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.
Jonathan S. Gooblar and Sherry A. Beaudreau
Anxiety disorders are among the most prevalent and understudied mental health problems in late life. Specific phobia, social anxiety disorder, and generalized anxiety disorder are the most prevalent anxiety disorders in older adults among the 11 disorders identified by the Diagnostic and Statistical Manual of Mental Disorders (fifth edition). Anxiety disorders lead to significant functional burdens and interface with physical health problems and cognitive impairment, concerns frequently experienced in adults over age 65. Additional contextual factors should be considered when assessing and treating late-life anxiety, including the effects of polypharmacy, other mental health conditions, role changes, and societal attitudes toward aging. The relationship between anxiety and physical health problems in older adults can be causal or contextual, and can involve poorer estimates of subjective health and lower ratings of functioning. These factors present unique challenges to the detection, conceptualization, and treatment of late-life anxiety, including the tendency for older adults to focus on somatic symptoms and the potential for long-term behaviors that can mask distress such as substance use. Researchers are increasingly incorporating a gerodiversity framework to understand the contributions of cultural, individual, and other group differences that may affect the presentation of anxiety symptoms and disorders. Older adults in general are less likely to be treated for anxiety disorders, and intersecting individual and group differences likely further affect how anxiety disorders are perceived by healthcare providers. Cognitive behavioral therapy and its variants have the most empirical support for treatment. Newer evidence lends support to acceptance and commitment therapy and problem-solving therapy, which tend to address some of the contextual factors that may be important in treatment.
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.
M. Lindsey Jacobs and Patricia M. Bamonti
The field of geropsychology has grown worldwide since the 1990s, particularly in the United States. In the early 21st century, professional geropsychology was recognized by the American Psychological Association as a clinical specialty. Despite this growth, there is a shortage of practicing psychologists proficient in geropsychology to meet the mental health needs of older adults. Moreover, the need for psychologists with geriatric training is continuing to grow as healthcare increasingly shifts to integrated care, creating a demand for psychologists in clinical settings such as nursing homes, hospice and palliative care, primary care, and home-based primary care. The widening gap between supply and demand requires strategic recruitment and educational initiatives to grow the number of providers with competency in working with older adults. Recruitment strategies emphasize increasing supply by “priming the pipeline” through the creation of early exposure opportunities at the secondary, undergraduate, and graduate school level, strategic recruitment of underrepresented students, and expanding financial incentives for practice.
Training and education in geropsychology have advanced considerably. The Pikes Peak Model for Professional Geropsychology Training provides the structure to gauge competency development. A framework for obtaining competency at the generalist, generalist with proficiency, and specialist levels has been created. In future years, there will be greater demand for post-licensure training in geropsychology, and geropsychologists will increasingly function as clinical educators. Technological advances will play a vital role in disseminating geropsychology education to generalist providers and related disciplines interested in gaining geropsychology exposure.
Faye F. Didymus
The cognitive–behavioral model of psychotherapy holds cognition at the core of psychological problems and disorders. The theoretical foundations of this model imply that dysfunctional thinking is common to all psychiatric disorders, psychological problems, and medical problems with a psychological component, and that changing an individual’s cognition results in causal changes in emotions and behaviors. In addition, when working with the cognitive–behavioral model, practitioners acknowledge that ongoing cognitive formulation is the basis of effective practice; that working with an individual’s beliefs about themselves, the world, and others results in sustained change; and that neurobiological changes occur following cognitive–behavioral therapy (CBT). The cognitive–behavioral model has been successfully applied in many domains (e.g., clinical, occupational, and sport psychology) where interventions are framed around the beliefs that characterize a presenting issue. Cognitive restructuring is one technique for implementing CBT that has been applied in sport and performance psychology. This technique is particularly relevant to performance domains because of the focus on cognitive formulation; the underpinning associations between cognition, emotion, and behavior; and the links between positively valenced emotions and superlative performance. Findings of sport psychology research extend the application of CBT beyond clinical populations and highlight the usefulness of cognitive–behavioral approaches for optimizing experiences of and performance in sport.
