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2011-01-21T20:54:25Z

In Short…

Children and youth with AD/HD, Conduct Disorder, or both, may be at high risk of engaging in intimate partner violence as young adults. Interventions for these conditions should address the promotion of healthy relationships.

The Issue: People who engage in violence against their partners – both men and women – often have a history of a troubled early home life. Many have been abused as children or have witnessed violence between their parents or a parent and his/her partner. They often have behaviour problems such as Conduct Disorder and Attention Deficit/Hyperactivity Disorder or other mental health problems that may persist into adulthood. What is not well understood is how these conditions act, either alone or in concert, to increase the risk of intimate partner violence (IPV), and which characteristics of the adolescents are the most important to target for treatment.

The Research: This study was part of the National Longitudinal Study of Adolescent Health, the participants in which were a representative sample of 11,238 United States youth aged between 20 and 23 years. The authors sought to understand whether childhood ADHD symptoms predict IPV in young adulthood when the symptoms of conduct disorder are also considered. The participants were asked often they had pushed, shoved or thrown something at their partner or how often they had slapped, hit or kicked their partner in the year previous to the survey. To elicit instances of injurious IVP those who had answered yes to either of these two questions were later asked if their partner had experienced a sprain, bruise or cut because of a fight with them. Participants were also surveyed using checklists about their recall of AD/HD symptoms between ages 5 and 12 and symptoms of conduct disorder in childhood or adolescence.

The Results: The analysis showed that early conduct disorder was consistently associated with later IPV. Symptoms of hyperactivity/ impulsivity, but not inattention, predicted young adult IPV resulting in injury, but not IPV without injury.

This research suggests that interventions with children and youth with AD/HD and/or conduct disorder should address the potential for intimate partner violence and promote knowledge about healthy relationships.

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The preceding is a summary of: Fang X, Massetti GM, Ouyang L, Grosse SD, Mercy JA. Attention-Deficit/Hyperactivity Disorder, Conduct Disorder and young adult intimate partner violence. Archives of General Psychiatry. 2010; 67(11): 1179-1186.

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2011-01-04T21:59:44Z

In Short…

A teacher-delivered intervention that was targeted to students with risk factors for alcohol abuse helped them delay starting to drink alcohol and reduced their alcohol consumption if they did drink. This is further evidence that school-based interventions to prevent and reduce problem drinking work.

The Issue: Many older children and teenagers use alcohol. For most, it is a one-time experiment; for others, it is the beginning of serious problems that, without intervention, can last a lifetime. School-based alcohol use prevention and harm reduction programs are not always successful, particularly if they are delivered to all students. It may be that targeting the intervention to students who are more prone to developing substance abuse problems would be more effective.

The Research: This study looked at whether a teacher-delivered intervention aimed at students with specific personality traits usually associated with alcohol abuse would delay their use of alcohol and reduce the harm it causes. The personality traits they looked at were poor impulse control, sensation-seeking, anxiety sensitivity, and feelings of hopelessness.

Two thousand six hundred and fifty students at 18 secondary schools in London, England participated in the screening process. Eleven of the schools were randomized to provide active treatment and 7 schools acted as the control group sites. At the active treatment schools, 696 met the personality risk criteria in the 11 active treatment schools, while 463 students in the 7 control schools did. The intervention with the students found to have the risk personality traits were two 90-minute group sessions that involved education about the psychological factors related to alcohol abuse, a therapy designed to increase the students’ motivation to change or modify their risk factors, and ways to identify the beliefs and thinking related to sensation-seeking, in particular. Teachers were trained in 3-day workshops and had at least 4 hours of supervised practice throughout the course of intervention with older students in their schools.

The Results: Adolescents who took part in this personality-targeted intervention delivered at their secondary school had significantly lower drinking rates at six-month follow up compared to the students in the control schools. Those in the intervention group also reported a 55% decreased risk for binge-drinking and also consumed a lower quantity when they drank. This study adds to the research evidence that teacher delivered interventions that target students with known risk factors help students with alcohol abuse problems.

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The preceding is a summary of: O’Leary-Barrett M, Mackie CJ, Castellanos-Ryan N, Al-Khudhairy N, Conrod PJ. Personality-targeted interventions delay uptake of drinking and decrease risk of alcohol-related problems when delivered by teachers. Journal of the American Academy of Child and Adolescent Psychiatry. 2010; 49(9): 954-963.

