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Impairing emotional outbursts, defined by extreme anger or distress in response to relatively ordinary frustrations and disappointments, impact all mental health care systems, emergency departments, schools, and juvenile justice programs. However, the prevalence, outcome, and impact of outbursts are difficult to quantify because they are transdiagnostic and not explicitly defined by current diagnostic nosology. Research variably addresses outbursts under the rubrics of tantrums, anger, irritability, aggression, rage attacks, or emotional and behavioral dysregulation. Consistent methods for identifying and assessing impairing emotional outbursts across development or systems of care are lacking.The American Academy of Child and Adolescent Psychiatry Presidential Task Force (2019-2021) conducted a narrative review addressing impairing emotional outbursts within the limitations of the existing literature and independent of diagnosis.Extrapolating from the existing literature, best estimates suggest that outbursts occur in 4%-10% of community children (preschoolers through adolescents). Impairing emotional outbursts may respond to successful treatment of the primary disorder, especially for some children with attention-deficit/hyperactivity disorder whose medications have been optimized. However, outbursts are generally multi-determined and often represent maladaptive or deficient coping strategies and responses.Evidence-based strategies are necessary to address factors that trigger, reinforce, or excuse the behaviors and to enhance problem-solving skills. Currently available interventions yield only modest effect sizes for treatment effect. More specific definitions and measures are needed to track and quantify outbursts and to design and assess the effectiveness of interventions. Better treatments are clearly needed.

U.S. reports show a decreasing preference for residential care placements within child welfare: In the past five years there has been a 25% decline. Child welfare utilization rates for residential care are comparatively low, but data gaps exist for private placements and those in mental health and behavioral health residential settings. Recent national child welfare reform legislation (Family First) sets out standards and requirements for a class of short-term, treatment-focused residential treatment programs with strict standards for use. The chapter concludes with a standardized matrix that provides information on the current policy context, key trends and initiatives, characteristics of children and youth served, preparation of residential care personnel, promising programmatic innovations, and present strengths and challenges.

Intellectual disability (intellectual developmental disorder) (ID/IDD) is both a psychiatric disorder and a risk factor for co-occurring psychiatric disorders in children and adolescents. DSM-5 introduced important changes in the conceptualization and diagnosis of ID/IDD, and current research studies clarify assessment and treatment of co-occurring psychiatric disorders in this population. Optimal assessment and treatment of psychiatric illness in children and adolescents with ID/IDD includes modifications in diagnostic and treatment techniques, appreciation of variations in the clinical presentation of psychiatric disorders, an understanding of the spectrum of etiologies of behavioral disturbance, and knowledge of psychosocial and medical interventions.

Children hospitalized in inpatient and residential treatment facilities often present with severe emotion dysregulation, which is the result of a wide range of psychiatric diagnoses. Emotion dysregulation is not a diagnosis but is a common but inconsistently described set of symptoms and behaviors. With no agreed upon way of measuring emotion dysregulation, the authors summarize the existing contemporary treatment focusing on proxy measures of emotion dysregulation in inpatient and residential settings. Interventions are summarized and categorized into individual- and systems-level interventions in addressing aggressive behaviors. Going forward, dysregulation will need to be operationalized in a standard way.

Objective: Prescription of multiple medications concurrently for children and adolescents has increased in recent years. Examination of this practice has been undervalued relative to its incidence....

In this debate article, we provide our thoughts and reflections on the issues and uses of Therapeutic Residential Care (TRC) in child welfare systems in the US and England. We highlight the issues associated with the lack of clarity of how TRC is defined and when and how it is used. The premise for the article is that some of our most vulnerable young people are living in residential homes without there being a sufficient evidence base to understand whether their needs are being adequately met, or the best outcomes are being achieved. We set out some suggested elements to try to progress debates and decisions that will ultimately improve the services and placements that are provided.

The purpose of this paper is to examine similarities and differences in recent English and U.S. initiatives which impact the residential child care sector. The English section summarizes the cataly...

Youth in the U.S. foster care system are prescribed risky psychotropic medications at high rates. In response, state child welfare agencies have developed policies, yet there is little rese...

