When children and teens present with behaviour and emotional problems the lure of a quick fix is
understandable and drugs present a ready-made solution. Therapists are often hesitant to talk about
medication and defer to medical professionals. In this paper DUNCAN, SPARKS, MURPHY and MILLER
highlight the explosion in the use of psychotropic medications for children and teens. This trend flies in the
face of the American Psychological Association’s recommendation of the use of psychosocial interventions
as the first intervention of choice with children and teens. The reliability and validity of psychiatric diagnoses is
questioned, in particular against a background of fluctuations in child development and social adaptations,
and a compelling critique is provided of the current research findings on the effectiveness of psychotropic
medications including antidepressants and ADHD medications. Therapists are urged to shed their timidity
and discuss openly the risks and benefits of medication with the knowledge that there is empirical support
for psychosocial interventions as a first line approach. Recommendations are offered to engage clients as
central partners in developing solutions—medical or non-medical—that fit each child and each situation.
This document summarizes a study that analyzed written responses from clients who had completed couple therapy. The study explored how clients experienced therapy through their responses to open-ended questions about therapy at a 6-month follow-up. The responses were analyzed thematically and compared between clients whose therapists did or did not use systematic feedback. Most clients found personable, active therapists who maintained neutrality to be helpful. Some expressed dissatisfaction with lack of structure or challenge from therapists. Lack of flexibility in scheduling was also problematic. Clients who used feedback generally found it very helpful.
This study examined the psychometric properties of Dutch translations of the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). Data was collected from 126 clients who completed a total of 1005 ORS and SRS assessments over multiple therapy sessions. Results found the Dutch translations had good internal consistency and test-retest reliability, similar to previous American studies. Scores on the ORS and SRS also converged with therapist satisfaction ratings. Additionally, SRS scores predicted later ORS scores, supporting the validity of both measures. Overall, the study provides preliminary support for using the Dutch ORS and SRS in cross-cultural settings.
Duncan & Sparks Ch 5 of Cooper & DrydenBarry Duncan
THIS CHAPTER DISCUSSES
•
Systematic feedback and the Partners for Change Outcome Management System (PCOMS)
•
PCOMS as a way to truly privilege clients, include them as full partners in decision-making and operationalize social justice and a pluralistic approach
The Partners for Change Outcome Management System: Duncan & Reese, 2015Barry Duncan
Despite overall psychotherapy efficacy (Lambert, 2013), many clients do not benefit (Reese, Duncan, Bohanske, Owen, & Minami, 2014), dropouts are a problem (Swift & Greenberg, 2012), and therapists vary significantly in success rates (Baldwin & Imel, 2013), are poor judges of negative outcomes (Chapman et al., 2012), and grossly overestimate their effectiveness (Walfish, McAlister, O'Donnell, & Lambert, 2012). Systematic client feedback offers one solution (Duncan, 2014). Several feedback systems have emerged (Castonguay, Barkham, Lutz, & McAleavey, 2013), but only two have randomized clinical trial support and are included in the Substance Abuse and Mental Health Administration’s National Registry of Evidence based Programs and Practices: The Outcome Questionnaire-45.2 System (Lambert, 2010) and the Partners for Change Outcome Management System (PCOMS; Duncan, 2012). This article presents the current status of the Partners for Change Outcome Management System, the psychometrics of the PCOMS measures, its empirical support, and its clinical and training applications. Future directions and implications of PCOMS research, training, and practice are detailed. Finally, we propose that systematic feedback offers a way, via large scale data collection, to re-prioritize what matters to psychotherapy outcome, reclaim our empirically validated core values and identity, and change the conversation from a medical model dominated discourse to a more scientific, relational perspective.
The first quasiexperiemental study of the ORS/SRS in a telephonic EAP company. Doubled outcomes and improved retension. Set the stage for the RCTs that followed
This document summarizes a study on implementing a systematic client feedback protocol into a marriage and family therapy training program to improve trainee competence and accountability. The study describes how the program integrated continuous client feedback into coursework, clinical training, and supervision using an Outcome Management system. Research shows that incorporating client feedback improves client outcomes and therapist effectiveness. The program believes this approach will train therapists to be more accountable to clients and enhance services provided at their family therapy clinic.
This study examined the effects of using client feedback, known as the Partners for Change Outcome Management System (PCOMS), with couples undergoing psychotherapy. 46 heterosexual couples were randomly assigned to either a treatment as usual (TAU) condition or to a feedback condition where therapists received feedback on client progress and the therapeutic alliance at each session via the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). It was hypothesized that couples receiving feedback would have better outcomes, improve more quickly, and be more likely to meet the criteria for clinically significant change. Results from this study aimed to replicate previous research finding client feedback beneficial for couples therapy.
This document summarizes a study that analyzed written responses from clients who had completed couple therapy. The study explored how clients experienced therapy through their responses to open-ended questions about therapy at a 6-month follow-up. The responses were analyzed thematically and compared between clients whose therapists did or did not use systematic feedback. Most clients found personable, active therapists who maintained neutrality to be helpful. Some expressed dissatisfaction with lack of structure or challenge from therapists. Lack of flexibility in scheduling was also problematic. Clients who used feedback generally found it very helpful.
This study examined the psychometric properties of Dutch translations of the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). Data was collected from 126 clients who completed a total of 1005 ORS and SRS assessments over multiple therapy sessions. Results found the Dutch translations had good internal consistency and test-retest reliability, similar to previous American studies. Scores on the ORS and SRS also converged with therapist satisfaction ratings. Additionally, SRS scores predicted later ORS scores, supporting the validity of both measures. Overall, the study provides preliminary support for using the Dutch ORS and SRS in cross-cultural settings.
Duncan & Sparks Ch 5 of Cooper & DrydenBarry Duncan
THIS CHAPTER DISCUSSES
•
Systematic feedback and the Partners for Change Outcome Management System (PCOMS)
•
PCOMS as a way to truly privilege clients, include them as full partners in decision-making and operationalize social justice and a pluralistic approach
The Partners for Change Outcome Management System: Duncan & Reese, 2015Barry Duncan
Despite overall psychotherapy efficacy (Lambert, 2013), many clients do not benefit (Reese, Duncan, Bohanske, Owen, & Minami, 2014), dropouts are a problem (Swift & Greenberg, 2012), and therapists vary significantly in success rates (Baldwin & Imel, 2013), are poor judges of negative outcomes (Chapman et al., 2012), and grossly overestimate their effectiveness (Walfish, McAlister, O'Donnell, & Lambert, 2012). Systematic client feedback offers one solution (Duncan, 2014). Several feedback systems have emerged (Castonguay, Barkham, Lutz, & McAleavey, 2013), but only two have randomized clinical trial support and are included in the Substance Abuse and Mental Health Administration’s National Registry of Evidence based Programs and Practices: The Outcome Questionnaire-45.2 System (Lambert, 2010) and the Partners for Change Outcome Management System (PCOMS; Duncan, 2012). This article presents the current status of the Partners for Change Outcome Management System, the psychometrics of the PCOMS measures, its empirical support, and its clinical and training applications. Future directions and implications of PCOMS research, training, and practice are detailed. Finally, we propose that systematic feedback offers a way, via large scale data collection, to re-prioritize what matters to psychotherapy outcome, reclaim our empirically validated core values and identity, and change the conversation from a medical model dominated discourse to a more scientific, relational perspective.
The first quasiexperiemental study of the ORS/SRS in a telephonic EAP company. Doubled outcomes and improved retension. Set the stage for the RCTs that followed
This document summarizes a study on implementing a systematic client feedback protocol into a marriage and family therapy training program to improve trainee competence and accountability. The study describes how the program integrated continuous client feedback into coursework, clinical training, and supervision using an Outcome Management system. Research shows that incorporating client feedback improves client outcomes and therapist effectiveness. The program believes this approach will train therapists to be more accountable to clients and enhance services provided at their family therapy clinic.
This study examined the effects of using client feedback, known as the Partners for Change Outcome Management System (PCOMS), with couples undergoing psychotherapy. 46 heterosexual couples were randomly assigned to either a treatment as usual (TAU) condition or to a feedback condition where therapists received feedback on client progress and the therapeutic alliance at each session via the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). It was hypothesized that couples receiving feedback would have better outcomes, improve more quickly, and be more likely to meet the criteria for clinically significant change. Results from this study aimed to replicate previous research finding client feedback beneficial for couples therapy.
PCOMS works with kids too!
Cooper, M., Stewart, D., Sparks, J., Bunting, L. (2013). School-based counseling using systematic feedback: A cohort study evaluating outcomes and predictors of change. Psychotherapy Research, 23, 474-488.
The Norway Couple Project: Lessons LearnedBarry Duncan
The document discusses lessons learned from studies on using client feedback to improve outcomes in couple therapy. A large randomized clinical trial in Norway found that routinely collecting and discussing client feedback on progress and the therapeutic alliance using brief measures led to better outcomes compared to treatment as usual. Specifically, couples receiving feedback showed greater improvement in their relationships and were less likely to deteriorate over time. The findings suggest incorporating systematic client feedback into routine practice can help therapists improve outcomes for couples across different therapy approaches.
Article by Dr Mary Haynes about her agency's journey to a recovery orientation via CDOI and PCOMS published in the SAMHSA Recovery to Practice Newsletter.
PCOMS as an Alternative to Psychiatric Diagnosis (Duncan, Sparks, & Timimi, 2...Barry Duncan
Part of an incredible series about diagnostic alternatives by the Journal of Humanistic Psychology edited by Sarah Kamens, Brent Dean Robbins, & Elizabeth Flanagan
The original validation of the CORS for kids and the ORS for adolescents. Allowed the benefits of client based outcome feedback to expand to youth and family and paved the way to the current RCT with kids in the schools.
PCOMS: A Viable Quality Improvement Strategy for Public Behavioral HealthBarry Duncan
This is the latest from the research team of the Heart and Soul of Change Project, published in the Journal of Consulting and Clinical Psychology. This study demonstrated that PCOMS is not only a viable quality improvement strategy but also that services to the poor and disenfranchised provided in a public behavioral setting, contrary to earlier research, can be as effective as those delivered in randomized clinical trials.
Slone, N. C., Reese, R. J., Mathews-Duvall, S., & Kodet, J. (2015). Evaluating the Efficacy of client feedback in group psychotherapy. Group Dynamics: Theory, Research, and Practice, 19, 122-136. doi:10.1037/gdn0000026
Feedback condition achieved nearly four times the amount of clients reaching reliable or clinically significant change. Nearly a 50% less separation/divorce at rate at follow up.
This is the validation study of the Group Session Rating Scale (GSRS). In a nutshell, this study found more than acceptable reliability and validity with not only an alliance measure but also with group climate and cohesiveness scales. The GSRS was also predictive of last session outcomes. An RCT comparing PCOMS to TAU in group therapy has been submitted.
