Editorial: Making clinical trials smarter (and more interesting)

At its heart, the field of child psychology and psychiatry is geared towards using science to develop interventions that promote children's healthy development and treat behavioural and emotional difficulties when they arise. While there have been some successes (e.g. stimulant medication for ADHD, parent training for child conduct problems, Fonagy et al., ) serious challenges lie ahead if we are to achieve reliable and lasting improvements for a larger number of children, and for a broader spectrum of problems.

Quality Improvement Activities and Expanded School Mental Health Services

Quality improvement (QI) activities, designed to enhance program evaluation efforts and to improve quality of care, have become increasingly important in children’s services research. QI activities examine outcomes and provide accountability data that can be very useful for telling the story of the development, implementation, and effectiveness of expanded school mental health (ESMH) programs. This article discusses the implementation and results of QI activities for two ESMH programs, one relatively new program, and one with 10 years of experience. When presenting each case example, the authors review key QI activities such as developing new measures and interventions, evaluating costs of care, and disseminating results to clinicians, program administrators, and funders. The article concludes with a discussion of the importance of QI in school-based mental health and reviews directions for future research and program development.

Adults' Insensitivity to Developmental Changes in Children's Ability to Report When and How Many Times Abuse Occurred

In legal settings, children are frequently asked to provide temporal information about alleged abuse, such as when it occurred and how often. Although there is a sizeable body of work in the literature regarding children's ability to provide such information, virtually nothing is known about how adults evaluate the veracity of that information. This omission is especially noteworthy given that adults' evaluations are critical to the progression and outcome of legal cases. We examined adults' perceptions of children's reports of temporal details regarding alleged sexual abuse. We varied both children's age (6 vs. 11 years) and how certain children were when providing such details to assess whether adults were sensitive to changes in how children of different ages typically talk about temporal information. With regard to credibility, adults were insensitive to children's age, perceiving younger and older children who reported temporal details with confidence as more credible than those who reported information tentatively. Normative developmental trends, however, would suggest that, with age, children are often tentative when reporting true temporal details. With regard to perceptions of children's accuracy in reporting temporal information, adults found younger children who were confident to be the most accurate. Regarding guilt judgments, adults rated defendants as having a higher degree of guilt when children were confident in reporting temporal details. The findings have implications for juror decision-making in cases of alleged sexual abuse in which children report when or how often abuse occurred. Copyright © 2016 John Wiley & Sons, Ltd.

Editorial: Trials and tribulations in child psychology and psychiatry: what is needed for evidence-based practice

If your child had leukaemia you would be distraught. Yet, there would also be hope. Most children with a diagnosis of leukaemia start their treatment as part of ongoing trials. The clinical teams looking after such children are motivated, knowledgeable and work in centres that specialise in the treatment of this lethal illness. The results speak for themselves. Not only have the trials helped oncologists learn more about which treatments work best. For years we have known that those who enter trials do better than those patients with similar characteristics who don't. We have recently also learnt that trials improve survival rates in those cancers population wide: the annual reduction between 1978-2005 in risk of death from childhood cancers ranged from 2.7% to 12.0%. This cancer trial culture is a splendid example of British health care delivery. What is happening in child psychiatry, though? If your child had, say, depression you would have every reason to be distraught too. The mortality rate is higher than in the general population and the burden of disease in the long run heavier than that of cardiovascular illness or cancer. Yet, your child would not have access to a trial. Instead, you would probably struggle to have your child's depression recognised in the first place. The care you would get would be determined by extreme regional variations and by what resources are available to local services and often the ideology or preferences of practitioners.

Editorial: Illuminating the dark matter of developmental neuropsychiatric genetics - strategic focus for future research in child psychology and psychiatry

Research on genetic factors influencing cognitive and behavioural traits or which are central to the aetiology of neuropsychiatric diseases has been complicated by a furtive discrepancy between high heritability estimates and a scarcity of replicable gene-disorder associations. This 'missing heritability' has been either euphemised as the 'dark matter' of gene-trait association or aggravated as the 'looming crisis in behavioural genetics'. Nevertheless, in recognising the importance of this topic for our understanding of child psychiatric conditions and highlighting its commitment to the field, the Journal of Child Psychology and Psychiatry (JCPP) has for the first time appointed an editor with special responsibility for molecular (epi)genetics.

