Kelsey E. Woods, Christina M. Danko, and Andrea Chronis-Tuscano
Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by developmentally inappropriate levels of hyperactivity, impulsivity, and/or inattention. ADHD is chronic, may persist into adulthood, and is associated with impairment in social and academic/work domains across the lifespan. Children and adolescents with ADHD often present with executive function deficits and emotion dysregulation, and these deficits may increase impairment and risk for co-occurring disorders. The etiology of ADHD is not yet understood, though research suggests that biological and environmental factors (e.g., family, community) contribute to its development and course. It should be noted that ADHD commonly co-occurs with additional psychiatric disorders, such as oppositional defiant disorder (ODD), conduct disorder (CD), and major depressive disorder.
Evidence-based assessment of ADHD requires information from multiple informants using multiple assessment methods to determine the presence of ADHD symptoms across settings and any co-occurring disorders. The evidence-based treatment options for ADHD are manifold. Pharmacotherapy for ADHD is common, although numerous behavioral interventions are also effective. Stimulant medications are commonly prescribed and are typically effective in ameliorating core ADHD symptoms. There is also evidence that the nonstimulant medication atomoxetine substantially decreases the symptoms of ADHD. Importantly, medication therapy works to reduce symptoms but typically does not alleviate the impairments associated with the disorder. Combined medication and behavioral interventions are more likely to reduce impairments and normalize behavior.
Benjamin T. Mast and Diana DiGasbarro
Clinicians conduct capacity evaluations to determine an older adult’s ability to make and execute a decision within key domains of functioning. Questions of capacity often arise when an older adult experiences a decline in cognitive functioning due to Alzheimer’s disease, stroke, or severe psychiatric illness, for example. Capacity is related to legal competency, and a lack of capacity may be proved by providing evidence that an older adult is unable to understand the act or decision in question; appreciate the context and consequences of the decision or act; reason about the potential harms and benefits; or express a choice. Capacity is domain-specific, time-specific, and decision-specific. Domains include financial capacity, medical treatment and research consent capacity, driving capacity, sexual consent capacity, and voting capacity. Each capacity domain encompasses activities that may vary in complexity or risk, and thus require different levels of capacity. For example, within the medical treatment consent capacity domain, an older adult may lack the capacity to consent to a complicated and risky surgical procedure while retaining the capacity to consent to a routine blood draw. Clinicians determine capacity by using a combination of tools including capacity assessment instruments, task-specific functional evaluations, interviews with the patient and family members, measures of cognitive functioning, and consideration of social, physical, and mental health factors. Extensive research has been conducted to determine the reliability and validity of a variety of capacity assessment instruments for many domains. These instruments generally assess the patient’s responses to vignettes pertaining to the domain in question, information gleaned from structured and semi-structured interviews, functional ability, or a combination of these methods. Although there is still need for more research, especially in emerging domains, capacity assessments help to protect vulnerable older adults from harm while allowing them to retain the highest possible level of autonomy.
Caring for an older adult who needs help or supervision is in many cases associated with mental and physical health issues, especially if the care recipient has dementia, although positive consequences associated with caregiving have also been reported. Several theoretical models have shown the relevance of psychological variables for understanding variations in the stress process associated with caregiving and how interventions may benefit from psychological techniques and procedures.
Since the 1990s it has been witnessed an increment in the number of studies aimed at analyzing caregiver health and developing and testing interventions for decreasing caregiver distress. Several examples of interventions for helping caregivers are considered empirically supported, including interventions for ethnically and culturally diverse caregivers, with psychotherapeutic and psychoeducational interventions showing strong effect sizes. However, efforts are still needed to maintain the results of the interventions in the long term and to make the interventions accessible (e.g., through technological resources) to a large number of caregivers who, because of time-pressure issues associated with caregiving or a lack of support, are not benefiting from them. Making these interventions available in routine healthcare settings would help a large population in need that presents with high levels of psychological suffering.
Competency to stand trial is a long-established legal principle in the U.S. criminal justice system that ensures that a criminal defendant’s right to a fair trial is protected. Fundamental justice requires that criminal defendants should be able to understand the charges against them, appreciate the nature and range of penalties, and communicate with their attorney. If they do not have the capacity in any of these areas, they may be found incompetent to proceed and the judicial proceedings are suspended until they are treated and competency is restored.