This 2 page article, which appeared in The Iowa Psychologist, provides an ultra brief summary of what makes therapy effective (the common factors) and how we can get better at what do: namely, add PCOMS, harvest client existing resources, and rely on that neglected old friend, the therapeutic alliance.
Although many of you may not be interested in the psychometric details of the ORS and SRS, it does bear importantly on whether there are seen as credible. Jeff Reese and I (Duncan & Reese, 2013) recently exchanged views with Halstead, Youn, and Armijo (2013), debating when a measure is too brief and when it is too long. Here is our paper. First regarding when a measure is too brief: There is no doubt that 45 items, 30 items, or even 19 items is psychometrically better than 4 items, and that the increased reliability and validity of longer measures likely result in better detection, prediction, and ultimate measurement of outcome. But how much better is the really the question. Are these differences clinically meaningful and do they offset the low compliance rates and resulting data integrity issues from missing data? These are the questions that require empirical investigation to determine how brief is too brief, although from my experience, the verdict has already been rendered. But when is a measure too long? The answer is simple: When clinicians won’t use it.
The article discusses the development and research supporting the Partners for Change Outcome Management System (PCOMS). PCOMS uses two brief measures - the Outcome Rating Scale (ORS) and Session Rating Scale (SRS) - to collect feedback from clients at each session on their progress and the therapeutic alliance. The ORS and SRS were developed to be brief and feasible for routine use. Research shows providing therapists feedback based on these measures improves client outcomes compared to treatment as usual. The article outlines how PCOMS was developed and refined, presents supporting research on the measures' psychometrics and clinical usefulness, and discusses examples of implementing PCOMS in behavioral health settings.
This article discusses applying research on psychotherapy outcomes, which has shown that common factors like the therapeutic relationship are more influential than theoretical approach or techniques. The article proposes intentionally using the client's frame of reference to enhance common factors and collaboration. It suggests emphasizing the client's perceptions of their relationship with the therapist and understanding of their issues over theoretical perspectives. A client-directed process is outlined that de-emphasizes theory and maximizes common factors and the client's involvement.
This article, "Casting a Wider Net in Behavioral Health Screening in Primary Care" found that the ORS identified more clients for behavioral healthcare consultation than the PHQ-9. A first step toward the upcoming RCT with PCOMS in an integrated setting.
Our recent article about therapist effects in couple therapy. So what distinguished one therapist from another? Demographics didn’t matter but 2 other things did. First, that tried and true but neglected old friend, the alliance accounted for 50% of the differences among therapists. Those who formed better alliances across clients got better outcomes. And therapist specific experience with couples accounted for 25% of the differences. So, experienced therapists can take some solace that getting older does have its advantages—as long as it is specific to task at hand.
This document discusses what makes an effective or "master" therapist. It begins by arguing that psychotherapy is a relational endeavor dependent on the client and therapist's connection, not just evidence-based treatments. The most important thing a therapist can do is identify clients who are not benefiting and change course.
It then discusses four questions about what makes an effective therapist. In response to the first question about what they do, the author emphasizes routinely measuring outcomes and the therapeutic alliance to ensure client perspectives are central. For the second question about who they are, the author believes their belief in clients and psychotherapy's ability to create change is important.
In response to the third question about what defines an extraordinary therapist, the author argues
Overview of PCOMS and couple and family therapy.
Duncan, B., & Sparks, J. (2017). The Partners for Change Outcome Management System. In J. L. Lebow, A. L. Chambers, & D. C. Breunlin (Eds.), Encyclopedia of Couple and Family Therapy (pp. 1-10). New York: Springer.
This document summarizes a debate between family therapists about discussing psychotropic medication with clients. It advocates that family therapists become informed about medication research so they can discuss risks and benefits with families, rather than deferring solely to medical professionals. Critics argue this position moves beyond family therapists' competence. Supporters counter that discussing treatment options is within their expertise, and that research shows psychosocial interventions are often safer and more effective than medication for children and adolescents. The debate centers around family therapists' role in informed consent for psychotropic medication.
This chapter is from Drugging Our Children (Olfman & Robbins, 2012), a great book about the epidemic prescription of antipsychotics to children, especially poor children and children of color.
PCOMS works with kids too!
Cooper, M., Stewart, D., Sparks, J., Bunting, L. (2013). School-based counseling using systematic feedback: A cohort study evaluating outcomes and predictors of change. Psychotherapy Research, 23, 474-488.
The Norway Couple Project: Lessons LearnedBarry Duncan
The document discusses lessons learned from studies on using client feedback to improve outcomes in couple therapy. A large randomized clinical trial in Norway found that routinely collecting and discussing client feedback on progress and the therapeutic alliance using brief measures led to better outcomes compared to treatment as usual. Specifically, couples receiving feedback showed greater improvement in their relationships and were less likely to deteriorate over time. The findings suggest incorporating systematic client feedback into routine practice can help therapists improve outcomes for couples across different therapy approaches.
Article by Dr Mary Haynes about her agency's journey to a recovery orientation via CDOI and PCOMS published in the SAMHSA Recovery to Practice Newsletter.
PCOMS as an Alternative to Psychiatric Diagnosis (Duncan, Sparks, & Timimi, 2...Barry Duncan
Part of an incredible series about diagnostic alternatives by the Journal of Humanistic Psychology edited by Sarah Kamens, Brent Dean Robbins, & Elizabeth Flanagan
The original validation of the CORS for kids and the ORS for adolescents. Allowed the benefits of client based outcome feedback to expand to youth and family and paved the way to the current RCT with kids in the schools.
PCOMS: A Viable Quality Improvement Strategy for Public Behavioral HealthBarry Duncan
This is the latest from the research team of the Heart and Soul of Change Project, published in the Journal of Consulting and Clinical Psychology. This study demonstrated that PCOMS is not only a viable quality improvement strategy but also that services to the poor and disenfranchised provided in a public behavioral setting, contrary to earlier research, can be as effective as those delivered in randomized clinical trials.
Slone, N. C., Reese, R. J., Mathews-Duvall, S., & Kodet, J. (2015). Evaluating the Efficacy of client feedback in group psychotherapy. Group Dynamics: Theory, Research, and Practice, 19, 122-136. doi:10.1037/gdn0000026
Feedback condition achieved nearly four times the amount of clients reaching reliable or clinically significant change. Nearly a 50% less separation/divorce at rate at follow up.
This is the validation study of the Group Session Rating Scale (GSRS). In a nutshell, this study found more than acceptable reliability and validity with not only an alliance measure but also with group climate and cohesiveness scales. The GSRS was also predictive of last session outcomes. An RCT comparing PCOMS to TAU in group therapy has been submitted.
This 2 page article, which appeared in The Iowa Psychologist, provides an ultra brief summary of what makes therapy effective (the common factors) and how we can get better at what do: namely, add PCOMS, harvest client existing resources, and rely on that neglected old friend, the therapeutic alliance.
Although many of you may not be interested in the psychometric details of the ORS and SRS, it does bear importantly on whether there are seen as credible. Jeff Reese and I (Duncan & Reese, 2013) recently exchanged views with Halstead, Youn, and Armijo (2013), debating when a measure is too brief and when it is too long. Here is our paper. First regarding when a measure is too brief: There is no doubt that 45 items, 30 items, or even 19 items is psychometrically better than 4 items, and that the increased reliability and validity of longer measures likely result in better detection, prediction, and ultimate measurement of outcome. But how much better is the really the question. Are these differences clinically meaningful and do they offset the low compliance rates and resulting data integrity issues from missing data? These are the questions that require empirical investigation to determine how brief is too brief, although from my experience, the verdict has already been rendered. But when is a measure too long? The answer is simple: When clinicians won’t use it.
The article discusses the development and research supporting the Partners for Change Outcome Management System (PCOMS). PCOMS uses two brief measures - the Outcome Rating Scale (ORS) and Session Rating Scale (SRS) - to collect feedback from clients at each session on their progress and the therapeutic alliance. The ORS and SRS were developed to be brief and feasible for routine use. Research shows providing therapists feedback based on these measures improves client outcomes compared to treatment as usual. The article outlines how PCOMS was developed and refined, presents supporting research on the measures' psychometrics and clinical usefulness, and discusses examples of implementing PCOMS in behavioral health settings.
This article discusses applying research on psychotherapy outcomes, which has shown that common factors like the therapeutic relationship are more influential than theoretical approach or techniques. The article proposes intentionally using the client's frame of reference to enhance common factors and collaboration. It suggests emphasizing the client's perceptions of their relationship with the therapist and understanding of their issues over theoretical perspectives. A client-directed process is outlined that de-emphasizes theory and maximizes common factors and the client's involvement.
This article, "Casting a Wider Net in Behavioral Health Screening in Primary Care" found that the ORS identified more clients for behavioral healthcare consultation than the PHQ-9. A first step toward the upcoming RCT with PCOMS in an integrated setting.
Our recent article about therapist effects in couple therapy. So what distinguished one therapist from another? Demographics didn’t matter but 2 other things did. First, that tried and true but neglected old friend, the alliance accounted for 50% of the differences among therapists. Those who formed better alliances across clients got better outcomes. And therapist specific experience with couples accounted for 25% of the differences. So, experienced therapists can take some solace that getting older does have its advantages—as long as it is specific to task at hand.
This document discusses what makes an effective or "master" therapist. It begins by arguing that psychotherapy is a relational endeavor dependent on the client and therapist's connection, not just evidence-based treatments. The most important thing a therapist can do is identify clients who are not benefiting and change course.
It then discusses four questions about what makes an effective therapist. In response to the first question about what they do, the author emphasizes routinely measuring outcomes and the therapeutic alliance to ensure client perspectives are central. For the second question about who they are, the author believes their belief in clients and psychotherapy's ability to create change is important.
In response to the third question about what defines an extraordinary therapist, the author argues
Overview of PCOMS and couple and family therapy.
Duncan, B., & Sparks, J. (2017). The Partners for Change Outcome Management System. In J. L. Lebow, A. L. Chambers, & D. C. Breunlin (Eds.), Encyclopedia of Couple and Family Therapy (pp. 1-10). New York: Springer.
This document summarizes a debate between family therapists about discussing psychotropic medication with clients. It advocates that family therapists become informed about medication research so they can discuss risks and benefits with families, rather than deferring solely to medical professionals. Critics argue this position moves beyond family therapists' competence. Supporters counter that discussing treatment options is within their expertise, and that research shows psychosocial interventions are often safer and more effective than medication for children and adolescents. The debate centers around family therapists' role in informed consent for psychotropic medication.
This chapter is from Drugging Our Children (Olfman & Robbins, 2012), a great book about the epidemic prescription of antipsychotics to children, especially poor children and children of color.
