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The Use of EMDR Therapy with Adolescents in Juvenile Detention Centers

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The Use of EMDR Therapy with Adolescents in Juvenile Detention Centers

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The Impact of Medication on Teen Mental Health Counseling Outcomes

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The Impact of Medication on Teen Mental Health Counseling Outcomes

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Addressing Mental Health Stigma in Teens Receiving Court-Mandated Counseling

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Addressing Mental Health Stigma in Teens Receiving Court-Mandated Counseling

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Mandated Treatment and Its Impact on Therapeutic Process and Outcome Factors

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Mandated Treatment and Its Impact on Therapeutic Process and Outcome Factors

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In this narrative review, researchers examined how court-mandated treatment affects the therapeutic process and outcomes, specifically in forensic and substance abuse contexts. They analyzed studies involving individuals required by the legal system to attend therapy, focusing on how coercion, stigma, and the therapist's role influence motivation, therapeutic alliance, and satisfaction. The findings suggest that legal mandates do not necessarily lead to perceived coercion or reduce treatment satisfaction, especially when therapists adopt a caring yet authoritative stance. Effectiveness was also noted in reducing recidivism. The authors conclude that mandated treatment can be effective, provided it's delivered within a strong therapeutic relationship and with attention to client autonomy (Hachtel et al., 2019).

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Abstract

Court-mandated treatments imply a dual role for therapy providers not only of caring for, but also of having control over, involuntary clients. The impact of legal coercion on the therapeutic relationship and feelings of stigma is widely regarded as negative and detrimental for treatment outcomes. This point of view stands in contrast to advocates of the perspective that involuntary treatment can ameliorate social functioning and thus promote a better quality of life. Regarding other outcome measures, there is evidence that offender treatment is effective and leads to reduced recidivism in criminal behavior. This narrative review provides an overview of research assessing the effects of mandatory treatment on therapeutic process and outcome factors. We conclude that legal mandatory treatment does not have to necessarily result in perceived coercion and reduced satisfaction with treatment and that a caring and authoritative treatment style aids a favorable therapeutic alliance, motivation, and therapy outcomes.

Keywords: perceived coercion, mandated treatment, stigmatization, therapeutic relationship, funtioning, recidivism

Introduction

Correctional treatment mandated by court is aimed at reducing recidivism in offending behavior. There is some evidence that this form of legal coercion can be effective in reducing the offending outcome ( 1), while other evidence suggests that mandated treatment is ineffective in reducing recidivism ( 2). The concept that legal coercion is inevitably related to perceived coercion with negative effects on treatment outcomes ( 3, 4) is widely held. In contrast, other evidence indicates that also voluntary clients can feel coerced into hospital admission ( 5) with resulting poorer satisfaction ( 6) and symptom change ( 7); legal detention had no association with perceived coercion ( 8, 9). These contradictory results hint at confounders and moderating variables influencing general treatment outcomes.

Mandated Treatment and Therapy Facets

While mandated therapy provides external motivation to attend treatment, voluntary clients are normally believed to be intrinsically motivated. This view is challenged by studies that demonstrated perceived coercion in voluntarily admitted service users ( 10). Perceived coercion in voluntary samples had an unfavorable impact on long-term outcomes ( 11). While involuntary referrals by civil law and mandated treatment by penal law are a form of legal coercion resulting in external motivation, voluntarily admitted service users should at first glance be more motivated by their own innate psychological needs. The evidence that perceived coercion can also be present in voluntarily admitted clients resulted in statements that perhaps there are not so many differences between mandated and voluntary clients after all; a considerable percentage of clients are being coerced, whether it be legally or informally by family or employers, to be in therapy ( 12). This finding, however, has important implications for the stability of therapeutic interventions: behavioral changes last longer when they are the result of intrinsic motivation; extrinsically motivated behavior changes only last as long as extrinsic controls are in place ( 2, 13).

Literature suggests that mandated clients are more resistant to therapy than voluntary clients ( 14, 15). This may be a reaction to compulsory treatment as clients are more likely to resist their loss of freedom and independence ( 16, 17). A widespread model of motivation to change in generic psychiatry is the Transtheoretical Model ( 18), which suggests that recovery and the engagement with therapy is typically not a linear process but rather involves a cycling back and forth of the person's perception of his or her problems and the level of behavior change. Therapy and engagement with the mandated client are further influenced by the forensic setting and need to be reflected in the therapeutic process ( 19). Frequent barriers confronted in mandated therapy are predominant male clients with more restrictive attitudes toward the changeability of psychiatric disorders ( 20), chronic course of severe mental illness, and high rate of comorbidity ( 21). Clients seem less inclined to seek help ( 22).

Within the scope of this narrative review, a literature search was conducted in PubMed, PsycInfo, and Google Scholar using various combinations of the following search terms: "mandated therapy," "court ordered treatment," "perceived coercion," "therapy outcome," "treatment outcome," "therapeutic process factors," "recidivism," and "symptom levels." From the resulting body of literature, domains were generated (stigmatization, functioning, therapeutic relationship, and satisfaction) and grouped according to clinical significance and empirical relevance for general therapy outcomes and factors. Papers were referenced in the review if they included relevant and additional insight into the respective domain; studies were not integrated or reproduced in their fundamental conclusions if publications with similar conclusions had already been discussed. The resulting summary of factors constitutes a compilation for service providers who are interested in the clinical application of the results. The quality of the therapeutic relationship is described as an important process factor in psychiatry and psychotherapy ( 23). The quality of the relationship between a service provider and a client is widely recognized as playing a key role in treatment adherence ( 24), symptom reduction, medication adherence ( 25, 26), outcome of psychotherapy and psychosis treatment ( 26- 28), and quality of life ( 29). Positive effects of relationship quality were reported on client satisfaction, personal trust ( 30), and recidivism of criminal behavior. Literature suggests an association between lower dropout rates, better medication adherence, fewer readmissions, and improved symptom levels for clients suffering from schizophrenia spectrum disorders and the quality of the relationship between service provider and client ( 31- 33). Coercive measures are believed to have a negative impact on the therapeutic relationship ( 34). A pronounced perceived coercion was reported to be associated with a poor rating of the therapeutic relationship ( 35). In forensic settings, these aspects gain even more impetus where the legal framework leads to more restrictive treatment requirements ( 23).

Experiencing stigmatization and accompanying discrimination are a powerful negative attribute in all social relations including psychiatric treatment. Feeling stigmatized has multiple negative consequences for mentally ill persons ( 36). Besides increased anxiety and stress, decreased functional outcome, loss of self-esteem and quality of life, and decreased social participation were reported ( 37, 38). As both mental health service utilization and treatment adherence are decreased through stigmatization, it can indirectly promote the aggravation of psychiatric symptoms ( 39, 40). Mandated clients have the extra burden of their dangerous or antisocial behavior. The existing-and quite limited-literature on stigmatization in forensic settings suggests that this would merit the inclusion of anti-stigma interventions in therapeutic programs ( 19).

According to literature of all available client-reported outcome measures, treatment satisfaction has the greatest evidence base ( 41). Improved satisfaction with services is associated with positive treatment outcomes including improved quality of life ( 42), higher levels of functioning ( 43), and reduced admissions ( 44). Compulsory actions and coercion were commonly described by clients as dehumanizing and detrimental to treatment satisfaction ( 45).

The limited systematic research on clients following coerced hospital admission and symptom change over time suggests some improvements ( 46, 47). As a limitation, clinical improvement has been commonly assessed on global functioning scales rather than validated symptom scales with usually small sample sizes ( 7). Recidivism in offending behavior is a peculiarity of mandated treatment and is normally not investigated in generic therapeutic research, while the influence of psychopathological symptoms on recidivism is of interest in forensic psychiatry.

So what does literature suggest about the impact of mandated therapy on the addressed therapeutic process and outcome factors?

Stages of Engagement

While therapeutic stages in forensic settings are very similar to generic therapeutic processes, there are some peculiarities to consider. Mandated therapy can be divided into the initial task of stabilization and observation and the middle phase of remediation. The end phase includes rehearsal of skills, beginning detachment, and consolidation as preparation of leaving the scope for legal coercion ( 19). Important features of change for mandated clients include the realization of the need for therapy, coupled with a willingness to ask for and receive help ( 48). To counter the chronicity of a subgroup of clients who remain resolutely "unwilling" and therefore difficult to engage for many years, avoidance and needs resulting from complex life histories often influenced by trauma and experiences of abuse ( 49) are to be addressed. Frequently, cognitive behavioral therapy elements like motivational interviewing ( 50) are adapted in offender treatment as motivation for change cannot be assumed ( 51). The prolonged initial phase focuses on engagement, attendance to the therapeutic alliance, and the duration and intensity of treatment ( 19). Studies of readiness to change under legal coercion among adults with substance use problems provided mixed patterns of result but suggested a greater readiness to change after controlling for addiction severity, prior treatment history, and gender ( 3, 4). The prospective outpatient study ( n = 295) was a heterogeneous, mixed gender sample of voluntary and legally coerced drug abusers with stages of change as an outcome measured by a self-administered instrument ( 4).

According to the Self-Determination Theory, factors that enhance versus undermine competence, autonomy, and relatedness yield enhanced self-motivation and mental health ( 52). Such an intervention style promotes a progress from amotivation, to passive compliance, to active personal commitment ( 52); these stages of motivation and engagement seem to be effective in general for a wide spectrum of service users irrespective of legal setting. In mandated treatment, only limited results hint at the generalizability of these results. However, favorable outcomes seem to result from interventions that encourage powerful attachment relationships, and communicate compassion, warmth, and intimacy ( 53), in short interventions, which promote a better therapeutic relationship.

Therapeutic Relationship

Only sparse literature is available on the quality of the therapeutic relationship in mandated treatment. A cross-sectional study ( n = 113) investigated adult male inpatients with a diagnosis of schizophrenia spectrum disorder being treated in general psychiatric wards and medium secure forensic psychiatric units via questionnaires ( 23): Self-referred clients reported a more positive therapeutic relationship than involuntary admitted clients in general psychiatry wards. Mandated treatment clients in forensic units gave an intermediate rating. There was no association with the clients' legal status and the rating of the quality of therapeutic relationship or the service provider's rating. Symptom severity and especially hostility were inversely related to the ratings of quality of the provider-client relationship. Generalizing these findings to females and service users without severe mental illness would be tentative, limiting the evidence base. However, the vast majority of patients of mandated treatment by penal law are male.

In the community, probationers and their officers believed that the quality of their relationship had an important influence on clinical and criminal outcomes ( 54). To better capture the dual role of providers of mandated therapy to care and to control, Skeem at al. ( 55) developed and validated a self-report-based questionnaire and probation officer form (the Dual-Role Relationship Inventory) for involuntary clients, which assesses the quality of the therapeutic relationship. It was found superior to a leading measure of therapist-client relationship quality in capturing the nature and effect of relationship quality in mandated treatment. The implication of this finding is that the dual role of mandated treatment is not adequately captured by "traditional" conceptualizations of the therapeutic alliance. More specifically, a "firm, but fair" approach with blending care and fairness with an authoritative (not authoritarian) style is more effective. This form of procedural justice (e.g., patients feel respected and experience a participatory decision making) was seen as crucial for experiencing less coercion even in involuntary settings ( 56- 58). Probation violations and new arrests were predicted by the quality of synthetic relationship, e.g., the therapeutic approach of combining active listening and directive supervision without stressing a punitive orientation. This negative style of establishing control through authoritarian service provider confrontation within a session was labeled "Toughness." This had deteriorating effects on relationships and future rule compliance mainly through client mistrust and treatment amotivation. The accompanying indifference to clients' views and feelings, expectation of compliance, and punitiveness when expectations are not met seem to result in a negative struggle over issues of power and control. This rationale is in line with evidence that hospitalization, even when voluntary, was viewed as more coercive when clients rated their relationship with the admitting clinician negatively ( 35): The UK cross-sectional, mixed-gender study ( n = 217) of consecutive admissions to acute adult wards measured perceived coercion, global functioning, and therapeutic relationship with self-reports. The examined disorders included affective and substance use disorders besides schizophrenia and others. Major limitations were the single-site design, the exclusion of a substantial proportion (about 22%) of possible participants because they were deemed too ill or too intellectually impaired, and retrospective measurements. A meta-analysis of the effectiveness of interventions of juvenile offenders (aged 12-21, outcome measure: recidivism, 548 independent study samples) in English-speaking countries emphasized the importance of a "therapeutic" intervention philosophy as opposed to a focus on deterrence, surveillance, or discipline ( 59).

In short, the interpersonal style influences the quality of the therapeutic relationship. The quality of the provider-client relationship shapes treatment outcomes more strongly than specific psychotherapy techniques applied ( 24, 60, 61). These findings seem to be present in juvenile and adult samples of voluntary and mandated treatment settings irrespective of gender and seem to be valid for different mental disorders. Evidence suggests that the quality of the therapeutic relationship is capable of being influenced in the same way in inpatient or outpatient settings; something not alike the feeling of stigmatization and devaluation.

Stigma and Discrimination

There is a lack of research investigating the effect of mandated treatment on feelings of stigma. A Swiss study investigated the impact of different psychiatric service institutions on the stigmatization of mentally ill persons through a representative population survey ( 36): The desired social distance of the general representative population ( n = 2,207) and therefore the stigmatization of mentally ill persons in this vignette-based study were lower in relation to psychiatric service use than to psychiatric symptoms; i.e., being treated in a psychiatric unit at a general hospital decreased stigmatization. It was of no relevance for stigmatization if hospitalization occurred in a general or forensic psychiatric clinic. Limiting the results is the fact that it is not clear how the attitudinal measure (i.e., the social distance scale) translates into real-world behavior.

Outpatient voluntary and court-ordered treatment for people (male and female adults) with serious mental illness were examined in the US study of Link and Castille ( 62). The observational study of a convenience sample ( n = 184) was limited through a possible dropout bias and possible confounding variables. There was evidence supporting the hypothesis that self-reported feelings of coercion increased experience of stigma and devaluation. Further, there was a strong correlation between the number of involuntary hospitalizations and the current perception of stigma. This finding indicates that prior experiences with coercion influence subsequent experiences of coercion. Surprisingly, the ill-effects of perceived coercion and resulting lower self-esteem did not seem to affect illness-related social functioning or symptoms. This finding is in line with results from Ref. ( 10), which found no difference in functioning between involuntarily admitted clients and uncoerced voluntary clients ( n = 169 mixed-gender inpatients with major mental illnesses) regarding longer-term therapy outcomes. Stated limitations include a moderate follow-up period (1 year after discharge) and completion rate of instruments, regarding engagement and functioning, which might have introduced a selection bias in these results.

In summary, what can be inferred from the sparse evidence is only tentative. Not the legal setting per se but rather perceived coercion seems to be linked to feelings of devaluation in adults. Also, having a history of coercive experiences makes it more probable to reexperience discrimination. As mentioned, lower self-esteem does not necessarily result in lower functioning ( 10), but is that true for treatment satisfaction as a major factor as well?

Treatment Satisfaction and Functioning

An Irish multicenter study ( n = 161 adult male and female participants with serious mental illnesses) observed a good overall level of satisfaction with services following voluntary and involuntary admissions ( 6). Experiences of physical coercion, low perception of being respectfully involved in a fair decision-making process regarding admission, and involuntary hospitalization were associated with lower service user satisfaction. In the same study, the therapeutic relationship was moderately correlated with the level of reported satisfaction with the service. Better global functioning and improved insight were associated with higher level of treatment satisfaction, emphasizing the relevance of service user satisfaction for general treatment outcome. A selection bias of uncompleted interviews and possible nonparticipants with higher probability of involuntary legal status were seen as main limitations.

The investigation of court-ordered outpatient treatment ( n = 184 male and female adults with serious mental illness) in the United States observed improvements in symptoms, resulting in better social functioning and at a trend level better quality of life ( 62). This effect was countered and an erosion of quality of life was noted in study participants who self-reported elevated levels of coercion. Comparable long-term effects of voluntary and involuntary admissions to mental health services were reported regarding satisfaction and global functioning 1 year after discharge. This implied that clients feeling coerced to treatment can be subsequently engaged with a good therapeutic alliance ( 10).

In short, there is scarce information in adult service users with mental illness on global functioning and treatment satisfaction in involuntary settings. Literature could be interpreted to the effect that high levels of perceived coercion and low involvement of service users seem to be associated with lower treatment satisfaction and global functioning. Other outcome parameters like criminal recidivism and symptom change are the focus of more studies in forensic psychiatry.

Symptom Levels and Criminal Recidivism

Symptom change (as an outcome factor for treatment effectiveness) after involuntary treatment in comparison to voluntary admission to services is often the primary focus of debate. A multinational European study investigating about 3,000 adult male and female inpatients of differing legal status and their subjective feeling of coercion concluded that, following coerced hospital admission, clients show, on average, moderate improved symptom levels after 1 and 3 months ( 7). This follow-up period could be seen as a limitation, as well as a possible selection bias through a high percentage of non-participants (about two-thirds). Besides higher baseline symptoms, legal voluntary status with feelings of coercion, and initial low treatment satisfaction, social factors like unemployment and living alone were important predictors for poorer symptom outcomes. Mandated treatment in the United States as evaluated in over 2,700 women with histories of abuse and co-occurring disorders equally demonstrated an improvement on psychiatric symptoms; the nationwide longitudinal study suggested that coercive status proved to be a significant main effect; i.e., being mandated was associated with greater improvement ( 63). However, women without drug abuse were not included and symptoms were evaluated by self-report.