While competency to stand trial is the most commonly used term, competency in the criminal trial process encompasses all stages of participation in the legal process, including pretrial, trial, sentencing, and appeals. It is also a consideration if a defendant chooses to represent him or herself. Indeed, the term itself is misleading because few defendants actually go to trial, as the vast majority of cases are resolved through plea bargaining. The competency issue is raised when an officer of the court (defense, prosecution, or judge) has reason to believe there is a bona fide doubt as to a defendant’s competence. Once raised, defendants are typically referred for an evaluation by a mental health professional. Legal precedence has established that the basis of a finding of incompetency must be the presence of a major mental illness or substantial cognitive deficit. However, the mere presence of either of these conditions is not sufficient, as a functional approach to assessing competency dictates that the mental illness or cognitive deficit must be shown to affect the defendant’s specific legal competencies. It is entirely possible, for example, that some defendants with a psychosis or other severe mental illness may nevertheless be able to proceed with their case if the mental illness does not impair the legal abilities necessary to go forward.
Zella Moore, Jamie Leboff, and Kehana Bonagura
Major depressive disorder, dysthymia, and bipolar disorder are very common diagnoses seen among athletes, and they are serious conditions that can be debilitating if not properly addressed. These disorders warrant careful attention because they can adversely affect multiple domains of an athlete’s life, including athletic motivation, performance outcomes, interpersonal well-being, health, and overall daily functioning. Key foci include the prevalence of, clinical characteristics of, causes of, and risk factors for major depressive disorder, persistent depressive disorder/dysthymia, bipolar I disorder, and bipolar II disorder. Sport psychologists should integrate such important information into their overall case conceptualization and decision-making processes to ensure that athletes and performers at risk for, or struggling with, such mental health concerns receive the most effective, efficient, and timely care possible.
Alan E. Kazdin
Research in psychotherapy has developed a number of treatments, numbering well over 300, that have a strong evidence base. These treatments can be applied to a broad range of psychiatric disorders (e.g., depression, anxiety, schizophrenia, and others) as well as other sources of impairment in psychological functioning among children, adolescents, and adults. This article provides an overview of evidence-based psychotherapies, including current advances in how treatments are applied. Examples of treatments for depression and autism spectrum disorder are provided to illustrate the diversity of procedures in use and how they are applied. Key challenges related to evidence-based psychotherapies are highlighted, and these include disseminating the research findings, so that effective treatments are being used in clinical practice, and devising novel ways of delivering treatment to reach the large number of individuals who are in need of psychological services but do not yet receive care.
Robert A. Neimeyer and Melissa A. Smigelsky
Death and loss are universal human experiences, yet understandings of and attitudes toward expressing grief have shifted across time. The earliest psychological conceptualization of grief pathologized “holding on” to the lost object, a notion that has since been rejected in favor of a conception of continuing bonds that can be adaptive in grief. Similarly, early stage theories of grieving suggested a linear progression toward resolution and acceptance of loss, which has been criticized in favor of approaches that allow for natural regulatory processes of attending to the loss and reengaging with a changed world. In sum, grief is no longer regarded solely as looking back on a past life with the deceased but rather is oriented toward creating and reconstructing a meaningful present and future that accommodate the loss and its impact.
Most people respond adaptively to loss by relying on their internal and social support systems. However, a significant subset of grievers struggles with complicated grief, which is characterized by intense longing for the deceased, causes impairment in various life domains, and extends beyond the period of grieving that is considered normal for the population and culture. Grief therapy is most appropriate and advantageous for grievers who self-identify the need for additional support, and this tends to happen among those who are struggling disproportionately. Complicated grief shares features with other common psychiatric diagnoses (e.g., Major Depressive Disorder and Posttraumatic Stress Disorder), as well as being characterized by distinctive separation distress regarding the deceased. Treatment for complicated grief targets the common symptoms among these disorders as well as the grief-specific manifestations of distress that are concentrated on issues of coping, attachment, meaning, and behavior.
This is an advance summary of a forthcoming article in the Oxford Research Encyclopedia of Psychology. Please check back later for the full article.