Samanthah pleaseTherapy for Pediatric Clients With Mood Disorders.docxinfantkimber
Samanthah please
Therapy for Pediatric Clients With Mood Disorders
Mood disorders can impact every facet of a child’s life, making the most basic activities difficult for clients and their families. This was the case for 13-year-old Kara, who was struggling at home and at school. For more than 8 years, Kara suffered from temper tantrums, impulsiveness, inappropriate behavior, difficulty in judgment, and sleep issues. As a psychiatric mental health nurse practitioner working with pediatric clients, you must be able to assess whether these symptoms are caused by psychological, social, or underlying growth and development issues. You must then be able recommend appropriate therapies.
This week, as you examine antidepressant therapies, you explore the assessment and treatment of pediatric clients with mood disorders. You also consider ethical and legal implications of these therapies.
Photo Credit: GettyLicense_185239711.jpg
Assignment: Assessing and Treating Pediatric Clients With Mood Disorders
When pediatric clients present with mood disorders, the process of assessing, diagnosing, and treating them can be quite complex. Children not only present with different signs and symptoms than adult clients with the same disorders, but they also metabolize medications much differently. As a result, psychiatric mental health nurse practitioners must exercise caution when prescribing psychotropic medications to these clients. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat pediatric clients presenting with mood disorders.
Note: This Assignment is the first of 10 assignments that are based on interactive client case studies. For these assignments, you will be required to make decisions about how to assess and treat clients. Each of your decisions will have a consequence. Some consequences will be insignificant, and others may be life altering. You are not expected to make the “right” decision every time; in fact, some scenarios may not have a “right” decision. You are, however, expected to learn from each decision you make and demonstrate the ability to weigh risks versus benefits to prescribe appropriate treatments for clients.
Learning Objectives
Students will:
Assess client factors and history to develop personalized plans of antidepressant therapy for pediatric clients
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in pediatric clients requiring antidepressant therapy
Evaluate efficacy of treatment plans
Analyze ethical and legal implications related to prescribing antidepressant therapy to pediatric clients
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a lo ...
Global Medical Cures™ | Get it Straight- The Facts about Drugs (STUDENT GUIDE) Global Medical Cures™
Global Medical Cures™ | Get it Straight- The Facts about Drugs (STUDENT GUIDE)
DISCLAIMER-
Global Medical Cures™ does not offer any medical advice, diagnosis, treatment or recommendations. Only your healthcare provider/physician can offer you information and recommendations for you to decide about your healthcare choices.
CHAPTER NINEMedicating ChildrenThis chapter is divided into se.docxDinahShipman862
CHAPTER NINE
Medicating Children
This chapter is divided into seven sections. Section One is an overview that discusses current trends in medicating children, problems the trends cause, and directions for the future. It also discusses developmental issues. Section Two focuses on stimulant medication and the diagnosis of attention deficit hyperactivity disorder (ADHD). Section Three focuses on research on combined interventions and particularly the Multimodal Treatment Study (MTA study) of Children with ADHD. Section Four focuses on children taking mood stabilizers. Section Five focuses on antipsychotics and children. Sections Six and Seven focus on anxiolytics and antidepressants in children, respectively.
SECTION ONE: PERSPECTIVES, DILEMMAS, AND FUTURE PARADIGMS
Learning Objectives
• Understand the problematic increase in psychotropic medications for children despite a dearth of evidence of the effectiveness of these drugs.
• Have a general understanding of the impact of the FDA Modernization Act and the Best Pharmaceuticals Act for Children.
• Be able to state the “developmental unknowns” associated with giving kids psychotropic medications.
Thus far, we have explored the medical model and psychological, cultural, and social perspectives as they relate to psychopharmacology. In this chapter, we demonstrate that using psychotropic medications with children and adolescents raises particular problems and concerns from several perspectives. As discussed in Chapter Three, we frequently see explanations and justifications from the medical model perspective used to reduce childhood disorders to chemical and genetic problems, excluding crucial consideration of environmental traumas, developmental foreclosures, or life stressors.
We explore child and adolescent psychopharmacology primarily from the medical model perspective but complement this approach with information from the other perspectives (psychological, cultural, and social). We set the stage by exploring the current status of the treatment of children and adolescents with mental and emotional disorders. This chapter is structured differently from the others in this book. We begin by discussing the context from the social and cultural perspectives and the problems with prescribing psychotropic medications to children. Then we cover an introduction to stimulants used to treat symptoms of ADHD. Finally, we give the status of their current use since the last edition of the book if that is possible.
THE COMPLEX STATE OF THERAPY
Dr. Frank O'Dell, Professor Emeritus of Counseling in the College of Education and Human Services at Cleveland State University, has argued in all his lectures on counseling children and adolescents that the United States is an “anti-kid” society (Personal Communication, 2001). By that he means fewer and fewer therapists and psychiatrists choose to treat or continue to work with children in counseling. To support his argument, O'Dell points out that resources for childre.
I NEED THIS 013021 BY 5PMPlease no plagiarism and make sur.docxflorriezhamphrey3065
I NEED THIS
01/30/21
BY 5PM
Please no plagiarism and make sure you are able to access all resources on your own before you bid. You need to have scholarly support for any claim of fact or recommendation regarding treatment. Grammar, Writing, and APA Format: I expect you to write professionally, which means APA format, complete sentences, proper paragraphs, and well-organized and well-documented presentation of ideas. Remember to use scholarly research from peer-reviewed articles that is current. Sources such as Wikipedia, Ask.com, PsychCentral, and similar sites are never acceptable.
Each classmate’s post is listed so please respond separately.
Read
your classmates' postings.
Respond
to your classmates' postings.
Respond to all colleagues by discussing the elements of the mini script that you liked, and why. What might you add or have said differently?
1.
Classmate (K. Tri)
Hello, think you for coming in the see us today. I know as a parent this can be hard trying to make the best decision for our children. Based off what you have told me, you want to know what is AHDH and The difference between ADHD? Why do you feel that this maybe the wrong diagnosed for Tonya? Alone with the right treatment plan and medication client should be okay. Medication is a major assets to overcome these type of diagnoses. I want you to know that you are making all the right choices to be proactive with this diagnoses going without having this cared for has short term and long term consequences. Short term it has a big effect on the brain and long term causes struggles with keep relationship. Long term there no cure for ADHD and looking for jump into a state environment. I’m sorry y’all had to come this time and offer gain knowledge. Everyone learn a different ways to discuss what come and stay come go. As you counselor I’m with you every step of the way a strive for my customer satisfaction.
Reference:
Sinacola, R. S., Peters-Strickland, T., & Wyner, J. D. (2020). Basic psychopharmacology for
mental health professionals (3rd ed.). Hoboken, NJ: Pearson.
2.
Classmate (L. Mil)
Mini Script
I hear that this diagnosis is new and it may take some time to get used to this. I understand that the idea of your daughter taking medication is new as well. You stated concern with Tonya taking a stimulant medication. There are options for non-stimulant medication. One medication is called Intuniv. It is a common non-stimulant drug. Some side effects include feeling tired or irritable, nausea, and dizziness/drowsiness (Drugs.com, 2021). If you are interested, we can also discuss stimulant medication such as Adderall, Ritalin, or Concerta. It is important to maintain contact with me. As counseling will provide you (mom) with the tools necessary to handle Tonya’s ADHD. Also, Tonya studies show that counseling will help improve your self-esteem and give you a sense of independence (Sinacola, Peters-Strickland & Wyner, 2020).
Lastly, untreat.
This document discusses the debate around using medications to treat childhood depression and ADHD. It notes that while these conditions need to be treated, there are concerns about overprescribing drugs and not thoroughly testing their effects on children. Critics argue that drugs should only be used along with psychotherapy and that behavioral therapy alone may be preferable. The document provides background on the history and current use of antidepressants and stimulants like Ritalin to treat these conditions in children.
Question 2 Help1. Not all media is created equally, so critical .docxmakdul
Question 2 Help
1. Not all media is created equally, so critical thinking is needed to digest what is presented.
2. In general, media depictions are inaccurate. This may be due to many factors—including but not limited to the following: (a) the media in the U.S.A. falls within the entertainment industry—not education or a government regulated agency, (b) shock value/sensationalism, (c) exaggerating taboo qualities, (d) stereotypes and biases within individuals who work for media corporations, (e) public preferences, and/or (f) the limited time and information sometimes available to the person in charge of the media presentation.
3. Negative representations lead to negative attitudes toward people with behavioral pathology.
4. The media both shapes public opinion and caters to public preferences. If there were no consumers for the product, there would be no sponsors and no media portrayals as they now exist. The students in this class are a part of the public and you make choices as consumers—like do other members of the public—which can encourage or discourage current practices in the media.
5. The type of media venue can greatly impact the degree and direction of the distortions or misinformation (e.g., news, dramas, comedies, biographical movies, social media, internet stories, magazines, documentaries, educational programming such as PBS).
6. Those who are educated would prefer that the focus of the media be redirected away from negative effects of psychopathology. Ideally, the media would use their resources to explore human consequences for psychopathology.
Question 3 Help
In favor of gender dysphoria being in the DSM-5. Differing thoughts on whether insurance should cover sex reassignment surgery (SRS) and hormone replacement—and whether insurance should cover reversals in the case of regret.
We were reminded that the key feature of inclusion in the DSM-5 as a psychiatric diagnosis was the presence of impairment in psychosocial functioning. Thus, looking at this criteria, if a person identified as being Transgender but is not experiencing any clinically significant distress or impairment in social, school, or other important areas of functioning, this individual would not be diagnosed with Gender Dysphoria according to the DSM-5. That being the case, the question then becomes is Gender Dysphoria the best diagnosis for such individuals or can they receive the treatment needed if this diagnosis is removed and what other diagnosis(es) in the DSM-5 would be appropriate for Transgender individuals who do show clinically significant distress or impairment in social, school, or other important areas of functioning if Gender Dysphoria is removed from the DSM?
The controversy extended to the ICD-10, and the instructor introduced another DSM-5 diagnosis for the class’ consideration that could apply to Transgender individuals who are experiencing distress that warrants intervention—not due to being Transgendered but due to homophobic discrimin ...
This document presents two viewpoints on whether schools should screen children and teenagers for signs of mental illness and suicidal tendencies. Viewpoint 1 argues that screening can help identify at-risk youth and improve care, while opponents worry about overdiagnosis. Viewpoint 2 asserts that misdiagnoses are common since sadness is normal for teens, and inaccurate diagnoses can negatively impact teens and increase unnecessary treatment. The reflection considers both perspectives and concludes that focusing on improving care for diagnosed teens, rather than widespread screening, may be best to avoid potential harms of misdiagnosis.
