Practitioner Review Research Articles

Opinion: A Response to the CDC Press Conference on Behavioral Parent Training and Treating ADHD in Young Children

Free AccessOpinion: A Response to the CDC Press Conference on Behavioral Parent Training and Treating ADHD in Young ChildrenRussell A. BarkleyRussell A. BarkleySearch for more papers by this authorPublished Online:June 2016https://doi.org/10.1521/adhd.2016.24.4.11PDFPDF PLUS ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations About"Opinion: A Response to the CDC Press Conference on Behavioral Parent Training and Treating ADHD in Young Children." , 24(4), pp. 11–11,16 Previous article Next article FiguresReferencesRelatedDetails Cited byCited by1. Attention-deficit hyperactivity disorder and youth’s emotion dysregulation: A systematic review of fMRI studiesOnline publication date: 5 September 2022. Go to citation Crossref Google Scholar2. Evidence-Based Treatments for Attention-Deficit/Hyperactivity Disorder (ADHD)Online publication date: 27 September 2020. Go to citation Crossref Google Scholar3. Practitioner Review: Assessment and treatment of preschool children with attention-deficit/hyperactivity disorderOnline publication date: 28 January 2019. Go to citation Crossref Google ScholarRussell A. Barkley4. Focus on the Side Effects of Psychosocial Treatments for Children and Teens with ADHD: A Special IssueOnline publication date: 7 February 2018. Go to citation Crossref Google Scholar Volume 24Issue 4Jun 2016 Information© 2016 The Guilford PressPDF download

Practitioner Review: Treatments for Tourette syndrome in children and young people - a systematic review.

Tourette syndrome (TS) and chronic tic disorder (CTD) affect 1-2% of children and young people, but the most effective treatment is unclear. To establish the current evidence base, we conducted a systematic review of interventions for children and young people. Databases were searched from inception to 1 October 2014 for placebo-controlled trials of pharmacological, behavioural, physical or alternative interventions for tics in children and young people with TS or CTD. Certainty in the evidence was assessed with the GRADE approach. Forty trials were included [pharmacological (32), behavioural (5), physical (2), dietary (1)]. For tics/global score there was evidence favouring the intervention from four trials of α2-adrenergic receptor agonists [clonidine and guanfacine, standardised mean difference (SMD)=-0.71; 95% CI -1.03, -0.40; N=164] and two trials of habit reversal training (HRT)/comprehensive behavioural intervention (CBIT) (SMD=-0.64; 95% CI -0.99, -0.29; N=133). Certainty in the effect estimates was moderate. A post hoc analysis combining oral clonidine/guanfacine trials with a clonidine patch trial continued to demonstrate benefit (SMD=-0.54; 95% CI -0.92, -0.16), but statistical heterogeneity was high. Evidence from four trials suggested that antipsychotic drugs improved tic scores (SMD=-0.74; 95% CI -1.08, -0.40; N=76), but certainty in the effect estimate was low. The evidence for other interventions was categorised as low or very low quality, or showed no conclusive benefit. When medication is considered appropriate for the treatment of tics, the balance of clinical benefits to harm favours α2-adrenergic receptor agonists (clonidine and guanfacine) as first-line agents. Antipsychotics are likely to be useful but carry the risk of harm and so should be reserved for when α2-adrenergic receptor agonists are either ineffective or poorly tolerated. There is evidence that HRT/CBIT is effective, but there is no evidence for HRT/CBIT alone relative to combining medication and HRT/CBIT. There is currently no evidence to suggest that the physical and dietary interventions reviewed are sufficiently effective and safe to be considered as treatments.

Practitioner Review: On the trustworthiness of clinical practice guidelines - a systematic review of the quality of methods used to develop guidelines in childand youth mental health.

