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Objective We conducted a 1-year prospective follow-up study of posttreatment clinical outcomes in adolescents with recent and repetitive self-harm who had been randomly allocated to receive 19 weeks of either dialectical behavior therapy adapted for adolescents (DBT-A) or enhanced usual care (EUC) at community child and adolescent psychiatric outpatient clinics. Method Assessments of self-harm, suicidal ideation, depression, hopelessness, borderline symptoms, and global level of functioning were made at the end of the 19-week treatment period and at follow-up 1 year later. Altogether 75 of the 77 (97%) adolescents participated at both time points. Frequencies of hospitalizations, emergency department visits and other use of mental health care during the 1-year follow-up period were recorded. Change analyses were performed using mixed effects linear spline regression and mixed effect Poisson regression with robust variance. Results Over the 52-week follow-up period, DBT-A remained superior to EUC in reducing the frequency of self-harm. For other outcomes such as suicidal ideation, hopelessness, and depressive or borderline symptoms and for the global level of functioning, inter-group differences apparent at the 19-week assessment were no longer observed, mainly due to participants in the EUC group having significantly improved on these dimensions over the follow-up year, whereas DBT-A participants remained unchanged. Conclusion A stronger long-term reduction in self-harm and a more rapid recovery in suicidal ideation, depression, and borderline symptoms suggest that DBT-A may be a favorable treatment alternative for adolescents with repetitive self-harming behavior. Clinical trial registration information : Treatment for Adolescents With Deliberate Self Harm; http://clinicaltrials.gov/; NCT00675129.

Objective To examine the efficacy and durability of a behavioral therapy (BT) protocol for pediatric TTM compared with a minimal attention control (MAC) condition. It was hypothesized that the BT condition would be superior to MAC at the end of acute treatment, and would also demonstrate durability of gains through the maintenance treatment phase. Method A randomized controlled trial in which 24 youths were assigned to either a pilot-tested BT protocol, consisting of eight weekly sessions, or to MAC, consisting of three sessions and five telephone calls over 8 weeks. Independent evaluators assessed outcome at pretreatment (week 0) and post-treatment (week 8) for BT and MAC, and again at week 16 for BT patients only. The primary outcome measure was the National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS). Results For the BT condition, the week 8 mean NIMH-TSS score was significantly lower than that of the MAC condition. The BT condition's mean week 8 score was also significantly lower than their own mean week 0 score, whereas no such reductions were observed for the MAC condition. Upon completion of acute treatment at week 8, the BT group's gains were maintained through an 8-week maintenance treatment phase. Conclusions BT produced a superior outcome compared with a condition that controlled for participation in a pediatric TTM research study, nonspecific therapist contact effects, repeated assessments, and the passage of time. Maintenance of gains after acute BT provides preliminary support for the durability of treatment gains. Clinical Trial Registration Information— Cognitive Behavioral Treatment of Pediatric Trichotillomania; http://www.clinicaltrials.gov; R21 MH 61457

KEY POINTS • No randomized clinical trials have been conducted in children with trichotillomania. Research examining the clinical course and natural history of childhoodonset trichotillomania is equally sparse. • Behavioral treatments such as habit reversal therapy have demonstrated efficacy in the treatment of adults with trichotillomania. Large uncontrolled trials have suggested similar efficacy of behavioral therapies in children. • Several double-blind, randomized, clinical trials have demonstrated that selective serotonin reuptake inhibitors have no efficacy in treating the primary symptoms of trichotillomania in adults. • Evidence from a recent double-blind, placebo-controlled randomized clinical trial suggests that the glutamatemodulating agent, N-acetylcysteine, may be effective in treating trichotillomania in adults. Trichotillomania (TTM) is a disorder in which patients chronically pull out their hair, producing noticeable hair loss, distress, and impairment. The lifetime prevalence of TTM is estimated to be 1% to 3%. Children with TTM can experience significant impairment because of peer teasing, avoidance of activities (such as swimming and socializing), difficulty concentrating on school work, and medical complications due to pulling behaviors. Trichotillomania has an average age of onset of 11 to 13 years and is considered to have a chronic course, often waxing and waning in severity. 1 The DSM-IV criteria for TTM are depicted in Table 1. One quarter of adult pullers do not report experiencing urges before pulling or relief after pulling and thus do not meet current DSM criteria for TTM. The proportion of children who experience chronic hair-pulling without reporting these sensory phenomena are considerably higher. In recent years, there have been advances in the development of evidence-based treatments for adults with TTM. 2 Despite these advances, only 15% of adults with TTM experience significant improvement with community treatment. More than 55% of adults with TTM felt that their clinician did not have sufficient knowledge of the disorder, and less than half were receiving evidence-based treatments. 3 The evidence base for judging treatment efficacy in pediatric patients is considerably less, and children’s success rate with community treatments is equally discouraging. 4 The lack of controlled clinical trials in children, the secrecy of many children with TTM, and the infrequency with which it reaches psychiatric attention present considerable challenges for clinicians. However, much can be learned by examining the randomized clinical trial data in adults and combining it with the evidence base from Psychopharmacology Perspectives aims to discuss practical approaches to everyday issues in pediatric pharmacotherapy. The discussions may address aspects of clinical care related to psychopharmacology for which we do not have adequate applicable controlled trials. Given the need to address symptoms in youths with often complex, severe, and comorbid disorders, recommendations are likely to be off-label from the perspective of the U.S. Food and Drug Administration. We fully appreciate that for virtually all disorders, medication is only one aspect of comprehensive care. This column focuses primarily on psychopharmacological management. Although it is important that clinicians address psychosocial issues in the evaluation and treatment of their patients, such discussion is beyond the specific scope of this feature. These are not meant to be practice guidelines, but rather examples of the thought process that may go into pharmacotherapy decision making. Accepted April 20, 2009. This article was reviewed under and accepted by Deputy Editor John T. Walkup, M.D. Dr. Bloch is with the Yale Child Study Center, Yale University School of

Objective The Juvenile Fire Awareness and Intervention Program was established to develop and evaluate an intervention to be offered by fire fighters for children who set fires. Method One hundred thirty-eight children, aged 5 to 16 years, with a history of firesetting participated in a randomized, controlled trial. The intervention involved education about fire safety and a behavior modification program designed to extinguish the desire to set fires through satiation. The frequency and severity of firesetting were recorded for 12 months after the intervention to measure outcome. Results There was a significant decrease in the frequency and severity of firesetting across all groups, with no additional improvement resulting from participation in the fire fighters' intervention. Conclusions There is no evidence to suggest that the multicomponent program offered by trained fire fighters is effective in reducing firesetting. The marked reduction in firesetting across all groups suggests that fire safety education by the fire fighters is the most appropriate approach to this serious community problem.