This document discusses abnormal psychology and different therapeutic processes. It begins by defining normal and abnormal psychology and how they relate to cultural values and societal acceptance. Two specific mental disorders are then examined: general anxiety disorder and post-traumatic stress disorder. The document outlines several therapeutic approaches used to treat mental illnesses, including psychodynamic, cognitive-behavioral, exposure, and humanistic therapies. It emphasizes that therapy can help individuals better understand and cope with their disorders to live fulfilled lives.
1) The document discusses treatment options for children diagnosed with ADHD, specifically whether medication should be the first option.
2) While medication can help mask ADHD symptoms, it risks long-term side effects as the brain is still developing.
3) There are alternative treatments that combine therapy, lifestyle changes, and non-stimulant options that may be more effective without side effects.
TranscriptI was surprised to hear all the drugs he did. I hadno .docxturveycharlyn
Transcript
I was surprised to hear all the drugs he did. I hadno idea that he was drinking that much, or that hewas high every day in school.
I'd get up some mornings and I'd be like, man,today's gonna suck. If I had some prescriptionpills left over from the weekend, I'd pop a coupleof those.
This is a disorder of young people. Very littleaddiction starts after the age of 30. It almostalways starts between the ages of 18 and 25.
How can we comprehend the concept of a personthat wants to stop doing something and theycannot, despite catastrophic consequences?We're not speaking of little consequences. Theseare catastrophic. And yet they cannot controltheir behavior.
There've been so many things that I haven'taccomplished because-- because of the problem, Ithink.
My drinking's killing me. I desperately need help.
The right medication with the right therapy reallycan give an individual a leg up in recovery.
There are more treatments available. There'sbetter understanding. There's more acceptancethat this is a medical condition with real medicalsolutions than there ever has been.
This whole addiction ruling your mind andthoughts-- even though I've lived through it, I stilldon't understand it.
How can we comprehend the concept of a personthat wants to stop doing something and theycannot, despite catastrophic consequences?We're not speaking of little consequences. Theseare catastrophic. And yet, they cannot controltheir behavior.
Drug addiction is a disease of the brain thattranslates-- that that disease translates intoabnormal behavior. Addiction is a result ofadaptations in the brain that leads to changes inbehavior that translate, among others, in theinability to control the intake of the drug. Theirbrains have been modified by the drug in such away that the drug makes a signal to their brainthat is equivalent to the signal-- if I have to comeup with a metaphor-- of when you are starving--the signal of seek the food and eat it when you arestarving. That's what the parent has tounderstand or the spouse has to understand, thatthere's been a change, an adaptation, from theuse of the drug that leads to the situation ofalmost as if the individual was in a state ofdeprivation, where taking the drug isindispensable for survival. It's as if their brainwere sensing that the drug is something that'snecessary for survival. It's as powerful as that.
It's likely to be multiple factors. But one of theones that is likely to be very important is geneticdifferences. We're all born differently. And likewith any other disease, there are some peoplethat are more vulnerable, for example, fordepression. Or they may be more vulnerable forhypertension or for cancer. The same thing withaddictions. There are some people that becauseof hereditary reasons are more likely to becomeaddicted to drugs. This is one of the elements.Environment-- we know that there are someenvironments that are actually higher risk whilethere are other environments that are protective.For example, ...
Writing Assignment#3Read Puterbaugh, D. Why Newborns Cause .docxodiliagilby
Writing Assignment:#3
Read: Puterbaugh, D. “Why Newborns Cause Acrimony and Alimony.” USA Today. 2005. Web. 10 Apr. 2013.
Please refer to Critical Analysis Guidelines for the criteria used to evaluate essays.
HU 140 Cultural Diversity Unit 3 Template
Communication: The Journey of Message
We have all had moments where communication meant the difference between resolving an issue and creating one. Describe an event or incident where being an active listener allowed you to calm a situation. Here are some questions to consider:
· What ways did dialogue contribute to diffusing the situation?
· Did you or the other people involved demonstrate body language cues that signaled the situation was escalating or diminishing?
· How did the situation resolve?
· If you could revisit that situation now, what would you change?
Click here to share your story!
Effective Communication in Art
Click on the picture icon to the right and insert images of art (any visual representation) that communicates new understanding of diversity issues. This can be anything from a multi-racial family to the physically active elderly sky diving or water skiing (defying the stereotypes on aging). Click on the word "Text" and describe the message being communicated and explain why some people might miss or ignore this message. If necessary, reference the image on the References page.
Listening to the Voiceless
Go to this YouTube channel and view three or more interviews with the homeless that are not from your race/ethnicity/gender group. Select one that you feel created the most effective message to help yourself and others understand the unique issues facing the homeless population. Once you select your video, click on 'share,' then click on 'embed,' and finally click on 'copy' found at the lower right.
Next, click inside the textbox below, then click on the "Insert" menu and select "Online Video" from the menu. Select the option where you 'paste' the embed code. If necessary, reference the video on the References page.
Click here
Address the following questions:
1. What feelings or emotions did the video draw out in you? What made you connect to the person being interviewed?
2. What stereotypes did you find yourself falling into initially?
3. How might this video or others like it bring an end to othering of the homeless?
Click here
Literature and Identity Power
Literature has been used over the centuries in assimilating cultures and establishing cultures, but in more modern times it has become an effective tool to bring 'voice' to the marginalized and underrepresented. One example is Amy Tan, an Asian American writer of the novel, The Joy Luck Club, and many others. Her essays often focus on Identity Power in ways that are inclusive to all groups which is one reason her work has been so effective. Click on this link and read her essay "Mother Tongue." In the textbox below add ...
Writing Assignment#3Read Puterbaugh, D. Why Newborns Cause .docxbillylewis37150
Writing Assignment:#3
Read: Puterbaugh, D. “Why Newborns Cause Acrimony and Alimony.” USA Today. 2005. Web. 10 Apr. 2013.
Please refer to Critical Analysis Guidelines for the criteria used to evaluate essays.
HU 140 Cultural Diversity Unit 3 Template
Communication: The Journey of Message
We have all had moments where communication meant the difference between resolving an issue and creating one. Describe an event or incident where being an active listener allowed you to calm a situation. Here are some questions to consider:
· What ways did dialogue contribute to diffusing the situation?
· Did you or the other people involved demonstrate body language cues that signaled the situation was escalating or diminishing?
· How did the situation resolve?
· If you could revisit that situation now, what would you change?
Click here to share your story!
Effective Communication in Art
Click on the picture icon to the right and insert images of art (any visual representation) that communicates new understanding of diversity issues. This can be anything from a multi-racial family to the physically active elderly sky diving or water skiing (defying the stereotypes on aging). Click on the word "Text" and describe the message being communicated and explain why some people might miss or ignore this message. If necessary, reference the image on the References page.
Listening to the Voiceless
Go to this YouTube channel and view three or more interviews with the homeless that are not from your race/ethnicity/gender group. Select one that you feel created the most effective message to help yourself and others understand the unique issues facing the homeless population. Once you select your video, click on 'share,' then click on 'embed,' and finally click on 'copy' found at the lower right.
Next, click inside the textbox below, then click on the "Insert" menu and select "Online Video" from the menu. Select the option where you 'paste' the embed code. If necessary, reference the video on the References page.
Click here
Address the following questions:
1. What feelings or emotions did the video draw out in you? What made you connect to the person being interviewed?
2. What stereotypes did you find yourself falling into initially?
3. How might this video or others like it bring an end to othering of the homeless?
Click here
Literature and Identity Power
Literature has been used over the centuries in assimilating cultures and establishing cultures, but in more modern times it has become an effective tool to bring 'voice' to the marginalized and underrepresented. One example is Amy Tan, an Asian American writer of the novel, The Joy Luck Club, and many others. Her essays often focus on Identity Power in ways that are inclusive to all groups which is one reason her work has been so effective. Click on this link and read her essay "Mother Tongue." In the textbox below add.
The document discusses the philosophy and practice of clinical outpatient therapy. It begins with a disclaimer about the purpose of improving therapy practice through a deeper understanding of methods. It then discusses the background and training of the author with various clinicians over 12 years. It also discusses training with Richard Belson in an innovative live supervision practicum employing solution-focused team therapy for chronic problems.
Depression is a growing problem among teenagers. It can be caused by biological factors, traumatic events like abuse, stress from body changes and independence struggles, and pessimistic thinking patterns. Screening tools like the PHQ-2 are used but have limitations like low sensitivity. Untreated depression can be damaging, so parents should support teenagers through open communication, prioritizing physical health with exercise, and considering talk therapy for mild to moderate cases before medication.
When Vernon Johnson wrote I’ll Quit Tomorrow in 1973, and Intervention: How to Help Someone Who Doesn’t Want Help in 1986, his radical ideas were met with resistance from many groups.
This document discusses various psychosocial approaches and psychotherapies relevant to child psychiatry. It describes therapies such as psychoeducation, parent counseling, psychodynamic psychotherapy, cognitive-behavioral therapy, family therapy, group psychotherapy, play therapy, and others. It notes that while principles are similar to adult psychotherapy, key differences for children include their developmental level, dependence on adults, and involvement of parents in treatment. Therapies aim to improve function by addressing cognition, emotions, and underlying psychopathology through therapeutic relationships and play. Skill and understanding of child development is important for effective psychotherapy in children.
This document discusses changing the conversation around mental illness. It notes that Demi Lovato discusses her own diagnosis to remind people to seek help. It urges using respectful language when discussing mental health and not labeling people by their conditions. Stigmatizing words can discourage people from getting help. The movement aims to improve understanding and end discrimination against those with mental illnesses.
Level 3 NCEA - NZ: A Nation In the Making 1872 - 1900 SML.pptHenry Hollis
The History of NZ 1870-1900.
Making of a Nation.
From the NZ Wars to Liberals,
Richard Seddon, George Grey,
Social Laboratory, New Zealand,
Confiscations, Kotahitanga, Kingitanga, Parliament, Suffrage, Repudiation, Economic Change, Agriculture, Gold Mining, Timber, Flax, Sheep, Dairying,
Gender and Mental Health - Counselling and Family Therapy Applications and In...PsychoTech Services
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إضغ بين إيديكم من أقوى الملازم التي صممتها
ملزمة تشريح الجهاز الهيكلي (نظري 3)
💀💀💀💀💀💀💀💀💀💀
تتميز هذهِ الملزمة بعِدة مُميزات :
1- مُترجمة ترجمة تُناسب جميع المستويات
2- تحتوي على 78 رسم توضيحي لكل كلمة موجودة بالملزمة (لكل كلمة !!!!)
