Autoimmunity and its expression in the analytic situation: A contemporary reflection on our inherent self-destructiveness.

This article explores the psychical expression of autoimmunity in the analytic situation; it is informed by biological theories of autoimmunity in contemporary immunology. Several of my patients developed autoimmune conditions in the course of their analyses, leading me to consider the role of psychical change in disrupting one's somatopsychic equilibrium. In the psychoanalytic literature, autoimmunity is used metaphorically for attack against what is foreign or unwanted in ourselves. Contemporary immunology, however, suggests a somewhat different metaphor. "Self-reactive" cells present in the body may attack self unless suppressed by inhibitory mechanisms. Biologically, limited self-destructiveness is necessary, but in autoimmune disease it becomes excessive and pathological. I suggest that the presence of biological "self-reactivity" implies an inherent self-destructiveness in line with Freud's thinking on the death instinct; the notion that this self-destructiveness also has adaptive aspects may contribute to our understanding of Freud's ideas. In three vignettes I illustrate clinical application of a modified metaphor of autoimmunity, finding that not only is the fusion of life and death instincts important for psychic development, but so is defusion when contained within the analytic relationship. The analytic task is to restore the balance between constructive and pathological self-destructiveness. Implications regarding controversies in psychosomatic theory are briefly considered.

The wraparound approach in systems of care.

Child and adolescent psychiatrists and general psychiatrists who serve children and adolescents with complex mental health needs, generally find themselves interfacing with multiple child-serving systems, including mental health, child welfare, juvenile justice, developmental disabilities, addictions services, and primary health care. In these systems of care, psychiatrists will likely encounter the term "wraparound," which describes a key intervention ushered in with the system-of-care model of service delivery. This article describes the wraparound approach, which has been at the forefront of mental health service delivery for children and youth with serious emotional disturbance since the mid-1980s. Wraparound is an empirically supported, family-driven, strengths-based planning approach that provides individualized care using an array of formal services and natural supports.

Practice parameter on child and adolescent mental health care in community systems of care.

This parameter presents overarching principles and practices for child and adolescent mental health care in community systems of care. Community systems of care are defined broadly as comprising the wide array of child-serving agencies, programs, and practitioners (both public and private), in addition to natural community supports such as religious and consumer organizations. Recommended principles and practices are derived from the system-of-care approach to service delivery. Based on the principles of the Child and Adolescent Service System Program, this approach has had a major influence on community systems of care through extensive federally funded projects and initiatives. The system-of-care model emphasizes that care should be tailored to the individual needs and strengths of the child and family and provided in the most community-based and least restrictive setting that meets their needs. Families are included as partners in the clinical process and are also involved in program development and evaluation. Services are coordinated and integrated into a comprehensive care plan. This model can be practiced even in the absence of formal systems of care or protocols, with the individual clinician promoting interagency coordination and child and family collaboration. This parameter is written for a broad audience of mental health professionals, with special emphasis on the roles of child and adolescent psychiatrists in community systems of care.

The case formulation in child and adolescent psychiatry.

This article reviews the various definitions of case formulation, differences between diagnosis and case formulation, how case formulation for the child patient differs from the adult patient, and case formulation in the context of residency training, including challenges for residents transitioning from adult psychiatry. It presents a suggested structure for constructing a biopsychosocial formulation that can be applied in a training setting. Several specialized types of psychotherapy formulation are reviewed in more detail. The article concludes with a case example of a child psychiatry resident's case formulation before and after discussion in supervision.

Ten-year review of rating scales, VII: scales assessing functional impairment.

OBJECTIVE: This is the seventh in a series of 10-year reviews of rating scales. Here the authors present scales measuring functional impairment, a sequela of mental illness. The measurement of functional impairment has assumed importance with the recognition that symptom resolution does not necessarily correlate with functional improvement. METHOD: The authors reviewed functional impairment from multiple sources over the past 20 years. Thus, this article includes a variety of scales ranging from those that have been subject to critical review with strong psychometric support to those that have not been critically reviewed but are in widespread use to those that are still finding their niche. RESULTS: These scales represent a continuum of constructs from symptoms to functional impairment to contextual factors that affect youths' functioning. Most older scales have focused on developmentally delayed youths. Newer scales strive to measure functional impairment separate from symptomatology. Some newer scales are also keyed to determination of level of service need. CONCLUSIONS: Scales measuring functional impairment can elucidate the impact of illness on youths, identify targets for treatment, determine service needs, and monitor treatment effectiveness. These scales are widely used in community mental health and health service delivery. They can assist in providing evidence-based treatment.

