Delinquency, Depression, and Psychosis among Adolescents in Foster Care: What Holds Three Heads Together?

Child psychopathology research has traditionally distinguished between internalizing and externalizing disorders, with the former treated with interventions that focus on alleviating negative internal states, and the latter with interventions that reward prosocial behavior and attempt to extinguish negative behavior. Not all disorders fall neatly into these categories, of course. Psychosis could be seen as an externalizing disorder (e.g., patients who become violent when hearing threatening voices) or an internalizing disorder (e.g., believing one is being punished). Multidimensional Treatment Foster Care (MTFC), a comprehensive care system for delinquent girls, appears to have beneficial effects on delinquency, depression, and subthreshold psychotic symptoms over 2 years. Although treatments that have nonspecific benefits might undermine the view that specific disorders have unique causal mechanisms, they are welcome in public health settings, where pure clinical presentations are rare.¹

In the well-done study by Poulton et al.² in this issue of the Journal, 166 girls (13–17 years of age) who had been arrested at least once in the prior 12 months and placed in out-of-home foster care were randomly assigned to MTFC or a group care as usual treatment. Unlike prior “ultra high-risk” studies, the sample was not selected for psychosis symptoms but had historical risk factors (i.e., childhood abuse and neglect) and current diagnoses (i.e., conduct disorder) that are related to psychosis onset. Although the primary purpose of MTFC was to decrease delinquency, the investigators observed secondarily that girls showed decreases in subthreshold psychotic symptoms.

MTFC was implemented in 22 group homes in which foster parents were trained and supervised to implement a reinforcement model. The adolescents attended public school and received concurrent individual therapy. After an average 6-month stay, adolescents returned to parents (or other caregivers) who were trained in effective parenting skills (e.g., consistency, non-harsh discipline) in a family-therapy format. Thus, the program aimed to change the context in which delinquent behaviors developed, first by providing a new home environment and then by modifying the old one. Participants in the group care condition lived in 1 of 35 intensive care settings, where they received at least weekly services and off- or on-grounds schooling.

Over 24 months, adolescents in MTFC had a steeper decline in psychotic symptom severity and roughly half the number of psychotic symptoms compared with adolescents in group care. Psychotic symptoms were measured from the Brief Symptom Inventory (5 items) and the Diagnostic Interview Schedule for Children–IV Psychotic Symptoms scale. The Brief Symptom Inventory included the items “feeling lonely even when you are with people” and “never feeling close to another person.” Psychosis and depression are both characterized by emotional withdrawal, and in this sense, it is not surprising that a treatment that decreased depression also would decrease subthreshold psychosis...

Full article at: http://goo.gl/1EfII3

By: Dr. David J. Miklowitz, 

Dr. David J. Miklowitz, University of California–Los Angeles School of Medicine;

Correspondence to David J Miklowitz, PhD, Division of Child and Adolescent Psychiatry, UCLA Semel Institute Room 58-217, David Geffen School of Medicine, 760 Westwood Plaza, Los Angeles, CA 90024-1759; Email: ude.alcu.tendem@ztiwolkimd

  

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