OBJECTIVE: Most youth in routine mental health care do not receive evidence-based treatments, and when implemented in real-world settings, their effects are typically smaller than those observed in controlled efficacy tr...OBJECTIVE: Most youth in routine mental health care do not receive evidence-based treatments, and when implemented in real-world settings, their effects are typically smaller than those observed in controlled efficacy trials. Trauma-focused cognitive behavioral therapy (TF-CBT) is one of the most efficacious and widely implemented evidence-based treatments for traumatized youth worldwide, yet little is known about how it is delivered and adapted in routine practice. We examined 25,000 treatment sessions to understand the following: (1) how TF-CBT is implemented in routine care; (2) what delivery adaptations are made based on child age and the presence of complex posttraumatic stress disorder (CPTSD) symptoms; and (3) whether adaptations are associated with outcomes. METHOD: Data came from an observational study of TF-CBT implementation (2018-2024) across Norwegian child and adolescent mental health services. Children and adolescents (6-18 years of age) with clinically significant posttraumatic stress symptoms (N = 1,373) received treatment from 357 therapists across 74 outpatient clinics representing 82% of such services in Norway. RESULTS: Overall, 66% completed treatment and 59% showed reliable improvement. Clinicians applied TF-CBT flexibly as prescribed by the model. Patients with CPTSD received more trauma processing but had less caregiver involvement than those without CPTSD. Children received more stabilization and caregiver involvement than did adolescents. More trauma experiences predicted higher dropout, whereas more caregiver sessions predicted lower dropout. CPTSD was associated with reliable improvement. Number of potentially traumatic event types were more strongly associated with dropout for children than for adolescents, and caregiver sessions more strongly predicted improvement in CPTSD cases. CONCLUSION: This study provides the first large-scale systematic documentation of TF-CBT delivery in routine care, and shows that TF-CBT can be scaled up in community clinics, with high improvement rates comparable to those in recent meta-analyses. A majority of the therapists received supervision, and future studies need to dismantle the importance of case consultation when scaling up evidence-based treatments.
I write in response to the Journal's call for work addressing structural discrimination and minoritization in child and adolescent mental health. The concept of trauma-informed care (TIC) has proliferated over the past s...I write in response to the Journal's call for work addressing structural discrimination and minoritization in child and adolescent mental health. The concept of trauma-informed care (TIC) has proliferated over the past several years. TIC is a foundational principle across systems and sectors that has the potential to promote safety, trust, and empowerment. The framework developed through research on adverse childhood experiences (ACEs) illustrates how such experiences influence psychiatric etiology, history, and treatment..
OBJECTIVE: Refugee and internally displaced children and adolescents experience high rates of post-traumatic stress symptoms (PTSS). Yet there is a lack of evidence of the effectiveness of psychological interventions in...OBJECTIVE: Refugee and internally displaced children and adolescents experience high rates of post-traumatic stress symptoms (PTSS). Yet there is a lack of evidence of the effectiveness of psychological interventions in this population. This systematic review and meta-analysis investigates the effects of psychological interventions on PTSS among refugee and internally displaced children and adolescents (PROSPERO CRD42024614752). METHOD: A comprehensive literature search up to December 19, 2025, was conducted in PubMed, PsycINFO, PSYNDEX, Web of Science, Epistemonikos, PTSDpubs, and ClinicalTrials.gov. Controlled trials were eligible if they studied psychological interventions aiming to reduce PTSS in refugee and internally displaced children and adolescents. Study quality was assessed using the Cochrane RoB-2 tool. Outcomes were analyzed using a random effects-model meta-analysis. RESULTS: Eight studies met the inclusion criteria, providing data on 9 active treatment conditions and 448 participants. Analyses showed a small effect of psychological interventions on PTSS reduction (g = -0.35, 95% CI = - 0.61, -0.09), and no significant effects on depression (g = -0.34, 95% CI = -0.76, 0.09) and dropout (odds ratio = 1.71, 95% CI = 0.35, 8.32). No significant moderators of PTSS reduction could be identified but pretest PTSS (b = -0.30), suggesting potentially greater effects in those with higher initial symptoms. CONCLUSION: The findings support the effectiveness of psychological interventions in treating PTSS in refugee and internally displaced children and adolescents. However, further research is needed to understand whether and why treatment effects appear smaller than in the general population, and whether this relates to migration factors or to factors associated with service provision and use or the need for intervention adaptations. STUDY REGISTRATION INFORMATION: Psychological interventions for post-traumatic stress disorder in internally displaced and refugee children and adolescents - A systematic review and meta-analysis; https://www.crd.york.ac.uk/PROSPERO/view/CRD42024614752.
