Kaplan + Sadock's Synopsis of Psychiatry, 11e

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31.19a Forensic Issues in Child Psychiatry

however, the drug-taking behavior typically requires interven- tion. Substance abuse treatments typically include a 12-step program with behavioral monitoring to accomplish sobriety as well as the ability to verbalize regarding the motivations for sub- stance use. These philosophies are adapted to inpatient, inten- sive outpatient, and once-a-week outpatient treatment. Suicide Suicide is the third leading cause of death among adolescents. Many hospital admissions of adolescents result from suicidal ideation or behavior. Among adolescents who are not psychotic, the highest suicidal risks occur in those who have a history of parental suicide, who are unable to form stable attachments, who display impulsive behavior, and who abuse alcohol or other substances. Many adolescents who complete suicide have back- grounds that include long-standing family conflict and social problems since early childhood and the escalation of subjective distress under the pressure of a sudden perceived conflict or loss. Early childhood loss of parents also can increase the risk of depression in adolescence. Adolescents who are susceptible to rapid and extreme mood swings and a history of impulsive behavior are at greater risk of responding to despair with impul- sive suicide attempts. Abuse of alcohol and other substances are known added risks for suicidal behavior in adolescents with suicidal ideations. The developmentally predictable “omnipo- tent” attitudes of adolescents may cloud the immediate sense of permanence of death and result in impulsive self-destructive behavior in adolescents. During a psychiatric evaluation of an adolescent with suicidal thoughts, plans and past attempts must be discussed directly when the concern arises and information is not volunteered. Recurring suicidal thoughts should be taken seriously, and a clinician must evaluate the imminent clinical danger requiring inpatient hospitalization versus an adolescent’s ability to engage in an agreement or contract mandating that the adolescent will seek help before engaging in self-destructive behavior. Adoles- cents typically are honest in their refusal of such agreements, and, in such cases, hospitalization is indicated. Hospitalization of a suicidal adolescent by a clinician is an act of serious, pro- tective concern. R eferences Beresin EV, Schlozman SC. The treatment of adolescents. In: Sadock BJ, Sadock VA, Ruiz, P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9 th ed. Vol. 2. Philadelphia: Lippincott Williams & Wilkins; 2009:3777. Biegel GM, Brown KW, Shapiro SL, Schubert CM. Mindfulness-based stress reduction for the treatment of adolescent psychiatric outpatients: A randomized clinical trial. J Consult Clin Psychol. 2009;5:855–866. Connor DF, McLaughlin TJ, Jeffers-Terry M, O’Brien WH, Stille CJ, Young LM, Antonelli RC. Targeted child psychiatric services: A new model of pediatric primary clinician–child psychiatry collaborative care. Clin Pediatr (Phila). 2006;45:423. Laugeson EA, Frankel F, Gantman A, Dillon AR, Mogil C. Evidence-based social skills training for adolescents with autism spectrum disorders: The UCLA PEERS Program. J Autism Dev Disord. 2012;42:1025–1036. Leckman JF. The risks and benefits of antidepressants to treat pediatric-onset depression and anxiety disorders: A developmental perspective. Psychother Psychosom. 2013;82(3):129–131. Lundh A, Forsman M, Serlachius E, Lichtenstein P, Landen M. Outcomes of child psychiatric treatment. Acta Psychiatr Scand. Jul 2013;128(1):34–44. Mathyssek CM, Olino TM, Hartman CA, Ormel J, Verhulst FC, Van Oort FV. Does the Revised Child Anxiety and Depression Scale (RCADS) measure anxiety symptoms consistently across adolescence? The TRAILS study. Int J Methods Psychiatric Res. Mar 2013;22(1):27–35.

Mufson L, Dorta KP, Wickramaratne P, Nomura Y, Olfson M, Weissman MM. A randomized effectiveness trial of interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry. 2004;61(6):577. Nevels RM, Dehon EE, Gontkovsky ST, Alexander K. Psychopharmacology of aggression in children and adolescents with primary neuropsychiatric disor- ders: A review of current and potentially promising treatment options. Exp Clin Psychopharmacol. 2010;8:184–201. Olfson M, Marcus SC, Shaffer D. Antidepressant drug therapy and suicide in severely depressed children and adolescents: A case-control study. Arch Gen Psychiatry. 2006;63:865. Richardson T, Stallard P, Velleman S. Computerised cognitive behavioural therapy for the prevention and treatment of depression and anxiety in children and ado- lescents: A systematic review. Clin Child Fam Psychol Rev. 2010;13:275–290. Romano E, Zoccolillo M, Paquette D. Histories of child maltreatment and psy- chiatric disorder in pregnant adolescents. J Am Acad Child Adolesc Psychiatry. 2006;45:329. Seidman LJ. Neuropsychological functioning in people with ADHD across the lifespan. Clin Psychol Rev. 2006;26:466. Stallard P, Sayal K, Phillips R, Taylor JA, Spears M, Araya R. Classroom based cognitive behavioral therapy in reducing symptoms of depression in high risk adolescents: pragmatic cluster randomised controlled trial. BMJ. 2012;345:e6058.

▲▲ 31.19 Child Psychiatry: Special Areas of Interest

31.19a Forensic Issues in Child Psychiatry

Forensic evaluations of youth span a broad spectrum of situ- ations and settings, including child custody during a parental divorce, trauma and abuse situations, and juvenile offender evaluations pertaining to juvenile and criminal court cases. Child and adolescent psychiatrists are increasingly being sought out by patients and attorneys for evaluations and expert opinions related to child sexual and physical abuse, to criminal behaviors perpetrated by minors, and to evaluate the relations between traumatic life events and the emergence of psychiat- ric symptoms in children and adolescents. As more youth enter the juvenile justice system, an increasing need exists for foren- sic psychiatrists with expertise in evaluation and treatment for detainees and committed youths. The specific tasks and role of a child and adolescent psychi- atric forensic evaluator are distinctly different from a child and adolescent psychiatrist doing a clinical evaluation and clinical treatment intervention. In clinical settings, child mental health professionals provide psychotherapy, medication evaluations, and advocacy for youth with psychiatric diagnoses. As a foren- sic child psychiatric evaluator, however, the main task is to be an expert, to report objective psychiatric findings related to the questions asked. Two essential characteristics of a forensic eval- uator, in contrast to a clinician are (1) the relationship between the evaluator and the patient is not therapeutic, rather, it is infor- mation seeking, and (2) there are clear limits of confidential- ity in this situation, that is, the information disclosed during a forensic evaluation may be brought to court, or to an attorney, or to whomever initiated the evaluation. Society’s view of children and their rights has evolved dra- matically. In 1980, the American Academy of Child and Ado- lescent Psychiatry (AACAP) published a code of ethics that