This Practice Parameter is a revision of a previous Parameter addressing reactive attachment disorder that was published in 2005. It reviews the current status of reactive attachment disorder (RAD) and disinhibited social engagement disorder (DESD) with regard to assessment and treatment. Attachment is a central component of social and emotional development in early childhood, and disordered attachment is defined by specific patterns of abnormal social behavior in the context of "insufficient care" or social neglect. Assessment requires direct observation of the child in the context of his or her relationships with primary caregivers. Treatment requires establishing an attachment relationship for the child when none exists and ameliorating disturbed social relatedness with non-caregivers when evident.

Objective Rapid growth of antipsychotic use among children and adolescents at the turn of the 21st century led Medicaid programs to implement 3 types of system-wide interventions: antipsychotic monitoring programs, clinician prescribing supports, and delivery system enhancements. This systematic review assessed the available evidence base for and relative merits of these system-wide interventions that aim to improve antipsychotic treatment and management. Method Using PRISMA guidelines, eligible studies were written in English and evaluated system-wide interventions to monitor antipsychotic treatment or promote antipsychotic management among children and adolescents (0–21 years of age). Studies were identified through Ovid MEDLINE and PsychInfo (years 1990–2018) and an environmental scan. From an initial review of 824 publications, 17 studies met eligibility criteria. Two authors independently conducted quality assessments using the Crowe Critical Appraisal Tool. Findings were summarized descriptively. Results Identified studies (n = 17) evaluated prior authorization programs (n = 10), drug utilization reviews (n = 2), quality improvement (n = 4), care coordination programs (n = 1), and multimodal initiatives (n = 2). Studies were predominantly pre-post analyses, without a comparison group. With the exception of care coordination and drug utilization reviews, more than half of the interventions in each category were associated with significant reduction in antipsychotic treatment or promotion of best practice parameters. Conclusion This evidence review concludes that evaluations of prior authorization programs demonstrate reductions in antipsychotic treatment, though evidence of impact of other system-wide interventions and other outcomes is limited. Additional research is necessary to investigate whether interventions influenced antipsychotic prescribing independent of secular trends, the comparative effectiveness and cost-effectiveness of interventions, the effect on functional outcomes, and the potential for unintended consequences.

This is the eleventh in a series of papers issued by the Association of Children’s Residential Centers (ACRC) regarding key issues faced by the field in response to emerging research, policy, and best practice. This paper builds on the previous papers in the Redefining Residential Series to address psychotropic medication use in residential treatment. Evidence for use of psychotropic medication with children and youth and the complications presented by youth typically served in residential centers are reviewed. Several critical practices residential programs should consider implementing are identified. Barriers to successful implementation are examined. A call is made for increased emphasis on what is described as rational use of psychotropic medications, prescribed in conjunction with other treatment modalities and careful monitoring of progress and outcomes.

In many developed countries around the world residential care interventions for children and adolescents have come under increasing scrutiny. Against this background an international summit was organised in England (spring 2016) with experts from 13 countries to reflect on therapeutic residential care (TRC). The following working definition of TRC was leading: "Therapeutic residential care involves the planful use of a purposefully constructed, multi-dimensional living environment designed to enhance or provide treatment, education, socialization, support, and protection to children and youth with identified mental health or behavioural needs in partnership with their families and in collaboration with a full spectrum of community based formal and informal helping resources". The meeting was characterised by exchange of information and evidence, and by preparing an international research agenda. In addition, the outlines of a consensus statement on TRC were discussed. This statement, originally published in English and now reproduced in a Dutch translation, comprises inter alia five basic principles of care that according to the Work Group on Therapeutic Residential Care should be guiding for residential youth care provided at any time.

