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Psychiatric Times
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How has the field of child and adolescent psychiatry matured over the last 3 decades? Our Special Report Chair, Peter S. Jensen, MD, elaborates.
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SPECIAL REPORT: CHILD AND ADOLESCENT PSYCHIATRY
The field of child and adolescent psychiatry has matured remarkably over the last 3 decades. Beginning in the late 1990s and continuing into this century, we now have a meaningful set of major National Institutes of Health–funded randomized clinical trials (RCTs) comparing the benefits of medication, evidence-based psychotherapy, or their combination for the most common disorders of pediatrics: attention-deficit/hyperactivity disorder (ADHD),1,2 major depressive disorder,3 anxiety disorders,4 and significant aggression.5 While total number of trials appears modest, their scope is remarkable, in that they address (by my rough estimate) as many as 75% to 80% of all children presenting to clinicians for diagnosing and treating pediatric mental health problems. Moreover, by the continuing analyses of these 5 major RCT findings, our research literature has been enriched by over 400 peer-reviewed articles—as each of these studies’ data sets continues to be mined through the ongoing participation of literally hundreds of clinician-scientists.
Why Developmental Trauma Disorder Should Be Included in the DSM: A Case Study
Jo A. Hughes, DMSc, PA-C, CAQ-PSY
Celiac Disease: An Overlooked Cause of Mental Illness in Children
James M. Greenblatt, MD
Who Are the Youth With Undiagnosed ADHD Symptoms?
Kenneth J. Bender, PharmD, MA
In every case, these 5 studies relied on the strength of a critical comparative test of an optimal medication strategy; an evidence-based psychotherapy; their combination; and some type of comparison group, eg, placebo or treatment as usual. In their totality, these trials together have demonstrated that anywhere from 75% to 85% of children with psychiatric disorders can receive substantial benefits from evidence-based approaches now known to us. While none of these now established treatments is perfect, as a collection, these trials have generally addressed the most common pressing questions that clinicians (and patients and their parents) face when deciding on a treatment for most US children with mental health problems. That said, much remains to be done. To that point, this interesting special section tackles 3 areas where—by contrast—we know relatively little.
The first article considers the topic of a new diagnostic category altogether: developmental trauma disorder. The authors argue—quite reasonably—that for some children, trauma(s) may unfold over time, may exert further impacts on subsequent development, and are often further layered by ongoing traumatic and deprivation experiences—sometimes called, by another term, adverse childhood experiences (ACEs).6 We do not yet know whether 1 or multiple ACEs, regardless of their specific characteristics (eg, personal injury, witnessing a shooting, death of a parent, etc), have a qualitatively different impact distinct from any other single or persisting trauma. But no experienced clinician (certainly not me!) would refuse to accept that multiple (and/or persisting) traumas are likely to be quantitatively different in their cumulative effect/severity in most cases. That said, the acid test for a new diagnostic category is that it can be differentiated by its (1) symptom presentation distinct from other disorders, (2) potential unique or differential treatment response, (3) differing pathophysiologic characteristics, or (4) different ultimate prognosis. That will require new research if this novel term is to survive.
The second article addresses a topic quite new to me, and likely to most readers: the impact of gluten on children who present with perplexing and lingering somatic complaints. Perhaps like most of us, I received little education on the potential mental health consequences of what we do (and do not) eat, and the possibility of substantial impact of these issues on a subset of our patients. Stay tuned.
The third article addresses another area where again more evidence is needed, namely the puzzlement we must all face when a child has had significant symptoms but has remained undiagnosed with ADHD into adolescence. The puzzle even grows when we consider the fact that most children and adolescents with ADHD do not receive any diagnosis and treatment as adults. I found this article useful, as it begins to elucidate some of the reasons it becomes only more apparent among teens, especially female patients or those with comorbid, possibly obscuring conditions (eg, autism). How do we change our practices to begin to address these nationwide problems, even for common and well-established disorders?
Dr Jensen is the founder and board chair of The REACH Institute and an adjunct professor of psychiatry at the Psychiatric Research Institute, University of Arkansas for Medical Sciences.
References
1. MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 1999;56(12):1073-1086.
2. Greenhill L, Kollins S, Abikoff H, et al. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD. J Am Acad Child Adolesc Psychiatry. 2006;45(11):1284-1293.
3. March J, Silva S, Petrycki S, et al; Treatment for Adolescents with Depression Study (TADS) Team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA. 2004;292(7):807-820.
4. Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavior therapy, sertraline, or a combination in childhood anxiety. N Engl J Med. 2008;359(26):2753-2766.
5. Aman MG, Bukstein OG, Gadow KD, et al. What does risperidone add to parent training and stimulant for severe aggression in child ADHD? J Amer Acad Child Adolesc Psychiatry. 2014;53(1):47-60.e1.
6. Hughes K, Bellis MA, Hardcastle KA, et al. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health. 2017;2(8):e356-e366.