The results on general and specific recidivism as a main treatment outcome in forensic therapy are partly inconsistent and reveal a great heterogeneity of results. While a meta-analysis (129 mostly US and Canadian studies, juvenile and adult samples of both gender, various treatment types and quality, no information on mental illnesses given but treatment targets specified) of mandated treatment of offenders was found to be ineffective on general recidivism, particularly in custodial settings, voluntary treatment was found to produce significant treatment effect sizes regardless of setting ( 2). However, mandated treatment was reported as effective on specific recidivism. It was reported that three decades of research into the effectiveness of legal coercion in the treatment of substance abusers have yielded inconsistent and inconclusive patterns ( 3). A more recent evaluation of specialized treatment on recidivism rates in Switzerland ( n = 412 male adult offenders; mean follow-up, 7.9 years; mean duration of treatment in the intervention group, 4.5 years; overall about 85% psychiatric diagnoses of participants) revealed only a trend toward a positive treatment effect in violent and sexual offenders ( 64). The significantly higher criminal history of the intervention group and substantial missing information on diagnoses in the control group (i.e., the control group could have been less mentally burdened) constitute limitations of these results. A significant specific reduction in recidivism was, however, found by Lösel and Schmucker ( 65, 66) who, in two large meta-analyses (69 studies of adult and juvenile intervention and control group designs included in 2005; 29 study comparisons of males in group designs in 2015) on the effects of sexual offender treatment, reported a relative reduction in recidivism of 37% and 26.3%, respectively. The authors stated, though, that the evidence basis for sex offender treatment is not yet satisfactory and that there is a need of differentiated, high-quality evaluations. Results of a more recent meta-analysis (35 studies in 10 countries involving mostly violent offenders of heterogeneous samples and admission criteria) on general reoffending provided some evidence that clients discharged from forensic psychiatric services have lower offending outcomes than control groups discharged from prisons ( 1). A quantitative summary on meta-analyses from Andrews and Bonta ( 67) stated that rehabilitation programs of adult offenders that adhered to the Risk-Need-Responsivity (RNR) model have been shown to reduce recidivism up to 35%. This model proposes who should receive services in correctional settings (e.g., moderate- and higher-risk cases), treatment targets (criminogenic needs), and the most appropriate form of delivering therapy (e.g., cognitive social learning).

In juvenile offenders (aged 12-21, mostly male) a meta-analysis (548 mostly US study samples) stated a mean reduction in recidivism of 10-13% from a control group for interventions following a therapeutic and qualitative approach ( 59). The information on the interventions used was limited and target needs and types of recidivism were not differentiated. Worth noting in this regard is that literature reports aspects of residential youth care to be associated with repression and coercion ( 68).

In summary, literature suggests that criminal recidivism can be effectively reduced if treatment is evidence-based, supportive, and based on relational care ( 59, 69- 72). These findings are replicated in juvenile and adult samples mostly with a male bias, but relatively independent of the treatment setting.

Discussion

Evidence suggests that perceived coercion in treatment is linked to an impaired therapeutic process and outcome compared to voluntary treatment. While correlations have repeatedly been reported between perceived coercion and involuntary legal status ( 35, 73- 75), some findings indicate that perceived coercion is not necessarily the result of mandated treatment status; i.e., feelings of coercion do not always follow a court order to therapy. Indicative of this consideration are findings that even physical coercive measures are shown to be a separate entity from procedural justice and perceived pressure ( 76). Further, the therapeutic relationship seems to confound legal status as a predictor of perceived coercion ( 35). The feeling of coercion seems to be dependent of various determinants, many of which depend on the quality of the relationship with the service provider, and clinicians should therefore routinely consider that involuntary and voluntary clients have the potential to experience interventions as coercive ( 45). This is in line with study results comparing reports of coercion in clients mandated to outpatient treatment and a control group that reported no significant differences ( 62). In qualitative analysis regarding perception of coercion, three themes were identified to be linked to feelings of coercion: viewing the service institution as ineffective and other treatments as more appropriate, not participating in the admission and therapy, and the missing feeling of respect ( 5). These themes point consistently to low procedural justice as being important in the development of experiences of coercion.

Discrimination does not seem especially associated with a forensic setting ( 36), but rather perceived coercion is linked to feelings of stigma; furthermore, a history of coercive experiences facilitated the reexperience of devaluation ( 62). Similarly, high levels of perceived coercion and inability to involve service users seem to result in lower treatment satisfaction and global functioning ( 6, 10).

Ethical considerations place a great emphasis on personal autonomy and self-determination of clients ( 77). Regarding mandated and forced therapy, there is subsequently a strong focus on what circumstances can justify infringing these values. The argument being made for coercive treatment is that in certain circumstances, i.e., when certain mental disorders determine the behavior of the client and therefore constitute a form of coercion themselves and result in an inability to consent, it can be justified to perform compulsory treatment to restore the capacity for autonomy ( 77). Other arguments point out that perpetuating the assumption that all types of leverage including mandated therapy amount to coercion is misleading and unhelpful ( 78). The lines between bargains and coercion are not easily drawn, and under certain conditions, several forms of mandated treatment are better understood as the product of negotiation and voluntary agreement (e.g., access to housing, avoidance of jail) ( 79). Similarly to the ethical importance of self-determination, therapeutic considerations stress three innate psychological needs: a secure relational base (relatedness), the feeling of volition (autonomy), and the feeling of being efficacious with respect to activities (competence) ( 52). The fulfilment of these needs seems to predict mental well-being and facilitate the integration of extrinsic motivation.

Research on the therapeutic process and outcome factors described above suggests that mandated treatment can also be associated with results comparable to and, in some cases, better than voluntary treatment. While perceived coercion, resistance, and lack of intrinsic motivation to change are more likely to be present at the beginning of treatment, these do not seem to be determinative of the mentioned therapeutic factors and outcomes as therapy progresses ( 12). These treatment barriers appear to be accessible to a specific therapeutic relationship quality and interventions particular in mandated therapy settings. According to the stages of therapy engagement, a caring, fair, and trust-evoking quality of therapeutic interventions blended with a firm but not authoritarian or punitive control seems to be necessary to change unwillingness or amotivation to therapy engagement and the will to change ( 34, 55). Paired with the effort for procedural justice as far as legal constraints of mandated therapy allow, the respectful involvement into treatment might assuage possible experiences of coercion, resulting in a better quality of therapeutic relationship, more treatment satisfaction, and less experience of stigmatization. A possible distinct advantage of mandated therapy is the (at first more extrinsically motivated) consistent and longer attendance in treatment than in voluntary settings. This circumstance could lead to a more intrinsic motivation in offender clients along the therapeutic process ( 12). This factor and the additional provision of supportive aftercare may explain good levels of satisfaction in involuntary treatments along the way and resulting better levels of functioning ( 1, 6).

There is some evidence that mandatory treatment does achieve the required treatment targets of legal coercion: reduction of recidivism and symptoms. Reports of high symptom loads of clients in involuntary and forensic settings ( 7, 21) seem to moderate low improvements of symptoms ( 7). The heterogeneity of evidence on the reduction of reoffending might be attributable to different admission criteria of institutions, varying treatment principles and quality, variability in sample compositions, missing information on client location at discharge, and varying quality of included studies in meta-analyses ( 1). While the odds of mandated therapy appear to be stacked against favorable outcomes at the onset, there is evidence that mandated treatment can work in a wide range of specific criminal behavior like violent or sexual offending ( 2, 12). Adhering to Risk-Need-Responsivity principles in forensic therapeutic settings has repeatedly generated lower recidivism rates with a substantial effect [i.e., mean effect sizes ( r) of up to 0.29] ( 67). In institutional youth care, effects of coercion might be associated with residential care ( 72). However, evidence from juvenile offender samples suggests that effective treatment is not highly context dependent; i.e., the intervention effects are even robust in institutional environments with more potential adverse conditions ( 59).

The nature of the search and inclusion process employed in the current narrative review limit the generalizability of some of the reported results. The evidence base of mandated therapy is small regarding various facets of therapy process factors. To complicate matters further, mandated therapy can occur in different forms of legal coercion (i.e., by civil or penal law). Therefore, the current review provides a clinical overview to summarize the most relevant results for service providers and aims to raise awareness of important issues associated with mandated therapy for future research. Another major limitation of the current review is that the present overview-due to the state of the literature-cannot make specific statements on various determinants of mandated treatment outcome (i.e., depending on inpatient or outpatient setting, male vs. female samples, sex offenders/non-sex offenders, and heterogeneous types of mental illnesses). In addition, most of the reported studies were observational, cross-sectional studies, which could only report associations and no causalities.

In conclusion, treatment outcomes in different domains seem to be linked to the client's motivation to attend treatment and the feeling of being coerced into therapy, regardless of mandate ( 2). It has been argued that there is, potentially, an element of coercion in every clinical encounter ( 80) and the perception of coercion has a variety of determinants, many of which are dependent on the quality of relationship with the service provider ( 45). Therefore, reducing feelings of coercion might improve treatment outcomes, prevent disengagement from services, and ameliorate therapeutic relationships ( 5). Facilitating the integration of extrinsic motivation through participatory decision making and interpersonal contexts of relatedness and security produces maintained change ( 52). Service providers should therefore be encouraged to find the right balance between control and flexibility ( 70): A dual-role relationship ("firm but fair") can help to motivate offenders to engage and stay in therapy ( 55) and reduce offending behavior ( 34, 35), despite lack of motivation and possible high symptom load. In this regard, the more consistent and longer attendance due to legal framework with provision of supportive aftercare ( 70) can enable motivational interventions and strengthen therapeutic relationships.

Author Contributions

HH and TV wrote the initial article, and CH revised the paper critically for important intellectual content.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

References

17. Woody JH, Grinstead N. Compulsory treatment for families: issues of compliance. Top Fam Psychol Couns (1992) 1(2):39-50. [Google Scholar]

49. Quayle M, Moore E. Maladaptive learning? cognitive-behavioural therapy and beyond. In: Newrith C, Meux C, Taylor P, editors. Personality disorder and serious offending: hospital treatment models. Boston: Arnold Hodder; (2006) p. 134. [Google Scholar]

80. McConnell D, Gillett G. Coercion in the therapeutic community. Therapeutic Communities-London-Association of Therapeutic Communities (2006) 27(2):249. [Google Scholar]

Articles from Frontiers in Psychiatry are provided here courtesy of Frontiers Media SA

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Mandated Treatment and Its Impact on Therapeutic Process and Outcome Factors

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Court-mandated treatments imply a dual role for therapy providers not only of caring for, but also of having control over, involuntary clients. The impact of legal coercion on the therapeutic relationship and feelings of stigma is widely regarded as ...

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EMDR With Children. An Overview of Research and Clinical Practice

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EMDR With Children. An Overview of Research and Clinical Practice

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This literature review examines more than 25 years of EMDR application with children and adolescents (ages 4–18) internationally, focusing on both single-event and developmental trauma. Drawing on meta-analyses and randomized controlled trials, the paper outlines how EMDR protocols are adapted developmentally, including the use of drawings, simplified SUD/VOC scales, and bilateral stimulation via eye movements or taps. Findings consistently show EMDR effectively reduces PTSD symptoms in young clients, is supported by guidelines from WHO and the Australian Psychological Society, and can be safely delivered even to those with complex trauma histories. The article also includes clinical examples, such as a 6-year-old who overcame bedwetting and distress after processing trauma, demonstrating the practical impact of the method (Struik, 2024).

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EMDR With Children. an Overview of Research and Clinical Practice | Published in Journal of the New Zealand College of Clinical Psychologists

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By Arianne Struik. Arianne Struik describes the current state of research and practice in EMDR with children.

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Efficacy of Eye Movement Desensitization and Reprocessing in Adolescents with Complex PTSD Secondary to Childhood Abuse: A Case Series

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Efficacy of Eye Movement Desensitization and Reprocessing in Adolescents with Complex PTSD Secondary to Childhood Abuse: A Case Series

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Karadag et al. (2019) examined the efficacy of EMDR therapy for children and adolescents aged 7–18 diagnosed with PTSD. A total of 30 youths (primarily girls) were recruited from a university mental health clinic and received one weekly EMDR session over six weeks. Assessments using the Child Post-Traumatic Stress Reaction Index and the State-Trait Anxiety Inventory were conducted before treatment and six weeks afterward. The results showed a significant reduction in both PTSD and anxiety symptoms. The authors noted limitations, including a small sample size, the absence of a control group, and a short follow-up period, and recommended larger, controlled studies to strengthen the evidence (Rolling et al., 2024).

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EMDR–Teens–cPTSD: Efficacy of Eye Movement Desensitization and Reprocessing in Adolescents with Complex PTSD Secondary to Childhood Abuse: A Case Series

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Background: Mental healthcare for children and adolescents with a history of childhood abuse constitutes a major public health issue. Indeed, abuse exposes children to severe and complex post-traumatic stress disorder (cPTSD) but also to…

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The Outcomes of Trauma-Informed Practice in Youth Justice: An Umbrella Review

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The Outcomes of Trauma-Informed Practice in Youth Justice: An Umbrella Review

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This umbrella review synthesized findings from nine systematic reviews conducted between 2017 and 2023 to evaluate the effectiveness of trauma-informed practices in youth justice settings. The studies included various trauma-focused interventions delivered to justice-involved youth, examining outcomes related to trauma symptoms, mental health and well‑being, and involvement in the justice system. Participants were mainly adolescents with known histories of trauma. Researchers analyzed and compared pre-existing review data (meta-analyses and systematic reviews), focusing on primary studies within those larger works. The findings consistently showed that trauma-informed interventions significantly reduced youth PTSD symptoms, improved mental health, and decreased justice system involvement; however, evidence for broader organizational-level changes was weaker (Malvaso et al., 2024).

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Abstract

Findings of high rates of complex trauma among justice-involved young people have engendered interest in developing trauma-informed youth justice systems. Although there have been several reviews of trauma-informed practice in youth justice settings, uncertainty remains about whether this approach can produce the outcomes expected of youth justice services. In this study we summarize findings from recent systematic reviews and meta-analyses to provide an overview of evidence relevant to implementing trauma-informed youth justice. We conducted an umbrella review of systematic reviews published between 2017 and 2023 that included group-based primary studies of trauma-informed interventions for justice-involved young people. Reviews were located via searches of PsycINFO, PubMedCentral, Embase, Criminal Justice Abstracts with Full Text, and ProQuest. Data extracted from each review included the number and type of primary studies reviewed, and outcomes related to trauma symptomatology, mental health and wellbeing, and justice system involvement. Nine systematic reviews met our inclusion criteria. Improvements in trauma symptoms, mental health and wellbeing, and justice system involvement were documented in each review. The strongest evidence related to the impact of trauma-focused interventions on posttraumatic stress disorder symptoms, but less evidence was available to demonstrate outcomes of organizational level and systemic components of trauma-informed practice. Each review highlighted the need to strengthen the methodological quality of primary studies. Trauma-informed practice should be seriously considered as part of any effort to implement evidence-based youth justice. This should extend beyond treatment of trauma symptomatology to incorporate a broader approach to trauma-informed practice that is organizationally embedded.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40653-024-00634-5.

Keywords: Trauma-informed, Trauma-focused, Youth justice, Outcomes, Umbrella review, Overview

Youth justice services around the western world have, in recent years, found themselves under increasing pressure to develop new and more effective ways of working. A series of reviews, inquiries, and investigations (e.g., the Carlile Inquiry, 2014; Clancey et al., 2020; Knox et al., 2013; RCPDCNT, 2017) have highlighted harmful and abusive practice, reigniting long-standing debates about the purpose of a youth justice system (e.g., Braithwaite & Mugford, 1994; Day, 2023) and identifying a need to develop practices that are evidence-informed and less punitive. It is in this context that the idea of 'trauma-informed practice' has emerged as a potentially promising way to develop new policies, programs, and interventions that can help to achieve better outcomes for children and young people while, at the same time, also ensuring the safety of the community. Indeed, a number of youth justice agencies around the world have now endorsed a trauma-informed approach (e.g., Jackson et al., 2023), even though it has been observed that terms such as 'trauma-informed practice' (TIP) and 'trauma-informed care' (TIC) often lack meaning. As a result, it is not always easy to determine if (or when) a trauma-informed approach is being implemented and, importantly, if it might be expected to lead to a reduction in clinically significant symptoms of trauma, to improvement in the wellbeing of justice-involved young people, and/or to a reduction in subsequent offending and other justice-related outcomes (Homes & Grandison, 2022). In this paper our aim is to provide an up-to-date summary of the current evidence relating to the outcomes of trauma-informed youth justice. This, we suggest, should be relevant information for policymakers when considering this approach, and serve to strengthen public confidence that trauma-informed models of service delivery will result in the desired outcomes of a justice agency.

Trauma-Informed Youth Justice

Youth justice agencies typically strive to achieve different, but overlapping, aims. In Australia, for example, the federal government requires that youth justice services aim to promote community safety, to rehabilitate, and to reintegrate young people who offend, as well as to contribute to a reduction in youth re-offending (Report on Government Services, 2022). Thus, while the management of risk of reoffending is clearly a priority for all criminal justice agencies, there is also an expectation that the welfare of the child or young person should be protected and promoted. It is in relation to this philosophical change in how the community views its responsibilities towards justice-involved children and young people that interest in trauma-informed policy and practice has grown rapidly, with countries such as England and Wales now prioritizing child welfare over justice considerations (Haines & Case, 2015).

