Rutter's Child and Adolescent Psychiatry Book 2

4 To inform discussion and understanding of a child’s behavior and the impact a child or family is having on relationships between the agencies involved (approximately 10%). Individual psychotherapy is often carried out by other staff with teaching and supervision from a child psychotherapist. Medium- or long-term one-to-one work is a scarce, intensive and expensive resource that tends to be reserved for situations where other perspectives have been tried or are ongoing, but there are still serious problems. This is commonly where there are chronic and complex difficulties, often in the context of trauma and disrupted or abusive caregiving. Qualified child therapists can often help another colleague to do this work in the relatively less disturbed and disturbing cases. An interesting study by Kam and Midgley (2006) of one large inner city service found that almost all children referred for individual child psychotherapy were referred by other members of the CAMHS team after an average of 3 years of contact with the service and input from an average of 3–4 other CAMHS professionals. They tended to have the most complex developmental and social problems (e.g., parental mental illness, maltreatment histories). Individual therapy is often a last resort for children who are particularly hard to help. Surveys and audits show that parent, foster carer and whole family work is usually carried out while therapy is provided for an individual child; this is not routine in the treatment of older adolescents. The parent or family work may be carried out by a colleague from another discipline, another child psychotherapist or the therapist who is treating the child. There are very often concerns about child protection in cases considered for referral to a child psychotherapist and this can raise difficult issues; psychotherapy for a child currently being emotionally, physically or sexually abused is clearly not a solution to the abuse. The first priority then is the child’s safety. Some therapists may look for that to have been achieved before beginning therapy, while others may try to establish a relationship with the child while steps are being taken to make sure that the child is safe. However, this risks disruption of the new therapeutic relationship if the child is removed from the current home or care environment to live outside the area. Child psychotherapists often carry out assessment work with the courts, and mostly carry out their ongoing therapeutic work with children who – even if still in unsatisfactory or disrupted care arrangements – are at least in a safe environment. The therapist may sometimes be the only consistent figure in the child’s life over a considerable period, and may effectively become an advocate for the child’s feelings and perspective. We suggest that, in general, child psychotherapists – who are relatively few in number and expensive to train – should be kept for the more intractable cases where a briefer symptomfocused approach has been tried and failed or seems inappropriate. This is particularly important when the child’s attachment history places them beyond the reach of therapists without extensive relational training. However, to sustain this position will require controlled trials assessing effectiveness and cost-effectiveness. A developmental psychodynamic approach includes a model of attachment processes and the ways in which the development of (for example) the social cognitive capacities of regulation of emotion and attention, and social understanding are shaped by early experiences particularly within the family. This framework also gives a rationale for relatively long-term work with a child to help build more positive capacities and to help the child to develop more coherent and effective social and mental functioning, and to increase resilience to cope with often ongoing trauma and dislocation (e.g., from disrupted care placements). Research needs to be designed that can include the type of children often seen by child psychotherapists, and that can follow up their outcomes in the longer term. Finally, we come to issues of training, treatment integrity and monitoring. In the UK, psychoanalytic child psychotherapists have a 4-year full-time training, usually based in a multidisciplinary CAMHS team, which includes supervised clinical practice, theoretical work and intensive personal psychotherapy. Trainees are required to have considerable work experience with children prior to starting. A masters-level preclinical course is followed by 4 years of clinical training. Most available training courses are accredited as professional doctorate programs. Personal therapy is required because child psychotherapists’ work with profoundly disturbed and disturbing children and parents will often be distressing or unnerving to the therapist. The therapist is thought to gain two advantages from personal therapy: the first is resolution of disturbances in the therapist’s own personality, which might complicate the relationship with patients, and the second is to give an intensive and direct experience of the process that the patient will later experience. Without such personal experience, intensive work with highly vulnerable and disturbed children could be damaging rather than therapeutic. Close awareness of the phenomena involved not only helps the qualified therapist to tolerate, conceptualize and work with profound disturbances of development and functioning, but also helps him or her to teach and supervise other workers who have not had psychoanalytic training or therapy but who wish to gain experience with the techniques. Every child psychotherapy post in the NHS has a set of skills and competencies (covering clinical, management and research knowledge) established within the knowledge and skills framework. This skill-set is individually reviewed annually and modified as needed. Maintenance of competence is through the registration requirements for continuing supervision and continuing professional development. Conclusions Psychodynamic psychotherapy is one of the oldest theory-driven forms of psychological treatment of mental disorders. The personal meaning of the discourse concerning the subjective world behind behavior has inspired many generations of clinicians. Psychodynamic ideas are applied in contexts well beyond the treatment of psychiatric disorders, including CHAPTER 66 1088 9781405145497_4_066.qxd 29/03/2008 02:59 PM Page 1088

psychology, other social sciences, literature and the arts. Sadly, empirical investigations of both its underlying constructs and its therapeutic outcomes are still in their infancy. The shortcomings of the psychodynamic approach are considerable and include: 1 Shortage of operationalization; 2 Uncritical application of a relatively uniform approach to a wide range of disorders; 3 Limited amount of good evidence supporting its efficacy; 4 Over-reliance on individual case reports for helping theory and technique develop; 5 Common vagueness of treatment goals; 6 Possibility of unnecessarily prolonged treatment and even iatrogenic effects; 7 Significant heterogeneity of theoretical and linked clinical approaches calling themselves psychodynamic almost defying integration and rationalization; and 8 Antagonism on the part of many psychodynamic practitioners to the idea of systematic evaluation and scrutiny. Notwithstanding these limitations, we remain convinced of the unique value of the psychodynamic approach, not only as a methodology for the study of the psychological difficulties of childhood, but also as a method of clinical intervention with children who are hard to reach using other methods. Considerable work remains to be done but a new culture of research is now emerging within the psychoanalytic community. It is, we believe, a realistic hope that over the next decade a substantial evidence base will emerge for child treatment. This would delineate the specific value of the approach for the long-term development of children with psychological disorders. Work is already under way at a number of centers internationally and will in time show whether psychodynamic treatment works for children and, if so, for whom. References Allen, J. G., & Fonagy, P. (Eds.). (2006). Handbook of Mentalizationbased treatment. New York: Wiley. 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1092 In the final analysis, all psychiatric treatments are biological. That is, whatever their mode of delivery, theoretical basis or assumed mode of effect, they modulate, change or otherwise alter the brain functions of behavior, cognition or affect. They do so in many ways, directly through their impact on neural networks (see chapter 16), and indirectly through altering attitudes and ideas. There is no ascribed nobility, precedence or honor to either psychological or physical interventions. There is only the moral imperative to improve the lives of those who suffer, to do more good than harm and to adhere to three fundamentals of knowledge acquisition and application: developmental neurobiology, evidence-based care and the systematic application of sound therapeutic principles. Thus, although this chapter deals with physical (predominantly chemical) treatments, they hold no a priori primacy of place over non-physical interventions. This chapter addresses the third of these fundamentals – the systematic application of sound therapeutic principles – using physical interventions as the model. Developmental neurobiology (see chapter 12) can be expected to inform our understanding of both patho-etiology and therapeutic response. Evidence-based care is woven into each of the chapters of this book in which interventions for specific disorders are discussed, and the details of somatic treatments for specific disorders are dealt with there. This chapter provides the clinician with a useful framework that can be applied to any therapeutic intervention. This framework has five components: selecting a treatment target; selecting a treatment; assessment and measurement; evaluating and maximizing treatment outcome; and the human interface. Selecting a Treatment Target Medical treatments are usually applied to three target conditions: illnesses/disorders, symptoms or risk factors. The target condition may be simply the illness/disorder (e.g., hypertension), it may be a symptom, such as pain (e.g., a “tension” headache), or it may be both (e.g., pain associated with arthritis). In some cases, treatment may be targeted towards a risk factor or constellation of factors, the effective treatment of which may prevent the onset of a known mental illness. Psychiatric treatments share the same contingencies. The target condition may be an illness/disorder (e.g., panic disorder), it may be simply a symptom (e.g., self-injurious behavior) or it may be both (e.g., panic attacks occurring only in the context of a major depressive disorder). In other cases, treating a risk factor (or constellation of risk factors) may prevent the onset of a mental illness (e.g., the prodrome in schizophrenia). It is imperative that the clinician (and by extension the patient, family or responsible caregiver) understands what the treatment target is. Otherwise, treatments may be wrongly prescribed, wrongly understood or wrongly expected to produce a particular outcome. Furthermore, efforts should be made to ensure that all treatment participants (patient, clinician and others) agree on what the treatment target(s) is/are. Often there may be more than one treatment target, but at least one of these targets needs to be of significant importance to the patient. Put simply – if the patient does not buy into a treatment target it is not a treatment target. The first step in the identification of a treatment target is determining if the patient has a psychiatric diagnosis. This is performed using standard DSM or ICD criteria, applied by a trained clinician in a systematic and reliable manner. The use of idiosyncratic diagnostic criteria makes it impossible to use the generalized experience of the profession. While interviewing creativity and the use of clinically suitable yet personally unique methods of data collection are to be encouraged, in the final analysis the information collected by the clinician must allow for a reliable application to determine diagnostic classification so that other clinicians obtaining information from the patient will arrive at similar diagnostic conclusions most of the time. As psychiatric diagnoses are syndromal and are not yet based on independent objective methods of validation (e.g., laboratory tests), the clinician must be aware of the problems inherent in their use. These problems fall into two categories: composition and threshold problems. Composition difficulties arise when diagnostic categories can be realized by different combinations of their components. For example, in major depression, the DSM demands that five of nine components be present in order for the category to be confirmed. The difficulty that arises is that the composition of the category can be quite different, depending on the combination of the components being used. It is not yet clear that in all cases, similar Physical Treatments 67 Stanley Kutcher and Sonia Chehil 9781405145497_4_067.qxd 29/03/2008 02:59 PM Page 1092 Rutter’s Child and Adolescent Psychiatry, 5th Edition, Edited by M. Rutter, D. V. M. Bishop D. S. Pine, S. Scott, J. Stevenson, E. Taylor and A. Thapar © 2008 Blackwell Publishing Limited. ISBN: 978-1-405-14549-7

therapeutic interventions are useful for all combinations. In child and adolescent psychiatry, this potential confounding effect may be even greater as developmentally determined expression of individual components (symptoms) may differ depending on age, pubertal status or cognitive capacity. Threshold problems occur at the level of the components (symptoms) of the category (diagnosis). For example, sleep difficulties, such as problems falling asleep, are a symptom used to make a diagnosis of depression. The issue facing the clinician is how much sleep difficulty must be present for that problem to be considered a symptom. This is obviously a crucial issue as difficulty falling asleep can be part of usual life, a response to a stressor or a symptom of a disorder. Thus, threshold considerations must be kept in mind whenever a diagnostic interview is being conducted. If the threshold is set too low, too many components will be classified as symptoms and individuals will be diagnosed as having a disorder when the reality is rather that they may be distressed or dysphoric. In these cases, unnecessary somatic interventions may be applied. If the threshold is set too high, individuals may be incorrectly classified as not requiring medical intervention. These problems can be alleviated somewhat by the use of standardized diagnostic interviews; for example, the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS), the Diagnostic Interview for Children and Adolescents (DICA) and others (see chapter 19). However, these standardized interviews are too cumbersome for everyday application and are unlikely to be used in most clinical settings. An alternative approach is to utilize a simple diagnostic checklist, to ensure that each of the components of the diagnostic category has been addressed and occasionally to apply one of the diagnostic interviews (e.g., K-SADS) to ensure continued reliable use of threshold criteria. However, the determination of a diagnosis is not an act of clinical finality. A diagnosis is merely a hypothesis that predicts a particular outcome and leads to a specific intervention. As new information becomes available the hypothesis may need refinement or revision, or may even need to be completely discarded. As much treatment research is based on diagnostic categories, diagnostic classification can assist the clinician in choosing a particular treatment by referencing their patient’s condition to the research data. Similarly, diagnostic classification can assist the clinician in the risk–benefit evaluation pertaining to treatment. Simply put, does the risk–benefit ratio of the treatment available for the condition outweigh the risk posed by not treating the condition? The diagnosis then helps the clinician to select a particular intervention, one that has been demonstrated to be effective in ameliorating the problems for which the intervention is being sought. However, choosing a diagnosis as a treatment target, while useful and necessary, is not without problems. Given that diagnoses are syndromal, it is possible that any particular intervention may improve some components of the syndrome while not affecting others, or perhaps even worsening some. For example, a particular medication taken to treat major depressive disorder may improve mood but may worsen sleep and enhance anxiety. Furthermore, some components of the syndrome may exhibit different phase effects in response to the same intervention. For example, in a young psychotic patient, an antipsychotic medication may show a positive effect on agitation within 3 days but not demonstrate a positive effect on delusions until 3 weeks of continued treatment. Additionally, some patients may have significant problems that in and of themselves may be legitimate treatment targets, regardless of diagnosis. For example, aggressive outbursts or self-harming behaviors may be treatment targets in an individual with autism, although neither of these symptoms is necessary for the diagnostic category. In other cases such as borderline personality disorder one component of the diagnostic category (e.g., self-harming behavior) may be a target for medication treatment while another component (e.g., chronic feelings of emptiness) may not. In other words, both diagnoses and symptoms can be legitimate treatment targets. It is essential that both the clinician and the patient know and agree on what the treatment targets are. Whatever the choice for the intervention target, the physician must be aware of the social and regulatory issues surrounding the use of medications for treatment of disorders or symptoms that are “off-label.” This means that the physician elects to use medications to treat disorders or symptoms, although the particular medication has not been approved by the regulatory agency in that particular country. In some cases, this will be because of procedural or work load delays at the level of the regulatory agency or because of decisions by manufacturers to differentially submit products for registration. These factors lead to a medication being registered for a particular indication in one jurisdiction (e.g., the EU) but not in another (e.g., the USA). In other situations, medications may not have been studied in youth and are therefore not registered for use in that age group although they are registered for use in adults. In other situations, medications will not have been studied in enough detail to be considered for registration – and if the medication is used for the control of specific symptoms, and if registration is disease-specific then by definition it will not have been registered for the purpose of specific symptom control. In child and adolescent psychiatric care, most medication interventions are “off-label” (as are all psychological interventions as there is no regulatory process for those). This does not mean that medications should not be used for “off-label” purposes. It does mean that the clinician should have reasonable evidence to support the use of “off-label” prescribing and that the rationale for this use should be clearly communicated to the patient and family and noted in the medical record. The choice of treatment target depends on three factors: patient need, clinician knowledge and weight of therapeutic evidence. Patient Need Patient need may be expressed in syndromal or symptomatic terms. A young person with a major depressive disorder requires an intervention that will address the entire syndrome. PHYSICAL TREATMENTS 1093 9781405145497_4_067.qxd 29/03/2008 02:59 PM Page 1093

A young person with Tourette’s syndrome complicated by severe obsessive-compulsive symptoms may require an intervention directed not only at the Tourette’s syndrome but also at the obsessive-compulsive symptoms. A young person with autism complicated by aggressive outbursts may benefit significantly from a treatment directed towards the aggressive outbursts alone. In some cases, treatment targets can be simultaneously syndromal and symptomatic (e.g., significant depressive symptoms in a schizoaffective disorder) and both somatic and nonsomatic interventions may be used – alone, concurrently or sequentially. Clinician Knowledge Clinicians must be informed about the unique strengths and weaknesses of each physical intervention, and of possible interactions (both therapeutic and adverse) amongst them. These include both pharmacodynamic (what the drug does to the body) and pharmacokinetic (what the body does to the drug) interactions (see chapter 16). For example, does adding an antipsychotic medication to a selective serotonin reuptake inhibitor (SSRI) enhance the treatment response in a young person with OCD? What are the potential drug–drug interactions associated with such a combination? How does the addition of the antipsychotic drug alter the serum levels and the half-life of the antidepressant? Weight of Therapeutic Evidence The field of physical treatments for child and adolescent psychiatric disorders is rapidly developing and reports of potentially effective somatic interventions for numerous syndromes or symptoms are frequently found in the literature. However, not all evidence is of similar value. Case studies and naturalistic studies (particularly those with small sample sizes) do not provide sufficient scientifically sound evidence to guide treatments. Meta-analyses that are based on inadequately conducted studies may lead to erroneous conclusions. Additionally, as the field is early in its development, few properly conducted studies have been carried out so absence of evidence cannot be equated with evidence of absence. Efficacy studies in homogeneous patient groups do not always positively translate into large heterogeneous populations – where effectiveness studies are needed. Acute results cannot be extrapolated into long-term conclusions, and studies of relapse prevention and length of remission are required to answer important duration-of-treatment questions. Some adverse and therapeutic effects (particularly those that are rare or require long-term use for expression) can only be identified using population surveillance techniques for which large numbers of patients treated for long durations are needed. Given this developing database it is sometimes difficult to address the issue of therapeutic evidence with complete confidence, and guidelines and algorithms for assisting the clinician have been devised (Emslie, Hughes, Crismon et al., 2004). Generally, these guidelines use levels of evidence, ranging from high to low, based on the quality of scientifically conducted research. Data from double-blind placebo-controlled studies are usually considered to be more robust evidence than data from naturalistic studies, which in turn are considered to be more robust than the opinions of “experts.” However, the thresholds used to define these levels of evidence can vary across guidelines and different authorities may support different guidelines. Guidelines along these lines (evidence-based medicine) have been developed for some conditions by national agencies (e.g., the UK National Institute of Health and Clinical Excellence [NICE]) and professional bodies (e.g., American Academy of Child and Adolescent Psychiatry). These can be helpful to the practitioner but, as recent history has shown, they are not always free from ideological bias that colors their interpretation of the available scientific evidence. For example, the NICE recommendations for the treatment of depression in young people differ significantly from the guideline standards used in their own literature review. Levels of evidence that are meant to inform the recommendations are not consistently applied. For example, interventions for which there is no evidence (such as watchful waiting) are recommended over an intervention for which there is the highest level of evidence (fluoxetine) (NICE, 2005). Multiple factors come into play when choosing if and how to treat (see p. 1092), but the evidence for efficacy, the probability and type of treatment emergent adverse effects, and the severity of the condition always need to be considered by the clinician, and his or her own experience used in the risk–benefit interpretation of any guidelines. Additionally, in a rapidly evolving field such as child and adolescent psychopharmacology, guidelines may lose their relevance not long after their publication. New compounds for a specific disorder may come on the market in rapid succession or new indications for older medications may be defined. Clinicians must therefore be able to apply basic principles of psychopharmacology to their practice of therapeutics and not rely simply on algorithms or guidelines to direct their practice (see chapter 16). Social factors (such as stigma against mental illness, strongly embedded belief systems regarding the effectiveness or danger of somatic interventions, belief-driven organizations or groups who are advancing unique political agendas, the overenthusiastic uptake of somatic interventions by professionals unskilled in their use prior to their systematic evaluation, pharmaceutical company marketing methods) combine with the deficiencies of the syndromal classification system of psychiatric medicine and with long-standing ideological differences amongst child and adolescent mental health practitioners may create situations that at times are confusing not only to patients and family members but also to practitioners. This situation can only be effectively addressed by frank, honest and open discussion between clinicians and their patients and their families about what is and what is not known about various somatic interventions for syndromes and for symptoms. The weight of scientific evidence, with all forms of possible interventions being equally evaluated (e.g., it is not valid to expect that somatic treatments be evaluated at the highest standard of evidence while non-somatic treatments are evaluated using a lower standard of evidence), must be reviewed by clinicians CHAPTER 67 1094 9781405145497_4_067.qxd 29/03/2008 02:59 PM Page 1094

and discussed with patients and their families. The decision to choose any treatment, somatic or not, must be the result of a joint decision-making process which recognizes the strengths and weaknesses of the available scientific evidence and which is not driven by preconceived ideological frameworks or professional biases. Addressing Treatment Needs – Physical or Non-physical Treatments Physical treatments are not provided in a vacuum but are always provided within a specific social context – the relationship between the clinician and the patient. In many cases, this social contract between provider and recipient of the treatment is complicated by the legitimate interests of third parties (e.g., parents and institutions). The impact of all of these different interests on the application, operationalization and outcome of any physical treatment must be taken into consideration at every intervention stage. Additionally, there may well be nonspecific “healing” impacts in the clinician–patient interaction, and this also needs to be recognized. In some cases, physical treatments will clearly be much more useful in addressing symptoms than non-physical treatments. In other cases, non-physical treatments may be as effective or even more effective. If the latter are available, then the preference may be to use them, because, in general, adverse effects are less common. In many circles it has become almost fashionable to “prescribe” non-physical treatments for disorders in which the evidence for the effectiveness of physical treatments is high – particularly if the disorder is judged to be “mild.” However, in many cases, such as the NICE guidelines for the treatment of depression in youth, there is little or no evidence that the suggested non-physical interventions are any better than placebo or the standard non-specific healing properties inherent in the clinician–client relationship. While such arguments are not without merit, it is important not to oversimplify the complexities of treatment effects. For example, depression is regarded by some as a degenerative disorder involving the hippocampus perhaps through an altered expression of brain-derived neurotropic factor, with antidepressants but not other interventions slowing down or reversing that process (Hashimoto, Shimizu, & Iyo, 2004; Swaab, Bao, & Lucassen, 2005). If that were to be the case (and it is not yet established), then not providing the physical treatment even to “mild” cases would have negative long-term effects on the progression of the disease. Generally, just as we are usually better at ascribing causality to proximal rather than distal causes, so we may be equally poorly prepared to consider longterm outcomes rather than immediate effects of treatments. This dilemma has no simple solution. It becomes a particularly vexing problem if our commitment to “first do no harm” has to challenge us with different types of possible harm, expressed in different ways at different points in time. How does the clinician address the difference between “harm” from tolerable but unpleasant side-effects (short-term effects) and “harm” from not intervening in the disease process (long-term effects)? To date, the research evidence to help address these concerns is still quite limited, but it would be professionally improper not to consider these complexities carefully, albeit in the face of imperfect data. In many cases, providing a particular physical treatment together with a specific non-physical treatment (such as fluoxetine plus cognitive–behavioral therapy [CBT] in adolescent depression) may lead to a better outcome than either one alone. In other cases, providing interventions designed to enhance learning, social or other skills when physical treatments have brought symptoms under control is necessary to improve outcomes over the use of the physical treatment alone (e.g., mathematics tutoring or social skills training for children with ADHD effectively treated with methylphenidate). At other times, physical treatments may be used to enable non-physical interventions to be more effectively applied (e.g., short-term benzodiazepines in the behavioral treatment of phobia when excessive anxiety prevents the application of a desensitization procedure from being initiated). Judicious application of physical treatments includes knowing when to use them and when not to use them; both are equally important. In the future, the ability of the clinician to select treatments – whether physical or non-physical – or to choose amongst various types of physical or non-physical treatments on the basis of genetic or other biological variables may supersede our currently imperfect and opinion-laden approaches to these topics. There is some promise in that direction, but for now there are no objective physiological guideposts to assist us; and best available evidence, clinical judgment and trial and monitoring still provide the decision-making triad from which we usually operate. Given this climate of uncertainty, it is necessary to address patient need using the best evidence we have, with humility and the willingness to modify or change our approach as science catches up with clinical care. Selecting a Physical Treatment Once the scientific evidence base has been reviewed, a target or targets selected and a treatment or treatments that meet(s) acceptable criteria for use has been identified, a further process of selection occurs. This process is driven by the following considerations: practitioner familiarity with the specific treatment; patient acceptability; comparative risk–benefit profile; ease of administration; cost and availability. Practitioner Familiarity Given all the possible somatic treatments available, it is not likely that the average clinician can become proficient in the use of every one of them. At the same time, it is essential that clinicians become very familiar with the treatment that they are using. It is therefore reasonable for the clinician to choose one or two compounds that will become his or her “personal” medication choices, which will be used in most cases in which that class of medication is indicated. This is also known as PHYSICAL TREATMENTS 1095 9781405145497_4_067.qxd 29/03/2008 02:59 PM Page 1095