Within psychology, the term habit is most often used to refer to a process whereby situations prompt action automatically, through activation of mental situation-action associations acquired through prior performances. Unlike consciously intended behavior, which proceeds via a cognitively effortful reflective processing system, behavior that is directed by habit is regulated by an impulsive processing system, and so can be elicited with minimal cognitive effort, awareness, control, or intention. The habit formation process involves a gradual transferral of action initiation from the conscious attentional or motivational processes involved in reflective processing, to external cuing mechanisms characteristic of impulsive processing. Behavior thus becomes detached from motivational or volitional control, freeing finite cognitive resources for unfamiliar or otherwise more demanding tasks. Upon encountering associated situations, habitual tendencies dominate action regulation, and alternative actions become less readily accessible.
By virtue of these characteristics, habit theory proposes that habit strength will predict the likelihood of enactment of habitual behavior, and that strong habitual tendencies will dominate over motivational tendencies. Evidence of these effects, albeit predominantly observational and correlational, has been found for many everyday socially significant and health-relevant behaviors, such as physical activity, healthy eating, alcohol consumption, TV viewing, and travel mode choice. Such findings have stimulated interest in habit formation as a behavior change mechanism—commentators have argued that adding habit formation components into behavior change interventions should sustain what are otherwise typically only short-term effects, by shielding new behaviors against potential motivational lapses. Habit-based interventions differ from non-habit-based interventions in that they include elements that promote context-dependent repetition, with the explicit aim of developing situation-action associations, and thus, situationally cued automatic behavioral responses. A wealth of habit-based behavior change interventions have been studied in clinical trials and have mostly shown positive effects on behavior. However, due to the methodological limitations of these trials, the longevity of such effects, and the unique impact on behavior of habit-focused components are not yet known. As an intervention strategy, habit formation has been shown to be acceptable to intervention recipients, who report that, through repetition, behaviors gradually become routinized and “second nature.” Whether habit formation interventions truly offer a route to long-lasting behavior change, however, remains unclear.
DeMond M. Grant and Evan J. White
Cognitive control is the ability to direct attention and cognitive resources toward achieving one’s goals. However, research indicates that anxiety biases multiple cognitive processes, including cognitive control. This occurs in part because anxiety leads to excessive processing of threatening stimuli at the expense of ongoing activities. This enhanced processing of threat interferes with several cognitive processes, which includes how individuals view and respond to their environment. Specifically, research indicates that anxious individuals devote their attention toward threat when considering both early, automatic processes and later, sustained attention. In addition, anxiety has negative effects on working memory, which involves the ability to hold and manipulate information in one’s consciousness. Anxiety has been found to decrease the resources necessary for effective working memory performance, as well as increase the likelihood of negative information entering working memory. Finally, anxiety is characterized by focusing excessive attention on mistakes, and there is also a reduction in the cognitive control resources necessary to correct behavior. Enhancing our knowledge of how anxiety affects cognitive control has broad implications for understanding the development of anxiety disorders, as well as emerging treatments for these conditions.
Deborah M. Capaldi, David C. R. Kerr, and Stacey S. Tiberio
Intergenerational studies are key to informing research, preventive intervention, and policy regarding family influences on healthy development and maladjustment. Continuities in family socialization and contextual risks across generations, as well as genetic factors, are associated with the development of psychopathology—including externalizing problems in children—and with intergenerational associations in the use of marijuana, alcohol, tobacco, and other drugs; these continuities are reflected in the low-to-moderate associations generally found in prospective studies. Until recent years, estimates of intergenerational continuities in problem behaviors and the processes explaining such associations (e.g., parenting behaviors) have been based largely on retrospective reports by adults about their own parents’ behaviors. Now there are some long-term prospective studies spanning as many as 30 years that can assess linkages between behaviors in one generation and the next. Whereas such studies have considerable design and implementation challenges, and are very expensive, it is of critical importance to examine the magnitude of associations of behaviors across generations. For example, a modest association across generations suggests either that genetic factors have a limited influence on that behavior or that they are subject to considerable moderation by environmental factors. These prospective studies relate to theoretical developments regarding intergenerational influences that are reviewed—for example, individual differences in genetic sensitivity to environmental influences. The theoretical approach employed in the Oregon Youth Study—Three Generation Study is a Dynamic Developmental Systems (DDS) model of continuous feedback across systems throughout development. A new hypothesis encompassed by DDS is developmental congruence of intergenerational associations in problem behaviors. As used in geometry, congruence refers to figures of a similar shape and size. This term has been adapted to refer to the expectation that ages of onset and patterns of growth in key behaviors will show similarity across generations. This is based on the theory that genetic and temperamental factors increase an individual’s risk when these factors are expressed at sensitive developmental periods. Thus, the timing of these manifestations (e.g., susceptibility to deviant peer influences) is expected to be similar across generations. Developmental similarity is also likely due to continuities in social-risk context and family mechanisms, such as parenting.