Reflections on developing collaborative research in pediatric psychology: implications and future directions

OBJECTIVES

Collaborative research with pediatric colleagues has become increasingly important in the professional agenda of pediatric psychology, and there is a continuing need to articulate the challenges of such research. To address this need, this article describes types of collaborative research, reasons for collaboration, collaborative process, challenges, and strategies to facilitate collaborative research.

METHODS

Experiences and lessons learned over the course of a career in collaborative research are described.

RESULTS

Challenges in collaborative research can be overcome by effective strategies of engagement and communication. Useful methods of training researchers in collaborative research include modeling and supervised mentored experiences in research initiated by trainees.

CONCLUSION

Data are needed to identify the characteristics of successful collaborative research, strategies to promote effective research, and methods of training and career development.

Oh how I try to use evidence in my social work practice: efforts, successes, frustrations, and questions

Convinced by the literature that they could do better for their clients, in this article the authors describe their efforts to transform a categorically-funded program model at one agency from relying on authority and good intentions to evidence-based practice (EBP). Using a case study approach the authors describe a six-year research effort in which they experienced a modicum of success, including completion of a few projects, followed by paralyzing frustrations that warrant sharing with other social work professionals. Reflecting on their experiences, they posit a few questions about EBP for practitioners and leaders in the profession to contemplate. The authors then offer five pathways for moving the profession closer to making EBP a reality in social work.

Overview of diagnosis and management of paediatric headache. Part I: diagnosis

Headache is the most common somatic complaint in children and adolescents. The evaluation should include detailed history of children and adolescents completed by detailed general and neurological examinations. Moreover, the possible role of psychological factors, life events and excessively stressful lifestyle in influencing recurrent headache need to be checked. The choice of laboratory tests rests on the differential diagnosis suggested by the history, the character and temporal pattern of the headache, and the physical and neurological examinations. Subjects who have any signs or symptoms of focal/progressive neurological disturbances should be investigated by neuroimaging techniques. The electroencephalogram and other neurophysiological examinations are of limited value in the routine evaluation of headaches. In a primary headache disorder, headache itself is the illness and headache is not attributed to any other disorder (e.g. migraine, tension-type headache, cluster headache and other trigeminal autonomic cephalgias). In secondary headache disorders, headache is the symptom of identifiable structural, metabolic or other abnormality. Red flags include the first or worst headache ever in the life, recent headache onset, increasing severity or frequency, occipital location, awakening from sleep because of headache, headache occurring exclusively in the morning associated with severe vomiting and headache associated with straining. Thus, the differential diagnosis between primary and secondary headaches rests mainly on clinical criteria. A thorough evaluation of headache in children and adolescents is necessary to make the correct diagnosis and initiate treatment, bearing in mind that children with headache are more likely to experience psychosocial adversity and to grow up with an excess of both headache and other physical and psychiatric symptoms and this creates an important healthcare problem for their future life.

Overview of diagnosis and management of paediatric headache. Part II: therapeutic management

A thorough evaluation of headache in children and adolescents is necessary to make the correct diagnosis and initiate treatment. In part 1 of this article (Özge et al. in J Headache Pain, 2010), we reviewed the diagnosis of headache in children and adolescents. In the present part, we will discuss therapeutic management of primary headaches. An appropriate management requires an individually tailored strategy giving due consideration to both non-pharmacological and pharmacological measures. Non-pharmacological treatments include relaxation training, biofeedback training, cognitive-behavioural therapy, different psychotherapeutic approaches or combinations of these treatments. The data supporting the effectiveness of these therapies are less clear-cut in children than in adults, but that is also true for the data supporting medical treatment. Management of migraine and TTH should include strategies relating to daily living activities, family relationships, school, friends and leisure time activities. In the pharmacological treatment age and gender of children, headache diagnosis, comorbidities and side effects of medication must be considered. The goal of symptomatic treatment should be a quick response with return to normal activity and without relapse. The drug should be taken as early as possible and in the appropriate dosage. Supplementary measures such as rest in a quiet, darkened room is recommended. Pharmaco-prophylaxis is only indicated if lifestyle modification and non-pharmacological prophylaxis alone are not effective. Although many prophylactic medications have been tried in paediatric migraine, there are only a few medications that have been studied in controlled trials. Multidisciplinary treatment is an effective strategy for children and adolescents with improvement of multiple outcome variants including frequency and severity of headache and school days missed because of headache. As a growing problem both children and families should be informed about medication overuse and the children's drug-taking should be checked.