Some would argue that the first scientifically testable paradigm that was built on the cognitive–behavioral model of psychotherapy, and came chronologically slightly before CBT, is rational emotive behavior theory (REBT). Because both CBT and REBT share cognitive–behavioral roots, they have many similarities in their underpinning assumptions and in the ways that they are applied. REBT, however, focuses on rational and irrational beliefs and the links between an individual’s beliefs and his or her emotions and performance. REBT has a more philosophical focus with motivational theoretical roots when compared to other CBT approaches. Distinguishing features of REBT also lie in the techniques used and, hence, the way in which the underlying principles of the cognitive–behavioral model are applied. Disputing is the applied foundation of REBT and is a method of questioning an individual’s beliefs that generate emotional responses. This technique aims to help an individual recognize and adjust flaws in his or her thinking to work toward a more functional philosophy. Research that has used REBT in sport and performance contexts is sparse but that which does exist highlights the approach as a promising one for optimizing athletes’ beliefs and their emotional, behavioral, and physiological responses.
Lydia K. Manning, Lauren M. Bouchard, and James L. Flanagan
There is a great deal of concern about the increasing number of older adults who suffer from chronic disease. These conditions result in persistent health consequences and have an ongoing and long-term negative impact on people and their quality of life. Furthermore, the probability that a person will experience the onset of multiple chronic conditions, known as comorbidities, increases with age. Despite the prevalence of comorbidity in later life, scant research exists regarding specific patterns of disease and the co-occurrence and complex interactions of the chronic conditions most closely associated with aging. It is important to review the body of literature on comorbidities associated with physical and psychiatric syndromes in later life to gain an overview of some of the most commonly seen disorders in older adults: hypertension, diabetes, cardiovascular disease, chronic obstructive pulmonary disease, arthritis, depression, and dementia. Specific patterns of disease and the co-occurrence and complex interactions of chronic conditions in later life are explored. In conclusion, we consider the need for a more informed understanding of comorbidity, as well as a related plan for addressing it.
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.
Sara Honn Qualls and Lacey Edwards
Family systems therapy seeks to alter the structure or processes of a family for the purposes of reducing distress in one or more persons and improving the ability of the family to meet members’ needs. Building from a general systems paradigm, family systems therapy recognizes that family structures shift over time as they respond to members’ developmental processes and broader system demands. As members enter and exit or change capacity, and as external stressors arise, the family typically uses adaptive processes to demonstrate resilience. Family systems therapy is useful when the family struggles to adapt, or the adaptation strategy further stresses the family.
Multiple models of family systems therapies offer variations in intervention approaches but have common tenets. Major models include Ackerman’s early psychodynamics model, transgenerational models of family therapy, structural family therapy, strategic family therapy, and communications approaches to family therapy. Models vary in their recommended roles for the therapist, strategies for therapist and family, and the salience of immediate versus longer-term goals. Family systems therapies conceptualize family interactions as complex, reciprocal, open, self-organizing, adaptive, social constructionist, and meaning-making.
Family systems therapy also can be used with systems larger than families, such as schools or organizations, or to understand cultural phenomena. The field of marriage and family therapy has defined competencies for practice, training requirements, and licensure standards and established national and international professional organizations.
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.
Benjamin Gardner and Amanda L. Rebar
Within psychology, the term habit refers to a process whereby contexts prompt action automatically, through activation of mental context–action associations learned through prior performances. Habitual behavior is regulated by an impulsive process, and so can be elicited with minimal cognitive effort, awareness, control, or intention. When an initially goal-directed behavior becomes habitual, action initiation transfers from conscious motivational processes to context-cued impulse-driven mechanisms. Regulation of action becomes detached from motivational or volitional control. Upon encountering the associated context, the urge to enact the habitual behavior is spontaneously triggered and alternative behavioral responses become less cognitively accessible.