Numerous practice guidelines (PGs) relevant to child and youth mental health (CYMH) are available, but their quality is uncertain. We used systematic review methodology to identify the methods employed to develop PGs in CYMH and assess whether they align with international quality standards. We used prespecified inclusion criteria to search for CYMH PGs (2009-2014) in journals of professional associations or websites of organizations who produce or house PGs. Eligible PGs and organization websites were screened to identify PG development methods. Two reviewers assessed the alignment of the PG development methods with PG quality criteria using the Appraisal of Guidelines for Research and Evaluation (AGREE II) domains and Institute of Medicine (IOM) standards. Five sets of eligible development methods were identified in 70 eligible PGs. Three sets adhered to all (National Institute for Health and Care Excellence; Scottish Intercollegiate Guidelines Network) or most (U.S. Preventive Services Task Force) AGREE II domains and IOM standards, and were used to develop 31.4% of PGs. The two remaining sets of development methods had important weaknesses (e.g. lack of mandatory rigorous systematic reviews, multidisciplinary development groups, or transparent conflict of interest methods) and were associated with 21.4% of PGs. No development methods could be identified in 40.0% of PGs; ineligible development methods were referenced in 7.1% of PGs. Up to 69% of available CYMH PGs may have been developed using methods that do not align with AGREE II quality criteria or IOM standards. The quality of available CYMH PGs needs to be assessed, and strategies designed to guide practitioners to highquality PGs and facilitate adherence by PG developers to international quality standards are needed.

A Pre-Hospital Patient Education Program Improves Outcomes of Bariatric Surgery.

We designed an assessment and education program which was delivered to patients prior to first outpatient appointment for bariatric surgery. We hypothesised that this program would streamline care and would lead to improved weight loss following bariatric surgery. The program incorporates a structured general practitioners (GP) review, a patient information evening and an on-line learning package. It was introduced in September 2012. Patient flow through the program was recorded. Outcomes of the new program were compared with contemporaneously treated patients who did not undertake the pre-hospital program. All 636 patients on the waiting list for first appointment at the Alfred Health bariatric surgery clinic were invited to participate. There were 400 patients ultimately removed from the waiting list for first appointment. Of the remaining 236 patients, 229 consented to participate in the new program. The mean BMI was 47.8 ± 9.2. The fail to attend first appointment rate dropped from 12 to 2.1%. At 12months post-bariatric surgery, patients who undertook the new program (n = 82) had a mean excess weight loss (EWL) of 41.1 ± 20.3% where as those treated on the standard pathway (n = 61) had a mean EWL 32 ± 18.0% (p = 0.012). The introduction of a pre-hospital education program has led to an improvement in attendance rates and early weight loss post-bariatric surgery.

Practitioner Review: Involving young people with callous unemotional traits in treatment--does it work? A systematic review.

Children and adolescents with callous unemotional (CU) traits are at risk of severe and persistent antisocial behavior. It is commonly assumed that these children are difficult to treat but it has been proposed that they may benefit from being involved in interventions that go beyond typical parent training programs. This systematic review sought to answer two previously unanswered questions: do interventions involving young people reduce levels of CU traits? Do CU traits predict the effectiveness of interventions for antisocial behavior involving young people? Studies were included that adopted an randomized controlled trial, controlled or open trial design and that had examined whether treatment was related to reductions in CU traits or whether CU traits predicted or moderated treatment effectiveness. Treatments used a range of approaches, including behavioral therapy, emotion recognition training, and multimodal interventions. 4/7 studies reported reductions in CU traits following treatment. There was a mixed pattern of findings in 15 studies that examined whether CU traits predicted treatment outcomes following interventions for antisocial behavior. In 7/15 studies, CU traits were associated with worse outcomes, although three of these studies did not provide data on baseline antisocial behavior, making it difficult to evaluate whether children with high CU traits had shown improvements relative to their own behavioral baseline, despite having the worst behavioral outcomes overall. CU traits did not predict outcomes in 7/15 studies. Finally, a single study reported that CU traits predicted an overall increased response to treatment. Overall, the evidence supports the idea that children with CU traits do show reductions in both their CU traits and their antisocial behavior, but typically begin treatment with poorer premorbid functioning and can still end with higher levels of antisocial behavior. However, there is considerable scope to build on the current evidence base.

Practitioner review

Practitioner review

Practitioner Review: Borderline personality disorder in adolescence--recent conceptualization, intervention, and implications for clinical practice.

