Behavioral profiles of children with epilepsy: Parent and teacher reports of emotional, behavioral, and educational concerns on the BASC-2

Behavioral health screening in pediatric epilepsy: Which measures commonly used in the United States are 'good enough'?

PURPOSE

To improve evidence-based implementation of behavioral health screening measures in pediatric epilepsy care, guidance is needed in the selection and interpretation of evidence-based screening measures. Therefore, the goals of this project were to (1) evaluate the clinical utility and psychometric properties of screening instruments frequently used in the United States (US) for anxiety, depression, and behavior problems in youth with epilepsy (YWE), and (2) provide guidance around selection and interpretation of these behavioral health screening measures.

METHOD

The critique was conducted in three phases: (1) identification of articles based on search criteria; (2) full review of articles for eligibility assessment; (3) evaluation of screening measures and organization into Tiers. Nine behavioral health measures frequently used to screen for anxiety, depression, and disruptive behaviors in the US were selected for evaluation. PubMed, CINAHL, Medline, and APA databases were searched using the following search terms: [target area] + [screening measure] + epilepsy + children [youth], [adolescents]. Inclusion/exclusion criteria for articles were as follows: (1) focused on YWE, (2) written in English, and (3) conducted in the US. Once articles were selected, Hunsley and Mash's criteria were used to evaluate and categorize the screening measures' psychometric properties, which have clear relevance to clinical practice. Measures were also classified into three tiers by the level of validation according to established evidence-based criteria.

RESULTS

Forty-one unique papers were identified through the literature search and assessed as eligible. Evaluation of screening measures revealed only two psychometrically sound measures that met criteria for Tier 1, the NDDI-E-Y and the Pediatric NeuroQoL-Depression, both depression screening measures. Several additional depression screening measures met criteria for Tier 2 (CDI-2, BASC-2-Depression Scale, and CBCL Withdrawn/Depressed Scale). Anxiety screening measures have not been validated in pediatric epilepsy and thus only met the criteria for Tier 2 (BASC-2 Anxiety Scale, CBCL DSM-IV Oriented Anxiety Problems Scale, MASC). Similarly for disruptive behaviors, two measures met Tier 2 criteria (BASC-2 Externalizing Problems Index, CBCL Externalizing Problems Index).

CONCLUSION

Strides have been made in the validation of behavioral health screening measures for YWE; however, continued research in this area is necessary to validate existing psychometrically sound measures and to develop and evaluate epilepsy-specific measures in the pediatric epilepsy population.

Risk factors, etiologies, and comorbidities in urban pediatric epilepsy

The Seizures and Outcomes Study in Children (SOS-KIDS) identifies risk factors, etiologies, and comorbidities in a pediatric epilepsy population in a major city with diversity in socioeconomic levels. A thorough understanding of the range of issues impacting children with epilepsy is critical to establishing treatment that will produce better health outcomes. SOS-KIDS is a cross-sectional cohort study of pediatric epilepsy patients who live in Washington D.C. and are evaluated at Children's National Hospital. Families were recruited at the time of the child's routine clinic appointment or inpatient visit. Information was extracted from participants' electronic medical records (EMR) and parent reports; participants were screened for comorbidities using standardized screening measures. Data were collected from 289 participants (47% female, 53% male), and mean age was 7.9 years (2 months to 17 years). Twenty-nine percent of participants had primary generalized epilepsy, 63% focal epilepsy, 0.3% combined generalized and focal epilepsy, and 8% could not be distinguished. There were a variety of epilepsy risk factors including prematurity (10%), intraventricular hemorrhage (7%), neonatal seizures (8%), and febrile seizures (17%). The most common etiologies were cerebral malformations (13%) and genetic disorders (25%). Numerous participants had documented comorbidities including developmental delay (56%), intellectual disability (20%), headaches (16%), attention-deficit hyperactivity disorder (23%), and autism (7%). Of participants aged six years and older, depression, and anxiety were reported in 5% and 6% within the EMR, 14% and 19% in parent surveys, and 22% and 33% with standardized screening measures. We identified a wide variety of risk factors and etiologies among urban pediatric epilepsy patients, with genetic and structural being the most common. Neurologic and psychiatric comorbidities were common, but the prevalence of several psychiatric disorders reported within the EMR was substantially lower compared to that found when using parent surveys and standardized screening measures.