the “Personal” or “P drug” selection. This approach to therapeutic medication selection is essential for primary or even secondary care, but even tertiary care physicians may find this approach useful (WHO, 2000; 2001). The “P drug” should have the following characteristics: 1 It should have good experimental evidence (placebocontrolled trials) supporting its therapeutic effect; 2 Its side-effect profile should be well known; 3 It should be relatively well tolerated by most patients; 4 It should be reasonably priced; 5 It should not have any significant disadvantages compared with other medications in its class; 6 It should be readily available; and 7 It should be relatively familiar to most clinicians. Applying these criteria to medications in every class or subclass should allow the clinician to select a “P drug” for any target syndrome or target symptom. For example, and as illustration only, fluoxetine would be a reasonable “P drug” for adolescent depression; methylphenidate would be a reasonable “P drug” for childhood ADHD; and risperidone would be a reasonable “P drug” for youth-onset schizophrenia. Once the “P drug” is selected, the clinician should become fully versed in its pharmacodynamics and pharmacokinetics. Repeated usage of the “P drug” will increase familiarity with its unique characteristics. Physicians in both primary and secondary care settings may find it useful to select two or three “P drugs” for each commonly treated condition using similar criteria to those noted above. This will allow greater flexibility in dealing with patients who may not have experienced therapeutic success with a previously used medication or who wish to have options in their choice of medications. Knowledge of the “P drug” also entails knowing its limitations, when others may be preferable and when a tertiary center should be consulted. Tertiary care physicians need to have a much wider familiarity with various therapeutic modalities. Patient Acceptability Patients and their families (as appropriate) should be active partners in their care and their acceptability of any treatment is important, not only for adherence but possibly also for therapeutic outcome. Patient (and family) participation in the choice of treatment (see p. 1104) is an important process of treatment selection. Patient preference for a specific intervention should be carefully considered whenever reasonable and may be driven by one or more of the following: previous experience with a medication (positive or negative); experience of a friend or relative with a medication; cost; and media coverage. Many young patients may find it difficult to swallow medications. For them, the type of preparation (tablet or capsule) or size of tablet is often an important consideration. Comparative Risk–Benefit Profile No medical treatment is risk-free. Every choice of medical treatment uses a risk–benefit approach. Risk–benefit can be analyzed by comparing the number needed to treat (NNT) with the number needed to harm (NNH). This creates a method for assessing the risk–benefit ratio of any treatment – regardless of its type. Such information may not be easily available for all somatic interventions (and is not available for most nonsomatic interventions) but when it is, it should be used to guide treatment choice. As a rule of thumb, the number 10 is often taken as a “cut-off point” in treatment decisions using the NNT. How many individuals does the clinician need to treat with a given intervention before he or she can be sure that at least one individual is getting better because of the intervention and not because of other reasons? In the Treatment of Adolescent Depression Study (TADS), the NNT was calculated for each of the four treatment arms. The combined fluoxetine and CBT treatment arm was found to have an NNT of 4, compared with fluoxetine alone which was 5 and CBT alone which was 12 (TADS, 2004). (Of course, single studies cannot by themselves provide sufficient assurance that NNT or NNH calculations based on their results alone are representative.) Clinicians should assess risk–benefit on the basis of likely therapeutic effect; likely adverse effects; rare adverse effects; likely outcome without treatment; and other available treatments. While there is no simple statistical or other method by which the individual practitioner can calculate the risk–benefit ratio for any single treatment for any single patient, the process of addressing the various domains will in itself raise issues that will need to be considered by both clinician and patient. For some individuals, certain treatments may be contraindicated (they should not be used because their risk far outweighs their potential benefit) or contra-advised (they should generally not be used but for some specific patient reason they may be considered). For example, a medication that is known to demonstrate significant negative interactions with another medicine that is being used would be a contraindication for treatment. Treating an agitated psychotic manic male with a history of ADHD with methylphenidate alone would be contraindicated. Contra-advised selection would be a treatment that may raise the risk for an untoward outcome because of patient or treatment characteristics (or both). For example, the use of benzodiazepines to treat anxiety in a young person who has a strong family history of alcohol addiction would be contra-advised (Evans, Levin, & Fischman, 2000). Ease of Administration Ease of administration is a vital criterion for treatment selection. The easier a treatment is to administer, the more likely adherence is to be high. Considerations include the number of times the treatment is given (e.g., number of doses per day) and method of delivery (oral, parenteral, rectal). Additionally, the presence or absence of other associated features such as the necessity for periodic venipunctures (to monitor serum levels) and ancillary investigations because of possible negative drug effects (e.g., electrocardiograms [ECG]; lipid and glucose monitoring) need to be considered in treatment selection. As a general “rule of thumb,” when effectiveness and adverse events are similar, medications that are more convenient for the patient to use are preferred to those that carry greater inconveniences. CHAPTER 67 1096 9781405145497_4_067.qxd 29/03/2008 02:59 PM Page 1096

Cost and Availability The cost of somatic treatments is an important factor in treatment selection. In this assessment, the availability of personal insurance or public health system coverage) should be considered. As many pharmacological treatments will be long term (a year or longer), clinicians and patients should consider the cumulative and not just the single-dose costs of a treatment. In situations where individuals do not have coverage of costs, careful consideration needs to be given to the assessment of comparative benefits between medications that are less costly but “traditional” and those that are more costly and novel. Higher cost does not always mean better medication. Additionally, the indirect costs of any specific medication must also be considered. For example, a medication may increase the likelihood of other medical problems for which later treatment will be needed (e.g., tardive dyskinesia or metabolic syndromes), or which entail frequent laboratory monitoring, either for serum levels of the medication (e.g., carbamazepine) or for medication-induced changes in physiology (e.g., prolactin, glucose or lipid levels which may be induced by some “atypical” antipsychotics). These “indirect” medication costs can have a substantial cumulative impact in both private and public payment systems. In some settings, medication availability is an important issue. In many low-income countries, the supply chain of psychotropic medications is vulnerable to a variety of negative impacts often not considered by practitioners working in wealthy countries. A patient who cannot rely on a consistent supply of needed medications may be at risk for a variety of negative outcomes associated with supply discontinuation – including but not limited to relapse and withdrawal. If that is the case, then the clinician may choose to treat using a medication that in circumstances of reliable supply may not be preferred. For example, a long-acting injectable antipsychotic may be chosen instead of lithium carbonate for the maintenance therapy of a patient with bipolar disorder. Assessment and Measurement Once treatment targets have been identified, treatment goals (amount of expected change and expected timeline for change) need to be defined. These will vary depending on the treatment target and the intervention chosen. For example, panic disorder may be selected as a syndromal treatment target. Within that framework, panic attacks may be selected as a specific symptom target, with anticipatory anxiety and phobic avoidance also being chosen as symptom targets. In this case, assessment and measurement will need to be directed at both the syndromal and the symptom targets. This will lead the clinician to select a number of different measurement tools. For example, the syndrome can be assessed using ICD or DSM criteria; the panic attacks can be assessed using a diary that captures the number and severity of attacks weekly; the anticipatory anxiety and phobic avoidance can be assessed using a visual analog scale. The expected timeline of effect will vary with the drug; not all treatment targets can be expected to show similar time courses of improvement. For example, in panic disorder, expected decreases in anticipatory anxiety may require 2–3 times longer to achieve than expected decreases in panic attack frequency. Phobic avoidance may similarly require a longer duration for a similar proportional improvement. In some cases, application of complementary concurrent interventions (e.g., behavioral therapy) may be required to achieve the treatment goals. Treatment goals may be response or remission. Response can be defined as symptomatic improvement that is clearly experienced by the patient accompanied by functional improvement across a variety of domains (e.g., interpersonal, vocational, academic). Remission can be defined as a return to premorbid conditions (both symptomatic and functional). These outcomes may vary amongst treatment targets, as not all syndromes or symptoms show equal potential for response or remission with currently available somatic interventions. In some cases, addition of non-somatic interventions (e.g., CBT added to SSRIs for youth with OCD) may enhance the probability of improved outcomes. Relapse prevention is also a treatment goal. Exacerbation of initial symptoms after treatment discontinuation is known as rebound, and the emergence of previously not experienced symptoms is known as withdrawal. Neither rebound nor withdrawal is synonymous with addiction, but either can occur in addictive states. One of the many areas of therapeutics that require extensive additional research is that of the continued effectiveness of interventions that have shown positive short-term effects with acute treatment (e.g., methylphenidate in ADHD). There is a dearth of long-term studies of continued effectiveness of treatments (both physical and psychological) that can be used to guide clinical practice. So, in many cases (e.g., in the treatment of depression) we have to use data extrapolated from studies in adults. While this is not optimal information (and depression in adolescents does not follow the same expectations for treatment as in adults), it often is the only treatment available and so is still used to inform clinical practice for young people. It is hoped that future editions of this textbook will be able to draw on child- and adolescent-specific research that can address this issue. Treatment emergent adverse events (commonly known as side-effects) are also treatment targets. However, here the target is to avoid or mitigate treatment emergent adverse events, not to achieve them. Treatment emergent adverse events are defined as any phenomena that have their onset during a treatment and are directly attributable to that treatment. For example, a specific medication can cause physical side-effects (e.g., nausea or diarrhea) by its effect on either the digestive system or the central nervous system. Similarly, behavioral sideeffects (e.g., agitation, impulsivity), cognitive/perceptual sideeffects (e.g., suicidal ideation or hallucinations) and affective side-effects (e.g., depressed mood) may occur as treatment emergent adverse events. PHYSICAL TREATMENTS 1097 9781405145497_4_067.qxd 29/03/2008 02:59 PM Page 1097

At times it may be difficult for the clinician to determine if patient complaints of adverse events are truly side-effects (i.e., they occur during treatment as a direct result of that treatment), or if they are reflections of another phenomenon. One such potentially confusing scenario is the onset of concurrent but unrelated events (e.g., the patient develops a flu-like illness during the flu season). Another potentially confusing scenario is attributional in nature. For example, the patient has had a long history of headaches, for which no cause has been established, but now is convinced that it is the treatment that is “causing” the headaches. In addition, negative outcomes occurring during treatment may also be the result of the natural history of the disorder and may be serendipitously linked to treatment application. For example, an increase in depressed mood that occurs a week after beginning an antidepressant may be a result of the natural progression of the illness prior to the onset of the therapeutic action of the treatment rather than a result of the application of the treatment. In such cases, the propensity for patients and clinicians alike to ascribe causality to proximal rather than distal factors may lead to the termination of a potentially effective intervention. Thus, prior to any somatic intervention, a thorough assessment of treatment targets (syndrome, symptom, side-effect) must be conducted by the clinician. The initial application of this comprehensive evaluation is commonly known as the “baseline assessment.” Baseline Assessment and Measurements The baseline assessment takes place during a specified period of time prior to the initiation of a specific somatic treatment. It is carried on concurrently with patient (and where appropriate, family or responsible other) education about the disorder and its treatment (see p. 1103). In psychiatric treatments, emergency or life-saving interventions are usually not the norm and in most cases an appropriate window of time exists for the baseline assessment to be properly conducted. The baseline assessment addresses all of the treatment targets, provides specific measurements of those targets and sets outcome and evaluation process expectations. Treatment targets can be syndromal, symptomatic, adverse effect or overall functioning. Syndromal targets are predefined by syndromal criteria (either ICD or DSM). Symptomatic targets can be directly defined by the disorder (e.g., hyperactivity, panic attacks, hopelessness). Functioning targets can be defined by assessing the effect of the disorder or symptom(s) on the individual’s functioning (e.g., interpersonal conflict, academic success). Adverse effects can be somatic, behavioral, cognitive/perceptual or affective. Measurements of targets have three complementary components: frequency, severity and duration. For each target on which a measurement is conducted, each of these components should be noted. For example, for an aggressive boy: how many fist-fights (frequency) occurred during the last week (duration); and how intense were they (pushing, hitting, using a weapon at three different levels of severity)? Each of these components should be consistently noted at each measurement point. Syndromal targets tend to be binary – that is, the syndrome is either present or it is not. They are therefore measured categorically. Syndromes may be measured in a variety of manners including the use of diagnostic rating scales such as the K-SADS and the DICA. These measurement tools are generally thought to be too cumbersome and time-consuming for routine clinical use but extensive training in their use may be associated with more comprehensive clinical assessments even when they are not being directly applied. Therefore, clinician training in one or more of these diagnostic instruments may be useful in a general sense for assessment and measurement purposes. Some authors suggest that syndromal checklists are a reasonable tool that can assist the clinician both in validating a clinical interview (does the patient clearly meet a syndromal diagnosis?) and in improving rater reliability over time (repeated application of the diagnostic checklist at designated intervals may enhance certainty in diagnostic outcome monitoring by ensuring that all the components of the diagnosis are appropriately considered each time the tool is applied). Application of a symptom checklist, which can be created directly from the diagnostic manuals for any psychiatric disorder, should be conducted at baseline. Symptom treatment targets can often be ordinarily defined and thus lend themselves to measurement by scales. Sometimes these can be measured as symptom clusters which relate strongly to diagnostic categories (e.g., depression rating scales which include many of the symptoms found in major depressive disorder or obsessive-compulsive symptom rating scales). At other times, one or two symptoms will be the target of treatment (e.g., tics, aggressive outbursts; Storch, Murphy, Geffken et al., 2005). In many of these cases, a well-validated scale such as the Yale Global Tic Severity Scale (Storch, Murphy, Geffken et al., 2005) may not be available, or the clinician may prefer to use simple clinically useful measurement tools such as a Visual Analog Scale or an ordinal 0–3 scale where 0 equals none, 1 equals mild, 2 equals moderate and 3 equals severe. If this type of “shorthand” clinical measurement is used, the clinician must ensure that both he or she and the patient (or responsible other) understand the meaning of the different measurement points on the scale. Symptom measurement tools can be either self- or otheradministered, with the “other” being a clinician, parent or a specified responsible observer (e.g., a classroom teacher). There are pros and cons associated with the use of each type of tool and different informants may rate differently. When parents and patients rate differently on similar instruments (e.g., for ADHD symptoms), the astute clinician may use the occasion to explore the different perceptions of the problem, its treatment and the hoped for results. Thus, quantitative tools may also facilitate qualitative assessment. For many mental disorders in children and adolescents, a variety of validated symptom rating scales are available. These often come complete with instructions for use and some may CHAPTER 67 1098 9781405145497_4_067.qxd 29/03/2008 02:59 PM Page 1098

be commercially available. The choice of measurement tool will depend on the realities of the clinician’s practice, the costs associated with their use and the acceptance of patients and responsible others. The routine application of 2–4 h of rating scales prior to therapeutic prescription is unlikely to find favor amongst patients and their families (nor is it necessary) outside of tertiary care or clinical research settings. However, routine application of some clinically useful standardized measurement tools at baseline and at appropriate times thereafter will improve clinical care. As functional improvement should be a target of every somatic intervention, there must be some baseline assessment and measurement of functioning in various domains. The Global Assessment of Functioning Scale found in the DSM is helpful in this regard but different clinicians may prefer to use different tools. Some functional assessment tools have been developed for specific syndromes (e.g., the Kutcher scale for Social Anxiety Disorder; Brooks & Kutcher, 2004). In many cases, application of the Visual Analog Scale methodology to one or more functional targets will suffice. For example, level of family discord in the past week, success in getting homework completed prior to class. For some targets, simple counting is appropriate (e.g., number of fist-fights in the past week). The “best” choice of measurement tool will depend on the target. Side-effects should be measured using standardized techniques that cover a wide variety of somatic dimensions (for examples see Kutcher, 1997) and must be applied at baseline before a somatic intervention is initiated. This will allow for appropriate identification of treatment emergent adverse effects, which can be either phenomena that arise for the first time during treatment or exacerbations of phenomena already existing at the onset of treatment. Appropriate medical assessments may also be indicated at baseline. These include laboratory and other investigations, which may be diagnostic of a medical condition (such as a thyroid-stimulating hormone [TSH] test for hypothyroidism or a magnetic resonance imaging [MRI] scan for pituitary adenoma) suggested by information obtained during the history and functional enquiry (see chapter 22). Routine laboratory screening is not indicated given its low positive predictive value. Additionally, those laboratory or other physiological parameters (such as heart rate/rhythm) that can be affected by the somatic treatment used (e.g., thyroid function for lithium, prolactin for risperidone, metabolic indices for olanzepine, ECG for tricyclics) should be assessed at baseline. Pubertal females should have a pregnancy test and high-risk teenagers may be strongly considered for sexually transmitted disease (STD) investigations. Evaluating and Maximizing Treatment Outcome Following the baseline and at the time of expected outcomes, evaluation of each target should be conducted, using the same measurements that were obtained at baseline. The timing of these will vary depending on the target being evaluated, the treatment being applied and the expected time course for change to occur. For example, if syndromal outcome is being measured in a teenager with major depressive disorder, a checklist for major depressive disorder should be repeated following 8–10 consecutive weeks of treatment if an SSRI is being used. Syndromal assessment for ADHD in a 9-year-old boy could be conducted following 2–4 weeks if a psychostimulant is being used. For panic disorder (PD) it is reasonable to conduct a syndromal evaluation following 4–6 weeks if a benzodiazepine is being used. Conversely, depressive symptoms in major depressive disorder measured using either a self-rating or clinician-rating scale should be conducted at week 4 and weekly thereafter, while both ADHD and PD symptoms should be monitored weekly following treatment initiation. Sideeffects should usually be evaluated within 2 days of initiation of treatment and weekly thereafter. In acute agitated psychotic states, both therapeutic and side-effects may need to be evaluated hourly if clinically indicated. School functioning in OCD may be next assessed at 3 months and every 2 months thereafter. Serum carbamazepine levels can be assessed weekly for 4 weeks and then every 6–8 weeks following hepatic calibration to steady state levels. In chronic treatments, similar criteria apply. For institutionalized children or teenagers, frequent evaluation of all target conditions will help ensure that appropriate clinical care is being provided, and institutional policies and procedures should be developed to ensure that such careful and standardized ongoing evaluation is in place. Once maximal treatment outcome has been obtained (remission or recovery), treatment evaluation becomes treatment monitoring. In this scenario, regularly scheduled visits should be structured to ensure that syndromal, symptomatic, functioning and side-effect targets can be parsimoniously evaluated. Additionally, qualitative evaluation becomes increasingly important in the face of insufficient scientific data on the potential risks and benefits of long-term treatments. Evaluation tools should therefore be supplemented by more open-ended dialog. Patients and their families should be instructed to report any untoward adverse events immediately. Always check with the treating physician if other medications are being prescribed (in case of drug–drug interactions). Patients and families should be instructed in the earliest signs of relapse so that potentially useful interventions are not delayed. Maximizing Treatment Outcome The ideal goal of treatment outcome is recovery, which is remission followed by a prolonged sense of well-being. Unfortunately, our therapeutics are not perfect and in many cases, because of either individual or therapeutics reasons, neither recovery nor remission occurs. The aim is then an optimal outcome – achieving the best improvements possible in all treatment targets. For this purpose, somatic treatments are often necessary but insufficient, and should be linked with various other interventions, including psychological, social and PHYSICAL TREATMENTS 1099 9781405145497_4_067.qxd 29/03/2008 02:59 PM Page 1099

vocational components, guided by the same principles of evidence and application as are used to direct somatic treatments. They should be chosen on the basis of patient need rather than clinician preference or ideological commitment. In many cases, somatic treatments may differentially affect chosen targets in a manner that limits their ability to address patient needs effectively. For example, the same dose of a “P” medication that maximizes symptomatic improvement may lead to intolerable side-effects, thus limiting its dose. This may require the use of a different medication or “layering” of medications (the use of a lower dose of the “P” medicine with the addition of another medication, usually from a different class of drug). These different strategies are known as substitution and augmentation. While there is often anecdotal evidence for these strategies, and in some cases there is reasonable scientifically supported evidence from adult populations, neither of these two sources of information provides the necessary weight of scientific evidence required to clearly guide clinical practice in young people. In such situations, clinicians will need to rely on their best judgment and must discuss the limits of evidence and the basis for their further treatment advice with their patient and his or her family or responsible caretaker. The rationale for choosing either substitution or augmentation strategies should be noted in the clinical file. Achieving therapeutic outcome with the initial “P” drug is based on two factors – dose and duration of treatment. The dose must be one that provides the greatest positive benefit with the fewest side-effects and it must be maintained for the necessary length of time – in both acute and long-term conditions. In dose determination, three factors are important: dose initiation, dose target and dose duration. The dose must be properly initiated; doses that are too high to begin with or which are raised too rapidly will not usually hasten symptomatic improvement but will often lead to significant side-effects. Sometimes there is a significant possibility of an individual showing adverse effects at an ordinary dose. For example, some individuals are slow metabolizers of atomoxetine (see chapter 16). A low dose may then be given as a check on sensitivity, with patient and family aware of the rationale. Choosing an initial dose target that is too low is unlikely to lead to optimal benefit, while choosing an initial dose target that is too high is unlikely to improve outcome over side-effects. Up-titration, the process of dose increases to achieve the initial target dose, should be carried out slowly – giving time for the patient to acclimatize to each stepped increase. Medications that achieve their initial dosing targets but are not maintained for a sufficient length of time are unlikely to provide optimal treatment response. It is essential that the clinician allow sufficient time for the treatment to demonstrate its effect. This time to response will differ depending on the condition and the medication used. For example, a young person treated with an SSRI for major depressive disorder should be maintained at the initial target dose for a period of 8 weeks. For a youth with OCD being treated with an SSRI the time to response is about 12 weeks. Discontinuation of treatment prior to the expected time to response may not only negate the therapeutic effects of an effective treatment, but may also lead to negative perspectives about the value of a particular intervention on the part of patient, family and clinician alike. Both dose initiation and dose duration must be based on the pharmacokinetics and pharmacodynamics of the medication chosen and the known response of a syndrome or symptom to the medication. For example, an SSRI used to treat OCD may require a higher therapeutic target dose level for a longer duration than the same SSRI used in the treatment of major depressive disorder. However, both will require similar rates of dose titration to reach the initial target dose. In general, for most medications, a “start low and go slow” dose titration model is to be preferred. Of particular importance in acute psychosis is that the expected course of clinical outcomes should be used to inform dose titration. For example, initial dosing strategies should target agitation and restore a “normal” sleep–wake cycle. Improvement in socialization and psychotic thinking can be expected later in the treatment course. Over-medicating by using higher doses of antipsychotics to treat agitation and sleep difficulties is to be avoided. The layering of medications (such as adding short-acting benzodiazepines to address agitation) is preferred to using larger (and potentially more problematic) doses of non-sedating antipsychotics. Possible drug–drug interactions must be considered whenever multiple medications are being used in the same individual. While it is unlikely that any clinician can remember all such interactions, it is possible to keep in mind the most common that could be expected for children and adolescents. Up-todate resources containing P450 level drug–drug interaction tables are readily available and any physician treating young people with medications should routinely consult these references. Some are free of charge (Flokhart, 2007) and others require a subscription (GeneMedRx, 2007). Every patient and responsible caregiver should be informed about the possibility of drug–drug interactions and asked to notify the treating physician before beginning any new medication. Over-thecounter and herbal compounds may also interact with prescribed medicines (Hu, Yang, Chan et al., 2005). Therefore, as a general rule, patients and responsible others should be informed (and repeatedly reminded) that any medication (including cold remedies, pain modulators and oral contraceptives) should be discussed prior to their use. Encouraging patients to have their prescriptions filled at reputable pharmacy outlets that maintain personal medication profiles is recommended. At a predetermined time (set by the known expected time course for therapeutic improvement) the therapeutic intervention should be systematically evaluated. Ideally, this should include a comprehensive review of the initial presentation, all treatment targets, the outcome in every target, newly emerging problems (including side-effects), functioning and a diagnostic re-evaluation. At that time one of three outcomes can be determined: 1 Remission has occurred; 2 Response has occurred but some difficulties remain; or 3 Insufficient therapeutic response has occurred or the situation has worsened. CHAPTER 67 1100 9781405145497_4_067.qxd 29/03/2008 02:59 PM Page 1100