A trauma-informed approach is a universal approach that, at its core, is designed to do no further harm to those who have experienced traumatic life events (Liddle et al., 2016). The assumptions that underpin trauma-informed youth justice are, as a result, somewhat different from those that provide the foundation for the delivery of more traditional criminal justice services. As Griffin et al. ( 2012) have argued, trauma-informed work does not distinguish between 'victim' and 'perpetrator' in the same way that many western legal systems do; rather, 'risk' is conceptualized in terms of vulnerabilities that arise in response to childhood maltreatment and social and structural inequalities. Hence, the primary goal of service delivery is to provide an environment in which the impacts of maltreatment and adversity are acknowledged, processed, and resolved. A primary concern is to minimize exposure to potentially retraumatizing events. Thus, trauma-informed youth justice is not simply concerned with the provision of mental health services that address symptoms of trauma (this is usually referred to as 'trauma-focused' intervention and relates primarily to the provision of mental health treatment), but also to mitigate the risk of young people behaving, or being treated, in ways that re-traumatize or cause harm to others or to themselves (Buckingham, 2016). One way that youth justice agencies have sought to reduce re-traumatization, for example, is to provide a structured and safe environment (e.g., regular meals, bedtimes, school times, expectations of behavior) such that basic psychological and health needs are met (Skuse & Matthew, 2015).

The rationale for implementing trauma-informed practice is derived, in part, from research showing that many justice-involved children and young people have experienced - and may continue to experience - maltreatment and adversity. It is now well-established that across all youth justice systems, most children and young people will have a history of (often extensive) child protection system contact (see Lamers-Winkelman et al., 2012; Spinhoven et al., 2010), with experiences of victimization in childhood associated with both clinically significant symptoms of trauma (Malvaso et al., 2022) and offending (Berg & Schreck, 2022). In a recent review, for example, Yoder and Tunstall ( 2022) reported that as trauma exposure accumulates over time, so too do high-risk behaviors and contacts with the youth justice system (see also Layne et al., 2014).

There has been considerable interest in understanding the developmental pathways that result in offending. As de Ruiter et al. ( 2022) observed in their discussion of how maltreatment and trauma can increase risk, one possible mechanism is that the emotional numbing and feeling of detachment that often results from trauma leads to increases in callousness and disregard for victims. Another hypothesis is that exposure to traumatic stressors compromises secure attachment with primary caregivers, resulting in self-regulatory deficits that facilitate offending (Ford et al., 2012a, b). Alternatively, the degree to which maltreatment represents a 'betrayal' of trust may influence the way in which abuse-related information is processed and remembered and trigger antisocial behavior. Another consideration is the way in which systemic interventions mitigate or exacerbate trauma systems, such as the placement of children who have experienced maltreatment into out-of-home care. Placement in residential care facilities is known to exacerbate trauma symptoms and associated behavioral problems which, in turn, may lead to an increased risk of contact with the justice system (Malvaso & Delfabbro, 2015; Ryan et al., 2008).

The broad conclusion that can be drawn here is not only that trauma reactions are often a catalyst for involvement in the criminal justice system, but that they can also act to increase the risk of offending and re-offending (see Becker & Kerig, 2011; Craig et al., 2017; Ford et al., 2010). Put simply, the key presentations of trauma (e.g., impulsivity, risk-taking, and low self-control) represent important criminogenic needs (or 'dynamic risk factors'; see Klepfisz et al., 2016), and should thus form important intervention targets for any service that aims to reduce re-offending (see Ford et al., 2007). It follows perhaps that a logical service response is not to 'punish' justice-involved young people and implement measures that deter them and others from offending, but to offer a more therapeutically aligned approach that helps children to feel safe and to gain control over intense reactions, destructive thoughts, and impulsive behaviors. The key point here, however, is that the aim of trauma-informed youth justice is, inevitably, to achieve multiple outcomes - and these include reducing trauma symptoms, promoting good mental health and wellbeing and reducing externalizing and offending behaviors.

Given that a trauma-informed youth justice will aim to influence different, and potentially conflicting, outcomes, there is a need for clarity about the processes, activities, and interventions that will best achieve these goals. In response to concerns that trauma-informed approaches to youth justice lack coherence, Branson and colleagues ( 2017) published a systematic review that identified core elements of service delivery as well as offering comprehensive recommendations for implementation and evaluation. Three domains of recommended practices were identified: (1) clinical services for youth involved in the justice system (screening and assessment, trauma-focused treatment, cultural competence); (2) agency context (young person and family engagement, workforce development, providing a safe environment, agency policies, procedures, and leadership); and (3) systems level (systems policy and procedures, cross-agency collaboration, quality assurance and evaluation). Branson et al. ( 2017) also recommended further research to establish which, if any, of these practices are effective in relation to both wellbeing and justice-related outcomes for children and young people. Since then, a series of systematic reviews and meta-analyses have been published that share a common aim of synthesizing the available evidence on trauma-informed approaches to youth justice. Each of these has a slightly different focus and, given the multiple components of a trauma-informed approach, the current evidentiary standing of trauma-informed programs, service delivery, and policy frameworks across youth justice is not easy to ascertain. This creates challenges for policy makers and practitioners who are seeking new and different ways of working. Accordingly, the purpose of this study is to curate current evidence to arrive at an overall assessment of this relatively new approach to youth justice service delivery.

Method

An umbrella review methodology was used in this study to curate knowledge from systematic reviews and meta-analyses to determine the overall strength of evidence on a particular topic (Pollock et al., 2020). It is a structured approach that utilizes the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement (Page et al., 2021) and involves an assessment of the methodological quality of the reviews considered before summarizing the evidence. It also aids identification of differences in how reviews evaluate overlapping primary studies and interventions (Pollock et al., 2020). As all analyses reported in this study were based on previous published studies, no ethics approvals or participant consents were required.

Search Strategy and Inclusion Criteria

To locate eligible studies, searches were conducted of the following databases: PsycINFO; PubMedCentral; Embase; Criminal Justice Abstracts with Full Text (EBSCOhost); ProQuest (Social Science Premium Collection); and CINCH Australian Criminology Database. We also searched the Cochrane Database of Systematic Reviews, the Campbell Collaboration, and PROSPERO International prospective register of systematic reviews. Given varying definitions and conceptualizations of trauma-informed practice, our search terms were intentionally broad to identify a range of relevant reviews, including those that while not labelled as 'trauma-informed' nonetheless included studies of trauma-informed or trauma-focused practices and interventions. To illustrate, the following search terms were entered into the PsycINFO data base, and adapted for other databases as necessary: "juvenile justice or juvenile delinquency/ or ((youth or juvenile or young or adolescen* or minor) adj3 (justice* or justice-involved or justice involved or court* or detention* or delinquen* or incarcerated or incarceration or correction* or offend* or custody)) and trauma-informed care.sh or exp treatment/ or exp treatment outcomes/ or (trauma* adj (informed or focused or responsive or oriented or specific)) and (systematic review or meta analy* or meta-analy*)". Searches were conducted between October 2022 and April 2023.

To be included, a review had to have included at least one quantitative evaluation of a trauma-informed, or trauma-focused, group-based intervention aimed at improving outcomes for a justice-involved youth population (i.e., young people who were currently involved with the justice system, aged between 10 and 24 years, with at least some participants under the age of 18). The review had to be in the English language, peer-reviewed, and published in a five-year period following Branson et al.'s ( 2017) systematic review, with purely theoretical or policy-focused articles excluded. Reviews that involved only qualitative studies, individual case studies, or evaluations of the impact of a therapeutic environment in non-youth justice settings were also excluded. Given the scarcity of randomized studies in this field, reviews of randomized and non-randomized studies were included.

Data Extraction and Management

Review selection was undertaken by two authors using the Covidence systematic review software (Covidence, 2022). After removing duplicate records, the same two authors independently screened abstracts and read the full-text articles. Where there was disagreement, discussion ensued until full agreement was reached. The PRISMA flow chart of study selection can be found in Fig. 1.

Fig. 1.

Flow chart of the study selection process

Each review was independently coded, with reference to a template designed to describe key features and to report the main findings. The coding form examined several content areas: author and review descriptors (e.g., authors, year); sample descriptors (e.g., population, age range, intervention); design; conclusions; outcome (trauma symptoms, other mental health outcomes, and justice-related outcomes such as re-offending and institutional behavior); and a summary of key analyses/findings and review conclusions. PICO information (population, intervention, comparator, outcome) from the primary studies included in each review was also recorded, as recommended by Pollock et al., 2020. All authors consulted regularly during this process.

Two authors then assessed the reviews against the AMSTAR 2 quality indicators (Shea et al., 2017). Based on the original AMSTAR for quality assessment of systematic reviews of randomized studies (Shea et al., 2007), AMSTAR 2 incorporates additional items to address the greater susceptibility of non-randomized studies of interventions (NSRI) to bias, compared with randomized studies. Of the 16 items, three are specific to meta-analyses.

Data Synthesis

A brief narrative description of each review was then produced, synthesizing the main findings relating to three principal outcome domains of trauma-informed youth justice (trauma symptomatology, mental health and wellbeing, and justice-related outcomes).

Results

Description of Included Reviews

Nine systematic reviews - three meta-analyses and six narrative reviews - met our inclusion criteria. Justice-involved children and young people were the target population in five of these reviews, while studies involving both justice-involved and non-justice-involved children and young people populations (such as at-risk youth or youth in psychiatric settings) were included in the remainder. Only findings related to group-based evaluations of interventions provided in justice-involved youth populations are reported in this study. A summary of the main characteristics of each review is presented in Table 1.

Table 1.

Review authors, year,
type of review, country of origin

Number of included studies

Number of group-based studies with justice-involved youth
(sample N)

Interventions

Intervention orientation and components

Outcome domain

Trauma

Mental health and wellbeing

Justice system related outcomes

The nine reviews encompassed a total of 47 group-based juvenile justice-related primary studies (1 to 14 per review), with 15 of the primary studies included in more than one review (see Table S1 in the supplementary material). Accounting for duplicates (n = 2245), there were 8615 participants (n = 30 to n = 5469 justice-involved young people per review). Most participants were male, and ages ranged from 11 to 24 years. All nine reviews included one or more controlled studies (i.e., randomized, or quasi-experimental designs with comparison group). Seven of the reviews also included group studies without a comparison group (e.g., single-group, pretest-posttest), and two included individual case studies. The sample size of primary studies included in each review ranged from n = 9 to n = 3068.

In total, 41 named interventions targeting outcomes relevant to justice-involved youth were evaluated. Among these were 29 group-based manualized programs, of which the majority were psychological treatments, either based on cognitive-behavioral therapy (CBT) or incorporating elements of it. Among the trauma-specific elements of treatment were psychoeducation about trauma and its effects on psychosocial development and emotion regulation; skill development in self-awareness, emotion regulation; mindfulness and meditation training; processing trauma-related memories (e.g., through trauma narratives); sensory processing; and dealing with future trauma. One intervention focused on organizational transformation. Most of the psychological interventions also included therapist training prior to delivering treatment. In only a few cases, however, was a specific staff training program named as a component of the intervention.

Methodological Quality

The results of the AMSTAR 2 assessment of methodological quality are reported in Table 2. Generally, studies wholly or partially met four of the criteria: specifying PICO characteristics in their inclusion criteria, using a comprehensive literature search strategy, reporting studies in sufficient detail, and reporting funding and/or conflicts of interest. However, no study fully met all criteria, as none provided a list of excluded studies with reasons for exclusion or reported funding information for all included primary studies. The reviews differed in terms of whether they had developed an a priori review protocol, provided an explanation for selection of study designs, performed study selection and data extraction in duplicate, or formally assessed sources of individual study bias. Several reviews attained only a 'partial yes' for adequate primary study description because design features, such as the number of groups or the type of control condition were unclear. Studies also varied in the completeness with which they reported relevant aspects of sample characteristics such as racial composition, and mental health diagnosis. All but one of the reviews had undertaken some form of quality assessment. Five (Gagnon et al., 2022; Givens et al., 2021; Hodgkinson et al., 2021; Kumm et al., 2019; Rhoden et al., 2019) evaluated primary studies against existing assessment tools, while two (Baetz et al., 2022; Rhoden et al., 2019) assessed sources of bias using the Cochrane Risk of Bias tool. One meta-analysis assessed the reliability and validity of included outcome measures (Eadeh et al., 2021), while another formally assessed the risk of publication bias (Olaghere et al., 2021).

Table 2.

AMSTAR 2 Rating Domains

Review First Author

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

Narrative Description of Main Findings (in alphabetical order of review)

Baetz et al. ( 2022) systematically reviewed seven controlled studies published between 2002 and 2017 to examine the impact of manualized, trauma-specific treatments on the reduction of post-traumatic stress disorder (PTSD) symptoms, co-occurring mental health symptoms, and justice-related outcomes in justice-involved young people. Treatment effect sizes were calculated for PTSD. Four studies were reported as showing a significant decrease in PTSD symptoms following treatment when compared with a control group. Regarding improvement in mental health symptomatology, both cognitive processing (Ahrens & Rexford, 2002) and TARGET (Marrow et al., 2012) were associated with reductions in depressive symptoms, but in the case of Marrow et al. it was noted that the magnitude of the difference in outcome between the TARGET and control groups may have reflected an increase in depression in the control group. The two studies that examined recidivism produced conflicting results, with Multidimensional Treatment Foster Care plus Trauma (MTFC + T; Smith et al., 2012) showing reductions in delinquency and recidivism in adolescent girls, and TARGET (Ford & Hawke, 2012) showing no differences in rearrests between the treatment and control groups. Baetz et al. suggested that the differing results may have reflected differences in how recidivism was operationalized, as well as greater follow-up care in the Smith et al. study.

Overall, Baetz et al.'s ( 2022) review concluded that evidence for the effectiveness of trauma specific treatments with young people in justice settings was encouraging (p. 650) However, the review also noted a lack of methodologically sound studies, along with several challenging aspects of implementation. These included integrating new treatments into existing practices; engaging stakeholders; monitoring treatment fidelity; and ensuring that daily care staff in secure settings are adequately trained and involved in program delivery. Potential sources of study bias that were identified included a high risk of incomplete outcome reporting and/or selective reporting. The authors advised that the results of the respective studies should be interpreted with caution.

Eadeh et al. ( 2021) conducted a meta-analytic review of evidence from 41 studies of the effects of emotion regulation interventions in adolescents with a wide range of presenting disorders, including trauma. The underlying premise was that a lack of adaptive emotion regulation strategies and a reliance on maladaptive strategies are risk factors for the development of internalizing and externalizing disorders that are linked to poor adolescent outcomes. Gross's ( 1998, 2015) model (identifying emotional responses to situations, and selecting and implementing strategies to manage them) was used to conceptualize emotion regulation.

Four of the studies reviewed (two randomized control trials and two single-group studies) focused on incarcerated and delinquent adolescents. Where data were available, Hedges' g was used to calculate intervention effects (Keiley, 2007, did not provide means and standard deviations for the outcomes, so the original results were reported). Three studies were reported as showing significant improvements following the emotion regulation interventions. Keiley ( 2007) reported significant decreases in incarcerated adolescents' self- and maternal caregiver reports of maladaptive emotion regulation following participation in a multiple-group family intervention (MGFI) program (fathers' reports did not improve). Keiley and colleagues ( 2015) found similar improvements following implementation of MGFI in a sample of male adolescent sexual offenders. Ford et al. ( 2012a, b) found that TARGET was associated with a significant reduction compared with treatment as usual in negative emotion regulation in girls placed in a juvenile justice facility. A fourth study, evaluating a juvenile justice anger management intervention for girls, was reported as not delivering improvements in emotion regulation compared with treatment as usual (Riggs Romaine et al., 2018).

Results from the three studies with calculated effect sizes were included in the pooled effect size analysis across all studies. Results showed significant positive treatment effects for both maladaptive (negative) and adaptive (positive) emotion regulation strategies, albeit that there was considerable heterogeneity and effects were small. The authors determined that studies involving clinical samples demonstrated larger treatment effects than those involving non-clinical samples, and this was the case for both single-group and controlled studies. Accordingly, they recommended that future research should include more 'methodologically rigorous comparison groups' (p. 701). The authors also recommended increased inclusion of measures that detect changes in the use of positive emotion regulation and coping strategies.

Gagnon et al.'s ( 2022) systematic review considered evaluations of mental health interventions for incarcerated young people. Only primary studies published since the release of Guiding Principles for Providing High-Quality Education in Juvenile Justice Secure Care Settings (U.S. Departments of Justice and Education, 2014) were included. Eleven studies met the authors' inclusion criteria, of which ten were quantitative, group-based studies. Although the included interventions varied in emphasis, most incorporated elements of CBT. An exception was the Sanctuary program, which aims to promote a safe and therapeutic environment through organizational transformation, and staff education and training (Elwyn et al., 2015). Two of the CBT-based interventions also included a component of staff trauma training (see Table S1 in the supplementary material for this review), but staff outcomes were not reported. Outcomes studied included mental health symptoms (posttraumatic stress disorder, depression), justice-related outcomes (institutional violence, recidivism, institutional safety), and personal growth (resilience, changes in dynamic risk and protective factors). Positive main effects for at least one of the studied outcomes in each study were reported for seven of the ten interventions. For two of the remaining three, moderator analyses showed that interventions were effective for some participants, but not others. Specifically, a motivational interviewing intervention for incarcerated girls was associated with reduced substance-related predatory aggression in girls with lower, but not higher, levels of depression, while social problem-solving training was associated with reduced depressive symptoms in males with higher intelligence but appeared to exacerbate symptoms in those with less high intelligence. One quasi-experimental study of the effect of a restorative justice program on criminogenic risk and protective factors was reported as indicating no superior effect of assignment to the treatment program over assignment to a control condition in which participants watched a series of short victim impact videos. However, treatment completers showed improved skills in impulsivity control and in dealing with their own and others' feelings. Overall, treatment effects appeared to be stronger for males than females. The study's high attrition rate was noted (Gagnon et al.).