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2011-01-04T21:56:04Z

In Short…

Alcohol use during pregnancy has severe consequences to the unborn child that cannot be undone after birth. Efforts must be made to help women avoid alcohol and other substance use, or to stop use during pregnancy.

The Issue: Many adoptees from Eastern Europe have been found, unfortunately, to suffer from physical and mental health problems. Their new families may be unable or unwilling to provide care for them and the children are again abandoned. Malnutrition, poor early emotional care, and substance abuse all play roles in these tragic events. Documenting these problems could help prevent them.

The Research: This was a study of children born between 1990 and 1995 in Russia, Poland, Romania, Estonia or Latvia, who were adopted to Sweden from 1993 to 1997. Records showed that 34% of the mothers said that they had drunk alcohol throughout their pregnancy. This is likely an underestimate. Of the 99 children identified, the families of 28 children declined participation. The remaining 71 children were examined for overall health and growth and to look for physical anomalies, particularly of the head, face, and eyes. Their mental health was assessed, looking specifically for attention deficit hyperactivity disorder (ADHD), Asperger Syndrome (AS), oppositional defiant disorder (ODD), conduct disorder (CD), obsessive compulsive disorder (OCD). They were also tested for intelligence, memory, and thinking ability.

The Results: Ninety per cent of the children had a neurodevelopmental, learning, or neurological disorder. Most had multiple disorders. Thirty-six of the children had ADHD, 16 were mentally retarded or had serious cognitive disability, 17 had birth defects affecting the structures of the eyes, head, face, or skeleton, 34% had developmental coordination disorder, and 9% had autism. Thirty children had microcephaly (a smaller than normal head). A minimum 52% of the children were later diagnosed with Fetal Alcohol Spectrum Disorder (amongst the highest rates recorded in the world) and 95% of them had multiple physical and mental disorders.

Substance abuse plays a significant role in the developmental disorders identified in this study. A significant number (probably underestimated in this study) suffered the effects of Fetal Alcohol Spectrum Disorder (FASD), the results of which are life-long: there is no cure for the physical and mental effects suffered by the child. The only way to deal with this tragedy is to prevent it. Alcohol use during pregnancy is not safe for the unborn child and it is he or she who suffers the consequences of their mothers’ substance abuse. Every effort should be made to prevent the development of substance abuse and to convince women to cease alcohol and other substance abuse before becoming pregnant, or at least as soon as pregnancy is apparent.

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The preceding is a summary of: Landgren M, Svensson L, Stromland K, Gronlund MA. Prenatal exposure to alcohol and neurodevelopmental disorders in children adopted from Eastern Europe. Pediatrics. 2009; 125(5): e1178-e1185

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2011-01-04T21:40:07Z

In Short…

Obsessive Compulsive Disorder (OCD) in children and youth is likely to become chronically disabling and persist into adulthood if the condition isn’t identified and treated early.

The Issue: Many people with Obsessive-Compulsive Disorder (OCD), a type of anxiety disorder, are diagnosed during childhood or adolescence. What is not well understood is whether all children with OCD continue to have the condition as they mature into adulthood, and what factors predict outcome. As well, information about the prevalence of other psychiatric disorders and use of and need for services into adulthood is needed.

The Research: This was a follow-up study of children and adolescents who had been assessed at a specialist clinic in England. One hundred and forty-two (61.5%) of the 276 young people who had received a diagnosis of OCD between 1996 and 2005 agreed to take part in the study. At assessment, the participants were asked about the severity of their symptoms and the impact they had on their daily life. They were also asked about any emotional or behavioural symptoms at that time. At follow up, both the participants and their parents filled out questionnaires about the OCD and other mental health or behaviour problems. They were then asked about whether they experienced impairment at work or school, in leisure activities, taking care of their home, and with their family and friends, and if they were still in treatment or felt the need for further treatment of their OCD symptoms.