If the outcome is recovery, the usual strategy is to continue the somatic treatment for an appropriate length of time following remission prior to deciding if treatment discontinuation is warranted. Although insufficient scientific literature exists to direct clinical decision-making on this point, practice should in general be guided by the answers to the following questions: what are the known or suspected negative outcomes of continuing medication treatment; what are the known or suspected positive outcomes of continuing medication treatment; what is the evidence for relapse if medication treatment is discontinued? Open discussion of these issues with a patient and responsible others can be used to guide continued treatment. In the situation where response has occurred but some significant problems remain, the clinician should reconsider the treatment targets and the known therapeutic gains that can be expected with available somatic interventions. For example, in cases of severe OCD treated with an SSRI, a 75% response in OCD symptoms may be the best that can be expected (see for example March, Biederman, Wolkow et al., 1998). Additionally, a search for other factors that could contribute to insufficient improvements such as treatment adherence difficulties; the presence of significant comorbid conditions; the effect of ongoing psychosocial stressors or the possibility of heretofore unrecognized substance misuse should be explored. Following from that, the initial treatment should be optimized. Pharmacologically, treatment optimization may require increasing the dose beyond the initial target dose. If adverse effects are tolerable, this may be initiated using dose increments similar to those used during the period of up-titration to the initial target dose. Once a new target dose is reached, this should be maintained for a reasonable period of time to determine if therapeutic response improves. This pattern of gradual step increases, interspersed with appropriate periods of waiting, can continue until either the patient no longer continues to demonstrate expected treatment gains or side-effects that are not tolerable to the patient occur. In some cases, the patient may be genetically predisposed to rapid metabolism of the medication. These “ultra-rapid metabolizers” are more common in African and Middle Eastern populations and demonstrate highly efficient CYP2D6 hepatic enzyme activity. Such individuals may rapidly metabolize various antidepressant and antipsychotic medications. However, a small percentage of the population demonstrates slower than usual metabolism of medications. These “poor metabolizers” as they are called, may have genetic differences of either the CYP2D6 or CYP2C19 hepatic enzyme systems (Desta, Zhao, Shin, & Flockhart, 2002). Now that a relatively simple test for genotyping of 2D6 and 2C19 has received Food and Drug Agency (FDA) approval, patients whose clinical presentation suggests a problem with drug metabolism could be tested in locations where that test is available (de Leon, Armstrong, & Cozza, 2006). Optimization of response may also be achieved with the addition of psychological treatments with well-demonstrated efficacy, such as CBT added to fluoxetine in depressed adolescents (TADS, 2004) or CBT added to sertraline in OCD patients (POTS, 2004). In other cases, augmentation with another class of medication (e.g., adding lithium to an antidepressant in the treatment of depression) may be indicated (Hughes, Emslie, Crismon et al., 1999). Another alternative is to switch medications, either to a compound in a similar class or to a compound from a different class (Hughes, Emslie, Crismon et al., 1999). In some circumstances, the clinician may choose to substitute a non-somatic intervention for a physical treatment that has not led to good therapeutic results. This should only be considered where the research evidence for the effectiveness of the non-somatic is substantial and if the patient and/or family concurs (e.g., in OCD; O’Kearney, Anstey, & von Sanden, 2006). If this course of action is contemplated, then a graduated medication withdrawal strategy should be put into place to minimize the potential for a withdrawal syndrome. Given the lack of substantive scientific evidence for any of the above strategies in the child and adolescent literature, treatment options will need to be discussed with the patient and responsible others and a jointly acceptable decision will need to be made as to the direction taken. Once that decision has been made, similarly rigorous assessments and treatment target selection and monitoring are necessary. In cases where improvement has been unsatisfactory or the situation has worsened, the diagnosis should be critically reviewed and the social ecology of the therapeutic situation critically addressed (including treatment adherence, family and peer factors, and possible substance abuse). Then a new conceptualization of the problems and treatment targets needs to be undertaken and the systematic assessment, measurement and application once again initiated. A consultation with an experienced colleague is often useful in such situations. The “N of One” Assessment Methodology For some conditions and with some medications, an “N of One” treatment trial can be effectively and relatively simply initiated (Kutcher, 1986). This approach has stood the test of time and is appreciated by patients and families alike (Kent, Camfield, & Camfield, 1999) and can be implemented over the telephone (Nikles, Mitchell, Del Mar, Clavarino, & McNairn, 2006). Ideally, the medication should be paired with an identical placebo which can be made up by a pharmacist (or a non-identical comparison with blind raters). Then an on–off cycle (3–5 days on the medication followed by a similar length of time on the placebo) is initiated. Ideally, this cycle should be repeated so that an ABAB model is applied (A = medication phase; B = placebo phase). Ideally, multiple raters of the patient’s symptoms, blind to the treatment condition and all using the same rating scale in the same manner across the entire ABAB sequence provide the assessments on which therapeutic decisions will be made. A positive trial demonstrates a repeated therapeutic effect of the medicine that is not found with the placebo. PHYSICAL TREATMENTS 1101 9781405145497_4_067.qxd 29/03/2008 02:59 PM Page 1101

This assessment method is well suited for a medication that demonstrates a rapid therapeutic onset and rapid therapeutic offset. Of all the child and adolescent disorders, ADHD is most amenable to this type of evaluation, using immediate-action medications and standard measures such as the SNAP (Pelham, Gnagy, Burrows-Maclean et al., 2001; Swanson, 1992) with a methylphenidate specific side-effects scale (Kutcher, 1997). If therapeutic response is limited or side-effects are substantial, the “N of One” can suggest that a non-stimulant alternative be considered, thus saving the time and expense of an initial unsuccessful clinical trial. Variations on this design can be used to answer other important clinical questions – for instance, of the need for different doses as a child with ADHD grows. Other, less rigorous “N of One” approaches to test hypotheses about medication treatments are less well supported by evidence and less well grounded in scientific validity. For example, some clinicians may choose to stop a medication to “see if it is still working.” While the intent may be honest this suggests that the initial approach to the treatment was weak on assessment and evaluation. It is not necessary to stop a treatment to see if it is working. That question can be answered by comparing current assessments of symptoms and functioning against the baseline. Furthermore, discontinuation of treatment is not without its risks – for example, in bipolar patients, continuation of lithium treatment is highly correlated with lower rates of suicide (Baldessarini, Tondo, Davis et al., 2006). Polypharmacy The increasing rate of psychotropic medication use in young people has been well documented (Thomas, Conrad, Casler, & Goodman, 2006). In some jurisdictions those increases (e.g., the use of SSRIs to treat depression) may be reasonably justified (Hunkeler, Fireman, Lee et al., 2005) while in other jurisdictions the choice of medications used (e.g., the use of tricyclic anti-depressants and herbal preparations to treat depression) is not supported by the available data on safety and efficacy (Fegert, Kolch, Glaeske, & Janhsen, 2006). Many reasons to explain this increase have been suggested, including but not limited to: changes in clinical practice (from inpatient to out-patient care); increased treatment of heretofore untreated populations; better diagnosis and case identification of mental disorders in young people; availability of less toxic and less dangerous medications; pharmaceutical industry promotion of medication use; and better data on the effectiveness of medication treatment. Given the complexities of this issue, it is reasonable to conclude that multiple factors have come together to create this phenomenon. As part of this increase, there is a general perspective that polypharmacy – the use of many medications concurrently – has become relatively commonplace, up to half of the populations studied in some reports (Russell, George, & Mammen, 2006), even though the evidence to support this use is not always robust (Lopez-Larson & Frazier, 2006). There may be a number of reasons for this increase. For example, some medications are routinely prescribed to counter possible adverse events caused by others (e.g., anticholinergic medicines used concurrently with “typical” antipsychotic compounds to limit extrapyramidal side-effects). Such clinical use is reasonable and consistent with both the pharmacodynamics and pharmacokinetics of the concurrently prescribed compounds. Another example of rational polypharmacy is the combined short-term use of a sedating benzodiazepine with an antipsychotic in the initial stages of an acute agitated psychosis. However, there are a number of concerns about the use of polypharmacy. These include but are not limited to: an increased risk of side-effects caused by drug–drug interactions; decreased treatment adherence; increased treatment cost; and using two medications when one will do in the treatment of comorbid conditions (e.g., depression and panic attacks). Therefore, it is necessary to consider carefully the rationale for combining psychotropic medications and to monitor their use closely. The following are issues that the clinician should consider prior to combining medications: 1 Why is the combination being considered? If it is for subtherapeutic response to a monotherapy, has the necessary review of the case and monotherapeutic optimization been conducted? 2 Is there a clinical and pathophysiological rationale for the combination? 3 Is there a scientific literature that addresses the combination being considered? 4 Are there known or likely drug–drug interactions? 5 If the combination is being used to treat a number of different symptoms or conditions, is there one medication that can be used instead? 6 How long will the combination be used and what are the evaluations that will be put into place to monitor therapeutic outcomes and adverse events? When combining medications (and when changing medications) it is advisable to add (or subtract) only one compound at a time, ensuring that enough time passes to allow for appropriate evaluation of the effects of the medication addition (or subtraction). Careful monitoring will also be necessary as insufficient research data are available on possible adverse reactions to medication combinations. The Human Interface No medical treatment takes place in a social vacuum. Every interaction includes a host of individual, group and society factors, which influence, color and impact on the interaction between clinician and patient. Indeed, this interaction in and of itself may have therapeutic effect and thus, by implication, may have a negative effect. In some disorders, specific psychological or social therapies may extend some of the activities found in the clinician–patient interface but do not substantively alter or necessarily even improve on them. For example, the best estimation of the effect size of CBT for major depressive disorder in adolescents is 0.3–0.4 (Weersing & Brent, 2006; Weisz, McCarty, & Valeri, 2006), which is strikingly similar CHAPTER 67 1102 9781405145497_4_067.qxd 29/03/2008 02:59 PM Page 1102

to the placebo rate found in strictly conducted studies of somatic therapies (Cheung, Emlie, & Mayes, 2006). In other disorders (such as OCD), however, a similar type of psychotherapeutic intervention shows a greater effect size, suggesting a unique positive effect of that specific treatment. The foundation of the clinician–patient interaction is based on two important principles: clinician responsibility to the patient and respect for the autonomy and rights of the patient. Each of these principles can be used to inform and direct the clinician– patient interaction in the delivery of somatic treatments. Clinician Responsibility to the Patient This value is arguably the basis for all physician–patient interaction, has its roots in centuries of medical history and is the framework on which the Hippocratic oath is built. In the provision of somatic treatments this value has certain specific applications. First, the clinician is obligated to provide the therapeutic intervention for which the best and strongest scientific evidence for safety and effectiveness is available. This means that in some cases the clinician may advise against the use of somatic interventions if equally effective, inexpensive, safer and readily available non-somatic modalities are available. Conversely, it means that any responsible clinician should advise the use of somatic treatments when these are clearly indicated. Personal adherence to a particular “school” of therapeutics is not the criterion upon which patient care is based. Ideology should not trump science. The tradition of offering the “least restrictive” treatment as the preferred intervention in child psychiatry is still very strong and has important human rights foundations which should not be ignored. In days when therapeutic interventions were both all very much of a kind and all with a minimal evidence base, that framework as the primary guide to treatment selection was at least partly defensible. Currently, it is not a sufficient criterion for treatment selection. Not only must treatment be as minimally restrictive as possible, but it must also be as safe and effective as possible. Additionally, clinicians must be honest with the patient and family about the strength of the scientific evidence used to guide their interventions. In a rapidly changing and imperfect world clinicians work with the best evidence that is available, not necessarily with the best evidence that should be available. Often therapeutic decisions need to be made on the basis of weak or even contradictory evidence. Sometimes, the available evidence is inconsistent. For example, we have a reasonable understanding of the acute therapeutic and side-effects of antidepressants but limited knowledge about their long-term therapeutic and side-effects. Long-term safety information can only be obtained from long-term use with ongoing surveillance. Apart from methylphenidate in the treatment of ADHD, this level of uncertainty is actually the norm and not the exception. A fair and reasonable discussion about the limits of the scientific knowledge is to be preferred to dogmatic statements about the prescriptions being offered. This of course applies to all therapeutic interventions, not just somatic treatments. Best clinical judgment means applying best available evidence to address the needs of the patient. Physicians are expected to ply their craft at the limits of certainty. Second, clinicians are obligated to be as up-to-date as possible regarding all aspects of the diagnosis and treatments for the population that they are serving. There is no excuse for “not knowing.” If the clinician is unsure, or uninformed, then referral should be made to a colleague who has the up-to-date knowledge needed to provide proper patient care. In child and adolescent psychiatry, it is still too common to find practitioners who practice what they learned as residents or house officers. Every clinician treating mentally ill children and adolescents either needs to have a solid working knowledge of diagnosis and somatic treatments, or else must discharge the obligation to the patient by referral to one who does. Furthermore, this requirement of life-long learning must be driven by appropriate educational activities. It is not appropriate to base one’s understanding of somatic treatments on information solely supplied by the pharmaceutical industry. Similarly, it is not appropriate to base this understanding on the basis of the opinions of colleagues alone. Ongoing critical reading of the evidence and constructive, unbiased peer discussion of the scientific literature form the foundation of continuing self-education. Third, the clinician is obligated to inform others, often within the wider society, of the values, risks and benefits of somatic treatments for child and adolescent mental disorders. Societies are complex organizations, comprised of many subgroupings, some of which are more certain of the truth than others. In some situations, social criticism of medical practice is well warranted and provides an independent and necessary counterpoint to medical tradition and self-certainty. In other situations, social criticism of medical practice is the result of certain ideologies or socioeconomic agendas, which may make great theater and sell newspapers or lead to wealth accumulation in some of the members of the legal profession. Responsible physicians need to become involved in proactively countering such negatively driven social discourse, as the outcome of some of these social processes, if not appropriately addressed, may lead to negative outcomes for patients and their families. At times, clinicians must discharge their obligation to their patients by active participation in the public debates of civil society. Here again this participation is to be driven by the scientific and not the ideological prerogative. Fourth, clinicians must discharge their obligation by doing no harm. This does not mean “Do not treat.” Nor does it mean “Do not treat using an intervention that may be harmful if used incorrectly or if inappropriately applied.” As chemists, alchemists and sorcerers have known for centuries, toxicity is mostly an issue of dose! The obligation is to ensure that the therapeutic intervention does not do more harm than good and that it does not do more harm than the unchecked progression of the disease and that it does not do more harm than an available, equally effective intervention. The clinician is obligated to use treatments that have a positive benefit–risk ratio, and to use them in a way that maximizes benefits and minimizes risks. In order to do this properly, the three obligations described above must be effectively discharged. PHYSICAL TREATMENTS 1103 9781405145497_4_067.qxd 29/03/2008 02:59 PM Page 1103

Clinician Respect for the Autonomy and Rights of the Patient In many religious and philosophical traditions, the “golden rule” is “Do unto others as you would have them do unto you.” This is a useful dictum for clinicians to follow, regardless of their personal beliefs. Treating your patient as you would like to be treated means that you respect the autonomy and rights of your patient. In practical consideration this includes such activities as ensuring that the patient provides informed consent to treatment. Younger patients (perhaps as young as 7–8 years of age) may be able to provide informed assent while all patients under the age of majority should (apart from exceptional circumstances that could be professionally or legally defended) receive parental or responsible other’s consent prior to treatment (De Lourdes, Larcher, & Kurz, 2003). The treatment contract between care provider and patient includes the framework of active patient participation in decision-making pertaining to care. This means that treatment decisions need to be shared with patients and responsible others and that treatment choices should be made mutually. There may be exceptional circumstances in which such collaborative decision-making may not be possible – such as a psychotic disorder with no insight from the patient – and in those cases, the legal framework governing physician–patient interaction must be followed. Psychoeducation, the provision and comprehensive review of information pertaining to the illness, its treatments and its treatment options should be provided to patients and their families in language that they can understand. Many such resources (including web-based materials) are easily available from reputable sources – such as the American Academy of Child and Adolescent Psychiatry and the National Institutes of Mental Health (or, e.g., World Health Organization, 1998). The patient and family should be given hard copies of “best information” and referred to other sources that they can review on their own. Following this, time should be spent answering questions and addressing specific concerns. This educational process should be ongoing and may require additional time at both baseline and follow-up visits. It is not clear whether good psychoeducational interventions can improve adherence to treatments, which may be especially problematic during the adolescent years (Staples & Bravender, 2002). Compared with adults, treatment adherence issues may be more complex in children and adolescents (Gau, Shen, Chou et al., 2006) for many reasons, including but not limited to: the input of parents; input of teachers or other institutional representatives; family conflicts; and peer pressures. The importance of treatment adherence is not to be overlooked, as it may not only impact on therapeutic outcome, but may also be linked to adverse effects – such as suicidality in depressed youth treated with antidepressants, in which it has been postulated that poor treatment adherence may explain “suicidality” (Weiss & Gorman, 2005). Additionally, the clinician and any others participating in the care of the mentally ill young person must be aware of the sociocultural aspects of their interaction. In this multicultural and global environment, not to understand and consciously consider the cultural, religious and social frameworks that the patient and family bring to the care interaction is to be disrespectful to the patient and his or her sense of self. Thus, the clinician cannot prescribe somatic treatments by “giving a prescription.” Somatic treatments are a science, dispensed in the form of an art. References Baldessarini, R. J., Tondo, L., Davis, P., Pompili, M., Goodwin, F. K., & Hennen, J. (2006). Decreased risk of suicides and attempts during long-term lithium treatment: A meta-analytic review. Bipolar Disorders, 8, 625–639. Brooks, S. J., & Kutcher, S. (2004). The Kutcher Generalized Social Anxiety Disorder Scale for Adolescents: Assessment of its evaluative properties over the course of a 16-week pediatric psychopharmacotherapy trial. Journal of Child and Adolescent Psychopharmacology, 14, 273–286. Cheung, A. H., Emslie, G. J., & Mayes, T. L. (2006). The use of antidepressants to treat depression in children and adolescents. Canadian Medical Association Journal, 174, 193–200. de Leon, J., Armstrong, S. C., & Cozza, K. L. (2006). Clinical guidelines for psychiatrists for the use of pharmacogenetic testing for CYP450 2D and CYP450 2C19. Psychosomatics, 47, 75–85. De Lourdes, L. M., Larcher, V., & Kurz, R. (2003). Informed consent/assent in children. Statement of the Ethics Working Group of the Confederation of European Specialists in Paediatrics (CESP). European Journal of Pediatrics, 162, 629–633. Desta, Z., Zhao, X., Shin, J. G., & Flockhart, D. A. (2002). Clinical significance of the cytochrome P450 2C19 genetic polymorphism. Clinical Pharmacokinetics, 41, 913–958. Emslie, G. J., Hughes, C. W., Crismon, M. L., Lopez, M., Pliszka, S., Toprac, M. G., et al. (2004). A feasibility study of the childhood depression medication algorithm: the Texas Children’s Medication Algorithm Project (CMAP). Journal of the American Academy of Child and Adolescent Psychiatry, 43, 519–527. Evans, S. M., Levin, F. R., & Fischman, M. W. (2000). Increased sensitivity to alprazolam in females with a paternal history of alcoholism. Psychopharmacology, 150, 150–162. Fegert, J. M., Kolch, M., Glaeske, G., & Janhsen, K. (2006). Antidepressant use in children and adolescents in Germany. Child and Adolescent Psychopharmacology, 16, 197–206. Flokhart, D. (2007). Drug interactions. Accessed March 14, 2007 from http://medicine.iupui.edu/flockhart/. Gau, S. S., Shen, H. Y., Chou, M. C., Tang, C. S., Chiu, Y. N., & Gau, C. S. (2006). Determinants of adherence to methylphenidate and the impact of poor adherence on maternal and family measures. Journal of Child and Adolescent Psychopharmacology, 16, 286– 297. GeneMedRx. (2007). Accessed March 14, 2007 from http://www. genemedrx.com/Drhome.html. Hashimoto, K., Shimizu, E., & Iyo, M. (2004). Critical role of brainderived neurotrophic factor in mood disorders. Brain Research Reviews, 45, 104–114. Hu, Z., Yang, X., Chan, S. Y., Heng, P. W., Chan, E., Duan, W., et al. (2005). Herb–drug interactions: A literature review. Drugs, 65, 1239–1282. Hughes, C. W., Emslie, G. J., Crismon, M. L., Wagner, K. D., Birmaher, B., Geller, B., et al. (1999). The Texas children’s medication algorithm project: Report of the Texas consensus conference panel on medication treatment of childhood major depressive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1442–1454. Hunkeler, E. M., Fireman, B., Lee, J., Diamond, R., Hamilton, J., He, C. X., et al. (2005). Trends in use of antidepressants, lithium and CHAPTER 67 1104 9781405145497_4_067.qxd 29/03/2008 02:59 PM Page 1104

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1106 The term delinquency is a legal one and refers to antisocial acts that could result in conviction, although most do not. The term juvenile refers to the age of the perpetrator. This extends from the age when they are first deemed able to be criminally responsible, through an age range when they are processed in a legal system for youths, until an upper age when they are dealt with in courts for adult crimes (see chapter 8). These ages vary between countries and states, and also may vary according to the offense (Cavadino & Allen, 2000; Justice, 1996). In England and Wales the juvenile age range is currently 10–18 years, although some have proposed the minimum age should be older (e.g., 14 years). Juvenile delinquency is a major public concern because of the damage inflicted on property and people, and the wasted unproductive lives of the young people themselves (Surgeon General, 2001). The legal term delinquency should be distinguished from scientific concepts in developmental psychopathology such as antisocial behavior and aggression, and from clinical psychiatric diagnoses such as conduct disorder (see chapter 35; Frick, 2006). There is a considerable degree of overlap because all involve antisocial behaviors that fail to conform to societal norms. However, they are not the same; for example, a child under 10 with conduct disorder in England cannot be a delinquent, and a single delinquent act by an otherwise welladjusted 15-year-old would not qualify for a diagnosis of conduct disorder. A major role of the forensic psychiatrist in the youth justice system is to bring the benefits of modern developmental psychopathology to illuminate the assessment and management of offenders. This task is helped by important advances in understanding the epidemiology, longitudinal course and treatment of antisocial behavior in recent years. Understanding is growing of how risk factors combine to both precipitate and maintain antisocial behavior (see chapter 35). Progress has been made in the development of validated screening, needs assessment and risk assessment tools for this specific population (Bailey, Doreleijers, & Tarbuck, 2006; Grisso, Vincent, & Seagrave, 2005) and in the development of promising interventions (Harrington & Bailey, 2003). This chapter has three sections. First, the contribution of psychiatric disorders to delinquency is reviewed. Second, three aspects of assessment are covered: determining the personal needs of delinquents; assessing the risks they pose to others; and judging their mental capacity with regard to their fitness to stand trial. Third, treatment of special groups is covered, and interventions for youths displaying delinquent behaviors are reviewed. Because of the trend to treat antisocial youth outside of expensive formal court proceedings where possible (AACAP, 2005; Bailey & Williams, 2005), this last section includes general treatment of offending youths whether or not they have come to the attention of justice systems. Historical Context The need to control a small group of very persistent recalcitrant youth, perhaps 1–2% of the population, is perennial. In the 18th and 19th centuries, offending children were seldom distinguished from adults and were placed in prison. In the England of 1823, boys as young as 9 years were held in solitary confinement in ships retired from the Battle of Trafalgar. Over the last 50 years, both community and secure residential interventions in youth justice have been characterized by a pattern of reforming zeal, followed by gradual disappointment as the results of evaluations have become available (Hagell, Hazel, & Shaw, 2000). Throughout the 20th century, concern about levels of juvenile offending has absorbed the attention of the public, politicians, practitioners and researchers (Burt, 1925; Glover, 1960; Rutter, Giller, & Hagell, 1998). Throughout the western world (Junger-Tas, 1994) there has been a widespread and growing perception that juvenile crime is inevitable, a fact of life in an increasingly violent society (Shepherd & Farrington, 1993). However, this has been accompanied by increasing urgency to curb the spread of serious juvenile crime. A century ago, the plan underlying the juvenile justice system in the USA had as its purpose, through the juvenile court, the creation of a whole new system of law for responding to youthful offending based on the developmental premise that young people were still malleable and could be saved from a life of crime. This philosophy held its ground for nearly 100 years, until the USA experienced an increasing tide of youth violence from the late 1980s (Zimring, 1998). Grisso (1996) commented that in its wake the “rehabilitative approach to juvenile justice has all but disappeared in the USA in an avalanche of massive legislative efforts to transform it.” These changes are echoed Juvenile Delinquency 68 Sue Bailey and Stephen Scott 9781405145497_4_068.qxd 29/03/2008 02:59 PM Page 1106 Rutter’s Child and Adolescent Psychiatry, 5th Edition, Edited by M. Rutter, D. V. M. Bishop D. S. Pine, S. Scott, J. Stevenson, E. Taylor and A. Thapar © 2008 Blackwell Publishing Limited. ISBN: 978-1-405-14549-7

in the overhaul of the youth justice system in England and Wales (Bailey, 1999). This more sobering view of whether delinquents naturally improve is supported by recent advances in developmental psychopathology. Increased understanding of the continuities between child and adult life (see chapter 13; Maughan & KimCohen, 2005) has served as a timely reminder that many childhood disorders once thought to resolve with age are known to cast long shadows over later development (Moffitt, 2005). This is especially true with regard to the trajectory from antisocial behavior in childhood, through adolescence and on into antisocial personality disorder (ASPD) in adult life where the prevalence is approximately 2% (Coid, 2003; Torgersen, Kringlen, & Cramer, 2001). ASPD is associated with a high degree of social handicap and increased risk of death through accidents, suicide, substance abuse and murder (Robins & Rutter, 1990; Tremblay & Pare, 2003). Once established, it is very hard to treat. Nonetheless, recent studies suggest that there are several promising interventions for juvenile offending, as reviewed below. Psychiatric Disorders and Offending Rates of psychiatric disorder in detained juveniles vary, according to study, from 50% to 100% (Lader, Singleton, & Meltzer, 2003; Lederman, Dakof, Larrea, & Li, 2004; Sailas, Feodoroff, Virkkunen, & Wahlbeck, 2005; Vermeiren, De Clippele, & Deboutte, 2000; Vreugdenhill, Vermeiren, Wouters, Doreleijers, & van den Brink, 2004). A survey in England and Wales by the Office of National Statistics (ONS) of 590 young offenders (aged 16–20 years) found that 80% had two or more disorders (Lader, Singleton, & Meltzer, 2003); broadly comparable figures were found in two large Finnish cohorts (Sailas, Feodoroff, Virkkunen et al., 2005). The most common disorders, unsurprisingly, are conduct disorders (CD), but other disorders such as substance abuse disorders, attention deficit/ hyperactivity disorder (ADHD), mood and anxiety disorders and post-traumatic stress disorder (PTSD) are common; psychoses are significant, and autistic spectrum disorders are being increasingly recognized. Conduct Disorders and Attention Deficit/Hyperactivity Disorder High rates of physically aggressive behavior are found in children and adolescents with CD, and particularly those with comorbid CD and ADHD. They are at substantially greater risk of delinquent acts in adolescence and continued violence and offending into adulthood; many develop ASPD (Loeber, Pardini, Homish et al., 2005; Seagrove & Grisso, 2002; Soderstrom, Sjodin, Carlstedt & Forsman, 2004; Sourander, Elonheimo, Niemela et al., 2006). Factors that may be protective for other outcomes may not necessarily reduce offending; thus, having a partner in itself does not appear to reduce criminality (indeed, juvenile delinquents with a partner commit more offenses); however, if the partner is supportive, this is associated with less offending (Meeus, Branje, & Overbeek, 2004). CD are discussed in more detail in chapter 35. Psychopathic Traits and Antisocial Personality Disorder Psychopathic traits are being increasingly recognized in children and adolescents (see chapter 51). Youths with these traits are commonly seen in justice systems as a result of the combination of deceptiveness and antisocial behavior. Factor analyses typically find three sets of characteristics (Cooke & Michie, 2001): 1 An arrogant, deceitful interpersonal style, involving dishonesty, manipulation, grandiosity and glibness; 2 Defective emotional experience, involving lack of remorse, poor empathy, shallow emotions and a lack of responsibility for one’s own actions; and 3 Behavioral manifestations of impulsiveness, irresponsibility and sensation-seeking. Delinquent offenders with these psychopathic traits have an earlier onset of offending, commit more crimes, re-offend more often (Forth & Burke, 1998) and more violently (Spain, Douglas, Poythress, & Epstein, 2004) than non-psychopathic criminal youth. In addition, they exhibit insensitivity to punishment cues irrespective of whether or not they have conduct problems, making them especially hard to treat (O’Brien & Frick, 1996). ASPD (using DSM-IV criteria) was found in 81% of sentenced 16- to 20-year-old males in the ONS survey (Lader, Singleton, & Meltzer, 2003). However, overconfident predictions about poor outcomes for youth with these traits should be avoided, as knowledge about the nature, stability and consequences of juvenile psychopathy is still very limited. There is only one published longitudinal study of its stability and it remains unclear to what degree the antisocial behaviors in callous-unemotional youths change over time. Autistic Spectrum Disorders Autistic spectrum disorders are being increasingly recognized in general populations (Baird, Simonoff, Pickles et al., 2006), and at a clinical level in adolescent forensic populations, although there have not yet been thorough surveys. Jones, Forster, and Skuse (2007) found high rates of impaired social cognition in young offenders, but they did not fully assess autistic spectrum disorders. Suspicion should be raised if an offense or assault is bizarre in nature, the degree or nature of aggression is unaccountable or there is a stereotypic pattern of offending. Howlin (1997) proposed four reasons for offending and aggression in autistic persons: 1 Their social naivety may allow them to be led into criminal acts by others; 2 Aggression may arise from a disruption of routines; 3 Antisocial behavior may stem from a lack of understanding or misinterpretation of social cues; and 4 Crimes may reflect obsessions, especially when these involve morbid fascination with violence – there are similarities with the intense and obsessional nature of fantasies described by some adult sadists (Bailey, 2002). JUVENILE DELINQUENCY 1107 9781405145497_4_068.qxd 29/03/2008 02:59 PM Page 1107