The past decade has seen an unprecedented increase in research activity on personality disorders (PDs) in adolescents. The increase in research activity, in addition to major nosological systems legitimizing the diagnosis of borderline personality disorder (BPD) in adolescents, highlights the need to communicate new research on adolescent personality problems to practitioners. In this review, we provide up-to-date information on the phenomenology, prevalence, associated clinical problems, etiology, and intervention for BPD in adolescents. Our aim was to provide a clinically useful practitioner review and to dispel long-held myths about the validity, diagnostic utility, and treatability of PDs in adolescents. Alongside providing up-to-date information on the phenomenology, prevalence, and etiology, we also report on associated clinical problems and interventions for adolescent BPD. It is only through early active assessment and identification of youngsters with these problems that a lifetime of personal suffering and health system burden can be reduced or altogether avoided. A variety of evidence-based approaches are now available to treat BPD and related clinical problems in young people. Future research should focus on establishing optimal precision in the diagnostic processes in different treatment settings.

A Systematic Review of the Empirical Support for Check-In Check-Out

Tier 2 interventions play an important role within the Positive Behavioral Interventions and Supports framework, bridging the gap between schoolwide Tier 1 interventions and individualized Tier 3 supports. Check-in Check-out (CICO) is a promising Tier 2 intervention for addressing mild problem behavior and potentially preventing the need for more intensive supports. In this systematic review, we synthesize the characteristics, methodological quality, and outcomes of 15 single-subject studies and one group design study examining CICO. The results suggest that CICO can be considered an evidence-based practice for students with problem behavior maintained by adult attention. Versions of CICO that were modified to address other functions (e.g., obtain peer attention, escape from tasks) demonstrated strong effects, but there were not a sufficient number of studies for modified CICO to qualify as an evidence-based practice. We discuss the implications of this review for practitioners as well as future research on CICO.

Non-Pharmacological Treatments for Stuttering in Children and Adults: A Systematic Review and Evaluation of Effectiveness, and Exploration of Barriers to Successful

There is an increasing range of treatments available for stuttering in children and adults and a need to examine the evidence base for these interventions in order to inform future guidelines and service delivery. Systematic reviews provide a structured summary of available evidence and can identify consistencies and inconsistencies in the research in order to present service providers and practitioners with evidence-based information. The systematic review that will be reported in this presentation was commissioned by the National Institute for Health Research as part of its Health Technology Appraisal programme, and is being carried out over one year (August 2013-August 2014). The systematic review consists of two elements: a synthesis of international evidence on the effectiveness of stuttering interventions; and an examination of qualitative primary study data for insights into factors that may underpin successful or less successful outcomes. A systematic search of key health and medical databases is being undertaken to identify recently published (since 1990) relevant studies. In addition to electronic searching, reference list checking, involvement of experts and citation searching is being used to identify evidence. The review process includes quality appraisal of each study to identify potential sources of bias and reliability of findings. Following the identification and quality appraisal, included studies will be synthesised (via appropriate methods including narrative synthesis, meta-analysis and thematic synthesis). The review is intending to be a broad review of the evidence regarding stuttering intervention. Populations of children, adolescents and adults who have developmental dysfluency in any OECD country are included. Non-pharmacological interventions delivered in any setting, by any individual are eligible for inclusion. Any outcome relating to a positive effect on stuttering or the emotional wellbeing of people who stutter is considered. A broad study design criteria has been set, with only case series, case reports and survey data excluded. The study is currently ongoing and will be completed in August 2014. To date we have examined over 4000 retrieved citations and identified 120 intervention studies and 24 qualitative studies for potential inclusion. A conceptual framework outlining the pathway from interventions to outcomes is being developed from the literature to provide further explanatory detail of the review findings. The presentation will consider the implications of the findings of the systematic review for practitioners and commissioners.

Practitioner Review: Self-injurious behaviour in children with developmental delay.

Self-injurious behaviour is shown by a significant minority of children with developmental delay and has a substantial impact on child and carer wellbeing. Characteristics such as a greater degree of intellectual disability, autism spectrum disorder, some genetic syndromes and repetitive and impulsive behaviours are positively associated with self-injury. Prevalence generally increases with age into midadulthood and the behaviour is notably persistent. In this review, we discuss the dominant causal theory of self-injury which draws on the principles of operant learning. We evaluate the utility of this theory to account for all empirical observations of self-injury. A model of self-injury is presented that extends a previous model described by Guess and Carr. The new model integrates child characteristics and operant learning principles in a phenotype × environment paradigm to explain the variance in developmental trajectory of the severity of self-injury. Behaviour dysregulation, as evidenced by the associations between self-injury, self-restraint, repetitive and impulsive behaviours, is identified as potentially influencing the severity and persistence of self-injury. Risk markers for self-injury are identified and the extended model indicates points of intervention and highlights the possibility of risk-related, targeted early intervention. The need for increased training of practitioners in the delivery of demonstrably effective interventions for self-injury is identified.