The children's services interview: validity and reliability

BACKGROUND

The Children Service Interview was designed as a brief measure of service use related to mental health problems in Great Britain.

METHOD

We validated the Children's Services Interview against medical records from a sample of 87 children, and assessed test-retest reliability from 25 parents completing two interviews. We examined criterion validity by looking at the service use patterns of children attending clinics for different types of disorders.

RESULTS

The Children's Services Interview showed high levels of face validity and moderate or better concordance with medical records as far as contacts were recorded in the case notes. Test-retest reliability was moderate or better apart from contacts with the voluntary sector, teachers, and the number and duration of appointments with some professionals.

CONCLUSION

The study suggests the Children's Services Interview can extract moderately valid and reliable data on service use.

DECLARATION OF INTEREST

Tamsin Ford was supported by a Wellcome Clinical Training Fellowship in Health Services Research while completing this work.

Using projective techniques in the evaluation of groups for children of rehabilitating drug addicts

Evaluators and researchers often have to deal with situations in which conventional research tools are impossible to use, either because of the characteristics of a population or unclear research variables. This paper presents a technique that succeeds in overcoming this kind of problem--a projective technique, but one that differs from the usual approach to projective techniques. The approach presented here is a hermeneutic one that assumes an interpretive process. By means of an example, this paper presents the process of working with projective techniques and concludes with a discussion of this approach.

Getting down to business: defining competencies for entry-level youth workers

In January 2004, the National Collaboration for Youth approved a list of core competencies needed by entry-level youth development workers for effective youth development practice. This chapter provides an overview of these competencies, explaining why and how the list was created, outcomes, and recommendations for next steps.

Achieve Boston: a citywide innovation in professional development

Achieve Boston is a broad-based collaborative effort to improve the overall quality of programs for children and youth by establishing a professional development infrastructure that supports those who work with young people during the out-of-school-time hours.

Professional development in the youth development field: issues, trends, opportunities, and challenges

This chapter reviews key issues in professional development in the youth development field, describing important work done over the past two decades and lessons learned from major philanthropic investments in capacity building both nationally and locally.

Professionalizing youth development: the role of higher education

Certificates, credentials, and degrees offered through institutions of higher education allow youth development professionals to acquire educational experiences that are recognized in a formal manner.

The intermediary role in youth worker professional development: successes and challenges

This chapter examines the role of a national network of local and regional intermediary organizations in initiating and sustaining community-based youth worker professional development systems. This approach is instructive for other intermediaries in establishing training standards, assessing impact, providing organizational supports for youth development workers, and going to scale.

Steps toward a clinically relevant science of interventions in pediatric settings: introduction to the special issue

OBJECTIVE

To describe methods and strategies to advance the science of interventions in pediatric psychology.

METHODS

We consider the advantages of various strategies to develop and extend the applications of intervention research in pediatric practice settings.

RESULTS

Strategies are needed to enhance application of empirically supported interventions to pediatric settings, including testing the generalizability of empirically supported interventions in clinical samples, developing interventions based on clinical experience and tested in controlled clinical trials, designing program evaluations in the context of practice settings, and conducting case studies and series. Critical next steps in intervention research include documenting the clinical significance of interventions, conducting multisite research concerning interventions, including interventions conducted in clinical settings, and implementing integrated clinical intervention and research. Training in empirically supported treatments and intervention research and developing policy related to intervention research would also promote a clinically relevant scientific agenda concerning intervention research with pediatric populations.

CONCLUSIONS

Pediatric psychologists have the opportunity to develop a clinically relevant science of interventions in pediatric settings by using multiple methods and strategies.

Evaluating outpatient pediatric psychology services in a primary care setting

OBJECTIVE

To provide descriptive and outcome information of an outpatient pediatric psychology clinic based in a medical center in a major metropolitan area.

METHODS

We coded the characteristics and outcomes of 100 patients prospectively on a number of dimensions. Surveys and interviews were used to gather follow-up information.

RESULTS

The majority of patients were Caucasian boys (n = 56 out of 100) between 2 and 12 years of age. The most common reasons for initiating contact with the clinic were assessment of school problems, behavior problems, anger, attention problems, depression, and temper tantrums. Eighty-one percent of the patients saw a therapist for brief treatment, between one and five sessions, and behavioral treatments were administered for the majority. The children's behavior for which the parents sought treatment improved significantly from pre- to posttreatment, as rated by parents and therapists.