Autistic spectrum traits share some characteristics with the callous-unemotional and interpersonal aspects of psychopathy: in both a lack of appreciation of, or concern for the feelings of others is prominent. Future studies need not only to disentangle these emotional dimensions of autistic spectrum disorders and psychopathy, but also to determine how the behavioral dimensions of impulsiveness and recklessness of psychopathy overlap with the same traits in ADHD. We need phenomenological, etiological and longitudinal studies to characterize these symptom clusters, and intervention trials to see what works in ameliorating them, and how they moderate response to treatment. Substance Misuse Drug and alcohol misuse are strongly associated with offending. The ONS survey (Lader, Singleton, & Meltzer, 2003) found that 70% of male and 51% of female young offenders had misused alcohol in the year before coming to prison (Alcohol Use Disorders Identification Test scores over 8), and that in the same period 30% of men and 26% of women had used heroin. Rutter, Giller, & Hagell (1998) describe three mechanisms that operate. First, both sets of behaviors share common antecedent risk factors, including individual characteristics such as impulsiveness with lower IQ, environmental characteristics such as harsh parenting with poor supervision, and associating with a deviant peer group. Second, while under the influence of substances, youths are more disinhibited and commit more offenses, including violent assault and driving offenses. Third, once addicted, some youths commit crimes to pay for their habits; for the same reason, a substantial proportion of female addicts turn to prostitution. Additionally, use of cannabis is associated with psychosis, which also increases the likelihood of offending (Arseneault, Moffitt, & Caspi, 2002; Henquet, Krabbendam, Spauwen et al., 2005). Early Onset Psychosis Of the juvenile population in the youth justice system, 5–10% have psychoses (Chitsabesan, Kroll, Bailey et al., 2006; Lader, Singleton, & Meltzer, 2003) compared with around 1% of the general juvenile population. As in adult life (Taylor & Gunn, 1999), most young people with schizophrenia are nondelinquent and non-violent. However, about 10% of adults with psychoses commit offenses (Soyka, Morhart-Klute, & Schoech, 2004) and the juvenile proportion is likely to be similar. Non-psychotic prodromal behavioral disturbances precede full-blown psychotic symptoms in about half of cases of early-onset schizophrenia, and can last between 1 and 7 years. They include disruptive behaviors, ADHD and CD. Therefore, the forensic psychiatrist needs to carry out mental health assessments repeatedly over time, to be able to detect changes in social functioning (often from an already disorganized baseline level) and mental state changes including perceptual distortion, ideas of reference and delusional mood. There is an increased risk of violence to others when youths with psychoses have active symptoms, especially when exacerbated by misuse of drugs or alcohol. The risk of violent acts is related to subjective feelings of tension, ideas of violence, delusional symptoms that incorporate named persons known to the individual, persecutory delusions, command hallucinations, fear of imminent attack, feelings of sustained anger, and fear and passivity experiences that reduce the youth’s sense of self-control. Protective factors include responding to and ongoing compliance with physical and psychosocial treatments, good social networks, a valued home environment, no interest in or knowledge of weapons as a means of violence, good insight into the psychiatric illness and any previous violent aggressive behavior, and a fear of their own potential for violence. These features require particular attention during assessment, but full general psychiatric assessment remains essential, as the best predictors of future violent offending in young people with mental disorder are the same as those in the general adolescent population (Clare, Bailey, & Clark, 2000). Depression, Anxiety and Post-Traumatic Stress Disorder These disorders are also very common in young offenders. The ONS survey, using the Clinical Interview Schedule, found 41% of men and 67% of women scored above the cut-off score of 12 for symptoms of “neurotic” (emotional) disorders, compared with 11% of the general population. The combination of depression, anxiety and severe PTSD is being increasingly recognized in the child literature as one pathway into adult ASPD (Harrington & Bailey, 2003; Pliszka, Stienman, Barrow, & Frick, 2000). In depression, as well as feelings of low mood, there may also be irritability, hostility and anger, which increase the risk of defensive aggression (Harrington, 2001), a pattern seen in juvenile justice populations (Harrington, Kroll, Rothwell et al., 2005). Anxiety and PTSD (see chapter 42) are relatively common in children who have experienced violence in war-torn countries and those who live in a context of “urban war zones” (Fletcher, 2003). Exposure to brutalizing violence can then lead the victims to be violent themselves. Garbarino (2001) has set out an ecological framework to explain the process and conditions that transform the “developmental challenge” of coping with violence into the “developmental harm” of meting it out to others. He proposed an accumulation of risk factors for understanding how and when children who suffer the most adverse consequences of exposure to community violence then have the limits of their resilience overwhelmed. Emotional symptoms such as these can easily be missed, so it is essential to enquire about them during the mental state examination. Suicide and Deliberate Self-Harm Deliberate self-harm and completed suicide are particular problems for both out-patient and incarcerated young offenders. In the community, youths with more severe conduct symptoms are more likely to have comorbid depressive symptoms, and rates of deliberate self-harm have long been recognized to be elevated to levels higher than in either condition alone. Thus, Kovacs, Goldston, and Gatsonis (1993) found 22% of adolescents with depression, 9% with CD, but 45% of those CHAPTER 68 1108 9781405145497_4_068.qxd 29/03/2008 02:59 PM Page 1108

with both had attempted suicide; Fombonne, Wostear, Cooper, Harrington, and Rutter (2001) found a similar pattern. Mechanisms to explain this include a higher genetic loading and also increased psychosocial risk factors. Rates are especially high amongst incarcerated youths. Because they are a more severely antisocial subsample, they tend to have more of the genetic and environmental risk factors mentioned above. Additionally, immediate proximal risk factors are elevated: self-harm is often a serious attempt to escape from unbearable feelings or situations (see chapter 40), and youths in prison often feel, and are, powerless and trapped. In England and Wales, the number of self-inflicted deaths in prison in 2006 was 99 per 100,000 prisoners per year, compared with 18 in the general community (Safer Custody Group, 2007). A total of 20% were by under twenties, 95% were by males (reflecting the prison population make-up), and over 90% were by hanging, with half occurring within the first month of imprisonment (Safer Custody Group, 2007). Violent and sexual offenders are at highest risk. Triggering factors include being bullied and being locked in a cell for long periods. These worryingly high rates led in 2004 to the Safer Custody Group being formed for England and Wales, and attempts are being made to ameliorate the risk factors within prisons. However, there is still a long way to go. It is incumbent on psychiatrists working with these youths to assess suicidal tendencies thoroughly and plan interventions accordingly; this can be overlooked when the focus is on the offending record. Assessment General Principles Assessment of need and risk are two separate but intertwined processes. The former has improving the health of the young person as its goal, the latter concerns the danger the young person poses to others, and is often more prominent in public debates about policy and legislation. Both types of assessment contribute to risk-management procedures (Bailey & Dolan, 2004). Needs Assessment While carrying out a traditional clinical psychiatric assessment with multiaxial diagnosis should form the backbone of a needs assessment, additionally using a formal needs assessment instrument can help because there are specific issues for the forensic population, and often a formal report is required for court in which it is essential to demonstrate that all key issues have been addressed (Bailey, Doreleijers, & Tarbuck, 2006). As there is rather little literature about needs assessment instruments for adolescent offenders (Knight, Goodman, Pulerwitz, & DuRant, 2001), the first author (S.B.), with colleagues, developed a new interview-based instrument called the Salford Needs Assessment Schedule for Adolescents (SNASA; Kroll, Woodham, Rothwell et al., 1999). This follows the design of the Cardinal Needs Schedule (Marshall, Hogg, Gath, & Lockwood, 1995), which is widely used with adult populations and has well-established reliability and validity. It covers 21 different domains, including individual behaviors (such as aggression), social relations and living situation (Kroll, Rothwell, Bradley et al., 2002). A clinical version is available, as is a shortened form (including a screening questionnaire) developed for use by youth offending teams (Youth Justice Board, 2007). A recent study in the UK used the SNASA. It adopted a crosssectional design and investigated 301 young offenders: 151 in custody and 150 in the community. Participants were found to have high levels of need in a number of different areas, including mental health (31%), education/work (48%) and social relationships (36%), but these needs were often unmet because they were not recognized. One in five young offenders were identified as having intellectual disability (IQ <70; Chitsabesan, Kroll, Bailey et al., 2006). Risk Assessment Risk assessment has a theory and methodology separate from needs assessment. Most instruments combine factors from various areas of risk (e.g., individual, family, neighborhood) in order to predict the probability of future offending. A number of instruments have been designed for application in the juvenile justice system (Barnoski & Markussen, 2005; Borum & Grisso, 2007; Corrado, 2002; Desai, Goulet, Robbins et al., 2006; Odgers, Burnette, Chauhan, Moretti, & Reppucci, 2005). For better reliability and validity, items should refer to multiple contexts of behavior and use multiple sources of independent information (Farrington & Loeber, 1999). They should tap into not only static risks, but also dynamic factors that can be changed by interventions. To maximize predictive power, information on risks should be complemented by data on protective factors and strengths; however, this is rarely done. Fitness to Stand Trial In the UK, a young person’s age, level of maturity and intellectual and emotional capacities must be taken into account when they are charged with a criminal offense, and appropriate steps taken in order to promote their ability to understand and participate in the court proceedings (T&V v United Kingdom, 1993). A responsibility therefore falls on the defense lawyer to be aware of the possibility that a young person may not be able to participate effectively in the trial process, particularly if they are under 14 years old, or have learning problems or a history of absence from school (Ashford, Chard, & Redhouse, 2006). Ashford and Bailey (2004) stated that all young defendants, regardless of the offenses they are charged with, should be tried in youth courts with permission for adult sanctions for older youths if certain conditions are met. The idea was to enable a mode of trial for young defendants that would be subject to safeguards that can enhance their understanding and participation. Assessment of cognitive and emotional capacities should occur before any decisions on venue and mode of trial take place. It needs to be borne in mind that a distinction is made JUVENILE DELINQUENCY 1109 9781405145497_4_068.qxd 29/03/2008 02:59 PM Page 1109

in criminal law between conditions that negate criminal liability and those that mitigate the punishment deserved (see chapter 8). Very young and mentally immature children, and the profoundly mentally ill, may lack the minimum capacity necessary to be criminally liable. Those exhibiting less profound impairments may meet the minimum conditions for some punishment but qualify for a lesser level. It should also be borne in mind that capacity is not a generic skill that a person either has or lacks; rather, it is specific to the issues in question and is multifaceted, with four key elements: 1 The capacity to understand information relevant to the specific decision at issue (understanding); 2 The capacity to appreciate one’s situation as the defendant when confronted with a specific legal decision (appreciation); 3 The capacity to think rationally about alternative courses of action (reasoning); and 4 The capacity to express a choice among alternatives (choice). In addition to these facets, capacity is also situation-specific, and open to influence. Evaluation of capacity should include assessment of all possibly relevant psychopathology, emotional understanding as well as cognitive level, the child’s experiences and appreciation of situations comparable to the one relevant to the crime and to the trial, and any particular features that may be pertinent to this individual in this particular set of circumstances (Barnum, 2000; Grisso, 1997). Particular attention needs to be paid to developmental background, emotional and cognitive maturity, trauma exposure and substance misuse. Appropriate sources for obtaining information relevant to assessment of a juvenile’s competence to stand trial will include a variety of historical records, a range of interviews, a variety of other observations and, in some cases, specialized tests. Records of the child’s school functioning, past clinical assessment, treatment history and previous legal involvements need to be obtained. In coming to an overall formulation, there should be a particular focus on how both developmental and psychopathological features may be relevant to the forensic issues that have to be addressed. Potentially relevant problems include: inattention, depression, disorganization of thought processes that interfered with the ability to consider alternatives, hopelessness, such that the decision is felt not to matter, delusion or other fixed beliefs that distort understanding of options (or their likely outcomes), maturity of judgment and the developmental challenges of adolescence (Ashford, Chard, & Redhouse, 2006). Interventions for Particular Crimes and Groups Juvenile Homicide Youths who have been prosecuted for murder or manslaughter are similar in background to other juvenile delinquents on points such as age, gender and ethnic background, but usually have more risk factors (Crespi & Rigazio-DiGili, 1996; Myers & Scott, 1998). However, there are differences – murder and manslaughter are more often committed alone rather than in a gang, and on average the perpetrators start their criminal activities at a later age and are much less likely to have previous convictions than other minors taken into judicial youth institutions. Nevertheless, there is great variety in terms of motives, victims and modus operandi – each case stands on its own. The majority of young persons who have killed initially dissociate themselves from the reality of their act, but gradually experience a progression of reactions and feelings akin to a grief reaction. In these early stages, while the young person is still facing an adversarial and public trial process, they may move through processes of disbelief, denial, loss, grief and anger/blame. Therapeutic work with juveniles who have killed needs to include an understanding of the role of violence and sadism in a young person’s life. The therapist has to understand the depth of the young person’s sensitivity and reaction to perceived threat, and how their past maladaptive behaviors may have allowed them to feel in control of their lives. There may be expression of considerable anger and distress in sessions as the young person comes to terms with their rage, and also when they are exploring feeling empathy for their victim and saying sorry for their actions and reattributing blame. PTSD arising from the participation in sadistic acts (either directly or observing the actions of co-defendants) has to be treated, as does any trauma arising from past personal emotional, physical or sexual abuse. Later, considerable work is likely to be needed to prepare the young person for the transition from long-term incarceration to re-entry into the community; preferably, this should be followed by extended aftercare (Heide, 1999). Sexually Abusive Behavior Sexually inappropriate behavior in children and adolescents constitutes a substantial health and social problem (Quinsey, Harris, Rice, & Cormier, 2006). Young abusers who have been charged come within the criminal justice system but should also be considered in their own right within the child protection framework (see chapter 32). Most, but not all, abusers are male, often come from disadvantaged backgrounds with a history of victimization, sexual and physical abuse (Bentovim & Williams, 1998; Skuse, Bentovim, Hodges et al., 1998) and show high rates of psychopathology (Hummel, Thomke, Oldenburger, & Specht, 2000; van Outsem, Beckett, Bullens et al., 2006). Of particular concern are a significant subgroup with mild learning disability, for whom treatment programs have to be tailored to their level of development and cognitive ability. Most adult sexual abusers of children started their abuse when adolescents, yet neither ICD–10 nor DSM-IV has a diagnostic category for pedophilia in those under 16 years (see chapter 52). Langstrom, Grann, and Lindblad (2000) advocated the development of empirically based typologies for this offender group. A structured, carefully planned multiagency approach is required when working with sexually aggressive younger chilCHAPTER 68 1110 9781405145497_4_068.qxd 29/03/2008 02:59 PM Page 1110

dren and sexually abusive adolescents (Becker, 1998; Vizard, Wynick, Hawkes, Woods, & Jenkins, 1996). The treatment process includes managing the crisis of the disclosure, assessing the family, therapeutic work in a protective context for the victim, separate therapeutic work for the offender, and work around the reconstruction and reunification of the victim’s family. To date, there have been few methodologically sound trials of sexually abusing children and adolescents, so it is of interest to note the results of adult studies. Lösel and Schmucker (2005) carried out a meta-analysis of 69 trials of treatments for adult sexual offenders involving 22,181cases. Despite a wide range of positive and negative effect sizes, the majority of trials confirmed the benefits of treatment with on average 37% less sexual recidivism than controls. Somatic treatments (surgical castration and hormonal medication) showed larger effects than psychosocial interventions, amongst which cognitive–behavioral approaches revealed the most robust effect. Non-behavioral treatments did not demonstrate a significant impact. New approaches to cognitive–behavioral therapy (CBT) with sexually abusing youth have recently been described within the context of relapse prevention (Steen, 2007). CBT group work with sexually abusing children and young people is widely practiced in the UK (Hackett, Masson, & Phillips, 2006), but there are few rigorous evaluations. In contrast to CBT, dynamic psychotherapy aims to work at an unconscious level with the sexually abusive young person to explore and understand the reasons for his or her persistent behavior. However, evidencebased treatment outcome studies have not yet been undertaken for dynamic therapy with juvenile sexual abusers. It is plausible that interventions carried out as early as possible with young oversexualized children, before their patterns of sexually aggressive behaviors become entrenched, may be more effective. However, there is a dearth of randomized trials and follow-up studies looking at treatment outcomes with this group of younger children. Recidivism as a sole outcome measure for treatment is often used in forensic studies of sexually offending adults, but is unlikely to be reliable with children and adolescents because persistent sexual behavior problems in children under the age of criminal responsibility will not appear in crime statistics, and conviction statistics for sex offenders of all ages are notoriously unreliable for a variety of reasons, including failure to report victimization experiences, failure to proceed with charges and a high rate of trial failures. More studies in this area are therefore needed. Firesetting/Arson Arson can have a devastating impact on the victim and more widely. Juvenile arsonists are not a homogeneous group, with a wide range of familial (Fineman, 1980), social (Patterson, 1982), developmental, interpersonal (Vreeland & Lowin, 1980), clinical and “legal” needs. Kolko and Kazdin (1992) highlighted the importance of attraction to fire, heightened arousal, impulsivity and limited social competence. Compared with one-off firesetters, recidivists show more covert antisocial behavior, have greater interest in fire and fire-related activities, are more likely to be male and have poorer social skills and more family dysfunction (Kennedy, Vale, Khan, & McAnaney, 2006; MacKay, Henderson, Del Bove et al., 2006). In addition to the general assessment of antisocial behavior, the specific domains to be considered include: history of fireplay; history of hoax telephone calls; social context of firesetting (whether alone or with peers); where the fires were set; previous threats/targets; type of fire, single/multiple seats of fire setting; motivation (e.g., anger resolution, boredom, rejection, cry for help, thrill-seeking, fire-fighting, crime concealment, no motivation, curiosity and peer pressure). As with other forms of serious antisocial behavior, no single standard treatment approach is appropriate for all individuals (Repo & Virkunnen, 1997). For recidivistic firesetters, therapy may include psychotherapy to increase the understanding of the behavior, including antecedents defining the problem behavior and the environmental or intrapersonal triggers, and establishing the behavioral reinforcers. Skills training may help to promote adaptive coping mechanisms, and carers will need to be trained in how to supervise the adolescent closely. However, to date there have been no randomized controlled trials of treatments. Female Delinquents Any framework offering treatment for young offenders must consider appropriate provision for the special needs of young females who constitute an important minority of offenders (Bailey, 2000a; Miller, Trapani, Fejes-Mendoza, Eggleston, & Dwiggins, 1995; Zoccolillo, 1993). Whereas the overall level of offending is far lower in girls, in general similar risk factors operate (Gorman-Smith & Loeber, 2005; Moffitt, Caspi, Rutter, & Silva, 2001) although early physical aggression seems not to predict later delinquency in girls (Broidy, Nagin, Tremblay et al., 2003). As well as external risk factors, the thinking patterns of violent girls are similar to those of violent boys (Jasper, Smith, & Bailey, 1998; Lenssen, Doreleijers, Van Dijk, & Hartman, 2000). Longitudinal data demonstrate that girlhood aggression often contributes to a cascading set of negative outcomes as young women move into adolescence and adulthood. Young girls who engage in disruptive behavior and fight are at risk for several negative outcomes, including being rejected by peers and feeling alienated and unsupported in their relationships with peers and adults; struggling academically; affiliating with other peers prone to deviant behavior and with them becoming involved in more serious antisocial behaviors; choosing antisocial romantic partners, and hence initiating and receiving partner violence; becoming adolescent mothers who are less sensitive and responsive as parents, and who have children with increased physical and mental health problems. A downward spiral can ensue in those who are sufficiently antisocial and violent; for example, if they are incarcerated, opportunities for stable employment and relationships may be much diminished. If they are also mothers they may lose custody of their children. In treatment, while similar general principles should be applied as for boys, specific consideration should be given to sexual and reproductive health – including education, JUVENILE DELINQUENCY 1111 9781405145497_4_068.qxd 29/03/2008 02:59 PM Page 1111