Practitioner Review: Pathways to care for ADHD - a systematic review of barriers and facilitators.

BackgroundAttention‐Deficit/Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder starting in childhood that may persist into adulthood. It can be managed through carefully monitored medication and nonpharmacological interventions. Access to care for children at risk of ADHD varies both within and between countries. A systematic literature review was conducted to investigate the research evidence related to factors which influence children accessing services for ADHD.MethodStudies investigating access to care for children at risk of ADHD were identified through electronic searches of the international peer‐reviewed and grey literature. Databases were searched from inception till 30th April 2012. This identified 23,156 articles which were subjected to three levels of screening (title, abstract and full text) by a minimum of two independent reviewers. Due to the heterogeneity in the study designs, a narrative approach was used to present the findings.ResultsTwenty‐seven papers met the inclusion criteria; these were grouped into four main themes, with some papers being included in more than one. These were wider determinants (10 papers); identification of need (9 papers); entry and continuity of care (13 papers) and interventions to improve access (4 papers). Barriers and facilitators to access were found to operate at the individual, organisational and societal level. Limited evidence of effective interventions to improve access was identified.ConclusionThis review explored the multilayered obstacles in the pathway to care for children at risk of ADHD and the lack of evidence‐based interventions designed to address these issues, thereby indicating areas for service development and further evaluative research.

Practitioner Review: Cognitive bias modification for mental health problems in children and adolescents: a meta-analysis.

Despite accumulating research and bold claims about the efficacy of cognitive bias modification (CBM) for young populations, no meta-analysis has attempted to synthesize the research literature so far. We examined whether there was empirical evidence for the clinical efficacy of CBM interventions in youths, while also considering the methodological quality of this evidence. Studies were identified through systematic searches in bibliographical databases (PubMed, PsychInfo, Cochrane Library and EMBASE to June 2014). We included randomized controlled trials of CBM interventions, and considered both clinical outcomes and targeted biases. We examined the quality of the trials, as well as potential publication bias and possible moderators. We identified 23 trials that reported on four types of outcomes: mental health, anxiety, depression and bias. Effect sizes were small and nonsignificant for all symptom outcomes considered. We found a moderate significant effect size for bias outcomes (Hedges' g of 0.53), with significant heterogeneity. There were no differences between types of CBM interventions, or between one versus multiple-session applications. A small but significant effect size for mental health problems arose when the intervention was delivered in schools. The quality of almost all of the included studies was suboptimal and the vast majority did not include information needed for allowing quality assessment. We conducted the first meta-analysis of CBM interventions for children and adolescents and found no effects for mental health outcomes, but we did find moderate and significant effects on the targeted biases. Our results cast serious doubts on CBM interventions having any clinical utility for nonadult populations. Demand characteristics might play an important part in CBM research.

Commentary: A social environment approach to promotive and protective practice in childhood resilience--reflections on Ungar (2014).

The field of mental health and psychosocial support for children in humanitarian emergencies has been evolving rapidly. A decade ago, researchers and practitioners frequently took a deficits approach that emphasized problems such as trauma, particularly post-traumatic stress disorder (PTSD), in zones of armed conflict. Assessments focused on PTSD and typically led to the provision of curative responses such as Western psychotherapies as the first response for the affected population. Practitioners expressed diverse concerns about this approach, including its narrow, medicalized definition of the problem (mental disorder), the unsustainability of the programs it generated, the relative inattention to the context, the privileging of individual over systemic approaches, and the lack of cultural sensitivity. For these and other reasons, humanitarian practitioners have increasingly favored a resilience approach that features the agency of children, families, and communities and seeks to build upon existing assets or strengths. Already there is evidence of the effectiveness of numerous interventions that embody a resilience approach. Yet resilience approaches have been limited by a lack of conceptual clarity and ongoing questions about how to assess and measure it. In this context, Michael Ungar's Practitioner Review is an important contribution to practice.

Practitioner review: Effective ingredients of prevention programs for youth at risk of persistent juvenile delinquency--recommendations for clinical practice.