[Author Affiliation]Presenters: Revital Racin. 1 Tufts Medical Center, Department of Psychiatry, Boston, Massachusetts.Christopher Bellonci. 1 Tufts Medical Center, Department of Psychiatry, Boston, Massachusetts.Discussant: Barbara J. Coffey. 2 Icahn School of Medicine at Mount Sinai, Department of Psychiatry, New York, New York.Address correspondence to: Barbara J. Coffey, MD, MS, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1230, New York, New York 10029, E-mail: Barbara.coffey@mssm.eduChief Complaint and Presenting ProblemM. was a 10-year-old African American boy with a history of attention deficit hyperactivity disorder (ADHD) and significant childhood trauma referred for hospitalization by his legal guardian for increased aggressive behavior and suicidal ideation.History of Present IllnessM. was removed from his biological mother's home for neglect approximately one and half years prior to hospitalization. He was subsequently placed under the legal guardianship of A., his 21-year-old half-sister. M. has had aggressive behavior problems since he moved to live with A. During the past year, M. has made homicidal statements toward A. and wrote with chalk on their apartment building that he wanted to 'kill" her. He was also physically aggressive toward his peers (e.g., punching an age-mate in the face) and brother (choking him during an altercation) and assaultive with school staff. A. reported that M. tended to "forget" incidents of aggression and often stated that he "can't remember what happened." A. stated that M. has had one isolated fire-setting incident when he was 7 years old. Additionally, A. reported that M. often lied, stole, and wrote statements expressing hatred for life and a desire to kill himself. M. was suspended from school as a consequence of his behaviors. A. reported that M.'s aggression and suicidality increased particularly when he was in unstructured environments and when limits were set by authority figures. Limits such as time-outs at home and school had proven ineffective.M. had recently started treatment with an outpatient psychiatrist who diagnosed ADHD and treated him with guanfacine 1 mg in the morning and 0.5 mg in the afternoon and amphetamine mixed salts extended release 5 mg daily. A. and the outpatient child and adolescent psychiatrist reported an increase in aggression, oppositional behavior, and suicidal and homicidal ideation over the course of several weeks prior to admission.M. was referred for voluntary admission to an inpatient child and adolescent psychiatry unit after wrapping a wire around his neck. He had expressed a desire to hang himself at school after getting into trouble. There was no reported precipitant or change in his environment that could explain his increased aggression and suicidality in the weeks leading up to admission. The amphetamine mixed salts had reportedly increased his aggressive behavior, and were discontinued a few days prior to his hospitalization. At the time of admission M. was taking guanfacine 1 mg in the morning and 0.5 mg at bedtime, which by A.'s reports only initially ameliorated impulsive and aggressive behaviors.Past Psychiatric HistoryM. had no prior inpatient psychiatric admissions. At the time of admission, M. was seeing a child and adolescent psychiatrist and an individual therapist, and met once weekly with a guidance counselor at his school.Developmental HistoryM. may have been exposed to illicit substances in utero due to a maternal substance abuse history. A full developmental history was not available. Biological mother and legal guardian provided no information regarding his developmental milestones or early development.Educational HistoryM. was currently in the fourth grade and reportedly performing well academically. He did not have a 504 plan and/or an individualized education plan. …

Over the past decade, the level of clinical needs of youth in residential treatment has increased significantly. Youth in out-of-home settings typically experience higher levels of psychotropic medication use than their peers living at home, even when controlling for the severity of clinical issues. The purpose of the current study was to examine the effects of an approach to clinically reassess psychotropic medication utilization for youth residing in residential treatment settings while also observing the impact on the youth's need for physical containment. Medication changes were based on a data-informed process, using input from a multi-disciplinary treatment team. Data for 531 youth who were consecutively admitted to one of two non-affiliated intensive residential treatment programs, one in the Midwest and one in New England, was analyzed. Over half of these youth (n = 292, 55%) had their medications reduced during their stay and only 14% (n = 76) were prescribed more medication at discharge than they had been taking at admission. The remainder either saw no change during their stay (n = 104, 20%) or were never on medication at any time (n = 59, 11%). From admission to discharge there was a 62% decrease in the number of assaultive incidents as well as a 72% decrease in the use of physical restraints. These results support the view that residential treatment can provide a treatment milieu that allows for thoughtful reassessment of the clinical basis for behavioral disorders in children that can achieve the dual goals of medication reduction and behavioral stabilization.