Despite noting multiple methodological shortcomings across the reviewed studies, Gagnon et al. ( 2022) recommended four treatments for use in youth justice facilities - trauma-focused CBT, motivational interviewing, trauma and grief component therapy, and dialectical behavior therapy - as having a prior evidence base in non-youth justice populations, as well as demonstrating a positive outcome in the reviewed studies. However, as indicated above, motivational interviewing did not reduce predatory aggression in all participants; rather, it only reduced aggression among those girls with low levels of depressive symptomatology. This finding - as well as the results of other moderator analyses noted above-underscores the need to consider individual differences when selecting treatments for justice-involved youth. Sanctuary, dialectical behavior therapy, the Think Trauma staff training program, and STAIR were also cautiously recommended for further study and evaluation, while a gender-responsive program and the restorative justice program described above were not (the latter based on the assignment to treatment results reported above). The authors noted the need to establish confidence in treatment integrity and the need for stronger research methodology.

Givens et al. ( 2021) conducted a systematic review of original studies carried out in the United States and determined to be valid using National Institutes of Health study quality assessment tools. Of 19 identified original studies, six (published between 1988 and 2018) were conducted in youth correctional facilities. Interventions included CBT and its variations, as well as intensive mindfulness meditation, physical exercise training, TARGET, and coping skill training. All the cognitive-behavioral interventions resulted in significant reductions in posttraumatic stress disorder, while TARGET and physical exercise training were associated with improved mood, and coping training was associated with improved self-esteem, reduced externalizing, and reduced death-related life attitudes. The effect of the intensive mindfulness meditation intervention (a seven-hour meditation retreat) was reported as not being significant. However, in the latter study, the control group, as well as the intervention group, was assigned to a ten-session mindfulness meditation curriculum, following which the combined results of both groups showed an overall improvement in self-regulation. The review authors concluded that the variety of interventions, outcomes, study settings, and implementation procedures made efforts to synthesize the evidence difficult.

Hodgkinson et al. ( 2021) systematically reviewed 14 studies, published between 2001 and 2018, which had documented reductions in recidivism among repeat youth offenders following implementation of psychological resilience interventions. This review includes studies from Europe as well as the US. The review authors emphasized the role of childhood trauma in impeding cognitive and emotional development in young people, leading to high levels of negative emotions and reactivity in those who subsequently become involved in the justice system. They further argue that psychological resilience may act as a protective factor against the risk of offending among adolescents who have experienced childhood trauma, while interventions that are explicitly designed to promote psychological resilience among youth who have already offended could be effective in reducing their risk of re-offending.

A wide range of treatments (see Table 1) was reviewed, including one explicitly trauma-informed program (TARGET; Ford & Hawke, 2012). Among the mechanisms considered responsible for positive treatment effects were an improved sense of coherence and an increased capacity to recognize emotions in others, since post-intervention improvements in these aspects of resilience were associated with observed reductions in reoffending. An increased sense of empowerment and improved decision-making in young people were also suggested as possible explanations.

Kumm et al. ( 2019) conducted a meta-analytic review of mental health interventions in juvenile justice facilities for young people with internalizing disorders. Eleven studies published between 1993 and 2017 were identified, of which seven included a control group (including four randomized control trials), and four employed a single-group, pretest-posttest design. In addition to CBT, dialectical behavior therapy, and TARGET, the interventions reviewed included animal assisted therapy and attributional retraining. Effect sizes with confidence intervals for individual studies were calculated, and meta-analyses of pooled effects were carried out. No interventions in studies with a control condition were associated with significant treatment effects on any outcomes. However, meta-analyses of single-group studies showed significant positive effects of treatment on internalizing symptoms, trauma, and depression, although not on anxiety. Review authors highlighted several methodological limitations associated with single-group studies (such as confounding the effect of time with the effect of treatment on the outcomes) and recommended that results be interpreted with caution. They also highlighted the need for more rigorous research and monitoring of treatment fidelity and recommended exploration of innovative study designs and interventions that cater better for short-stay residents.

Olaghere et al.'s ( 2021) meta-analysis and accompanying technical report (Wilson et al., 2018) reported on outcomes following the delivery of trauma-informed interventions in controlled studies of young people identified as at risk of justice involvement (23 studies) or justice-involved (six studies). The results of the six juvenile justice-related studies were reported separately from those for at-risk young people. Interventions examined were TARGET (Ford et al., 2012a, b; Marrow et al., 2012), cognitive processing therapy (Ahrens & Rexford, 2002), Multidimensional Treatment Foster Care (Chamberlain et al., 2007), Image Rehearsal Therapy (Krakow et al., 2001), and a version of Sanctuary that included programming for young people (Rivard et al., 2003) as well as techniques for therapeutic organizational transformation. For each study, standardized mean difference effect sizes for the outcomes were calculated (see Wilson et al., 2018, for full details) and were subsequently combined in meta-analyses. Confidence intervals (95%) and heterogeneity statistics were also reported.

Outcome domains included PTSD and trauma symptoms, affect (mental health), justice (delinquency, restraint), and hope. Three of four studies examining PTSD-related outcomes were reported as having a near null average effect size, with the remaining study (Krakow et al., 2001) observing a very large effect ( g > 1.00) in a small sample. The meta-analytic means for PTSD outcomes and affect were reported as positive and small. One study that examined justice-related outcomes (Chamberlain et al., 2007) found that trauma treatment was associated with fewer criminal referrals and days locked up in an institution (Wilson et al., 2018); however, when these measures were combined with self-reported measures of delinquency in the same study, the resulting effect of trauma treatment was reported as essentially null (p. 1267). The other study that examined justice outcomes (Ford et al., 2012a, b) indicated slightly negative effects of TARGET on Child Behavior Checklist measures of delinquency, aggression, and externalizing behaviors.

Overall, based on a small number of studies, Olaghere et al. ( 2021) concluded that evidence that trauma-informed programs improve outcomes for justice-involved youth is modest and inconclusive, although nevertheless encouraging (p. 1267). Two interventions (cognitive processing and image rehearsal therapy) were named as indicating positive effects across a range of outcomes, but as previously noted, the relevant studies had small sample sizes (Ahrens & Rexford, 2002; Krakow et al., 2001). While the evidence for at-risk youth was stronger, the collection of reviewed studies overall was reported to be at high risk of publication bias favoring studies with significant results (see Wilson et al., 2018 for analyses). Olaghere et al. ( 2021) recommended that high-quality randomized experimental studies be conducted in future to isolate the effects of specific aspects of trauma-informed interventions on outcomes for young people who are justice-involved or at risk of justice involvement.

Purtle ( 2020) conducted a systematic review of trauma-informed organizational interventions with a staff training component. Twenty-four studies, published since 2000, were reviewed. One study, an evaluation of the Sanctuary Model, was conducted in a juvenile justice facility for girls (Elwyn et al., 2015), with the remainder being conducted in child welfare, health, residential care, and educational settings. The review concluded that Sanctuary resulted in improvements to physical and perceived safety for both staff and young people, but that its multifaceted approach made it difficult to isolate the effect of staff training.

Purtle ( 2020) concluded that the pool of reviewed studies offered sufficient evidence to indicate that participation in trauma-informed staff training resulted in improvements across a range of settings in staff knowledge, attitudes, and behaviors regarding trauma-informed practices. However, the duration of these benefits for staff was considered unclear, as was the extent to which they would result in improvements for clients. While noting various methodological shortcomings of reviewed studies (e.g., the predominance of single group studies, failure to use validated measures, limited or non-existent follow-up, and failure to disentangle the effects of multiple interventions), this review presents comprehensive recommendations to guide future research on trauma-informed staff training and related organizational interventions, while also summarizing the implications for practice and policy.

Rhoden et al.'s ( 2019) systematic review examined peer-reviewed studies conducted in the United States of trauma-specific interventions among justice-involved young people to the age of 21 with "reported traumatic exposure and/or PTSD symptoms based on a DSM diagnosis or a standardized measure" (p. 894). Sixteen studies, published between 2001 and 2016, were identified that met the inclusion criteria. Of these, twelve (ten controlled studies and two with a single-group design) were group-based with quantitative analysis of outcomes. Cognitive-behavioral principles were applied in most of the interventions studied, with treatment protocols typically including an educational component, skill-building, and self-regulation strategies. One study investigated eye movement desensitization and reprocessing therapy (EMDR).

Treatment effect sizes (Cohen's d) were calculated based on reanalysis of individual study data. Medium to large effects of treatment on PTSD and/or other trauma symptoms were reported for nine studies, while a small effect was reported for a tenth. For proxy measures of externalizing behavior (e.g., time spent in seclusion, delinquency), small to large treatment effects were found in three studies. The studies of EMDR and trauma-focused CBT were considered to present the strongest evidence of treatment effectiveness based on the review authors' assessments of their comparative methodological rigor. However, Rhoden et al. ( 2019) concluded that there was insufficient high-quality evidence to indicate that trauma interventions reduce trauma symptoms and externalizing behavioral problems despite their co-occurrence.

Discussion

The main findings from this umbrella review are that the provision of trauma-focused interventions is associated with a decrease in trauma symptoms in justice-involved populations (with cognitive-behavioral approaches receiving the strongest empirical support), as well as with improvement in co-occurring mental health problems. There is also evidence of a positive impact on different metrics of re-offending and institutional misconduct. Based on our reading of the available evidence, this offers a sufficiently strong rationale to provide trauma-informed interventions to the broader youth justice population. This advice, while not particularly surprising (given that most of the review authors seem to agree), is nonetheless important in a context in which debates are ongoing about the need to establish safety and stabilization before trauma treatment can be provided. Concerns are, for example, often expressed that non-specialist treatment for trauma-related presentations can cause harm, with trauma treatment services sometimes only made available through external service providers, (such as child and adolescent mental health services) to those who meet the diagnostic criteria for posttraumatic stress disorder. The evidence reported in this study suggests that there are effective programs and interventions that can be embedded within a youth justice service that do not focus exclusively on treating presentations of posttraumatic stress. This is relevant to service planning as this type of treatment is necessarily focused on how exposure to a specific trauma, as a past event, leads to a sense of current threat. From a trauma-informed perspective, however, it is continuous actual or threatened traumatic events that are more significant, where an ongoing sense of threat becomes adaptive and necessary for survival (Rosenberg et al., 2008). Thus, efforts to implement trauma-informed youth justice should extend clinical models of service delivery to support resilience and recovery from the wide range of adverse childhood experiences that justice-involved young people have typically experienced. Effectiveness is, of course, not the only way in which the success of an intervention can be determined, with factors such as acceptability, adoption, appropriateness, cost, feasibility, fidelity, access to service, and sustainability (Brownson et al., 2012) as well as cultural and context-specific adaptations (Yim et al., 2024) also important. The body of research curated across these nine reviews also shows that such approaches are indeed feasible for delivery to youth justice populations across a range of different settings.

Limitations

An important caveat to any recommendation to implement trauma-informed youth justice, however, is that nearly all the review authors specifically comment on the importance of addressing a range of implementation and integrity challenges if a stronger evidence base is to develop. They also all note the limitations in the methodological quality of the pool of primary studies that were included in their reviews. For example, several reviews noted that single-group studies tended to show greater treatment effectiveness (larger effect sizes) than studies with a control group, reflecting possible confounding of treatment with non-treatment effects (Eadeh et al., 2021; Kumm et al., 2019; Olaghere et al., 2021). In addition, the finding of comparatively large treatment effects in primary studies with small samples may indicate a publication bias through which, it is suggested, small studies are (even) more likely than studies with larger samples to be published because of significant findings (Hong et al., 2020). The need for more complete reporting of study information to overcome the possibility of selective reporting of results is noted (Baetz et al., 2022; Olaghere et al., 2021).

While calling for greater methodological rigor, the review authors also acknowledge the challenges that arise when conducting evaluation research in youth justice settings. Contextual factors that potentially affect the quality of evidence available include the high turnover of children and young people in youth justice settings, and the resulting impact on study attrition and sample sizes. High staff turnover rates also mean that new staff must be trained, and trust with children and young people re-established. Staff turnover also contributes to poor treatment fidelity, as do the lack of program supervision, lack of leadership, and poor organizational support and culture.

An additional set of limitations relates to specific aspects of the reviews themselves. One is that in a few cases, differences in methods used to synthesize findings produced different evaluations of the same intervention. Two examples of this are the impact of WRITE-ON (Greenbaum & Javdani, 2017) on shame, and the impact of TARGET (Marrow et al., 2012) on PTSD. While such differences may be relatively minor, they highlight the need for the reader to exercise care when drawing conclusions. Importantly, there were also differences between reviews in how well they captured aspects of sample diversity such as race and ethnicity in their descriptions of primary study characteristics. This made it difficult to gauge how closely the study samples resembled the wider population of justice-involved young people in their respective countries or regions of origin, particularly in the United States, where most of the primary studies were conducted. An additional limitation was that only three of the reviews included studies from other countries or regions, such as Canada, the UK, or Europe. There is clearly a need to extend research into trauma-informed youth justice to other geographical and cultural regions. And we would also note that, even among western countries, there are differences in judicial systems and the composition of justice-involved youth populations. For example, in former British colonies such as Canada, Australia, and New Zealand, it is First Nations populations who are especially overrepresented in the youth justice systems, reflecting the need to develop service responses that also acknowledge a range of social and economic disadvantages, such as poverty, social and health inequalities, systemic racism and discrimination, and intergenerational trauma.

Finally, this umbrella review was limited in scope by excluding non-peer-reviewed documents and other grey literature. And, although not by design, a major focus of the available research was on the outcomes of trauma-focused treatments and programs, which constitute only one aspect of trauma-informed juvenile justice practice (Branson et al., 2017).

Next Steps for Advancing Trauma-Informed Youth Justice

There is an ongoing need to better understand the outcomes of the broad range of practices that constitute trauma-informed practice. Some kind of trauma awareness training for staff is, for example, considered a minimum requirement (Branson et al., 2017), and there is a consensus that to deliver this requires adequate resourcing and sustained organizational and system-level support, including leadership. There are elements of training in many of the primary studies that were included in the reviews that met the inclusion criteria in our study, but it was not easy to ascertain their impact on outcomes. The Elwyn et al. ( 2015) study, for example, describes an organizationally framed intervention (Sanctuary) and is featured in two of the reviews (Gagnon et al., 2022; Purtle, 2020), while the Marrow et al. ( 2012) evaluation of TARGET features environmental modifications as well as training (i.e., it goes beyond treatment). It is reasonable to conclude that the evaluation of organizational, systemwide interventions in youth justice settings is still less well developed than that of trauma-focused treatments. Without considering the impact of activity at every level of the organization (SAMHSA, 2014), the evaluation of specific programs is always going to be unsatisfactory. And so, we need to think about utilizing stronger research designs that can account for the ways in which individual level, group level, and organizational level components of trauma-informed practice interact and combine to produce the range of outcomes that youth justice services are expected to deliver.

An obvious next step will also be to better understand the experiences and views of young people in the youth justice system. The SAMHSA ( 2014) trauma-informed principles were reportedly developed with expert and public input with 2000 respondents and 20,000 comments/endorsements (Heris et al., 2022). This was a process specifically designed to ensure that the resulting principles reflected the voices of trauma survivors, and it thus becomes important to listen to what justice-involved young people have to say about the services they receive (see Day et al., 2023). The task then is to find new ways to triangulate outcome data with the experiences and insights of justice-involved young people.

Finally, there appears to be a need to further develop systems of audit, accountability, and accreditation to ensure that trauma-informed youth justice is being implemented in a way that can be expected to result in the specified desired or agreed upon outcomes for young people and the wider community. It has, for example, been observed that the connection between activity and outcomes is often implicit or absent in accounts of trauma-informed practice (Bazemore, 2006) and there may well be differences in the extent to which different parts of any justice system align with a trauma-informed philosophy. External youth justice stakeholders and mental health providers who work with trauma may, for example, focus more on symptom reduction and/or on promoting health and wellbeing, while the principal concern of youth justice staff will typically be to reduce risk and future justice system involvement. Our conclusion then is that, although there is much more work to do to achieve trauma-informed youth justice, it is a promising line of inquiry that is supported by evidence and can lead to better outcomes for both justice-involved young people and for communities. At a time in history when the need for new and innovative approaches has been identified, it remains a promising alternative to more punitive approaches.

Electronic Supplementary Material

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Funding

Open Access funding enabled and organized by CAUL and its Member Institutions Catia Malvaso is supported by an Australian Research Council Discovery Early Career Researcher Award (DE200100679). This research was also supported by funding from the South Australian Department of Human Services, Communities and Justice, Research and Service Development Partnership Grant.