It is important that children and adolescents have safe spaces in their lives. That space can be a physical location, with a person they know, or even a place they can go in their mind. When dealing with the many stresso...It is important that children and adolescents have safe spaces in their lives. That space can be a physical location, with a person they know, or even a place they can go in their mind. When dealing with the many stressors around them, knowing there is a place that can provide some relief is essential. Research has shown that having access to a physical safe space can decrease the risk of posttraumatic stress disorder, anxiety, and substance use. Having safe spaces, safe people, or even the ability to use skills to take a break from these stressors can be a privilege that is not shared by all, based on income, race, intellectual status, and much more. Feeling like one is constantly being targeted and less likely to have a safe space can cause kids to be more avoidant or to feel more like they need to defend themselves. As child and adolescent psychiatrists, one of our roles is to help our patients to be able to find these safe spaces wherever they can. Identifying a trusted adult in various settings is a great example of this, especially for youth who have had adults treat them poorly. Knowing safe spaces in your community that youth can go to, both to have a place in which they can relax and a place in which they can open up to others if needed, is essential. It is also important to recognize that not everyone can access the same spaces when identifying these resources. Not everyone can get to a location or can afford a membership, so being aware of this will be essential to ensure access for all your patients. This month's Media Forum highlights an example in which having a safe space was essential for the safety of the main character, and another in which the lack of safe spaces had significant impacts on the family.
Lock J, Matheson B, Jo B
… +7 more, Bohon C, Datta N, Whyte A, Boyce H, Gurcan HY, Cogburn AE, Kim B
J Am Acad Child Adolesc Psychiatry
· 2026 Apr · PMID 42019720
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OBJECTIVE: To examine the comparative efficacy of Family-based Treatment for Avoidant/Restrictive Food Intake Disorder (FBT-ARFID) to individual Psychoeducational Motivational Therapy (PMT) for underweight children with...OBJECTIVE: To examine the comparative efficacy of Family-based Treatment for Avoidant/Restrictive Food Intake Disorder (FBT-ARFID) to individual Psychoeducational Motivational Therapy (PMT) for underweight children with ARFID between the ages of 6 and 12 years of age. The main outcome evaluated was the difference between groups on change in percent estimated body weight (%EBW) from baseline (BL) to end of treatment (EOT). METHOD: Ninety-eight children with ARFID were randomized to 14 sessions over 4 months of telehealth FBT-ARFID or PMT. Assessments of weight/height, eating-related cognitions, and behaviors associated with ARFID were collected online at BL, 1 month, 2 months, and EOT by assessors masked to treatment condition. RESULTS: FBT-ARFID was superior to PMT at the EOT in promoting increased %EBW. There were no differences between groups on improvements in overall severity of ARFID symptoms or other related ARFID symptoms; however, BL severity of ARFID symptoms moderated the effect, with children who were most symptomatic improving significantly more in FBT-ARFID than in PMT (exploratory analyses). CONCLUSION: FBT-ARFID is superior to PMT for promoting weight gain in low-weight children with ARFID, especially for those children with greater severity of ARFID symptoms.