The Results: The time between the initial and follow-up assessments ranged from 1 to 11 years, with most of the follow-up assessments taking place around 5 years after diagnosis. Most of the follow-up participants were boys, who had had moderate OCD symptoms for an average of 3.7 years before their diagnosis. Approximately 41% still had the diagnosis of OCD at follow up, and about 25% had both OCD and generalized anxiety disorder, while about 16% had OCD and depression. Participants experienced mild to moderate impairment in their daily life and about 50% felt they needed further treatment of their condition. Approximately half were still in treatment since their first assessment. The strongest predictor of persistence of OCD was how long the child or teenager had had the symptoms by the time they were assessed initially. Those who had other mental health problems prior to assessment had persistent problems with these conditions at follow up.

In this follow-up study of 142 children and teenagers with Obsessive Compulsive Disorder, the condition was found to persist over time and the study participants still had impairing symptoms that required further treatment. The study authors suggested that early intervention could reduce the likelihood of OCD becoming a chronic, disabling condition.

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The preceding is a summary of: Micali N, Heyman I, Perez M, Hilton K, Nakatani E, Turner C, Mataix-Cols D. Long-term outcomes of obsessive-compulsive disorder: follow up of 142 children and adolescents. 2010; 197: 128-134.

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2011-01-04T21:35:10Z

In Short…

The positive effects of Cognitive Behavioural Therapy (CBT) used in childhood to treat anxiety was shown to persist into adulthood. CBT prevented negative social and personal effects usually seen in adults with a childhood diagnosis of anxiety.

The Issue: Childhood anxiety disorders do not get better by themselves. If left untreated, they tend to persist, and can lead to poor relationship, social, and educational outcomes. When they do seem to disappear on their own, other mental health problems soon replace them. Cognitive Behavioural Therapy (CBT) is known to be a successful treatment for anxiety disorders in the short term, but it is not known whether it makes a difference in the long run, especially during the sometimes difficult transition from adolescence to adulthood. It is also not known if the type of CBT used makes a difference to outcome.

The Research: This was a follow-up study of 67 young people between the ages of 16 and 26 years who had been treated with exposure-based CBT for anxiety 8 to 13 years previously. The group was composed of 36 males and 31 females, of whom 17 were under 18 and 50 were over 18 years of age at the time of follow up. All of the participants had successfully completed individual or group exposure-based CBT in childhood. The individual treatment focused either on self-control or “what if” situations (e.g., what if they encounter a dog, when they’re afraid of dogs). The groups used peer support and modelling of helpful behaviours and techniques to control their symptoms of anxiety.

At follow up, the researchers made careful diagnoses of anxiety disorders and other mental health problems such as substance abuse, and mood problems. They also asked about present life situation, including current educational and marital status, the number of children they had, and their income level. This was done because early school leaving, early childbearing and job level are good indicators of anxiety and other mental health problems.

The Results: In the original study, the gains made using CBT for anxiety were maintained by one year follow up and at long-term follow up, the positive effects remained. The same results were found for depression and for substance abuse. There was little or no effect of the previous diagnosis of anxiety or other mental health problems on adult educational attainment educational attainment and few of the young adults in follow up had children (3%). Type of CBT made no difference to whether or not anxiety symptoms persisted but did matter for depression and substance abuse. However, individual therapy that taught children how to observe their own feelings and behaviour, engage in self talk to calm their fears, and reward themselves for persisting even if they had symptoms tended to work better for depression and preventing substance abuse.

In this study, successful completion of Cognitive Behavioural Therapy in childhood or early adolescence predicted continued remission or strong reduction of anxiety, depression and substance abuse symptoms in late adolescence or young adulthood. Generally, the participants were likely to have remained free of their anxiety no matter the type of CBT was used. Individual therapy that taught children specific techniques that helped them learn to control their own symptoms tended to work better for depression and preventing substance abuse.

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The preceding is a summary of: Saavedra LM, Silverman WK, Morgan-Lopez AA, Kurtines WM. Cognitive behavioural treatment for childhood anxiety disorders: Long-term effects on anxiety and secondary disorders in young adulthood. Journal of Child Psychology and Psychiatry. 2010; 51(8): 924-934.

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2010-12-23T20:38:13Z

In Short…

Teenagers with conduct problems, no matter their severity, frequently go on to experience serious personal and social adversity. Society as a whole would benefit from prevention and treatment of behaviour problems.

The Issue: Previous research has shown that children and teenagers who have behaviour problems go on to have higher rates of unemployment, divorce, legal problems, and depression and anxiety compared to those without these behaviours. The most severe form, conduct disorder, is found in about 7% of children between 9 and 15 years of age. Most research has focused on children and youth with conduct disorder and there has been little or no research done on those with “mild” symptoms.