Stuart Linke and Elizabeth Murray
Alcohol-use disorders are widespread and associated with a greatly increased risk of health-related and societal harms. The majority of harms associated with consumption are experienced by those who drink above recommended guidelines, rather than those who are alcohol dependent. Brief interventions and treatments based on screening questionnaires and feedback have been developed for this group, which are effective tools for reducing consumption in primary care and in other settings. Most people who drink excessively do not receive help to reduce the risks associated with excessive consumption. Digital versions of brief and extended interventions have the potential to reach populations that might derive benefit from them. Digital interventions utilize the same principles as do traditional face-to-face versions, but they have the advantages of availability, confidentiality, flexibility, low marginal costs, and treatment integrity. The evidence for the feasibility, acceptability, costs, and effectiveness of digital interventions is encouraging, and the evidence for effectiveness is particularly strong in studies of student populations. There are, however, a number of unresolved questions. It is not clear which components of interventions are required to maximize effectiveness, whether digital versions are enhanced by the addition of personal contact from a facilitator or a health professional, or how to increase take up of the offer of a digital intervention and reduce attrition from a program. These questions are common to many online behavior-change interventions and there are opportunities for cross-disciplinary learning between psychologists, health professionals, computer scientists, and e-health researchers.
Gregory A. Hinrichsen
In clinical practice with older adults, depression is a common presenting problem and is usually interwoven with one or more life problems. These problems are often the focus of psychotherapy. Interpersonal Psychotherapy (IPT) is a highly researched and effective treatment for depression in adults and older adults. IPT is time-limited, and as an individual psychotherapy it is usually conducted over 16 sessions. IPT focuses on one or two of four interpersonally relevant problems that may be a cause or consequence of depression. These include: role transitions (life change), interpersonal role disputes (conflict with another person), grief (complicated bereavement), and interpersonal deficits (social isolation and loneliness). The four IPT problem areas reflect issues that are frequently seen in psychotherapy with depressed older people.
Nicole D. Anderson
Healthy aging is accompanied by decrements in episodic memory and working memory. Significant efforts have therefore been made to augment episodic and working memory in healthy older adults. Two principal approaches toward memory rehabilitation adults are restorative approaches and compensatory approaches. Restorative approaches aim to repair the affected memory processes by repeated, adaptive practice (i.e., the trained task becomes more difficult as participants improve), and have focused on recollection training, associative memory training, object-location memory training, and working memory training. The majority of these restorative approaches have been proved to be efficacious, that is, participants improve on the trained task, and there is considerable evidence for maintenance of training effects weeks or months after the intervention is discontinued. Transfer of restorative training approaches has been more elusive and appears limited to other tasks relying on the same domains or processes. Compensatory approaches to memory strive to bypass the impairment by teaching people mnemonic and lifestyle strategies to bolster memory performance. Specific mnemonic strategy training approaches as well as multimodal compensatory approaches that combine strategy training with counseling about other factors that affect memory (e.g., memory self-efficacy, relaxation, exercise, and cognitive and social engagement) have demonstrated that older adults can learn new mnemonics and implement them to the benefit of memory performance, and can adjust their views and expectations about their memory to better cope with the changes that occur during healthy aging. Future work should focus on identifying the personal characteristics that predict who will benefit from training and on developing objective measures of the impact of memory rehabilitation on older adults’ everyday functioning.