Examining relations between neuropsychological and clinical epilepsy-specific factors with psychopathology and adaptive skills outcomes in youth with intractable epilepsy

Pediatric epilepsy is a prevalent childhood neurological disorder. Youth with a diagnosis of medically uncontrollable or intractable epilepsy are at increased risk for poor neurocognitive and psychosocial functioning. To date, there is a paucity of clinical research examining and/or characterizing the relations of neuropsychological, clinical, and epilepsy-specific medical factors in clinical outcomes among youth with diagnosed intractable epilepsy. One hundred and twenty-six patients (6-20 years) with diagnosed intractable epilepsy and who were evaluated as part of a presurgical work-up and medical standard of care participated in a neuropsychological evaluation, including parent completion of the Behavior Assessment System for Children - Second Edition Parent Report Scale (BASC-2 PRS). Medical chart review was conducted to obtain demographic and epilepsy-specific information. Results indicated that an increase in the BASC-2 PRS Adaptive Symptoms Index T-Scores was associated with a decrease in the BASC-2 PRS Internalizing, Externalizing, and Behavioral Symptoms Index score. Additionally, the Wechsler (Wechsler Intelligence Scale for Children - Fourth Edition [WISC-IV], Wechsler Intelligence Scale for Children - Fifth Edition [WISC-V], Wechsler Adult Intelligence Scale - Fourth Edition [WAIS-IV]) Similarities z-score was associated with the BASC-2 PRS Externalizing Symptoms Index T-Score. No demographic or clinical medical factors remained in any of the three final models. Findings highlight the importance of verbal reasoning and adaptive functioning as protective factors in clinical outcomes among youth with diagnosed intractable epilepsy and may provide future direction for targeted interventions.

Overview on Emotional Behavioral Testing in Rodent Models of Pediatric Epilepsy

Psychiatric and cognitive disturbances are the most common comorbidities of epileptic disorders in children. The successful treatment of these comorbidities faces many challenges including their etiologically heterogonous nature. Translational neurobehavioral research in age-tailored and clinically relevant rodent seizure models offers a controlled setting to investigate emotional and cognitive behavioral disturbances, their causative factors, and potentially novel treatment interventions. In this review, we propose a conceptual framework that provides a nonsubjective approach to rodent emotional behavioral testing with a focus on the clinically relevant outcome of behavioral response adaptability. We also describe the battery of neurobehavioral tests that we tailored to seizure models with prominent amygdalo-hippocampal involvement, including testing panels for anxiety-like, exploratory, and hyperactive behaviors (the open-field and light-dark box tests), depressive-like behaviors (the forced swim test), and visuospatial navigation (Morris water maze). The review also discusses the modifications we introduced to active avoidance testing in order to simultaneously test auditory and hippocampal-dependent emotionally relevant learning and memory. When interpreting the significance and clinical relevance of the behavioral responses obtained from a given testing panel, it is important to avoid a holistic disease-based approach as a specific panel may not necessarily mirror a disease entity. The analysis of measurable behavioral responses has to be performed in the context of outcomes obtained from multiple related and complementary neurobehavioral testing panels. Behavioral testing is also complemented by mechanistic electrophysiological and molecular investigations.

Quality of life improves with integrated behavioral health services in pediatric new-onset epilepsy

The current study compared differences in health-related quality of life (HRQOL) between youth with new-onset epilepsy with and without elevated psychological symptoms at time of epilepsy diagnosis within an integrated behavioral health and epilepsy service. Patients received both behavioral health and epilepsy care during clinic visits. A retrospective chart review was conducted between July 2011 and December 2015. Caregivers completed the Behavior Assessment System for Children-2: Parent Rating Scale (BASC-2: PRS) to assess psychological symptoms at the diagnostic visit, along with completing the Pediatric Quality of Life Inventory (PedsQL™ 4.0) at the diagnostic visit and each subsequent epilepsy clinic visit during the first year of treatment. Latent growth curve modeling was used to identify HRQOL changes over the first year of treatment. Health-related quality of life was significantly lower for youth with elevated psychological symptoms at diagnosis and over the first year of treatment compared with those without psychological symptoms. For those with elevated internalizing, inattention, withdrawal, and atypical symptoms at diagnosis, greater HRQOL improvements were detected over the first year of treatment compared with those without elevated psychological symptoms at the diagnostic visit. Within integrated behavioral health and epilepsy routine care, targeted psychological interventions can improve HRQOL over the first year of treatment, particularly for those with premorbid psychological symptoms.