contraceptive advice, information about help for sexually transmitted diseases, appropriate support for problems around menstruation, and support and access to relevant resources in the event of a pregnancy. For those who have been abused, when the adolescent female is ready to engage in it, post-abuse counseling from an appropriate adult should take into account the gender of the therapist. Where there is parasuicidal behavior, medical and psychiatric assessment should be followed by appropriate treatment, remembering that the distraction and attention provided by the emergency may be an important component in reinforcing the use of this behavior as a coping strategy. Recognizing that eating problems are far more common in girls is important. Girls seem to respond as well as boys to evidence-based treatments. The trial of Multidimensional Treatment Foster Care (MTFC) by Leve, Chamberlain, and Reid (2005) randomized 81 girls to MTFC or usual care and found 1 year later that those in the experimental group had fewer days locked up and 42% fewer criminal referrals, a similar success rate to that in boys. Early identification of girls at risk is an important step for prevention and intervention programs but can get overlooked given the low base rates of girls engaging in physical aggression and violence. As well as the usual risk factors, high-risk groups of girls to consider for early intervention include those girls who are temperamentally overactive as well as antisocial as toddlers and preschoolers (fewer than boys) and those who have early pubertal development. Interventions for Offending Behavior A large number of different treatments have been used to try to reduce antisocial and offending behavior. These include psychotherapy, pharmacotherapy, school interventions, residential programs and social treatments. A decade and a half ago, Kazdin (1993) documented over 230 psychotherapies that were available, the great majority of which had not been systematically studied. In this review, focus is on treatments with a testable scientific basis and which have been evaluated in randomized trials (Sukhodolsky & Ruchkin, 2006) and applied to populations of young offenders. This section is concerned with the treatment of youth who offend, whether or not they have been formally apprehended by the criminal justice system. There is increasing interest in using community-based interventions for young offenders, because incarceration on its own is barely effective in the longer term, and for intervention to be effective, the young person has to learn not to offend once released back into the home environment. Prevention is covered in chapter 61, and treatment of younger children with CD is covered in chapter 35. Rational Targets for Intervention Derived From Longitudinal and Causal Research There is an abundance of research describing risk and protective factors influencing delinquency (Loeber, Pardini, Homish et al., 2005; Rutter, Giller, & Hagell, 1998), so a rational starting point when considering intervention is to consider the main causal factors and processes, and then design interventions around them. However, in practice many other considerations have shaped interventions, from the desire to punish offending youths, to making use of what is currently available at relatively low cost. These different motives may conflict with what is effective for the young person and what works in reducing the damage they cause to society. One of the best examples of this is shock incarceration in military style boot camps, which, although recommended in the 1990s by the US Office of Juvenile Justice and Delinquency Prevention, and satisfying the desire for retribution and somewhat lower running costs, have repeatedly proven at best ineffective, and often positively harmful (see p. 1119; Benda, 2005). We now turn to consider factors that may be modifiable. Factors Within the Young Person On their own, temperamental and personality factors with high heritability and little malleability would seem poor candidates for intervention (e.g., being male or having a low IQ). However, even when this is the case, treatability is not ruled out. Thus, part of the effect of being male on delinquency is associating with more violent peers, which is potentially treatable; low IQ has many effects such as poorer understanding of social situations, lower empathy (Jolliffe & Farrington, 2004) and lower academic attainments, which in turn affect, for example, propensity to violence and employability. Social skills training and remedial education may moderate some of the impact of low IQ. There are other individual risk factors for which there is good evidence of modifiability; for example, hyperactivity and inattention are eminently treatable (see chapter 34), and hostile attributional styles can be changed (see chapter 63). Even psychopathic traits can be improved through treatment (Hawes & Dadds, 2007). Factors in the Environment Family factors have repeatedly been associated with delinquency (see chapter 25). Parenting styles are characterized by low warmth and involvement, high hostility, inept discipline and poor supervision (Stouthamer-Loeber, Loeber, Wei, Farrington, & Wikstrom, 2002), and these are not just reactive to irritating child behavior, but also have a causal role (Patterson, 2002; Snyder & Stoolmiller, 2002) and are modifiable (see chapter 64). More distal parental characteristics such as having a criminal record and being alcoholic may be impossible or hard to treat, but the mechanism through which they convey risk is likely to be partly through inherited temperament, and partly through parenting style and values (Rutter & Quinton, 1987), which may be modifiable. Beyond the family, peers have an important role through two mechanisms: peer rejection and deviant peer association (Gifford-Smith, Dodge, Dishion, & McCord, 2005). Again, both of these are potentially modifiable. A particularly harmful aspect of the latter is membership of a gang, although the evidence suggests that part of the poor prognosis accrues from gang members being worse than other antisocial youths before CHAPTER 68 1112 9781405145497_4_068.qxd 29/03/2008 02:59 PM Page 1112

they join, but nevertheless being in a gang promotes further antisocial acts (Gatti, Tremblay, Vitaro, & McDuff, 2005). The neighborhood a youth lives in can exacerbate delinquent tendencies, with low ties to the neighborhood, poor social control of irregular behavior and exposure to risky activities such as drug-taking (Sampson, Morenoff, & Gannon-Rowley, 2002). Whereas community-wide interventions to improve neighborhoods are beyond the scope of this chapter, they are mentioned because they are a potentially modifiable risk factor. Implications for Treatment of Mechanisms Through Which Risk Factors are Postulated to Work Social learning theory proponents (Patterson, 1982) suggest that the immediate proximal environment is crucial in engendering antisocial behavior, with the contingencies provided by parents, and then later peers, shaping delinquency. By ignoring prosocial overtures, and inadvertently rewarding aggression (e.g., by giving in to threats or tantrums), parents and peers reinforce deviant behavior. This has formed the basis of parenting programs for antisocial behavior (see chapter 64) that try to change these contingencies; some peer-relationship programs also take this approach (Frankel & Myatt, 2003). Other processes implicated by social learning theorists are imitation and identification (Bandura, 2004), although interventions addressing these mechanisms are not well developed. Parenting also involves the transmission of values, and some treatment approaches specifically address these (e.g., attempting to dissuade parents from believing in the effectiveness of excessive corporal punishment). Within the individual at a psychological level, different theories lead to different intervention approaches. Thus, cognitive theory has led to cognitive therapies that concentrate on the way the youth perceives threats and cues; whereas if the causal theory postulates that the fundamental problem is one of emotional over-reactivity, then teaching youth to become more aware of their own emotions and develop strategies to control these may be tried, as in anger-management programs. Likewise, where a deficit in empathy has been postulated, “restorative justice” programs have attempted to reduce recidivism by confronting perpetrators with their victims, so they have sympathy for what they have done. Each of these treatment approaches is discussed below. Within the individual at a biological level, rather few findings on mechanisms have led to treatment approaches so far. Low autonomic reactivity (as seen in resting and reactive pulse rates) has not led to any well-validated drug treatment, and no neurotransmitter abnormalities have been identified, so the use of neuroleptics is not based on solid etiological theory. At a simple level, risk factors appear to operate in a cumulative fashion that is not simply additive, so that increasing numbers of risk factors appear to confer disproportionately higher risk. The Minnesota group (Appleyard, Egeland, van Dulmen, & Sroufe, 2005) recently reconfirmed Rutter’s (1979) findings that multiple risks had a disproportionately harmful association with poor outcomes and, taking a cluster analytic approach, Stattin and Magnusson (1996) found that antisocial behavior alone did not carry substantial risks unless accompanied by several other risk factors. A clinical implication of this would be that to get a reasonable effect, several risk factors need to be tackled or, alternatively, tackling only one is unlikely to lead to much change. At a rather more sophisticated level, risk factors also do not co-occur randomly. Moving a child experiencing harsh parenting to a different family with parents who are calm, could reduce his or her experience of hostility. However, impulsive children evoke harsher, more critical parenting than controls (Schachar, Taylor, Wieselberg, Thorley, & Rutter, 1987), so this mechanism needs to be borne in mind when planning interventions. Even if there is placement within a foster family, the new parents may need training in techniques of delivering calm discipline. Finally, there may be active selection of environments, so that an impulsive youth might, for example, positively seek out peers and neighborhoods where drugs are sold. Understanding these mechanisms has practical implications, because simply removing a youth from a high-risk neighborhood in the hope that he or she will not get into trouble will not help if the child actively seeks the troublespots. Beyond this, interactions between environmental and constitutional factors may play a part, rather than risk factors operating in a linear fashion. Thus, the MAOA gene confers an increased risk of antisocial behavior only in the presence of adverse parenting (Kim-Cohen, Caspi, Taylor et al., 2006), and adoption studies indicate that whereas having biological parents who are criminal or alcoholic raises the risk of delinquency two- or three-fold, the odds increase to four to five times if the adoptive parents are also criminal or alcoholic (Bohman, 1996). The implication then is that children who are constitutionally at risk may be more susceptible to adverse environments. A therapeutic sequel of this is the potentially optimistic point that if the environment can be substantially changed, youths with greater constitutional risk factors may show the greatest improvements. Intervention is not solely the removal of risk, but also the enhancement of protective factors. Simply conceived, a protective factor may only be the positive end of a risk factor. However, in clinical intervention terms, conceptualizing a factor as protective can lead to a different approach from directly reducing risk factors for antisocial behavior. This could take the form of encouraging parents to build a positive relationship for the young person outside the home, or helping the youth find an activity or hobby in which they can take pride and develop self-esteem. Longitudinal studies suggest that protective factors may be especially important in high-risk individuals. Stattin, Romelsjo, and Stenbacka (1997) found that having physical, emotional, social and cognitive personal resources at age 18 was associated with far lower later conviction rates in high-risk individuals, but made little difference in low-risk cases. Other experiences along the life path found to be protective in the follow-up of delinquents to age 70 by Laub and Sampson (2003) included marriage and military service; in both cases it seemed the changes in practical external circumstances and contingencies were the JUVENILE DELINQUENCY 1113 9781405145497_4_068.qxd 29/03/2008 02:59 PM Page 1113

crucial change agent, rather than any shift in internal motivation or intention. Although not immediately relevant for the treatment of delinquents, perhaps a learning point is that it can be effective to change the context and contingencies around these youths. Given these theoretical considerations, treatment is more likely to be effective if it alters several risk variables for the youth. It follows that, ideally, these risk mechanisms should be measured during treatment to see if they alter. In the past, therapy has often been carried out with only one approach, for several months, and then progress in achieving the end goal (e.g., offending) has been reviewed. It would be preferable to measure progress regularly (say, weekly or monthly) and include risk mechanisms such as quality of parental monitoring and school attendance so that the proximal mechanisms as well as end targets of treatment can be monitored. Then, if there is no change in the youth offending, it would be possible to see whether this was because the mechanisms had been changed and the youth failed to respond, or whether no change in mechanism had occurred. For example, hostile cognitions or negative parenting or teacher rewards could be monitored. If they do not change, they can be addressed and more therapeutic effort directed at them; if they do change, but the youth is not changing, then other barriers to improvement can be explored and a different formulation made. A number of the interventions described below do this more or less formally. Interventions in Practice Political and Social Context The major challenge of altering the trajectories of persistent young offenders has to be met in the context of satisfying public demands for retribution, together with welfare and civil liberties considerations. Treatment of delinquents in institutional settings has to meet the sometimes contradictory needs to control young people, to remove their liberty and to maintain good order in the institution, at the same time as offering education and training to foster future prosocial participation in society and meeting their welfare needs. In England and Wales, over 3000 juveniles aged 13–18 are locked up at any one time, out of a total population of around 3.5 million, a rate approaching 1 in 1000 overall but around 1 in 300 late teenage boys. In 1998, the Crime and Disorder Act led to an overhaul of youth justice systems, mandating practitioners to improve community treatments and so fill the gap before and after institutional detainment by involving families in the use of new Youth Offending Teams (YOTs). The use of empirically validated interventions by YOTs is gradually increasing but still has a long way to go. As well as leading to better provision of community treatment, the 1998 Act introduced instruments to enable magistrates to make control orders for lower level disruptive behavior in the community, called Antisocial Behaviour Orders (ASBOs). Prevention Prevention is discussed more fully in chapter 60. This chapter does not discuss crime prevention, which is a wide subject. However, it is worth noting that as well as prevention being aimed at individual propensities, environmental factors can also be altered. For example, target hardening refers to the strengthening of the security of premises with a view to minimizing the risk of attack. Such deterrence aims to reduce the opportunity for the juvenile to steal from or vandalize the premises. Examples include fitting grilles over windows, installing cables on computers or fitting stronger locks on doors. Evaluations show that these simple measures can be relatively cost-effective (Bowers, Johnson, & Hirshfield, 2004). Need for Assessment Because multiple factors affect antisocial behavior, and each case is different, giving the same treatment to all cases would seem likely to be less effective, although there do not seem to be studies comparing “one size fits all” interventions with those in which a thorough assessment has been conducted. Nonetheless, it seems logical to know which youths have a low IQ or a high one, particular skills to build on, comorbid depression or hyperactivity, parents needing treatment for alcoholism before they can set limits, and so on. In contrast, if the family is taking all steps to manage their adolescent well, then an approach based on family management might not be very effective. Overviews of Intervention Effectiveness Belief in the effectiveness of treatments for offending behavior has oscillated between modest hope and downright pessimism. In the 1950s and 1960s, practitioners and scholars were optimistic about interventions. However, in 1974, Martinson reviewed the literature of the time and concluded “nothing works.” The early controlled studies later in the 1970s were more optimistic (Gendreau & Ross, 1979). The first metaanalysis of outcomes in residential or community settings was of studies between 1960 and 1983 in the USA. It found that psychoanalytically oriented residential treatment had an effect size of 0.01 on recidivism, behavioral approaches 0.18 and educational approaches 0.28 (Garrett, 1985); by 1990 it was possible to conclude “Some things work in some settings with some people” (Izzo & Ross, 1990). Lipsey and Wilson (1998) in their classic meta-analysis included nearly 400 programs with around 40,000 juveniles. The effect size for institutionalized offenders was 0.10, and 0.14 for non-residential or noninstitutional (community) settings. Behavioral programs and those training interpersonal skills produced the highest effects, whereas group counseling, milieu therapy and programs focusing only on employment produced little or no effect. An updated meta-analysis by Wilson, Lipsey, and Soydan (2003) concluded that the programs were equally effective for those from ethnic minorities as for White people. Lösel and Köferl (1989) carried out the first meta-analysis of studies outside the USA, focusing on 16 studies of sociotherapeutic prisons in Germany with around 3500 juvenile offenders. The aim of these is social training and encouragement of contacts in the outside world with preparation for release. Compared with normal prisons, the mean effect size was 0.21. Dowden CHAPTER 68 1114 9781405145497_4_068.qxd 29/03/2008 02:59 PM Page 1114

and Andrews (2000) included US and Canadian studies published after 1990 in their meta-analysis. Although the overall effect size was 0.09, effects were greater for high-risk (0.12) than for low-risk offenders (0.03); programs targeted at personal needs (e.g., academic achievement, enhancing selfesteem, supervision, affection from family members) were more effective (0.22) than those that were not (−0.01); those with behavioral methods (e.g., role play, modeling) had larger effects (0.24) than those that did not (0.04). An overview of meta-analyses is provided by Grietens and Hellinckx (2004), and in 2001 the Campbell Collaboration Crime and Justice Group was set up to make available reviews of criminological interventions (Farrington, 2001). Further work is needed using stricter inclusion criteria, because there is evidence that if one only includes the highest methodological quality, effect sizes reduce, sometimes to zero (Dowden & Andrews, 2003; Latimer, 2001). What principles should guide interventions? Over a decade ago, McGuire and Priestley (1995) identified six principles for effective programs which still hold: 1 The intensity should match the extent of the risk posed by the offender; 2 There should be a focus on active collaboration, which is not too didactic or unstructured; 3 There should be close integration with the community from which the offender came; 4 There should be an emphasis on behavioral or cognitive approaches; 5 The program should be delivered with high quality and the staff should be trained adequately and monitored; and 6 There should be a focus on the proximal causes of offending behavior rather than distal causes. In other words, the program should focus on peer groups, promoting current family communication, and enhancing selfmanagement and problem-solving skills. There should not be a focus on early childhood or other distal causes of delinquency. All of the reviews suggest that there are a number of promising targets for treatment programs, which include antisocial thoughts, antisocial peer associations, promotion of family communication and affection, promotion of family supervision, identification of positive role models, improving problemsolving skills, reducing chemical dependencies, provision of adequate living conditions and helping the young offender to identify high-risk situations for antisocial behaviors. Conversely, the systematic reviews have also suggested a number of approaches that are unlikely to be promising. For instance, improving self-esteem without reducing antisocial cognitions is unlikely to be of value. Similarly, it is unlikely that a focus on emotional symptoms that is not clearly linked to criminal conduct will be of great benefit. Psychological Interventions with Individual Youths On theoretical grounds, working with youths to control anger and promote more sociable interactions would seem a plausible approach. There are a number of programs, broadly based on cognitive–behavioral principles. Elements include: 1 Attributional retraining; 2 Anger management; 3 Social problem-solving; 4 Social skills training; and 5 Helping the youth set targets for desirable behavior and negotiate rewards for achieving them. While each of these elements can be separated out, most modern programs incorporate a number of these themes blended together. Attributional retraining helps correct the cognitive distortions identified by Dodge (1993) whereby the youths tend to perceive threat and hostile intent even in neutral scenarios; work is done to help understand others’ points of view. The anger management aspect usually lasts several sessions and provides techniques to slow down instant angry arousal. Techniques include coping self-talk, distraction and relaxation; plenty of in vivo practice is needed because otherwise what is learned as a good idea in the clinic often does not generalize to the more emotionally arousing scenarios on the street (Kazdin, Siegel, & Bass, 1992). Social problem-solving programs follow classic lines: 1 Defining the problem; 2 Analyzing the intentions of the other party; 3 Generating a range of solutions; 4 Evaluating them; 5 Selecting the best and putting it into action; then 6 Reviewing how well it worked (see chapter 63 for further details). The social skills element involves lots of practice in role plays and in real life, whereby the youth practices conversations, asking teachers for guidance, expressing disappointment, declining drugs without getting angry, and so on. The target setting is usually agreed in negotiation with teachers or parents, and involves starting with small achievable goals with strong immediate rewards to promote success. Two of the best validated programs of the type described above are Problem Solving Skills Training (PSST), which lasts 22 weeks (Kazdin, Siegel, & Bass, 1992) and the Coping Power (CP) program, which lasts 18 weeks (Lochman & Wells, 2004). PSST was found to be effective in a randomized controlled trial with in-patients with severe conduct problems (Kazdin, Siegel, & Bass, 1992), but now needs independent replication. CP has been shown to have effects that lasted both at home and in school at 1-year follow-up (Lochman & Wells, 2004); independent replications in Holland and Germany are under way. More generally, a meta-analysis of randomized controlled trials of social skills training confirmed its usefulness, although studies with larger samples led to smaller effect sizes (Lösel & Beelman, 2003). Likewise, a meta-analysis of CBT with offenders found that it worked, and better effects were obtained for higher-risk offenders, higher-quality treatment implementation and a CBT program that included anger control and interpersonal problem-solving but not victim impact or behavior modification components (Landenburger & Lipsey, 2005). More directly within the justice system, individual offenders JUVENILE DELINQUENCY 1115 9781405145497_4_068.qxd 29/03/2008 02:59 PM Page 1115

have had to take part in victim–offender mediation sessions, so-called “restorative justice” (Latimer, Dowden, & Muise, 2005). A meta-analysis of 15 studies concluded the approach was effective, with a rate of re-offending 70% of that of controls (Nugent, Williams, & Umbreit, 2004). Similarly, a metaanalysis of “reasoning and rehabilitation” programs by Tong and Farrington (2006) concluded that these reduced offending by 14%. Special Education Approaches to special education are covered in chapter 74. Here we simply note that because of the high rates of poor literacy and educational attainments in offenders, this is a crucial component of interventions. If formerly offending youths are expected to conform to societal norms and become employed and work within the system, then they need sufficient educational attainments and work skills to succeed in getting and holding down jobs. Without these, it is far harder even for well-motivated youths to avoid the apparently quick rewards crime appears to offer them (Hawkins, Herrenkohl, Farrington et al., 1998). Family-Based Interventions These typically attempt to alter the structure and functioning of the family unit, being based on systemic family therapy theories (see chapter 65). The best known in the context of delinquency is Functional Family Therapy (FFT), brought into being in 1969 by James Alexander and colleagues. It is designed to be practicable and relatively inexpensive: 8–12 1-h sessions are given in the family home to overcome attendance problems common in this client group; for more intractable cases, 26–30 h are offered, usually over 3 months. The target age range is 11–18 years. One of the attractive aspects of FFT is that it has evolved and changed over four decades. Thus, there is now a standardized assessment, including separate family and therapist perspectives on the issues, which the therapist monitors and updates regularly. Following assessment, there are four phases to treatment. The first two are the engagement and motivation phases. Here the therapist works hard to enhance the perception that change is possible, and to minimize perceptions that might signify insensitivity or inappropriateness (e.g., poor program image, difficult to access, insensitive referral). The aim is to keep the family in treatment, and then to move on to find what precisely the family wants. Techniques include reframing, whereby positive attributes are enhanced (e.g., a youth who offends a lot but does not get caught is labeled as bright), and the emotional motivation is brought out (e.g., a mother who continually nags may be labeled as caring, upset and hurt). Families are encouraged to see themselves as doing the best they can under the circumstances. Problem-solving and behavior change are not commenced until motivation is enhanced, negativity decreased and a positive alliance established. Explicit attempts are made to reduce negative spirals in family interactions, by interrupting and diverting the flow of negative blaming speeches. Reframes do not belittle the impact of the negative behavior, but each family member should feel at the end of these two initial stages that: 1 They are not inherently bad, it is the way they have done things that has not worked; 2 Even though they have made mistakes, the therapist “sided” with them as much as with everybody else; 3 Even though they experience the problems differently, each family member must contribute to the solution; 4 Even though they may have a lot to change, the therapist will work hard to protect them and everyone else in the family; and 5 They want to come back to the next session because it finally seems that things might get better. The third phase of FFT targets behavior change. There are two main elements to this: communication training and parent training. The success of this stage is dependent on the first two having been achieved, and is not commenced unless they have been (this differs from some programs where a predetermined number of sessions is allocated to each topic irrespective of the rate of family progress). This stage is applied flexibly according to family needs. Thus, if there are two parents who continually argue and this is impinging on the adolescent, the “marital subsystem” will be addressed, using standard techniques. These include using the first person voice rather than the second (instead of “you are a lazy slob,” “I find it upsets me when you leave your socks on the floor”), being direct (instead of complaining to partner “he never . . . ,” say it directly to the youth), brevity instead of long speeches, behavioral specificity about what is desired, offering alternatives to the young person and active listening. Parent training techniques are similar to those found in standard approaches, and include praise, rewards (called contracting in FFT; e.g., “If you come home by 6pm each night, I will take you to the cinema on Saturday”), limit setting, consequences and responsecost (e.g., losing TV time for swearing; for more details of these techniques see chapter 64). The fourth and final phase of FFT is generalization. Here, the goal is to get the improvements made in a few specific situations to generalize to other similar family situations; to help the youth and family negotiate positively with community agencies such as school, and help them get the resources they need. Sometimes, this latter goal may require the therapist to be a case manager for the family. To do this therefore requires that the therapist knows the community agencies and how the system works, and be prepared to spend time engaging it – these characteristics are specified in the model. This is a very different approach from traditional therapies in which the therapist stays neutral with regard to outside agencies. Beyond specifying the intervention, FFT has a formal schedule for training professionals, which over and above the initial 3 days, requires three 2-day follow-up visits in the ensuing year and supervision for 4 h per month with FFT supervisors for the first 2 years. There are four levels of worker: functional family therapist, FFT clinical team leader (who coordinates a site), FFT clinical supervisor (who takes clinical responsibility for therapists’ cases and provides individual and CHAPTER 68 1116 9781405145497_4_068.qxd 29/03/2008 02:59 PM Page 1116

group surpervision) and FFT trainer, who is officially certified to run training. These personal training approaches to maintaining treatment fidelity are backed up by a tracking system of questionnaires filled in by the clients as well as the therapist. However, there is no insistence that supervision is by showing video or audio tapes of actual sessions, although the three on-site visits per year offer an opportunity for the developers to do this. The effectiveness of FFT is well established; there have been over 10 replication studies (Alexander, Pugh, Parsons, & Sexton, 2000), of which over half have been independent of the developers, and four are under way in Sweden. The trials published to date have all been positive, with typical recidivism rates being 20–30% lower than in controls. Family programs can be delivered within school settings (e.g., as part of after-school programs). Thus, “Project Back-onTrack” included family therapy and diversionary projects for only 4 weeks (although for 4 days a week, giving 32 h contact time) and led to significant reductions in offenses 1 year later (Myers, Burton, Sanders et al., 2000). Multiple Component Interventions The example of Multisystemic Therapy (MST) is taken as it is one of the best developed treatments of this kind. MST was developed by Henggeler, Rowland, Randall et al. (1999) in the USA. There are nine treatment principles: 1 An assessment should be made to determine the fit between the problems and the wider environment: difficulties are understood as a reaction to a specific context, not seen as necessarily intrinsic deficits. 2 Therapeutic contacts emphasize the positive and use systemic strengths as levers for change. Already, the assessment will have identified strengths (e.g., being good at sports, getting on well with grandmother, the presence of prosocial peers in grandmother’s neighborhood), and the implementation of this principle means that each contact should acknowledge and work on these. The strengths may be in the young person (competencies and abilities), the parent (skills, friendliness, motivation), the family (practical resources such as nice house, affection between members, some good parenting practices, supportive friends locally, and so on), peers (any with prosocial activities or hobbies, with parents who monitor well), at the school (good classroom management, understanding of youth’s special needs, drama, music or sports facilities) and in the community (organized activities by voluntary or church organizations, parks, well-functioning social services departments, children’s centers). Each contact should reinforce these strengths and use a problem-solving approach to mobilize them. 3 Interventions are designed to promote responsible behavior and decrease irresponsible behavior. This principle is similar to other parenting programs, and is core: by increasing prosocial behavior and the amount of time during which it is carried out, then inevitably antisocial behavior is not being carried out. Eventually, the objective is more than the elimination of antisocial behavior, it is to help the youth become independent and to have prosocial life skills to make relationships, contribute effectively in work and so stay out of trouble and have a productive life. However, this goal is not just for the youth; parents too have their role in changing their practices and beliefs, which includes taking more responsibility for their youth’s behavior and making life changes to enable this to happen – which could include giving up a second job or helping with school work. 4 Interventions are focused in the present and are action oriented, and have specific well-defined goals. The approach is what can be done in the here and now, in contrast to some therapies which emphasize the need to understand the family’s and the youth’s past. By having clear targets, all family members are aware of the direction of treatment and the criteria that will be used to measure success. This also means that effectiveness can be monitored effectively and accurately, and there are clear treatment termination points when targets are met. In this respect MST is similar to behavioral and some other therapies, but differs from counseling and psychoanalytic approaches. 5 Interventions target sequences of behavior in multiple systems that maintain problems. This is an approach similar to systemic family therapy (see chapter 65), in that change is postulated to be mediated by interpersonal transactions rather than insight. What is different is that multiple arenas are explicitly assessed and, where appropriate, targeted (e.g., the youth’s peer group, extended family, school). 6 Interventions are developmentally appropriate. They should fit the life stage and personal level of the family members. 7 Interventions require daily or weekly effort by family members. This enables frequent practice of new skills and frequent positive feedback for efforts made; non-adherence to treatment agreements rapidly becomes apparent. 8 Intervention effectiveness is evaluated continuously from multiple perspectives, with the intervention team assuming responsibility for overcoming barriers to successful outcomes. 9 Interventions are designed to promote treatment generalization by empowering parents to address youth needs across multiple contexts. Interestingly, the precise nature of the moment-to-moment content of intervention is not tightly prescribed, although in practice the greater part is not dissimilar to the approach used in behavioral family therapy. However, MST is not limited to work on psychosocial interactions; for example, when the program developers found that despite influencing the more distal risk factors for drug-taking, such as parental supervision and school attendance, drug use was not diminishing as much as they had hoped, they instituted daily urine tests and paid the young people if they were clear of drugs. What is noticeably different from many therapies is the explicit recognition of the multiple contexts in which difficulties may occur, and the need to influence these. In a sense, MST is a set of operating principles that draw on the evidence for whatever works (e.g., CBT, close monitoring of association with deviant peers, constructive teaching) rather than one specific therapy. The way the therapy is delivered is closely controlled. Because of the weekly monitoring of progress, if there are barriers to improvement these should be rapidly addressed, and the JUVENILE DELINQUENCY 1117 9781405145497_4_068.qxd 29/03/2008 02:59 PM Page 1117