Jonathan S. Abramowitz
Obsessive-compulsive disorder (OCD) is one of the most destructive psychological disorders. Its symptoms often interfere with work or school, interpersonal relationships, and with activities of daily living (e.g., driving, using the bathroom). Moreover, the psychopathology of OCD is seemingly complex: sufferers battle ubiquitous unwanted thoughts, doubts, and images that, while senseless on the one hand, are perceived as signs of danger on the other hand. The thematic variation and elaborate relations between behavioral and cognitive signs and symptoms can be perplexing to even the most experienced of observers. Cognitive-behavioral models of OCD explain these phenomena and account for their heterogeneity. These models also have implications for how OCD is treated using exposure and response prevention, which research indicates are effective short- and long-term interventions.
Katy W. Martin-Fernandez and Yossef S. Ben-Porath
Attempts at informal personality assessment can be traced back to our distant ancestors. As the field of Clinical Psychology emerged and developed over time, efforts were made to create reliable and valid measures of personality and psychopathology that could be used in a variety of contexts. There are many assessment instruments available for clinicians to use, with most utilizing either a projective or self-report format. Individual assessment instruments have specific administration, scoring, and interpretive guidelines to aid clinicians in making accurate decisions based on a test taker’s answers. These measures are continuously adapted to reflect the current conceptualization of personality and psychopathology and the latest technology. Additionally, measures are adapted and validated to be used in a variety of settings, with a variety of populations. Personality assessment continues to be a dynamic process that can be utilized to accurately and informatively represent the test taker and aid in clinical decision making and planning.
Felipe B. Schuch and Brendon Stubbs
Depression is a leading cause of global burden affecting people across all ages, genders, and socioeconomic groups. Antidepressants are the cornerstone of treatment, yet treatment response is often inadequate. While some psychological interventions such as cognitive behavioral therapy can also help alleviate depressive symptoms, alternative and complimentary treatment options are required. In particular, therapeutic interventions that also address the greatly increased levels of obesity and cardiovascular disease among people with depression may offer added value. With the rising burden of premature mortality due to cardiovascular disease in people with depression and promising evidence base for physical activity to improve depressive symptoms, it is important to review the role, benefits, and underlying neurobiological responses of exercise among people with depression.
There has been a growing body of evidence to suggest that higher levels of physical activity reduce a person’s risk of incident depression. It appears that lower levels of cardiorespiratory fitness increase an individual risk of depression, suggesting that physical activity and physical fitness have a key role in the prevention of depression. Moreover, exercise can improve depressive symptoms in those with subthreshold depressive symptoms and major depressive disorder. Despite the effectiveness of exercise, the optimal dose and frequency are yet to be fully elucidated. Nonetheless, exercise appears to be well accepted by people with depression, with relatively low levels of dropout from interventions, particularly when supervised by qualified professionals with expertise in exercise prescription. Various barriers to engaging in exercise exist and motivational strategies are essential to initiate and maintain exercise. A number of hypotheses have been postulated to determine the antidepressant effect of exercise; however, most are based on animal models or models elucidated from people without depression. Therefore, future representative research is required to elucidate the neurobiological antidepressant response from exercise in people with depression. Physical activity interventions targeting fitness should be a central part of the prevention and management of depression. In particular, physical activity interventions offer a viable option to prevent and address cardiometabolic abnormalities and cardiovascular disease, which account for a significant amount of premature deaths in this population and are not addressed by standard pharmacological and psychological therapies.
Scott O. Lilienfeld
Although psychotherapy is on balance effective for a broad array of psychological problems, a relatively small but steadily accumulating body of evidence suggests that at least some psychological interventions are harmful. Until recently, however, relatively little research attention has been paid to the identification of harmful psychological treatments. Although it has long been recognized that a nontrivial minority of people become worse following therapy, this finding does not necessarily mean that they have become worse because of therapy. Nevertheless, recent research has homed in on a small subset of interventions that may produce psychological harm, physical harm, or both. In addition, there is growing interest in pinpointing potential mechanisms of deterioration effects in psychotherapy, as well as in distinguishing harmful therapies from harmful therapists.