There is a lack of knowledge about specific effective ingredients of prevention programs for youth at risk for persistent delinquent behavior. The present study combines findings of previous studies by examining the effectiveness of programs in preventing persistent juvenile delinquency and by studying which particular program, sample, and study characteristics contribute to the effects. Information on effective ingredients offers specific indications of how programs may be improved in clinical practice. A literature search in PsychINFO, ERIC, PubMed, Sociological Abstracts, Criminal Justice Abstracts, and Google Scholar was performed. Only (quasi)experimental studies and studies that focused on adolescents at risk for (persistent) delinquent behavior were included. Multilevel meta-analysis was conducted on 39 studies (N=9,084). Participants' ages ranged from 6 to 20years (M=14years, SD=2.45). The overall effect size was significant and small in magnitude (d=0.24, p<.001). Behavioral-oriented programs, focusing on parenting skills training, behavioral modeling, or behavioral contracting yielded the largest effects. Multimodal programs and programs carried out in the family context proved to be more beneficial than individual and group-based programs. Less intensive programs yielded larger effects. Prevention programs have positive effects on preventing persistent juvenile delinquency. In order to improve program effectiveness, interventions should be behavioral-oriented, delivered in a family or multimodal format, and the intensity of the program should be matched to the level of risk of the juvenile.

Commentary: G × E in child psychiatry and psychology: a broadening of the scope of enquiry as prompted by Munafò et al. (2014).

The accompanying Practitioner Review by Munafò et al. (2014) presents two main arguments: (1) that there are few (if any) examples of G × E in psychiatry so it cannot aid gene discovery, and (2) that genome-wide association studies (GWAS) are already yielding important findings. With respect to the supposed weakness of G × E research, they fail to mention any of the substantial body of evidence in support of G × E – see various chapters in Dodge and Rutter (2011).

Practitioner Review: Diagnosing childhood resilience--a systemic approach to the diagnosis of adaptation in adverse social and physical ecologies.

With growing interest in resilience among mental health care providers globally, there is a need for a simple way to consider the complex interactions that predict adaptive coping when there is exposure to high levels of adversity such as family violence, mental illness of a child or caregiver, natural disasters, social marginalization, or political conflict. This article presents diagnostic criteria for assessing childhood resilience in a way that is sensitive to the systemic factors that influence a child's wellbeing. The most important characteristics of children who cope well under adversity and avoid problems like depression, PTSD, and delinquency are highlighted. A multidimensional assessment of resilience is presented that examines, first, the severity, chronicity, ecological level, children's attributions of causality, and cultural and contextual relevance of experiences of adversity. Second, promotive and protective factors related to resilience are assessed with sensitivity to the differential impact these have on outcomes depending on a child's level of exposure to adversity. These factors include individual qualities like temperament, personality, and cognitions, as well as contextual dimensions of positive functioning related to the available and accessibility of resources, their strategic use, positive reinforcement by a child's significant others, and the adaptive capacity of the environment itself. Third, an assessment of resilience includes temporal and cultural factors that increase or decrease the influence of protective factors. A decision tree for the diagnosis of resilience is presented, followed by a case study and diagnosis of a 15-year-old boy who required treatment for a number of mental health challenges. The diagnostic criteria for assessing resilience and its application to clinical practice demonstrate the potential usefulness of a systemic approach to understanding resilience among child populations.

Creating Successful Vernal Pools: A Literature Review and Advice for Practitioners

Vernal pools provide critical breeding habitat for amphibians adapted to temporary waters, but they seldom receive the same level of protection as permanent wetlands. In response to continued degradation and loss of pools, managers often attempt to mitigate losses through pool creation or restoration. However, mitigation efforts often fail to provide suitable aquatic habitat for vernal pool amphibians. We review the literature on pool creation in northeastern and central North America, highlighting how and why constructed pools often fail to support amphibian-related objectives. We recommend that practitioners consider the complex ecology of pool ecosystems and the historical and current distribution of pools and other wetlands in their local context before designing pool mitigation projects. Using vernal pool creation as a mitigation option should be a last resort (i.e., when elimination of natural pools is unavoidable). Monitoring should be target-specific and conducted for at least 5 years. Topographic, geologic, and other local factors affecting pool hydrology and ecology vary regionally; pool creation remains an imperfect science that will only advance by documenting failures and successes. We recommend an adaptive management approach to vernal pool creation in which the effectiveness of techniques is evaluated and refined based on research.