Clinically Significant Psychological and Emotional Distress in 32% of Adolescent Idiopathic Scoliosis Patients

STUDY DESIGN

Prospective study of 92 patients.

OBJECTIVES

To determine if the incidence of clinically significant psychological and emotional distress in adolescent idiopathic scoliosis (AIS) patients is higher than the general population and if this correlates with deformity severity.

SUMMARY OF BACKGROUND DATA

Adolescents with scoliosis may exhibit a less positive outlook on life, suffer from lower self-esteem, and have more difficulty connecting with peers; however, there is conflicting evidence whether different stages of treatment prompt different psychological problems and the long-term psychological effect of scoliosis.

METHODS

Patients aged 12-21 years with a diagnosis of AIS were included. The Behavioral Assessment System for Children, Second Edition (BASC-2), is a validated 139-item survey normed on more than 1 million children in the United States. It can detect clinical and subclinical levels of psychosocial problems in five domains: school problems, internalizing problems, inattention/hyperactivity, emotional symptoms index, and personal adjustment. The BASC-2 self-report form was completed by 92 adolescents with AIS (mean age = 14 years; range 12-18) and a parent. BASC-2 scale scores were compared to validated age-matched normative data. Comparisons were made between those undergoing surgery (n = 31), bracing (n = 31), or observation (n = 30) at the start of treatment.

RESULTS

32% (29/92) of patients scored in the clinically significant range in at least one of the subscales. There were no clinically significant emotional or behavioral differences when stratified by treatment type (p = .560), Cobb angle (0.630), or age (0.313). Twenty-one percent (19/92) of parent responses deemed their kids as having clinically significant emotional or behavioral differences. In only 34% (10/29) of the cases did children and parent concurrently report clinically significant psychological difficulties, such that 66% of parents were unaware that their child has clinically significant emotional or behavioral problems.

CONCLUSIONS

AIS patients undergoing observation, bracing, and surgery are all at risk for clinically significant psychological symptoms.

LEVEL OF EVIDENCE

Level II.

Executive Dysfunction and Depression in Pediatric Temporal Lobe Epilepsy: The Contribution of Hippocampal Sclerosis and Psychosocial Factors

OBJECTIVES

Temporal lobe epilepsy (TLE) has been identified as a risk factor for increased depression features in children and adolescents; however, less is known regarding specific neurocognitive predictors of depression in this population above and beyond seizure-specific and sociodemographic factors.

METHODS

The study included 62 patients with TLE (64% male) aged 8 to 16 years (M=12.62; SD=2.26) who underwent comprehensive neuropsychological evaluation.

RESULTS

Correlation analyses revealed significant association between patient depression and WCST Total Perseverations, BRIEF Behavioral Regulation Index (BRI) and family stress. Perseverative errors on the WCST and the BRI were found to significantly predict depression features in youth with TLE. Patient performance on WCST was also found to fully mediate the significant relationship between hippocampal sclerosis (HS) and depression in pediatric TLE. Finally, logistic regression indicated HS in the presence of TLE was associated with a four-fold risk of clinically significant depression ratings.

CONCLUSIONS

The current findings offer strong support for the relationship between executive function (EF) and depression in pediatric TLE. Also, as HS is not modifiable, these findings suggest EF intervention may be a potential modality for improving health-related quality of life (HRQOL) in youth with TLE. (JINS, 2018, 24, 606-616).

The influence of endophenotypic, disease-specific, and environmental variables on the expression of anxiety in pediatric epilepsy

Children and adolescents with epilepsy often show higher rates of anxiety, which carries an increased risk for reduced health-related quality of life (HRQOL). The current study assessed the role of parental psychiatric history (i.e., anxiety, depression, and/or bipolar disorder) on the rate of anxiety features in youth seen in a tertiary epilepsy clinic. Data included parental ratings on the Behavior Assessment System for Children (BASC-2) and the Quality of Life in Childhood Epilepsy (QOLCE) questionnaire for 180 children and adolescents (mean age=11.40, SD=3.98). Our results identified clinically elevated anxiety ratings in nearly half the sample (47%) with previous psychiatric history endorsed by 48% of parents. The effect of parental psychiatric history on youth anxiety was found to be significant and associated with a threefold increase in the rate of youth anxiety features. This risk increased to fourfold in refractory epilepsy, and the impact of family psychiatric history is greater in adolescent females and in families that report higher levels of stress. In those families who reported no psychiatric history, anxiety was best predicted by epilepsy-specific factors above and beyond sociodemographic factors. Parental psychiatric history was also identified as a significant risk factor for diminished patient HRQOL, even after accounting for seizure control. These findings highlight the impact of family and epilepsy factors on psychological functioning and offer further support for the strong relationship between parental adjustment and child outcome in pediatric epilepsy.

