了国际上对成人注意缺陷多动障碍的诊断与心理治疗的研究进展,希望引起国内临床心理学家、精神病学家和心理咨询师等的充分重视。     

Buffering negative effects of immigration on cognitive,social, and educational development: A multinational meta-analysis of child and adolescent prevention programmes

Growing up in migrant families is a well-known distal risk factor related to poorer outcomes in child and adolescent health, academic, socioemotional and behavioural development. This article reviews the effects of various prevention measures such as early education programmes, cognitive and language training or parent and teacher training on child and adolescent developmental outcomes in immigration samples. Using several comprehensive literature searches, we found 138 research reports with 141 studies and 175 comparisons on preventing negative effects of immigration. Overall, programmes yielded an effect size of d = 0.26 at post-test using the random effect model. These effects decreased over time while still differing significantly from zero. A cross-tabulation of prevention approach/programme type by different outcome domains revealed several important results such as high effects of child cognitive and language training programmes on child academic and language outcomes and relatively low effects of all programmes on child socioemotional outcomes. In addition, individualised and culturally tailored programmes seems to be more effective. However, generalised effects on more distal educational outcomes (e.g., school degrees) were generally weak. Hence, it remains questionable whether individual psychosocial and educational programmes are able to counterbalance the multifaceted risks of immigration.     

The development of antisocial behaviour patterns in childhood and adolescence

A developmental model of antisocial behaviour is presented in this paper. Arguments and evidence are presented for the position that although many factors such as parent criminality, social and economic disadvantage, child temperament, and marital discord systematically affect the development of antisocial child behaviour, their influence is mediated by the extent to which they disrupt day-to-day parenting practices. Particularly, it is argued that irritable, ineffective discipline and poor parental monitoring are the most proximal determinants of the early development and maintenance of antisocial behaviour. The implications of this model for prevention and intervention in child conduct problems are discussed, using examples of promising clinical work that focuses on direct parent training.     

Research,policy, and the federal role in prevention initiatives for children

With the ability and the funds to implement programs on a national level, federal policy is a potentially potent tool in primary prevention. Despite the U.S. government's history of ambivalence toward intervening in child rearing and limited national support for primary prevention, several initiatives have been implemented for children and families with some measure of success. The successes, however, are mitigated by limitations of the initiatives themselves and by the inconclusive nature of much of the evaluation data. This review of 5 federal policy-based initiatives for children and families provides the backdrop for discussing aspects of federal prevention program design, implementation, policy, and research.     

Preventative Behavioral Parent Training: A Preliminary Investigation of Strategies for Preventing At-Risk Children From Developing Later Conduct Problems

Children exhibiting conduct problems comprise the largest source of referrals to children's mental health services. The treatment for conduct problems that possesses the greatest amount of empirical support is behavioral parent training. Unfortunately, a cogent approach to the identification of risk factors and prevention of chronic conduct problem display has not been developed. This project was an initial longitudinal assessment examining the merits of preventative behavioral parent training as a primary prevention strategy for at-risk children. Results demonstrated that prevention participants were engaging in normative rates of disruptive behaviors at 6-month follow-up, whereas comparison children showed a behavioral decline over time.