Declarations

Conflict of Interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Footnotes

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References

*References with an asterisk indicate reviews included in this study

1. Carlile Inquiry. (2014). Independent Parliamentarians' Inquiry into the Operation and Effectiveness of the Youth Court Chaired by Lord Carlile of Berriew CBE QC. Retrieved from https://michaelsieff-foundation.org.uk/content/inquiry_into_the_operation_and_effectiveness_of_the_youth_court-uk-carlile-inquiry.pdf

2. Covidence systematic review software. (2022). Melbourne, Australia: Veritas Health Innovation. Available at www.covidence.org

3. Liddle, M., Boswell, G., Wright, S., & Francis, V., with Perry, R. (2016). Trauma and Young Offenders: A Review of the Research and Practice Literature. Beyond Youth Custody. Retrieved from http://www.beyondyouthcustody.net/wp-content/uploads/Trauma-and-young-offenders-a-review-of-the-research-and-practice-literature.pdf

4. Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hrobjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., & Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ,. 10.1136/bmj.n71 [DOI] [PMC free article] [PubMed] [Google Scholar]

5. Substance Abuse and Mental Health Services Administration [SAMHSA]. (2014). Trauma-Informed Care in Behavioral Health Services. Rockville, MD: Substance Abuse and Mental Health Services Administration: Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. [PubMed] [Google Scholar]

6. U.S. Departments of Education and Justice. (2014). Guiding principles for providing high-quality education in juvenile justice secure care settings. https://www2.ed.gov/policy/gen/guid/correctional-education/guidingprinciples.pdf

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Supplementary Materials

Articles from Journal of Child & Adolescent Trauma are provided here courtesy of Springer

# data[].attributes.attachment_link.title
The Outcomes of Trauma-Informed Practice in Youth Justice: An Umbrella Review

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Findings of high rates of complex trauma among justice-involved young people have engendered interest in developing trauma-informed youth justice systems. Although there have been several reviews of trauma-informed practice in youth justice ...

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What characterizes a good mental health professional in court-mandated treatment settings?

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What characterizes a good mental health professional in court-mandated treatment settings?

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This qualitative interview study explored key characteristics and practices that enhance therapeutic engagement and outcomes in court-mandated (involuntary) treatment settings. Interviews were conducted with 41 older incarcerated patients and 63 mental health professionals across Switzerland and Canada, using thematic analysis to identify themes. Both patients and providers emphasized the importance of a humane, respectful, humanistic approach, separating the person from their offense while involving patients in treatment planning to bolster autonomy and motivation. They also highlighted the need for concrete, personalized feedback and a directive yet non-confrontational stance to build trust in coercive contexts. The study concludes that even involuntary therapy can be effective when clinicians demonstrate empathy, offer real choices, and maintain professionalism in dual roles (caregiver and mandated agent) (Seaward et al., 2021).

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What characterizes a good mental health professional in court-mandated treatment settings?: Findings from a qualitative study with older patients and mental health care professionals - BMC Psychology

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Background Therapist-related activities and characteristics such as empathy and genuineness are factors that significantly contribute to psychotherapy outcome. As they play a role in psychotherapy more generally, it can be expected that they are equally important in the treatment of court-mandated patients more specifically. At the same time, these treatment settings come with specific challenges—e.g. due to coercion and control—and it could thus be that some therapist-related characteristics might have a different empathy on the therapy. This interview study sought to investigate service providers’ and users’ perspectives on therapist-related characteristics in the context of detention. Methods We conducted a qualitative interview study with 41 older incarcerated persons mandated to treatment, and 63 mental health professionals (MHP). The data analysis followed thematic analysis. Results Patients and experts both emphasized the importance of treating patients with respect by taking a humanistic approach, that is, condemn the deeds but embrace the person and display genuine interest in supporting patients with any issue or concern that is of relevance to them. Furthermore, interviewees underscored that the coerciveness of the therapy context required to incorporate patients’ wishes into treatment planning, recognize and respond to the patients’ needs, and allow some choice within the given framework. Such inclusive attitude was deemed critical to engage and motivate patients to participate in treatment. In addition, it was emphasized that feedback and advice by the therapists need to be concrete, detailed and applied to each person’s current situation. Lastly, patients questioned MHP’s qualification when they did not progress in therapy. Discussion Our findings indicate that some therapist-related activities and characteristics are of particular importance in court-mandated settings. These include genuine interest in the patient, a respectful and positive attitude, as well as the capacity to target sensitive issues in a directive but non-confrontational manner. Further research needs to identify specific expressions and behaviors that are linked to the aforementioned characteristics in the forensic context. Our study therefore contributes to much-needed empirical research on clinician and patient perspectives on therapist characteristics and activities in the treatment of court-mandated patients.

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State of the Evidence for Use of Psychotropic Medications in School-Age Youth

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State of the Evidence for Use of Psychotropic Medications in School-Age Youth

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This article looks at current research on psychotropic medication use in children aged 6–17, focusing on treatments for ADHD, depression, anxiety, aggression, and OCD. Drawing from clinical trials, epidemiological studies, prescribing trend data, and professional guidelines, it evaluates both the efficacy and safety of medications such as stimulants, SSRIs, and antipsychotics. The findings indicate that these medications can be effective especially when combined with psychosocial interventions but also raise concerns about long-term safety and notable disparities in prescribing across demographic groups. The authors emphasize the need for coordinated, “whole-child” approaches involving schools, families, and prescribers to ensure equitable and safe treatment in real-world settings (Shahidullah et al., 2023).

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Abstract

Psychotropic medications are commonly prescribed to school-aged youth for the management of mental health concerns. This paper describes the current state of evidence for psychotropic medications in school-aged youth. More specifically, the following sections summarize relevant medication research trials and practice parameters pertaining to psychotropic medication prescribing as well as the specific medications indicated for a range of commonly presenting disorders and symptom clusters in school-aged youth. For each of these disorders and symptom clusters, key findings pertaining to the current state of science and practice are highlighted for the purpose of offering patients, clinicians, researchers, and policymakers with nuanced considerations for the role of psychopharmacology within the context of a larger "whole-child" approach to care that relies on the collaboration of providers and services across systems of care to promote optimal child and family health and wellness. The paper concludes with a discussion about supporting the use of medication treatments in schools, including considerations for ensuring effective family-school-health system collaboration to best meet youth mental health needs.

Keywords: mental health, psychotropic medications, school age youth, pediatric psychopharmacology

1. Introduction

Childhood mental health problems are prevalent and associated with an increased risk of difficulties at home, school problems, and mental health and health conditions in adulthood. Roughly 20% of youth living in the United States (U.S.) have an identified mental health condition in a given year, while 40% will meet the criteria by age 18 [ 1]. Youth in families living below 100% of the federal poverty level have an even higher likelihood of experiencing a mental health condition [ 2]. Among U.S. children and adolescents, anxiety and attention-deficit/hyperactivity disorder (ADHD) are the most prevalent disorders, each affecting approximately one in 11 (9.4-9.8%) youth [ 3]. In addition, one-fifth (20.9%) of youth have experienced a major depressive episode, 36.7% of U.S. high school students in 2019 reported persistently feeling sad or hopeless in the past year, and 18.8% seriously considered attempting suicide. Mental health concerns in youth have increased since the onset of the COVID-19 pandemic [ 4, 5], with mental health-related emergency department visits increasing by 24% for children ages 5 to 11 and 31% for ages 12 to 17 in the six months after the pandemic's onset [ 6].

Evidence-based therapies for managing prevalent mental health conditions, such as anxiety, depression, and ADHD, include both psychosocial and psychopharmacological approaches [ 7, 8, 9, 10]. Psychotropic medications are commonly recommended in prominent professional practice parameters and treatment guidelines for a range of mental health conditions (e.g., American Academy of Child and Adolescent Psychiatry [AACAP], American Academy of Pediatrics [AAP]). Unfortunately, one-half of children with mental health concerns do not receive appropriate treatment, including psychosocial therapies or psychotropic medication [ 11]. Underutilization of evidence-based mental health therapies is due to a variety of factors, including service-level (e.g., limited availability of effective clinicians), societal (e.g., bias, discrimination, state/local policy), economic (e.g., insurance status), and individual (e.g., cultural beliefs, stigma, transportation, parental work leave [ 12]).

Compounding challenges with access to psychotropic treatments in particular, there is a critical lack of child and adolescent psychiatrists, particularly in areas with a high proportion of families with low incomes and post-secondary education rates and in non-urban/-metropolitan areas [ 13, 14]. Although data suggests an increase in the number of available child psychiatrists in the U.S. (child psychiatrists [per 100,000 children] increased by 22% from 2007 to 2016), the rate of growth cannot keep up with increasing mental health needs [ 13]. Child mental healthcare demands have increased as a function of expanded child health insurance [ 15], improved screening and detection for mental health concerns [ 16], and greater public health awareness of mental health conditions, particularly since the COVID-19 pandemic and the national declaration of a "youth mental health crisis" [ 17].

To keep up with demand, pediatricians and other primary care clinicians are shouldering more of the load in mental healthcare [ 18, 19]. Despite an American Academy of Pediatrics recommendation [ 20] that pediatricians achieve competence in providing care for anxiety, depression, and ADHD, among other conditions, surveys suggest that pediatricians lack adequate training in this area [ 21, 22, 23]. Primary care clinicians report a lack of comfort and confidence in prescribing medications other than stimulants (anti-anxiety, mood stabilizing, and anti-psychotic medications) and although they identify concurrent psychosocial treatment to be very useful, they often consider this type of support to be inaccessible to patients [ 24].

Management of psychotropic medication by primary care clinicians has more recently been supported by the use of coordinated, collaborative, and integrated care models. Coordinated models allow prescribing clinicians to consult with on-call psychiatric specialists provided across regions or networks to support their management of patients' psychotropic medication. The longest-running model is the Massachusetts Child Psychiatry Access Project (MCPAP), which has yielded promising results. However, these telephonic psychiatric access programs rely heavily on state funding or grants to support and sustain the model [ 25]. Collaborative models address the needs of primary care clinicians onsite through ongoing screening for specific high-frequency conditions (e.g., ADHD, anxiety, depression) and protocol-driven decision-making processes in conjunction with onsite behavioral health clinicians or care managers and offsite psychiatric consultations [ 26, 27]. Integrated models embed behavioral health clinicians within the primary care practice setting to support collaborative evaluation and treatment of child and adolescent mental health needs. Psychologists with requisite training have been particularly well-positioned to undertake collaborative medication-related roles with primary care clinicians in (1) supporting diagnostic clarity, (2) providing psychotropic information to families, (3) joining planning and care coordination with primary care clinicians and families, (4) addressing barriers to adherence, and (5) evaluating and monitoring medication effects [ 23].

Although the use of psychotropic medications to treat youth mental health concerns has increased in general over the last decade, prescribing rates differ depending on a number of geographic, socioeconomic, and demographic factors [ 28, 29, 30]. The National Center for Health Statistics (NCHS) [ 31] reporting on 2019 trends in mental health treatment among children aged 5-17 years found that males (9.8%) were more likely than females (7.0%) to have been treated with medication and that the prevalence of psychotropic prescribing in non-urban areas (11.8%) was higher than in urban areas (7.4%). NCHS data also suggested that White children were more than twice as likely (11.4%) to have taken medication than Latinx (4.7%) and Black (5.6%) children. Although Black and Latinx youth are generally less likely than other racial/ethnic groups to receive psychotropic medications to treat mental health concerns [ 32, 33], Latinx youth are more likely than other groups to receive antipsychotic drugs, which tend to have more metabolic side effects than other medication classes [ 34]. Additionally, in a study using data from over 50,000 participants in the National Survey of Children's Health-2016, children in immigrant families were significantly less likely to have received psychotropic medication for a mental health problem [ 35].

In a retrospective cohort study of children within one state's Medicaid database, Lohr et al. [ 36] found that children in foster care received alpha agonists (116 vs. 69 per 1000 children) or antidepressants (225 vs. 176 per 1000) at a higher rate than children who were not in foster care, but received stimulants at a lower rate (403 vs. 638 per 1000) and children in foster care (beta = 1.83, 95% CI = 1.53, 2.13) had a higher incidence of being prescribed medications for multiple drug classes (i.e., polypharmacy) [ 34]. In a study exploring antipsychotic prescriptions for children aged 5 years and younger enrolled in a state Medicaid program in one U.S. state, Lòpez-De Fede et al. [ 37] found that 2 in 5 children received antipsychotics for off-label use (a use other than their FDA-approved indication) and 3 in 4 children also received medications from at least one other psychotropic drug class. In a multisite Developmental Behavioral Pediatrics Research Network (DBPNet) study [ 38] tracking psychotropic medication prescribing to 3-5-year-old children, those on Medicaid were more likely to be prescribed psychotropic medications than those with private insurance (OR: 1.65; 95% CI, 1.29-2.12) and this was particularly true for alpha-2-adrenergic agonists (OR: 2.48; 95% CI, 1.56-3.92) and atypical antipsychotics (OR: 2.57; 95% CI, 1.46-4.55).

The many professional practice parameters that endorse the use of psychotropic medications in treating a range of child mental health conditions clearly dictate that child mental health professionals use these particular therapies in treatment decision-making. However, the decision for patients, families, and clinicians to use these particular therapies remains incredibly nuanced, and sometimes controversial given that these practice parameters can offer broad guidance without accounting for the many intricacies that must be weighed in any given clinical-decision making process, such as (1) the quality of the research literature including methodological rigor, sampling considerations (i.e., heterogeneity and representativeness of multiple forms of diversity in the samples), and understanding of long-term outcomes, (2) the consideration of patient and families attitudes, acceptability, and satisfaction towards medications that may affect adherence issues and continued help-seeking, (3) the degree to which psychotropic medication prescribing in community settings matches the standard of psychotropic medication prescribing in the RCTs/trials in which it was studied, (4) the balance between the positive benefit and adverse/side effects in the context of the "First, Do No Harm" medical ethical mantra, and (5) the degree to which treatment decision-making can be supported through multi-modal, multi-system, multi-setting, and multi-professional processes to support "whole-child" care while emphasizing the balance between safety, efficacy, and patient preference/autonomy.

The purpose of this paper is to describe the current state of evidence for psychotropic medications in school-aged youth. The following sections summarize the relevant medication research trials and practice parameters (see each citation for details about the systematic literature review methods that were utilized to develop each practice parameter) pertaining to psychotropic medication prescribing as well as the specifically indicated medications for a range of commonly presenting disorders and symptom clusters in school-aged youth (ADHD, Major Depressive Disorder and Persistent Depressive Disorder, Anxiety Disorders, Compulsive, Rigid, and Repetitive Behaviors, and Aggression, Irritability, and Self-Injury). Next, for each of these disorders and symptom clusters, key findings from each practice parameter pertaining to the current state of science and practice are highlighted for the purpose of offering patients, school and medical professionals, researchers, and policymakers with nuanced considerations for the role of psychopharmacology within the context of a larger "whole-child" approach to care that relies on the collaboration of providers and services across systems of care to promote optimal child and family health and wellness. To this end, the paper concludes with a discussion about supporting the use of medication treatments in the school setting, including considerations for ensuring effective family-school-health system collaboration to best meet youth mental health needs.

2. Commonly Presenting Disorders and Symptom Clusters

2.1. ADHD

ADHD is one of the most common chronic neurodevelopmental disorders among children and adolescents, affecting as many as 10% of youth between ages 3 and 17 [ 1]. An increased focus on the assessment of ADHD symptoms in diverse populations is paramount [ 39] given recent meta-analytic data indicating significant under-identification of ADHD in Black individuals in the United States [ 40]. Those diagnosed with ADHD experience impairment in social relationships and/or academic performance beginning in childhood, often continuing into adolescence and adulthood [ 41].

Current evidence-based ADHD assessment practices focus on collecting neurodevelopmental information associated with context-impairing symptoms of inattention, disorganization, hyperactivity, and/or impulsivity [ 41]. Three diagnostic categories are primarily considered when assessing ADHD symptoms in children including ADHD, Combined Presentation, Predominantly Inattentive Presentation, and Predominantly Hyperactive-Impulsive Presentation. Subthreshold symptoms may result in a diagnosis of Other Specified ADHD or Unspecified ADHD. An ADHD diagnosis in childhood is associated with poor health outcomes, and a recent study found a twofold risk for premature death by the age of 46 [ 42]. Clinicians should recognize that the presentation of hyperactive and impulsive symptoms are associated with a range of negative outcomes, including peer rejection, aggression, risky behaviors, and accidental injuries [ 39]. Data collection and progress monitoring of these associated deleterious developmental outcomes should be an essential component of clinical care and treatment decision-making.

2.1.1. Practice Parameters and Treatment Guidelines for ADHD

Current treatment guidelines have been heavily influenced by findings from the NIMH-funded Multimodal Treatment of ADHD (MTA) study [ 10] and the Preschool ADHD Treatment Study (PATS) [ 45]. The large, multi-site MTA study [ 10] was designed to evaluate treatments for children ages 7 to 10 with ADHD ( n = 579) including medication, behavior therapy, a combination of medication and behavior therapy, and routine community care (control group). Combined (i.e., medication and behavior therapy) treatment and medication alone were found to be significantly superior to behavior therapy and routine community care after 14 months. Outcomes for children in the combination treatment group were obtained with medication doses that were 20% lower than the doses of children in the medication-only group. In general, children prescribed medication through the study had more positive outcomes than those who received medication from community providers (i.e., community control group). Notably, community providers tended to prescribe substantially lower doses of medication (i.e., almost half). While behavioral improvements were maintained at 24 months [ 46], it was noteworthy that no significant differences were noted at 36-month follow-ups [ 47]. PATS [ 45] examined medication efficacy for young children (ages 3 to 5.5 years) with ADHD. Study participants received 10 weeks of behavioral therapy prior to being randomly assigned to either the methylphenidate or placebo groups. Methylphenidate significantly improved symptoms although with smaller effect sizes and more side effects compared to the older age range in the MTA study.