The Research: At ages 13 and 15 adolescents were assessed by their teachers for conduct problems (externalizing behaviour problems). Surveys later carried out with these 3652 participants of the British 1946 Birth Cohort study at ages 36, 43, and 53 asked about their life experiences in adulthood. The outcomes the researchers looked at were mental health, family life, employment and educational achievement and a measure of global adversity that applied one point for each problem, such as depression, anxiety or other “nervous trouble”, substance abuse, divorce, family or relationship problems, teen parenting, early school leaving, unemployment, and financial problems.

The Results: Of the original group of 13 and 15 year olds, 61.7% were assessed by their teachers as having no externalizing behaviour problems, while 9.5% had severe externalizing behaviour, and 28.8% had mild externalizing behaviour, with more males than females being identified. By age 53, compared to the group with no externalizing behaviour problems, those with either mild or severe behaviour problems were more likely to have adverse personal, family, legal, and other social problems. Thus, as they aged, people first identified with externalizing behaviour problems at ages 13 and 15, no matter the severity, experienced more adversity, psychiatric problems, family discord and other social problems, all of which have wide personal and societal effects.

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The preceding is a summary of: Colman I, Murray J, Abbott RA, Maughan B, Kuh D, Croudace TJ, Jones PB. Outcomes of conduct problems in adolescence: 40 year follow up of national cohort. BMJ. 2009; 338:a2981.

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2010-12-23T20:31:12Z

In Short…

Children who are exposed to multiple personal and environmental risk factors tend to have persistent mental health and behavioural problems that put them at risk for poor outcomes as they get older.

The Issue: Research has given us solid information about what personal and environmental factors influence child mental health and behaviour problems. Less is known about what predicts whether these conditions will either persist or change over time.

The Research: This was a follow up to the 1999 British Child and Adolescent Mental Health survey in which over 10,000 children and their families participated. This time, a sample of 2573 parents, 1842 teachers, and 1681 children 11 years of age and over were given the Strengths and Difficulties questionnaire in order to get information about the children from multiple sources, including the children themselves. All of them were asked about conduct problems, hyperactivity, problems with classmates and neighbourhood children, caring about and feeling empathy towards others, and stressful life events. The goal was to see what factors predicted if the behaviour and mental health of these children stayed the same, got better, or got worse at 3-year follow up.

The Results: There were multiple factors that predicted poor outcomes at the end of 3- year follow up:

Conduct disorder at the outset of the study
Young age
Physical health problems
Low reading and verbal skills scores
Being male
Having a distressed mother
Living in a step- or single-parent family
Low income
Exposure to stressful life events such as parental separation, family financial problems, parental mental health problems, and loss of friendship.

This study found that behavioural and mental health problems in children exposed to multiple adverse conditions tended to persist through the follow-up period. These chronic problems have serious consequences for the child, his/her family, and society as a whole. Some of the risk factors for them, like poor reading skills, could be alleviated with individual interventions provided in the schools. Others, like low income can be helped through government policies. Family problems can be addressed through the availability of social programs and agencies. Whatever the level of intervention, children’s mental health and behavioural problems need to be addressed to ensure children’s healthy development.

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The preceding is a summary of: Ford T, Collishaw S, Meltzer H, Goodman R. A prospective study of childhood psychopathology: Independent predictors of change over three years. Social Psychiatry and Psychiatry Epidemiology. 2007; 42: 953-961.

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2010-12-23T20:19:02Z

In Short…

Understanding the different paths that delinquent girls take as they mature could help prevent them from becoming chronic offenders. This would help reduce crime and the personal, family, and community costs that come with it.

The Issue: Teenaged girls may not commit as many crimes as boys, but the numbers who do are growing. We need to understand what drives their behaviour if we want to reduce crime rates. Up until recently, there were only two groups of teenaged offenders identified: those who were arrested, tried, jailed and then never appeared before the courts again (desisters), and those who committed more crimes and went through the system again (recidivists). Such groupings do not describe the real situation very well and are not helpful in understanding, treating, and preventing adolescent criminal behaviour.