CONCLUSIONS

Overall, parents were satisfied with the services received and indicated that the recommendations given during therapy were helpful and easy to implement. This study provides general evidence for the effectiveness of pediatric psychology services.

Empirically supported treatments in pediatric psychology: regimen adherence

OBJECTIVE

To review empirical studies of psychological interventions for nonadherence to medical regimens for three chronic illnesses: asthma, juvenile rheumatoid arthritis (JRA), and type 1 diabetes.

METHODS

The Chambless criteria for "promising," "probably efficacious," or "well-established" were applied to 8 intervention studies on asthma, 4 on JRA, and 11 on type 1 diabetes.

RESULTS

For asthma, organizational strategies appear probably efficacious in promoting adherence, whereas educational and behavioral strategies appear promising. For JRA, behavioral strategies appear probably efficacious in improving adherence. For type 1 diabetes, multicomponent packages and operant learning procedures appear probably efficacious, whereas cognitive-behavioral strategies appear promising. No interventions were identified as "well-established."

CONCLUSIONS

Future studies will need to develop adequate definitions of adherence, accurate methods of assessing adherence, and appropriate designs to evaluate multicomponent treatment programs to advance interventions to the "well-established" category.

[Decision of German Supreme Court on July 30, 1999 relating to scientific evidence requirements for psychological expert opinion with respect to credibility of testimony and its consequences for future expert consultation]

Basically nothing has been changed by this significant, clarifying, establishing and, most important, determining decision of the Highest Federal Court concerning the specific methods long since applied by experts in the field of deciding whether or not a testimony is believeable. None the less such a decision through the higher courts was obviously long overdue because numerous opinions of experts utilized in court cases were reached by applying methods not free of fault. The psychological evaluation of the content of truth in a testimony in cases of sexual abuse will therefore still be established with help of a methodical procedure of steps made under the assumption that statements pertaining to personal experiences differ in quality from those resulting from imagination in their characteristics of reality.

Methodological issues in analyzing psychological test scores in pediatric clinical trials

Clinical trials to address drug dosing, safety, and efficacy issues in the pediatric population are becoming more common. In some studies, tests of mental ability are administered at regular intervals in drug trials for treatment of children with HIV, certain types of cancer, sickle cell anemia, and diabetes. The test scores are used to examine differences between treatments in efficacy and safety over time. In addition to the well-known problems of analyzing repeated measures with incomplete data profiles, the analyses of these data are complicated by a number of unique features, including that children can be so ill that their raw scores cannot be mapped to a normed scaled score, and that children may be in the studies long enough that they transition between the age-appropriate instruments. These issues are often ignored in data analyses and can potentially cause incorrect conclusions regarding treatment efficacy and safety. This article describes these issues and their possible consequences. A simple approach to determine their impact on the statistical analysis of a particular clinical trial is suggested. The approach is illustrated with data from a Phase III trial in HIV-infected children.

Low-end specificity of childhood measures of emotional distress: consistent effects for anxiety and depressive symptoms in a nonclinical population

Previous research regarding the low-end specificity of self-report measures of affective distress in children suggests that defensiveness acts differentially to lower scores on self-report measures of depressive symptoms, but not on self-report measures of anxiety. This investigation examined this issue in a nonclinical sample of 442 children, ages 7 to 16. Participants completed measures of depressive symptoms (Children's Depression Inventory), anxiety symptoms (State-Trait Anxiety Inventory for Children) and defensiveness (Children's Social Desirability Scale). In contrast to previous research, the results in this study indicated similar effects of defensiveness on measures of depressive symptoms and anxiety. Low-end depression participants obtained significantly higher defensiveness scores, as did low-end anxious participants. In an attempt to circumvent the effects of defensiveness, we measured anhedonia (Pleasure Scale for Children, or PSC) as a proxy of depressive symptoms. We also found the PSC to be subject to the effects of defensiveness at approximately the same magnitude as the measures of anxiety and depressive symptoms.

Empirically supported psychosocial interventions for children: an overview

Discusses issues related to the identification of psychosocial interventions for children that have demonstrated efficacy. Recent debate concerning differences between clinical trials research and clinical practice is summarized, including the tradeoff between interpretability (internal validity) and generalizability (external validity) of outcome studies. This article serves as an introduction to the special issue containing articles that have as their focus the identification of empirically supported psychosocial interventions for children as part of a task force. The article provides an overview of the history, agenda, and methodology used by the task force to define and identify specific empirically supported interventions for children with specific disorders. Whereas a number of well-established or probably efficacious interventions are identified within the series, more work directed at closing the gap between research and practice is needed.