The relationship of seizure focus with depression, anxiety, and health-related quality of life in children and adolescents with epilepsy

For youth with epilepsy, comorbid psychiatric conditions, such as depression and anxiety, require further examination as they carry increased risk for reduced health-related quality of life (HRQOL). The current study assessed whether rates of depression, anxiety, and withdrawal behaviors differed based on seizure location. Data included parental ratings on the Behavior Assessment System for Children (BASC-2) and the Quality of Life in Childhood Epilepsy (QOLCE) questionnaire for 132 children and adolescents (mean age=11.34, SD=3.95) with generalized or partial (i.e., frontal [FLE] or temporal lobe epilepsy [TLE]) epilepsy. Our results identified clinically significant internalizing psychopathology in nearly half of our sample (41%). Although rates of internalizing behavior were similar between generalized and partial groups, children and adolescents with TLE demonstrated higher rates of depression compared to youth with FLE. No effects of laterality on internalizing behaviors were identified between TLE and FLE groups. Finally, for youth with TLE, parental depression ratings along with current number of antiepileptic medications (AEDs) were found to be significant barriers to HRQOL above and beyond anxiety, withdrawal, and epilepsy-specific variables. Temporal lobe epilepsy was associated with a two-fold risk of clinically significant depression ratings. These findings highlight the high prevalence of internalizing psychopathology features in pediatric epilepsy and offer further support for the relationship between depression and TLE in children and adolescents with epilepsy.

Parental experiences before and long-term after their children's hemispherotomy - A population-based qualitative study

Severe childhood epilepsy has an impact on the whole family. For selected children, hemispherotomy is the treatment of choice. The aim of this study was to explore parents' experiences before and after hemispherotomy as reported at a long-term follow-up and their view on received information and support. This was a population-based qualitative descriptive study, using qualitative content analysis of interviews. Seven to eighteen years after hemispherotomy, parents of twenty-one operated children were interviewed about the family life situation, expectations before surgery, and support and information before and after surgery. Before surgery, the theme 'Living in a chaotic bubble' illuminates how parents felt: the family lived in isolation, they felt both dissatisfaction and satisfaction about support and information, and they experienced that surgery was a question about life or death. After surgery, the theme 'Hovering between success and disaster' illuminates how parents hovered between happiness if the surgery was successful and sadness about e.g., complications and behavior problems. They experienced both excellent and poor support, in hospital and at rehabilitation. Regardless of all concerns, parents were satisfied that the child had received an operation. The hemispherotomies were successful and generated a better life situation. However, in order to cope, families need support and information throughout the whole process, from the onset of epilepsy and for a long time after surgery. If the child has behavior problems, an assessment should be made before surgery in order for the families to get adequate support. The specialist team needs to be involved as early as possible and follow the families for several years after surgery. Focus should be on the whole family, if needed including grandparents; family-centered care might be relevant for this patient group.

Predictors of trajectories of epilepsy-specific quality of life among children newly diagnosed with epilepsy

OBJECTIVE

The objective of this study was to identify two-year trajectories of epilepsy-specific health-related quality of life (HRQOL) among children newly diagnosed with epilepsy and to evaluate the predictive value of a comprehensive set of medical, psychosocial, and family factors.

METHODS

Ninety-four children with epilepsy (8.14 ± 2.37 years of age and 63% male) and their caregivers participated in this study. Caregivers completed the Quality of Life in Childhood Epilepsy Questionnaire (QOLCE) and measures of psychological and family functioning at one month postdiagnosis. The QOLCE was also given at eight additional time points during the subsequent two years as a part of a large observational study in children with epilepsy. Adherence data were collected via MEMS TrackCaps, and medical information was collected through chart review.

