Data-gathering tools for "real world" clinical settings: a multisite feasibility study.

OBJECTIVE: To determine the mental health needs and optimal treatments for children and families in "real world" settings, data-gathering strategies are needed that can be easily implemented across a variety of clinical settings. To address this need, the authors developed and piloted a "clinician-friendly" questionnaire that includes demographic, psychosocial, medical, and family history variables, such as those routinely gathered in standard clinical evaluations. METHOD: Optical scanning technology was used to encode data from more than 1,900 children, including 1,458 consecutive referrals in four military child psychiatry clinics, 285 consecutive admissions to a civilian psychiatric state hospital, 71 pediatric patients, and a community sample of 113 children. RESULTS: Despite geographic and logistic obstacles, clinical data were reliably obtained across multiple settings. Data analyses revealed meaningful differences across samples in subjects' presenting complaints, and a range of psychosocial, demographic, and background variables. Data were characterized by an apparently high degree of accuracy and completeness. CONCLUSIONS: Findings illustrate the importance and feasibility of standardized data-gathering approaches in routine clinical settings and clarify the hazards as well as the opportunities afforded by these research approaches. Such data-gathering tools appear to have significant merit and deserve further implementation and testing across a range of clinical and research settings.

Anxiety and depressive disorders in attention deficit disorder with hyperactivity: new findings.

OBJECTIVE: The authors examined the discriminant validity of the diagnosis of attention deficit disorder with hyperactivity. METHOD: They used standardized rating scales of life stresses and child and family functioning to assess psychosocial and family risk factors in 47 children who had the diagnosis of attention deficit disorder with hyperactivity, a matched group of 47 children in the community, and a matched group of 47 children seen in a psychiatric clinic. RESULTS: Children who had the diagnosis of attention deficit disorder and children in the psychiatric clinic reported significantly more depression and anxiety than did the children in the community; furthermore, children diagnosed as having attention deficit disorder with hyperactivity had more externalizing symptoms than did children in the psychiatric clinic. Children diagnosed as having attention deficit disorder with hyperactivity plus a comorbid anxiety or depressive disorder had higher levels of coexisting life stresses and parental symptoms than did children who had the single diagnosis of attention deficit disorder with hyperactivity. CONCLUSIONS: These results underscore the need for future studies to carefully assess children diagnosed as having attention deficit disorder with hyperactivity for concurrent psychiatric disorders as well as family and psychosocial stressors that may contribute to childhood symptoms. Such information is essential because different subtypes of attention deficit disorder with comorbid disorders may arise from different etiologic pathways, may require varying treatment options, and may foreshadow different eventual outcomes.

The "military family syndrome" revisited: "by the numbers".

Because concerns have been raised about high levels of psychopathology in military children, the authors used standardized psychopathology rating scales to survey 213 six-to twelve-year-old children of military parents and their parents. Results from children's symptom self-reports, as well as from teachers' ratings of children, indicated that children's symptom levels were at levels consistent with national norms. In contrast, parents' (especially mothers') ratings of children were significantly higher than national norms, as were parents' ratings of their own symptoms. Also, parents' own symptom reports showed somewhat stronger relationships with life stressors presumably affecting the child than did the children's and teachers' reports. Results suggest that parents' reports of children's symptoms may be mediated by the effects of military life stressors on the parents, but these stressors do not necessarily result in higher symptoms in the children. Overall results do not support the notion that levels of psychopathology are greatly increased in children of military parents. Further studies of military families should address the effects of rank and socioeconomic status, housing, and the current impact of life stressors on the parents as well as the children in order to avoid drawing erroneous conclusions about parts or all of the military community.

Consultation in the aftermath of an air tragedy.

In the early morning hours of December 12, 1985, a chartered jet airliner carrying 248 soldiers crashed shortly after takeoff, killing all aboard. The day after, the authors were designated as a consultation team to the mental health staff at Fort Campbell who were providing services in the aftermath of the crash. This report describes and analyzes the experiences of this consultation on disaster management. Our consulting experience has been one of the most profound and demanding events of our professional lives. Salient lessons of the consultation include: (a) the need to clarify leadership roles among the local mental health care team; (b) the need to help the local team establish clear roles among team members; (c) the value of enabling the local team to mourn the loss of their fellow soldiers and community members; and (d) the value of establishing a clear plan of mental health services for both short-term and long-term management.

Group psychotherapy in the treatment of adolescent and preadolescent military dependents with recurrent diabetic ketoacidosis.

The adolescent military dependent with recurrent diabetic ketoacidosis (DKA) is a difficult management problem. Career relocations and an absentee sponsor frequently preclude family-oriented interventions. We recently treated four patients with recurrent DKA who had failed to improve following intensive medical and educational programs. They were enrolled into weekly outpatient group psychotherapy in addition to routine medical management. Three out of the four patients improved in compliance and had a decrease in the frequency or severity of DKA. This approach may be effective when individual psychotherapy or lengthy hospitalization are either too far removed or too costly.

Diagnosis and treatment of attention deficit disorder in two general hospital clinics.

In two clinics in military general hospitals, the charts of all children with a presumptive diagnosis of attention deficit disorder who were prescribed psychostimulants (N = 68) were audited to assess the quality of the primary physicians' evaluation and treatment. The audit instrument, constructed by a multidisciplinary team, indicated high interrater reliabilities, high face and concurrent validity, and moderate internal consistency. The audit found that only 51.5 percent of the children being treated with psychostimulants met the audit criteria for attention deficit disorder. A school intervention plan was documented in only 16.2 percent of the cases, and a psychotherapy intervention in only 19.1 percent; low rates were also found for other treatment and follow-up criteria. Overall, the assessment, the follow-up care, and the overall quality of care were found to be inadequate or less than adequate in about two-thirds of the cases.

Father absence: effects on child and maternal psychopathology.

The effects of fathers' absences during the previous year on 213 military children were examined, using multiple measures of children's functioning and psychiatric symptoms. Children whose fathers had been absent 1 or more months during the previous 12 months experienced significantly higher self-reported depression and anxiety, but these symptoms were not apparent to adult observers (parents and teachers). These effects were not demonstrated when maternal psychiatric symptoms and intercurrent family stressors were controlled. Thus, the effects of father absence under routine conditions in relatively healthy samples may exert no significant effects independent of intervening family stressors or maternal psychopathology. Clinic referrals of children during times of father absence may partly be due to an effect of additional stressors impacting on the mother during the absence of the father.

Therapists' actions that influence their perceptions of "good" psychotherapy sessions.

Psychotherapists' and an independent observer's ratings of the "good" to "poor" quality of therapy sessions were correlated with their ratings of various therapist actions. As predicted, significant positive correlations were obtained between the goodness ratings and the emphasis given by therapists to actions encouraging patients' expression of thoughts and feelings and the exploration of their reactions. For a number of other actions, however, therapists and the independent observer disagreed about whether emphasis of the actions correlated with "good" or "poor" sessions. Some possible causes and implications of these differences are discussed.