Depression among adolescents has risen significantly over the past two decades with increases in both diagnoses of major depressive disorders (MDD) and subclinical persistent sadness and hopelessness. Depressive symptoms...Depression among adolescents has risen significantly over the past two decades with increases in both diagnoses of major depressive disorders (MDD) and subclinical persistent sadness and hopelessness. Depressive symptoms rose dramatically from 2007 to 2015 within the United States, a trend that intensified during the COVID-19 pandemic, particularly among adolescent girls and youth with histories of adversity. Adolescent depression is associated with significant impairment including difficulties with academic performance, interpersonal relationships, substance use, and suicidality. Cognitive-behavioral (CBT) and interpersonal therapies are well-established for adolescent MDD, however, treatment response remains disappointing with non-response rates upwards of 60% among treated youth. These limitations underscore the need for studies of alternative intervention models, such as the meta-analysis by Huang and colleagues evaluating Behavioral Activation for adolescent depression, included in this JAACAP issue.
OBJECTIVE: Irritability, conceptualized as elevated proneness to anger, is a transdiagnostic feature and robust predictor of multiple psychological disorders. Identifying neurophenotypes of irritability in early childhoo...OBJECTIVE: Irritability, conceptualized as elevated proneness to anger, is a transdiagnostic feature and robust predictor of multiple psychological disorders. Identifying neurophenotypes of irritability in early childhood is critical to inform timely intervention, as irritability persisting into school age is associated with increased psychopathology and impairment. The present study aims to examine the neural substrates of irritability in early childhood in relation to reward processing, which is implicated in multiple disorders. METHOD: Data from 185 children (M = 6.16 years, SD = 0.50) were included. A child-friendly version of the Monetary Incentive Delay task during functional MRI acquisition assessed neural activity during reward anticipation (i.e., reward vs. no-reward) and feedback (i.e., hit vs. miss the target with a reward expected vs. not). The Multidimensional Assessment Profiles - Temper Loss Scale assessed irritability. Whole-brain multilevel analysis on neural activation and functional connectivity examined associations between irritability and reward processing. RESULTS: Greater irritability was associated with greater differences in response to reward vs. no-reward, reflected in left putamen activation. It was also associated with alterations in amygdala and striatal connectivity with multiple frontotemporal and parietal regions. The directionality of the effects varied depending on task-specific conditions (e.g., hitting a target with reward expected, missing a target with no reward expected). CONCLUSION: Our findings provide insights into the reward-related neural pathways of irritability in early childhood, a critical yet understudied developmental stage, which has the potential to facilitate timely and mechanistically informed interventions in young children.
As deficit narratives of children of color and race-related hate crimes increase across the country, racial health disparities persist and risk becomes exacerbated. It is imperative that scholars, through their scholarsh...As deficit narratives of children of color and race-related hate crimes increase across the country, racial health disparities persist and risk becomes exacerbated. It is imperative that scholars, through their scholarship, continue to document, challenge, and advocate against deficit narratives and racial discrimination in the lives of youth. Yet, parallel to the substantial body of research on racism-related stressors among youth of color, there exists also a robust well of science that elucidates the cultural assets that families have historically drawn upon to protect youth of color amid inequitable systems. Identification of and promotion of these strengths serves as a form of resistance within an increasingly divisive context. Among these cultural assets are racial-ethnic protective factors (REPFs)-defined as tools, practices, and ways of being that buffer some of the impact from racism-related stressors and that promote well-being. Constructs such as racial socialization, racial-ethnic identity, fictive kin relationships, and spirituality are all considered REPFs. Extant research identifies REPFs as unique developmental competencies that inform youth of color's self-esteem, self-efficacy, social support, and cognitive appraisal in the face of racial inequity. Practitioners across psychology, pediatric medicine, and education have long called for thoughtful integration of these REPFs in pediatric clinical care settings. Elucidating the strengths that families hold, while simultaneously advocating across levels for more equitable care, are acts of empowerment, as these REPFs are well researched and challenge deficit-based language.
