Stressors and development: a reciprocal relationship.

In this article we have attempted to delineate the importance of developmental levels in a young person's response to stressors and, conversely, the effect of stressors on levels of development. In so doing, we isolated specific lines of development from their context. We neglected the important roles of rewards and punishments, permissions and prohibitions, family and community dynamics, values, stories and myths. Even in this simplified schema, we have not addressed the importance of protective and risk factors, neither of which are found in isolation; but all of these issues are the subject of articles elsewhere in this issue.

Dealing with stress and trauma in families.

Traditional models of individual adaptation to stress increasingly are being supplemented with family-based conceptualizations of stress appraisal, coping, and resiliency. This article begins with a brief description of a theoretic framework for understanding how families evaluate stressors and their own coping resources and how this process guides their response to stress. Characteristics associated with successful family adaptation to stress then are outlined in relation to a number of both normative and unexpected stressors. Most families at some point experience stress in the context of normative transitions, such as changes in family composition through birth, maturation, or family break-up. Severe unexpected stressors that place significant strain on family functioning include serious illness, death, violence, and both natural and man-made disasters. Recommendations for therapeutic interventions with families are provided.

Results of treatment one year later: child and adolescent partial hospitalization.

OBJECTIVE: One criticism of academicians is that they evaluate and disseminate outcome studies based more on the value and merit of the research design than on the utility of the findings for improving clinical practice. Increasing pressure on programs to evaluate the effectiveness of behavioral health care is transitioning outcome measurement from the exclusive domain of the researcher toward the clinical/organizational domain. To explore the multiple applications of such clinical outcome data, this article presents the results from a study of 114 patients completing treatment in two child and adolescent partial hospital programs. METHOD: Four areas define the scope of clinical outcome measurement pertinent to partial hospitalization: changes in the patient's clinical status, changes in the patient's level of daily functioning, impact on the utilization of behavioral health services after discharge, and patient/family satisfaction with treatment. Using these four domains, this study compares data assessed at admission and at 1 year postdischarge. RESULTS: Analyses used paired t tests primarily to measure change between admission and 1 year after discharge. Overall, the data show improvement in general functioning that remains evident up to 1 year postdischarge. CONCLUSIONS: Finding positive results in specific areas emphasized therapeutically--such as family functioning and use of community-based mental health resources after discharge, and the parent's attribution of improvement to experiences in treatment--provides justification for relating improvement to the treatment episode.

Physical and sexual abuse in childhood: relationship with post-traumatic stress disorder.

This study describes the reactions of children and adolescents to physical and/or sexual abuse, suggesting two distinct symptom pictures. Findings indicate that a majority (55%) of this clinical population develop symptoms characteristic of post-traumatic stress disorder, whereas abused children and adolescents who do not develop associated post-traumatic stress disorder symptoms exhibit more anxiety, depression, externalizing behaviors, and more problems overall. Significant differences were also found between children and adolescents reacting to single event abuse who display more behavior disorders and victims of ongoing abuse who appear significantly more disturbed, with symptoms ranging from depression to psychosis.

Treatment protocols in child and adolescent day treatment.

Twenty treatment protocols in a day treatment program for children and adolescents have been developed by multidisciplinary groups based on a review of 200 patients. The protocols classify patients according to symptom clusters and provide standardized treatment plans for each classification. Each protocol contains a definition of the symptom cluster, a list of presenting problems, a list of other protocols to consider, admission guidelines, treatment options, and discharge criteria. The authors describe the developmental process for the protocols and present a clinical case example to illustrate their use. The application of treatment protocols in research, quality assurance, and teaching is briefly discussed.

Testing the limits: special treatment procedures for child and adolescent partial hospitalization.

How does a child and/or adolescent partial hospitalization program structure care for patients who are suicidal, assaultive, or combative or using drugs? Special treatment procedures designed for use in child and adolescent partial hospitalization programs must adequately address the issue of safety and involve the family and the community, while maintaining the patient in the least-restrictive environment. This paper deals with management of child and adolescent partial hospitalization patients whose behavior and level of impulsivity have escalated to the point where they require special programs. Special treatment procedures for dealing with patients displaying aggressive, acting-out behaviors, noncompliance with program rules, suicidal or runaway ideation, and drug usage are described.