RESULTS

Unique trajectories were identified for the overall QOLCE scale, as well as the subscales. Most trajectory models for the QOLCE subscales contained at least one at-risk trajectory for children, indicating that there is a subgroup of children experiencing poor long-term HRQOL. Health-related quality-of-life trajectories remained predominantly stable during the two-year period following treatment initiation. The number of AEDs, internalizing problems, and externalizing problems emerged as the most consistent predictors across the HRQOL domains.

SIGNIFICANCE

Medical and psychosocial interventions, such as cognitive-behavioral strategies, should target modifiable factors (e.g., internalizing symptoms, externalizing symptoms, number of AEDs trialed) shortly after diagnosis to improve HRQOL for children with epilepsy over the course of their disease.

Comorbidity of childhood epilepsy

Epilepsy in children is occasionally associated with variable comorbidities although the frequency of such comorbidity is often difficult to determine. They can be divided into three categories: neurological, psychological, and physical comorbidities. The goal of the present review is to discuss the reported comorbidities of epilepsy in children. The possible mechanisms and associated risk factors-including the effect of seizure frequency and seizure control, types of epilepsy, age of seizure onset, duration of illness, and the possible detrimental effect of antiepileptic drugs-will be described.

Adaptive skills and somatization in children with epilepsy

Objective. Children with epilepsy are at risk for less than optimum long-term outcomes. The type and severity of their epilepsy may contribute to educational, psychological, and social outcomes. The objective of this study was to determine the relation between somatization and adaptive skills based on seizure type that could impact on those outcomes. Methods. This study examined adaptive functioning and somatization in 87 children with epilepsy using archival data from a tertiary care facility. Results. No significant differences in adaptive skills emerged between groups of children diagnosed with complex partial (CP) as compared to CP-secondary generalized (SG) seizures; however, deficits in adaptive behavior were found for both groups. The number of medications, possibly reflecting the severity of the epilepsy, was highly correlated to adaptive function. Conclusions. Identification of deficits in adaptive behavior may represent an opportunity for tailored prevention and intervention programming for children with epilepsy. Addressing functional deficits may lead to improved outcomes for these children.

Health-related quality of life before and after pediatric epilepsy surgery: the influence of seizure outcome on changes in physical functioning and social functioning

Health-related quality of life (HRQOL) is an important outcome in pediatric epilepsy surgery, but there are few studies that utilize presurgical ratings to assess the effect of surgery on HRQOL. We collected parental ratings on the Quality of Life in Childhood Epilepsy (QOLCE) questionnaire for 28 children who participated in neuropsychological assessment before and after epilepsy surgery. Our results revealed significant improvements in overall HRQOL after surgery, especially in physical and social activities. These changes were apparent despite generally unchanged intellectual and psychological functioning. Children with better seizure outcome had more improvement in HRQOL; however, improvements were not statistically different among children with Engel class I, II, and III outcomes. Our results suggest that children can experience significant improvements in HRQOL following epilepsy surgery even when neuropsychological functioning remains unchanged. Moreover, improvements in HRQOL appear evident in children who experience any worthwhile improvement in seizure control (Engel class III or better).

Early screening and identification of psychological comorbidities in pediatric epilepsy is necessary

Youth with epilepsy often have co-occurring psychological symptoms that are due to underlying brain pathology, seizures, and/or antiepileptic drug side effects. The primary study aim was to compare the psychological comorbidities of youth with new-onset epilepsy versus chronic epilepsy. Primary caregivers of youth with either new-onset (n=82; M(age)=9.9±2.9) or chronic epilepsy (n=76; M(age)=12.8±3.3) completed the Behavioral Assessment Scale for Children-2nd Edition. Compared to those with new-onset epilepsy, the chronic group had significantly higher depressive and withdrawal symptoms, as well as lower activities of daily living. A higher proportion of youth with chronic epilepsy exhibited at-risk/clinically elevated depressive symptoms and difficulties with activities of daily living compared to the new-onset group. Proactive screening in youth with epilepsy to ensure timely identification of psychological symptoms and to guide early psychological intervention is warranted.

Extratemporal, nonlesional epilepsy in children: postsurgical clinical and neurocognitive outcomes

OBJECT

Patients undergoing epilepsy surgery without evidence of a lesion on MR imaging and without a temporal source for seizure onset generally have less favorable outcomes than patients with structural lesions or temporal onset. However, many of these patients are viable candidates for invasive monitoring and subsequent resection or multiple subpial transections (MSTs). The purpose of this study was to evaluate the surgical treatment of pediatric patients with extratemporal, nonlesional epilepsy in order to better understand the clinical and neuropsychological outcomes expected in this patient group.