#فهم_ماكو_درخ
3- دقة الكتابة والصور عالية جداً جداً جداً
4- هُنالك بعض المعلومات تم توضيحها بشكل تفصيلي جداً (تُعتبر لدى الطالب أو الطالبة بإنها معلومات مُبهمة ومع ذلك تم توضيح هذهِ المعلومات المُبهمة بشكل تفصيلي جداً
5- الملزمة تشرح نفسها ب نفسها بس تكلك تعال اقراني
6- تحتوي الملزمة في اول سلايد على خارطة تتضمن جميع تفرُعات معلومات الجهاز الهيكلي المذكورة في هذهِ الملزمة
واخيراً هذهِ الملزمة حلالٌ عليكم وإتمنى منكم إن تدعولي بالخير والصحة والعافية فقط
كل التوفيق زملائي وزميلاتي ، زميلكم محمد الذهبي 💊💊
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Philippine Edukasyong Pantahanan at Pangkabuhayan (EPP) CurriculumMJDuyan
(𝐓𝐋𝐄 𝟏𝟎𝟎) (𝐋𝐞𝐬𝐬𝐨𝐧 𝟏)-𝐏𝐫𝐞𝐥𝐢𝐦𝐬
𝐃𝐢𝐬𝐜𝐮𝐬𝐬 𝐭𝐡𝐞 𝐄𝐏𝐏 𝐂𝐮𝐫𝐫𝐢𝐜𝐮𝐥𝐮𝐦 𝐢𝐧 𝐭𝐡𝐞 𝐏𝐡𝐢𝐥𝐢𝐩𝐩𝐢𝐧𝐞𝐬:
- Understand the goals and objectives of the Edukasyong Pantahanan at Pangkabuhayan (EPP) curriculum, recognizing its importance in fostering practical life skills and values among students. Students will also be able to identify the key components and subjects covered, such as agriculture, home economics, industrial arts, and information and communication technology.
𝐄𝐱𝐩𝐥𝐚𝐢𝐧 𝐭𝐡𝐞 𝐍𝐚𝐭𝐮𝐫𝐞 𝐚𝐧𝐝 𝐒𝐜𝐨𝐩𝐞 𝐨𝐟 𝐚𝐧 𝐄𝐧𝐭𝐫𝐞𝐩𝐫𝐞𝐧𝐞𝐮𝐫:
-Define entrepreneurship, distinguishing it from general business activities by emphasizing its focus on innovation, risk-taking, and value creation. Students will describe the characteristics and traits of successful entrepreneurs, including their roles and responsibilities, and discuss the broader economic and social impacts of entrepreneurial activities on both local and global scales.
Philippine Edukasyong Pantahanan at Pangkabuhayan (EPP) Curriculum
JustSayNo
1. Just Say ‘No’ to Drugs as a First
Treatment for Child Problems
Barry L. Duncan, Jacqueline A. Sparks,
J o h n J . M u r p h y AN D S c o t t D . M i ll e r
When children and teens present with behaviour and emotional problems the lure of a quick fix is
understandable and drugs present a ready-made solution. Therapists are often hesitant to talk about
medication and defer to medical professionals. In this paper DUNCAN, SPARKS, MURPHY and MILLER
highlight the explosion in the use of psychotropic medications for children and teens. This trend flies in the
face of the American Psychological Association’s recommendation of the use of psychosocial interventions
as the first intervention of choice with children and teens. The reliability and validity of psychiatric diagnoses is
questioned, in particular against a background of fluctuations in child development and social adaptations,
and a compelling critique is provided of the current research findings on the effectiveness of psychotropic
medications including antidepressants and ADHD medications. Therapists are urged to shed their timidity
and discuss openly the risks and benefits of medication with the knowledge that there is empirical support
for psychosocial interventions as a first line approach. Recommendations are offered to engage clients as
central partners in developing solutions—medical or non-medical—that fit each child and each situation.
A mother has a moment of panic,
spying her daughter’s arms
crisscrossed with red cuts.
medication with the families they see,
choosing instead to defer to medical
professionals. But to not talk about
Aren’t we stepping out of our expertise
and professional role to discuss
medications with clients?
A harried teacher does a double psychiatric drugs in today’s world of While we may be stepping out
take when the behaviour of a typically ubiquitous chemical imbalances and of our comfort zones, we are not
disruptive middle schooler takes a glossy advertising remedies is to ignore travelling beyond the boundaries of our
bizarre turn. Young parents are at a the proverbial elephant in the living expertise to discuss options regarding
loss to explain the uncontrollable rages room. Prescriptions of psychotropic treatment approaches for young people
of their five-year old. In each case, drugs for children and adolescents have in distress. We need not fear these
the spectre of mental illness hovers, skyrocketed. To skip a discussion of conversations or feel timid in the face
whispering an urgent command to “get medication is to disregard a growing of medical opinion; the data speak
professional help!” Psychotherapists are reality that impacts on children clearly about just how safe and effective
often the first stop for help—we, like and their families. The Rx (medical psychiatric drugs are for children. The
our clients, feel the pressure to solve the prescription) elephant won’t go away empirical evidence supporting the
problem rapidly with the best standard just because we don’t talk about it. benefit of child medication is far from
of care. And, more and more, that Our reticence is mirrored in parents substantial, while concerns about safety
standard has become synonymous with and children who are reluctant to offer continue to surface. Therapists can use
psychiatric medication. an opinion or ask a question about this knowledge to confidently assist
With daily pressure on therapists other options or side effects. The end with medication decisions—they can
to manage youth behaviour and result is that children, parents, and help children and parents get the facts
emotional problems, the lure of a therapists are often shut out of the about risks and benefits, and make
quick fix is understandable, and loop—their questions, ideas, and clear the take-home message that there
drugs seem a ready-made solution. solutions take a back seat. But how are many paths to preferred ends.
But beyond referring families for can therapists broach this topic—after It is not our aim to discredit
psychiatric consultations, therapists all, we are not medical experts, or as individual preferences for or
are often hesitant to talk about the joke goes, we are not ‘real’ doctors. experiences with medication, or to
32 PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007
2. claim that psychiatric drugs are not Explosion in the use of a psychiatrist is made and Jess is
ever helpful. We are not wide-eyed psychotropic medication prescribed an antidepressant.
anti-drug zealots. Instead, we are for children and teens Jess is not alone. The past decade
anti-privileging drugs as a first-line Jess, a 15-year old girl enters school has seen an explosion of psychotropic
solution—especially for children and through the front door, proceeds down medication prescriptions for children
adolescents. And while we are adamant the hallway and out the back, another and teens (Zito et al., 2003). In
about putting clients in charge of the no-show for the day. Jess finds it the United States prescriptions for
decision to medicate and have been difficult to attend to classroom work, antidepressants have increased at a
writing passionately about the lack preferring to hang out with the pony rate of 11 per cent each year from 1994
of demonstrated efficacy of drugging she helps care for as a part-time job. At to 2000, and five per cent each year
children for nearly ten years, we are the school meeting, Jess’s mother states since, a total of over eleven million
actually in the mainstream of current that she found marks on her daughter’s prescriptions written annually. The
scientific thinking, The American arms, apparently self-inflicted with number taking antipsychotic medicines
Psychological Association Working Group her father’s pen knife. A referral to soared 73 per cent in the four years
on Psychotropic Medications for Children
and Adolescents, 2006 states:
‘It is the opinion of this working group
that…the decision about which treatment
With daily pressure on therapists to manage
to use first…should be guided by the
balance between anticipated benefits
youth behaviour and emotional problems,
and possible harms of treatment choices… the lure of a quick fix is understandable,
For most of the disorders reviewed herein,
there are psychosocial treatments that are and drugs seem a ready-made solution.
solidly grounded in empirical support
as stand-alone treatments. Moreover,
the preponderance of available evidence
indicates that psychosocial treatments
are safer than psychoactive medications.
Thus, it is our recommendation
that in most cases, psychosocial
interventions be considered first’.
(p. 175, emphasis added)
The report further points out:
‘Ultimately, it is the families’ decision
about which treatments to use and
in which order. A clinician’s role is to
provide the family with the most up-to-
date evidence, as it becomes available,
regarding short- and long-term risks
and benefits of the treatments.’ (p. 175)
The APA is hardly an organization
known for going out on a limb or
taking risky liberties with the data!
This knowledge means that when
children experience difficulties,
discussions about solutions can be
open, creative, and evolving, and
encompass a range of views about
change based on each person’s
concerns, circumstances, and
preferences. While medication may
be useful for some children, it does
not have to dominate intervention
strategies or monopolize talk about
change. Therapists can expand the
range of options, and their clinical
roles, even in circumstances that
typically trigger prescriptions.
Illustration: Shannon Rose
PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007 33
3. ending in 2005, far outpacing the to neuro-imaging research as proof Yeah…I told my mom about Nick (Jess’s
increase in adults—over 2.5 million positive of the biology of behavioural boyfriend). She knows we broke up.
youth in the US per year are prescribed and emotional problems. A highly Therapist: Is that what’s bothering you
antipsychotics (dosReis, Zito, Safer, publicized study claimed to show the most now?
Gardner, Puccia & Owens, 2005). that the brains of ADHD-diagnosed Jess: Yeah. That, and school sucks.
Spending on drugs like Ritalin for children were smaller than their non- Jess, her mom and the therapist
behavioural problems exceeds any other ADHD counterparts (Castellanos et talk about how Jess cuts herself to help
category for the first time, including al., 2002). However, anatomy Professor with the emotional hurt. They also
antibiotics. The number of kids taking Jonathan Leo and researcher David talk about Jess’s boredom with her
one or more prescription medicines to Cohen report that the control group classes and her desire to work more
treat mental health-related conditions was two years older, heavier, and taller to earn money and not ‘waste time’ at
has hit nearly nine per cent. If Jess than the ADHD diagnosed children, school. They listen to Jess and value
that she feels comfortable enough to
let them into her world. All agree that
We are not wide-eyed anti-drug zealots. the first order of business is for Jess to
be safe. Since Jess is adamant about
Instead, we are anti-privileging drugs not wanting medication, they agree to
set up a safety plan. The practitioner
as a first-line solution—especially ensures that Jess is the primary
architect of the plan, prompting her to
for children and adolescents. identify strategies that she believes will
work. Instead of cutting at night when
she felt down, Jess planned to listen to
lived in a foster home, she would be 16 undermining any conclusion about music, get in her mom’s bed or call her
times more likely to be medicated; if brain size and ADHD (Leo & Cohen, friends. Jess writes the strategies down
the diagnosis ended up bipolar disorder 2003). Despite fifty years of efforts to and signs an agreement to tell her mom
or ADHD, her chances of being on find one, no reliable biological marker or call the therapist if she feels like it is
more than one medication at the same has ever emerged as the cause of any not working.
time would be as much as 87 per cent psychiatric ‘disease’. There are many ways to reach desired
(Duffy et al., 2005). Knowing there is no irresistible ends. Not every child is Jess and not
The push to medicate young people scientific justification to medicate, the every parent will react the same way.
is fueled partially by the belief that therapist is free to put other options on What will work can only be known one
problems are biological and require the table and draw in the voices of Jess child and one family at a time after an
medical intervention. Web pages, and her mother. open consideration of options.
doctor’s office brochures, magazine Mother: Jess, you can’t keep doing this.