none 32 si The International Work Group for Therapeutic Residential Care convened an International Summit on ‘Pathways to Evidence-Based Practice’ at Loughborough University (GBR), Centre for Child and Family Research on 27-29 April, 2016 with generous support from the Sir Halley Stewart Trust and in partnership with The European Scientific Association on Residential and Family Care for Children and Adolescents (NLD) (EUSARF), the International Association for Outcome-Based Evaluation and Research on Family and Children’s Services (ITA) (IAOBER) and the Association of Children’s Residential Centers (USA) and with the additional support of Action for Children (GBR) and the National Implementation Service (NIS) (GBR). Membership includes: Lisa Holmes (Chair), Director, Centre for Child and Family Research, Loughborough University (GBR); James K. Whittaker (Co-Chair), Charles O. Cressey Endowed Professor Emeritus, University of Washington, School of Social Work, Seattle (USA); Jorge Fernandez del Valle, Professor of Psychology and Director, Child and Family Research Group, University of Oviedo (ESP); Frank Ainsworth, Senior Principal Research Fellow (Adjunct), James Cook University, School of Social Work and Human Services, Townsville, Queensland (AUS); Tore Andreassen, Psychologist, The Norwegian Directorate for Children, Youth and Family Affairs (NOR); James P. Anglin, Professor, Faculty of the School of Child and Youth Care, University of Victoria (CAN); Christopher Bellonci, Board-Certified Child/Adolescent and Adult Psychiatrist; Associate Professor, Psychiatry Department, Tufts University School of Medicine, Boston, MA (USA); David Berridge, Professor of Child and Family Welfare, School for Policy Studies, University of Bristol (GBR); Amaia Bravo, Lecturer, Department of Psychology, University of Oviedo (ESP); Cinzia Canali, Senior Researcher, Fondazione Emanuela Zancan, Padova (ITA) and President, International Association of Outcome-Based Evaluation and Research in Family and Children’s Services (IAOBER); Mark Courtney, Professor, School of Social Service Administration, University of Chicago (USA); Laurah Currey, Chief Operating Officer, Pressley Ridge, Pittsburgh, PA (USA) and President, Association for Children’s Residential Centers, (USA); Daniel. L. Daly, Executive Vice President and Director of Youth Care, Father Flanagan’s Boys’ Home, Boys Town, NE (USA); Robbie Gilligan, Professor of Social Work and Social Policy, Trinity College Dublin IRE), Hans Grietens, Professor, Centre for Special Needs Education & Youth Care, University of Groningen (NLD) and President, European Scientific Association on Residential and Family Care for Children and Adolescents (EUSARF); Annemiek T. Harder, Assistant professor, Department of Special Needs Education and Youth Care, University of Groningen (NLD); Martha J. Holden, Senior Extension Associate with the Bronfenbrenner Center for Translational Research and the Principal Investigator and Director of the Residential Child Care Project at Cornell University, Ithaca, NY (USA); Sigrid James, Professor, Department of Social Work & Social Ecology, School of Behavioral Health, Loma Linda University, CA (USA); Andrew Kendrick, Professor of Residential Child Care, School of Social Work and Social Policy at the University of Strathclyde (GBR) and Consultant at the Centre of Excellence for Looked After Children in Scotland (CELCIS) and the Centre for Youth and Criminal Justice (CYCJ) (UK); Erik J. Knorth, Professor, Department of Special Needs Education and Youth Care, University of Groningen (NLD); Mette Lausten, Senior Researcher at SFI - The Danish National Centre for Social Research, Copenhagen (DNK), John S. Lyons, Senior Policy Fellow at Chapin Hall, University of Chicago, IL (USA); Eduardo Martin, Lecturer at the Department of Developmental and Educational Psychology, University of La Laguna, Tenerife (ESP); Samantha McDermid, Research Fellow, Centre for Child and Family Research, Loughborough University (GBR); Patricia McNamara, Senior Fellow (Honorary), Department of Social Work, University of Melbourne (AUS); Laura Palareti, Assistant Professor in Social Psychology, Department of Education Studies, University of Bologna (ITA); Susan Ramsey, Parent and Former Children’s Mental Health Advocate, The Walker School, Needham, MA (USA); Kari M. Sisson, Executive Director, Association of Children’s Residential Centers (USA); Richard W. Small, Walker Executive Director Emeritus, The Walker School, Needham, MA (USA); June Thoburn, Emeritus Professor of Social Work, University of East Anglia (GBR); Ronald Thompson, Senior Director, Boys Town National Research Institute for Child and Family Studies, Boys Town, NE (USA); Anat Zeira, Professor, School of Social Work and Social Welfare, Hebrew University of Jerusalem, and Head of Research and Evaluation at the Haruv Institute (ISR). Our work group wishes to thank CFRC staffer Laura Dale at Loughborough for extraordinary efforts in producing this statement in record time and for her care and assistance with all phases of our Summit activity. Whittaker, James K; Holmes, Lisa; del Valle, Jorge F.; Ainsworth, Frank; Andreassen, Tore; Anglin, James; Bellonci, Christopher; Berridge, David; Bravo, Amaia; Canali, Cinzia; Courtney, Mark; Currey, Laurah; Daly, Daniel; Gilligan, Robbie; Grietens, Hans; Harder, Annemiek; Holden, Martha; James, Sigrid; Kendrick, Andrew; Knorth, Erik; Lausten, Mette; Lyons, John; Martin, Eduardo; Mcdermid, Samantha; Mcnamara, Patricia; Palareti, Laura; Ramsey, Susan; Sisson, Kari; Small, Richard; Thoburn, June; Thompson, Ronald; Zeira, Anat Whittaker, James K; Holmes, Lisa; del Valle, Jorge F.; Ainsworth, Frank; Andreassen, Tore; Anglin, James; Bellonci, Christopher; Berridge, David; Bravo, Amaia; Canali, Cinzia; Courtney, Mark; Currey, Laurah; Daly, Daniel; Gilligan, Robbie; Grietens, Hans; Harder, Annemiek; Holden, Martha; James, Sigrid; Kendrick, Andrew; Knorth, Erik; Lausten, Mette; Lyons, John; Martin, Eduardo; Mcdermid, Samantha; Mcnamara, Patricia; Palareti, Laura; Ramsey, Susan; Sisson, Kari; Small, Richard; Thoburn, June; Thompson, Ronald; Zeira, Anat