Trent A. Petrie
Although the specific prevalence rates may vary, eating disorders (ED) affect male and female athletes regardless of sport type and competitive level. Generally, rates of subclinical disorders are much higher than clinical ones, with the most frequent clinical classification being Eating Disorders Not Otherwise Specified. Further, EDs occur not only among active athletes, but are also found in samples of retired athletes as well. Existing research on the prevalence of EDs in athletes, however, has been limited due to its reliance on out-of-date diagnostic criteria, sometimes small samples, and a focus on point prevalence to the exclusion of examining how rates might change over time. Central to prevalence research and clinical assessments is the ability to accurately assess EDs in athletes. Although structured clinical interviews represent the most valid approach, they are time consuming and not often used in determining prevalence. Researchers have relied on self-report measures instead. Such measures include those developed initially in nonathletes, but used to study athletes (e.g., Questionnaire for Eating Disorder Diagnosis; Mintz, O’Halloran, Mulholland, & Schneider, 1997), and those specifically for athletes (e.g., Athletic Milieu Direct Questionnaire; Nagel, Black, Leverenz, & Coster, 2000). Most of these measures, though having adequate psychometric properties, are based on diagnostic criteria that are no longer in use, so additional research that employs prevalence measures that reflect DSM-5 criteria is needed with athletes. Most ED research in sport has used samples of active athletes; few studies have considered how the transition out of sport might affect athletes’ perceptions of their bodies, their relationship to food, and their approaches to exercise and being physically active. Retirement from sport generally is considered to be a developmental stressor and thus may exacerbate ED symptoms and body image concerns in some athletes. Yet, for other athletes, retirement may represent a positive transition in which they emerge from a sport culture, focused on weight and appearance, to reclaim themselves and their bodies. Initial qualitative findings appear to support each hypothesis in part, though longitudinal quantitative studies that track athletes from active competition through retirement are needed to understand the changes athletes experience in relation to their bodies, food, and exercise, and when such changes are most likely to occur.
Mary V. Minges and Jacques P. Barber
Psychodynamic psychotherapies (PDP) is an umbrella term for a variety of therapeutic modalities that have evolved out of the psychoanalytic/psychodynamic tradition, each theorizing a trajectory of human development that includes an etiology of and treatment for psychopathology. PDPs have in common the belief that people have an unconscious mind that influences thoughts and behaviors outside of the individual’s awareness. These processes operate from birth till death and are responsible for adaptive and maladaptive functioning at the level of interpersonal relationships and daily living.
The psychodynamic therapist creates a case formulation for the individual seeking treatment, which incorporates a formal diagnosis with an understanding of the underlying dynamic factors contributing to the individual’s suffering. From this case formulation a treatment plan is created specific to the individual. During treatment, the therapist develops a strong working alliance while utilizing psychodynamic-specific techniques targeted at bringing insight into these unconscious thoughts and behaviors. Greater self-understanding enables greater choice ability and flexibility in functioning.
In contrast to prevalent views, empirical research has found support for the efficacy of PDP in the treatment of mental disorders, including but not limited to: depression, anxiety disorders, somatic disorders, and personality disorders. In general, PDP was found more effective than control conditions and not different from active treatments. PDP effects have been shown to remain stable post treatment.
Jarred Gallegos, Julie Lutz, Emma Katz, and Barry Edelstein
The assessment of older adults is quite challenging in light of the many age-related physiological and metabolic changes, increased number of chronic diseases with potential psychiatric manifestations, the associated medications and their side effects, and the age-related changes in the presentation of common mental health problems and disorders. A biopsychosocial approach to assessment is particularly important for older adults due to the substantial interplay of biological, psychological, and social factors that collectively produce the clinical presentation faced by clinicians. An appreciation of age-related and non-normative changes in cognitive skills and sensory processes is particularly important both for planning the assessment process and the interpretation of findings. The assessment of older adults is unfortunately plagued by a paucity of age-appropriate assessment instruments, as most instruments have been developed with young adults. This paucity of age-appropriate assessment instruments is an impediment to reliable and valid assessment. Notwithstanding that caveat, comprehensive and valid assessment of older adults can be accomplished through an understanding of the interaction of age-related factors that influence the experience and presentation of psychiatric disorders, and an appreciation of the strengths and weaknesses of the assessment instruments that are used to achieve valid and reliable assessments.