Validity and reliability of
articles and TV advertisements I don’t want you to hurt yourself.
psychiatric diagnosis
describe depression, ADHD, What’s wrong? What do you want?
mood swings, and the like as brain Jess: (Shrugs shoulders and Michael, age 13, is home from
dysfunctions. Even when we know they looks down.) residential treatment and recently
are promotions from drug companies, Therapist: Jess, we just want to make reunited with his mother who is
pictures of neurotransmitters or talking sure you’re safe? What do you think now attending regular Narcotics
serotonin cartoons are powerful, lasting will help? Anonymous meetings. When
images. This biological perspective is Jess: I don’t know. confronted about his ‘clowning’
also backed up by impressive sounding (Everyone just sits for a while. in math class, Michael makes a
clinical studies. Social explanations There is genuine puzzlement and beeline for the door and is found
and solutions are not accorded the same concern from everyone in the room— hanging halfway up the flagpole
weight in the media as medical ones there does not seem to be a way out o like a frightened monkey. In short
and are a distant second when it comes f the dilemma.) order, Michael’s diagnosis is changed
to research funding and marketing. As Mother: Jess, do you want to take the from ADHD to early onset bipolar
a result, claims are rarely questioned medicine that Dr. Stevens gave you? He disorder. His medication is changed
and the assumption that child and said you were clinically depressed and from stimulants to anticonvulsant and
adolescent problems have a biological that it would help. antipsychotic medications.
basis has become accepted fact. Jess: No! I don’t want to take any pills. ‘Early onset bipolar disorder’ has an
Cartoons notwithstanding, I’ve got to do this myself. ominous ring to it. At first glance
biochemical imbalances and other Mother: Okay. medication seems the most logical
so-called mind diseases remain the Therapist: Jess, do you want to talk with intervention for preventing a slide
only territory in medicine where me and your mom, or maybe just one of us into more distress and coping with
diagnoses are permitted without a alone, about some of that stuff we talked the disorder. Diagnosis, as the sole
single confirmatory test (Duncan, about last week? gateway to medications, provides
Miller & Sparks, 2004). Many point Jess: (after a lengthy pause, thinking) the official rationale for medical
34 PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007
4. intervention. The belief that diagnosis like the old ones, but these are even worse. as making sense within the context of
can provide accurate identification of Mom says I should take them, but they the child’s life. And if medication is a
discreet disorders is a key assumption make me feel weird! part of treatment, children can monitor
that underlies medication prescription. Therapist: I saw what the doctor said in whether medication is useful and, with
Therapists may feel that they have the report he sent me. It says that it seems the help of adults, can be in the driver’s
little choice but to assume that a like your moods kind of go up and down. seat in medication decisions.
diagnosis explains what is wrong Does that seem right to you?
Are research findings on the
and provides a solution. Michael: Yeah. Kind of. I never know if
effectiveness of psychotropic
In spite of its widespread mom is going to, you know, go off again.
medication reliable?
acceptance, the validity and reliability It’s hard to sit there in class when I keep
of psychiatric diagnosis is suspect thinking about that, so I just start joking Six-year old Kyle, according to his
(Duncan et al, 2004; Sparks, Duncan around. Then Mr. Riley gets on my case, parents, ‘flies into a rage at the drop of a
& Miller, 2006). In particular, and I haven’t even done anything so I say hat.’ They note that Kyle’s rages occur
diagnostic validity is questionable ‘I’m outta here!’ when playing with his three-year
when it comes to children. According Therapist: Wow. That makes a lot of old sister and they fear that he may
to the World Health Report, ‘Childhood sense. No wonder you wanted to do hurt her. Kyle’s mother shares with a
and adolescence being developmental something to get that thought out of your therapist her concern that Kyle might
phases, it is difficult to draw clear mind for a while. have a mental illness and wonders
boundaries between phenomena that are Michael: So, you mean I’m not crazy? whether medication could help. When
part of normal development and others It was important for Michael to parents hear that even young children
that are abnormal’ (World Health make sense of his own experience can be mentally ill and that problems
Organization, 2001). The notion of and actions, and to understand these result from undiagnosed disorders, it
stable, fixed psychiatric syndromes as reactions to stressful events. The makes sense that they may adopt this
does not fit the fluctuations of child therapist refused to allow the diagnosis point of view when other explanations
development and adaptation to social or his situation at home to get him and options are not readily available.
environments—children change off the hook. They brainstormed The decision to pursue psychotropic
continually with age and context. ways that Michael could deal with drugs is based largely on the belief that
Reliability has to do with whether or his stress without getting in trouble. they work. People assume that Prozac
not clinicians looking at the same array The therapist returned to the pills and similar drugs are the intervention
of symptoms will come up with the because Michael expressed discomfort of choice for child and adolescent
same diagnosis. If there is independent with them. Referring to the outcome depression, and that stimulant
agreement on a diagnosis amongst measure the therapist was using, the medications are consistently effective
professionals, it is considered reliable. practitioner suggested that Michael for children labeled with ADHD.
Robert Spitzer, the primary architect monitor his response to the medication Pediatricians and family doctors also
of the DSM, commented on the ability to determine whether it was working or endorse such assumptions based on
of the DSM to provide consistent making him feel worse. published evidence from clinical trials.
agreement in clinical diagnosis: ‘To say Instead of certain diagnoses The clinical trials most often cited
that we’ve solved the reliability problem resulting in knee-jerk prescriptions, for medication effectiveness include:
is just not true…It’s been improved. But troubling behaviour can be validated the two clinical trials that gained
if you’re in a situation with a general
clinician it’s certainly not very good. There’s
still a real problem, and it’s not clear how to
solve the problem’ (Spiegel, 2005, p. 63).
In other words, Michael might well be
diagnosed with depression if he were
seen by a different clinician, or may
not have received a diagnosis at all.
A bipolar diagnosis can last a lifetime;
out-of-the ordinary child behaviours
tend to be time-limited. Recognizing
the potential negative effects, the
American Counseling Association’s
Ethical Code supports counsellors who
refrain from making a diagnosis.
Returning to Michael, consider the
therapist’s response to his diagnosis:
Therapist: Hey, Michael, how’s it going?
Michael: Not so good. The doctor says I
have some kind of…I forget. Anyway, he
gave me these new pills to take. I didn’t
PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007 35
5. Prozac FDA approval for childhood inactive pill takers easily, effectively between medication and placebo
depression conducted by psychiatrist un-blinding the study and skewing groups tend to dissolve by 16 weeks.
researcher Graham Emslie of the results. In support of this theory, a Without longer term follow-ups,
University of Texas Southwestern meta-analysis conducted by psychiatrist researchers cannot make accurate
Medical Center and colleagues researcher Joanna Moncrieff of the conclusions about effectiveness in
(1997, 2002) (hereafter called the University College of London found everyday life. The Emslie studies were
Emslie studies); and the Multimodal that when studies used active placebos, of eight weeks duration, calling into
Treatment of ADHD (MTA) little or no differences were found question their usefulness in real-world
examining the efficacy of Ritalin versus between the dummy pill and the drug decision making.
behavioural and combined intervention (Moncrieff, Wessely & Hardy, 2004). A key component of evaluating
(MTA Cooperative Group, 1999, The Emslie studies used inactive, sugar any drug trial is learning who
2004ab). pill placebos drawing into question paid for it and what the authors’
The gold standard for research is the integrity of the study’s double potential conflicts of interest are. The
the randomized, double blind, placebo blind. Evidence of the compromised pharmaceutical industry’s influence
controlled trial. In this design, two double blind were apparent in the drug over scientific inquiry has, in some
groups are formed, presumably similar manufacturer’s own records where ways, become almost a cliché. In
since they are selected randomly from ‘it was not uncommon to see notations May of 2000, the editor of the New
the initial pool of applicants. One defining the patient’s blinded treatment, England Journal of Medicine, Marcia
group gets the drug being tested; the or in some cases to find fluoxetine (Prozac) Angell called attention to the problem
other, a placebo. In this design, neither plasma concentration results’ (FDA, of ‘ubiquitous and manifold…financial
study participants, researchers, nor 2001, June 25, p. 19). associations’ of authors to the companies
assisting clinicians, should know who The instruments chosen as primary whose drugs were being studied
is in which group—that is, who is measures in drug trials are clinician- (Angell, 2000, p. 1516). Why is it
taking the real drug and who is getting rated. Frequently, client ratings of important to know who sponsors a
the dummy pill. This helps eliminate improvement differ from clinician’s, study? One recent review (Heres,
the bias that comes when participants often in ways that run counter to Davis, Maino, Jetzinger, Kissling &
and researchers know who is in each findings of drug effectiveness. In Leucht, 2006) looked at published
group, and weeds out factors like hope both clinical trials that resulted in head-to-head comparisons of five
and expectancy that could interfere FDA approval of Prozac, no client- popular antipsychotic medications. In
with determining what is actually rated measures indicated superiority nine out of ten studies, the drug made
responsible for any differences found of the drug over placebo. However, by the company that sponsored the
between groups. The validity of the both studies concluded that Prozac study came out on top.
trial depends upon the ‘blindness’ of outperformed placebo. How valid Without an appreciation of the
participants who rate the outcomes. can an assessment of improvement role industry influence plays in how
However, most studies do not use be if the client does not agree with the study is designed, carried out,
active placebos—pills that mimic the it? In the first Emslie study, two and disseminated, it would be easy
effects of real drugs. Rather, they use out of four clinician-rated measures to accept bottom line conclusions as
inert sugar pills as the placebo which indicated a difference between the fact. However, recent regulations now
makes it possible for most participants placebo and SSRI groups. Two client- require authors to fully disclose their
and clinicians to tell who is getting rated measures found no difference. affiliations, allowing a more critical
the medication. Inert sugar pills, or Similarly, the primary measure of appraisal of any study’s conclusions.
inactive placebos, do not produce the the second study failed to show a The first Emslie study, published prior
standard side effect profile of actual significant difference—all client- to disclosure requirements, did not
drugs—dry mouth, weight loss or gain, rated and two clinician-rated scales identify author affiliations. However,
dizziness, headache, nausea, insomnia showed no difference. Out of seven, FDA data indicate that Eli Lilly
and so on. Study participants are likely three clinician-rated measures showed sponsored the study. The second and
to be on the alert for these types of significant differences between the approval-clinching trial of Prozac for
events and, since most have been on experimental drug and placebo. If child and adolescent depression lists
medications before, many are familiar children and their parents do not author affiliations on the first page.
with these effects. As a consequence, detect improvement over placebo, how Here, readers learn that Emslie is
these subjects are likely to identify effective are the drugs? a paid consultant for Eli Lilly, who
correctly which group they are in Standard time frames for clinical funded the research and whose product
(Fisher & Greenberg, 1997; Sparks & drug trials are 8 to 12 weeks. In was being investigated. The remaining
Duncan, in press). contrast, most prescriptions for youth authors are listed as employees of
Researchers interview participants psychiatric medication assume that the Eli Lilly and ‘may own stock in that
throughout the study to collect drug will be taken for much longer. company’ (p. 1205). Combining this
information about change and side Assessing how well a drug does in an information with the ‘unblinding’
effects. On-going interviews that listen 8 to 12-week period cannot portray that results from inactive placebos
for or are active in asking about side an accurate picture of the drug’s seriously calls into question whether
effects can reveal the active versus performance in real life. Differences the researchers, either employees or
36 PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007
6. consultants of the company whose drug (the 7–9 year old children) rated MTA authors have significant ties to
was under investigation could, with so themselves as no more improved when drug companies. Specifically, Jensen
much at stake, remain objective. using medication than when using is listed as a consultant to Novartis,
Recent pooled analyses of both behavioural or community alternatives. the makers of Ritalin, the drug under
published and unpublished trials of Of interest, peer ratings concurred investigation in the MTA.