Child and adolescent day treatment: population profile.

This paper presents the demographic and clinical data necessary to define the population of children and adolescents served in a model day treatment program. On the day of admission, patients (N = 204) and parents complete a batter of instruments designed to measure reliably characteristics of the patient's system at three levels: individual, parental, and family. Design of the assessment establishes comparisons among self-report, parent/other report, and clinician report measures at each subsystem level. Results of the CBCL, YSR, PIC, Piers-Harris, MCMI, DAS, and FES indicate moderate levels of disturbance, usually consistent with norms reported on referred or clinical populations. Patients are being treated for a wide variety of childhood disorders within systems demonstrating dysfunction at parental, marital, and familial levels.

A comparison of intensive psychiatric services for children and adolescents: cost of day treatment versus hospitalization.

Proponents of day treatment for children and adolescents assert that this mode of intervention is a viable alternative to hospitalization based on both treatment and cost effectiveness. Preliminary studies on treatment effectiveness are beginning to appear in the literature. This paper focuses on the relative cost difference of treating children and adolescents in a day-treatment program vs three inpatient-hospital settings. The study finds that the populations in the two settings are similar with regard to demographic and diagnostic characteristics and that day treatment is significantly less costly on a daily basis. A conservative conclusion, based on the findings reported, is that over the course of treatment partial hospitalization is equal or less costly than hospitalization. The authors conclude that further research exploring both treatment efficacy and cost effectiveness is in order to define what role day treatment should serve in the continuum of mental health-care services for children and adults.

Psychological factors affecting children's response to medical procedures: a guideline for clinicians.

The effects of major technologic interventions on children are acknowledged and a focus is made on the less extensive diagnostic interventions. Selected aspects of childhood development are reviewed to examine the possible effects a diagnostic procedure might have on a child. The authors conclude that the possible psychological effects of a diagnostic procedure should be considered by the physician ordering the test.

A survey of child and adolescent day-treatment programs: establishing definitions and standards.

A survey of 82 programs operating nationally is used to assess the present status of child and adolescent day-treatment services. Overwhelming variability in the responses leads the authors to suggest criteria for standards and definition. Survey results are presented for programming issues, patients, staff, clinical issues, funding, and research, followed by specific recommendations in each area. The authors conclude that without substantial changes toward standardization, child and adolescent day-treatment programs will continue to struggle in the highly competitive mental health-care market.

Affective disorders in referred children and younger siblings of manic-depressives. Mode of onset and prospective course.

We studied 68 referred juvenile offspring or siblings of adult bipolar patients. Mean age at onset of affective and related disturbances was 15.9 years (range, 6 to 24 years). Although four of the ten prepubertal children had hypomanic features, full-blown manic psychosis did not appear before puberty. In the sample at large, 12 were classified as dysthymic and ten as cyclothymic. Eleven additional subjects with polysubstance abuse, who at onset did not meet criteria for affective disorder, were reclassified as having either a dysthymic or a cyclothymic disorder during follow-up. Of the remaining patients--24 depressive, eight manic, and three mixed state--71% experienced recurrences; mood-incongruent features, present in four cases at onset, recurred in only one patient during subsequent episodes. Overall, half the sample evidenced signs of bipolarity during a mean prospective follow-up period of three years.

Child and adolescent day treatment: a descriptive analysis of a model program.

Since the inception of the University of Tennessee Child and Adolescent Day Treatment Program in 1982, a total of 53 patients has received services. This paper provides a broad overview of the patient population as well as descriptive data accumulated during the first 18 months of operation of the program. Several factors which determined patient eligibility and availability are briefly described. Special attention is given to the following variables: (1) age, (2) sex, (3) referral source to the program, (4) diagnosis, (5) length of stay in the program, and (6) discharge disposition. Interrelationships among these variables are also discussed.