Finding, evaluating, refining, and applying empirically supported treatments for children and adolescents

Structured child and adolescent treatments, tested through controlled clinical trials, have produced beneficial effects in hundreds of studies. By contrast, the limited pool or research on traditional clinical treatments raises doubts about their effectiveness. Thus, identification of empirically supported treatments may contribute something of real value to clinical practice and training. The Child Task Force report represents an important initial step in this direction. Here we offer both praise and critique, suggesting a number of ways the task force process and product may be improved. In addition, we suggest several ways to strengthen and enrich the clinical trials research available to the Task Force, emphasizing the need to test empirically supported treatments with referred youth in practice settings.

Empirically supported treatments for children with phobic and anxiety disorders: current status

Reviews the empirically supported status of behavioral and cognitive-behavioral interventions in the treatment of childhood phobias and anxiety disorders. For childhood phobias, it is concluded that imaginal desensitization, in vivo desensitization, filmed modeling, live modeling, and cognitive-behavioral interventions that use self-instruction training are probably efficacious and that participant modeling and reinforced practice are well established. For anxiety disorders, only cognitive-behavioral procedures with and without family anxiety management (FAM) were found to be probably efficacious. However, much of the support for these procedures comes from analogue studies conducted in research laboratory or school settings, delivered in small-group format and, not infrequently, with nonclinically referred children. Additional research that examines high-strength interventions with clinic-referred children is recommended. Furthermore, research that examines the pathological processes involved in the onset and maintenance of phobic and anxiety disorders as well as the change processes used to treat these disorders is called for.

Toward terminological, conceptual, and statistical clarity in the study of mediators and moderators: examples from the child-clinical and pediatric psychology literatures

Numerous recent attempts to identify mediated and moderated effects in child-clinical and pediatric research on child adjustment have been characterized by terminological, conceptual, and statistical inconsistencies. To promote greater clarity, the terms mediating and moderating are defined and differentiated. Recommended statistical strategies that can be used to test for these effects are reviewed (i.e., multiple regression and structural equation modeling techniques). The distinction between mediated and indirect effects is also discussed. Examples of troublesome and appropriate uses of these terms in the child-clinical and pediatric psychology literatures are highlighted.

Child and adolescent psychotherapy outcomes in experiments versus clinics: why the disparity?

In a recent article, Weisz, Weiss, and Donenberg (1992) compared the effects of child and adolescent psychotherapy in experimental studies and in studies of clinic practice. Here we update that report with new information and we explore 10 possible reasons why, to date, therapy in experiments appears to have shown larger effect sizes than therapy in clinics. We find that beneficial therapy effects are associated with three factors which are more common in research therapy than in clinic therapy: (a) the use of behavioral (including cognitive-behavioral) methods, (b) reliance on specific, focused therapy methods rather than mixed and eclectic approaches, and (c) provision of structure (e.g., through treatment manuals) and monitoring (e.g., through review of therapy tapes) to foster adherence to treatment plans. These three factors all involve dimensions along which clinic procedures could be altered.

The diagnosis of child sexual abuse

OBJECTIVE

To examine how the history, psychological evaluation, medical examination, and child's response to the examination contributed to a diagnosis of child sexual abuse by an interdisciplinary team.

DESIGN

Patient series.

SETTING

Subspecialty clinic for evaluating prepubertal children alleged to have been sexually abused.

PARTICIPANTS

One hundred thirty-two children alleged to have been sexually abused and their parents or guardian, evaluated consecutively in a subspecialty clinic between September 1989 and June 1990.

MEASUREMENTS/MAIN RESULTS

A social worker interviewed the parents, a psychologist interviewed the child, and a pediatrician obtained a medical history and examined the child. Parents completed a Child Behavior Check list and the child's response to the physical examination was noted. Both a disclosure by the child and abnormal physical findings were significantly and independently associated with the team's diagnosis of sexual abuse, whereas the presence of sexualized behavior, somatic problems, and the child's response to the examination did not make an additional contribution to the diagnosis.

CONCLUSIONS

The findings support the need for a skilled psychological interview and a medical examination of a child alleged to have been sexually abused to make the diagnosis of sexual abuse. An interdisciplinary team appears to be a valuable approach for evaluating these children and their families.