hypotheses of what is going on in the family and systems around the youth should be revised in the light of progress. Clinicians only take on 4–6 cases because the work is intensive; there is close attention to quality control by weekly supervision along prescribed lines, and parents and youths fill in weekly questionnaires on whether they have been receiving therapy as planned. Therapy is given for 3 months and then stopped. Given that MST makes good use of up-to-date evidence on the causes of antisocial behavior, and good use of effective treatment principles such as close measurement of effectiveness during treatment and close attention to implementation quality, one might hope that results would be encouraging. Indeed, the first raft of outcome studies by the program developers were positive. Thus, the meta-analysis of papers up to and including 2002 by authors that include one of the program developers, Charles Borduin, found that in seven outcome studies comparing MST with treatment as usual or an alternative with 708 youths by 35 therapists, the mean overall effective size across several domains was 0.55 (Curtis, Ronan, & Bourduin, 2004). Outcome domains ranged from offending (arrests, days in prison, self-reported criminality, self-reported drug use), where the mean effect size was 0.50, peer relations (ES 0.11), family relations (self-reported 0.57, observed 0.76), and individual youth and parent psychopathology symptoms (0.28). When these studies were subdivided into chronic offenders versus the remainder (youths who were abusing drugs, sex offenders and psychiatrically disturbed youths), no differences were found. However, the three studies using the developers’ own graduate students as therapists obtained noticeably larger effect sizes (mean 0.81) than when the developers were supervising local community therapists, where the mean effect size was 0.26. Long-term follow-up 14 years later (when the individuals’ mean age was 29 years) by the developers of one of the first trials, with 176 cases allocated to MST or usual individual therapy, gave recidivism rates of 50% versus 81%, respectively. There have been at least 27 published reviews of MST (Littell, 2005), and the sorts of findings cited above have led MST to be cited as an effective evidence-based treatment by the US National Institute on Drug Abuse, the National Institute of Mental Health, the Office of Juvenile Justice and Delinquency Prevention, and others. However, in the process of evaluation, the next test of any therapy is its effectiveness when carried out by teams who have no financial or employment ties with the developers (although they may pay the developers for materials and supervision), with an independent evaluation team. The only independent evaluation was also the only one to use proper intent-to-treat analyses (rather than exclude treatment refusers, etc.), and it found, with a large sample (n = 409) in Ontario, Canada, that MST gave no improvement on treatment as usual on any outcome, either immediately or by 3-year follow-up (Leschied & Cunningham, 2002). A smaller independent study in Norway (n = 75; Ogden & Hagen, 2006) was more positive, and found effect sizes of 0.26 for self-reported delinquency, 0.50 for parent-rated and 0.68 for teacherrated, although here there was 40% missing data. Likewise, a totally independent trial by Timmons-Mitchell, Bender, Kishna, and Mitchell (2006) in the USA randomized 93 delinquents and also obtained substantial beneficial effects. The Canadian study (not published in a peer-reviewed journal but of high quality) was included in the Cochrane Library’s review of MST (2005), but the other two independent Norwegian and US studies were not. The Cochrane conclusion that “Evidence suggests that MST is not consistently more effective than other alternatives” is thus in our view unduly harsh; its general tone was very conservative, thus it also concluded that MST had no harmful effects and that nothing else was proven better than MST. This conclusion is more cautious than the previously established view. A number of reasons are possible. First, the developers’ own studies did not do full intent-to-treat analyses, and may have been more favorable because some cases with worse outcomes (the dropouts) were excluded. Second, the degree of skill with which the intervention was delivered may have been higher in the developers’ sites. Evidence on treatment fidelity for MST is mixed – in the independent Ontario study, fidelity as rated on-site was unrelated to outcomes. Henggeler, Rowland, Randall et al. state that fidelity is crucial for effectiveness, and in their first paper on the subject they made 105 correlations between fidelity and outcomes, but only 11 were significant, with some being in the opposite direction to that predicted (i.e., better adherence leading to worse results). However, the same group (Huey, Henggeler, Brondino, & Pickrel, 2000) found that when they used a latent variable approach, therapist-rated fidelity improved family functioning and parent monitoring, both of which reduced youth delinquency, but that parent- and youth-rated fidelity had no effect. This rater effect could be because it requires a therapist to appreciate the complexity of fidelity, and also because therapists working across cases will be more consistent in their ratings than parents and youths, who may differ widely in their rating of the same phenomena. Third, the financial conflict of interest may have consciously or unconsciously led the developers to bias their results favorably. Henggeler and his associates direct and hold stock in MST Services Inc., which has the exclusive licensing agreement for MST. It serves around 10,000 families a year and total fees amount to around $500 per youth served (Littell, 2006). Fourth, the comparison treatment may have been different in Canada, where the justice system is perhaps better organized; however, the Cochrane reviewers (2005) point out that their conclusions would have been largely the same even without this study. Given that MST is predicated on sound modern principles, why is it often hard to obtain consistently reliable effects? A further possibility is that 3 months of treatment is too short a duration. To disentangle possible explanations, we need good measures of mediators during treatment and, crucially, after the end of treatment. This would enable, for example, one to see whether parenting practices continue to be strong after the intervention ceases, and whether this mediates relapse; or is it deviant peer association that leads to more offending? Some CHAPTER 68 1118 9781405145497_4_068.qxd 29/03/2008 02:59 PM Page 1118

conclusions are in order. We need more randomized controlled trials independent of the program developers. They should use intent-to-treat analyses, develop therapist adherence and skill to as high a level as possible and measure it, and be of sufficient power to measure moderators and mediators, so that variations in outcomes can, where possible, be accounted for. Interventions with Multiple Components that Put Youths into Foster Families The best example of this approach is Multidimensional Treatment Foster Care (MTFC). It evolved at the Oregon Social Learning Center (OSLC), beginning in 1983 (Chamberlain, 2003), where parent training with families of delinquents proved extremely difficult, although reasonably effective (Bank, Marlowe, Reid, Patterson, & Weinrott, 1991), because of the inability of the family to cope with the extreme demands of having a delinquent youth. This led to the idea of placing them in a specially trained foster family. It has a number of similarities with MST: it is based on an interactive model, whereby the moment-to-moment interactions are seen as the key to change. However, it differs in that the regime in the foster home is based on the youth earning points from the moment they get up. They have to earn 100 points a day for privileges such as going to bed later, having time on the computer or extra time to phone friends. Points are awarded for day-to-day living and social skills, such as making the bed, being polite, getting to school on time. While at school points are awarded for good behavior in class. Unlike some programs, in MTFC points are also taken away (e.g., for swearing or being unhelpful). Foster carers are carefully trained to take away points with the minimum of negative affect, and to quickly offer the young person the opportunity to make up points by doing a small chore. For the youth, the immediacy of experiencing a contingent response to their behavior is often a stark contrast to being left alone or having long coercive interchanges with their parents. In addition to close liaison with the school, close supervision is key – the young person loses a point a minute for all the time when they cannot verify their whereabouts, a sizeable fine. There is a relatively large team to carry out MTFC. The program supervisor oversees the case, and has a maximum caseload of 10. An individual therapist sees the youth once or twice a week, for problem-solving and to develop skills-based coaching of how to negotiate everyday situations – not for traditional psychotherapy. When the youth is in the community, there is a skills trainer, usually a young graduate, to help them negotiate prosocial activities and avoid dangerous situations. MTFC lasts for around 6 months and then the young person returns to their birth family. However, crucial to the model is the birth family therapist who, while the youth is in the foster family, works with the birth family to inculcate the same regime. While the youth is in foster care, there is a weekly clinical meeting for all team members, and a weekly foster carer meeting attended by the program supervisor and other team members at which progress is discussed, support given to foster carers and the day-to-day management regime carefully adjusted. However, each youth’s progress is even more closely monitored, because every morning a team member calls the foster carer and goes through the Parent Daily Report, a simple 36-item checklist of antisocial behaviors requiring a yes/no answer. The clinical team plot progress graphically, so that any deterioration is quickly detected and remedial action put in place. There have been two main trials completed with MTFC for delinquency: one in boys and one in girls, both by the program developers. With boys (n = 79), MTFC compared with group care led to a reduction in the number of arrests at 2-year follow-up (for two or more arrests, 5% versus 24%) and reduced self-reports of aggression and fighting (Eddy, Whaley, & Chamberlain, 2004). With girls at 1-year followup (n = 81), criminal referrals showed a trend (mean 0.76 referrals in MTFC, 1.3 for group care; P = 0.10), 22 versus 56 days locked up (P < 0.05) and a reduction on Child Behavior Checklist (CBCL) delinquency but none on Elliott delinquency. No report of CBCL aggression scales or other measures such as the Parent Daily Report (PDR) are given (Leve, Chamberlain, & Reid, 2005). Clearly, independent replications of MTFC are now needed, and are in progress. The model is being extended to younger children, and to less intensive forms. Rather few intervention studies measure mediators of effectiveness, but the Oregon Social Learning Center (OSLC) staff did this for the male delinquency study (Eddy & Chamberlain, 2000). Three family process mediators and one relating to the youth’s peer group were found to be relevant. The three family mediators were harsh and inappropriate discipline, quality of the parent–youth relationship and supervision of the youth’s whereabouts; the peer dimension was association with deviant peers. When these variables were changed by treatment, then delinquency reduced. Here then is a model of how to measure mediators during treatment. Not only can these findings guide treatment targets, but they confirm important information about the causes and maintenance of antisocial behavior. Interventions That Do Not Work Harsh, military style, shock incarceration, so-called “boot camps” are still popular for young offenders in the USA, and were promoted by the Office of Juvenile Justice and Delinquency Prevention in 1992 when three pilot programs were set up. However, several reviews have concluded that they are ineffective (Benda, 2005; Cullen, Blevins, Trager, & Gendreau, 2005; Stinchcomb, 2005; Tyler, Darville, & Stalnaker, 2001), and a randomized controlled trial by the California Youth Authority that included long-term arrest data found no difference between boot camp and standard custody and parole (Bottcher & Ezell, 2005). In contrast, a meta-analysis of 28 studies of wilderness programs found an overall effect size of 0.18, with recidivism rates of 29% versus 37% for controls (Wilson & Lipsey, 2000). Programs with intense physical activity and a distinct therapeutic component were the most effective. Another approach is to attempt to frighten delinquents with visits to prisons in an attempt to deter them, as for example in the “Scared Straight” program. However, JUVENILE DELINQUENCY 1119 9781405145497_4_068.qxd 29/03/2008 02:59 PM Page 1119

a meta-analysis of nine controlled trials found that on average the intervention is more harmful than doing nothing, as it led to worse outcomes in participants (Petrosino, TurpinPetrosino, & Buehler, 2003). Peer group work can also be harmful. In an evaluation of the Adolescent Transitions Program, Dishion and Andrews (1995) studied 120 families with an antisocial youth who were randomized to one of four conditions: parent only, youth only, parent and youth, and control. The parents attended standard parent-training sessions, but the youths attended in groups of 4–6. At 1- and 3-year follow-up, adolescents allocated to the youth group intervention fared significantly worse on a number of outcomes, including teacher-rated delinquency and self-reported antisocial behavior and substance use. Those allocated to the parent-only condition in contrast showed reduced teacher-(but not parent-) rated delinquency, and less negative family interaction patterns as assessed by direct observation. Videotapes of the group process revealed that despite the group leaders supporting a reduction in deviant talk and promoting positive peer support for prosocial behavior, in fact youth engaged in surreptitious deviant talk both during sessions and in intervals. Subsequent analyses proved that those youths who took part in increasing amounts of deviant talk predicted poor outcomes 3 years later, such as expulsion from school, arrests and drug use (Granic & Dishion, 2003). Over 40 years ago Patterson had shown that within residential institutions for antisocial youths, for every one positive behavior reinforced by an adult, nine deviant behaviors were reinforced by peers (Buehler, Patterson, & Furniss, 1966). The famous Cambridge–Somerville delinquency project studied 400 youths, half of whom were offered a range of interventions for 4 years which were state of the art at the time in the early 1940s, but 30-year follow-up showed increased criminal activity, drug, cigarette and alcohol use by the intervention group compared with controls (McCord, 1978). Dishion encouraged her to reanalyze the data, and she concluded that those who had done poorly were those who had been sent on summer camp twice, where she hypothesized “deviancy training” occurred amongst delinquent peers; subsequent deviant acts were 10 times more likely (Dishion, McCord, & Poulin, 1999; McCord, 1997). These lines of evidence have led the group (Gifford-Smith, Dodge, Dishion et al., 2005) to warn against “peer contagion” in a whole range of settings. However, Weiss, Caron, Ball et al. (2005) have questioned these findings and, in a fresh meta-analysis to address the question, found that in 17 of 18 studies group treatments for antisocial behavior did not support iatrogenic or deviancy training effects. In conclusion, it seems likely that unsupervised and prolonged contact with deviant peers is harmful, but wellsupervised and well-supported contact during which youths are actively taught new skills can be effective. Pharmacological Therapies As for non-offenders, medication may be helpful in juvenile delinquents with diagnosed mental disorders for which it has been shown to be effective, such as schizophrenia, bipolar disorder and ADHD (for details of appropriate treatment see the chapter covering the relevant disorder). The question arises whether medication has any role in the management of longstanding antisocial or aggressive behavior in offenders. Most authorities agree that, on present evidence, psychopharmacological treatments alone are unlikely to be an effective and acceptable treatment for behavioral problems in adolescents. However, in younger children with more unpredictable explosive aggression there has been a recent trend by some clinicians to prescribing a range of drugs, from mood stabilizers such as carbamazepine and lithium to newer antispsychotics such as risperidone; certainly reviews by employees of the drug manufacturers argue for their effectiveness and acceptability (Pandina, Aman, & Findling, 2006). However, the evidence for the effectiveness of these medications in straightforward antisocial behavior without comorbid diagnoses or intellectual disability over the medium to long term is minimal (for review see chapter 35); most trials to date have lasted under 2 months and have not been undertaken with teenage offenders (Pappadopulos, Woolston, Chait et al., 2006). Conclusions There is now a considerable body of knowledge about the causes of delinquency, how to assess the young people and what interventions are likely to be effective. Recent advances in genetics at a molecular and behavioral level have shown that certain genotypes predispose to antisocial behavior, but that it is likely that in many cases these interact with adverse environmental conditions to lead individuals towards antisocial and offending behavior. In future, genetic and longitudinal studies should further elucidate not only the mechanisms through which individuals embark on a pathway of crime, but also what is the crucial combination of influences leading to desistance in particular groups of cases. Person-centered analyses such as cluster analysis and its longitudinal variants should illuminate what is likely to be a heterogeneous picture, and take forward the majority of current findings, which have often lumped whole samples together when using multivariate statistics. Thus, the causal factors influencing a child born with callous-unemotional traits who is brought up in favorable circumstances may be very different from a child with hyperactive traits who is subjected to prolonged abuse and rejection. Studies will need to combine such an approach with consideration of wider societal influences such as the effects of valuing violence and criminal behavior that predominate in some youth subcultures. It is to be hoped that treatments will be developed in tandem with increasing specificity according to the youth’s needs. For example, while at present psychopathic traits have the reputation of being associated with untreatable offending behavior, this needs to be tested out using treatments tailored to the psychopathology – thus, if these individuals are, as experimental studies suggest, punishment insensitive but reasonably responsive to rewards, then intensive reward programs need to be CHAPTER 68 1120 9781405145497_4_068.qxd 29/03/2008 02:59 PM Page 1120

devised and then subjected to trials. For the established treatments for general delinquency, again greater differentiation according to youth need is required, rather than a “one size fits all” approach. This should include trials where the intervention is given for reasonably long periods if necessary (say, 9–12 months) rather than for the more typical 3 months. While the studies envisaged above may lead to potential further improvements in outcomes for young offenders, there will be little improvement in their prospects unless high-quality services are implemented. To clarify what difference this could make, it would help to have trials of model forensic services. These would include preventive community services, thorough assessments of all apprehended youths and high-quality interventions based on the assessments. The issue of implementation quality is important, because with highly motivated and skilled teams, good effect sizes are repeatedly achieved with the better interventions. Such trials of model services would need thorough economic evaluations so that potential economic gains of good services could be clarified. Armed with the results of such trials, it might be easier to persuade policy-makers to invest in adequate services. In the meantime, there is a need for a change in culture at local and national governmental levels so that evidence-based interventions are demanded and their effectiveness regularly monitored. At present there are considerable opportunities in most countries to switch from currently used interventions to more effective ones without incurring extra expenditure. Finally, by way of prevention, we need further studies of how to better identify, screen and effectively intervene with young children at risk of antisocial behavior. 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1126 The last decade has seen a rapid evolution in the structure and delivery of mental health services in many countries. The use of in-patient beds has generally declined in developed countries and there is an increasing interest in alternative models of intensive service delivery such as day provision or intensive outreach. In parallel, the context within which children’s mental health disorders are seen has progressively widened to encompass the context of family, school and wider community. The stage emphasis in personality and social development, which provided a rationale for intensive episodic interventions, has largely been replaced by a new appreciation of chronicity and long-term pathways in the evolution of many disorders (see chapter 13). Acute episodes of intensive treatment have therefore to be considered now in the wider contexts of family and local environment as well as in the longitudinal context of what is known about the natural history of particular disorders. This chapter reviews new developments in intensive mental health treatments for young people, the evidence base for intensive treatments in the light of these considerations and prospects for the future. In-patient Treatment Historical Roots Two broad forms of residential mental health care for young people emerged in the early 20th century. The first was based on the idea that a self-contained environment could act as a “therapeutic milieu,” effecting personality and behavior change (Kennard, 1983). Examples in the UK were Homer Lane’s “Little Commonwealth” (Bazeley, 1928) and residential therapeutic schools such as the Mulberry Bush; in the USA, there was the work of Bettelheim (1955). The second historical root was the adaptations made for children within the asylums of the 19th century (Parry Jones, 1998) and the accelerated development of specialized medically based psychiatric units for children following the encephalitis epidemic in the USA in the 1920s (Beskind, 1962). Such hospital units developed to provide a comprehensive approach to assessment and treatment based on a biopsychosocial model (Cameron, 1949). Here, the hospital environment was the location for assessment and treatment rather than its primary agent. The decades after World War II saw a rapid expansion of in-patient units, usually combining elements of both models. Recent decades have seen a plateauing or reduction in numbers of units and increasing specialization, alongside an awareness of the potential negative effects of residential treatment (Wolkind, 1974). However, the two historical themes remain a useful way of conceptualizing the in-patient treatment process. The Ward as a Therapeutic Milieu The “therapeutic milieu” is a term subject to numerous reinterpretations but little research (Green & Burke, 1998). Early psychodynamic formulations (Bettelheim, 1955) contained an assumption that the milieu substituted for a lack in the child’s previous experience – particularly, sensitive parental care. There was an emphasis on a closed environment and long treatments. Later, systemic models (Woolston, 1989) emphasized the ward as an “open system” mediating the “goodness of fit” between young person and their environment through collaboration with other agencies and the family; parents often taking an active part in the ward caregiving. Other models have emphasized the ward environment as a shorter-term “corrective emotional experience” with high levels of warm staff communication, peer contact and active behavioral control (Cotton, 1993). A few specialized developments have involved admitting whole families (Lynch, Steinberg, & Ounsted, 1975); these then can have some convergent roles with mother and baby units. Five-day residential patterns have become common (Green & Jacobs, 1998). Recent developments – notably driven by managed care in the USA (Nurcombe, 1989) – have in contrast reduced the ward environment to its most minimal form. The emphasis here is on symptom stabilization and “minimum necessary change” before rapid discharge. Stays are often under 2 weeks; a radically different form of milieu from the 3-year or more stays described by earlier writers. In this recent model, the “therapeutic milieu” as historically understood has essentially disappeared and in-patient care has returned to its root in acute hospital practice. Provision of Intensive Treatment: In-patient Units, Day Units and Intensive Outreach Jonathan Green and Anne Worrall-Davies 69 9781405145497_4_069.qxd 29/03/2008 02:59 PM Page 1126 Rutter’s Child and Adolescent Psychiatry, 5th Edition, Edited by M. Rutter, D. V. M. Bishop D. S. Pine, S. Scott, J. Stevenson, E. Taylor and A. Thapar © 2008 Blackwell Publishing Limited. ISBN: 978-1-405-14549-7