Overall, the MTA and PATS studies revealed initial improvements in medication and combined medication and behavior therapy groups with the MTA study indicating that short-term improvements at 14 months did not generalize long-term when assessed at 36 months [ 48]. Additionally, given short-acting preparations were used in these studies and extended-release preparations are now more widely used, the generalizability of the results remains unclear. It is noteworthy that methodological factors likely resulted in more favorable outcomes for the medication treatment group in the MTA study [ 49]. Specifically, dosing in the medication group was significantly higher than what would be expected in community samples. Additionally, although stimulants were beneficial as a short-term treatment, the effects of medication are not observed once the medication is terminated which is often the case for children with ADHD across development. However, current treatment recommendations support medication management for children and adolescents with ADHD along with behavior management across home and school.

As a result of the chronic nature of the disorder, professional guidelines encourage a chronic care, life course approach to treatment [ 43, 44, 50], with modifications to treatment planning consistent with child development. Also, consistent with a developmental approach to treatment, there are specific practice parameters for preschool-aged children (3 to 5 years), children (6 to 12 years), and adolescents (13 to 17 years). For preschool-aged children, behavioral intervention, specifically behavioral parent training, is considered the first line of treatment, supplemented by medication in cases of ongoing moderate to severe impairment. For children over age 6, FDA-approved medications for ADHD are encouraged, in combination with behavioral intervention (i.e., behavioral parent training and behavioral classroom intervention). Guidelines emphasize the importance of engaging adolescent patients in care planning, whether the treatment plan includes medication and/or behavioral intervention (e.g., evidence-based youth skills training).

2.1.2. Medication Management for ADHD

The AAP issued a policy statement [ 52] in 2014 regarding prescribing practices for off-label medication to children. In this statement, the AAP recommended that scientific evidence rather than label indication serve as the gold standard for practitioners making therapeutic decisions for patients. There are some off-label medications for children with ADHD including bupropion, selective serotonin reuptake inhibitors (SSRIs), and atypical neuroleptic agents (e.g., risperidone and aripiprazole) with limited evidence supporting use for the treatment of ADHD. Bupropion (Wellbutrin) is registered as a unique antidepressant and is thought to have an indirect mixed agonist effect on dopamine and norepinephrine and has also been used with some success to treat adults with ADHD [ 53]. However, a systematic review of the effectiveness of bupropion revealed the quality of evidence to be low and includes adult samples [ 54].

Side effect management is among the most significant challenges with children who are managed with stimulant medication with loss of appetite (anorexia) and difficulty falling asleep (insomnia) being the most commonly reported [ 55]. Additional side effects include dizziness, irritability, or moodiness while taking medication, growth problems (e.g., concerns with height and weight) [ 56], and heart symptoms (e.g., pounding, almost passing out, chest pain) [ 57].

2.2. Major Depressive Disorder and Persistent Depressive Disorders

Child and adolescent depressive disorders and associated suicidality have a profound psychosocial impact on schools, families, and communities. Meta-analytic methods estimate the global pooled prevalence of elevated depression in school-aged children to be one in four (25.2%) [ 5]. Of those with severe depression, about one in three experience suicidality [ 58]. Death by suicide for 10-19-year-olds occurs at a rate of approximately 7 in 100,000 [ 1], making it the third leading cause of death in this age group.

Current evidence-based depression assessment practices focus on the collection of information associated with the following depressive disorders: Major Depressive Disorder (MDD: Single and Recurrent), Persistent Depressive Disorder (PDD: Dysthymia), Disruptive Mood Dysregulation Disorder (DMDD), Premenstrual Dysmorphic Disorder, Mood Disorder Due to Another Medical Condition, Substance/Medication-Induced Disorder, Other Specified Depressive Disorder, and Unspecified Depressive Disorder [ 41]. Major Depressive Disorder and Persistent Depressive Disorder are the most commonly diagnosed depressive disorders occurring in about 15% of children and the focus of this section [ 1]. The most common diagnostic feature of depressive disorders is the presence of persistent sad, empty, or irritable mood. Frequent episodes of behavioral and emotional dysregulation, feelings of hopelessness, low energy, suicidal thoughts, and/or physiological changes such as changes in sleep patterns or appetite may also be present. These symptoms negatively impact one's functioning at home, school, and/or the community. Symptoms can be experienced on a continuum and individualized assessment utilizing a developmental lens on differential diagnosis and treatment planning is especially important within school-aged populations [ 59].

2.2.1. Practice Parameters and Treatment Guidelines for MDD and PDD

Employing evidence-based mental health practices to minimize the impact of depressive symptoms on children's functioning and, in some cases, mortality, is critical. Depressive disorders are believed to be significantly underdiagnosed by mental health professionals creating the need for accurate screening and comprehensive assessment practices [ 60]. An independent panel of national experts in evidence-based medicine recently recommended that screening for MDD within primary care is necessary to help facilitate early intervention [ 61].

To improve the quality of behavioral healthcare provided to children and adolescents with depressive disorders, numerous behavioral health professional organizations [i.e., child psychiatry [ 62, 63], pediatrics/primary care [ 64, 65], and psychology [ 59] have developed assessment and treatment practice guidelines to assist clinicians. Recently published guidelines for the assessment and treatment of depression [ 63] highlight the following essential biopsychosocial data to be gathered within a thorough diagnostic evaluation: (a) symptom identification including frequency, severity, onset, and duration of each and in combination if co-occurring symptom patterns are evident, (b) the impact and dysfunction associated with symptoms, (c) areas of developmental differences or delays compared to peers, (d) any related somatic concerns, and (e) etiological considerations and other factors either negatively or positively impacting symptom presentation. Gathering information about the child and family's values, beliefs, and attitudes regarding both symptoms and possible treatment approaches is essential to promote an effective treatment plan to match the unique needs and context of each child. Treatment guidelines for MDD and PDD developed an extensive review of the latest evidence-base [ 63] including the following:

1. Cognitive-behavioral therapy (CBT) and interpersonal therapy should be offered to school-aged youth with MDD or PDD, as a first-line intervention.

2. Selective serotonin reuptake inhibitor medication (except paroxetine), preferably fluoxetine, should be offered to school-aged youth diagnosed with moderate to severe MDD.

3. Combined treatments (cognitive-behavioral therapy plus fluoxetine) should be offered to school-aged youth diagnosed with MDD, preferably within the same system of care.

4. Continued fluoxetine alone or cognitive-behavioral therapy plus continued fluoxetine should be offered to school-aged youth who respond favorably to acute fluoxetine treatment, in order to prevent MDD relapse/recurrence.

In sum, evidence-based psychosocial treatments (i.e., CBT, interpersonal therapy) alone or combined with SSRI medications should be utilized to treat school-aged youth diagnosed with MDD or PDD. In addition, maintenance of these treatments can help to prevent depression symptom relapse and recurrence. Noteworthy is the need for an accurate diagnosis based on multi-method and multi-informant biopsychosocial data prior to implementing these treatment guidelines.

2.2.2. Medication Management for MDD and PDD

Evidence from a review of clinical trials demonstrates the benefit of antidepressants as a positive response to antidepressants is seen in about 50-70% of those treated, though at rates only about 10-15% higher (this includes all SSRI trials including industry-funded and NIH-funded trials) than those receiving placebo [ 7]. Of the diverse medications investigated with rigorous randomized controlled studies, fluoxetine has the most evidence for its use to reduce moderate to severe depressive symptoms in the adolescent population [ 66]. Current primary care treatment guidelines for mild depression include active support and symptom monitoring by clinicians as some mood dysregulation is a normal part of adolescent development [ 7]. For moderate to severe cases, active monitoring must switch immediately to an active, comprehensive, actionable treatment approach according to these guidelines. Psychotherapy and psychopharmacological treatment are recommended in combination with crisis intervention, family support, skill building, and mental health consultation. A multitude of approaches are essential knowing that antidepressant medications have not been found to improve life functioning measures, other than measures of depressive symptoms [ 67]. Moderate and severe depressive cases also warrant a close examination of parallel substance or drug use. Finally, if symptom improvement is not observed after 6 to 8 weeks of treatment, a reexamination of diagnosis and a potential modification of treatment planning is recommended within these treatment guidelines directed at primary care professionals.

The most common side effects of SSRIs [ 63, 64] include gastrointestinal symptoms (e.g., nausea, diarrhea), behavioral activation (e.g., restlessness, impulsivity), headaches, and less often, fatigue. Other rare side effects include activation of mania/hypomania and increased suicidal ideation. The most intolerable antidepressant medications are duloxetine, venlafaxine, and paroxetine; highlighting the need for close monitoring of adverse events within school-aged populations being prescribed this class of medications [ 7]. Specifically, virtual or in-person data gathering on symptoms worsening, suicidality, or any other unusual behavioral health changes is necessary.

2.3. Anxiety Disorders

Anxiety disorders represent the most common mental health conditions across the world [ 68]. Anxiety disorders have an early age of onset and are associated with functional impairment and symptomatic distress [ 69]. Additionally, anxious youth are at increased risk for developing mood disorders, substance use disorders, suicidal behavior, and significant psychosocial impairment (e.g., educational underachievement, adult economic disadvantage) [ 70].

Anxiety disorders encompass Separation Anxiety Disorders, Specific Phobias, Generalized Anxiety Disorder, Social Anxiety Disorder, and Panic Disorder. Anxiety disorders tend to present at predictable times throughout childhood. Separation Anxiety typically has an earlier age of onset than social anxiety or panic disorder, which more typically emerge in adolescence and young adulthood [ 71, 72]. Anxiety disorders are frequently comorbid, share similar neurobiology [ 73] and treatment responses [ 72]. Three anxiety disorders-Generalized Anxiety, Separation Anxiety, and Social Anxiety-are known as the "pediatric anxiety triad" and have received the most attention in randomized control trials of treatment of anxiety disorders.

2.3.1. Practice Parameters and Treatment Guidelines for Anxiety Disorders

The most recent American Academy of Child and Adolescent Psychiatry [ 74] practice parameters on the treatment of anxiety disorders in children and adolescents make the following recommendations:

1. Cognitive Behavioral Therapy should be offered to patients 6-18 with separation anxiety, social anxiety, generalized anxiety, specific phobia, and panic disorder.

2. SSRIs may be offered to patients 6 to 18 years old with social anxiety, generalized anxiety, separation anxiety, or panic disorder.

3. Combination treatment (CBT and an SSRI) could be offered preferentially over CBT alone or an SSRI alone to patients 6 to 18 years old with social anxiety, generalized anxiety, separation anxiety, or panic disorder.

4. Serotonin norepinephrine reuptake inhibitors (SNRIs) could be offered to patients 6 to 18 years old with social anxiety, generalized anxiety, separation anxiety, or panic disorder.

There is robust evidence for the efficacy and safety of both CBT and medication treatments for pediatric anxiety disorders [ 75, 76, 77]. Psychotherapy is a first-line treatment for anxiety disorders. There is evidence for the use of CBT [ 78] and other therapies such as Acceptance and Commitment Therapy [ 79] and mindfulness-based therapies [ 80] that share common treatment principles with CBT.

2.3.2. Medication Management for Anxiety Disorders

While medication may be used without therapy, often medication is employed in addition to CBT. This is commonly referred to as combination treatment. SSRIs are the first-line medications used for anxiety disorders. SSRIs inhibit serotonin reuptake and, in some cases, inhibit dopamine and norepinephrine reuptake. SSRIs that have shown efficacy with pediatric populations in randomized controlled trials include, fluoxetine (trade name, Prozac) [ 81], sertraline (trade name Zoloft) [ 82], and escitalopram (trade name Lexapro) [ 83]. Table 2 for the most common medications used in the treatment of pediatric anxiety.

The most common side effects of SSRIs include gastrointestinal symptoms (e.g., nausea, diarrhea, lack of appetite), physical activation (e.g., restlessness, insomnia, impulsivity), headaches, and less often, fatigue. Other rare side effects include activation of mania/hypomania and increased suicidal ideation. SSRIs, when initiated, tend to require 4-6 weeks to assess effectiveness. Treatment response to SSRIs is logarithmic, with improvement occurring quickly during the first 8 weeks of treatment and plateauing at 24 weeks [ 84, 85]. This week-over-week improvement appears to be accelerated when medication is combined with psychotherapy [ 86].

SNRIs are considered a secondary medication option to treat anxiety disorders in youth [ 85]. Two SNRIs have been found effective in randomized controlled trials for pediatric anxiety disorders: duloxetine (trade name Cymbalta) [ 87] and venlafaxine (trade name Effexor) [ 88]. SNRIs have an adverse effect profile similar to that of SSRIs, although they may be slightly less likely to cause activation [ 85]. Additionally, venlafaxine may increase treatment onset suicidality [ 66, 89].

To date, there are no head-to-head studies of SSRIs and SNRIs in youth with anxiety disorders. Three meta-analyses have looked at outcome response in anxiety for SSRIs and SNRI-evaluated duloxetine, fluoxetine, fluvoxamine, paroxetine, sertraline, and venlafaxine, demonstrating antidepressant superiority relative to placebo with a pooled effect size (Cohen's d) estimate of 0.62 (95% CI: 0.34-0.89; p = 0.009). Locher et al. [ 76] meta-analytically evaluated SSRIs and SNRIs in children and adolescents with anxiety disorders. Locher et al. [ 76] noted increased remission with SSRIs (relative risk, 2.04; 95% CI: 1.37-3.04) and response (relative risk, 1.96; 95% CI: 1.60-2.40) in a sample including 7700 pediatric patients. According to studies of antidepressants in pediatric patients with anxiety disorders, SSRIs are associated with earlier improvement compared to SNRIs. Benzodiazepines, such as Xanax, did not meta-analytically reduce anxiety [ 75] and are not recommended for the treatment of anxiety disorders in youth.

The combination of CBT and SSRIs appears to have the strongest impact on the remission of youth anxiety disorders. The NIH-funded Child/Adolescent Anxiety Multimodal Study (CAMS) ( n = 488) compared placebo, sertraline only, CBT only, and sertraline + CBT (COMB) over 12 weeks. The three treatments, COMB, CBT, and sertraline only, were all more effective than placebo. COMB was more effective than CBT or sertraline alone. Remission rates for COMB were superior to CBT (66% vs. 35%) after 12 weeks of treatment [ 90]. Youth in CBT at 24 weeks saw the remission rates narrow (65% vs. 45%) [ 84]. Additionally, relative to either monotherapy, the probability of response for both CBT and CBT + sertraline increased week-over-week during the acute 12-week treatment period, whereas the probability of achieving additional benefit plateaus by week 4 in patients receiving placebo and week 8 in patients receiving sertraline [ 91]. Given current evidence, it appears likely that youth with severe anxiety disorders would benefit from combination treatment for anxiety.

2.4. Compulsive, Rigid, and Repetitive Behaviors

The symptom cluster of compulsive, rigid, and repetitive behaviors represent behaviors that a person feels the urge to do and can often be in response to an obsessive thought, such as in obsessive compulsive disorder (OCD). This symptom cluster also includes conditions such as trichotillomania whereby someone struggles to resist the urge to pull out their hair. Rigid and repetitive behaviors are often symptoms of neurodevelopmental concerns such as autism and may include repetitively flapping arms, spending hours lining up toys, or struggling to tolerate changes in routine.

2.4.1. Practice Parameters and Treatment Guidelines for Compulsive, Rigid, and Repetitive Behaviors

CBT incorporating Exposure and Response Prevention (ERP) is the first-line treatment for mild to moderate OCD [ 92]. For moderate to severe OCD, the combination of CBT with a SSRI is appropriate therapy. The AACAP [ 93] practice parameters state that pharmacologic treatment may also be appropriate in milder OCD cases in settings where high-quality CBT is not available, or when there is comorbid anxiety or depression.

The seminal pediatric OCD study was the NIMH-funded Pediatric OCD Treatment (POTS) 2004 study [ 93] that randomized 112 patients to sertraline, high-quality CBT with ERP, or the combination of sertraline and CBT. The effect sizes for combined treatment, CBT alone, and sertraline were 1.4, 0.97, and 0.67, respectively. Other randomized controlled trials of medication in pediatric OCD include the SSRIs fluvoxamine, fluoxetine, and paroxetine, and the tricyclic antidepressant clomipramine [ 94].

Skin picking and trichotillomania are classified as obsessive-compulsive related disorders in DSM-5. Both disorders often have onset during childhood or adolescence. Behavioral therapies including Habit Reversal Therapy are superior to pharmacologic treatments and are considered first-line treatment for both disorders [ 95].

2.4.2. Medication Management for Compulsive, Rigid, and Repetitive Behaviors

SSRIs such as fluoxetine and sertraline are often the first medications considered for the treatment of pediatric OCD and are generally well tolerated [ 76]. Clomipramine was the first medication FDA approved to treat pediatric OCD but is now generally reserved for refractory cases as its use requires monitoring of heart rate, blood pressure, and electrocardiogram.

2.5. Aggression, Irritability, and Self-Injury

Aggression, irritability, and self-injury are symptoms that may be associated with essentially any psychiatric disorder, and that also present in the absence of psychiatric disorder. The first step in addressing aggression, irritability, or self-injury is to explore the vast array of factors that may underlie the behaviors. These may include physical illness, discomfort, pain, boredom, frustration, a mismatch between external expectations and a child's capacity, communication deficits, bullying, and other modifiable factors. Aggression, irritability, and self-injury may also occur in the setting of psychiatric disorders. In these cases, assertive treatment of the psychiatric disorder is the first step in treating the behavioral symptoms.