By virtue of its cue-dependent automatic nature, theory proposes that habit strength will predict the likelihood of enactment of habitual behavior, and that strong habitual tendencies will tend to dominate over motivational tendencies. Support for these effects has been found for many health-related behaviors, such as healthy eating, physical activity, and medication adherence. This has stimulated interest in habit formation as a behavior change mechanism: It has been argued that adding habit formation components into behavior change interventions should shield new behaviors against motivational lapses, making them more sustainable in the long-term. Interventions based on the habit-formation model differ from non-habit-based interventions in that they include elements that promote reliable context-dependent repetition of the target behavior, with the aim of establishing learned context–action associations that manifest in automatically cued behavioral responses. Interventions may also seek to harness these processes to displace an existing “bad” habit with a “good” habit.
Research around the application of habit formation to health behavior change interventions is reviewed, drawn from two sources: extant theory and evidence regarding how habit forms, and previous interventions that have used habit formation principles and techniques to change behavior. Behavior change techniques that may facilitate movement through discrete phases in the habit formation trajectory are highlighted, and techniques that have been used in previous interventions are explored based on a habit formation framework. Although these interventions have mostly shown promising effects on behavior, the unique impact on behavior of habit-focused components and the longevity of such effects 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. Whether habit formation interventions truly offer a route to long-lasting behavior change, however, remains unclear.
Despite high rates of mental illnesses, older adults face multiple barriers in accessing mental health care. Primary care clinics, and home- and community-based senior-serving agencies are settings where older adults routinely receive medical care and social services. Therefore, integration of mental health care with existing service delivery systems can improve access to mental health services and reduce the unmet mental health needs of seniors. Evidence suggests that with innovative components mental health provided in collaboration with primary care providers with or without co-location within primary care clinics can improve depression and anxiety. Home-based models for depression care are also effective, but more research is needed in examining home-based approaches in late-life anxiety treatment. It is noteworthy that integrative models are particularly helpful in expanding the reach in underserved communities: elders from minority and low-income backgrounds and homebound seniors.
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.
Sleep health is understood as a key factor in lifelong health and for social participation, function, and satisfaction. In later life, insomnia and other sleep disturbances are common. Insomnia is experienced as poor, disrupted, or insufficient sleep associated with significant daytime impairments including increased fatigue or reduced energy, impaired cognitive function, and increased mood disturbance. Poor sleep is associated with negative outcomes across a range of dimensions that impair quality of life, increases risk for other diseases, and may interact negatively with the progression and treatment of other disorders. Evidence for effective psychological interventions to improve sleep in later life, specifically cognitive behavioral therapy for insomnia, is robust and well described. Good sleep should be understood as a substrate for psychological health and a reasonable expectation in later life.
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.
Nasreen A. Sadeq and Victor Molinari
The need for facilities that provide residential aged care is expected to increase significantly in the near future as the global population ages at an unprecedented rate. Many older adults will need to be placed in a residential care setting, such as an assisted living facility (ALF) or nursing home, when their caregivers can no longer effectively manage serious medical or psychiatric conditions at home. Although the types of residential care settings worldwide vary considerably, long-term care residents (LTC) and staff benefit from environmental and cultural changes in LTC settings. Unlike traditional medical models of LTC, culture change advocates for a shift toward holistic, person-centered care that takes place in homelike environments and accounts for the psychosocial needs of residents. Carving out a role for family members and training professional caregivers to address behavioral problems and quality-of-life issues remain a challenge. In LTC settings, preliminary research indicates that implementing person-centered changes addressing resident and caregiver needs may lead to better health outcomes, as well as increased satisfaction among patients, families, and staff. With the burgeoning world population of older adults, it is incumbent that they be provided with optimal humane culturally sensitive care.
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.