SSRIs for the under-18 age group with this assessment. The fact that When practitioners know what to
reveal that, as far as how well they neither blinded classroom observers, look for—does the study have a true
work, these drugs, plain and simple, the children themselves, or their peers double blind, are outcome measures
do not deserve a blank cheque. An found that medication was better than clinician or client rated, how long
did the study last, who funded the
study and what are the authors’
The notion of stable, fixed psychiatric industry affiliations—they realize that
medication should not be privileged
syndromes does not fit the fluctuations over other psychosocial options
(Sparks & Duncan, in press). Equipped
of child development and adaptation to with this information, therapists also
have a powerful method for evaluating
social environments—children change future studies without having to take
the word of the latest headline or sound
continually with age and context. byte on the evening news.
Kyle and his family are at a
crossroads. It would not be hard
analysis by researcher Jon Jureidini behavioural interventions suggests that to start down a path that saw his
found that, out of 42 reported measures stimulant drugs offer no advantages difficulty as the early signs of mental
in six published trials, only 14 showed over non-medication alternatives. illness. Through this lens, a proactive
a statistical advantage. None of the With regard to time frames, the approach might make sense, warding
youth and parent measures in this MTA surpassed its predecessors off a potential downward spiral before
sample indicated any advantage of because it evaluated outcomes at 14 it becomes entrenched and intractable.
the drug over a sugar pill—only the months instead of the customary 8–12 However, knowing also that such an
doctors reported improvement. They weeks. The assessment occurred at approach most likely means medication
also discovered that the effect size for the 14-month endpoint while subjects with its attendant risk and unproven
the drug over placebo was quite modest were actively medicated. However, efficacy, it also makes sense to explore
(0.26), amounting to only a 3 to 4 point behavioural intervention had long since other ways to understand and to resolve
difference on scales which had ranges stopped—endpoint measures were his and his family’s dilemma.
from 17 to 113 as possible scores. This taken four to six months after the last Therapist: I can certainly see that you
may be statistically significant, but fails face-to-face contact. Thus, the endpoint have some concerns here. I really appreciate
the test of clinical significance—that MTA comparison was between how you’re trying to make sure that you
is, fails to tells us anything meaningful active medication and withdrawn know what’s going on so that you can take
about the client sitting in front of us, behavioural intervention. This made action sooner rather than later. Usually,
much less serve as a mandate, or ‘best the comparison hardly a head-to-head it’s a lot easier to head things off at this
practice’. Unpublished trials fared contest, making the slight superiority age, rather than wait until the child is 8 or
much worse—only one in nine showed of medication (on 3 of 19 unblinded 9 when it is a lot harder.
a statistical advantage for the drug over measures) a foregone conclusion. A Mother: Exactly! That’s what we [with
placebo (Jureidini, Doecke, Mansfield, 24-month follow-up of the MTA Kyle’s dad] thought too. That’s why I
Haby, Menkes & Tonkin, 2004). shows that the improvements of wanted to speak to you. You know, since
The Multimodal Treatment Study children on medication deteriorated (up we moved here, and the new baby came,
of Children with ADHD (MTA), to 50 per cent) while the behavioural and starting the business and all, we
the major trial supporting the intervention group retained their gains. hardly have time to sleep.
superiority of ADHD medication, All advantage of the combined group Therapist: Well, it says a lot about you
not only didn’t use an active placebo, over the behavioural intervention also that you could make the time to get in
it lacked a pill placebo control group dissipated (MTA, 2004a). here today!
altogether (MTA Cooperative Group, Finally, consider the conflicts of Mother: Thanks. What you said about
1999). As a consequence, it relied on interest. For those studies conducted doing something now rather than later,
evaluations made by teachers, parents, before the disclosure requirement, a did you think we should have him see a
and clinicians who were not blinded to little sleuthing can help. An online doctor, or have some kind of evaluation,
the intervention conditions. The only database published by a non-profit maybe some medication or something?
double-blind measurement (made by health advocacy group (Integrity in Therapist: Well, that is certainly
classroom raters) found no difference Science, www.cspinet.org/integrity/) something that could be done. But, we
among any of the intervention groups. reveals that lead MTA investigator don’t really know if that will be needed
In fact, the subjects themselves Peter Jensen and at least five other at this point. Most of the time, we can
PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007 37
7. work with the schools and also recommend children are prescribed ‘off label’. participants receiving Prozac in this
things at home, that can move things in This means that the majority of drugs study attempted suicide (FDA, 2001,
a better direction. Children of Kyle’s age prescribed frequently do not have the June 25).
typically respond well to behaviour plans. requisite two clinical trials that show After a review of published
We can observe what’s working for him they are safe and effective. Included and unpublished trials, the FDA
and what we can do to build in some in off label medications are the new issued a black box warning for
rewards for when things are going well. antipsychotics and all anticonvulsants. all antidepressants for children,
It would be helpful if you could do the Additionally, there are no studies alerting consumers and providers
same—see what is working or what isn’t to support the efficacy or safety of to increased risk of suicidality and
at home. Would you note the times that
Kyle is getting along with his sister and
when things are going well? (Mother
nods in agreement) If we can meet again
In both clinical trials that resulted in FDA
next week, we might have some better
ideas of what’s going on and where to go
approval of Prozac, no client-rated measures
with things. Does that make sense? indicated superiority of the drug over
Mother: Yes, it does. Problem is, his dad
and I are so busy, and the baby takes up placebo. However, both studies concluded
so much of my time, we hardly pay much
attention to Kyle these days except to tell that Prozac outperformed placebo.
him to do things, like get ready for bed or
to stop doing things. Come to think of it,
we don’t even have time to get him in prescribing multiple medications. All clinical worsening (FDA, October, 15,
bed like we used to, with his favorite antidepressants, with the exception of 2004). The Medicines and Healthcare
game and story. Prozac, are prescribed off label for child Products Regulatory Authority
Kyle’s mother and the therapist and adolescent depression. The window (MHRA) in the United Kingdom took
detailed concrete steps that could of approved drugs for children is very it further, banning all antidepressants
be implemented at school and home. narrow—more narrow than what (except Prozac, which can only be used
A follow-up meeting was scheduled might justify the robust prescription with children over eight years when
to review progress and develop a rates. Even approved medications often talk therapies have failed). Growth
behavioural plan based on the mother’s have risks that are minimized in the suppression and adverse cardiac effects
and the teacher’s observation of decision-making process. have been noted as well (FDA, 2001,
what was working. Diagnosis and As the APA report noted, a June 25; FDA, 2003, January 3).
medication, while not discounted, thoughtful weighing of risk versus ADHD drugs also have troubling
were not the primary discussion benefit is at the heart of any medication records when it comes to side effects.
topics. Instead, other ways to view decision. Much of the data that has Sixty four percent of the children
and address the problem emerged been collected raises concern. A in the MTA reported adverse drug
from a therapeutic partnership to systematic evaluation of 82 medical reactions: 11 per cent were rated
explore options. charts of children and adolescents as moderate and three per cent as
treated with SSRIs found that 22 severe. In March of 2006, an FDA
Safety
per cent experienced some type of safety advisory committee called for
Jess’s mother was torn. On one psychiatric adverse event (PAE), stronger warnings on ADHD drugs,
hand, she feared for her daughter’s typically a disturbance in mood citing reports of serious cardiac risks,
life and would do whatever it took to (Wilens, Biederman, Kwon, Chase, psychosis or mania, and suicidality.
protect her. On the other, she was leery Greenberg & Mick , 2003). Estimates Stimulant medications have also been
of medications and, in particular, ones of PAEs in child and adolescent associated with increased emergency
not approved for children. Michael studies is complicated by inconsistent room visits. A recent study conducted
was placed on an antipsychotic and an collection methods for side effects by the U. S. Centers for Disease
anticonvulsant. All he knew was that data, and benign or misleading Control and Prevention found
he didn’t feel right. His teacher noted assessments of data actually reported. that thousands of children taking
that Michael no longer disrupted class, In the first Emslie study, six per cent stimulants wind up in the ER with
but instead put his head on the desk a of participants taking Prozac dropped chest pain, stroke, high blood pressure,
good portion of the day. Many popular out due to manic reactions compared fast heart rate, and overdose (Johnson,
drugs are viewed as safe for children. with two per cent in the placebo 2006, May 25). Finally, the MTA
However, safety is often tied to a group. If extrapolated to the general also revealed that the average height
lesser-of-two-evils argument. Many are population, for every 100,000 children suppression for older children was
willing to accept certain risks when the on Prozac, as many as 6,000 might about 1 cm per year, while younger
possible alternative is a child’s school be expected to experience this serious children averaged 1.4 cm per year
failure, drug abuse, crime or suicide. adverse effect. In addition, according height loss with a 20 per cent reduction
Most psychiatric medications for to FDA documents, at least two in growth rate.
38 PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007
8. Children like Michael, diagnosed systematic feedback on an outcome C. L., Walter, J. M., Zijdenbos, A., Evans,
with pediatric bipolar disorder, are measure that is understood easily A. C., Giedd, J. N. & Rapoport, J. L. (2002).
Developmental trajectories of brain volume
taking antipsychotic medications in by all (like the Child Outcome abnormalities in children and adolescents
record numbers (Duffy et al., 2005; Rating Scale—free download with attention-deficit/hyperactivity disorder.