This study uses data collected from multi-state interviews, document review, and the U.S. Census to provide a national perspective on the policies and practice guidelines for mental health evaluation and psychotropic medication oversight among youth in foster care within 47 states and the District of Columbia. This study specifically employs descriptive statistics and logistic regression models to examine various components of these policies/guidelines and the state characteristics and organizational structure associated with the presence of a policy/guideline for mental health evaluation and psychotropic medication oversight. Almost half of states (47.9%) endorsed a mental health evaluation in policies/guidelines; policies/guidelines varied with respect to specific sub-populations targeted and the components of the evaluation. Over half of states (52.7%) held policies/guidelines for psychotropic medication oversight with substantial variation in populations and medications covered, and in the mechanism for psychotropic medication oversight (e.g., informed consent, child- and population-level monitoring). Organizational structure, specifically staffing both a medical and mental health director, and percentage of urban land area (i.e., Metropolitan Statistical Area) were associated with presence of policies/guidelines. Implications for federal and state implementation of the Fostering Connections to Success and Increasing Adoptions Act (Public Law 110–351) and future research on child welfare policy are discussed.

Many different programs define themselves or are defined as residential treatment centers (RTCs). These range from small, freestanding, private, nonprofit programs to subacute units within large, for-profit health care systems. This article focuses on the role of the physician leader in community-based, nonmedical institutions. First, the physician's role in an RTC is to optimize clinical outcomes through direct service, teaching, training, coaching, and consulting with the child and family and the child care, multidisciplinary, educational, and administrative staff. Physician leaders are needed to integrate and translate the various assessments of the child's needs and strengths into a coherent narrative that can be used for treatment planning within the RTC and in the child's home and community. Second, physician leadership can help ensure that programs remain family-centered and that they use the best available evidence-based practices. Third, physician leaders must help the RTC to develop and sustain its unifying theory of treatment and to use this theory to guide its practice, mission, and vision. Physician leaders in RTC must be "trilingual and tricultural" and adept in the mental health, special education, and child welfare systems to be effective advocates for youth and their families.

This parameter reviews the current state of the prevention and management of child and adolescent aggressive behavior in psychiatric institutions, with particular reference to the indications and use of seclusion and restraint. It also presents guidelines that have been developed in response to professional, regulatory, and public concern about the use of restrictive interventions with aggressive patients with regard to personal safety and patient rights. The literature on the use of seclusion, physical restraint, mechanical restraint, and chemical restraint is reviewed, and procedures for carrying out each of these interventions are described. Clinical and regulatory agency perspectives on these interventions are presented. Effectiveness, indications, contraindications, complications, and adverse effects of seclusion and restraint procedures are addressed. Interventions are presented to provide more opportunities to promote patient independence and satisfaction with treatment while diminishing the necessity of using restrictive procedures.