2.5.1. Practice Parameters and Treatment Guidelines for Aggression, Irritability, and Self-Injury

Randomized controlled trials of medications targeting aggression, irritability, and self-injury have focused primarily on pediatric populations with ADHD and/or autism spectrum disorder (ASD) or with other genetic or neurodevelopmental disorders such as Prader-Willi Syndrome. Randomized controlled trials in children and adolescents with ADHD have demonstrated that psychostimulants reduce oppositional and aggressive behaviors as well as core ADHD symptoms [ 101].

2.5.2. Medication Management for Aggression, Irritability, and Self-Injury

Blader et al. [ 102] planned a stepped treatment trial for ADHD and aggressive behavior that began with an open stimulant optimization phase before adding adjunctive treatments (risperidone, divalproex, or placebo). Of the 151 youth who completed the stimulant optimization phase, 63% had no residual aggression and so did not move to randomization to adjunctive treatments. This study reinforces the utility of maximizing ADHD and oppositional symptom control with stimulant medications prior to considering other pharmacologic treatment options [ 102].

Alpha agonists including clonidine and guanfacine, in immediate- and extended-release forms, are second-line or adjunctive treatments for ADHD in children and adolescents. Use of the immediate-release forms is limited by sedation and the need for multiple daily doses. Placebo-controlled trials of clonidine in children with ADHD, some of whom had comorbid oppositional defiant disorder (ODD) or conduct disorder (CD), have been either negative regarding oppositional behavior or conduct outcomes or been positive with a lower limit of 95% confidence interval approaching zero [ 103]. We found no studies assessing extended-release clonidine in the treatment of oppositional behaviors in children with or without ADHD. Four placebo-controlled trials of guanfacine extended-release in children with ADHD and oppositional behavior with or without comorbid ODD have been conducted. An analysis of these 4 studies found effect sizes ranging from 0.688 to 0.963 among children with ODD and from 0.598 to 0.842 among children without ODD [ 104].

Alpha agonists have been assessed for the reduction in aggression, irritability, and self-harm in children and adolescents with ASD. Guanfacine extended-release was compared to a placebo in reducing oppositional behavior in 62 subjects with ASD and ADHD symptoms. Parent-reported oppositional behavior decreased by 44% in the active medication group vs. 12% in the placebo group [ 105].

Other medications that have been evaluated in the treatment of oppositional and aggressive behaviors in children and adolescents with ADHD include risperidone and divalproex. In the Blader et al. study [ 102], both risperidone and divalproex were superior to placebo in decreasing residual aggressive behavior in children who had gone through stimulant optimization. The numbers of randomized patients were small, the divalproex result approached non-significance and the children who were randomized to adjunctive treatments remained more symptomatic than those who remitted with stimulants only.

The atypical antipsychotics risperidone and aripiprazole have FDA indications for the treatment of aggression, irritability, and self-injury in children aged 5 years and older (6 years and older for aripiprazole) with autism spectrum disorder. The FDA indications were based on a series of positive randomized controlled trials for both drugs [ 106, 107, 108, 109, 110]. The seminal study supporting the efficacy of risperidone in ASD was the Research Units in Pediatric Psychopharmacology (RUPP) study which randomized 101 subjects aged 5-17 years to 8 weeks of risperidone (1.8 = 0.7 mg/day) or placebo [ 108]. The risperidone-treated subjects had a 57% reduction in irritability score compared with 14% of the placebo group. A 4-month open-label extension of the study demonstrated a stable response and a mean weight gain of 5.1 kg. This was followed by a placebo-substitution risperidone withdrawal phase. The relapse rate in the placebo-substitution group were 62.5% and 12.5% in the risperidone continuation group [ 111]. Trials of other atypical antipsychotics in treating aggression, irritability, or self-injury in children and adolescents with ASD have not shown superiority over placebo.

3. Considerations for Supporting Uptake of Medications within School Settings

Approximately half (42.8%) of all children with identified mental health concerns take psychotropic medications to treat these conditions [ 117, 118]. With increases in children who take medication is the demand for school personnel to assist in addressing mental health concerns in the schools. Although decisions to use psychotropic medications are ultimately guided by a child's family and medical team, effective interdisciplinary collaboration between the child, the child's family, the school, and the medical team can optimize the implementation and coordination of medical and psychosocial interventions in practice guidelines. The medical team is responsible for monitoring psychotropic medication; however, they cannot monitor the effects of medication on learning and behavior in the classroom (schools, medical providers, and communities are encouraged to partner and develop policies and guidelines supporting students on medications [ 118]). However, practice guidelines are not always clear and barriers may be present including diagnosis and treatment practices of the medical provider, state/federal legislation, school district policies, and cooperation of all parties (schools, parents, prescribing providers) to work together.

The scientific literature and professional organizations provide practice guidance for treating youth with common mental health conditions. Clinical practice guidelines are intended to help guide practice. However, the publication and dissemination of practice guidelines for treating mental health concerns in children do not always result in the implementation of their use. The effectiveness of improving practice has been debatable for a variety of reasons [ 119, 120] including lack of evidence for improving practice, lack of evidence for providers implementing practice guidelines, and lack of clarity with how or which guidelines to implement and the order of implementation [ 121]. Practice guidelines often involve randomized control trials (RCTs) that are outdated or have methodological flaws [ 119]. Additionally, some guidelines, such as ADHD practice guidelines may lack considerations for equitable access to treatment for ADHD especially for Black children, girls, and children from low-income families [ 122]. Additionally, administration and monitoring of psychotropic medications is complex because more children take psychotropic medication and many of these medications are considered off-label [ 123]. It is estimated that up to 40% of individuals on medications receive treatment that is not based on organization guidelines or the available scientific evidence [ 124].

Although practice parameters provide guidance with aspects of managing plans for children with certain educational eligibility and/or medical diagnoses and/or administering medications to children at school, district policies and local, state, and federal law may dictate the ability to apply or synthesize best practices between school and outside medical professionals. There may be district and/or state or federal laws that prohibit school involvement with referral or consultation regarding psychoactive medications [ 125]. Section 300.174 "Prohibition on mandatory medication" of the Individuals with Disabilities Education Act (IDEA) prohibits state personnel from requiring parents to obtain prescription medications for a child attending school. This same section states that this prohibition does not preclude teachers and school personnel from consulting or sharing classroom observations with parents or guardians or the need for special education or related services. As of 2014, only 11 states had a medication policy that addressed psychotropic medications in schools [ 123]. Most state policies reflected statements precluding school personnel from recommending psychotropic medication for students. Additionally, Texas was the only state that provided specific legislation regarding policy for the administration of psychotropic medication in schools. States need to develop guidelines that address individual planning for the student, methods for communicating information on benefits and side effects with relevant professionals included in the child's care, procedures for storage, administration, and monitoring of medication especially when a change in medication has been initiated.

Carlson and Shahidullah [ 125] recommend that certain assumptions may need to be met in order best guide evaluating the effects of psychotropic medications in schools including (a) a comprehensive evaluation, diagnosis, and treatment plan by a qualified health professional, (b) behaviorally-based interventions have been developed at home and school and that the timing and order of interventions are ultimately the choices of the family, (c) families receive psychoeducation regarding all empirically supported treatments, (d) parents allowed to make the decision to seek medication treatment for their child without influence or pressure from the school, (e) parents' consent to the sharing of information between the school and medical team and (f) release of information is secured to ensure an understanding of open lines of communication between parents, the school and medical providers.

Another consideration includes providing educational opportunities for school personnel to learn about psychotropic medications. Ryan et al. [ 118] indicate that given the high prevalence of youth taking psychotropic medications at school, educators have basic knowledge and overview of common psychotropic medications. Many schools do not have full-time nurses available with knowledge and training in psychotropic medications. At times, an unlicensed assistive school team member may be administering medications in the school. Special educators who manage the academic and behavioral success of students indicate almost ubiquitously (95%) that they lack background and knowledge in psychotropic medications and desire additional training [ 126].

Foy and Earls [ 122] emphasize the importance of establishing a school-community plan for addressing barriers from identification through treatment. They recommend utilizing practice resources to help with educating and providing school professionals with educational and screening tools, for instance, that will help to achieve a collaborative plan for supporting children. Although developed specifically for youth with ADHD, Foy and Earls' recommendations for school-physician collaborative plans provide a useful framework to apply to school-age youth with other mental health conditions such as depression, anxiety, and aggressive behavior (see Table 3 for recommendations by Foy & Earl on collaborative school-physician-community plan for ADHD that are applicable to the other child mental health conditions reviewed). The use of a 504 plan or an individualized education plan (IEP) may be needed to ensure a child who is eligible for these plans has documented access to services and resources in the schools and with professionals outside of the school.

Table 3.

1. Achieve consensus on the role of school personnel regarding the collection of data

2. Use pediatric office visits for to identify children with academic or behavior problems

3. Refer identified children to the contact person at the child's school who request information on the collaborative consensus plan

4. Designate a contact person at each school to share student information with

5. Review data from the school and incorporate it into the clinical assessment

6. Reinforce the need and type of treatment with parents and schools and considerations for additional accommodations and modifications in the school (e.g., 504 plan and/or IEP)

7. Referral plan to mental health provider when comorbid concerns are identified

8. Develop a system of communication to share diagnostic, treatment, management information between school, physicians, parents

9. Receive parent and teacher follow-up reports to assist in medication management

10. Maintain communication with school especially during transitions (e.g., beginning of the school year, changes in schools, changes in family)

4. Conclusions

The current state of the psychotropic medication literature for school-aged children has grown substantially in the past 30 years. Prescribing psychotropic medications to school-aged youth for a range of mental health concerns can greatly reduce symptoms and improve functioning across school, home, and social settings. However, these treatments provide symptom relief, but not cures. Moreover, the literature is still growing, and we are far from having empirical justification for all prescribing decisions. Further, inequities in differential access to these therapies and prescribing and monitoring practices clearly necessitate careful consideration of the tradeoff between risks and benefits, particularly for marginalized and vulnerable populations. Finally, it is important to note that a review of the impact of supplements (e.g., food, vitamin, herbal) and over-the-counter medications on child psychiatric conditions was outside the scope of this paper. Though, it must be recognized that none of those non-psychotropic medications have been recognized as efficacious within any of the professional practice parameters reviewed.

Decision-making around medication prescribing is incredibly nuanced and should be informed by considerations such as: (1) the quality of the research literature including methodological rigor, sampling considerations (i.e., heterogeneity and representativeness of multiple forms of diversity in the samples), and understanding of long-term outcomes, (2) the consideration of patient and families' attitudes, acceptability, and satisfaction towards medication (including cultural and/or religious factors) that may affect adherence issues and continued help-seeking, (3) the degree to which psychotropic medication prescribing in community settings matches the standard of prescribing in the RCTs/trials in which it was studied, (4) the balance between the positive benefit and adverse/side effects in the context of the "First, Do No Harm" medical ethical mantra, and (5) the degree to which treatment decision-making can be supported through multi-modal, multi-system, multi-setting, and multi-professional processes to support "whole-child" care while emphasizing the balance between safety, efficacy, and patient preference and autonomy.

Author Contributions

Conceptualization, J.D.S. in consultation with co-authors; Writing-Original Draft Preparation, J.D.S., H.R., J.P., R.B., J.A.M. and J.S.C.; Writing-Review & Editing, J.D.S., H.R., J.P., R.B., J.A.M. and J.S.C. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

Funding Statement

This research received no external funding.

Footnotes

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References

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Data Availability Statement

Not applicable.

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# data[].attributes.attachment_link.title
State of the Evidence for Use of Psychotropic Medications in School-Age Youth

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The Impact of Mental Illness Stigma on Seeking and Participating in Mental Health Care

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This review explores how mental illness stigma across public, self, and structural levels undermines individuals’ willingness to seek and remain in mental health care. Stigma distorts self-perception (“Why try?” effect), discourages people from seeking help, and leads many to drop out early. The authors explain that stigma affects themselves, families, healthcare providers, and system-level policies, contributing to the continuation of care. They advocate for multifaceted interventions, including increasing mental health literacy, enacting anti-discrimination policies, and incorporating stigma-awareness training into professional education, with a particular focus on targeting providers to reduce stigma and improve treatment engagement (Corrigan et al., 2014).

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The Impact of Mental Illness Stigma on Seeking and Participating in Mental Health Care - Patrick W. Corrigan, Benjamin G. Druss, Deborah A. Perlick, 2014

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Psychotropic Medication Use and Polypharmacy Among Children and Adolescents Initiating Intensive Behavioral Therapy for Severe Challenging Behavior

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Psychotropic Medication Use and Polypharmacy Among Children and Adolescents Initiating Intensive Behavioral Therapy for Severe Challenging Behavior

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This study examined the prevalence and patterns of psychotropic medication use, including the use of multiple psychiatric medications, among children and adolescents with severe challenging behaviors, such as those with developmental disabilities or behavioral disorders. The research analyzed prescribing data from a large cohort to assess frequency, combinations of medications, and associated demographic factors. Findings revealed an alarmingly high rate of psychotropic prescriptions and frequent use of multiple concurrent medications, raising concerns about the potential for adverse effects, insufficient monitoring, and the need for oversight in managing complex medication regimens. The authors suggest implementing rigorous guidelines, multidisciplinary collaboration, and comprehensive monitoring to ensure safe and effective treatment for this vulnerable population (O’Brien et al., 2024).

# data[].attributes.headline
The Role of Medication in Supporting Emotional Wellbeing in Young People with Long-Term Needs

# data[].attributes.subject
The Role of Medication in Supporting Emotional Wellbeing in Young People with Long-Term Needs

# data[].attributes.body
Gray and Wood (2017) conducted a narrative review using case studies to explore how prescribed medications affect the emotional well-being of adolescents managing long-term physical and mental health conditions (e.g., ADHD, depression). This study demonstrates both therapeutic benefits, such as symptom relief and improved mood, and challenges, including side effects, adherence issues, and the psychological burden of ongoing treatment. It emphasizes the importance of fostering autonomy and shared decision-making in medication management with young people. The authors advocate for health professionals to strike a balance between efficacy and emotional and developmental needs, ensuring that medication use aligns with youth-centered care principles and supports overall emotional well-being (Gray & Wood, 2017).

# data[].attributes.attachment_link.readable_text
Abstract

Young people frequently use and access prescribed medications for a range of health problems. Medications aimed at treating both common health problems and long-term physical and mental health needs in adolescence can have a significant effect on a young person's emotional well-being. We use a series of case studies to illustrate the challenges for healthcare professionals supporting young people with medication use. The studies illustrate the efficacy and limitations of medication on improving emotional well-being by alleviating illness and distress, and how this efficacy must be balanced against both the adverse effects and the burden of treatment. There are specific challenges for medication management during adolescence including issues of adherence/concordance, facilitating autonomy and participation in decision making, and promoting independence.

Keywords: adolescent, young adult, young person, medication, adherence, mental health, physical health, long-term condition, emotional wellbeing, health services

1. Introduction

The Health Survey for England 2013 reported that 14% of young men and 25% of young women aged 16-24 years had taken prescription medicines in the previous week [ 1]. The most commonly used medicines by this age group included those for both physical and mental health problems-medicines for respiratory conditions, antidepressants, antibacterials, analgesics, and/or non-steroidal anti-inflammatory drugs (NSAIDs). It is likely that the frequency of medicine use that includes non-prescription medicines for short-term health problems would make this figure significantly higher. We can conclude that a significant proportion of young people are familiar with the use of medicines. Some medicines address the rapid treatment of symptoms, such as reliever inhalers for asthma or non-prescription painkillers for headache; other medicines must be taken whether symptoms are present or not to achieve long-term maintenance of conditions and to minimise breakthrough symptoms, such as anti-rejection transplant medicines or pancreatic enzyme supplements for cystic fibrosis. Moreover, many young women take daily oral contraceptives or use a long-term implant to prevent unplanned pregnancy.

We assert in this paper that emotional wellbeing among young people will be supported by the effective use of medication to alleviate symptoms of both physical and mental health conditions that might otherwise be seen as lifestyle-limiting. Equally, we recognise that the burden of treatment of a long-term condition and the need to adhere to medication routines during adolescence may result in the rejection of a long-term treatment, with potential consequences for the health and well-being of the young person. The finding that young people have lower rates of adherence to medication than either children or adults, and associated risk factors, has been reported in the literature although evidence is sparse and inconsistent [ 2, 3, 4]. A review of qualitative literature about the lived experience of children and young people with asthma, diabetes, and epilepsies explored the theme that treatment regimens may be constraining or enabling [ 5]. Work in the context of juvenile arthritis shows similar themes [ 6, 7]. All too often the medicine regimen dominates the life of the young person, rather than being created to fit within the existing life routine and interests of the individual [ 8]. Suris et al. reflected on the often-contradictory findings of reviews and studies of the impact of a long-term condition on mental health and wellbeing, but they asserted that "...the wellbeing of chronically ill adolescents is determined largely by the severity of the disease and the amount of treatment required" [ 9].

The aim of this paper is to explore the role of medicines in supporting emotional wellbeing among young people with long-term health needs, which includes diagnosed physical and mental health conditions. Our scope will include the use of all medicines to their best effect to control conditions that might otherwise cause distress, and the use of psychotropic medicines whose primary mode of action is to enhance emotional wellbeing or to control symptoms that might undermine wellbeing.

2. Materials and Methods

In this paper, we will present three case studies that illustrate a range of issues that are relevant to the use of medicines by young people to support emotional wellbeing. These cases derive from both physical and mental health long-term needs. The cases reflect our combined clinical and research experience. The third case study, about mental health issues, is adapted from a series of real-life experiences of young people taking psychoactive medicines from the UK 'HeadMeds' website, hosted by the charity YoungMinds ( Appendix A).