The evolution of systems of care for children's mental health: forty years of community child and adolescent psychiatry.

Over the past 20 years, child and adolescent community mental health has evolved conceptually, clinically, and scientifically towards the community-based systems of care model. This model asserts important values and principles, including the centrality of the child and family in the care process, the integration of the efforts of disparate agencies and interveners into a contextual approach, and the importance of serving children with serious disturbances in their homes and communities. The article reviews the evolution of the community-based systems of care model, its evidence-base, its application in practice, and the challenges it faces in today's human services environment.

Trends and shifting ecologies: Part II.

Community-based systems of care offer some promising ecologically based approaches to child psychiatric emergencies. More community-based effectiveness research is needed on child and adolescent mental health crisis services. To meet the needs of real-world children with serious emotional disorders and their families, however, research should include integration of multiple evidence-based modalities (such as psychopharmacology, behavioral, and cognitive approaches) and the effectiveness of single modalities. Funding priorities in mental health systems also should shift significantly to support community-based crisis services over more restrictive approaches that have a less solid evidence base.

Ten-year review of rating scales. III: scales assessing suicidality, cognitive style, and self-esteem.

OBJECTIVE: This is the third article in a series of 10-year reviews of rating scales. Here, the authors review scales that are useful in tapping the affective disturbances experienced with various psychiatric disorders, including suicidality, cognitive style, and self-esteem. METHOD: The authors sampled articles incorporating these constructs over the past 25 years and selected scales with established uses or new development. Those presented here have adequate psychometric properties and high utility for efficiently elucidating youths' functioning, plus either wide literature citations or a special niche. RESULTS: These scales were developed bimodally. Many were developed in the 1980s when internalizing disorders were elucidated, but there has been a resurgence of interest in these constructs. Scales assessing suicidality have clear constructs, whereas scales of cognitive style demonstrate deficits in developmental relevance, and scales of self-esteem suffer from lax constructs. CONCLUSIONS: The constructs underlying these scales tap core symptoms of internalizing disorders, mediate the expression of affective disturbances associated with various disorders, and depict the impairments resulting from these disorders. Overall, the psychometrics of these scales are adequate. These scales provide a broader representation of youths' functioning than that conveyed with diagnostic scales alone.

Ten-year review of rating scales. II: Scales for internalizing disorders.

OBJECTIVE: This article, the second in the Journal's series of 10-year updates on rating scales, summarizes scales assessing internalizing disorders. METHOD: The authors sampled articles on mood and anxiety disorders over the past 25 years, selected scales with multiple citations over many years, and reviewed their properties. Those with adequate psychometric properties, plus continued wide literature citations or a current special niche, are presented here. RESULTS: Rating scales for depression were developed and/or examined in the 1980s. Despite generally strong properties, they lack clear construct validity. Most have parent-report forms that broaden their suitability with youths. Anxiety scales were developed bimodally. Those developed in the 1960s to 1970s were downward modifications of adult scales. They have been criticized for unclear constructs and unsuitability for youths. Newer scales developed in the 1990s have addressed these problems and have parent-report forms. However, their utility is still being determined. CONCLUSIONS: Rating scales can reliably, validly, and efficiently measure youths' internalizing psychopathology. They have great utility in research, treatment planning, and accountability in practice. However, the user must define the goals of measurement, consider the construct the scale measures, and use the scale within its defined capabilities. The use of more than one scale for a task is recommended.

Ten-year review of rating scales. I: overview of scale functioning, psychometric properties, and selection.

OBJECTIVE: As part of the Journal's 10-year Research Update Reviews, a series of articles will be presented on the role of rating scales in child and adolescent psychiatry. The first article in the series summarizes principles underlying scale functioning. METHOD: Sources were reviewed regarding testing theory, scale development, variability in scale functioning, psychometric properties, and scale selection. The extracted information was adapted to issues in child and adolescent psychiatry. RESULTS: Rating scales can make major contributions to understanding youths' needs. They provide easy and efficient measurement of psychopathology and quantify underlying constructs for comparison across youths, time, and applications. Although multiple factors may affect a scale's functioning, these factors can be understood and managed by considering the goals of measurement and basic psychometric principles. CONCLUSIONS: Potential users of rating scales should not blindly assume that a well-known scale will meet the measurement needs for a particular application. Rather, they can relatively easily educate themselves regarding the appropriate use of rating scales. This article provides the background information needed to evaluate scales for intended applications. It will also assist in reviewing the individual scales presented in subsequent articles in this series.