When compared with the general United States child population, children entering foster care have elevated rates of mental health problems. This study examines: (1) state approaches to mental health evaluations for children entering foster care for the first time, (2) the consistency of these approaches with professional guidelines, and (3) whether the specific instruments endorsed are supported by available evidence. Semi-structured qualitative interviews and a document review of available protocols/policies were conducted for 47 states and the District of Columbia. All states endorsed mental health evaluations; variation existed between states in approach, timeframe, administrator, and specific instruments endorsed.

The Best Practices for Mental Health in Child Welfare Consensus Conference focused on developing guidelines in five key areas (screening and assessment, psychosocial interventions, psychopharmacologic treatment, parent engagement, and youth empowerment) related to children's mental health. This paper provides an overview of issues related to the first three areas, presents the guidelines developed in these areas, and discusses the implications these guidelines have for the field of child welfare.

Objective Second-generation antipsychotics (SGAs) have increasingly been prescribed to Medicaid-enrolled children; however, there is limited understanding of the frequency of concurrent SGA prescribing with other psychotropic medications. This study describes the epidemiology of concurrent SGA use with 4 psychotropic classes (stimulants, antidepressants, mood stabilizers, and α-agonists) among a national sample of Medicaid-enrolled children and adolescents 6 to 18 years old between 2004 and 2008. Method Repeated cross-sectional design was used, with national Medicaid Analytic eXtract data (10.6 million children annually). Logit and Poisson regression, standardized for year, demographics, and Medicaid eligibility group, estimated the probability and duration of concurrent SGA use with each medication class over time and examined concurrent SGAs in relation to clinical and demographic characteristics. Results While SGA use overall increased by 22%, 85% of such use occurred concurrently. By 2008, the probability of concurrent SGA use ranged from 0.22 for stimulant users to 0.52 for mood stabilizer users. Concurrent SGA use occurred for long durations (69%–89% of annual medication days). Although the highest users of concurrent SGA were participants in foster care and disability Medicaid programs or those with behavioral hospitalizations, the most significant increases over time occurred among participants who were income-eligible for Medicaid (+13%), without comorbid ADHD (+15%), were not hospitalized (+13%), and did not have comorbid intellectual disability (+45%). Conclusion Concurrent SGA use with other psychotropic classes increased over time, and the duration of concurrent therapy was consistently long term. Concurrent SGA regimens will require further research to determine efficacy and potential drug–drug interactions, given a practice trend toward more complex regimens in less-impaired children/adolescents.

Residential treatment is a potentially powerful intervention for children and families, currently facing the imperative to fundamentally change practice models to achieve greater quality efficacy, efficiency, and effectiveness. Such transformation is best accomplished from a solid foundation which is created by licensing, regulation, accereditation, and internal standards.

In veel ontwikkelde landen wordt in toenemende mate kritiek geleverd op residentiële interventies bij kinderen en jongeren. Tegen de achtergrond hiervan vond in het voorjaar 2016 in Engeland een internationale conferentie plaats van experts uit 13 landen op het gebied van therapeutische residentiële zorg (TRZ). De volgende werkdefinitie van TRZ was leidend: "Therapeutische residentiële zorg omvat het geplande gebruik van een speciaal hiervoor ontwikkelde, multidimensionale leefomgeving, die tot doel heeft behandeling, onderwijs, socialisatie, ondersteuning en bescherming te bieden of te versterken voor kinderen en jongeren met welomschreven psychische en/of gedragsmatige problematiek; dit in samenwerking met hun gezin/familie en een breed scala aan formele en informele hulpbronnen in de samenleving". De bijeenkomst stond in het teken van kennisuitwisseling en het ontwikkelen van een internationale onderzoeksagenda. Tevens werden de contouren van een consensusverklaring over TRZ besproken. Deze verklaring, die hier integraal wordt weergegeven, omvat onder meer vijf basisprincipes van zorg, die in de visie van de Werkgroep TRZ altijd richtinggevend dienen te zijn voor goede residentiële jeugdhulp.