Table Of ContentTreatment Strategies
in Child and
Adolescent Psychiatry
Treatment Strategies
in Child and
Adolescent Psychiatry
Edited by
/ovan G. Simeon
University of Ottawa
Ottawa, Ontario, Canada
and
H. Bruce Ferguson
Royal Ottawa Hospital
Ottawa, Ontario, Canada
With a foreword by
Daniel Offord
Springer Science+Business Media, LLC
Library of Congress Catalog1ng-tn-Publ1 cation Data
Treatment strategies In child and adolescent psychiatry / edited by
Jovan G. Simeon and H. Bruce Ferguson ; with a foreword by Daniel
Offord.
p. en.
Includes bibliographical references.
Includes index.
ISBN 978-1-4899-2601-2
1. Child psychotherapy. 2. Adolescent psychotherapy. I. Simeon.
Jovan G. II. Ferguson. H. Bruce.
tDNLM: 1. Mental Disorders—1n adolescence. 2. Mental Dlsorders-
-1n Infancy & childhood. 3. Mental Disorders—therapy. HS 350
T7845]
RJ504.T74 1990
618.92'89—dc20
DNLM/DLC
for Library of Congress 90-7429
CIP
ISBN 978-1-4899-2601-2 ISBN 978-1-4899-2599-2 (eBook)
DOI 10.1007/978-1-4899-2599-2
© 1990 Springer Science+Business Media New York
Originally published by Plenum Press, New York in 1990
Softcover reprint of the hardcover 1st edition 1990
All rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, microfilming,
recording, or otherwise, without written permission from the Publisher
Contributors
Magda Campbell Department of Psychiatry, New York University Medi-
cal Center, New York, New York 10016
Vincenzo E DiNicola Division of Child and Adolescent Psychiatry, Uni-
versity of Ottawa; and Family Psychiatry Service and Adolescent Day
Care Program, Royal Ottawa Hospital, Ottawa, Ontario KIZ 7K4, Canada
Denis M. Donovan The Children's Center for Developmental Psychiatry,
St. Petersburg, Florida 33710
Michel Dugas Service de Psycho-Pathologie de I'Enfant et de l' Adoles-
cent, Hopital Robert Debre, 75935 Paris CEDEX 19, France.
H. Bruce Ferguson Department of Psychology, Royal Ottawa Hospital,
Ottawa, Ontario K1Z 7K4, Canada
Martine E Flament International Hospital of the University of Paris,
75014 Paris, France
Barry D. Garfinkel Division of Child and Adolescent Psychiatry, Univer-
sity of Minnesota Medical School, Minneapolis, Minnesota 55455
Christophe Gerard Service de Psycho-Pathologie de I'Enfant et de l' Ado-
lescent, Hopital Robert Debre, 75935 Paris CEDEX 19, France.
Vivian Kafantaris Department of Psychiatry, New York University Medi-
cal Center, New York, New York 10016
S.P. Kutcher Department of Psychiatry and Department of Psychology,
Sunny brook Medical Centre, University of Toronto, Toronto, Ontario
M4N 3M5, Canada
Richard P. Malone Department of Psychiatry, New York University Medi-
cal Center, New York, New York 10016
P. Marton Department of Psychiatry and Department of Psychology,
Sunnybrook Medical Centre, University of Toronto, Toronto, Ontario
M4N 3M5 Canada
v
vi Contributors
Deborah McIntyre The Children's Center for Developmental Psychiatry,
St. Petersburg, Florida 33710
Nicholas L. Rock Department of Psychiatry, Louisiana State University
Medical Center, New Orleans, Louisiana 70112
Walid O. She kim Department of Psychiatry and Biobehavioral Sciences,
UCLA Neuropsychiatric Institute and Hospital, Los Angeles, California
90024
/ovan G. Simeon Department of Psychiatry, University of Ottawa, Ot-
tawa, Ontario KIZ 7K4, Canada
Kai Tolstrup University Clinic of Child Psychiatry, Rigshospitalet Uni-
versity Hospital, Copenhagen, Denmark 2100,0
Luis Vera Robert Debre Hospital, 75019 Paris, France
Foreword
It is clear that child and adolescent psychiatric disorders impose a heavy burden
of suffering. Recent large-scale community epidemiological studies suggest
that as many as 20% of children and adolescents in the general population may
have clinically important mental disorders. These disorders are accompanied
by associated impairments in various domains of the child's life, resulting in
lowered life quality for the child and his or her family. In addition, for some
conditions, the onset of the disorder in childhood heralds a lifetime of serious
psychosocial disturbance for a significant subgroup of affected children. For
instance, about 40% of children seen in clinic settings with conduct disorder in
late childhood and early adolescence will have serious psychiatric disorders in
adult life. Finally, the heavy burden of suffering of these conditions is indicated
by the large amounts of both human and financial resources devoted to their
assessment and treatment.
There is a pressing need in the field for effective treatments (that is, those
that have been shown to do more good than harm) that will result in a significant
reduction in the burden of suffering resulting from these disorders. Further,
these effective interventions must be readily available and acceptable to clini
cians in the settings in which children with mental disorders (and their families)
seek care.
This book addresses an important need in the treatment field. It provides a
concise description of the treatments currently in use for child and adolescent
psychiatric disorders and, more important, presents a critical appraisal of their
effectiveness.