In recent years, unprecedented numbers of new arrival families have entered the United States seeking safety. Child and adolescent immigrants (including refugees, asylum seekers, humanitarian parolees, and those with und...In recent years, unprecedented numbers of new arrival families have entered the United States seeking safety. Child and adolescent immigrants (including refugees, asylum seekers, humanitarian parolees, and those with undocumented and temporary protected statuses-hereafter referred to as "immigrants") are frequently exposed to severe trauma and face elevated risk for depressive, anxiety, post-traumatic stress, and psychotic disorders. The "triple trauma paradigm" describes how adversity often accumulates across stages of migration: pre-migration (eg, witnessing violence or warfare), migration (eg, trafficking), and post-migration (eg, community violence, race-based trauma, xenophobia), with post-migration stressors serving as powerful and ongoing determinants of mental health. The United States has seen rapidly shifting federal immigration policies that affect child well-being and adjustment. In 2025, cuts to safety net services supporting food (SNAP benefits), housing, Medicaid eligibility, and legal aid exacerbated existing post-migration stressors and structural barriers to care. Marked increases in immigration enforcement activity-including at schools, hospitals, and courthouses-have intensified fears of deportation. There is an urgent need for trauma-informed and culturally attuned care that acknowledges structural oppression while emphasizing compassionate and strengths-based treatment.
OBJECTIVE: The directionality of longitudinal pathways among adolescent mental health, subjective school experiences, and attendance is unclear, and the nature of sex differences is uncertain. This study aimed to disenta...OBJECTIVE: The directionality of longitudinal pathways among adolescent mental health, subjective school experiences, and attendance is unclear, and the nature of sex differences is uncertain. This study aimed to disentangle reciprocal, within-person dynamics between internalizing symptoms and key school-related factors (attendance, relationships with staff, school belonging) and to test for moderation by sex. METHOD: Data were from 3 annual waves (2021-2023) of the #BeeWell study and linked administrative attendance records: N = 25,506 English adolescents, 12 to 15 years of age, attending 154 schools. Multigroup random-intercept cross-lagged panel models examined within-person longitudinal pathways by sex. RESULTS: A robust "child-driven" pathway was found for both sexes: increases in internalizing symptoms predicted later reductions in school belonging (βs= -0.07 to 0.13). This pattern extended to relationships with staff for boys (T2→T3, β= -0.08) and school attendance for girls (T1→T2, β= -0.09; specific to authorized absences). Sex-specific protective pathways also emerged: improved relationships with staff predicted reduced internalizing symptoms for boys (T2→T3, β= -0.07), whereas increased school belonging predicted reduced internalizing symptoms for girls (T2→T3, β= -0.07). The majority of pathways (19 of 24) operated equivalently across sexes. Notably, changes in attendance did not predict changes in internalizing symptoms for either sex. CONCLUSION: Most within-person dynamics between internalizing symptoms and school-related factors did not vary by sex, but significant moderation was found for key protective and risk pathways. Results support tiered intervention: universal strategies strengthening subjective school experiences for all students, alongside targeted approaches leveraging enhancements in relationships with staff for boys, and school belonging for girls. STUDY REGISTRATION INFORMATION: Longitudinal associations across school attendance, school belonging, relationships with staff, and internalising symptoms in early-to-middle adolescence: A developmental cascades investigation; https://doi.org/10.17605/OSF.IO/DKFW9.
Preterm birth, defined as delivery before 37 weeks' gestation, remains a major global public health concern. Although many children born preterm survive without major neurodevelopmental disabilities, a substantial propor...Preterm birth, defined as delivery before 37 weeks' gestation, remains a major global public health concern. Although many children born preterm survive without major neurodevelopmental disabilities, a substantial proportion experience behavioral and socioemotional challenges, with risk increasing in a stepwise fashion as gestational age decreases. Understanding how symptoms evolve in this population, including who improves, who worsens, and when such changes occur, has important implications for anticipatory guidance, clinical surveillance, and the timing and nature of intervention.