What are the components of a successful milieu? Systematic research into the comparative effectiveness of different types of milieu has been identified as a priority in a number of reviews (Pfeiffer & Strzelecki, 1990; Pottick, Hansell, Gaboda, & Gutterman, 1993). Work in adult psychiatry addressed the character and effect of different forms of residential milieu (Moos, Shelton & Petty, 1973) and Steiner, Marx, and Walton (1991) applied similar methods to a study of an adolescent unit. The clinical literature, as one might expect, identifies the importance of a combination of appropriate physical environment, space design, adequate staff numbers, skill mix, therapeutic culture and leadership (Green & Burke, 1998). The creation of a coherent therapeutic culture – “like a wellconducted orchestra” – is found in meta-analysis to be strongly related to therapeutic outcome (Pfeiffer & Strzelecki, 1990) but there has been little research into its component parts until recently (Green, Jacobs, Beecham et al., 2007). A necessary condition clearly is shared values and complementary theoretical approaches within the multiprofessional team. Other important and related indicators are staff morale, consistency, good communication and self-confidence. A milieu has above all to remain functionally intact in the face of staff and patient turnover, disruption and conflict, and challenges from the patients, individually and as a group. Self-confidence will communicate itself to the children and increase their ability to trust. The instilling of hope is one of the first outcomes of successful treatment and the milieu is no exception. Recently, a national comparative study of UK in-patient units measured the variation of ward atmosphere between units (Green, Jacobs, Beecham et al., 2007) and showed the negative effect of patient aggression on atmosphere and reduced length of stay. Social Functioning and Education By the time of admission, a young person’s social adaptation in their community has often broken down, sometimes in all areas of school, family and community life. Widespread social difficulties were found in 58 consecutive general admissions in New Zealand, including a moderate to severe language handicap in 40% of cases (Paterson, Bauer, McDonald, & McDermott, 1997). In the USA, Luthar, Woolston, Sparrow, and Zimmerman (1995) similarly found severe impairments on Vineland social competency scores in 126 patients admitted with disruptive and mixed emotional–disruptive disorders. Social competency was associated with specific reading scores rather than broad intelligence quotient. These findings have practical implications. The traditional therapeutic milieu contains elements of group living, peer relationships and intensive staff–patient contact. Removal from social difficulties in the external environment and exposure to such a milieu can produce rapid gains in functioning and self-esteem. Nevertheless, young people with significant social impairments may not be able to make effective use of such a socially orientated therapeutic environment. Assessing and targeting social difficulties more precisely and defining the effective milieu characteristics for different problems are important tasks for future developments in milieu treatment. Similarly, many in-patients have a history of school failure or acute school breakdown. The individualized assessment and intensive educational input possible within the in-patient unit can make a radical impact (French & Tate, 1998). Recent studies (Green, Kroll, Imre et al., 2001; Green, Jacobs, Beecham et al., 2007) have shown rapid reduction in teacher ratings of behavioral disturbance in the classroom from pre-admission to early admission. Green, Kroll, Imre et al. (2001) showed that these persisted when reassessed in a 6-month follow-up. Rapid gains in socialization and academic achievement represent two of the potential therapeutic strengths of residential treatment. They can be used as a platform from which to reintegrate patients into their own communities with enhanced resilience, as long as there is good linkage into aftercare. However, such targeted interventions take time and are not compatible with ultrashort in-patient stays. Admission Practice Admission rates into in-patient care differ greatly between countries. A national survey of young people receiving mental health treatment in the USA during 1986 (Pottick, Hansell, Gaboda et al., 1993) found 5% of the children (6–12 years) and 30% of the adolescents (13–18 years) were being treated in in-patient facilities (combined proportion 20%). More recent UK admission rates are much lower, estimated at around 1% of the clinical pool of children in one area (Maskey, 1998). Costello, Dulcan, and Kalas (1991) studied 389 children between 2 and 12 years referred for in-patient evaluation in the USA. Factors leading to admission included deterioration despite out-patient treatment; increasing aggressiveness; difficulties with assessment or diagnosis; family difficulties in the context of psychiatric disorder making treatment impossible; and the need for 24 h observational nursing care. A prospective study of 276 admissions to UK adolescent units (Wrate, Rothery, McCabe, & Aspin, 1994) characterized diagnostic formulation as the key factor accounting for most admissions. However, Pottick, Hansell, Gutterman, and White (1995) found that the strongest influence on admission in the USA was the presence of insurance cover: a cut in insurance benefit between 1978 and 1983 coincided with a significant drop in US in-patient usage (Patrick, Padgett, Burns, Schlesinger, & Cohen, 1993). Proximity to a specialist center increases referral rates in developed countries (Gutterman, Markovitz, LoConte, & Beier, 1993) and Blanz and Schmidt (2000) describe how devolution of in-patient care to smaller local units in Germany reduced admission times and changed admission practice. On the other hand, it may be that sparsely distributed or generally poorly provided populations might tend to use concentrated in-patient provision more. Pragmatically, admission is often a negotiation between referrer, family and admitting unit around which the specific needs of each party can be met by admission (Bruggen & O’Brien, 1987). In the future it is to be hoped that an increasing part of INTENSIVE TREATMENT 1127 9781405145497_4_069.qxd 29/03/2008 02:59 PM Page 1127

such decision-making will be the empirical evidence regarding the effectiveness of in-patient treatments in particular situations and for particular disorders (see pp. 1132–1133). Whereas the in-patient resource is rightly held in reserve for the most complex and severe cases, referral should not be overdelayed: a well-timed intensive treatment may often prevent further deterioration in an acute disorder. Admissions generally fall into a number of broad categories: 1 The need for detailed assessment in complex cases where the formulation is unclear. The combination of the medical setting with the range of health professionals makes the ward particularly well able to address the interaction of biological, psychological and social aspects of disorders. 2 Assessment or treatment away from the family. This can be crucial when the role of family in a presentation may be unclear – for instance, in possible factitious presentations (see chapter 57), or when complex symptoms seem confined to home. 3 When psychiatric symptomatology is escalating despite the most intensive out-patient treatment available. This includes acute risk management of self-harm or family disruption associated with psychiatric disorder. 4 For controlled trials of specific interventions. Pre-admission evaluation is a crucial area. The admission must be seen within the context of a continuum of service use and the developmental trajectory of the child, because it will be a brief episode in both these areas. Many of the key predictors of in-patient outcome lie in details of previous family adaptation, child social functioning and child symptomatology (see p. 1132); assessment should thus focus on these aspects as well as the needs and motivation of patient and family. Preadmission evaluation may lead to a decision not to admit. For instance, many children with social and behavioral difficulties may be more appropriately cared for within the social care system with psychiatric input. Emergency Admission Studies of referrer attitudes emphasize the high priority given to the specialist unit’s responsiveness and capacity to admit emergencies (Gowers & Kushlick, 1992; Worrall & O’Herlihy, 2001). This is particularly the case in situations of acute risk management. Responsive consultation around the emergency may meet referrer needs without admission (Cotgrove, 1997). However, provision of emergency beds is likely to be an increasing priority and will shape service provision. Street (2000) found that even with a clear agreement between referrer, admitting in-patient unit and family, the time taken to actually acquire a UK child and adolescent mental health services (CAMHS) bed from time of acute referral averaged 3 days. Where facilities are not immediately available, young people may have to be temporarily cared for in inappropriate environments such as pediatric wards, adult psychiatric wards or out-of-district facilities (Street, 2000). Discharge and Aftercare Discharge planning should receive equal attention to admission planning. Many studies point to the crucial role of aftercare in the maintenance of treatment gains made during admission (Pfeiffer & Strzelecki, 1990). In a minority of cases, admission may prove to be a stepping stone towards longerterm alternative care or residential schooling. Because of the multifaceted nature of in-patient problems, the team liaises with a wide variety of local services in education, social services and mental health. A “care program approach” may be used along lines developed in adult mental health as an aid to transition into adult services. Hoagwood, Jensen, Wigal et al. (2000) showed that a limited period of intensive specialist treatment resulted in a more effective use of other services thereafter; this may explain some “sleeper” effects in outcome. There is evidence (Green, Jacobs, Beecham et al., 2007) that in-patient treatment can have a similar effect, but provision of postdischarge services is vital, and the same study showed that in the majority of cases the discharge plan recommendations were not carried out. Potential Unwanted Effects Theoretically, unwanted effects could derive from: 1 Loss of support from the child’s local environment; 2 Presence of adverse effects within the in-patient environment; and 3 The effects of admission on family life (Green & Jones, 1998). However, there is no convincing research into their prevalence. Losses Consequent on Admission Reporting bias towards acute problems during pre-admission assessment could obscure hidden sources of support and resilience in the local environment – within the extended family, peers or school. Pre-admission assessment should therefore actively focus on strengths as well as difficulties and identify key areas of individual resilience. Admission may also result in the loss of important local professional input, which should be ameliorated by good communication between unit, referring teams and local services. These factors need particular attention from in-patient clinicians because they may be less obvious than active effects from within the in-patient environment itself. Impact of the In-patient Environment Some young people may enter the ward with a profound sense of relief but others may find it at least initially frightening or bewildering. Patient ratings after in-patient psychiatric care (usually collected by the units themselves) generally show positive evaluation of the treatment. However, parents are often concerned that their child may be negatively affected (“contaminated”) by other patients’ problems. There is additionally the stigma that is often attached to the prospect of in-patient psychiatric treatment. Units must be constantly vigilant to the possibility of the negative impact of peers on each other, the pooling of problems or abuse. To counter such potential problems, Newbold and Jones (1998) suggested a proactive emphasis on child welfare and rights, embodied in the appointment of a “welfare co-ordinator,” with a role to investigate any complaints. This is done in the context of CHAPTER 69 1128 9781405145497_4_069.qxd 29/03/2008 02:59 PM Page 1128

procedural agreements with local child protection agencies and a continuing program of awareness training and education of staff. There have been no specific studies into institutionalization in child or adolescent psychiatry units. Well-publicized episodes of abuse in residential social care environments (Levy & Kahan, 1991) may be unreasonably generalized into attitudes towards residential psychiatry treatments by families, although the intensity of monitoring and supervision in the latter hopefully makes such disasters less likely. Effect on Families Some professional concern has focused on the effect of admission on family dynamics, for instance the reinforcement of “scapegoating.” This may indeed be a contraindication to admission, although equally a scapegoated child has a right to the best possible assessment and care – and this may involve admission. As the child engages with the ward there can also be a danger that the parents feel deskilled (Green, 1994). Good family contracting pre-admission and sustained family work can counteract these negative effects. A family’s commitment to intensive treatments can be disruptive and expensive. In a study of eight UK units, Green, Jacobs, Beecham et al. (2007) found that family-borne costs averaged £2400 per admission, a good proportion of the average annual wage. It is essential to anticipate this by building support for family travel into the contracting around the case and actively to support the family in relation to employers. However, there is a need for systematic study of unwanted effects rather than reliance on theoretical concerns or anecdote. Along with general standards of good practice, systematic procedures of anticipation, prevention, recognition and repair should minimize unwanted effects (Green & Jones, 1998). Day Units The concept of psychiatric day care developed in the USA in the 1940s with the therapeutic nursery school for very young children (Zimet & Farley, 1985). Relieved of the need to provide residential aspects of care, day unit environments have been able to evolve in a host of different directions. These have ranged from specific day programs for young children with developmental problems, as an adjunct to specialist school provision, to intensive 5 day a week treatment interventions with whole families. The range is now too great to summarize neatly and this is a difficulty in appraising the effectiveness of day units from published literature. Day hospital units are often associated with in-patient units in the UK (Green & Jacobs, 1998), Germany and Switzerland. In Finland, there is a high number of in-patient beds but only 8% of these units offered a day program (Ellila, Sourander, Valimaki, & Piha, 2005). Integrated in-patient and day units can share programming, staff and infrastructure; the advantages of independent day units relate to flexibility. The reduced need for a shift system to cover nights allows ward staff to work predictable hours and be available regularly for liaison sessions and outreach work. Partial attendance also means that staff can have days free for supervision and continuing education. Flexibility of in-patient, day and outreach is emerging as a priority; Street (2004) highlighted the need for more CAMHS to be able to offer outreach and/ or day care before and after admission. Amid the variety of day unit functioning, a number of broad themes may be distinguished: 1 Day units for the treatment of disruptive behavior. A number of programs have been developed, usually using multimodal treatment packages with a combination of individual family and liaison intervention alongside psychopharmacology. Grizenko (1997) and Rey, Denshire, Wever, and Apollonov (1998) reported the outcome of such programs. 2 Units have specialized in the management of younger children with developmental disorders such as autism, speech and language disorders or attention deficit/hyperactivity disorder (ADHD). These provide centers for comprehensive assessment and initiation of treatment management involving family and school liaison. 3 Units whose prime aim is to influence family functioning in situations of family breakdown or child maltreatment. A number of influential programs of this kind have been described (Asen, Stein, Stevens et al., 1982). The partial milieu of the day unit shares care with family or local school to a greater extent than residential units. Thus, liaison takes up correspondingly more time and contact with parents may be more frequent. The day unit has the opportunity to generate treatment programs that link closely with parental care. The emphasis on education means that the academic focus of the milieu in day care can be fully exploited. Educationally, therefore, in-patient and day unit treatment can be identical. There are also opportunities to transfer learned skills into the community and family setting (McCarthy, Baker, Betts et al., 2006) or to provide outreach into the community (http://www.swindonmarlborough.nhs.uk/departments/child/ beacon_under_8’s.htm). Disadvantages of the day unit milieu mirror these advantages. Many stand alone day units do not have the critical mass of staff to mount a full educational program and make do with sessional teacher inputs. This may not in itself be enough to achieve the key academic goals necessary for a child failing in school. The day unit has to achieve a balance between adequate intense academic input on the one hand and the socialization and therapeutic experience on the other; they may find that they have insufficient time to do both properly with children with complex problems. The child may have to make multiple adaptations to different environments during the week and in many areas the daily transport to and from the unit can be complex and tiring. The opportunities for completeness and intensity of treatment and observation are less. There are some multiagency collaborative units (http://www.tavi-port. org/patient/tavistock-clinic/patient-services-and-departments/ mulberrysvc.html?no_cache=1&sword_list%5B%5D=bush) using facilities from education, health or social care services to meet complex needs. INTENSIVE TREATMENT 1129 9781405145497_4_069.qxd 29/03/2008 02:59 PM Page 1129

Common Aspects of Day Unit and In-patient Treatment Therapeutic Alliance Therapeutic alliance is poorly researched in child psychiatry when compared with adult mental health treatments (Green, 2006), yet proxy measures of therapeutic alliance such as “parental co-operation” commonly provide the most significant predictor of in-patient and day patient outcome (Grizenko, 1997; Sourander, Helenius, Leijala et al., 1996). Kroll and Green (1997) reviewed the complexity of the therapeutic alliance in in-patient and day patient care. Alliances are necessary between child and parents separately and a complex in-patient team. The team acts in a number of different roles, ranging from a quasi-parenting role in relation to a child’s basic needs to a therapeutic role while undertaking specific programs; from a “collaborative” role with parents to a “patient” status for adults within family therapy. Adult studies find that therapeutic alliance relates to pretreatment social adaptation (Hougaard, 1994) and social competency is found to be a key variable predicting adaptation into an adolescent in-patient treatment environment (Luthar, Woolston, Sparrow et al., 1995). Such findings emphasize the importance of pre-admission work for building a therapeutic alliance. Techniques for maximizing alliance independently with both child and parent need consideration. Two studies (Green, Kroll, Imre et al., 2001; Green, Jacobs, Beecham et al., 2007) found that child and parental alliances were independent of each other and that the child alliance was a main predictor of health gain during admission. Assessment Strategies The ward environment creates opportunities for detailed assessment of biological and psychological aspects of disorder. Covert causes of behavioral difficulties can be elucidated – for instance, a study of unselected adolescent admissions (Szabo & Magnus, 1999) revealed 4% of patients with undiagnosed complex partial seizures. Wards need ready access to the full range of biological investigations, including scanning, electroencephalography (EEG) and clinical chemistry; a range of developmental assessments such as detailed speech pathology, occupational therapy and psychometric evaluation; and the opportunity for pediatric and neurological liaison. There are unique opportunities for observational studies in settings ranging from highly structured individual assessments to naturalistic observations during ward and school activities. Making best use of these opportunities requires good planning because important observations are often made by the least experienced staff and multiple assessments have to be integrated into a whole. One solution is to have structured assessment protocols for particular problems in which different staff have defined tasks towards a common end (Green, 1996). Assessments carried out in this way are always challenging – initial assumptions based on limited information can be examined critically in the light of different staff perspectives: this is one of the strengths of multidisciplinary working in the ward environment. Staff use specific skills from their core profession as well as skills developed within the team to serve these tasks – the team thus needs a program of generic skill development to meet the priorities of the unit. Planning Treatment Goals The concept of treatment goal planning was elegantly outlined by Shaw (1998) and has many attractive features. It acts to organize thinking and focus treatment in complex cases and counters therapeutic drift. However, it is deceptively simple and needs significant assessment and engagement with the family. Shaw suggested that treatment goals should be understandable, ideally framed in the child’s own words, achievable and measurable; they are distinguished from the staff hypothesis (a professional formulation of the case) and the treatment plan established by the staff group on the basis of this hypothesis. Rothery, Wrate, McCabe, and Aspin (1995) made an audit of treatment goals in admissions to four adolescent units. They found that the majority of treatment goals reflected relationship and maturational aims rather than symptom change alone. Improvement across such goals was noted during treatment. Goals should be flexible enough to be able to evolve in potentially unexpected directions when necessary during treatment. Adapting Treatments to the In-patient and Day Patient Settings In addition to individualized treatments, there remain generic aspects of ward management. Behavioral management on any unit is a key area, requiring ward policies on the management of aggression, use of seclusion or restraint, bullying and runaway behavior (AACAP, 2000). Minimization of problems begins with a thorough initial risk assessment and treatment planning, but equal emphasis needs to be placed on the overall culture of the unit, staff behavior and the ongoing use of social skills and anger-management programs (Cotton, 1993; Higgins & Burke, 1998). The AACAP review commented that the trend to brief treatment stays can undermine such a culture. Luiselli, Bastien, and Putnam (1998) applied a behavioral analysis to incidents of mechanical restraint in a US unit and concluded that such extreme measures were often the result of a failure of preplanning, unit policy or staff awareness. Antecedents to restraint were commonly an escalation of conflict initiated by staff behavior rather than child behavior and based on unrealistic staff expectations of child compliance. The authors advocated a comprehensive functional assessment, proactive treatment planning and the use of short time-out procedures in which the child has control as to duration. When prevention fails, crisis intervention techniques can range from de-escalation strategies and seclusion to brief carefully trained physical holding. More controversial techniques include use of medication and mechanical restraint (papoose boards or holding blankets) but these are contraindicated for younger children or when there is previous trauma related to confinement (AACAP, 2000). There are no comparative studies of the relative value of these techniques and the whole CHAPTER 69 1130 9781405145497_4_069.qxd 29/03/2008 02:59 PM Page 1130

area is relatively under-researched and subject to clinical fashion (Angold & Pickles, 1993). However, careful reviews of available evidence and explicit clinical guidelines such as those from the AACAP form the best current safeguard for patients and professionals alike. Individual treatments such as cognitive–behavioral therapy (CBT) and individual psychotherapy are incorporated into individualized treatment planning. The trend towards shorter treatment stays favors brief and focal treatments such as CBT. The detailed assessments provided by individual psychotherapy have continuing value but there are particular challenges in adapting psychotherapeutic treatment techniques to the modern treatment milieu when stays are relatively short (Leibenluft, Tasman, & Green, 1993; Magnagna, 1998). The challenge of mounting family therapy in the context of a busy in-patient unit has been reviewed by Lask and Maynerd (1998). Pre-admission family functioning has been found to be a predictor of health gain during treatment in a number of studies (Pfeiffer & Strzelecki, 1990) but Green, Kroll, Imre et al. (2001) found in one study that family functioning did not improve during admission. An option may be for the formal family therapy to take place at the local site of referral in partnership with the in-patient team. The ward staff provide a form of psychological care which inevitably has elements of substitute parenting, especially for younger children, and have the opportunity to pioneer the development of specialized forms of care for extreme difficulties. In wards taking multiple diagnostic groups, flexibility and thoughtfulness are needed; the management of a behaviorally disturbed child with attachment disorder will be very different to superficially similar behaviors in a child with pervasive developmental disorder or obsessivecompulsive disorder (OCD). Consent and Motivation The United Nations Convention on the Rights of the Child (UNICEF, 1995) and national legislation with regard to children (e.g., the UK Children Act; White, Carr, & Lowe, 1990) have significant implications for practice. The trend is for consent to be increasingly explicit, treatment-specific and involving of the child. Developmental issues around competency have been reviewed (Shaw, 1998). Within residential units, the social and linguistic impairments of patients, described elsewhere in this chapter, need to be carefully considered. In a useful study of competency in a consecutive series of 25 psychiatric child in-patients, Billick, Edwards, Burget, Serlen, and Bruni (1998) found that “legal competency” (the ability to understand legal rights and the principle of consent) was associated with the achievement of a 5th or 6th grade (year 12 equivalent) reading level. Another principle of consent should be collaboration with parents. A generic consent to treatment can be obtained early in admission in conjunction with treatment goal planning, based on what is likely to happen within a particular program of care. Such an approach combines the best principles of both consent and treatment goal planning. In the case of enforced treatment, there is debate as to whether it is best to use various aspects of children’s legislation or adult-orientated mental health legislation in particular circumstances (see chapter 8). The Staff Team As treatment approaches become more sophisticated, the staff team in both in-patient and day patient care have increasingly complex tasks to perform. In many countries, nurses with mental health and/or pediatric qualifications form the main ward staff group but play specialists, trainee psychologists and volunteers can also usefully add to the skill mix. Guidance from both the USA (AACAP, 1990) and the UK (Royal College of Psychiatrists, 1999) emphasized the wide variety of other professionals that should be represented in well-run in-patient or day patient units: consultant child and adolescent psychiatrists; social workers; psychologists; speech and language therapists; occupational therapists; family therapists; and psychotherapists. Attempts to operate with too few staff are a recipe for stress, burnout and institutional decay. Staff numbers are best discussed in “shift ratios” (number of staff per shift) or in sessional terms, because this allows application to diverse unit functioning. For nursing staff, factors influencing the shift ratio include skill mix, the task demands of a particular shift (from low-intensity observation at night to high-intensity active therapy) and patient dependency (Table 69.1). Units caring for those with diverse disorders need more intensive staff ratios. Furlong and Ward (1997) piloted a dependency measure that shows predictable weekly fluctuations and interactions with staffing levels and quality of care. American and UK guidelines (AACAP, 1990; Royal College of Psychiatrists, 1999) recommend nursing shift ratios of 1:3 for lowintensity activities rising to 1:2 for active treatment and 1:1 for intensive care. Recommendations for other staff include 1 whole time equivalent (WTE) consultant per 10–12 bedded unit, up to 1 WTE in clinical psychology and up to 0.5 WTE sessional inputs from social work, psychotherapy, family therapy and occupational therapy. The UK recommendation for specialized teaching is 1 teacher to 4 students per lesson. INTENSIVE TREATMENT 1131 Table 69.1 Factors indicating the need for higher shift ratios. [After Cotton, 1993 with permission.] 1 Patient heterogeneity Greater number of patients Broader range of ages Variation in levels of developmental functioning and diagnosis (e.g., combining cognitively impaired or psychotic children with brighter, behaviorally disordered children) 2 Case severity Greater severity and pervasiveness of impairments Severity of symptoms, such as suicidality, aggressiveness, sexualization 3 Lack of family or support systems outside the hospital 4 Poor therapeutic alliance (e.g., families with statutory orders or referred from courts) 5 Frequent staff turnover 6 Shorter lengths of stay (more acute admissions and an inability to develop routines and relationships) 9781405145497_4_069.qxd 29/03/2008 02:59 PM Page 1131