The book has a number of laudable strengths. First, it furnishes excellent
coverage of the wide diversity of conditions that constitute child and adolescent
mental disorders. Second, it makes it clear that advances in treatment for these
conditions are dependent to an important extent on progress in other areas of
investigation, such as research design, classification, measurement, and etiol
ogy. Third, it presents a balanced view of the different treatment modalities
from psychopharmacology to individual and family therapy and, further, cov
ers succinctly the advantages and disadvantages of various combinations of
treatments. Last, the book continually points out the limitations in our knowl
edge in the treatment domain and suggests the next steps that are needed to
move the field forward.
vii
viii Foreword
After reading the manuscript I was left with a couple of strong impres
sions. There have been a number of important recent advances in the treatment
of child and adolescent mental disorders, and this book provides the means for
clinicians to be brought up to date on this progress in such a way that they can
use the knowledge immediately and directly for the benefit of their patients. In
addition, the rigorous evaluation of commonly used and innovative treatments
is of prime importance to the child mental health field. This conclusion is
supported by the recently released report by the Institute of Medicine entitled
Research on Children and Adolescents with Mental Disorders and Developmen
tal Disorders: Mobilizing a National Initiative.
Drs. Simeon and Ferguson and their colleagues are to be congratulated on
bringing together in one book a summary of existing treatments for child and
adolescent psychiatric disorders, an evaluation of their effectiveness, coverage
of the limitations of knowledge in this domain, and suggestions for future
research. This has resulted in an important contribution, which will be useful
to clinicians, teachers, and researchers concerned with children and adoles
cents with mental disorders.
Daniel R. Offord, M.D.
Preface
LIFE is short, and the art long; the occasion fleeting; experi
ence fallacious, and judgement difficult. The physician must
not only be prepared to do what is right himself, but also to
make the patient, the attendants and externals co-operate.
Hippocrates
Of all branches of medicine, Hippocrates' famous aphorism seems to apply
most appropriately to child psychiatry. Unlike other medical fields, therapists
who work with children and adolescents must take into account complex inter
actions involving the genetic, physical, and psychological aspects of the pa
tient, the family and social environment, as well as the child's academic and
developmental tasks. Thus, when treating children, therapists need to also get
involved with their families, social and school environments, and various
institutions.
Although child psychiatry is a young science, research has produced rapid
advances in theoretical and empirical knowledge. These developments have led
to further specialization such as infant, child, and adolescent psychiatry. A
variety of approaches have evolved in relation to both diagnosis and therapy,
and a number of different "schools" have emerged in the areas of psycho
therapy, behavioral therapy, family therapy, and group therapy. This has pro
duced some interesting situations in child psychiatry. For example, children
with identical problems may receive different diagnoses as well as very differ
ent therapies, depending on who treats them and where.
Not only are there marked differences in the psychiatric management of
children and adolescents from country to country, but therapists often seem
either unaware of or uninterested in the methods of others. Certain differences
in management may be easily understood, since developing countries do not
have the same priorities or financial and professional resources as developed
countries. In countries where children are exposed to epidemics, malnutrition,
starvation, overpopUlation, and war, child psychiatry services are obviously a
very low priority. It is more difficult, however, to accept the marked differences
in therapies offered children with similar behavioral problems among devel
oped countries or among different professionals within the same country or
center. These differences depend on multiple factors, such as training, theoreti-
ix
x Preface
cal orientation, personal style, and experience, as well as cultural background
and social context. The training of child psychiatrists is a very long process.
Compared with most other medical disciplines, the life of the practicing child
psychiatry therapist is short. Further they may practice in the isolation of their
offices, trying to help children without ever knowing for certaiI) if their work is
effective. Since many biological, psychological, and social factors are in
volved, therapy may be done poorly. Treatment-resistant children are often
referred from one therapist to another. Conversely, many children are treated by
the same therapist, or by the same method, for long periods of time with no
attempt to modify the treatment strategy or to quantify any clinical changes.
Therefore, it is important that child therapists become more open to differ
ent approaches to practice and learn to evaluate treatment effects on an on
going basis.
Discussions on effectiveness and cost-benefit analysis of psychiatric inter
ventions and child mental health programs often result in conflicting viewpoints
as to whether the "best approach" is prevention, community-based treatment
programs, or clinic-based interventions. Obviously, all of these approaches are
important. The real challenge, however, lies in how to integrate them, so that
they complement each other rather than compete for resources. Most of the
advances in child psychiatry have benefited the individual patient, while pro
gress on a broader level depends on prevention, which in turn depends on a
range of social and political factors. The focus of child psychiatry training and
responsibility remains the treatment of individual children and families. While
there is now widespread interest in more global prevention programs, the
present state of our knowledge is not adequate to implement such programs
effectively. While child psychiatrists have an important role to play in these
developments, at this time we believe it would be inappropriate for the disci
pline to shift its main focus away from treatment.
Prior to any therapeutic intervention, it is essential to undertake a compre
hensive diagnostic evaluation. Any therapy where the diagnostic process is
viewed as unnecessary, or as "labeling possibly harmful to the child," is
doomed to failure. Diagnostic evaluation represents much more than the as
signment of a classification. It is the process by which all the child's deficits,
symptoms, and disorders are described and assessed, and other disorders are
ruled out. The diagnostic process lays the foundation for the treatment, and the
evaluation of its efficacy. Therapists must also learn to use recently developed
rating scales and diagnostic interview techniques. In most cases, it is important
to obtain careful information from several sources since the child's problems
may manifest in several contexts. Improvements in therapeutic interventions on
a more global scale depend on the evolution of valid diagnostic entities for
which effective treatments can be developed. For this reason, the broad accep
tance of clearly operationalized diagnostic criteria (e.g., DSM-III-R, lCD-tO)