The proportion of youth experiencing school attendance problems (SAPs) sharply rose during the COVID-19 pandemic and remains elevated. Among many contributing factors, 2 recent contextual shifts are particularly relevant...The proportion of youth experiencing school attendance problems (SAPs) sharply rose during the COVID-19 pandemic and remains elevated. Among many contributing factors, 2 recent contextual shifts are particularly relevant. First, the increasingly widespread acceptance of online learning has contributed to a growing perception among caregivers and youth that in-person school attendance is optional. Second, the youth mental health crisis has heightened recognition of psychological distress, at times prompting overly accommodative responses that are well intentioned but that ultimately reinforce avoidance (eg, when clinicians, educators, or caregivers recommend frequent "mental health days"). These developments carry some benefits-online learning can be essential for some medically complex students, and may serve as a temporary component of a re-entry plan for youth with SAPs. Increased mental health awareness has reduced stigma and highlighted the need for more effective support. Nevertheless, for most youth in-person schooling is critical for identity development, social competence, and access to supportive relationships. Clinicians should be prepared to recognize and address the ways in which these societal shifts may unintentionally exacerbate SAPs.
J Am Acad Child Adolesc Psychiatry
· 2026 Mar · PMID 41933650
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The term second-generation antipsychotics (SGA) is applied to a rather heterogeneous group of medications that share pharmacological activity on the dopaminergic neurotransmitter system and demonstrated efficacy in reduc...The term second-generation antipsychotics (SGA) is applied to a rather heterogeneous group of medications that share pharmacological activity on the dopaminergic neurotransmitter system and demonstrated efficacy in reducing psychotic symptoms in schizophrenia. They are commonly also prescribed to children and adolescents for the treatment of other conditions, either with regulatory approval (bipolar disorder, irritability in autism, Tourette disorder) or off-label (aggressive, disruptive, and impulsive behaviors). In fact, most pediatric use is for treating non-psychotic conditions. A more correct designation than SGA, based on the specific neurotransmitter activity of these medications, has been introduced. Evidence of the efficacy of SGA in reducing symptoms comes from randomized controlled trials, but little information is available on their effects on "hard" or "real-world" outcomes such as hospitalization, self-harm, violent crime, or accidental injury. To this end, randomized trials are of questionable feasibility because of the large sample sizes and extended duration of observation that would be required. Therefore, alternative methods are needed.
J Am Acad Child Adolesc Psychiatry
· 2026 Mar · PMID 41933649
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"I refuse to promote the gacha system in this game anymore." This was a comment made by a 13-year-old YouTuber named Michael "@mtashed" Tash with more than 600,000 followers. Many of his followers are children who were l..."I refuse to promote the gacha system in this game anymore." This was a comment made by a 13-year-old YouTuber named Michael "@mtashed" Tash with more than 600,000 followers. Many of his followers are children who were likely drawn to his entertaining commentary on popular games such as Destiny, Dark Souls, and Genshin Impact. Although the concept of a "gacha game" is likely unfamiliar to many clinicians, this phenomenon has significant relevance to child and adolescent psychiatry.
The September 2025 Proclamation, "Restriction on Entry of Certain Nonimmigrant Workers," conditions entry on H-1B visa status on a $100,000 payment attached to new petitions with an effective time of 12:01 a.m. EDT on Se...The September 2025 Proclamation, "Restriction on Entry of Certain Nonimmigrant Workers," conditions entry on H-1B visa status on a $100,000 payment attached to new petitions with an effective time of 12:01 a.m. EDT on September 21, 2025. This policy, when considered in the broader context of increasingly restrictive visa-issuing processes including surveillance of social media accounts, introduces substantial uncertainty for non-US international medical graduates (IMGs) whose training and employment routes involve J-1 and H-1B visas. The Immigration Act of 1990 created the H-1B visa program to hire highly educated foreign professionals in select occupations, such as technology and medicine, that face a dearth of US workers. While H-1B visa holders can train and practice in the United States, J-1 visa holders must return to the home country for 2 -years following completion of residency or fellowship training unless a J-1 waiver is granted. In addition, IMGs may experience other obstacles in training programs or the healthcare job market in the current climate. However, the national discourse overlooks the voices of the many youths, families, US citizens, healthcare systems, and communities that they serve and the personal stories of IMGs themselves. IMGs make up approximately 25% of the US healthcare workforce; they work largely with underserved families and fill a workforce shortage that is anticipated to exceed 86,000 physicians by 2036. Furthermore, they have the ability to connect to a growing population of American children of immigrant families and contribute to the innovation and economic engines of our nation..