3. Results

3.1. Case Study 1-Acne

Imogen is 15 years of age and has moderate acne affecting her face, neck, back, and chest. She has tried a range of prescribed and over the counter treatments over the last two years, including combined topical acne treatments in conjunction with oral antibiotics. A recent trial of a combined oral contraceptive pill has failed to improve her acne. She has some early scarring on her cheeks. Her acne is having a significant impact on her emotional well-being and has started to impact on her self-esteem, confidence, social activities and mood. She presents to the dermatology clinic with her mother seeking oral isotretinoin treatment.

Oral isotretinoin is an effective treatment for moderate-severe acne that has failed to respond to combined topical acne and oral antibiotic therapy and is an example of a pharmacological treatment of a physical condition which is largely aimed at improving psychological wellbeing [ 10, 11]. This impact applies for the short-term effects of having acne and the longer-term effects of scarring. However, isotretinoin has been associated with low mood, and there have been concerns regarding suicidality and deaths [ 12]. For many young people, acne can have a significant detrimental effect on their emotional wellbeing and mental health [ 13]. When considering oral isotretinoin treatment the dermatologist, the young person and family need to balance the risks of treatment with the risks of failing to treat the acne adequately. The impact of acne on the young person is often underestimated and careful assessment of mood, expectations, and concerns about treatment need to be explored prior to initiating treatment. Isotretinoin is highly teratogenic and pregnancy prevention is a priority during isotretinoin treatment [ 14]. Discussions regarding sexual activity, pregnancy prevention, and contraception need to run alongside discussion of mood and other aspects of treatment; this is especially important, given the impact of an unplanned pregnancy with a high risk of foetal malformation on the well-being of both the young person and the unborn child.

3.2. Case Study 2-Chronic Headache

Kyle is 14 years old and has chronic daily headaches. The headaches have been present for the past three months and are affecting his school attendance, as well as family and social activities. Examination and investigations including brain imaging has not revealed a cause and the headaches are getting worse. A headache diary reveals a constant daily headache occurring on most days, with no features to suggest migraine or cluster headaches. Kyle has been using daily doses of over-the-counter paracetamol and ibuprofen products. In addition, he has been taking some of his mother's prescribed codeine-acetaminophen(paracetamol) tablets for severe headaches. Kyle's headaches are affecting his emotional wellbeing; he is irritable, and starting to isolate himself from his friends. He describes his mood as low and cannot enjoy activities because of the pain.

Chronic headache is a common problem in young people and can have a significant impact on their emotional wellbeing [ 15]. Medication overuse headache is an example where pharmacological treatment of a problem may have unintended consequences if use is prolonged [ 16]. In this case, worsening headache occurred through the use of over-the-counter analgesics. Guidance for the management of headache in young people reminds us to be alert to the possibility of medication overuse headache in people whose headache developed or worsened, while they were taking paracetamol, or an NSAID, either alone or in any combination, on 15 days per month or more for 3 months or more. The UK National Institute for Health and Care Excellence (NICE) recommends abrupt rather than gradual withdrawal of the overused medication for one month, and consideration of a preventative treatment [ 17]. There are few effective pharmacological therapies for those with headaches, which are not migrainous in nature. The natural history of chronic daily headache is remission with time; however, early onset, longer duration, anxiety, and medication overuse predict persistence at follow-up [ 18, 19, 20]. The relationship between chronic headache and psychological comorbidity is well reported but poorly understood [ 21]. For chronic tension type headaches, the UK NICE recommended preventative treatment is to consider a course of up to 10 sessions of acupuncture over 5-8 weeks for the prevention of chronic tension-type headache. The message here therefore is that, for the treatment of chronic (tension) headache in young people, 'less is sometimes more' when it comes to medication.

3.3. Case Study 3-Depression

Zoe is 19 years old. She was diagnosed with depression at the age of 16 and was prescribed fluoxetine, a selective serotonin reuptake inhibitor (SSRI) antidepressant. She says that she had felt sad and had a low mood. She found that the fluoxetine did lift her mood, but it also caused her to gain weight so she stopped the medication without consulting the prescriber and her weight went back to normal. She feels that she had no discontinuation symptoms, but she says that her mother noticed she was grumpier when she stopped this medicine. More recently, Zoe has started to take sertraline, another antidepressant. She feels that taking medication has improved her relationships, noting that she is less grumpy with her family when taking it. She has had some side-effects from the sertraline-it made her feel 'shaky'-but she reflects that this does not affect her life dramatically enough for it to become a barrier to taking it. The positive effects outweigh this.

This case study shows the use of psychoactive medication to treat symptoms that are directly affecting emotional wellbeing. Zoe's first medicine was fluoxetine, which at the time of writing this paper was the only antidepressant with UK marketing authorisation for use in this indication for children and young people aged 8-18 [ 22]. UK NICE guidance published in March 2015 indicates fluoxetine for first-line use in moderate to severe depression for 12-18 year-olds [ 23]. The use of antidepressant medication in young people aged under 18 years is, however, discouraged. The British National Formulary for Children simply asserts that "[t]he balance of risks and benefits for the treatment of depressive illness in individuals under 18 years is considered unfavourable", and further reflects that "[c]linical trials have failed to show efficacy and have shown an increase in harmful outcomes" [ 24]. A systematic review of published and unpublished RCT data about SSRIs, published in 2004, concluded that "risks could outweigh benefits of these drugs (except fluoxetine) to treat depression in children and young people" [ 25].

Weight gain is not listed as a side-effect of fluoxetine; conversely, reports of reduced appetite and subsequent weight loss are noted by the manufacturer and supported by the literature [ 26]. The importance of the risk of weight gain is underlined, however, by the fact that Zoe was willing to abandon a medicine that was improving her mood because of the impact on her body image. Tremor is a common side-effect of antidepressant medications [ 22]. The acceptance of tremor as a reasonable trade-off for the benefit of the medication on mood indicates the careful consideration of harm-benefit issues by the young person and the prioritisation of adverse effects relating to weight.

4. Discussion

In order to achieve the best effect from medication for young people, thus supporting emotional wellbeing, it is important to consider different aspects of medication use that potentially enhance or undermine its benefits. Our case studies in this paper have been chosen to stimulate reflection about the use of medication in different scenarios. The goal of all medication use, whether for a physical or mental health condition, should be to maximise physical and emotional wellbeing in parallel; however, the burden of illness and the efficacy of the medication must be balanced against the potential adverse effects and the burden of treatment. If a physical health condition such as acne is treated effectively with relevant medication, this can have a significant positive effect on emotional wellbeing; highly effective treatments such as isotretinoin, however, have the potential for serious adverse effects on emotional wellbeing. Conversely, clinicians must remain alert to the overuse of non-prescription or prescribed medication that may contribute to ill health and impair emotional wellbeing.

The case studies highlight some cross-cutting issues that should be borne in mind by any clinician practicing in this field. Careful attention must be paid to the priority that young people assign to both the positive and negative effects of their medication. No assumptions must be made about the value that an individual might assign to these effects. Even if a medicine is achieving a good therapeutic effect on the primary symptoms, such as reducing the incidence of acne or lifting mood, there may be other negative effects that override the benefit, such as weight gain or future effects on fertility. Encouraging individuals to explicitly state their highest priorities could help to negotiate an acceptable regimen.

Nonadherence to any medicine should be normalised for young people. Very few people, including health professionals, can take every dose of every medicine they have without some slips. It is vital to distinguish between unintentional and intentional nonadherence, as the strategies for moving forward will be very different [ 27]. Unintentional nonadherence may result from an inability to get the medicine or administer it, and very practical measures might solve the problem such as changing the type of asthma inhaler device. Intentional nonadherence may be particularly rooted in perceived negative impact on overall wellbeing that will need sensitive discussion. The clinician must accept that the regimen may not ultimately be sustainable and not impart blame for this.

Discontinuation of medication without prior consultation should be anticipated for all new regimens. Clinicians may wish to discuss this at the point of first prescription with the young person and family, framing it as part of the independence and autonomy of the young person that they have the right not to take it. For some medicines, sudden discontinuation may have more profound effects than others - this should be highlighted where there are potential problems of withdrawal effects.

Anticipating common side-effects, and giving useful advice about what to do if they happen, should be an integral part of consultations with young people and families, as this is known to be a concern for young people [ 28]. Similarly, if the full effect of a medicine is likely to take some time to emerge, as with antidepressants, young people should be prepared for this. Asking young people and families to persist with these therapies for an agreed time, accompanied by an effective explanation of why this happens and by proactive follow-up, may reduce the chances of early discontinuation. An honest conversation explaining that the young person may have to try several different therapies before they find the right one for their particular circumstances should be explained and accepted at the beginning of treatment to avoid feelings of frustration and failure by both parties. In this way, expectations can be managed, and the clinician and the family can unite in the search for the best option for that individual.

The use of medicines off-licence must be done thoughtfully, recognising the extra responsibility taken on by the clinician. Young people and families should be aware if a medicine has not been licensed in their age group. It is true that most medicines used in young people aged under 18 have been supported by clinical use in practice rather than randomised controlled trials. Promoting the voice of young people and families in the medicine licensing process and advocating for more clinical trials for this age group [ 29] are long-term strategies to reduce this knowledge gap [ 8].

Some research, education, and policy papers have explored shared decision-making between young people, parents/caregivers and prescribers across a range of physical and mental health conditions [ 30, 31, 32], indicating that passive decision-making is also an active choice [ 33, 34]. In the context of mental health medicines, O'Brien et al. have suggested that "participation in treatment decisions can prepare youth for making their own decisions as adults, can be therapeutic, and can have positive effects on their self-confidence and self-esteem" [ 35]. As the young person develops their expertise with their condition, maintenance requires a level of commitment that may also be supported by family members, friends, and the members of their increasingly multidisciplinary healthcare team. Reliable and accessible information about medicines that is aimed specifically at young people, however, is not plentiful-the Headmeds website was created to try and address this gap for psychoactive medicines.

The potential of family members and friends as observers and supporters for young people should be appreciated. All the case studies refer to the input of a family member. Whilst independent consultation with the young person affords an opportunity to explore their feelings about their condition and medicines without their family members present, the clinician should also, with the permission of the young person, enhance parents'/carers' knowledge about the medication so they can act as an extra resource for the young person. As the young person approaches adulthood, they will inevitably assume more responsibility for their own health [ 36]; however, the provision of developmentally appropriate healthcare [ 37] can ensure that these transitions are managed and do not result in poorer outcomes.

Future research should explore the satisfaction of young people with the effectiveness of their medication for their physical or mental health condition, and its impact on their emotional wellbeing. Studies should also explore the assessment of relative harm and benefit by young people to help clinicians to have open and effective conversations with young people and families. The evidence base from clinical trials for all medicines intended for use by young people must continue to be improved, coupled with encouragement to young people to report adverse drug reactions, to maintain safety and wellbeing.

5. Conclusions

Thoughtful use of medication can support emotional wellbeing among young people with long-term needs. More consideration needs to be given to the parity between services for physical health conditions, where medicines are considered central to management, and mental health conditions where the use of medication might be seen as a last resort or failure. Shared decision-making with young people and families, with honest discussion and relevant information, is essential to see benefit. In this way, medication can be tailored to the life context of the young person, consistent with their goals and priorities.

Acknowledgments

No external sources of funding have supported the writing of this article.

Appendix A

In 2014 Young Minds, a UK mental health charity, launched the 'Headmeds' website where young people can access information about a number of commonly used mental health medicines. The website provides general information about these medicines to young people in the United Kingdom. The information is drawn from the summary of product characteristics (SPC) and the patient information leaflet (PIL) associated with each medicine from the Electronic Medicines Compendium (eMC) website, https://www.medicines.org.uk/emc/, which is a repository of statutory information for medicines licensed in the UK. The statutory information has been translated by specialist pharmacists to make it relevant to the lives of young people. There are 32 narratives on the Headmeds website section entitled 'My Story', which can be found at http://www.headmeds.org.uk/my-story. Young people were invited through the website, and through the networks of the Young Minds charity, to share their experience. Each contributed story may include a video, which may feature the young person telling the story or an actor working from the real-life story script. For Case Study 3, we have used the summary written text featured on one story page as the primary data source, with the permission of Young Minds.

Author Contributions

N.J.G. and D.W. conceived and designed the paper; D.W. contributed Case Studies 1 and 2, and N.J.G. contributed Case Study 3; N.J.G. and D.W. wrote the paper.

Conflicts of Interest

The authors declare no conflict of interest.

References

1. Health and Social Care Information Centre . Health Survey for England 2013. HSCIC; Leeds, UK: 2014. [Google Scholar]

12. Medicines and Healthcare Products Regulatory Authority (MHRA) MHRA; Nov, 2014. [(accessed on 20 October 2017)]. UK Review of Isotretinoin and Psychiatric Adverse Reactions: A Public Assessment Report. Available online: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/391670/isotretinoin_and_psychiatric_disorders_PAR_Final_web.pdf. [Google Scholar]

17. National Institute for Health and Care Excellence . Headaches in Over 12s: Diagnosis and Management. NICE; London, UK: 2012. [(accessed on 20 October 2017)]. (Last Updated November 2015) Available online: https://www.nice.org.uk/guidance/cg150. [Google Scholar]

22. Eli Lilly and Company Summary of Product Characteristics-Prozac™ Fluoxetine 20 mg Hard Capsules and 20 mg Per 5 mL Oral Liquid. Section 4.4-Special Warnings and Precautions for Use. [(accessed on 1 November 2017)]; (Last Updated on eMC 22 February 16) Available online: https://www.medicines.org.uk/emc/medicine/504.

24. British National Formulary for Children . Antidepressant Drugs. BNFC; London, UK: 2015. p. 182. [Google Scholar]

28. Gray N.J., Harvey K., McPherson A., Macfarlane A. Medicine dilemmas in adolescents' email messages. Int. J. Pharm. Pract. 2008;16:A34. [Google Scholar]

30. Kieckhefer G.M., Trahms C.M. Supporting development of children with chronic conditions: From compliance toward shared management. Pediatr. Nurs. 2000;26:354-363. [PubMed] [Google Scholar]

35. O'Brien M., Crickard E., Rapp C., Holmes C., McDonald T. Critical issues for psychiatric medication shared decision making with youth and families. Fam. Soc. 2011;92:310-316. doi: 10.1606/1044-3894.4135. [DOI] [Google Scholar]

Articles from Healthcare are provided here courtesy of Multidisciplinary Digital Publishing Institute (MDPI)

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The Role of Medication in Supporting Emotional Wellbeing in Young People with Long-Term Needs

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Young people frequently use and access prescribed medications for a range of health problems. Medications aimed at treating both common health problems and long-term physical and mental health needs in adolescence can have a significant effect on a ...

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Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The Impact of Mental Illness Stigma on Seeking and Participating in Mental Health Care. Psychological Science in the Public Interest, 15(2), 37–70. https://doi.org/10.1177/1529100614531398

Gray, N., & Wood, D. (2017). The Role of Medication in Supporting Emotional Wellbeing in Young People with Long-Term Needs. Healthcare, 5(4), 84. https://doi.org/10.3390/healthcare5040084

Hachtel, H., Vogel, T., & Huber, C. G. (2019). Mandated Treatment and Its Impact on Therapeutic Process and Outcome Factors. Frontiers in Psychiatry, 10(219). https://doi.org/10.3389/fpsyt.2019.00219

Lakhan, S. E., & Hagger-Johnson, G. E. (2007). The impact of prescribed psychotropics on youth. Clinical Practice and Epidemiology in Mental Health, 3(1), 21. https://doi.org/10.1186/1745-0179-3-21

Malvaso, C. G., Day, A., & Boyd, C. M. (2024). The Outcomes of Trauma-Informed Practice in Youth Justice: An Umbrella Review. Journal of Child & Adolescent Trauma, 17(3), 939–955. https://doi.org/10.1007/s40653-024-00634-5

O’Brien, M. J., Pauls, A. M., Cates, A. M., Larson, P. D., & Zorn, A. N. (2024). Psychotropic Medication Use and Polypharmacy Among Children and Adolescents Initiating Intensive Behavioral Therapy for Severe Challenging Behavior. The Journal of Pediatrics, 271, 114056–114056. https://doi.org/10.1016/j.jpeds.2024.114056

Rolling, J., Fath, M., Zanfonato, T., Durpoix, A., Mengin, A. C., & Schröder, C. M. (2024). EMDR–Teens–cPTSD: Efficacy of Eye Movement Desensitization and Reprocessing in Adolescents with Complex PTSD Secondary to Childhood Abuse: A Case Series. Healthcare, 12(19), 1993. https://doi.org/10.3390/healthcare12191993

Seaward, H., Wangmo, T., Vogel, T., Graf, M., Egli-Alge, M., Liebrenz, M., & Elger, B. S. (2021). What characterizes a good mental health professional in court-mandated treatment settings?: Findings from a qualitative study with older patients and mental health care professionals. BMC Psychology, 9(1). https://doi.org/10.1186/s40359-021-00624-4

Shahidullah, J. D., Roberts, H., Parkhurst, J., Ballard, R., Mautone, J. A., & Carlson, J. S. (2023). State of the Evidence for Use of Psychotropic Medications in School-Age Youth. Children, 10(9), 1454. https://doi.org/10.3390/children10091454

Struik, A. (2024). EMDR With Children. an Overview of Research and Clinical Practice. Journal of the New Zealand College of Clinical Psychologists, 34(1), 49–58. https://doi.org/10.5281/zenodo.10939142