The Research: This study tracked 499 girls from age 16 to 28, whose records formed part of a study of criminal recidivism ordered by the New York State Legislature in 1995. One of the goals of the study was to look at their criminal “careers” to see if there were separate groups with different risk factors and outcomes as they became adults. Knowing these things could help prevent crime by intervening in the situations that caused them, and help turn around the young women’s lives. The researchers wanted to determine if there were distinct paths followed by the girls that could predict who would be a desister and who would be a recidivist. Their arrest, court, jail and prison records were searched, as were state death records, the latter because girls and women involved in criminal activity are more likely than those in the general population to die young.

The Results: Of the 499 girls, 81% were recidivists, with the remaining 19% classified as desisters. The recidivists each had an average of 6 adult arrests by age 28. The risks for adult criminal activity in this group were being Black, family criminality, and having experienced multiple forms of child maltreatment. Being Hispanic and being at an older age at first juvenile arrest reduced individual rates of recidivism.

Four pathways were found for these girls by the time they reached 28 years of age:

Rare/Non-offending: This group only rarely offended after age 16. Of the 32% making up this group, 82% were arrest free after they turned 21.

Low-chronic offenders: This was the largest group, making up over 53% of the recidivists. They accounted for over 50% of all adult arrests experienced by this sample. They tended to commit crimes in adolescence, with their arrests peaking at age 18, by which time about 19% have been arrested. The rate then started to slowly decline to less than 10% by age 28.

Low-rising offenders: These young women made up about 9% of the sample. They tended to experience steadily increasing numbers of arrests starting with an arrest rate of about 19% at age 16, that rose to 57% by age 28. They accounted for 24% of all the arrests in the group of 499.

High-chronic offenders: They had the highest arrest rates overall, peaking at 40 to 60% of the group members being arrested from age 16 to 21, and then slowly declining by age 28. While comprising only just over 5% of the entire sample, they accounted for 21% of all arrests. This group was arrested at a younger age than girls in the rare/nonoffending and low chronic groups. They were most likely to have significant mental health problems identified when they entered the system and to have poor reading and math skills, and to have experienced both sexual and physical abuse, and to have been in foster care compared to the low chronic and rare/nonoffending groups.

Girls in the low-rising and high-chronic groups comprised only 14% of the 499 girls followed in this study, but they were responsible for 45% of adult arrests in this group.

This study showed that understanding the different trajectories of delinquent adolescent girls and the risk factors associated with their criminal “careers” offers opportunities to interrupt these paths. Adverse family situations and personal experiences of abuse predicted arrests that occurred into adulthood. Preventing these events and circumstances could reduce the personal and societal costs associated with them.

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The preceding is a summary of: Colman RA, Kim DH, Mitchell-Herzfeld S, Shady TA. Delinquent girls grown up: Young adult offending patterns and their relation to early legal, individual, and family risk. Journal of Youth and Adolescence. 2009; 38: 355-366.

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2010-03-15T17:36:08Z

In short…

Most interventions for substance abuse target individuals who are already abusing. But there are many other approaches that are effective in preventing, stopping, reducing, or lessening harm from substance use and abuse. These include:

Policies to reduce the availability of substances like tobacco and alcohol and prevent serious outcomes like death from drunk driving, personal injury from alcohol intoxication, or disease resulting from smoking;

Interventions to ensure children are raised in an emotionally healthy environment;

Interventions given when a young person has just begun to use substances and that are designed to help them alter their habits to prevent later, serious substance abuse;

Treatment for anxiety or depression to reduce or eliminate substance abuse in teens with those conditions; and

Needle exchange programs to help reduce the spread of disease among those who are already addicted.

Whatever the intervention, it should be based on good evidence that it works in real life situations.

The Issue: Adolescent substance abuse is a widespread problem, creating major social and personal consequences for young people, their families, and their communities. While most interventions are targeted to individual substance abusers, some public policies, like public smoking bans or drinking age limits, can work to reduce the harm that can result from alcohol misuse, such as deaths from drunk driving or cardiovascular or lung disease from cigarette smoke.

The Research: The authors of these systematic reviews looked at programs designed to prevent, stop, or reduce adolescent substance abuse and the harm associated with it. These included:

interventions that use laws and policies to restrict access to substances;
early childhood interventions (including prenatal) to ensure healthy development and reduce the social and family risk factors that can lead to adolescent substance abuse;
early screening and brief treatment programs that try to change behaviours and reduce the likelihood of occasional use turning into a substance abuse problem; and
treatment of mental health problems that exist along with established substance abuse using cognitive behavioural therapy (CBT), family therapy, or 12-step programs.