METHODS

Forty-three pediatric patients with negative results on MR imaging and lateralized, extratemporal findings on electroencephalography underwent invasive monitoring with grid and/or strip electrodes. Thirty-three subsequently had resection of an epileptogenic focus and/or MSTs.

RESULTS

Outcome was classified as Engel class I or II in 54.5% of the patients who underwent resection/MSTs and Engel class III or IV in 45.5%. Use of MSTs was associated with poor outcome. Neuropsychological evaluation showed significant improvement in immediate auditory attention following surgery and revealed several significant results on subgroup analysis. Complications occurred in 14% of patients (a 7% rate per procedure). Ten patients (23%) underwent invasive monitoring without proceeding to therapeutic surgery because no epileptogenic region was amenable to resection. Neuropsychological outcomes were generally stable.

CONCLUSIONS

Patients with extratemporal, nonlesional seizures are viable candidates for invasive monitoring with grid/strip electrodes, and good outcomes can be obtained with resective surgery. The use of MSTs may correlate with worse outcome. This study also provides additional data to assist in counseling patients on the risks of negative invasive monitoring, deficits resulting from resection/MSTs, and possible operative complications.

Examining health-related quality of life, adaptive skills, and psychological functioning in children and adolescents with epilepsy presenting for a neuropsychological evaluation

The purpose of this study was to characterize 132 children and adolescents (mean age = 10 years, 11 months) with epilepsy in terms of psychosocial functioning and to determine the extent to which adaptive skills and psychological functioning predict health-related quality of life (HRQOL), above and beyond demographic and epilepsy-specific characteristics. A chart review was conducted to obtain demographic and epilepsy-specific information as well as caregiver responses on the Behavior Assessment System for Children, Second Edition (BASC-2) Parent Report and the Quality of Life in Childhood Epilepsy Questionnaire (QOLCE). In addition to Full Scale IQ and age at seizure onset, the BASC-2 Clinical and Adaptive Skills subscales also predicted HRQOL, indicating that this measure may be particularly helpful in predicting HRQOL above and beyond information routinely collected in a medical setting. It is imperative to evaluate children with epilepsy for psychosocial difficulties and diminished HRQOL to ensure the provision of comprehensive quality care and intervention services.

Parents report more ADHD symptoms than do teachers in children with epilepsy

Children with epilepsy have a high rate of attention deficit/hyperactivity disorder (ADHD), yet parent-teacher agreement on ADHD symptoms in epilepsy is unknown despite the need to assess symptoms across settings such as home and school. Parent-teacher agreement on ADHD ratings was investigated in 208 children with epilepsy (mean age = 11.2, SD = 3.6) using the ADHD Rating Scale IV, along with associations with demographic variables, epilepsy severity, adaptive level, and quality of life. Children were four times more likely to be identified as having clinically elevated ADHD symptoms when parent ratings were the benchmark versus teachers. Agreement was highest for children with more severe ADHD symptoms, for the Hyperactivity-Impulsivity dimension of behavior, and for children with broadly normal adaptive behavior. Higher parent and teacher ADHD ratings were related to reduced quality of life, but unrelated to epilepsy severity. Exclusive reliance on parent or teacher ratings may yield variable rates of ADHD symptoms in children with epilepsy.

Depression and anxiety in children and adolescents with epilepsy: prevalence, risk factors, and treatment

Among the psychiatric comorbid conditions in children and adolescents with epilepsy, depression and anxiety disorders require further attention because they carry the risk of reduced quality of life and life-threatening complications (e.g., suicide). Research in recent years has shed light on both the prevalence of emotional problems in youth with epilepsy and the safety and efficacy of treatment options. A number of challenges exist in treating patients with epilepsy. This is particularly true when seizures are difficult to control and medication regimens are more complex. Some pharmaceutical options may provide assistance with both seizures and emotional distress, but care is needed when considering such treatment approaches. In addition, integration of mental health professionals into the care of patients is necessary when cases are complicated and risk factors are high. Thorough methods to accurately diagnose emotional conditions and regular monitoring of symptoms can help prevent serious problems that can negatively affect the success of children and adolescents in everyday life. Collaboration between disciplines offers the best hope for early identification and treatment of these conditions.