Staller, Wade, & Baker, 2005). Side at www.talkingcure.com.) If JAMA, 288(14), 1740––1748.
effects for these drugs in adults are medication is part of the plan, dosReis. S., Zito, J. M., Safer, D. J.,
well known, including irreversible invite the youth and others to Gardner, J. F., Puccia, K. B., Owens,
movement disorders, obesity and the monitor the effects and use the P. L. (2005). Multiple psychotropic
risk of diabetes. Given that one in five results as a basis for discussion medication use for youths: a two-state
visits to a psychiatrist by a young person with medical professionals. Invite comparison. Journal of Child & Adolescent
Psychopharmacology, 15(1), 6877.
results in an antipsychotic prescription, the youth and others to view
a six-fold increase in recent years, it’s positive change as resulting from Duncan, B., Miller, S., & Sparks, J. (2004).
hard not to be alarmed at what these their efforts—‘Given that some The Heroic Client. San Francisco:
Jossey-Bass.
risks might mean for children (Olfson, take meds and they don’t work, how
Blanco, Liu, Moreno & Laje, 2006). is it that you made them work for Duffy, F. F., Narrow, W. E., Rae, D. S., &
West, J. C., Zarin, D. A., Rubio-Stipec,
you?’ These kinds of questions
Conclusion M., Pincus, H. A. & Reiger, D. A. (2005).
encourage people to take ownership Concomitant pharmacotherapy among
The decision of whether or not for successful outcomes. youths treated in routine psychiatric
to medicate a child is one of the Lack of critical awareness takes practice. Journal of Child and Adolescent
most difficult any family can face. A on greater weight where children Psychopharmacology, 15(1), 12–25.
medical path is always a choice, and are concerned because children trust Emslie, G. J., Heiligenstein, J. H.,
its pros and cons can be explored with adults to make good decisions on Wagner, K. D., Hoog, S. L., Ernest, D. E.,
medical and non-medical professionals. their behalf. We hope that knowing Brown, E., Nilsson, M. & Jacobson, J. G.
Therapists can feel free to shed their about the APA recommendations, (2002). Fluoxetine for acute treatment of
timidity and discuss openly the risks depression in children and adolescents:
the lackluster empirical support for A placebo-controlled, randomized clinical
and benefits of medication, with the drugging children as a first-line trial. Journal of the American Academy of
knowledge that there is empirical intervention, and the attendant safety Child and Adolescent Psychiatry, 41(10),
support for psychosocial intervention risks has bolstered your confidence to 1205–1215.
as a first line approach. The following talk about medication, raise concerns Emslie, G.J., Rush, A.J., Weinberg, W. A.,
are recommendations for engaging about robotic prescription practices and Kowatch, R. A., Hughes, C. W., Carmody,
clients as central partners in developing side effects, and offer alternatives. An T. C. & Rintelmann, J. R. (1997). A double-
solutions—medical or non-medical— awareness of the relationship between blind, randomized, placebo-controlled trial
that fit each child and each situation. of fluoxetine in children and adolescents
a profit-driven industry and science, with depression. Archives of General
• Gather input from multiple sources and what that science actually reveals, Psychiatry, 54(11), 1031–1037.
including the child, parents, enables therapists to assist families
teachers, school records, and Fisher, S., & Greenberg, R. P. (1997). From
to make intervention decisions—not Placebo to panacea: Putting psychiatric
other community care-givers. only permitting a fuller picture from drugs to the test. New York: Wiley.
• Develop multiple frameworks which to construct solutions, but also
of understanding the problem Heres, S., Davis, J., Maino, K., Jetzinger,
an appreciation that a child constantly E., Kissling, W., & Leucht, S. (2006). Why
based on the perspectives of the changes with the ebb and flow of life, Olanzapine beats Risperidone, Risperidone
youth, parents, teachers, and and is indeed like a river. You cannot beats Quetiapine, and Quetiapine beats
significant others. Include step in the same river twice. Olanzapine: An exploratory analysis
developmental, familial and of head-to-head comparison studies
environmental explanations. References of second-generation antipsychotics.
American Journal of Psychiatry, 163(2),
• Develop a concrete plan of action. American Psychological Association
185–194.
Working Group on Psychoactive
If medication is part of the plan,
Medications for Children and Adolescents. Johnson, L. A. (2006, May 25). ADHD
make sure that all involved, (2006). Report of the working group on drugs linked to scores of ER visits. Chicago
including the youth, are aware of psychoactive medications for children & Tribune, p. 6.
potential risks, adverse events, the adolescents. Psychopharmacological,
Jureidini, J. N., Doecke, C. J., Mansfield,
meaning of off label prescription, psychosocial, and combined interventions
for childhood disorders: Evidence base, P. R., Haby, M. M., Menkes, D. B., &
and the lack of studies supporting Tonkin, A. I. (2004). Efficacy and safety
contextual factors and future directions.
combining medications. Suggest Washington, DC: American Psychological of antidepressants for children and
resources for obtaining additional Association. Retrieved Sept. 22, 2006 from adolescents. British Medical Journal,
information about risks and http://www.apa.org/pi/cyf/childmeds.pdf. 328, 879–883.
benefits. Include discussion of a Angell, M. (2000). Is academic medicine Leo, J., & Cohen, D. (2003). Broken brains
time frame for discontinuation for sale? The New England Journal of or flawed studies? A critical review of ADHD
of medication. Medicine, 341(20), 1516–1518. neuromimaging research. The Journal of
Mind and Behavior, 24(1), 29–56.
• Work with the child, parents, Castellanos, F. X., Lee, P. P., Sharp, W.,
teachers and others to implement Jeffries, N. O., Greenstein, D. K., Clasen, L. Moncrieff, J., Wessely, S., Hardy, R. (2004).
the plan and modify it based on S., Blumenthal, J. D., James, R. S., Ebens, Active placebo versus antidepressants for
PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007 39
9. depression. The Cochrane Database of Sparks, J. A. & Duncan, B. L. (in press). U. S. Food and Drug Administration
Systematic Review: The Cochrane Library, Do no harm: A critical risk/benefit analysis (2004, October 15). FDA launches a
2, Oxford: Update Software. of child psychotropic medication. Journal of multi-pronged strategy to strengthen
Family Psychotherapy. safeguards for children treated with
MTA Cooperative Group. (2004a) 24-month
antidepressant medications. Retrieved
outcomes of treatment strategies for Sparks, J. Duncan, B. & Miller, S.(2006).
October 30, 2004 from http://www.fda.gov/
attention deficit/hyperactivity disorder Integrating psychotherapy and
bbs/topics/news/2004/NEW01124.html
(ADHD): The NIMH MTA follow-up. pharmacology: Myths and the missing
Pediatrics, 113, April, 754–761. link. Journal of Family Psychotherapy, Wilens, T. E., Biederman, J., Kwon, A.,
17, 83–108. Chase, R., Greenberg, L. & Mick, E. (2003).
MTA Cooperative Group (2004b). Changes A systematic chart review of the nature of
in effectiveness and growth during Spiegel, A. (2005). The dictionary of
psychiatric adverse events in children and
the follow-up phase of the multimodal disorder: How one man redefined
adolescents treated with serotonin reuptake
treatment study of children with psychiatric care. The New Yorker, January
inhibitors. Journal of Child and Adolescent
attention deficit/hyperactivity disorder. 3, 56–63.
Psychopharmacology, 13, 143–152.
Pediatrics, 113, April, 762–769. Staller, J. A., Wade, M. J., & Baker, M.
(2005). Current prescribing patterns World Health Organization (2001). World
MTA Cooperative Group (1999). A 14-
in outpatient child and adolescent Health Report, 2001. Available at http://
month randomized clinical trial of treatment
psychiatric practice in central New www.who.int/whr/2001/en/
strategies for attention-deficit/hyperactivity
disorder. Archives of General Psychiatry, 56 York. Journal of Child and Adolescent Zito, J. M. & Safer, S. J. (2005). Recent
(12), 1073–1086. Psychopharmacology, 15(1), 57–61. child pharmacoepidemiological findings.
U. S. Food and Drug Administration Journal of Child and Adolescent
Olfson, M., Blanco, C., Liu, L., Moreno, C. &
(2001, June 25). Medical review. Psychopharmacology, 15(1), 5–9.
Laje, G. (2006). National trends in outpatient
treatment of children and adolescents with Retrieved July 3, 2004 from http://www. Zito, J. M., Safer, S. J., dosReis, S.,
antipsychotic drugs. Archives of General fda.gov/dcer/foi/nda/2003/18936SO64_ Gardner, J. F., Magder, L., Soeken, K.,
Psychiatry, 63(6), 679–685. Prozac%Pulvules_medr .pdf Boles, M., Lynch, F. & Riddle, M. A. (2003).
Psychotropic practice patterns for youth: A
10-year perspective. Archives of Pediatric &
Adolescent Medicine, 157(1), 17–25.
AUTHOR NOTES
BARRY DUNCAN, Psy.D. is co-director of the Institute for the Study of Therapeutic Change.
Dr. Duncan is the author or co-author of over one hundred publications, including fourteen books.
The latest: The Heroic Client (Jossey Bass, 2004), Brief Intervention for School Problems (Guilford, 2007),
and the self-help book, What’s Right With You (HCI, 2005).
JACQUELINE A. SPARKS, Ph.D. is an Assistant Professor of Family Therapy in the Department of
Human Development and Family Studies at the University of Rhode Island. She is co-author of The
Heroic Client (2004) and Heroic Clients, Heroic Agencies (ISTC Press, 2002). Her numerous publications
and trainings advocate for a transformation of ‘business as usual’ in mental health to put clients at
the forefront of their own change.
JOHN J. MURPHY Ph.D., Professor of Psychology at the University of Central Arkansas (US), is an
internationally recognized author and trainer on collaborative approaches with young people and
school problems. He has authored (with Barry Duncan) the recent book, Brief Intervention for School
Problems: Outcome-Informed Strategies.
SCOTT D. MILLER, Ph.D. is co-director of the Institute for the Study of Therapeutic Change, a private
group of clinicians and researchers dedicated to studying ‘what works’ in mental health and substance
abuse treatment. As a therapist he provides clinical services pro bono to traditionally under-served
clients. He is author or co-author of numerous articles and books: Escape from Babel, (with Barry
Duncan & Mark Hubble, 1997), The Heart and Soul of Change (with Mark Hubble & Barry Duncan,
1999), The Heroic Client (with Barry Duncan & Jacqueline Sparks, Revised, 2004), and the forthcoming
Making Treatment Count: Outcome-Informed Treatment (with Michael J. Lambert & Bruce Wampold).
For more information and recent articles visit www.talkingcure.com
Comments: barrylduncan@comcast.net
40 PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007