Buchweitz C, Duarte I, Bondar J
… +6 more, Araújo RM, Caye A, Mondelli V, Kohrt BA, Fisher HL, Kieling C
J Am Acad Child Adolesc Psychiatry
· 2026 Mar · PMID 41921820
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Adolescent depression remains one of the leading causes of disability worldwide, contributing substantially to the global burden of disease. Despite growing interest in early identification and prevention of depression,...Adolescent depression remains one of the leading causes of disability worldwide, contributing substantially to the global burden of disease. Despite growing interest in early identification and prevention of depression, a persistent challenge is to deliver the right support to the right young people, at the right time. Lessons from other fields in medicine illustrate how risk-informed prevention-guided by composite prediction models-can make preventive efforts both proportionate and effective. Depression, in particular, demands a multifaceted, individualized approach to early detection-especially during adolescence, when incidence peaks and prevention opportunities are greatest. Psychiatry, however, has traditionally emphasized discrete factors, thereby constraining our capacity to model the complex interplay of risk and protective factors that underlie vulnerability. Current approaches also often rely on subthreshold depressive symptoms, limiting the ability to identify adolescents most at risk before symptoms emerge. Furthermore, although early predictive models show promise, their performance often fails to generalize beyond development samples.
Ogle CM, Rice AJ, Zhou J
… +3 more, Fisher JE, Hisle-Gorman E, Cozza SJ
J Am Acad Child Adolesc Psychiatry
· 2026 Mar · PMID 41921819
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OBJECTIVE: In a retrospective case-controlled study of children of deceased male active duty service members, we examined the prevalence of mental health diagnoses in paternally bereaved children before loss and 1 and 2...OBJECTIVE: In a retrospective case-controlled study of children of deceased male active duty service members, we examined the prevalence of mental health diagnoses in paternally bereaved children before loss and 1 and 2 years after loss compared to non-bereaved children. METHOD: Prevalence rates of mental health diagnoses in 1,212 bereaved and 1,212 non-bereaved children (matched on child age, child sex, pre-loss military health care use, parental military rank and deployment history) were calculated based on electronic medical record data in the military health care system. Logistic regressions compared prevalence rates between bereaved and non-bereaved children 1 and 2 years following paternal loss. RESULTS: Prevalence rates of depressive and adjustment disorders were 2 to 4 times higher in bereaved compared to non-bereaved youth 1 and 2 years after loss. Rates of acute stress disorder/post-traumatic stress disorder (PTSD) were 9.5 times higher in the first year after loss in bereaved vs non-bereaved youth. Models stratified by sex indicated that rates of depressive disorders, adjustment disorders, and acute stress disorder/PTSD were higher in both bereaved male and female youth compared to their non-bereaved counterparts. However, few sex differences were found. An examination of developmental differences indicated that bereaved school-aged children had higher rates of acute stress disorder/PTSD compared to adolescents in the first year after paternal death. CONCLUSION: Paternal bereavement is associated with increased prevalence of depressive disorders, adjustment disorder, and acute stress disorder/PTSD 1 and 2 years following loss among children in active military duty families. Paternally bereaved school-aged children may be at heightened risk for trauma-related diagnoses.