They included interventions that were both universal (given to all members of a population) and targeted (given only to those at risk). The review concentrated on interventions for which there was evidence of effectiveness, that is, programs that work in the “real world”, as opposed to programs where evidence was limited to experimental conditions.

The Results: Results of the systematic reviews showed that the following interventions were effective in preventing or stopping adolescent substance abuse or reducing the harms associated with it.

Regulatory intervention

There is evidence for the effectiveness of the enforcement of laws that limit access by adolescents to alcohol. Interventions included raising age limits and ensuring compliance with minimum age requirements for purchasing alcohol or tobacco products.

Developmental prevention

There is evidence of efficacy in using home visitation or other social strategies to improve conditions that promote healthy child development and adolescent development.

Early screening and brief treatment

There is evidence for the efficacy of brief motivational interventions to change substance use behaviours, that is, helping young users to stop using substances before they experience serious harm. For instance, teens could be helped to recognize how substance use will interfere with their goals or relationships with family and friends.

Treatment

There is evidence for the effectiveness of treating psychiatric disorders like depression or anxiety to reduce or eliminate substance abuse.

Harm reduction

There is evidence that needle exchange programs for reducing the risk of contracting HIV or hepatitis B are effective in reducing harm associated with injectable drugs. Other examples include random breath testing and graduated licence programs, which have been shown to be effective in reducing drunk driving.

The authors conclude that it is necessary to use a combination of these types of interventions to significantly reduce the numbers of adolescents involved in substance abuse.

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The preceding is a summary of: Toumbourou JW, Stockwell T, Neighbors C, Marlatt GA, Sturge J, Rehm J. Interventions to reduce harm associated with adolescent substance use. Lancet 2007, 369: 1391-1401.

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2010-03-15T15:44:34Z

In Short…

There is evidence that some forms of psychotherapy, or talk therapy, works to relieve moderate to severe symptoms of depression in 12- to 18-year-olds. Cognitive behavioural therapy and interpersonal therapy were found to have the best outcomes but not past six months. We do not know if CBT/interpersonal psychotherapy can prevent recurrence of depression

The Issue: If left untreated, depression in children and adolescents can have lifelong personal, school, and work life consequences. Treatment is crucial to prevent these negative effects. Although there is a lot of media attention focused on drug treatment of depression in youngsters, there are other therapies available. Psychotherapy, or “talk therapy” has been used for decades, but there has been little research comparing it to either no treatment or to placebos.

The Research: This study looked at whether or not psychotherapy successfully treated depression in 6- to 18-year-olds. Psychotherapy in this review means therapies like Cognitive Behavioural Therapy (CBT) (or either behavioural therapy or cognitive therapy), interpersonal therapy, supportive therapy, problem-solving therapy, or psychodynamic therapy. The goal of any of the therapies had to be reduction in symptoms of depression that meant the child or adolescent no longer met criteria for the condition. The authors also looked at adverse effects and the economic costs of the therapy.

The Results: 1744 participants in 35 randomized controlled trials (RCTs). Twenty-five studies looked at CBT, 2 looked at cognitive therapy; three looked at behavior therapy; two were studies of interpersonal therapy; and one each looked at problem solving therapy, psychodynamic therapy, or supportive therapy. Control groups consisted of children and adolescents on waiting lists for treatment, those engaged in therapies other than those being researched and “attention-placebo”, that is, treatments that are not known to have positive effects on depression (e.g., art therapy, psychodrama, health education) or no treatment at all.The review found that CBT and interpersonal therapy are effective in alleviating symptoms of depression in 12- to 18-year-olds, and in adolescents with moderate to severe depression but not mild to moderate depression. Patients receiving psychotherapy improved more than those on waiting lists or those receiving art therapy or health education for at least six months after treatment. None of the studies reported on adverse effects or cost-effectiveness.

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The preceding is a summary of: Watanabe N, Hunot V, Omori IM, Churchill R, Furukawa TA. Psychotherapy for depression among children and adolescents: a systematic review. Acta Psychiatrica Scandinavica. 2007; 116: 84-95.