Models of team management and functioning vary with the style of the unit. A popular current style is a model of “matrix management,” which combines different disciplines with multiple tasks in a flat hierarchy with task-focused “mini teams” (Maskey, 1998). Whatever the organization, responsive and adequate staff supervision is vital. Effectiveness of In-patient and Day Patient Treatment Generic Outcomes In-patient and day units are considered as a single entity for the purposes of administrative planning and therapeutic organization, and most studies have investigated generic outcomes across a range of disorders. Pfeiffer and Strzelecki (1990) reported a meta-analysis of 34 such in-patient outcome studies; there have been subsequent reviews (Curry, 1991; Pottick, Hansell, Gaboda et al., 1993) and individual reports. These studies pointed to the overall efficacy of in-patient care and have been able to identify predictors of outcome. However, the reviews have also highlighted significant methodological limitations. Few early studies included control groups or standardized outcome measures and sample sizes have often been insufficient to overcome problems of patient heterogeneity. Pottick, Hansell, Gaboda et al. (1993) argued for more experimental designs to investigate the value of the residential component of care against other components, and prospective randomized trials of in-patient versus other forms of treatment for particular disorders are now beginning to appear (see p. 1136). Outcome measurement is also becoming more sophisticated with “triangulation” methods to measure multiple perspectives on outcome (Jensen, Hoagwood, & Petti, 1996). Use of change-sensitive common methodologies in the future will greatly help the field. It will also be necessary to be creative in the variables measured; markers such as social competency may be more relevant for treatment and outcome than diagnostic groupings per se. Grizenko, Papineau, and Sayegh (1993), in a study of multimodal day treatment for children with disruptive behavior problems, found that compared with a waitlist control group, day treatment produced significantly greater improvement in behavior, and that this was maintained at 6-month follow-up. Predictors of Outcome Pfeiffer and Strzelecki (1990) identified a number of predictors of in-patient outcome in their meta-analysis, which have received support and extension in subsequent studies. However, the design limitation of these studies must again be emphasized. By contemporary standards of evidence, these older studies do not robustly establish the causal link between admission and outcome or test predictor variables against other possible explanations. More recent study designs have begun to address these limitations. High levels of aggressive antisocial behavior and “organicity” of symptoms, as in schizophrenia, predict poor outcome; emotional disorders do better. Wellorganized treatment, multimodal treatment, positive alliance and good aftercare are common predictors (Grizenko, Papineau, & Sayegh, 1993). Intelligence measured as IQ shows a moderate positive effect, but the study of Luthar, Woolston, Sparrow et al. (1995) suggested that functional achievement may be a more critical variable than IQ per se. Pretreatment family functioning is a strong predictor of outcome but the effects may be complex and disorder-specific. In a study of anorexia nervosa, North, Gowers, and Byram (1997) found that the child’s perception of family functioning was prognostic but parents’ perception was not. Gender, age and emergency or elective admission were found to have little predictive value. Length of Stay (LOS) had only a modest association with outcome in Pfeiffer and Strzelecki’s (1990) review. However, interest in treatment lengths has been increased by the rapid progress in the USA and elsewhere towards managed care and very short hospital stays. Influences on LOS are complex. A retrospective case note study of pre-admission variables in 100 children in one private US unit (Gold, Shera, & Clarkson, 1993) found that longer LOS was predicted by greater global impairment, post-traumatic symptoms and psychosocial stressors; diagnosis of adjustment disorder predicted shorter stays. In contrast, Christ, Tsernberis, and Andrew (1989) found that LOS was predicted by funding constraints or unit philosophy rather than diagnosis. In a multi-unit study, Green, Jacobs, Beecham et al. (2007) showed that longer treatment stays were associated with improved outcome independent of diagnosis and when other factors were controlled using robust standard errors. Because of the size of the sample (n = 155) and the variation in LOS between the units, this may be a salient finding. The clinical lore that symptoms often decline rapidly early in an admission and then worsen – the “honeymoon” effect – was supported by LaBarbera and Dozier (1985), who showed symptom increase from early to late in admission. No measure of preadmission symptomatology was made here but the authors argued that shortening admissions beyond a certain limit might well produce spurious health gains based on symptom inhibition early in admission. Alternatively, the fact of admission may relieve contextual causes of symptoms in the young person’s environment and the early symptom reduction may be a valid effect – but the work needed to maintain these positive changes into discharge will take longer. Outcome for Specific Disorders Eating Disorders There is unresolved debate on the value of in-patient treatment for eating disorders. The anxiety that these disorders induce, the issues around control and the significant mortality often combine to produce a desire for admission as a safe option. Adolescents themselves often resist admission and some of the extreme behavioral methods previously used on units to promote eating continue to cause anger when patients recount their experiences (Shelley, 1997). On the other hand, the residential experience can be therapeutically powerful. Studies of the outcome of in-patient treatment show widely CHAPTER 69 1132 9781405145497_4_069.qxd 29/03/2008 02:59 PM Page 1132

differing results. Steinhausen and Seidel (1993) followed 50 patients over 5 years and found a 68% recovery rate, with 14% still diagnosable with eating disorder. Saccomani, Savoini, Cirrincione, Vercellino, and Ravera (1998) followed 81 children over 9 years and found a 53% good outcome. A comparison of out-patient and in-patient treatment (Crisp, Norton, Gowers et al., 1991; Gowers, Weetman, Shore, Hossain, & Elvins, 2000) showed little additional benefit from in-patient care, and in a recent large randomized study no significant difference was found between in-patient and assertive outpatient arms in weight outcomes (Gowers, Weetman, Shore et al., personal communication). Depression and Suicidality Admission practice following suicide attempts shows great regional variation. A recent large study found that, for similar presentations, 39% of cases in the USA were admitted compared with 12% in Europe (Safer, 1996). There are no studies directly comparing hospitalization with other forms of post-overdose care although an evidence-based review (Hawton, Arensman, & Townsend, 1998) recommended that psychiatric admission should not be the intervention of first choice for self-harm (see chapter 40). A number of recent uncontrolled studies have investigated suicide risk following in-patient treatment of depression or suicidality. Of 111 emergency admissions, 20% remained depressed and suicidal at 2–4-year follow-up (Ivarsson, Larsson, & Gillberg, 1998), 18% of 100 patients admitted with depression reported suicidal behavior at 6-month follow-up (King, Segal, Kaminski, & Naylor, 1995) and 25% of 180 similar admissions attempted suicide within 5 years of discharge (Goldston, Sergent-Daniel, Reboussin et al., 1999). Predictors of ongoing symptoms were suicide attempts prior to hospitalization, high levels of depressive symptomatology and family dysfunction at in-patient assessment. Psychosis Adolescents with first-onset psychotic illness will commonly be admitted but there are no studies comparing admission with alternative forms of treatment at this stage. One study of 58 adolescents admitted with psychotic disorder showed that 78% were continuously ill at follow-up after 2 years (Cawthron, James, Dell, & Seagroatt, 1994). Conduct Disorder The presence of unsocialized aggressive or disruptive behaviors at presentation is a consistent predictor of poor outcome for in-patient treatment (Green, Jacobs, Beecham et al., 2007; Pfeiffer & Strzelecki, 1990). However, this reflects the general prognosis for these disorders. Conduct disorder is a specific exclusion criterion in some units but accounted for 25% of child admissions overall in a study of UK child psychiatry units (Green & Jacobs, 1998) and 15% of children and adolescents referred to Finnish in-patient units in 1990 and 1993 (Sourander & Turunen, 1999). In a recent UK study of eight units, conduct and aggression were associated with worsened ward milieu and shorter stays. Current evidence suggests that the management of conduct disorder is best seen in terms of long-term maintenance rather than episodes of care and the contextual basis of much of the symptomatology supports community intervention as a first-choice treatment. In spite of these arguments, and the often disruptive effect of such children on the milieu, there is good indication for admitting selected patients: for assessment when there are concerns about covert underlying comorbidity relevant to treatment (e.g., ADHD, emotional disorder, pervasive developmental disorder, specific learning disability or subclinical seizures; Jacobs, 1998); or when a trial of treatment is needed within a controlled setting. Children with disruptive disorders receiving a multimodal day program showed improvements in adjustment at 5-year follow-up (Grizenko, 1997). Another multimodal day program (Rey, Denshire, Wever et al., 1998) also showed improvement over matched controls who had received other treatments; however, both groups showed poor outcome. In a study of in-patient treatment of adolescents with emotional and conduct disorder, patients who completed the treatment showed more progress 1 month post-discharge than patients who were early dropouts, but these differences had become insignificant at 1- and 2-year follow-up (Wells & Faragher, 1993). Substance Misuse A number of in-patient and day patient addiction programs have been evaluated. Of 280 adolescents treated in a substance abuse in-patient program (Dobkin, Chabot, Maliantovitch, & Craig, 1998), 67 subjects completed 1-month follow-up questionnaires; 19 had improved and 48 had not. The improvers tended to be older with better motivation for social adjustment and less emotional symptomatology; those who did worse were distinguished by more mental state abnormalities at admission. Cornwall and Blood (1998) compared in-patient with day patient programs in this area and found they showed similar outcomes. A random allocation trial comparing inpatient with intensive community treatment of adolescents with substance misuse and juvenile offending (Schoenwald, Ward, Henggeler, & Pickrel, 1996) showed additional benefits for the community treatment. Freeman, Garrick, Kreisher et al. (1993) report a matched study comparing long-term outpatient treatment with short-term in-patient treatment and found benefits in the longer-term out-patient treatment. Obsessive-Compulsive Disorder In a prospective naturalistic study, Wever and Rey (1997) examined the effectiveness of combined CBT and psychopharmacology in a group of 57 children and adolescents first diagnosed with OCD, 20% of whom received in-patient treatment. Factors leading to admission included the severity and type of OCD symptoms, the failure of past therapy, comorbidity, family factors and geographical isolation. 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Alternatives to In-patient Care Historical Development Over the last 40 years changing philosophical beliefs among educators and health professionals (Bracken & Thomas, 2002) have led to a movement away from residential psychiatric care in the UK, Europe and North America (Smyth & Hoult, 2000). Reforms in US mental health policy (including the introduction of Medicare, Medicaid and the Supplemental Security Income program) encouraged policy-makers to discharge patients to the community and transfer state mental health costs to the federal government. Systemization of the Child and Adolescent Service System Program (England & Cole, 1992) opened up discussion among in-patient service providers about how best to meet the complex needs of children and young people (Burns & Friedman, 1990). A range of alternative community-based services were then developed, many now systematically evaluated (Henggeler, Rodick, Borduin et al., 1986). In general, evidence-based changes to mental health care have underpinned reform of psychiatric service provision for adults and young people, and intensive home-based treatments are central to these changes (McGorry, 2005). In the UK, the development and evaluation of psychiatric intensive home treatment has somewhat lagged behind the US developments (Smyth & Hoult, 2000). However, a commitment to tackling the links between mental illness and social deprivation has been made explicit in the National Service Frameworks for Mental Health (Department of Health, 1999) and for Children (Department of Health, 2003), which challenge health professionals to widen their approaches to care. A review of home-treatment studies (Joy, Adams, & Rice, 2004) found that patient and relative satisfaction was higher in home care compared with admission in adults and that carers found home care less disruptive and burdensome. Recent surveys showed that young people and families want CAMHS to be delivered flexibly (Baruch & James, 2003) and in a variety of settings, including the home (National Service Framework for Children, 2004). Current Developments In adult mental health services a range of treatment models are now used, sometimes specifically to reduce the need for hospitalization, sometimes to allow more patient choice and active involvement in care (Department of Health, 1999; Priebe, Fakhoury, White et al., 2004). These include assertive community treatment (Wright, Burns, James et al., 2003), case management (Burns, Fioritti, Holloway, Malm, & Rossler, 2001a) and home treatment (Burns, Knapp, Catty et al., 2001b), all of which have the aim of providing increased support and care for the mentally ill within their own homes so that hospitalization can be avoided where possible. However, the disorders for which young people – especially children – are admitted vary greatly from those in adults, as does the developmental context. Thus, direct comparisons with adult psychiatry can be misleading. Assertive outreach, case management and wraparound models have been adapted for use in child services but there has also been the development of developmentally specific models, such as treatment foster care and multisystemic therapy. The heterogeneity of these initiatives makes comparison difficult, although they tend to share common features (e.g., the importance of the family and social context, the complex needs of young people and families, multimodal interventions and the understanding of outcomes as being multifaceted). The services with which home treatment is compared are often poorly defined as “standard care,” which can vary enormously from study to study (Burns, Knapp, Catty et al., 2001b). Furthermore, the majority of the studies focus on young people not at the highest risk (often the acutely suicidal or psychotic are excluded) and therefore results may not be generalizable outside of a specific and narrow patient group. While most studies report that effective systems of care can be developed in the community (Henggeler, Rodick, Borduin et al., 1986), other work suggests that outcomes may not always be substantially improved (Burns, Farmer, Angold, Costello, & Behar, 1996). Models of Out-of-Hospital Care Family Preservation Family Preservation is a home-based intensive service for families who need additional support beyond typical out-patient services. It can be used as a transitional service for families with children returning home from psychiatric admission, or to prevent admission. The aims are to improve parenting skills, promote healthy child development, prevent out-of-home placement of children and provide or co-ordinate services needed to maintain family stability. The therapists make contact with the family several times a week, providing assessment and treatment, and access to educational and practical resources. Family Preservation services are usually limited to weeks in duration. However, family contact with therapists is intensive during this time, almost double that in residential units (Wilmshurst, 2002). A randomized controlled trial of young people allocated to either Family Preservation or a 5-day residential program found that at 1-year follow-up more of the Family Preservation group had sustained the improvements in behavior and the symptom reduction than had those in the residential program (Wilmshurst, 2002). Home Treatment Home treatment can be summarized as a service for young people with mental illness who are in crisis and are eligible for hospital admission. Features of an effective home treatment team are 24 h a day, 7 days a week availability; rapid response time; and the ability to work flexibly with families and their networks (Smyth & Hoult, 2000). In a series of studies from Germany, home treatment was compared with “standard” in-patient treatment. The first study (Remschmidt, Schmidt, Mattejat, Eisert, & Eisert, 1988) randomly allocated young people to home treatment or admission; it found that the baseline severity of symptoms was similar for both treatCHAPTER 69 1134 9781405145497_4_069.qxd 29/03/2008 02:59 PM Page 1134

ment groups, and that immediate treatment effects were similar. However, only about 15% of young people could safely be diverted from in-patient to home treatment, exclusion criteria for the home treatment arm being severe psychosis, lifethreatening eating disorders, families living more than 30 km from the therapeutic unit and risk-taking behavior. Mattejat, Hirt, Wilken, Schmidt, and Remschmidt (2001) conducted a re-analysis and 3-year follow-up of these data. They contacted 68 of the original 92 families (in-patient n = 33, home treatment n = 35). Baseline symptom scores and psychosocial functioning were similar for both groups. Home treatment was found to be as effective as in-patient treatment across diagnoses in reducing symptom scores and improving psychosocial functioning, both immediately after treatment and at 3-year followup. The longer-term treatment effect declined somewhat, to an equal extent in both groups. Compliance of the child with the therapeutic regime and the skill of the therapist were the most important predictors of treatment outcome. The study suggested that, even if community treatment is an effective alternative to admission, it could only be used for a small proportion of all possible admissions, a finding also reported by others (Woolston, Berkowitz, Schaefer, & Adnopoz, 1998). Case Management Case management encompasses a number of approaches including assertive outreach, assertive community treatment, wraparound and intensive community treatments. It can be defined as “a commonly used strategy for increasing access to and coordination of services within the care system” (Farmer, Dorsey, & Mustillo, 2004). Case management in a child and adolescent mental health setting assigns the coordination and responsibility of care for an individual young person with a serious mental illness to a single person (or team). Case managers may be responsible for a variety of tasks, ranging from linking young people and families to services to providing intensive clinical or rehabilitative services. Other core functions include outreach to engage clients in services, assessing individual needs, arranging support services (such as education, careers advice, family benefits), monitoring medication and advocating for young people’s rights. Case management is not a time-limited service, but is intended to be ongoing, providing clients with whatever they need whenever they need it, for as long as necessary. This is a controversial point, as some authors feel that the “never discharge” philosophy encourages pathologizing of normal behaviors and re-invention of some of the worst practices of the old asylums, a de facto “institutionalization” in the community (Smith, 1999). Case management has been adopted in the UK, Germany and Sweden, but not in all European countries (Burns, Fioritti, Holloway et al., 2001a). The two models of case management described most often are assertive community treatment (ACT) and intensive case management. A third model, clinical case management, refers to a program where the case manager assigned to a client also functions as their primary therapist, generally considered to be less effective (Burns, Farmer, Angold et al., 1996). The assertive outreach/community treatment model for adults originated in an in-patient research unit at Mendota State Hospital, Madison, Wisconsin in the late 1960s (Stein & Test, 1980) in an attempt to create a “hospital without walls.” In the UK, it is now part of the national mental health policy for adults (Department of Health, 2003) with over 200 teams, but in Europe it has not developed to the same extent (Bonsack, Adam, Haefliger, Besson, & Conus, 2005). The key features of ACT are multidisciplinary teams, 24 h a day, 365 days a year care; low client : staff ratios; an emphasis on assertive outreach; provision of in vivo services (in the client’s own setting); an emphasis on assisting the client in managing their illness; assistance with activities of daily living (ADL) skills; emphasis on relationship building; and crisis intervention. The interventions are strengths-based and focused on promoting symptom stability, increasing the individual’s ability to cope and relate to others. Adult patients are rarely discharged (Smith, 1999) and this may lead to everyday difficulties being reframed as symptoms or dissuade commissioners and providers from developing ACT services (Bonsack, Adam, Haefliger et al., 2005). In the UK, assertive outreach is a requirement for adults of working age only (Office of the Deputy Prime Minister, 2004) although as Early Intervention in Psychosis teams become more common and report on their outcomes this situation will change. Much of the evidence for the effectiveness of assertive outreach is from studies with overlapping age groups of young people and working age adults. Broadly, assertive outreach in young and working age adults is effective (Marshall & Lockwood, 2004; Minghella, Ford, Freeman et al., 1999) despite concerns that fidelity to the model is not always adhered to. Good quality assertive outreach studies have shown that assertive outreach is effective with young adults with early psychosis, the treatment effect size is similar to that of in-patient care, in-patient admission can often be avoided without increasing risk of critical incidents, and it can be highly cost-effective (Craig, Garety, Power et al., 2004). Whether it is more effective than “standard” community care is debatable, with mixed findings perhaps related to many community mental health teams being able to provide the “assertive” component for young adults when required. Two randomized studies of only young people report that compared with those who received standard community care, young people who received assertive outreach were more likely to access and continue using services, had better family relationships and fewer psychiatric symptoms (Evans, Boothroyd, Armstrong et al., 2003; Godley, Godley, Dennis, Funk, & Passetti, 2002). Service user views of young people and their families suggest that assertive community treatment is useful and valued (White, Godley, & Passetti, 2004), although this should be taken with caution as it was based on young people with substance abuse problems and may not be generalizable. Intensive case management typically targets young people with the greatest service needs. 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approach. In addition, intensive case managers are more likely to “broker” treatment and rehabilitation services rather than provide them directly. Finally, intensive case management focuses more on family strengths and empowering families. Case managers act as advocates and brokers between services, and coordinate, plan and implement services. Clinical case management is one of the intensive case management models but has the weakest effect of the models. An aggregation of studies comparing ACT with clinical case management found that while the generic approach resulted in increased hospital admissions, it significantly decreased the length of stay. This suggests that the overall impact of clinical case management is positive but might result in “revolving door” admissions. However, randomized trials have shown fulltime case manager models to be perceived as more satisfactory and allow young people to access community rather than residential-based services, compared with treatment models where the primary worker or therapist also acts as case manager (Burns, Farmer, Angold et al., 1996). Wraparound helps families develop a plan to address the child’s individual needs at home and school (Burns, Schoenwald, Burchard, Faw, & Santos, 2000). Research on the effectiveness of this model is still at an early stage. Wraparound addresses a child’s individual needs and builds on the child’s and family’s strengths, so the exact services vary. The services are provided through teams that link children, families and foster parents and their support networks with child welfare, health, mental health, education and the criminal justice services to develop and implement comprehensive support plans. Findings suggest that this broker/advocacy model results in behavioral improvements and fewer days in hospital. A randomized controlled trial of treatment foster care versus case management (with wraparound components) found that outcomes were better for young people in case management interventions than for treatment foster care and at one-third of the cost (Evans, Armstrong, Kuppinger, Huz, & Johnson, 1998). More radically, families or volunteers sometimes act as case managers in wraparound care, although this is probably more as a result of lack of support and funding than a philosophical step forward. Multisystemic Therapy Multisystemic therapy (MST) was developed as an intensive approach to juvenile offenders presenting with serious antisocial behaviors and who were at risk of being placed out-of-home (see chapter 68). It is an intensive family and community-based treatment program (Henggeler, Rodick, Borduin et al., 1986) designed to make positive changes in the various social systems (home, school, community, peers) that contribute to the serious antisocial behaviors of children and adolescents. It is based on the work of systems theorists such as Haley and Minuchin. Time-limited (4–6 months), it adheres strictly to a treatment manual with nine treatment principles, and relies for success on adherence to the treatment model and ongoing training of staff to this end (Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998). The main purpose of assessment is to understand the fit between the identified problems and their broader systemic context (Henggeler, Schoenwald, Borduin et al., 1998). Interventions are designed to promote treatment generalization and longterm maintenance of therapeutic change by empowering caregivers to address family members’ needs across multiple systemic contexts. Outcome studies show that staff adherence to the treatment model correlates to strong case outcomes (Henggeler, Rowland, Halliday-Boykins et al., 2003). MST has a relatively strong evidence base (Farmer, Dorsey & Mustillo, 2004). Consistently positive outcomes are reported for young offenders compared with standard out-patient treatment (reduced offending, fewer out-of-home placements, less substance-related offending). Randomized controlled trials and pooling of previously conducted studies demonstrated significant symptom improvement in psychiatrically ill young people receiving MST compared with standard care (Curtis, Ronan & Bourdin, 2004; Henggeler, Rowland, HallidayBoykins et al., 2003; Schoenwald, Ward, Henggeler, & Rowland, 2000). However, at 12-month follow-up, the two treatment approaches yielded similar results. Schoenwald, Ward, Henggeler et al. (1996) randomized MST against service as usual for adolescent substance abusers. The MST treatment resulted in a 46% decrease in the need for residential care at 1-year follow-up and succeeded in reducing dramatically the rate of imprisonment for substance abuse and abuse-related in-patient stays. The cost savings made through this almost compensated for the increased cost of the MST treatment. A recent randomized trial (Henggeler, Rowland, Randall et al., 1999) compared MST with brief hospitalization for a diverse group of adolescent psychiatric emergencies in a relatively disadvantaged population. MST was given for 4 months whereas hospitalization was for 2 weeks only, followed by standard community aftercare. The MST condition involved a mean of 97.1 h of therapy contact time during the study and 24 h, 7 days a week availability of staff. Staff had a caseload of three cases each and there was high-frequency psychiatric supervision. By comparison, the hospitalization condition had a mean contact time of 8.5 h subsequent to the admission period. Nearly half of the young people in the MST condition in fact needed psychiatric admission in the initial period and MST only had the effect of reducing out-of-home placement by 50% through the whole study. Given these methodological qualifications, the MST had a significantly greater effect than hospitalization on disruptive behavior and targeted social outcomes such as enhanced family cohesion, structure and school attendance. Family and youth satisfaction was also higher. The hospital condition showed a significantly greater impact on youth self-esteem – a result that may reflect the individually orientated treatment model in the hospital group. No follow-up data beyond 4 months are reported. The study concluded that even this highly intense form of ecologically focused care does not substitute for the need for in-patient provision – but it can reduce the need, and results in enhanced outcomes over treatment as usual. 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unfortunate for the design of the study that there was such an imbalance between the treatment intensity in the two conditions. The study – important as it is – does not yet address the question of the relative value of the residential component per se. Treatment Foster Care Treatment foster care (TFC) is one of the least restrictive treatment-based residential options for young people with emotional or disruptive disorders (Farmer, Dorsey, & Mustillo, 2004). It comprises structured therapy within a foster family setting, delivered with a multiagency approach. Theoretically, TFC is largely based on social learning theory. TFC programs recruit, train and support foster families, who usually only look after one fostered child. The families are closely supervised and supported, and receive a monthly salary. TFC specialists work with the child and foster parent on identified goals 1–2 h per week. This work is supervised by a mental health practitioner, who also meets with the foster-care family frequently (every 1 to 2 weeks) to coordinate services and ensure the treatment plan is being followed. TFC programs also prepare the child for successful transition to return home. TFC differs from standard foster care in three ways: 1 Substantial training and supervision of foster parents by experienced case managers; 2 Detailed functional assessment and close monitoring of behaviors, their antecedents and consequences; and 3 Emphasis on “therapy.” The evidence base comes mainly from two well-reported randomized controlled trials undertaken by those who deliver the Oregon model (Chamberlain, 2002). Outcomes (improved behavior, reduced offending behavior) for both psychiatrically ill and offending young people were significantly better for those who received TFC than group home or hospital care. Outcomes were dependent on four main factors: the amount and type of supervision received by the young person; consistency of parental discipline; presence of a close, confiding relationship with a trusted adult; and not being closely linked with delinquent or deviant peers (Chamberlain, 2002). Although most of the evidence base for TFC comes from its original proponents in Oregon, it has translated across the Atlantic successfully, albeit in an altered format (Brady, Harwin, Pugh, Scott, & Sinclair, 2005). Outcomes reported for young people in this project include: a greater stability in placements; an increase from 14% (on admission) to 71% in young people attending school. 21% showed significant improvements in their behavior and a further 25% some behavioral improvement. There was also a significant decrease in young people being cautioned or convicted of offenses with less than 1% receiving a custodial sentence. 21% young people returned home to their birth family and 10% moved to independent living. However, the level of professional and financial risk involved in a TFC project could only be sustained if it is based on a partnership agreement with one or more local authorities and CAMHS teams. A modified form of TFC is currently being implemented in the UK for looked-after children at risk of multiple placement breakdowns and is being systematically evaluated. Projects are also under way in Sweden, Finland and Holland. Staffing These intensive outreach models need much skilled professional time. In Woolston’s (1998) model between three and five professional teams, consisting of two senior clinicians or counselors, provide the home-based assessment and therapeutic input. They are backed up by a multidisciplinary infrastructure described in the model as a program director and medical director, a child psychiatrist, a clinical program co-ordinator, two senior clinicians and an administrator. This staff level is quoted as sufficient for a caseload of 25 patients. The intensity of the involvement can vary according to need and expense but a 24 h, 7 day on-call crisis intervention service is provided throughout the duration of the input. In one study of MST (Schoenwald, Ward, Henggeler et al., 1996), the average duration of treatment was 130 days (standard deviation [SD] 32 days), during which there was an average of 40 direct contact hours between professionals and family (range 12–187 h, SD 28 h). Woolston emphasized that the intensive homebased services are considered as supplementary to an array of more traditional services including in-patient and day patient hospitalization and out-patient programs. Conclusions There is now research evidence supporting the use of alternatives to in-patient care for certain groups of young people with mental health problems. The evidence suggests that, within these groups, treatment effects of several outreach models of care can be of similar size to those obtained through residential treatment, and may be sustained as long after follow-up. MST, TFC and assertive outreach have the strongest evidence bases, wraparound care the weakest. However, it should be remembered that the evidence for TFC is largely based on the model as delivered in Oregon solely, clearly limiting generalizability of the findings. Assertive outreach work is largely based on older adolescents and young adults, and comparisons with “standard” treatment do not reflect a fair comparison with CAMHS “standard” treatments, which arguably are already more “assertive” and “outreach” than standard adult mental health services. The evidence surrounding MST is now extending beyond use with antisocial behavior but still needs further work to demonstrate effectiveness in other disorders. Therefore, there is not always the evidence to decide which model is best for which group of young people, and funding and service provision issues may not allow development of the chosen model, requiring pragmatic choices to be made by commissioners and providers. Little, Kohm, and Thompson (2005) rightly called for less ideology and more science. Comparative studies are needed to allow an informed decision INTENSIVE TREATMENT 1137 9781405145497_4_069.qxd 29/03/2008 02:59 PM Page 1137