Practitioner review: Engaging fathers--recommendations for a game change in parenting interventions based on a systematic review of the global evidence.

BackgroundDespite robust evidence of fathers’ impact on children and mothers, engaging with fathers is one of the least well-explored and articulated aspects of parenting interventions. It is therefore critical to evaluate implicit and explicit biases manifested in current approaches to research, intervention, and policy.MethodsWe conducted a systematic database and a thematic hand search of the global literature on parenting interventions. Studies were selected from Medline, Psychinfo, SSCI, and Cochrane databases, and from gray literature on parenting programs, using multiple search terms for parent, father, intervention, and evaluation. We tabulated single programs and undertook systematic quality coding to review the evidence base in terms of the scope and nature of data reporting.ResultsAfter screening 786 nonduplicate records, we identified 199 publications that presented evidence on father participation and impact in parenting interventions. With some notable exceptions, few interventions disaggregate ‘father’ or ‘couple’ effects in their evaluation, being mostly driven by a focus on the mother–child dyad. We identified seven key barriers to engaging fathers in parenting programs, pertaining to cultural, institutional, professional, operational, content, resource, and policy considerations in their design and delivery.ConclusionsBarriers to engaging men as parents work against father inclusion as well as father retention, and undervalue coparenting as contrasted with mothering. Robust evaluations of father participation and father impact on child or family outcomes are stymied by the ways in which parenting interventions are currently designed, delivered, and evaluated. Three key priorities are to engage fathers and coparenting couples successfully, to disaggregate process and impact data by fathers, mothers, and coparents, and to pay greater attention to issues of reach, sustainability, cost, equity, and scale-up. Clarity of purpose with respect to gender-differentiated and coparenting issues in the design, delivery, and evaluation of parenting programs will constitute a game change in this field.

BIM 기반 건축설계 관리 지원을 위한 클라우드 컴퓨팅 서비스 기능 제안

Recently, there have been various attempts for the adoption and spread of Building Information Modeling (BIM) in the construction industry. However, the spread of BIM has been less satisfied than expected, because of the insufficient, expensive hardware and software for the authoring, analysis and so forth. As a solution to resolve the obstacles, the applications of cloud computing technology to BIM have been introduced. Due to the vendor-dependent functions and lack of verification on the work process, the spread of cloud-based BIM has been limited in Korea. Therefore, this study proposes the functions of cloud computing services which can support BIM-based design processes through the review of practitioners, questionnaire survey and analysis of design process.

Practitioner review: Long-term pharmacological treatment of pediatric bipolar disorder.

Although long-term treatment is a core aspect of the management of children and adolescents with bipolar disorder (BD), most clinical recommendations are based on results from short-term studies or adult data. In order to guide clinical practice, we review the efficacy and safety profile of mood stabilizers, antipsychotics, and other pharmacological strategies for the long-term treatment of BD in pediatric patients. A MEDLINE, EMBASE, Cochrane and PsycInfo search (inception through November 2013) was performed to identify prospective studies longer than 12weeks assessing the use of pharmacological strategies for the long-term treatment of BD in pediatric patients (0-18years of age). Four randomized controlled trials (RCT) [three placebo-controlled (assessing aripiprazole (2) and flax oil), and one head-to-head comparison of lithium vs. divalproex], and thirteen noncontrolled studies (six open-label studies assessing lithium or anticonvulsants, five assessing second-generation antipsychotics (SGAs) and four assessing combination strategies) were included in the review. Aripiprazole has shown efficacy for relapse prevention in children with pediatric bipolar disorder (PBD) 4-9years of age in one placebo-controlled RCT. Positive results have been reported in noncontrolled studies with quetiapine and lithium for relapse prevention, as well as with lithium, quetiapine, ziprasidone, and the combination of risperidone and divalproex or lithium for long-term symptom reduction in PBD. The most frequently reported adverse events in children and adolescents treated with lithium and anticonvulsants are gastrointestinal and neurological, whereas use of SGAs is mainly related to weight gain and sedation. According to the limited empirical evidence, aripiprazole can be useful for relapse prevention in children with PBD. Given the lack of consistent efficacy data, clinical decision making should be based on individual clinical aspects and safety concerns.